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  • 7/31/2019 NAIIC Report Lo Res

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    MembersK Ib

    Seismlgist; Prfessr Emeritus f Kbe University

    Kz OAdvisr t the President f Japan Internatinal CperatinAgency; Frmer Ambassadr f Japan t the United Natins

    H SyMedical Dctr; Frmer Chief f the Natinal Institute f

    Radilgical Sciences

    M SLawyer; Frmer Chief Prsecutr f the Nagya High Public

    Prsecutrs Office; Frmer Inspectr General fr LegalCmpliance, Inspectr Generals Office, Defense Ministry

    K TChemist; Fellw, Shimadzu Crpratin

    M TScience jurnalist

    Sy N

    Prfessr, Chu Law Schl, Chu University; lawyer

    R HChair, Sciety f Cmmerce and Industry, Okuma Twn,

    Fukushima Prefecture

    Y YyScial System Designer; Directr, University f Tky Executive

    Management Prgram (Tdai EMP)

    ChairmanKy Kw

    Medical Dctr; Academic Fellw, Natinal Graduate Institute fr Plicy Studies;Frmer President f the Science Cuncil f Japan

    Advisors to the CommissionI K

    T K

    T H

    ReviewersT I

    M S

    J S

    I Nj

    T M

    Office of AdministrationT Aj

    Directr General

    S UManaging Directr f Investigatin

    The National Diet of JapanFukushima Nuclear Accident Independent Investigation Commission

    l

    l

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    P

    T N D JT F N A I Ig C 2012, T N D JA g .

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    Contents

    Message from the Chairman 9

    Overview

    The Commission's mandate 10The accident 12

    Conclusions and Recommendations 16

    Summary of Findings 25

    1: Was the accident preventable? 262: Escalation of the accident 293: Emergency response to the accident 324: Spread of the damage 375: Organizational issues in accident prevention

    and response 426: The legal system 45

    Appendices 49

    Survey of the evacuees 50Survey of the workers 62Commission meeting reports 71Glossary of terms 84

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    7NAIIC

    To:Mr. Takahiro Yokomichi, Speaker of the House of RepresentativesMr. Kenji Hirata, President of the House of CouncillorsThe National Diet of Japan

    THE UNPRECEDENTED NUCLEAR ACCIDENT g M 11, 2011

    g , N D J . W A Rgg FN A I Ig C.

    O g , x C M D 2011.

    T g g g . A D J g, , J .

    The National Diet of JapanFukushima Nuclear Accident Independent Investigation Commission

    (NAIIC)

    Kiyoshi Kurokawa

    Members:

    Chairman:

    Kenzo Oshima

    Yoshinori Yokoyama

    Katsuhiko Ishibashi

    Hisako Sakiyama

    Mitsuhiko Tanaka

    Reiko Hachisuka

    Masafumi Sakurai

    Koichi Tanaka

    Shuya Nomura

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    9NAIIC

    Message from the Chairman

    THE EARTHQUAKE AND TSUNAMI M 11, 2011 g . Ag gg , -q F D N P P g . I . A g .

    H J, g g x gg g? T C J g , q.

    O g gg F M 11. A x TEPCO, g g.

    F x , g gg .

    W M J.

    I g J : x ; q ; g g; g; .

    H J , .

    Fg 1970 , J g . A , g g , g- J .

    W , , . I g g . A J - g, g

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    O gg J g g T M I C; g - .I F D N P.

    T g g , g . T g , , .

    M , J .

    T q gg F , J. I gg , .

    A g g , J .

    A , g . T F, J g g .

    Kiyoshi Kurokawa

    Chairman:

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    10 N A I Ig C

    Sendai

    Mito

    NaritaInternationalAirport

    Nihonmatsu

    FUKUSHIMA

    PREFECTURE

    Niigata

    Iwaki

    Tokyo

    Fukushima

    Fukushima Daiichi

    Nuclear Power Plant

    30 km20 km

    Fukushima Daiichi

    Nuclear Power Plant

    Sendai

    Iwaki

    Tokyo

    Fukushima

    Overview

    The Commissions Mandate

    O O 30, 2011, NAIIC A (, A gg F N A- I Ig C) , g - g F q q g g q. T J g.

