The National Diet of Japan | 2012

The evaluation of the Fukushima Daichii nuclear disaster in 2011 related to an earthquake followed by a tsunami is a good example of zooming out from a disaster and learn the lessons. It is as report a true example report of self reflection, because it digs deep into the public ecosystem where government, business and civic society meet. It is a form of network analysis. The disaster had a major impact on the natural environment and ecosystems. The disaster shocked the entire world.

Disaster location map (p.10) from the National Diet of Japan.

The National Diet of Japan

The conclusions by Fukushima Nuclear Accident Independent Investigation Commission were thorough and blistering. It shed a light on how attitudes, stakes and rules and their interdependencies as well as the lack of cooperation in peace-time (read: before the earthquake and the tsunami) between organisations related to the public domain had increased the disaster. The major conclusions [quote]:

• In order to prevent future disasters, fundamental reforms must take place. These reforms must cover both the structure of the electric power industry and the structure of the related government and regulatory agencies as well as the operation processes. They must cover both normal and emergency situations. 
• The TEPCO Fukushima Nuclear Power Plant accident was the result of collusion between the government, the regulators and TEPCO, and the lack of governance by said parties. They effectively betrayed the nation’s right to be safe from nuclear accidents. Therefore, we conclude that the accident was clearly “manmade”. We believe that the root causes were the organisational and regulatory systems that supported faulty rationales for decisions and actions, rather than issues relating to the competency of any specific individual. 
• We conclude that TEPCO was too quick to cite the tsunami as the cause of the nuclear accident and deny that the earthquake caused any damage.
• The Commission concludes that there were organisational problems within TEPCO. Had there been a higher level of knowledge, training, and equipment inspection related to severe accidents, and had there been specific instructions given to the on-site workers concerning the state of emergency within the necessary time frame, a more effective accident response would have been possible. 
• The Commission concludes that the situation continued to deteriorate because the crisis management system of the Kantei, the regulators and other responsible agencies did not function correctly. The boundaries defining the roles and responsibilities of the parties involved were problematic, due to their ambiguity. 
• The Commission concludes that the residents’ confusion over the evacuation stemmed from the regulators’ negligence and failure over the years to implement adequate measures against a nuclear disaster, as well as a lack of action by previous governments and regulators focused on crisis management. The crisis management system that existed for the Kantei and the regulators should protect the health and safety of the public, but it failed in this function. 
• The Commission recognizes that the residents in the affected area are still struggling from the effects of the accident. They continue to face grave concerns, including the health effects of radiation exposure, displacement, the dissolution of families, disruption of their lives and lifestyles and the contamination of vast areas of the environment. There is no foreseeable end to the decontamination and restoration activities that are essential for rebuilding communities. 
• The Commission concludes that the government and the regulators are not fully committed to protecting public health and safety; that they have not acted to protect the health of the residents and to restore their welfare. 
• The Commission has concluded that the safety of nuclear energy in Japan and the public cannot be assured unless the regulators go through an essential transformation process. The entire organisation needs to be transformed, not as a formality but in a substantial way. Japan’s regulators need to shed the insular attitude of ignoring inter- national safety standards and transform themselves into a globally trusted entity. 
• TEPCO did not fulfil its responsibilities as a private corporation, instead obeying and relying upon the government bureaucracy of METI, the government agency driving nuclear policy. At the same time, through the auspices of the FEPC, it manipulated the cozy relationship with the regulators to take the teeth out of regulations. 
• The Commission concludes that it is necessary to realign existing laws and regulations concerning nuclear energy. Mechanisms must be established to ensure that the latest technological findings from international sources are reflected in all existing laws and regulations.
• Replacing people or changing the names of institutions will not solve the problems. Unless these root causes are resolved, preventive measures against future similar accidents will never be complete.” [unquote] 

Diagram (p.35) of the emergency communication protocol, from the National Diet of Japan.

The chairman of the research commission of the National Diet report Kiyoshi Kurokawa summarised the conclusions [quote]:

• The disaster cannot be regarded as a natural disaster. It was a profoundly manmade disaster – that could and should have been foreseen and prevented. And its effects could have been mitigated by a more effective human response.
• Our report catalogues a multitude of errors and wilful negligence that left the Fukushima plant unprepared for the events of March 11. And it examines serious deficiencies in the response to the accident by TEPCO, regulators and the government. 
• What must be admitted – very painfully – is that this was a disaster “Made in Japan.” Its fundamental causes are to be found in the ingrained conventions of Japanese culture: our reflexive obedience; our reluctance to question authority; our devotion to ‘sticking with the program’; our groupism; and our insularity.  Had other Japanese been in the shoes of those who bear responsibility for this accident, the result may well have been the same. 
• Following the 1970s “oil shocks,” Japan accelerated the development of nuclear power in an effort to achieve national energy security. As such, it was embraced as a policy goal by government and business alike, and pursued with the same single-minded determination that drove Japan’s postwar economic miracle. 
• With such a powerful mandate, nuclear power became an unstoppable force, immune to scrutiny by civil society. Its regulation was entrusted to the same government bureaucracy responsible for its promotion. At a time when Japan’s self-confidence was soaring, a tightly knit elite with enormous financial resources had diminishing regard for anything ‘not invented here.’ 
• This conceit was reinforced by the collective mindset of Japanese bureaucracy, by which the first duty of any individual bureaucrat is to defend the interests of his organisation. Carried to an extreme, this led bureaucrats to put organisational interests ahead of their paramount duty to protect public safety. 
• Only by grasping this mindset can one understand how Japan’s nuclear industry managed to avoid absorbing the critical lessons learned from Three Mile Island and Chernobyl; and how it became accepted practice to resist regulatory pressure and cover up small-scale accidents. It was this mindset that led to the disaster at the Fukushima Daiichi Nuclear Plant. 
• This report singles out numerous individuals and organisations for harsh criticism, but the goal is not—and should not be—to lay blame. The goal must be to learn from this disaster, and reflect deeply on its fundamental causes, in order to ensure that it is never repeated. 
• Many of the lessons relate to policies and procedures, but the most important is one upon which each and every Japanese citizen should reflect very deeply. 
• The consequences of negligence at Fukushima stand out as catastrophic, but the mindset that supported it can be found across Japan. In recognizing that fact, each of us should reflect on our responsibility as individuals in a democratic society. 
• As the first investigative commission to be empowered by the legislature and independent of the bureaucracy, we hope this initiative can contribute to the development of Japan’s civil society. Above all, we have endeavoured to produce a report that meets the highest standard of transparency. The people of Fukushima, the people of Japan and the global community deserve nothing less. [unquote]

Bibliography

The National Diet of Japan (2012) The Fukushima Nuclear Accident Independent Investigation Commission. The National Diet of Japan https://warp.da.ndl.go.jp/info:ndljp/pid/3856371/naiic.go.jp/en/report/