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Term Paper: TOKAIMURA CRITICALITY ACCIDENT 1999

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Tokaimura Criticality Accident 1999

IE Intro Management for Engineers and Scientist

Dr. Gana Natarajan

Ashley Burleigh

ONID: 932531963

Term Paper

PART I:

Introduction

Would you go to work if you thought you had a chance of dying? NO! These workers who were killed during the Tokai-mura accident didn’t think so either. However, how would you feel if I told you that their deaths were preventable? Pretty upsetting right? The cause of the accident was based on "human error and serious breaches of safety principles," according to the International Atomic Energy Agency (IAEA) (Nighswonger , 1999) The headline statement from the IAEA really jumped out at me especially when safety should be priority when dealing with radiation and nuclear facilities. Throughout my term paper, I will identify and describe appropriate managerial principles to solve technical management challenges that the Tokaimura facility faced as key failures identified by the Nuclear Regulatory Commission. These failures were very SIMPLE and PREVENTABLE issues that could have saved and prevented death and injury that these three workers sustained that day on September 30th, 1999 at the Tokaimura facility.

Background of Failure

On September 30, 1999, an accident occurred at a uranium fuel conversion test facility of JCO Co., Ltd. Tokaimura, Japan. JCO has operated mainly conversion facilities to produce uranium oxide powder or uranyl nitrate solution from low enriched uranium hexafluoride. The accident was triggered by pouring a sufficient amount of the 18.8% enriched uranium solution into a precipitation vessel, causing a high-level reaction, and was terminated after approximately 19 hours by draining the cooling water around the vessel, which acted as a neutron reflector to maintain the condition. As a result, this accident gave serious radiation doses to 3 employees and fatal doses to 2 of them; further, neutrons and gamma-rays emitted by the accident caused doses to many residents, JCO employees, and emergency personnel who attempted to terminate the condition and to rescue the 3 employees. The dominant dose for the residents and the JCO employees was caused by neutrons and gamma-rays produced in the precipitation vessel. The individual dose was estimated for 234 residents, 169 JCO employees and 260 emergency personnel, respectively. (Tanaka, 2002) The Tokaimura accident of 1999 is the third most serious accident in the history of nuclear power, after the 1986 Chernobyl accident and the 1979 Three Mile Island accident but unlike the other cases, the Tokaimura accident did not involve a nuclear power station but a nuclear fuel factory where no nuclear chain reaction should ever happen. (Hoover, 2011) The accident happened when workers preparing nuclear fuels mixed uranium oxide with nitric acid using a stainless-steel container instead of a mixing apparatus. The shortcut was described in an illegal operating manual drafted by the company. The manual had never been approved by the supervising ministry, as was legally required. The procedure violated some of the most basic safety requirements that were well known in the nuclear industry since the early 1940's. Safety in the nuclear fuel cycle has always been focused on reactor operations, where a huge amount of energy is released continuously in a small volume of material, and where there are substantial amounts of radioactive materials which would be very hazardous if released to the biosphere. The investigations of the accident revealed that JCO allowed unsafe procedures in order to save time and money. In addition, the workers had no proper qualifications and had not received proper training. Moreover, no emergency routines had been prepared, as criticality events were considered unrealistic. The poor crisis management and restrictive information policy during and after the accident were criticized by scientists, politicians and reporters.. With all of this identified, I will continue to analyze the failures from this report.