    O D 8, 2011, , g

    S P N D g , - A 10 NAIIC A:

    1. T g T E P CF M 11, 2011 - G E J Eq.

    2. T g g .

    3. T g g -q g; q ; g .

    4. T g gg xg .

    5. T qg g g. T g.

    6. T g .

    Expectations of the CommissionB C g g, g J C C R A B H A F N P P T E P C:

    l

    T g g x g, , g .l W g g , g

    g g

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    11NAIIC

    .l A g ,

    .l T g ,

    .l T g g q

    J.l T g ,

    gg g .

    What we didO g 900 g 1,167 .

    W g F D, F- D, T E P C Og N P P, T JA P C T D P P, g -g .

    T x g , 19 -

    g (x ), J Eg, 800,000 . W , F , g 170,000 -. T g g , , - g x U.S, F, R, U B.

    I Eg x , Eg.

    W g, TEPCO g.

    I , -g, 400 . W F, O, T, N, N, K,

    H, K, M, T, I, K g , . W 10,633 , - 500 .

    What we did not doT g , .

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    W g .W g q -

    g .W g -

    , .W TEPCO g

    - .W - q .W g J

    .N g g -

    .W g F

    , g g

    g. N g g F .A, , g g

    g .

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    12 N A I Ig C

    The accident

    O M 11, 2011, G E J Eq gg x F D N P P, TE P C (TEPCO). T g L 7 (S A) I N E S (INES).

    W q , U 1 F D g ; U 2 3 ; U 4 6 gg . T g - , SCRAM, U 1, 2 3 - .

    T g TEPCOS T S F D N P

    P, g - . T - 66V - T E P C, - U 1 - (M/C) U 1 - .

    T q g g, g , g DC U 1, 2 4, g x x U 6 - g g. I , U 1, 2 4 ; U 3 AC , DC M 13, 2012. U 5 AC .

    T g . T , , , g. I g,

    q . S g x g g U 3 4, (C P Bg).A , g ,

    Layout of the Fukushima Daiichi

    Nuclear Power Plant

    Adapted from: INPO Special Report on

    the Nuclear Accident at the Fukushima

    Daiichi Nuclear Power Station

    Turbine buildings

    Cooling water discharge

    Cooling water discharge

    Turbine buildings

    Reactor 4

    Reactor 3

    Reactor 2

    Reactor 1

    Radiationwastetreatmentfacility

    Extra-highvoltage switching yard

    Extra-high voltage

    switching yard

    Admin oce

    Anti-Earthquake building

    Common Pool Building

    South breakwater

    North breakwater

    500K

    vtrans

    miss

    ionlin

    e

    275K

    vtrans

    miss

    ionlin

    e

    275K

    vtrans

    miss

    ionline

    Service hall

    Eastbreakwater

    Reactor 5

    Reactor 6

    Emergency response center

    Intake canals

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    13NAIIC

    Timeline following the earthquake and tsunami

    3.11

    3.12

    3.13

    3.14

    3.15

    Unit 1 Unit 2 Unit 3 Unit 4

    approx. 18:10 Start of reactor core

    exposure (analysis)

    approx. 18:50 Start of reactor core

    damage

    15:36 Hydogen explosion at

    reactor building

    approx. 9:10 Start of reactor core

    exposure

    approx. 10:40 Start of reactor core

    damage

    11:01 Hydrogen explosion

    at reactor building

    approx. 6:00 Hydrogen explosion

    at reactor building

    approx. 17:00 Start of reactor core

    exposure

    approx. 19:20 Start of reactor core

    damage

    approx. 6:00 Damage to

    Suppression Chamber (S/C)

    Mass discharge of radioactive

    material

    Operated at rated output

    Loss of all electricity

    Loss of external AC electricity

    Automatic activation of emergency diesel generators

    Under periodical inspection

    5:46 Start of freshwater injection

    approx. 14:30 Venting

    19:04 Start of seawater injection

    Interference with the recoveryoperation

    Start of core cooling by isolation

    condenser (IC)

    Start of core cooling by Reactor Core

    Isolation Cooling System (RCIC)

    Start of core cooling by Reactor Core

    Isolation Cooling System (RCIC)

    Repetition of opening and closing

    of IC valve

    Station blackout (SBO)

    11:36 Shutdown of RCIC

    2:42 Shutdown of HPCI

    9:25 Start of freshwater injection

    approx. 9:20 Venting

    Backward flow of hydrogen from

    Unit 3 via Standby Gas

    Treatment System (SGTS)

    12:35 Start of high-pressure coolant

    injection (HPCI)

    13:12 Start of seawater injection

    13:25 Diagnosis of RCIC shutdown

    Interference with recovery operation

    19:54 Start of seawater injection

    SCRAM

    Loss of all electricity

    14:46 Earthquake

    15:37 Tsunami (peak of waves)

    *Start of reactor core exposure and start of reactor core damage times are both from TEPCO's MAAP analysis results.

