Accidents Fukushima Daiichi Accident Challenger and Macondo Oil Well Explosion By Anthony J Spurgin Independent Consultant San Diego 11142012 1 IEEE Section amp Reliability Meeting Introduction ID: 778328
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Impact of Management Decisions onAccidents: Fukushima (Daiichi Accident), Challenger and Macondo Oil Well Explosion
ByAnthony J SpurginIndependent ConsultantSan Diego
11/14/2012
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IEEE Section & Reliability Meeting
Slide2IntroductionThe presentation will discuss an important aspect in the underlying causes of accidents, namely the role of management decision-making
Here I want to consider the role of management in the process of accident initiation and progressionAccidents are often perceived as random events involving natural events or caused by the actions of humans, so called human errorsManagement decisions are considered to be the greatest contribution to both accident initiation and faulty recovery11/14/2012
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Slide3All Organization are:Shaped by Accidents-Continued
Industry has always reacted to accidentsChanges have occurred in organizationsOrganizations have changed:Their outlooks, Mgmt. organization and functions, training/maintenanceRegulators have changedINPO and WANO have been formed in the Nuclear Business
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Slide4Areas of Influencedby Decisions
Prior to the accidentDuring the accidentPost accident - recovery
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Slide5Prior to Accident: Influential Decisions
Selection of Specific Plant DesignSelection and training of staffApproach to accidents, including design of procedures; normal, abnormal, emergency and post accident procedures
Specifics of man-machine interfaces
Failure to deeply consider possible accidents on defense capabilities of plant (not identical to why one selects a plant because of economic reasons)
Consideration of impact of accidents on the capabilities of internal and external personnel to recover a plant (terminate/mitigate)
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Slide6Decisions;During Accident
Formation of Response teamsPrior development and test of response proceduresTraining of teams
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Slide7Decisions;Post-Accident recovery
Availability of well trained rescue teams Understanding of how accidents can affect accident working conditions Rapid availability of support materials and tools: generators, etc
Flexible emergency procedures capable of being applied to a variety circumstances
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Slide8Illustration of Findings:Selection of accidents and situations
Daiichi accident, JapanChallenger Accident, NASABP Macondo accident
Sandy, N-E Coast Weather
Time is short so these will not be coveredThree Mile Island Accident
LA rail Accident
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Slide9Fukushima, Daiichi Accident and Impact
These are my comments on the accident and are not the position of IEEE or anyone elseClearly this accident has already had an effect on the Nuclear Industry world wideJapan and some other countries have taken actions to shutdown or phase-out NPPs. These actions, I think, are basically unscientific, emotional and/or political inspired
Lessons to be drawn from the accident
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Slide10Fukushima Accident and Impact : ReviewSome damage from the earthquake, but real damage caused by the resulting tsunami
Tepco (plant owners) completely responsible for their inaction in protecting NPPs : this resulted in the future cost of the NPPs being written-off and resulting cleanup due to core partial melts (like TMI #2)Electrical distribution within plants shorted due to ingress of water, even if loss of diesels had not occurred, the plant personnel could not have quickly connected pumps, valves, etc.Plant personnel had not established and practiced procedures to deal with the issue (Tepco Mgmt deficiency, see earlier item)Plant supervisor tried to ad hoc actions to rescue the NPPs, too little too late
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Slide11Fukushima Accident and Impact , continuedWater Levels: Tsunami related
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Slide12Cross Section of a Fukushima NPP showing plant and key water levels11/14/2012
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Slide13Fukushima Accident and Impact , continued
Plant personnel tried to deal with the situation as best they could, but even as they got things moving, but often the effects of the accident negated their actionsHydrogen releases following core damage were not dealt with effectivelyResulting hydrogen led to explosions, which caused injuries, blocked paths and destroyed cables, trucks,
The crews had problems with valves, poor access and bad working conditions, radiation
Eventually they were able to inject both clean and sea water to cover the remains of the cores
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Slide14Direct Lessons fromthe Fukushima Accident
Failure to prevent the consequences of the Tsunami: need to re-evaluate external events and management decisions –act promptly to rectifyDiesels were placed too low vs a vs the high water level:
increase height margins or add protective methodsElectrical systems, switch gear, etc. located in basement of Reactor buildings, too vulnerable to floods:
need for better protection, consider all pathways!Poor emergency planning, training and positioning of support equipment :
review, update and train
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Slide15Fukushima Accident and Impact: lessons for all
Need to review design bases on a regular period to ensure assessment of external and internal events has not changed and then act promptly to correct situationBe aware that "Black-out" is not just the diesels and batteries, but includes power and instrumentation distribution systems
Develop emergency procedures, somewhat like the symptom-based EOPs, that take into account unknown accident conditions, that can affect the plant and ability of personnel to prevent core damage
Practice these procedures and use of emergency equipment on a regular basis, more than once a year
Be aware of the cost-benefit of safety upgrades relative to the costs related to the effects of core damage, loss of plant, loss of generation and long clean-up follow a core-damage accident
Need for political bodies to realize that effects of radiation releases maybe significantly less than the direct effects of earthquakes and tsunamis on the public
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Slide16Macondo Well Accident: British PetroleumDecisions
BP underestimated the issues with the local management relative to taking actions not in the real interest of BP as a whole. Decisions made to save small amounts of money, but risking much more. Lack of perspective on behalf local managementBP main management failed to have a risk study to identify the consequences of a failure of the BOP valve isolation system. Superficial understanding of common cause issues led to a locally reliable system that failed to performLocal BP management did not have an effective quality control programLocal rig members seemed to be not as well trained in safety aspects as they should be
BP analysis of the possibility of stopping the leak along with others was too optimistic leading to a failure by BP management to state the correct time to fix
US Government fixated on BP’s responsibility in the case of the leak and failed to see what their proper role was. They acted much too late and even then did not fully commit both US and other resources. In fact they seemed to act against the interests of the citizens living the Gulf regions
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Slide17Challenger Accident: Managementand Engineering Decisions
NASA top management wanted to launch the Challenger on time and did not wish to hear any engineering ‘overly conservative engineering opinions’, because of implied political pressure.
