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LESSONS LEARNED FROM THE FUKUSHIMA NUCLEAR ACCIDENT FOR IMPROVING SAFETY OF U.S. NUCLEAR PLANTS Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants Nuclear and Radiation Studies Board Division on Earth and Life Studies NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu Prepublication Copy

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract/Grant No. NRC-HQ-12-G-03-0002 between the National Academy of Sciences and the U.S. Nuclear Regulatory Commission. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data International Standard Book Number 0-309-0XXXX-X Library of Congress Catalog Card Number 97-XXXXX Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, N.W., Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; Internet, http://www.nap.edu/. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Prepublication Copy

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org Prepublication Copy

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Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants NORMAN P. NEUREITER, Chair, American Association for the Advancement of Science, Washington, District of Columbia B. JOHN GARRICK, Vice Chair, Independent Consultant, Laguna Beach, California ROBERT A. BARI, Brookhaven National Laboratory, Upton, New York PERCY M. BEARD, JR., Institute of Nuclear Power Operations (retired), Atlanta, Georgia JAN BEYEA, Consulting in the Public Interest, Lambertville, New Jersey M. QUINN BREWSTER, University of Illinois at Urbana-Champaign MICHAEL L. CORRADINI, University of Wisconsin-Madison RICHARD S. DENNING, The Ohio State University, Columbus 1 VIJAY K. DHIR, University of California, Los Angeles MICHAEL W. GOLAY, Massachusetts Institute of Technology, Cambridge BARBARA L. HAMRICK, University of California, Irvine Medical Center SHELLEY A. HEARNE, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and Big Cities Health Coalition, National Association of County and City Health Officials, Washington, District of Columbia PAUL A. LOCKE, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland JAMES E. MATHESON, SmartOrg, Menlo Park, California NAJMEDIN MESHKATI, University of Southern California, Los Angeles2 THOMAS G. MOSER, Osprey Global Solutions, Wilmington, North Carolina ARTHUR T. MOTTA, Pennsylvania State University, University Park JOHN A. ORCUTT, Scripps Institution of Oceanography, University of California at San Diego, La Jolla EMILIE M. ROTH, Roth Cognitive Engineering, Menlo Park, California JOSEPH E. SHEPHERD, California Institute of Technology, Pasadena ELIZABETH Q. TEN EYCK, ETE Consulting, Inc., Great Falls, Virginia MARK H. THIEMENS, University of California, San Diego3 FRANK N. VON HIPPEL, Princeton University, Princeton, New Jersey LORING A. WYLLIE, JR., Degenkolb Engineers, San Francisco, California Technical Advisor NAJMEDIN MESHKATI, University of Southern California, Los Angeles4 Staff KEVIN D. CROWLEY, Study Director OURANIA KOSTI, Senior Program Officer DANIEL POMEROY, Postdoctoral Fellow (December 10, 2012 to September 1, 2013) DARLENE GROS, Senior Program Assistant __________________ 1 Separated from committee on November 21, 2012 2 Resigned from committee on June 12, 2013 3 Resigned from committee on July 26, 2012 4 Effective July 10, 2013 Prepublication Copy v

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Nuclear and Radiation Studies Board ROBERT C. DYNES, Chair, University of California, San Diego BARBARA J. MCNEIL, Vice Chair, Harvard Medical School, Boston, Massachusetts JOHN S. APPLEGATE, Indiana University School of Law, Bloomington DAVID J. BRENNER, Columbia University, New York, New York MARGARET S. Y. CHU, M.S. Chu & Associates, LLC, Albuquerque, New Mexico MICHAEL L. CORRADINI, University of Wisconsin, Madison TISSA H. ILLANGASEKARE, Colorado School of Mines, Golden, Colorado CAROL M. JANTZEN, Savannah River National Laboratory, Aiken, South Carolina ANNIE B. KERSTING, Glen T. Seaborg Institute, Lawrence Livermore National Laboratory, Livermore, California MARTHA S. LINET, National Institutes of Health, Bethesda, Maryland FRED A. METTLER, JR., New Mexico VA Health Care System, Albuquerque, New Mexico NANCY JO NICHOLAS, Los Alamos National Laboratory, Los Alamos, New Mexico LAWRENCE T. PAPAY, PQR, LLC, La Jolla, California DANIEL O. STRAM, University of Southern California, Los Angeles RICHARD J. VETTER, Mayo Clinic (retired), Rochester, Minnesota SERGEY V. YUDINTSEV, Russian Academy of Sciences, Moscow Staff KEVIN D. CROWLEY, Director JENNIFER HEIMBERG, Senior Program Officer OURANIA KOSTI, Senior Program Officer TONI GREENLEAF, Administrative and Financial Associate LAURA D. LLANOS, Administrative and Financial Associate DARLENE GROS, Senior Program Assistant ERIN WINGO, Senior Program Assistant Prepublication Copy vi