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    14 N A I Ig C

    g . M , g gg g. I , q , , g , x . R g - . T g q- , . Lgg . T , .

    T . Cg g g- , g , , g g -. T , , g , - , g .

    T - . T -g .

    14 meters: inundation level

    10 meters

    4 meters

    sea level

    emergency dieselgenerator room

    main

    control

    room

    Cross section of the plant

    showing the inundation level

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    15NAIIC

    Conclusions and

    recommendations

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    16 N A I Ig C

    Conclusions

    After a six-month investigation, the Commission has concluded the following:

    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 struc-ture of the related government and regulatory agencies as well as the operation

    processes. They must cover both normal and emergency situations.

    A manmade disasterThe TEPCO Fukushima Nuclear Power Plant accident was the result of collusionbetween the government, the regulators and TEPCO, and the lack of governance by said

    parties. They ef fectively betrayed the nations right to be safe from nuclear accidents.Therefore, we conclude that the accident was clearly manmade. We believe that theroot causes were the organizational and regulatory systems that supported faultyrationales for decisions and actions, rather than issues relating to the competency of

    any specific individual. (see Recommendation 1)

    T M 11, 2011. B F D N P P g q . T (TEPCO), g (NISA NSC) g g (METI), - q g g, g g g , g .

    TEPCO N I S Ag (NISA) g, g , NISA -

    . T C q U 1 g 3 . T NISA g g .I , g NISA g , g , TEPCO g .

    S 2006, g TEPCO g - F D g . T g g J S C Eg. NISA TEPCO , .

    W g g x

    g . F x, NISA (SBO) . I g . I g , C x g g NISA, NISA q.

    T g g g g . I NISA TEPCO B.5. U.S. 9/11 , TEPCO , .

    T g M 11. T

    TEPCO , NISA NS C (NSC) g. T g , g , .

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    17NAIIC

    F TEPCO , g . T g TEPCO gg g g g F E P C (FEPC). T g g , . A , g. F xg NISA - M E, T & I (METI), g g .

    Earthquake damageWe conclude that TEPCO was too quick to cite the tsunami as the cause of the nuclearaccident and deny that the earthquake caused any damage. We believe there is a pos-sibility that the earthquake damaged equipment necessary for ensuring safety, andthat there is also a possibility that a small-scale LOCA occured in Unit 1. We hope these

    points will be examined further by a third party. (see Recommendation 7)

    Ag q q

    , g . T q , . A x .

    TEPCO q, , g , q g q (g , x , TEPCO g IAEA). H, . T C g x ( ), , q.

    Tg g,

    q . F, g U 1 q, g : 1) g (SCRAM); 2) JNES - LOCA ( ); 3) U 1 g , 4) (SR) g.

    A, x , q-: q- x , S-F q . (S S 2 S Fg)

    .

    Evaluation of operational problemsThe Commission concludes that there were organizational problems within TEPCO.

    Had there been a higher level of knowledge, training, and equipment inspection relatedto severe accidents, and had there been specific instructions given to the on-site work-ers concerning the state of emergency within the necessary time frame, a more effec-tive accident response would have been possible. (see Recommendation 4)

    T - g . E , - . R, g (IC) U 1, DC , . TEPCO IC , g g, g . Rgg , g

    g g x g. O , g g. W g , , g -

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    18 N A I Ig C

    g g . T K (P M O) TEPCOg x , g x .

    M , . H RCIC U 2 g , - g g , gU 2 3 . W g - g , g , g .

    Emergency response issuesThe Commission concludes that the situation continued to deteriorate because thecrisis management system of the Kantei, the regulators and other responsible agenciesdid not function correctly. The boundaries defining the roles and responsibilities of the

    parties involved were problematic, due to their ambiguity. (see Recommendation 2)

    T g, g, TEPCO g, K -

    g . N, , g g q g.

