After the Fukushima nuclear plant accident in March, 2011, the National Diet of Japan established in October, 2011, the Fukushima Nuclear Accident Independent Investigation Commission (NAIIC) chaired by Kiyoshi Kurokawa, a former president of the Science Council of Japan. The NAIIC is the first independent commission created in the history of Japan's constitutional government.
The Commission began work in December, 2011 and after a six month investigation including 900 hours of hearings and interviews with 1167 people (government, regulators, and TEPCO) and 19 commission meetings open to public and broadcast on the internet (simultaneously in Japanese and English) has just submitted its report (only the Executive Summary is available in English at present).
The main players in the report are the Prime Minister's Office (Kansei), the Ministry of Economy, Trade and Industry (METI), the Nuclear and Industrial Safety Agency (NISA), the Nuclear Safety Commission (NSC), and the Tokyo Electric Power Company (TEPCO).
The key conclusion of the report was that the accident was a "manmade" disaster
The TEPCO Fukushima Nuclear Power Plant accident was the result of collusion between the government (METI), the regulators (NISA and NSC), and TEPCO. Therefore, we conclude that the accident was clearly "manmade".
Replacing people or changing the names of institutions will not solve the problems. The underlying issue is the social structure that results in "regulatory capture" and the organizational, institutional and legal framework that allows individuals to justify their own actions, hide them when inconvenient, and leave no records in order to avoid responsibility.
Since 2006, the regulators and TEPCO were aware of the risk that a total outage of electricity (station blackout) at the Fukushima Daiichi plant might occur if a tsunami were to reach the level of the site.
The regulators also had a negative attitude toward the importation of new advances in knowledge and technology from overseas. If NISA had passed onto TEPCO measures that were included in the B.5.b subsection of the U.S. security order that followed the 9/11 terrorist action, and if TEPCO had put measures in place, the accident may have been preventable.
There were many opportunities for taking preventative measures prior to March 11. The accident occurred because TEPCO did not take these measures, and [the regulators] NISA and NSC went along.
Further exacerbating the problem was the fact that [the regulator] NISA was created as part of the Ministry of Economy, Trade and Industry (METI), an organization that has been actively promoting nuclear power.
The crisis management system of the Prime Minister's Office, the regulators, and other responsible agencies did not function correctly. NISA was expected to play the lead role as designated in the Act on Special Measures Concerning Nuclear Emergency Preparedness. However, NISA was unprepared for a disaster of this scale and failed in its function.
TEPCO's mindset which included the reluctance to take responsibility epitomized by President Shimuzu's inability to clearly report to the Prime Minister's Office the intentions of the operators of the plant.
The Commission concludes that there organizational problems within TEPCO. Events make it clear that if there are not response measures for a severe accident in place, the steps that can be taken on-site in the event of a station blackout are very limited. On top of this, sections in the diagrams of the severe accident instruction manual were missing.
TEPCO was too quick to cite the tsunami as the cause of the nuclear accident. The Commission believes that this is an attempt to to avoid responsibility by putting all the blame on the unexpected (the tsunami) and not on more the foreseeable earthquake. The damage to Unit 1 was caused not only by the tsunami but also by the earthquake. Additionally there two causes for the loss of external power, both earthquake related: there was no diversity or independence in the earthquake-resistant external power systems, and the Shin-Fukushima transformer substation was not earthquake resistant.
I remember hearing early in the accident, that it was at the time that the Prime Minister was briefing the opposition in the Diet to reassure them on the status of the plant, based on information he had received from TEPCO, 20 minutes into his presentation is when the first (hydrogen) explosion occurred.
Three Mile Island
On March 28, 1979, the United States experienced the worst accident in the history of commercial nuclear power generation at Three-Mile Island (TMI). Two weeks later, the President of the United States Jimmy Carter established an independent Presidential Commission headed by John G Kemeny. Oct 30, 1979, about six months later, the President's Commission on the Accident at Three Mile Island submitted its report.
Its overall conclusion was
To prevent nuclear accidents as serious as Three Mile Island, fundamental changes will be necessary in the organization, procedures, and practices -- and above all -- in the attitudes of the Nuclear Regulatory Commission and, to the extent that the institutions we investigated are typical, of the nuclear industry. ...
We are convinced that if the only problems were equipment problems, this Presidential Commission would never have been created. The equipment was sufficiently good that, except for human failures, the major accident at Three Mile Island would have been a minor incident. But, wherever we looked, we found problems with the human beings who operate the plant, with the management that runs the key organization, and with the agency that is charged with assuring the safety of nuclear power plants.
In conclusion, while the major factor that turned this incident into a serious accident was inappropriate operator action, many factors contributed to the action of the operators, such as deficiencies in their training, lack of clarity in their operating procedures, failure of organizations to learn the proper lessons from previous incidents, and deficiencies in the design of the control room. These shortcomings are attributable to the utility, to suppliers of equipment, and to the federal commission that regulates nuclear power. Therefore -- whether or not operator error "explains" this particular case -- given all the above deficiencies, we are convinced that an accident like Three Mile Island was eventually inevitable.
Specifically on the Nuclear Regulatory Commission (NRC), the Commission said
We had a broad mandate from the President to investigate the Nuclear Regulatory Commission. When NRC was split off from the old Atomic Energy Commission, the purpose of the split was to separate the regulators from those who were promoting the peaceful uses of atomic energy. We recognize that the NRC has an assignment that would be difficult under any circumstances. But, we have seen evidence that some of the old promotional philosophy still influences the regulatory practices of the NRC. While some compromises between the needs of safety and the needs of an industry are inevitable, the evidence suggests that the NRC has sometimes erred on the side of the industry's convenience rather than carrying out its primary mission of assuring safety. ... The old AEC attitude is also evident in reluctance to apply new safety standards to previously licensed plants.
About the operator GPU and its subsidiary Metropolitan Edison
First of all, it is our conclusion that the training of TMI operators was greatly deficient. While training may have been adequate for the operation of a plant under normal circumstances, insufficient attention was paid to possible serious accidents. And the depth of understanding, even of senior reactor operators, left them unprepared to deal with something as confusing as the circumstances in which they found themselves.
Second, we found that the specific operating procedures, which were applicable to this accident, are at least very confusing and could be read in such a way as to lead the operators to take the incorrect actions they did.
We found that at both companies, those most knowledgeable about the workings of the nuclear power plant have little communication with those responsible for operator training, and therefore, the content of the instructional program does not lead to sufficient understanding of reactor systems.
...the analysis of this particular accident raises the serious question of whether all electric utilities automatically have the necessary technical expertise and managerial capabilities for administering such a dangerous high-technology plant. We, therefore, recommend the development of higher standards of organization and management that a company must meet before it is granted a license to operate a nuclear power plant.
And I remember a documentary about TMI where the then Lieutenant Governor of Pennsylvania related that it was while he was briefing the press to reassure them about the status of the plant, based on information just received from Met Ed, that the first release of radioactive material occurred.