Learning how to learn from failures: The Fukushima nuclear disaster

Engineering Failure Analysis

Volumn 47, Issue PA, 2015, Pages 117-128

  Labib, Ashraf ^a   Harris, M J ^b  

^a UNIVERSITY OF PORTSMOUTH   (United Kingdom)

^b UNIVERSITY OF MANCHESTER   (United Kingdom)

Author keywords

Common mode failure; Fault tree; Fukushima; Hydrogen explosion; Loss of cooling

Indexed keywords

DISASTERS; NUCLEAR REACTOR ACCIDENTS; NUCLEAR REACTORS;

COMMON MODE FAILURES; FAULT-TREES; FUKUSHIMA; FUKUSHIMA NUCLEAR DISASTERS; LEARNING FROM FAILURES; LEARNING HOW TO LEARN; PRESENTATION FORMATS; SEQUENCE OF EVENTS;

FAILURE (MECHANICAL);

EID: 84910032166     PISSN: 13506307     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.engfailanal.2014.10.002     Document Type: Article

References (38)

1. Apostolakis GE. Risk informing the regulatory system: an uphill climb, power-point presentation, near and long-term regulatory changes after Fukushima: does the accident in Japan call for a major overhaul of nuclear safety regulations? panel, slides 5-6, 9, 12, 16-17. American Nuclear Society (ANS) Winter Meeting, San Diego, California, November, 11-15; 2012.
2. Apostolakis G.E. How useful is quantitative risk assessment?. Risk Anal 2004, 24(3):515-520.
3. Aoki M., Rothwell G. A comparative institutional analysis of the Fukushima nuclear disaster: lessons and policy implications. Energy Policy 2013, 53:240-247.
4. Areva. The Fukushima Daiichi Incident. Presentation can be found at:; 2011. http://hps.org/documents/areva_japan_accident_20110324.pdf.
5. Argyris C., Schön D.A. Organizational learning: a theory of action perspective 1979, Addison Wesley, Reading (MA).
6. Carroll J.S., Fahlbruch B. The gift of failure: new approaches to analyzing and learning from events and near-misses. Honoring the contributions of Bernhard Wilpert. Safety Sci 2011, 49(1):1-4.
7. Cyret R.M., March J.G. A behavioral theory of the firm 1963, Prentice Hall, Englewood Cliffs (NJ).
8. Deverell E., Hansén D. Learning from crises and major accidents: from post-crisis fantasy documents to actual learning in the heat of crisis. J Conting Crisis Manage 2009, 17(3):143-145.
9. Dechy N., Dien Y., Funnemark E., Roed-Larsen S., Stoop J., Valvisto T. Results and lessons learned from the Esreda's accident investigation working group. Introducing Article to "Safety Science" Special Issue on "Industrial Events Investigation". Safety Sci 2012, 50(6):1380-1391.
10. Drupsteen L., Guldenmund F.W. What is learning? a review of the safety literature to define learning from incidents, accidents and disasters. J Conting Crisis Manage 2014.
11. IAEA. Key practical issues in strengthening safety culture, INSAG-15. Self-assessment of safety culture in nuclear installations highlights and good practices, TECDOC-1321. Safety culture in nuclear installations: guidance for use in the enhancement of safety culture, TECDOC-1329; 2002.
12. IAEA. The international nuclear and radiological event scale (INES) Scale [accessed November 2013]; 2013. http://www-pub.iaea.org/MTCD/publications/.
13. IMechE. On Fukushima Daiichi nuclear power plant and Tohoku earthquake: what happened when? 11th March; 2011.
14. Kashyap A, et al. The economic consequences of the earthquake in Japan, Web Publication. Freakonomics Web; 2011.
15. Kletz T. Learning from accidents 2001, Butterworth-Heinmann.
16. Krolicki K, DiSavino S, Fuse T. Engineers knew Tsunami could overwhelm Fukushima plant. Insurance J; 2011. http://www.insurancejournal.com/news/international/2011/03/30/192204.htm.
17. Labib AW. Learning from failures using decision making techniques. Risk management for complex socio-technical systems. American Nuclear Society (ANS) Winter Meeting, Washington DC, USA, November, 12-14; 2013.
18. Labib A. Learning from failures: decision analysis of major disasters 2014, Butterworth-Heinemann, Oxford, p. 450.
19. Lampel J., Shamsie J., Shapira Z. Experiencing the improbable: rare eventsand organizational learning. Org Sci 2009, 20(5):835-845.
20. Le Coze J.C. What have we learned about learning from accidents? post-disasters reflections. Safety Sci 2013, 51(1):441-543.
21. Lindberg A.K., Hansson S.O., Rollenhagen C. Learning from accidents - what more do we need to know?. Safety Sci 2010, 48(6):714-721.
22. Lukic D., Margaryan A., Littlejohn A. How organizations learn from safety incidents: a multifaceted problem. J Workplace Learning 2010, 22(7):428-450.
23. MIT. Explanation of hydrogen explosions at units 1 and 3. Nuclear Science and Engineering at MIT, March; 2011.
24. Mohagheg Z, Mosleh A. Special session on risk management for complex socio-technical systems. American Nuclear Society (ANS) Winter Meeting, Washington DC, USA, November, 12-14; 2013.
25. Nuclear Energy Outlook, NEA-OCED; 2008.
26. Pfotenhauer S.M., Jones C.F., Saha K., Jasanoff S. Learning from Fukushima 2012, Issues on Science and Technology, University of Texas.
27. Pidgeon N., O'Leary M. Man-made disasters: why technology and organizations (sometimes) fail. Safety Sci 2000, 34(1-3):15-30.
28. Report of the Japanese Government to the IAEA Ministerial Conference on Nuclear Safety: The Accident at TEPCO's Fukushima Nuclear Power Stations Nuclear Emergency Response Headquarters Government of Japan June 2011.
29. Saleh J.H., Marais K.B., Bakolas E., Cowlagi R.V. Highlights from the literature on system safety and accident causation: review of major ideas, recent contributions, and challenges. Reliab Eng Syst Safety 2010, 95(11):1105-1116.
30. Saleh J.H., Haga R.A., Favaro F.M., Bakolas E. Texas City refinery accident: case study in breakdown of defence-in-depth and violation of the safety-diagnosability principle in design. Eng Failure Anal 2014, 36:121-133.
31. Simic Z., Mikulicic V., Vukovic I. Risk from nuclear power utilization after Fukushima accident. Int J Elect Comput Eng Syst 2011, 2(1):25-35.
32. Smythe D. An objective nuclear accident magnitude scale for quantification of severe and catastrophic events. Physics today: points of view, December, 12; 2011.
33. Tisdall S. The Guardian. UK government must learn from Japan's catastrophe as it plans a new generation of plant, nuclear chief claims; 19 November 2013.
34. Turner BA. Man-made disasters. Wykeham Science Series; 1978. p. 254.
35. Wahlstrom B. Organizational learning - reflections from the nuclear industry. Safety Sci 2011, 49(1):65-74.
36. Weightman M. Japanese earthquake and tsunami: implications for the UK nuclear industry-interim report. Office for Nuclear Regulation; May 2011.
37. Weightman M. Japanese earthquake and tsunami: implications for the UK nuclear industry - final report. Office for Nuclear Regulation; September 2011.
38. Weightman M. Learning from Fukushima. Physics World.com [online journal], 6th March; 2012.