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ACKNOWLEDGMENTS The successful completion of this study would not have been possible without the cooperation and assistance of a very large number of organizations and individuals. The committee would especially like to thank the following organizations and individuals for providing logistical support, advice, and assistance during this study. U.S. Nuclear Regulatory Commission, which sponsored the study and provided information on the agency’s post-Fukushima activities and actions. The committee would especially like to thank former Executive Director of Operations Bill Borchardt and staff in the Japan Lessons-Learned Division, Office of Nuclear Reactor Regulation: David Skeen, Rob Taylor, Bill Reckley, and Kevin Witt. Mr. Witt served ably as the agency’s liaison to the committee and was effective in responding to the committee’s many requests for information. U.S. Embassy in Tokyo, which assisted the committee with logistical arrangements for its meeting in Japan: former Ambassador John Roos and embassy staff Jeffrey Miller and Jen Ladlein. Government of Japan for its full cooperation with NAS on this study and for providing technical and logistical assistance:  Japanese Embassy in the United States: Ambassador Kenichiro Sasae, former Ambassador Ichiro Fujisaki, embassy staff members Takashi Toyota and Akira Tsugita, and former staff member Seiichi Shimasaki. Embassy staff responded effectively to the committee’s many requests for information and logistical support.  Atomic Energy Commission of Japan: former Chairman Shunsuke Kondo.  Japan Atomic Energy Agency: former President Atsuzuki Suzuki.  Japan Science and Technology Agency: Center for Research and Development Strategy (CRDS) Director General Hiroyuki Yoshikawa; CRDS Deputy Director General Tateo Arimoto; Principal Fellow Kenkichi Hirose; and Washington, DC representative Takashi Ohama.  Nuclear Regulation Authority: Commissioner Toyoshi Fuketa and staff member Masahiro Aoki. National Graduate Institute for Policy Studies (Tokyo) for cosponsoring and supporting the committee’s meeting at the institute’s facilities in Tokyo: President Takashi Shiraishi and faculty members Tateo Arimoto, Kiyoshi Kurokawa, and Atsushi Sunami. Science Council of Japan for assisting with the identification of technical experts for the committee’s meeting in Tokyo: President Takashi Onishi and Vice President Fumiko Kasuga. Tokyo Electric Power Company (TEPCO) for its full cooperation and support for this study, particularly for providing technical information about the company’s response to the earthquake and tsunami at the Fukushima Daiichi and Fukushima Daini nuclear plants; for arranging and hosting tours of those plants; and for participating in the committee’s meeting in Tokyo: Chief Nuclear Officer and Executive Vice President Zengo Aizawa Prepublication Copy vii

