All estimates indicate that the accident at Japan's Fukushima Daiichi nuclear power plant will have a very small cost in human lives. Still, its overall impact is enormous. The country saw one of its major sources of electrical power go entirely offline at the same time it was attempting to recover and rebuild following a staggering earthquake and tsunami. A large area remains off-limits, and the country's nuclear experts are now forced to secure the material in the melted-down reactors and fuel storage areas before another earthquake hits. The total cost of Fukushima is likely to be astronomical.

It's easy to dismiss the accident as a freak occurrence—both the earthquake and tsunami were of exceptional magnitude, after all. Events of that size aren't unprecedented in Japan, yet the Fukushima reactors were poorly prepared for them. Now there are many indications that the recovery from the initial shock didn't go according to plan either. Today, the Japanese parliament released the English version of its analysis of Fukushima, performed by an independent investigative committee.

The report hammers both TEPCO, the utility that ran the plant, and the government regulators who were meant to oversee it. Although a number of the problems may be unique to the Japanese situation, the report provides lessons that could be valuable for the nuclear programs in other nations.

Regulatory Capture

Japan has little in the way of domestic fossil fuels, and in the wake of the energy crises of the 1970s, decided to pursue greater energy independence by pushing for nuclear power. This effort, however, ended up directed in a way that created a significant structural problem: the same agency that was tasked with promoting the use of nuclear power was entrusted with regulating the safety of nuclear reactors. The problems didn't end there. At this year's meeting of the American Association for the Advancement of Science, Roland Schenkel from the European Commission's Joint Research Center stated that these regulators had no authority to force the implementation of any changes.

The new report suggests that this questionable structure was made worse by some aspects of Japanese culture. Among those, "the collective mindset of Japanese bureaucracy," which focused on the interests of the agency itself rather than the public it was meant to serve (it should be noted, this clearly occurs outside of both Japan and government). "As they had firmly committed themselves to the idea that nuclear power plants were safe," the report concludes, "they were reluctant to actively create new regulations."

This overlap between the interests of regulators and the industry resulted in what the report terms "regulatory capture." Those who were supposed to be generating and enforcing safety measures made sure that any steps they took largely reflected the wishes of industry.

One outcome of this, according to the report, is that the lessons learned at Three Mile Island and Chernobyl didn't translate into any significant changes within the Japanese nuclear industry. Safety features in Japan simply fell behind those of other industrialized nations. The EC's Schenkel said that Fukushima had "no filters on the pressure release, which is an easy retrofit." That forced the plant operators to choose between allowing gasses to build up inside the reactors and venting radiation into the environment.

Another key outcome is that the nuclear industry didn't keep pace with changing knowledge about seismic risks. We now know, Schenkel said, that even magnitude 7.5 quakes are capable of generating enormous (>50m) tsunamis. Ones over 10m strike somewhere on the Japanese coast as often as every 30 years. The updated knowledge should have been translated to updated safety standards. But, as the report details, it wasn't.

A history of failure at Fukushima

Fukushima's operator, TEPCO, was made aware of the enhanced seismic risks, but its response wasn't focused on safety. "If the risk factors of tsunami are raised, for example, TEPCO would only look at the risk to their own operations, and whether it would result in a suspension of existing reactors or weaken their stance in potential lawsuits," the report states. "They ignored the potential risk to the public health and welfare."

And, to keep the plant operating, TEPCO generally stalled. When regulators set a 2009 deadline for a safety evaluation based on updated seismic standards, "TEPCO made the decision internally and unilaterally to reschedule the deadline to January 2016." The regulators enabled this behavior: "NISA [the Nuclear and Industrial Safety Agency] knew that TEPCO had not prepared any measures to lessen or eliminate the risk, but failed to provide specific instructions to remedy the situation."

The lack of robustness in the wake of the tsunami resulted in the total loss of power at the reactors, leaving their cooling systems inoperative. Here again, the report identifies how the collusion between operators and regulators killed any chance of preparation for this eventuality: "NISA informed the operators that they did not need to consider a possible station blackout (SBO) because the probability was small and other measures were in place. It then asked the operators to write a report that would give the appropriate rationale for why this consideration was unnecessary."

The aftermath

One of the most detailed accounts of the aftermath at Fukushima was put together by Eliza Strickland for IEEE Spectrum. From a safety perspective, however, the report makes a few additional things clear. The lack of realistic planning for the tsunami left the damage control efforts in a bad position. Not only did the tsunami destroy significant pieces of the reactor hardware, it also washed away a lot of the equipment needed to get matters back under control. In its place was a variety of wreckage that blocked access to critical places on the site.

Even if procedures for a disaster of this scale had been in place, the report suggests the lax attitude toward safety might have obviated them. A severe accident manual existed, but when it was consulted, it turned out that sections of critical diagrams were missing entirely.

There were some bits of good luck in among the problems. A backup cooling system in reactor 2 ran for much longer than expected, and a piece of hardware that fell off the reactor building happened to release a lot of the pressure from built up hydrogen by doing so. The report also praises TEPCO subcontractors that cleared a lot of the wreckage away from the reactor buildings at an impressive clip.

With the reactors melting down, however, bad management came into play. "TEPCO’s manual for emergency response to a severe accident was completely ineffective," and the company's chairman and president had different understandings of what the emergency procedures should be. The company quickly fell back on the habit of telling the government what its executives thought it wanted to hear. On the government side, most agencies devoted to emergencies had their hands full with seismic events. The report also singles out the Secretariat of the Nuclear Emergency Response Headquarters for a failure to gather and disseminate any information on what was going on.

Sensing an apparent void, the Prime Minister's office (Kantei) stepped in. It was woefully unprepared to do so.

The first engineer set to dealing with Fukushima was put in a basement office where there was no cell phone reception, and he ended up getting better information on the situation by watching TV.

Also at the AAAS meeting, Miho Namba from Japan's Science Media Center described some of the problems. For two days after the start of the disaster, the Kantei tried to handle matters without the benefit of any science and engineering expertise. The first engineer set to dealing with Fukushima was transferred from an agency that didn't deal with nuclear issues. He was put in a basement office where there was no cell phone reception, and he ended up getting better information on the situation by watching TV. It took until four days after the disaster for the Kantei to put out a call for a scientist with relevant expertise in nuclear power.

In the middle of all of this, the Prime Minister himself chose to visit the stricken plant, an event that "disrupted the chain of command and brought disorder to an already dire situation at the site." Although lines of communication were eventually established and a chain of command eventually worked out, problems persisted throughout the evacuation of the exclusion zone. All that may have contributed to the amount of time it took to get the reactors under control.

General lessons

A lot of the lessons from Fukushima have been obvious for a while. Nuclear safety is a global challenge, and every country has to learn from the best practices of others. These best practices include retrofitting passive safety features wherever possible, and continuing to update safety measures in response to our changing understanding of the plant's environment. Plant operators need not only multiple chains of command to rely on in times of crisis, but the training and approval to operate independently if none of those are accessible.

But the report makes it clear that there needs to be a cultural commitment to make sure the best practices are the actual practices. As long as plants are operated for profit, their operators will necessarily face pressure to run the plants for as much of their lifespan as possible, and spend as little to retrofit them as they can. To ensure that this pressure doesn't erode safety, there needs to be a regulatory agency that operates independently and has the ability to mandate changes that aren't in the utility's best interests.