In August 2011, we held the 11th Bieleschweig Workshop on Systems Engineering. The theme was the accident at the Fukushima Daiichi nuclear power plant.
We have just published a book on it. An Analytical Table of Contents may be found at the end of this note.
I had convened a mailing list in the days after the accident, after receiving a short note from Charles Perrow which he had written in response to a newspaper’s request for comment. He pointed out there was an obvious, indeed known, design feature that left the plant’s emergency electricity generation systems susceptible to flooding, and therefore that this was not a “normal accident” in his sense, but a design-failure accident. The accident clearly had a high organisational/human factors/sociological component, as do many accidents with process plants. The mailing list, which was closed to enable frank discussion, rapidly attracted system safety engineers and sociologists concerned with the safety of engineered systems as they are deployed. Discussion was intense. I surveyed the New York Times, the Washington Post, and the Guardian every day as key sources of information, as well as the BBC News Live Feed, which ran for a month or so, and the daily news reports from the nuclear regulators on technical matters at the Fukushima Dai-Ichi plant.
Indeed, Charles Perrow himself had anticipated the mechanisms of the accident (flooding of the basement taking out the emergency electrical systems and thus rendering cooling systems ineffective) in his 2007 book The Next Catastrophe. Why, I continue to think, is it a sociologist who put his finger right on a hazard which safety engineers had overlooked for some four decades? It does, of course, require a sociologist to answer such a question of organisational weakness.
I became and remain convinced that engineering-safety sociologists are essential partners to engineers in safety matters with high-impact engineering. Their presence is somewhat subdued with those areas with which I have been more concerned, such as rail, air and road transport but let us hope it can be increased. The first step was to organise a workshop in August 2011 on the Fukushima accident to which system safety engineers, scientists involved in safety, and sociologists concerned with engineering safety were invited. I take workshops seriously: lecturers were asked for 45 minutes of material, given a 90-minute slot, and discussions ran full course.
The University of Bielefeld’s CITEC project, the Excellence Cluster in Cognitive Interaction Technology, which pursues studies in anthropomorphic robotics, generously sponsored the Workshop, thanks to a strong recommendation from its convenor, Helge Ritter, enabling us to bring some stars to Bielefeld as speakers, including Perrow, his colleagues John Downer and Lee Clarke as well as engineering-safety experts Martyn Thomas, Robin Bloomfield and Nancy Leveson. We had some pretty good nosh, sponsored by the UK Safety-Critical Systems Club and Causalis Limited.
The book of essays is now out. The Fukushima Dai-Ichi Accident, ed. Peter Bernard Ladkin, Christoph Goeker and Bernd Sieker, LIT Verlag, Vienna, Berlin, Zürich, Münster, November 2013, 291pp, ISBN 978-3-643-90446-1. List price €39.90. See below for an analytical table of contents.
The book is currently on the WWW page of the publisher, LIT Verlag (there is a language switch button between English and German) and if you click on the image, you get to the product page. The book is also available as a downloadable PDF at a slightly reduced price.
A word about publishing politics. We chose the publisher specifically with a view to (a) keeping the retail price reasonable; and (b) authors retaining our intellectual property. The big scientific publishers generally violate both conditions. For example, appropros (a), a reprint of a single article in a journal from “the big two” scientific publishing firms will cost something similar to the costs of this book. Apropos (b), author contracts for one of those companies require you not only to transfer copyright but also the intellectual property (I personally renegotiated my last contract with this company in 2011. According to the colleagues who assisted that negotiation and who had published with them for twenty years, the company has stopped doing that. My colleagues now self-publish. Their proceedings contain articles from companies as well as academics, and companies do not sign over their intellectual property without compensation – if they are content to do so in a particular case, it’s because what they wrote is anodyne). I don’t agree with either phenomenon and am happy there is an alternative. We availed ourselves of it. My students are now able to afford to buy the book at the student discount price of 40%; this is becoming rare in technical subjects. The costs of studying at university are rising, it appears inexorably. A decade ago, having received offers to publish my system safety book, I decided not to publish at a price which I thought students could not afford. It’s taken me that length of time to understand and pursue alternatives. We are very happy to be working with LIT.