    NISA x g A S MCg N Eg P, - JCO T, I P 1999. H-, NISA , .

    I , K g. T g g K , g K g. I, K TEPCO q F- , . A TEPCO-K TEPCO q M 15, g .

    T K, g TEPCO U 1. TEPCO g NISA, , g.B g METI, K. T NISA TEPCO q K g TEPCO.

    T P M g g . T K - - . WTEPCO q , K, g K . T TEPCO , , P S K - .

    A , P M g TEPCO, , -: 1) TEPCO g g ; 2) T g TEPCO q; 3) T M. S K g g (g ); 4) T -g NISA S , ; 5) T - , g , - . C g g g g .

    Evacuation issuesThe Commission concludes that the residents confusion over the evacuation stemmed

    from the regulators negligence and failure over the years to implement adequate mea-

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    sures against a nuclear disaster, as well as a lack of action by previous governmentsand regulators focused on crisis management. The crisis management system thatexisted for the Kantei and the regulators should protect the health and safety of the

    public, but it failed in this function. (see Recommendation 2)

    T g g g , .S, g -g . S, 20 g 3 21:23 g M 11. M 10 5:44 M 12, 12 A 15 x . M g .T g , g -- . S g g g . S -

    g g, g A.

    T C g gg g - x , g g- g g xg g .

    Continuing public health and welfare issuesThe Commission recognizes that the residents in the affected area are still struggling

    from the ef fects of the ac cident. They continue to face grave concerns, including thehealth effects of radiation exposure, displacement, the dissolution of families, disrup-tion of their lives and lifestyles and the contamination of vast areas of the environ-ment. There is no foreseeable end to the decontamination and restoration activities

    that are essential for rebuilding communities. The Commission concludes that thegovernment and the regulators are not fully committed to protecting public health andsafety; that they have not acted to protect the health of the residents and to restoretheir welfare. (see Recommendation 3)

    Ax 150,000 . A 167 x 100 g . I 1,800 q FP 5 g . I g g - x. O , g g g .

    T g

    q . T g , , , gg . I . T 10,000 , C M g g g .

    W x g , g- g . T - , , . T g g, - , . A , g g gg

    , g q : W x- g g- ? H ?H ?

    T g g -

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    20 N A I Ig C

    g g. T x, x-, x g , , xg , .

    Reforming the regulatorsThe Commission has concluded that the safety of nuclear energy in Japan and the pub-

    lic cannot be assured unless the regulators go through an essential transformationprocess. The entire organization needs to be transformed, not as a formality but in asubstantial way. Japans regulators need to shed the insular attitude of ignoring inter-national safety standards and transform themselves into a globally trusted entity. (seeRecommendation 5)

    T g . T x g , g-. T g g . T , g g, . T , x . M, g-

    . W g C, g g, g g g .

    Reforming the operatorTEPCO did not fulfil its responsibilities as a private corporation, instead obeying andrelying upon the government bureaucracy of METI, the government agency drivingnuclear policy. At the same time, through the auspices of the FEPC, it manipulated thecozy relationship with the regulators to take the teeth out of regulations. (see Recom-mendation 4)

    T g TEPCO . I

    , x, TEPCO , xg -. T g . (S S 5)

    P TEPCO g , g g , x g . I K g . TEPCO , g g x . (S S 3)

    A , TEPCO g .I , . S x g g g , -- .

    Reforming laws and regulationsThe Commission concludes that it is necessary to realign existing laws and regula-tions concerning nuclear energy. Mechanisms must be established to ensure that thelatest technological f indings from international sources are reflected in all existinglaws and regulations. (see Recommendation 6)

    L g g g -, . T gg .A , .

    T xg g g

    , , . T g - . T g g. T -- .

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    21NAIIC

    Cosmetic solutionsReplacing people or changing the names of institutions will not solve the problems.Unless these root causes are resolved, preventive measures against future similar acci-dents will never be complete. (see Recommendations 4, 5 and 6)

    T C g . T g g , g, , g , , . A , C g- g g g . W g g g . W , g g. W g- - g x .

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    Recommendations

    B g, C g . W g N D J g .

    Recmmendatin 1:Monitoring of the nuclear regulatory body by the National DietA gg N D g . I :

    1. T g g x g g g, - .

    2. T , g x g -, g g g.

    3. T g .4. T g -

    .