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Acknowledgments General Manager of International Relations and Strategy Group Akira Kawano; Fukushima Daiichi Superintendent Takeshi Takahashi; Fukushima Daini Superintendent Naohiro Masuda; TEPCO’s Washington, DC, representative Kenji Tateiwa; and the many other TEPCO staff listed in Appendix B. Mr. Tateiwa served effectively as a liaison between TEPCO and National Academy of Sciences’ staff. Tohoku Electric Power Company for arranging and hosting the tour of the Onagawa nuclear plant and participating in the committee’s Tokyo meeting: Managing Director Shigeru lnoue; Onagawa Superintendent Shun Tsubata; Deputy Superintendent lsao Kato; staff members Masayoshi Abe and Satoshi Otokita; Washington, DC, representative Hiroya Shimanuki; and the other Tohoku staff listed in Appendix B. Nuclear Energy Institute for providing information about the U.S. nuclear industry’s response to the Fukushima Daiichi accident to improve safety of nuclear plants in the United States: President and Chief Executive Officer Marvin Fertel; Executive Director (Fukushima Response) Jim Scarola; Vice President of Nuclear Operations Joe Pollock; and Senior Technical Advisor Steven Kraft. Mr. Kraft provided lead support for the committee’s information requests and visits to the Oyster Creek Generating Station and Edwin I. Hatch Nuclear Plant. Institute of Nuclear Power Operations for providing information about the U.S. nuclear industry’s response to the Fukushima Daiichi nuclear accident: President and CEO Robert Willard and Vice-President David Hembree. Southern Company for hosting a tour of the Edwin I. Hatch Nuclear Plant: Site Vice President Dennis Madison, staff member J. Derwood Tootle, and the many other plant staff who supported the plant tour. Exelon Corporation for hosting a tour of the Oyster Creek Generating Station: Site Vice President Garey Stathes, Plant Manager Russell Peake, and the many other plant staff who supported the plant tour. Speakers and invited participants at the committee’s information-gathering meetings. These individuals are too numerous to be listed here. Their names are provided in Appendix B. Other individuals and organizations who provided information and support for this study: Scott Deitchman, Centers for Disease Control and Prevention; Nancy Hedinger, Paula Gotsch, and Kerry Margaret Butch, League of Women Voters of New Jersey; Jaewon Hong, U.S. Food and Drug Administration; Kiyohiko Mabuchi, National Cancer Institute; Alan Morris, Anbex; Damian Peko, U.S. Department of Energy; Andrew Sowder, Electric Power Research Institute; Satoru Tanaka, Atomic Energy Society of Japan; and the World Health Organization, especially María del Rosario Pérez. Najmedin Meshkati, University of Southern California, who served as a technical advisor to the committee for issues related to nuclear safety culture. And last, but certainly not least, National Academy of Sciences’ staff for organizing and facilitating this study. Study Director Kevin Crowley and Senior Program Officer Ourania Kosti organized the committee meetings and assisted the committee with report writing and review. They also provided valuable technical and policy insights and perspectives. Postdoctoral Fellow Daniel Pomeroy assisted with research and report writing. Program Assistant Darlene Gros managed the logistics of the meetings, report review, and publication. Senior Program Officer Jennifer Heimberg and Program Assistant Erin Wingo assisted with production of the final report. Prepublication Copy viii

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REVIEWER ACKNOWLEDGMENTS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the Report Review Committee of the National Research Council. The purpose of this independent review is to provide candid and critical comments that will assist the National Research Council in making this published report as sound as possible and will ensure that this report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: Brian Atwater, United States Geological Survey and University of Washington Lake Barrett, L. Barrett Consulting Dennis Bley, Buttonwood Consulting, Inc. Daniel Blumenthal, U.S. Department of Energy Robert Budnitz, Lawrence Berkeley National Laboratory Cynthia Costello, New York State Department of Health Jeffrey Gabor, ERIN Engineering and Research, Inc. Randall Gauntt, Sandia National Laboratories Robert Geller, University of Tokyo David Gertman, Idaho National Laboratory Sherrell Greene, Advanced Technologies Insights, LLC Dave Klimek, Nexus Technical Services Corporation Joseph Klinger, Illinois Emergency Management Agency Shunsuke Kondo, Japan Atomic Energy Commission (retired) Kiyoshi Kurokawa, National Graduate Institute for Policy Studies David Lochbaum, Union of Concerned Scientists Thomas McKenna, International Atomic Energy Agency Richard Meserve, Carnegie Institution for Science Randall Mumaw, Boeing Commercial Airplanes Per Peterson, University of California, Berkeley William Radasky, Metatech Corporation Scott Sagan, Stanford University Craig Sawyer, General Electric Company (retired) Fred Tollison, Institute of Nuclear Power Operations (retired) Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions and recommendations of this report, nor did they see the final draft of the report before its release. The review of this report was overseen by Marvin Adams, Texas A&M University, and Chris Whipple, ENVIRON. Appointed by the National Research Council, Drs. Adams and Whipple were Prepublication Copy ix

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Reviewer Acknowledgments responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were considered carefully. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. Prepublication Copy x

