The report of the Fukushima Nuclear Accident Independent Investigation Commission appointed by the Diet (Parliament) of Japan was published yesterday. Among the findings which may be of broad relevance to environmentally regulated industries:

• 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.
• The root causes were the organizational and regulatory systems that supported faulty rationales for decisions and actions.
• The operator (TEPCO), the regulatory bodies (NISA and NSC) and the government body promoting the nuclear power industry (METI), all failed to correctly develop the most basic safety requirements—such as assessing the probability of damage, preparing for containing collateral damage from such a disaster, and developing evacuation plans for the public in the case of a serious radiation release.
• The regulatory agencies would explicitly ask about the operators’ intentions whenever a new regulation was to be implemented. For example, NSC [the regulator] 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 regulators also had a negative attitude toward the importation of new advances in knowledge and technology from overseas.
• There were many opportunities for taking preventive measures prior to March 11. The accident occurred because TEPCO did not take these measures, and NISA and the Nuclear Safety Commission (NSC) went along. They either intentionally postponed putting safety measures in place, or made decisions based on their organization’s self interest, and not in the interest of public safety.
• From TEPCO’s perspective, new regulations would have interfered with plant operations and weakened their stance in potential lawsuits. That was enough motivation for TEPCO to aggressively oppose new safety regulations and draw out negotiations with regulators via the Federation of Electric Power Companies (FEPC).
• The regulators should have taken a strong position on behalf of the public, but failed to do so. As they had firmly committed themselves to the idea that nuclear power plants were safe, they were reluctant to actively create new regulations.
• Further exacerbating the problem was the fact that NISA [another regulator] was created as part of the Ministry of Economy, Trade & Industry (METI), an organization that has been actively promoting nuclear power.
• TEPCO was quick to assign the accident cause to the tsunami, and state that the earthquake was not responsible for damage to equipment necessary for safety (although it did add, “to the extent that has been confirmed,” a phrase that also appears in TEPCO reports to the government and to the IAEA). However, it is impossible to limit the direct cause of the accident to the tsunami without substantive evidence. The Commission believes that this is an attempt to avoid responsibility by putting all the blame on the unexpected (the tsunami), as they wrote in their midterm report, and not on the more foreseeable earthquake.
• The Commission concludes that there were organizational 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.
• 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.
• 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.

The Commission concludes its report with a set of recommendations that may well be worthy of review by regulators and operators in other sectors that have potentially large environmental and public health impacts.

A summary report is available in English at http://naiic.go.jp/en/. The Commission indicates that an English version of the full report will follow.