Analysis of Human Factors in Fukushima Daiichi Nuclear Disaster

This report provides a comprehensive analysis of the human factors contributing to the Fukushima Daiichi nuclear disaster. It begins with an introduction to the disaster, highlighting the technological failures and the significance of human and organizational factors. The report then delves into the Human Factors Analysis and Classification System (HFACS), explaining its methodology, usability, and importance in investigating such events. The application of HFACS to the Fukushima disaster is detailed, examining the active and latent factors that led to the accident, and the limitations of the HFACS method are also explored. The report also discusses the usefulness of HFACS in learning from past events and preventing future disasters. The conclusion emphasizes the importance of understanding human factors in preventing future disasters and the potential of HFACS to guide investigations and improve organizational safety. The reflection section reveals the student's learning and insights gained from the report, including how the knowledge can be applied to other disaster investigations.

Running head: HUMAN FACTOR INVESTIGATION
Human Factor Investigation
Name of the Student:
Name of the University:
Author Note:

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Table of Contents
Part A: Analysis...................................................................................................................2
Introduction..........................................................................................................................2
Fukushima Daiichi NPP disaster and human factor issues..................................................2
HFACS................................................................................................................................3
HFACS usability..............................................................................................................4
Importance of HFACS in investigating human factor issues..........................................5
Usefulness of HFACS in learning and for prevention of future events...........................6
Analysis of Fukushima disaster using HFACS...................................................................7
Limitation of HFACS..........................................................................................................7
Conclusion...........................................................................................................................8
Part B: Reflections...............................................................................................................9
References..........................................................................................................................11

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Part A: Analysis
Introduction
Fukushima Daiichi nuclear power plant (NPP) disaster is one of the worst nuclear
disasters, after Chernobyl nuclear disaster, which the world has witnessed. It is important to
understand the different factors that resulted in the accident. Traditionally, the human and
organizational factors responsible for such a disaster is often over-looked and neglected. This
report analyzes the human factors involved in the accident with the help of Human Factors
Analysis and Classification System (HFACS) method.
Fukushima Daiichi NPP disaster and human factor issues
Fukushima disaster is the outcome of a series of events, which includes errors in design
and technology as well as involves physical, social, cognitive, and organizational factors (Espina
and Teng-Calleja 2015). The root cause of the Fukushima disaster is the power failure of the
plant caused by the subsequent occurrence of earthquake and Tsunami on March 11, 2011. This
resulted in the loss of coolant property of the nuclear reactors No. 1, 2, and 3 (Blandford and
Ahn 2012). The increase in the pressure inside the reactor and the loss of containment and
venting function of the nuclear reactor resulted in the melting of the core, which finally
culminated in the explosion of the reactors No. 1, 3, and 4 and release of the radioactive
materials in the environment (Blandford and Ahn 2012).
Apart from technological errors, human factors also played a major role in the nuclear
disaster (Dekker 2016). This includes the failure of the management to anticipate, take
immediate action, and lack of resilience in case of emergency (Hollnagel and Fujita 2013). The

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increase in the collisions between the management and the workers and failure to take
collaborative action also increased the severity of the disaster (IAEA 2014). The disaster is also
due to the cognitive impairment experienced by the workers (Espina and Teng-Calleja 2015).
This report helps to understand the active and latent factors responsible for the disasters with the
help of HFACS.
HFACS
Drs. Doug Wiegmann and Scott Shappell developed a tool, HFACS, to analyze and
investigate the apparent and latent factors for the disaster. It is a modified version of Reason’s
Swiss Cheese model. According to this model, the different human errors associated with the
disaster are recognized as a barrier that forms a hole in the safety of the industry (Peltomaa
2012). There are four distinct barriers identified in an organization (Figure 1).
Figure 1. Swiss Cheese Model.
Source: Peltomaa (2012).

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HFACS usability
HFACS framework is based on the above Swiss Cheese model. It was originally
developed to examine the human errors associated with aviation. However, it is now widely used
to investigate and analyze the human factors involved in different kinds of disasters. Each level
of failure is associated with at least one human error that results in the adverse events (Ergai et
al. 2016). It is easy to understand the direct cause of the disaster such as technological- and
design-related failures, which is termed as active cause of the disaster. However, factors such as
cognitive impairment, fatigue, anxiety, stress, collision between the managements, and others are
usually over-looked and neglected (Espina and Teng-Calleja 2015). These factors are termed as
latent factors, which plays an equal important role in the disaster as the active factors. Figure 2 is
a representation of HFACS framework (HFACS 2017).