    Recmmendatin 2:Reform the crisis management systemA x g . T - g g . T :

    1. A x g g. A g .

    2. N g - . T .

    3. T - , g g , g .

    Recmmendatin 3:Government responsibility for public health and welfareRgg , g :

    1. A g- , g- . M g g. I -, g . T , .

    2. C g

    . M .

    3. T g g - , -g .

    Recmmendatin 4:Monitoring the operatorsTEPCO g g, g gg g-, g g g , gg , g . I F E P C (FEPC) g

    gg g g, g , .1. T g gg

    .

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    23NAIIC

    2. O -g g g .

    3. TEPCO g , g g -g .

    4. A g N D g , g g, g , g - g.

    Recmmendatin 5:Criteria for the new regulatory bodyT g g g . I :

    1. I: T , : () I g g () I () I .

    2. T: () T -g x - . () D -g N D . () T g- g g,

    g . () T N D g - .

    3. P: () T g . Exg g g , xg . () A g g -g . () T - x.

    4. C: T g, g -, -g , .

    5. P: T g g -g, g D.

    Recmmendatin 6:R w yL g g .

    1. Exg g , .

    2. T g g g .

    3. Rg g , g g g .

    4. N , .

    Recmmendatin 7:

    Develop a system of independent investigation commissionsA g g , g x g , , g, , g , g , g .

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    24 N A I Ig C

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    Summary of findings

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    26 N A I Ig C

    1

    The Commission has verified that on March 11, 2011, the structure of the

    Fukushima Daiichi Nuclear Plant was not capable of withstanding the effectsof the earthquake and the tsunami. Nor was the Fukushima Daiichi NuclearPlant prepared to respond to a severe accident. In spite of the fact that TEPCOand the regulators were aware of the risk from such natural disasters, neitherhad taken steps to put preventive measures in place. It was this lack of

    preparation that led to the severity of this accident.

    Was the accident preventable?

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    27NAIIC

    The yield strength of the Fukushima Daiichi Unit 1T F D U 1 g q M 11, 2011. T q -q - g : 1) g - g U 1 g 3 1960, 2) g x q g. B , x - g 265 g (.. g ), q .

    I 1981, G A- Dg Rgg N R F E G NSC. I 2006, NSC - g. NISA q - g g - - . I M2008, TEPCO - U 5 FD, g - , g x 600 g. I 2009, NISA , g -

    g q. IJ 2009, U 1 g 4 6 - .

    N - TEPCO, g- . W J 2009,TEPCO J2016. TEPCO g - q g, g - TEPCO U 1 g 3 M 11 q. Ag NISA g , g g TEPCO g.

    I , TEPCO NISA

    g U 5 - q. TEPCO g , C g q g , , g -- , . T C U 1g 3, U 5. S 2 g F D x g. I - M 11 q.

    The lack of tsunami countermeasuresT F D P g 1967 g g . A ,

    g g - , g . TEPCO g, g x q g .

    S 2006, g TEPCO - g g F D . T g g g g J S C Eg.

    T g g . F,NISA - gg . N

    NISA . A , .T g J S C Eg-

    g . E g g

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    28 N A I Ig C

    , ,NISA xg .

    A .TEPCO , g g .TEPCO g g g g g , g- g .

    A g g, NISA TEPCO g , . N - g.

    T TEPCO g g g. I g , g - , . R g q- g , TEPCO g , g g.

    Countermeasures not up to international standardsA g (SA) J - . T SA , , x q , g J q .

    F , SA . I1991, C I D P NSC x -g, g x x g q , x, q g .

    T - g g. I , q- g q g g q. C, g q q - g . A q g, SA J , g .

    Ag SA g g F E P C (FEPC).T 2010, g g g g-g SA g , , FEPC, g gg g . T g

    g : 1) 2) g g q xg. Ag, g - gg M 11 , g, .

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    29NAIIC

    2

    The Commission closely investigated the development of the accident.

    We studied whether the accident could have been contained, and whetherit could have become even more serious. We also examined the role of theearthquake as a cause of the accident, and the validity of TEPCOs claim thatthe tsunami was the sole direct cause.

    Escalation of the accident

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    30 N A I Ig C

    How the accident developedT F D N P . T - , , .