LIT Verlag is hitherto known for its series in the humanities and social sciences. With this book, it is starting a series in engineering, which we hope to continue focusing on engineering in its social context. I am the series editor. If anyone has, or is planning, book-length material which they might wish to publish at a reasonable price, while retaining authors’ intellectual property, please get in touch!
The Fukushima Dai-Ichi Accident: Analytical Table of Contents
Chapter 1: The Fukushima Accident, Peter Bernard Ladkin. Ladkin explains the technical background, the structure of the plant, describes how the severity of a nuclear accident is measured by the IAEA, and comments on what went right and what went wrong in dealing with the events triggered by the Tohoku earthquake and tsunami.
Chapter 2: Hazard Analysis and its Application, Peter Bernard Ladkin. Ladkin explains the background to the safety-engineering technique of hazard analysis (HazAn) in layman’s terms, as well as how one engineers a safety-critical system in general. He compares this ideal picture with what appears to have been done at Fukushima Dai-Ichi and draws some conclusions about safety engineering practice in general.
Chapter 3: The Nuclear Accident at the Fukushima Dai-Ichi Plant: Physics and Parameters, Bernd Sieker. Sieker explains the physics of nuclear power, and then analyses the daily data put out by the operator from its sensors. He concludes inter alia that there was likely only one cooling system at first, and then two, operating for the defueled Units 5 and 6. This suggests a reduction in “defence in depth” (with one system there is no “depth”) which did not cohere with the Japanese self-assessment that Units 5 and 6 suffered an INES Level 0 event. He argues that it should really have been Level 2.
Chapter 4: I’m Warning You, Lee Clarke. Clarke considers the social effectiveness of warnings (and rescinding warnings): what they are meant to do, and how they may operate. Who one trusts in issuing and commenting on warnings. He argues that there is a major question of institutional trust.
Chapter 5: Rationalising the Meltdown, John Downer. Downer argues that, when the public has been assured that a safety-critical system is “safe” and then an accident happens, there are only a very few public responses available to the operators and regulators. He lists and analyses them all.
Chapter 6: Fukushima as a Poster Boy, Charles Perrow. Perrow points out that much about this accident is commonplace or prosaic, and is all but inevitable when we have high concentrations of energy, economic power and political power. He enumerates the resulting phenomena to illustrate this typicality, and the risks we run by indulging it.
Chapter 7: Japan, a Tale of Two Natural Disasters, Stephen Mosley. In this short note, written for a collection of short essays organised by the research group on Communicating Disaster, meeting for the year at Bielefeld’s Centre for Interdisciplinary Research (ZiF), Mosley compares the 1891 Great Nobi earthquake with the 2011 Tohoku earthquake.
Chapter 8: The Destruction of Fukushima Nuclear Power Plant: A Decision Making Catastrophe?, Stefan Strohschneider. In another short note for the ZiF group Communicating Disaster, Strohschneider looks at the decision making in the immediate aftermath and finds it wanting.
Chapter 9: Judging from the color of smoke: What Fukushima tells us about Information Structure Breakdowns and IT development methodologies, Volkmar Pipek and Gunnar Stevens. Pipek and Stevens note that, with all the IT informational systems supposedly available to plant operators, 17 days after the initiation of the accident it was still not clear what had happened and what was going on. They suggest lessons to be learned in the design of such informational systems.
A Fukushima Diary, Peter Bernard Ladkin. Ladkin redacts many of his contributions to the mailing list, as a “diary” of the accident. Many themes arise, from engineering and sociological to political as well as the role of the press and various agencies of various governments as well as the UN, as well as commentary on the daily reports from the regulator about “progress” in dealing with the accident.
Authors: who they are and what they are professionally known for.
Bibliography: 423 items, most available on the World-Wide Web, although some newspaper reports seem to have disappeared from the public WWW at time of writing, and requests to the newspaper have not yielded replacements.