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Figure 2. The HFACS Framework.
Source: HFACS (2017).
Importance of HFACS in investigating human factor issues
In HFACS approach for investigating human factor issues in a disaster, it uses the same
four levels such as unsafe acts, condition of operators, preconditions for unsafe acts, and
organizational influences as identified as safety barriers by Reason, which are linked directly to
the disaster (Peltomaa 2012). However, with the help of HFACS framework, it is able to
breakdown each levels in order to investigate the latent and active factors for the disaster.
Theoretically, failure at any one of the level will result in the disaster. If any one of the failure at
any given point of time is rectified, the disaster can be prevented largely. Using HFACS as a

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guide, investigators can investigate the underlying cause of the disaster systematically (HFACS
2017).
The main question here is how to identify the errors even before it has occurred. It is
mostly seen that there is a common trend followed in a disaster as far as human errors are
concerned. HFACS provides a scientific and systematic framework to critically analyze different
disasters and deduce the common pattern followed in the disaster. By breaking down each level
and identifying the obvious reason as well as latent factors behind the disaster helps to identify
the common errors in a disaster (Ergai et al. 2016). Mostly, errors are observed in any one of the
levels as shown in Figure 2. After the proper identification of the cause behind the disaster,
remedial measures and intervention can be applied to prevent such disaster in the future.
Identifying the human error allows for improvement and better human performance such that the
rate of the disaster is decreased.
Usefulness of HFACS in learning and for prevention of future events
Although HFACS is primarily developed for identifying human factors in aviation
accident, it is now used increasingly to investigate human factors in different disasters due to its
increased usability and popularity. By identifying the real cause behind the disaster, proper
interventions can be implemented to prevent such occurrences in the future. It not only helps to
reduce the rate of accidents but also to sustain the reduced rate over time (Almheiri and Chung
2013). The data generated through HFACS by systematically studying the disaster can also help
to maintain a record that can help for future references. Comparing the errors that occurred in the
past with the present human error helps to identify the differences in the approach and thus
developing proper interventions to overcome such differences. It is possible to analyze historical

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events systematically with the help of HFACS framework so that to better understand the role of
human errors in the disaster and to prevent such errors in the future (Ergai et al. 2016).
Analysis of Fukushima disaster using HFACS
A detailed explanation of the application of HFACS in order to analyze the human factors
issues in Fukushima disaster NPP is provided in the mind map. With the help of HFACS, it is
easier to identify and break down the root underlying cause of the disaster (Hale et al. 2012). It
also helps to understand the growing trends that results in the re-occurrence of the disaster.
Hence, better mitigation measures and improved interventions are developed to prevent such
mishap in the future (Almheiri and Chung 2013). HFACS helps to understand the psychological
factors behind the disaster. Nowadays, it is a successful tool implemented in every industry as a
safety measures to prevent disaster. It acts as a guide for the organization to prepare them for the
unseen emergency (Almheiri and Chung 2013).
Limitation of HFACS
Although HFACS is widely utilized in several industries as a tool to analyze the human
factors issues, it has certain limitations. It is a labour intensive method and requires special
analyst to perform the task. Another limitation is that the reliability of the method is dependent
on the quality of the available data. In some cases, presence of faulty data can decrease the
output of the method (Almheiri and Chung 2013).
For the further development of HFACS in future, it is recommended to instruct and
educate people about the uses and mechanism of HFACS. As more and more people understand

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HFACS, they are better able to implement the method that will prevent such disaster in the
future.
Conclusion
Understanding the role of human factors in disaster is important to develop and
implement proper measures to prevent such mishap in the future. HFACS helps to analyze both
active and latent factors for the disaster. Hence, it helps in developing countermeasures that
covers all the aspects of the organization. With the development of HFACS, such occurrences
can be prevented in the future. The human factors can both cause of prevent the disaster. Proper
analyzing and developing better human factors investigation tools helps to prevent the disaster
and prepare the management for such a circumstances.