Analysis of Failure using the Management Functions

This objective of this paper will consist of analyzing the failures by listing and applying the functions of engineering management decisions with the accident using the five management functions. The Nuclear Regulatory Committee analyzes the failure of management in this accident that led to a few by conclusions drawn by the investigations conducted by the Government of Japan. It revealed that there were three general root causes involved with the Tokai-mura criticality accident: The report from the NRC addressed failures that led to the cause of the accident, which included: inadequate regulatory oversight; overall lack of an appropriate safety culture at the JCO facility and inadequate worker training and qualification. (NRC Review, 2000) I think that most of these failures led to human factors issues. The procedure verification and validation wasn’t happening both from the employees nor supervisors. Operational management deficiencies related to operational control as well as operator training and qualification that presented as lacking as well as approval for transfer of nuclear material. There should have been supervisory authorization of solution transfers, however supervisors were not present. Technical management of the preparation, review and approval of operating procedures, specifically highlighting the failure to require and obtain approval of the safety management group were neglected. Business management in that the company did not pay full attention to a process involving the manufacturing of special products in small quantities on an irregular basis and a licensing process that did not consider a criticality accident to be credible. Lastly, the safety regulation process did not include appropriate inspections. The ah-ha moments that occurred to me was trying to understand how long supervisors allowed these kinds of acts to keep occurring. Why hadn’t another authority caught these kinds of unsafe acts and rituals??? How long had this been occurring? Why were inspections not being done? What really surprised me after all this was the little changed in terms of a nuclear safety culture, as the meltdowns of the Fukushima reactor in 2011 painfully demonstrated. Analyzing the management’s decision based on the accident and proposing effective and possible solutions to presented problems and using the management functions listed below is categorized by using the acronym POSDCORB. (Bonoma, T, & Slevin, 1978) We can use these categories to progress on the proposed plan as well to discuss the way ahead for JCO to prevent and mitigate an accident like Tokaimura from happening again.

· Planning: planning the way ahead to prevent an accident like this from happening again I believe will take ALL aspects of management and outside agencies to help assist with policy. Anticipating problems and preventing accidents from reoccurring will be top managements priority and goal.

·  Organizing: management will establish structures and systems that will address the response of specific objectives to meet the need in case an emergency arises.

· Staffing: will ensure the company has adequate staffing to meet the demand of isotope and nuclear production safely and effectively. This will include selecting and training staff and maintaining safe work conditions and ensure all certifications and responsibilities are met.

· Directing: management will need to make appropriate, effective and safe decisions and set the example by leading and directing what right looks like.

· Coordinating: this will take JCO and several other agencies to come in and set up remedial training and continuing to conduct routine audits and inspections of the facility to ensure employee safety is being met and short-cuts are avoided.

· Reporting: criticality drills will be rehearsed and everyone will report and UNSAFE acts to their immediate supervisors.

· Budgeting: this will be an initial burden due to the accident; however will be management’s responsibility to invest the money into shielding barriers and lead PPE that will satisfy the safety requirement for employees.

Moving forward and implementing some kind of organizational strategy for both short and long term plans I developed this flow chart to help JCO consider moving forward.

2. Choice of controls:

Consider the controls in the form of rules or work procedures needed to achieve process goals while controlling the process.

1. Process Designer:

Define processes, scenarios. Performance goals and hazards associated with worker activities.

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7. Modify Rules:

Ensure participation of users in changes to procedures.

3. Procedure Author:

Capture designer’s intent in the form of explicit rules for workers to follow.

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5. Promulgate, train, and execute work procedures

-Train of perceiving work activity risks, reasons for specific rules and dangers in violating them

- Provide good mental models of what rules are trying to achieve

-Balance need for internalization of rules as tacit knowledge with consultation of written rules

4. Management:

Ensure an appropriate work culture for:

-Accepting Procedures

-Appropriately interpreting and applying procedural rules

-Enabling feedback as a basis for modifying procedures

Establish training requirements for procedures

Enforce use of good procedures

Ensure that modification and basis for adaptations to procedures are stored in organizational memory

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6. Procedure Supervision:

-Supervise application of procedures

-Monitor violations and errors

- Evaluate the effectiveness and appropriate of procedures for controlling risks

Analysis of Failure using the Balanced Scorecard Approach

	Goals	Measures
Financial	Expense of safety equipment installation	Safety measures implemented (physical barriers)
Customer	Safety Trusted processes	QA/QC inspection Employee Satisfaction Routine Audits
Internal	Supervision Communication Management improvement	Follow up and monitoring Communicate risks effectively Knowledgeable supervisors
Innovation and Learning	Employee education Feedback	Skills assessed of handling radioactive material Process improvement with functional excellence

Risk Management: Through the use of a Balanced Scorecard (Kaplan, 1992) an analysis of a management plan can be obtained, ideally alleviating some risks that may arise and outline goals and measures for the Tokaimura facility.