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CONTENTS SYNOPSIS Sy-1 SUMMARY S-1 S.1 Causes of the Fukushima Daiichi Accident S-1 S.2 Lessons Learned for the United States S-3 1. INTRODUCTION 1-1 1.1 Background on the Study Charge 1-1 1.2 Study Process 1-3 1.3 Strategy to Address the Study Charge 1-4 1.4 Report Organization 1-6 2. BACKGROUND ON JAPANESE AND U.S. NUCLEAR PLANTS 2-1 2.1 Nuclear Plant Design and Operation 2-1 2.2 Boiling Water Reactors 2-4 2.3 Nuclear Plants in Japan 2-8 2.4 Nuclear Plants in the United States 2-10 2.5 Comparison of Japanese and U.S. BWR Plants 2-10 3. GREAT EAST JAPAN EARTHQUAKE AND TSUNAMI AND IMPACTS ON 3-1 JAPANESE NUCLEAR PLANTS 3.1 Great East Japan Earthquake and Tsunami 3-1 3.2 Impact on Japanese Nuclear Plants 3-5 3.3 Differences in Plant Impacts 3-9 3.4 Tsunami Hazards at Japanese Nuclear Plants 3-10 3.5 Discussion and Finding 3-12 4. FUKUSHIMA DAIICHI NUCLEAR ACCIDENT 4-1 4.1 Timeline for Fukushima Daiichi Accident 4-2 4.2 Challenges for Responding to the Accident 4-5 4.3 Key Events and Response Actions 4-7 4.4 Discussion 4-26 4.5 Finding 4-31 5. LESSONS LEARNED: PLANT OPERATIONS AND SAFETY REGULATIONS 5-1 5.1 Nuclear Plant Systems, Procedures, and Training 5-2 5.2 Nuclear Plant Safety Risks 5-20 6. LESSONS LEARNED: OFFSITE EMERGENCY MANAGEMENT 6-1 6.1 Radiological Consequences of the Fukushima Daiichi Accident 6-2 6.2 Challenges for Responding to the Accident 6-5 6.3 Offsite Emergency Response 6-6 6.4 Vulnerabilities in Emergency Response in Japan 6-11 Prepublication Copy xi

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Contents 6.5 Lessons Learned from the Fukushima Daiichi Accident for the United States 6-17 7. LESSONS LEARNED: NUCLEAR SAFETY CULTURE 7-1 7.1 Background on Nuclear Safety Culture 7-1 7.2 Nuclear Safety Culture in Japan 7-4 7.3 Nuclear Safety Culture in the United States 7-8 7.4 Recommendations 7-17 REFERENCES R-1 APPENDIXES A. Biographical Sketches of Committee, Technical Advisor, and Staff A-1 B. Presentations, Breakout Sessions, and Visits B-1 C. Detailed Accident Timeline C-1 D. Operation and Support Organizations D-1 D.1 Main Control Rooms D-1 D.2 Onsite Emergency Response Center D-2 D.3 Headquarters Emergency Response Center D-2 D.4 Off-site Center D-3 E. Recommendations from Other Organizations E-1 F. Regulator and Industry Actions in the United States F-1 F.1 Regulator Actions F-1 F.2 Industry Actions F-5 G. Hydrogen Control in Severe Accidents G-1 G.1 Regulatory Actions Following the Three Mile Island Accident G-1 G.2 implications of Fukushima Daiichi Accident for Hydrogen Control G-2 H. Nuclear Plant Emergency Procedures and Guidelines H-1 H.1 Emergency Operation Procedures H-1 H.2 Severe Accident Management Guidelines H-1 H.3 Extensive Damage Mitigation Guidelines H-3 H.4 Post-Fukushima Changes H-5 I. Probabilistic Risk Assessment I-1 I.1 Risk Assessment I-1 I.2 Probabilistic Risk Assessment I-2 I.3 Use of PRA in Japanese Nuclear Plants I-2 I.4 Use of PRA in U.S. Nuclear Plants I-4 J. Human Reliability Analysis J-1 J.1 Need to More Realistically Model Complicating Situational Factors J-1 J.2 Need to Model the Broader Distributed Response Team J-2 J.2 Need to Consider Temporal, Physical and Psychological Stressors J-2 J.3 Need for Greater Emphasis on Searching vs. Screening J-2 J.4 Need for Greater Appreciation of People as a Source of Resilience and Recovery J-3 K. Tsunami Hazards in the Atlantic Ocean Basin K-1 K.1 Lisbon Earthquake and Tsunami (1755) K-2 K.2 Grand Banks Tsunami (1929) K-2 K.3 Storegga Tsunamis (Prehistoric) K-3 L. Factoring the Costs of Severe Nuclear Accidents Into Backfit Decisions L.1 Prepublication Copy xii

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Contents M. Access to Timely and Reliable Information to Support Decision Making During a M.1 Nuclear Power Plant Accident N. Conversions and Units N.1 O. Acronyms O.1 Prepublication Copy xiii

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