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Part B: Reflections
The impact of Fukushima nuclear disaster was huge and affected a large number of
people. While many people blame nature to be responsible for the disaster and miseries, human
factors play a major dominant role for the sufferings of the people (Stanton, Salmon and Rafferty
2013). With the help of this report, I understood the importance of investigating the
organizational and human factors involved in the disaster (IAEA 2014). Fukushima disaster is
the outcome of the human errors. There were error in the design and the technology of the plant;
however, such errors would have been rectified if the management at the proper time initiated
proper steps. Largely, HFACS tool has provided new insights and helped me to review and
understand the disaster through a different point of view. Organizations such as NISA, IAEA
have provided the required data and details, which helped me in preparing the report (IAEA
2014).
With the knowledge of the role of human factors in the disaster, I was able to relate and
analyze New Zealand coal mine disaster that I investigated previously (Lamare et al. 2015). I
acknowledged that the disaster was due to the fault of the organizations who risked the life of the
people just for the sake of increasing the productivity as they were in immense pressure by the
finance company. They kept the safety of the people low on their priority scale (Lamare et al.
2015). With the help of the human factors tools, it helped to shed new light on the disaster and to
understand better the underlying cause of the disaster (Hale et al. 2012).
Human factors tools were not developed to blame the organization or people for their
errors or irresponsible behaviour, but it acts as a guideline to provide better mitigation measures
that acts as a remedy for the disaster (Dekker 2016). It helps to prevent such disaster in the future

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and also helps the management to be prepared for any such unseen circumstances. It helps in
reducing the severity of the disaster (Stanton, Salmon and Rafferty 2013).
The human factors investigation of the Fukushima nuclear disaster has helped me to
bring many changes in my future practices. I have planned to uncover the human and
organizational roles for any disaster to understand the real cause of the disaster. In order to do so,
I have to deeply study the mishap and unknot the real issues behind the event. With the help of
different human factor tools such as HFACS, SCHAZOP, CUD, HAZOP, and others, I can better
investigate the event and deduce better results and conclusion.

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References
Almheiri, M.S. and Chung, Y.H., 2013. Analysis of Fukushima Daiichi Accident Using HFACS.
In Transactions of the Korean Nuclear Society Auntum Meeting (pp. 24-25).
Blandford, E.D. and Ahn, J., 2012. Examining the nuclear accident at Fukushima
Daiichi. Elements, 8(3), pp.189-194.
Dekker, S., 2016. Patient safety: a human factors approach. CRC Press.
Ergai, A., Cohen, T., Sharp, J., Wiegmann, D., Gramopadhye, A. and Shappell, S., 2016.
Assessment of the human factors analysis and classification system (HFACS): intra-rater and
inter-rater reliability. Safety science, 82, pp.393-398.
Espina, E. and Teng-Calleja, M., 2015. A social cognitive approach to disaster
preparedness. Philippine Journal of Psychology, 48(2), pp.161-74.
Hale, A., Walker, D., Walters, N. and Bolt, H., 2012. Developing the understanding of
underlying causes of construction fatal accidents. Safety science, 50(10), pp.2020-2027.
HFACS. (2017). HFACS, Inc | The HFACS Framework. [online] Available at:
https://hfacs.com/hfacs-framework.html [Accessed 19 Sep. 2017].
Hollnagel, E. and Fujita, Y., 2013. The Fukushima disaster–systemic failures as the lack of
resilience. Nuclear Engineering and Technology, 45(1), pp.13-20.
IAEA, 2014. IAEA report on human and organizational factors in nuclear safety in the light of
the accident at the Fukushima Daiichi nuclear power plant. Vienna: International Atomic Energy
Agency.

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Lamare, J.R., Lamm, F., McDonnell, N. and White, H., 2015. Independent, dependent, and
employee: Contractors and New Zealand’s Pike River Coal Mine disaster. Journal of industrial
relations, 57(1), pp.72-93.
Peltomaa, K., 2012. James Reason: Patient safety, human error, and Swiss cheese. Quality
Management in Healthcare, 21(1), pp.59-63.
Stanton, N., Salmon, P.M. and Rafferty, L.A., 2013. Human factors methods: a practical guide
for engineering and design. Ashgate Publishing, Ltd.