Conclusion

The criticality accident was the violation of procedural regulations, but revealed in itself a simple accident. However, it is by no means simple from the standpoint of prevention of similar accidents discussing the lessons learned from JCO accident, it is one of the most thought-provoking experiences in a nuclear energy related facility, not only in Japan but also in the world. It caused fatalities among employees as well as emergency evacuation of neighboring residents. It posed a lot of issues which should be discussed not only among nuclear fuel processing industries but also among other nuclear industries and among those who handle radioactive materials. What has really been learned is that another significant event can still happen anywhere and at any time if a strong vigilance of maintaining safety is not exercised by highest priority. Recommendations will place heavy responsibilities upon those who are expected to carry them out and will take extraordinary efforts from the management of the facility. I recommend that the Tokaimura facility be inspected and audited routinely to foster a safe work environment and to avoid shortcuts.

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· References:

1.) Todd Nighswonger , Nov 17, 1999, http://www.ehstoday.com/news/ehs_imp_32563

2.) S. Tanaka, "Summary of the JCO Criticality Accident in Tokai-Mura and a Dose Assessment," J. Radiat. Res. 42, Suppl., S1 (2001).

3.) W. D. Hoover, Historical Dictionary of Postwar Japan (Scarecrow Press, 2011).

4.) NRC Review of Tokai-mura Criticality accident , April 2000 Division of Fuel Cycle Safety and Safeguards Office of Nuclear Material Safeguards US Nuclear Regulatory Commission (pg. 3) https://www.nrc.gov/reading-rm/doc-collections/commission/secys/2000/secy2000-0085/attachment1.pdf

5.) Bonoma, T, & Slevin, D. P. (1978). Executive survival manual. Boston: CBI Publishing Company

6.) Kaplan, R., Norton, D. (1992). The Balanced Scorecard-Measures that Drive Performance. Harvard Business Review, January-February Edition, 69-80.

Part II: Using a SWOT analysis can help alleviate risk by identifying those factors that will be effective when evaluating JCO. These factors include inadequate regulatory oversight, lack of safety, inadequate training, communication, motivation and conflict resolution.

 

SWOT Analysis table with proposed actions

Key Skill or principle	Strengths	Weaknesses	Proposed actions
· Inadequate regulatory oversight · Overall lack of an appropriate safety culture at the JCO facility · Inadequate worker training and qualification. · Communication · Motivation · Conflict Resolution	· Having involvement from outside agencies will strengthen the safety culture of the company · Team members will realize the dangers associated with their job and implement safety practices and procedures · Be able to mold employees to correct techniques and skill · Communication between employees and supervisors are effective. · Builds stronger team cohesion and spirit d ’corps · Having leadership resolve conflict with impartialness	· Necessary adaption of international safety controls · Inadequate regulatory oversight · Ill- suited employees lacking education and experience · Communication between JCO and regulatory agencies are neglectful · Lack of motivation creates complacency · Avoid speaking up or voicing opinion create a hostile work environment	· Coordinate with NRC for quarterly audits of the facility · Implements new standards and procedures to mitigate hazards and risks · Ensure all staff attend mandatory annual and refresher training and new employees with provide copy of certifications · Create a standard for communication and voice hazards when they occur · Have monthly team building events to build cohesion · Allow enough to time to become involved with conflict and allow for mediation to occur
	Opportunities · Agencies will be able to provide additional outside support to facilitate safety training and implement controls · More involvement from the NRC to prevent an issue like this from arising · Allow leaders to grow from mistakes and/or remove from position due to neglect to workers · Effective planning and strategy occurs · Creates supportive relationships between team members · Allows team building to occur and development of interpersonal skills	Threats · Nuclear proliferation with multiplication of units · Acceptability by populations and politics · Death/injury to radiation workers · Lack of communication will lead injury and work hazards · There will always be a time and place. (situation awareness) · May not have receptive supervisors to respond appropriately to conflict

Week 1 Personal SWOT Analysis

1.) List your objectives for this course:

My objectives for this course are to be able to be able to set clear goals and objectives for my team. Communicate effectively. Learn how to balance priorities and deliver that message appropriately. I hope to be able to work on my writing style and develop personal and professional growth in management throughout this course.