    Ag x , , q, g x . T g q,g , , . T (SBO) DC , x .

    I g g , g . T , gg -, gg q g - , . T .

    R - , g g g -g. E g g . T TEPCO .

    U 1, 3 4 x, U 2. C -g U 5 6, . T C , , U 2 3, U 5 6 . I g , g .Dg U 4 , g -g . T gg .

    Verification of eventsT : q g. Y g

    , q g .

    I , TEPCO g q -g g q, . I g x . T g I A Eg Ag (IAEA).

    W g g , g - . T C g g TEPCO g g :

    1. Sg g 30 SCRAM,

    50 . T , , - g . I g g q g g g , g q g - .

    2. T (LOCA) q .H J N Eg S Og(JNES) T Fg NISA LOCA, g q - , g . I LOCA 10 ,

    g .3. T g- g , NISA TFg, TEPCO , g AC g

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    31NAIIC

    g . TEPCO 15:27 15:35. H, gg 1.5 , . T gg g A U 1 g g. B ,

    q g x g g .

    4. S TEPCO g g U 1 q , g (IC) -g IC. T C g . H, g - , .

    5. T (A B2 ) U 1 14:52, U 1 IC 11 -. TEPCO x - g - x

    55 g (C), . T g- g , g IAEA, . H, g IC g-, IC g IC g . W x , TEPCO x .

    6. T (SR) U 1, g . (S U 2 3.) W SR g U 2 C C R U 2, g U 1 U 1 SR g. I SR g U 1. I , LOCA

    U 1.

    Reactor 4 Reactor 3

    Reactor 2

    Reactor 1

    Views of the reactor buildings

    following the explosions

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    32 N A I Ig C

    3

    The Commission investigated the accident response of TEPCO, the regulatoryagencies, the government and the Kantei (Prime Ministers office)includingthe early stages of the response, the development of the accident, theemergency response system and the crisis management system.

    Emergency response tothe accident

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    33NAIIC

    TEPCOs accident responseA , C P TEPCO , . T C- P g g -, TEPCO .

    TEPCO g , . T g , g F, g.

    T g g. I ,TEPCO g N I S Ag (NISA) g - Eg R C (ERC), g - , - q g. T - U 1 NISA P M , TEPCO - g, g g PM . T P M q g g - ,

    , g g, P M . H TEPCO - , x , .

    N TEPCO . A U 2 , M Y, g g F , CEO VP S M , - , . TEPCO q Y qg K, NSC C M, g , .

    F, TEPCO g

    . T P S K . R g g g, TEPCO g g g. I P M g , , : 1) g ; 2) TEPCO , 3) , M.S K, g g ;4) D-G NISA, M. S , ; 5) - , g - , . I g K,

    TEPCO g , , - .

    The governments emergency response organizationsA , g . T - q. T g g K .

    T g g PM N Eg R Hq, S N E-

    g R Hq NISA Rg N Eg R. O, g .T P M N Eg R Hq S

    g ,

    Former TEPCO president

    Masataka Shimizu at the

    18th Commission meeting

    Former prime minister

    Naoto Kan at the 16th

    Commission meeting

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    34 N A I Ig C

    g , .

    Ag K g , S N Eg R Hq g g g . A, Rg N Eg R T , g .T q, g , g, .

    T C Mg C, K g, q , . T N S C g g. T M E .

    A g , - . Ag g K g, , - g K g. TEPCO

    g - F. H TEPCO g g, .

    The Kanteis emergency responseA g , g K, P M- K g , NISA.T g x q g - .

    T K . A g TEPCO

    A 15 A S M Cg N E-g P, D N Eg S-, g g . I , P M K g D Eg S , .

    T K g C Mg C, - , g q .T NISA NSC g .T , , q q, g . T U 1 x. F , P M- K .

    Ag TEPCO g g

    , K , , g . I g M 15, g g , P M K . I TEPCO g g U 2, P M- K P S , . S, g g-TEPCO q - TEPCO.

    Tg , P M gg . Cg - -q g , g S N Eg R Hq - q . T x ;

    S N Eg R Hq , K . T g: 1) , - g g; 2)

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    ; 3) x . T g.

    Evaluating the government and Kantei emergency responseW g g x g , -q x g- . T

    , q g g g g .B . F , g K

    K . T g K TEPCO TEPCO . H, TEPCO . I , K , .