Interesting the pressure seemed to be self imposed by NASA, since no trace of a request from Reagan has been located. NASA should have investigated the “O” ring near failures earlier. This was a failure on the part of NASA and Morton Thiokol. There are suggestions this was a failure of personnel at lower levels to forward information on the problems with the design of the “O” ring joint
NASA had a launch review procedure, the launch directors should have followed a more conservative process based upon engineering advice
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Slide18Sandy and similar storms:Comments & DecisionsStorms and floods occur on regular basis
Specific lessons have been learned and forgottenThe Dutch invented the polder system, including wind driven pumps, many years agoIn more times the British have introduced the Thames barrage system to protect London from North sea storm surges and high water 11/14/2012
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Slide19Storms in later part of 20th Century, source: Wikipedia
Season Storm Category: Peak intensity,
Intensity at landfall,
Date
1938
New England Hurricane of
1938
Category 5 Category 3 September 21, 1938
1944 Great Atlantic Hurricane
Category 4 Category 1 September 15, 1944
1952
Hurricane Able
Category 2 Tropical Depression September 1, 1952
1954 Hurricane Carol
Category 3 Category 3 August 31, 1954
1954 Hurricane Edna
Category 3 Category 1 September 11, 1954
1955 Hurricane Diane
Category 3 Tropical Storm August 18–19, 1955
1959 Hurricane Cindy
Category 1 Tropical Storm July 11, 1959
1960 Hurricane Donna
Category 5 Category 2 September 12, 1960
1961 Hurricane Esther
Category 4 Tropical Storm September 26, 1961
1966 Hurricane Alma
Category 3
Extr
. Storm June 13, 1966
1971 Tropical Storm
Doria
Tropical Storm Tropical storm August 29, 1971
1972 Hurricane Agnes
Category 1 Tropical Storm June 22, 1972
1972 Tropical Storm Carrie
Tropical Storm Tropical Storm September 3, 1972
1973 Subtropical Storm Alfa
Tropical Storm Subtropical Storm July 30, 1973
1976 Hurricane Belle
Category 3 Tropical Storm August 10, 1976
1985 Tropical Storm Henri
Tropical Storm Tropical Depression September 23, 1985
1985 Hurricane Gloria
Category 4 Category 1 September 27, 1985
1988 Tropical Storm Chris
Tropical Storm Tropical Depression August 29, 1988
1991 Hurricane Bob
Category 3 Category 2 August 19, 1991
1996 Hurricane Bertha
Category 3 Tropical Storm July 13, 1996
1999 Hurricane Floyd
Category 4 Tropical Storm September 16–17, 1999
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Slide20Storms in North-East
Mostly in Fall21 over 91 years (20% probability)Ranged from Tropical depression to category 5 storm
Affected N-E areas from New Jersey to MaineCaused flooding to wind caused destruction
Predicable
Not due to Global weather change (not a new phenomena
)
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Slide21Sandy: Observations and Comments related to Organizational Deficiencies
Failure to learn from past storms and equivalent accidentsFailure of to understand limitations of emergency electric power for hospitals, see Daiichi accident (need to protect power supplies from flooding)
Inadequate establishment and training of teamsNeed to develop and test of response procedures
Inadequate availability of supplies to support civilians and rescuers
Failure to foresee limitations of water barriers and consequences for citizens, either build defenses or limit areas to building near coast
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Slide22Recommendations for decision-makers
Failure to prevent the consequences of the weather induced effects: need to re-evaluate external events and management decisions –act promptly to rectifyEmergency power systems were placed too low vs a vs the high water level: increase height margins or add protective methods
Electrical systems, switch gear, etc. located in basement of buildings, too vulnerable to floods: need for better protection, consider all pathways!
Poor emergency planning, training and positioning of support equipment : review, update and train
Consider possible design solutions from other places, time and people, consider barriers and other solutions:
review options and make better decisions
Top managers often lack basic skills and training:
Acquire better training and/or rely on your support team
Support team:
Have more faith in your advice
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