My Leadership SWOT

Strengths: Being in the Military and progressing through the ranks, leadership comes whether you’re ready or not. Progression will occur and stagnant leaders are removed from within. So I was able to adapt quickly and learn to prioritize tasks and get the mission done.

Weaknesses: With the attitude of “getting the mission done” it has really drove me to if you are going to be in my way then move. This can foster a toxic climate and leader. Also old leaders or should I say “experienced” leaders have always usually done things “their way” Even if there was a faster, newer and easier way out there. I also usually don’t trust others to do the job or task correctly imposing on becoming a micromanager.

Opportunities: I will be able to practice with subordinates here at my current assignments as I am training to become a manager of a Radiation Health Physic program. I thinking taking the time and be able to understand each employee has their own specific personal need for occasional support, guidance and information is a great way to progress as a team as well as being able to balance that as it relates to each employee and adjust accordingly.

Threats: I might inappropriately take control of a subordinate's work because of a threatening deadline or suspense leading back to my strength and eventual weakness.

Update-Week 5 Personal SWOT Analysis

I think moving forward from week 1 to today, I have tried to take in the input from others and take a step back to get the “bigger picture” rather than being so focused on one task. I also have been allowing deadlines to be met without pushing or micromanaging. See below for SWOT Analysis with week by week task and proposed actions.

Key Skill or Principle	Strengths	Weaknesses	Proposed Actions
Leadership SWOT (week1) Attention to detail (week 1) Hard worker (week 2) Good communication skills (week 3) Decent public speaking skills (week 4) Compassionate and genuinely care for others (week 5)	· Strong Follow thru-Micromanager · Task Oriented · Try to do my best with everything that is assigned to me. · Can usually get my point across pretty clearly and not afraid to explain something or speak up. · Been told I have good voice projection, tone and delivering the information. · Takes time out of the day to see how people are doing and look out for their overall well being	· Impatient and obsessive over details · Strong will to get things done regardless of others time and availability · Can become burnt out by taking in too many tasks at once · May have disagreements in regards to what I think is the right way of doing something if someone disagrees with my idea · Can sometimes go too long into explaining a topic and can go passed given time. · Perception could show possible favoritism due to spending too much time with employees or a specific employee when caring for a matter or issue.	· Engage others and learn everyone’s learning style and philosophy. What motivates my employees? (week 1) · Take time to self-reflect and work on obtaining a balanced work and life ethic. (week 1) · Maximize my ability to do my best with everything I do and take on what I can at that given time (week 2) · Continue to practice giving clear, concise and appropriate guidance and avoid derailing the conversation (week 3) · Continue to rehearse and practice prior to give a class or presentation. Be educated on material taught to portray confidence and utilize a stop watch or timer to stay on track as well as practicing for the time allotted. (week 4) · Ensure fairness is being emphasized and all employees and staff are engaged to discouraged perception on favoritism. Continue to be compassionate about others (week 5)
	Opportunities	Threats
	· To be able to work on my ability to trust others to get the mission completed and refrain from how it gets done vs. end state · Be able to give deadline and suspense’s and allow employees to get the job at their own rate · Communicate intended goals	· Will detract from the larger picture at hand if I micromanage down to the lowest level · Time pressure and constraints will inevitably bring me back to my following strengths and weaknesses at the same time · Inability to take in others opinion or ideas

2.) Analysis of before and after class improvement I think that overall this class was very informative and allowed for progression to occur at a good rate. I valued the feedback from Dr. Natarajan and believe that it made for my own developmental skills to occur throughout the course. Coming into the course, I had an idea of what leadership meant, but did not realize all the tools and skills it takes to master being a supervisor and manager. Looking back at week 1 and the SWOT analysis given, I could see the shift in efforts with what it takes to be a good communicator and understanding the principles behind management.