    I K TEPCO g, , g P S . I -

    , g g-TEPCO q TEPCO, q .A K, g P M

    K F D , g . Sg P M F D , K F D TEPCO. T F D TEPCO NISA K ( P M N Eg RHq). T q TEPCO NISA K, g TEPCO - .

    A , g -

    . B K gg g . T K g TEPCO .

    Kantei (Prime Ministers Oce) O-site Center

    Cabinet Oce

    Secretariat of the

    Emergency Response HQ

    NISA Emergency

    Response Center

    Secretariat of the Nuclear

    Emergency Response HQ

    Prime Ministers Emergency

    Response HQ

    Prime Ministers Nuclear

    Emergency Response HQ

    Crisis ManagementCenter

    Nuclear Safety Commission Operators Related Institutions

    Prefectural Emergency

    Response HQ

    Town Emergency

    Response HQ

    Council on

    Nuclear Emergency

    Measures

    Local Government

    Emergency Response Team

    Regional Nuclear

    Emergency Response Team

    supports supports

    reports

    reports

    delegates

    authority

    instructs

    advises

    instructs

    commands

    supervises

    advises

    dispatches sta

    dispatches

    sta

    dispatches

    Commission members

    advises

    Diagram of the emergency

    communication protocol

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    36 N A I Ig C

    Ag g , NISA - g N- Eg R Hq -g. H, K TEPCO, . T - g. I g , g x- , g g g g.

    Fukushima Prefectures accident responseF P g q . A , .

    T F P FP Rg D P P, . D g - , F

    g g . Fg , F g - , g -g. T 30 g g - . H, q g g , .

    F P g g. O 24 x g g; g . M g M 15 - . T q gq, .

    Information disclosure by the central governmentD , x q gg . M. E, , , gg . I , , g q x , g- . T g x g . L , g - , g .

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    4

    The Commission made a number of findings regarding the spread of damages

    from the accident at the nuclear plant. We studied how decisions weremade, and how the policies and defensive measures were communicated tothe public. We also investigated these matters from the perspective of theresidents affected by the accident damage.

    Spread of the damage

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    38 N A I Ig C

    Damage from the nuclear power plant accidentT , , g , . A , x 900PBq , 1/6 C . T 1,800 q F P- qg 5S/ .

    R g x . H, . A x x g x 14,000 (xg -) g g, 0.7 x 10S , 42.3 x 10S, 57 x 1S .W g , g g .

    Chaotic evacuation ordersT C g -

    , g, g- .

    A g g , . B, g , - , g.

    A 146,520 g . H, -. U , . E x g 3- 10 , 20 , . E x,

    q . S g . H g 20- gg ; 60 M . F g .

    O M 15, 20 30 --. S , - g . A , -- . Ag, g g, g . T C g- .

    T 30- g - S P E Eg D I-

    (SPEEDI) M 23. B g g q q ; .

    Lack of preparation for a nuclear disasterT g g - , . A , g g .

    T N S C (NSC) g - g- 2006 . H, NSC g , g

    g g - g. NSC x , . Ag -g 2007, g.

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    A Ng Eq 2007, x . S, NISA g x . NISA - gg x .

    M, g x . A x, , , .T g g g SPEEDI. Tg , .

    T Eg R S S (ERSS) SPEEDI . T g g ERSS - , SPEEDI - ERSS. P ,g , .

    I ERSS, SPEEDI g g . S , .

    T g - .

    T . T ERSS, g- SPEEDI g xg . A , NSC - . Tg NSC g- g , g g .T .

    A , g g , g JCO 1999. N x

    F. B , - , , .T g .

    Current and future health damage from radiationO gg g . N-, g F P g gg g, , . W g -g.

    T g x x, g . T g-

    x , , . T g g g . T g , x, x x g , ,x , .

    M C x,g g . Ag g g , g g q g g .

    A x gg

    - g-. Ag g , g :g , , , . Tg g

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    40 N A I Ig C

    , g . N g F P x .

    TEPCO , g . I x , g g .

    A , x . P F

    g , g C . T C - , g. S F -, q q g .M . U, g g g .

    Prolonged environmental and decontamination issuesO , , . O , C - . A

    C , - , . W, .

    R g

    Bq/m2

    3000K


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