IAEA专家组对福岛核事故的调查报告(最终版)

Fukushima a disaster 'Made in Japan'05 July 2012The faults of every player in last year's Fukushima crisis have been laid out by a parliamentary commission. No organisation was singled-out as responsible - but rather Japanese culture itself.The report published today comes from Japanese Diet's Fukushima Nuclear Accident Independent Investigation Commission, one of three bodies investigating the circumstances of the accident. The 88-page executive summary elaborated in detail the organisational, cultural and technical failings that allowed the accident to occur, as well the issues that stymied the country's response.While it must be remembered that the Fukushima accident was directly cause by the enormous Tohoku earthquake and tsunami of 11 March 2011, the commission report pointedly dubbed it 'man-made'.Chairman KiyoshiKurokawa's forewordexplained: "What must beadmitted – very painfully –is that this was a disaster'Made in Japan.' Itsfundamental causes are tobe found in the ingrainedconventions of Japaneseculture: our reflexiveobedience; our reluctanceto question authority; ourdevotion to 'sticking withthe program'; ourgroupism; and ourinsularity."The mindset of government and industry led the country to avoid learning the lessons of the previous major nuclear accidents at Three Mile Island and Chernobyl, wrote Kurokawa."The consequences of negligence at Fukushima stand out as catastrophic, but the mindset that supported it can be found across Japan. In recognizing that fact, each of us should reflect on our responsibility as individuals in a democratic society."Opportunities missedLong before the natural disasters, the report said, improvements hadbeen identified for Fukushima Daiichi that would have protected the plant or helped during an emergency. Some of these had been recommended but not required by the regulator NISA, and Tepco had not implemented them on its own volition by the time of the natural disasters.Principal among these were, of course, tsunami and flood mitigation. Tepco had been aware since 2006 that Fukushuima Daiichi could face a station blackout if inundated with water, as well as the potential loss of ultimate heat sink if a tsunami came that exceeded the Japan Society of Civil Engineers' official estimation. However, NISA gave no instruction to the company to prepare for severe flooding, and even told all nuclear operators that it was not necessary to plan for station blackout.During the initial response to the tsunami, this lack of readiness for station black-out was compounded by a lack of planning and training for severe accident mitigation. Plans and procedures for venting and manual operation of isolation condensers were incomplete and their implementation in emergency circumstances proved very difficult as a result.NISA also had a "negative attitude" to learning from its peers overseas. The commission said that the Fukushima accident "may have been preventable" if NISA had set new requirements similar to those brought in by its US equivalent after the terrorist attacks of 11 September 2001. "We have concluded that - given the deficiencies in training and preparation - once the total station black-out occurred, including the loss of a direct power source, it was impossible to change the course of events," said the commission.Poor coordinationAt the national level, plans and procedures were similarly underdeveloped, untested and unknown. NISA had been central to the overall plan for handling nuclear emergencies but failed to respond adequately, while the cabinet did not understand its own role in the plan and began to communicate directly with Tepco - cutting NISA out of the loop.This continued to the point that a cabinet team with "no legal authority" was established at Tepco's Tokyo headquarters, to which Tepco eventually "became subordinate". The operator's absolute responsibility for matters on site was not officially specified and Tepco became "reluctant" to assert it, "prioritising the cabinet's intent over that of the technical engineers at the site." Meanwhile, the "unprecedented intervention" of a personal visit by prime minister Naoto Kan to Fukushima Daiichi distracted workers and confused the chain of command even further.NISA was also criticised for its "negligence and failure over the years" to prepare for a nuclear accident in terms of public information and evacuation, with previous governments equally culpable. Most residents within 10 kilometres of the power plant only learnt of the crisis whenordered to evacuate - some 12 hours after the official notification of an emergency situation, itself delayed by cabinet confusion.What comes nextThe commission concluded that "the safety of nuclear energy in Japan and the public cannot be assured unless the regulators go through an essential transformation process. The entire organization needs to be transformed, not as a formality but in a substantial way. Japan's regulators need to shed the insular attitude of ignoring international safety standards and transform themselves into a globally trusted entity."Furthermore, "Mechanisms must be established to ensure that the latest technological findings from international sources are reflected in all existing laws and regulations." The regulatory body must be monitored by the Diet, which would be supported by an independent expert panel with a global view.Among several recommendation areas, relating to regulation, crisis management and legal frameworks, only one relates to the performance of the nuclear utilities. It specifies that the government's relationship to a nuclear operator must be controlled by rules and openly disclosed. Tepco, and by extension all Japanese nuclear operators, must "undergo dramatic corporate reform, including governance, risk management and informaiton disclosure "with safety as the sole priority." Japanese operators must also "construct a cross-monitoring system" to maintain safety standards at the highest global levels.Kurokawa noted that there were many lessons relating to policies and procedures, "but the most important is one upon which each and every Japanese citizen should reflect very deeply... The consequences of negligence at Fukushima stand out as catastrophic, but the mindset that supported it can be found across Japan. In recognizing that fact, each of us should reflect on our responsibility as individuals in a democratic society."Researched and writtenby World Nuclear News© 2012 World Nuclear News。

Final Report on the Accident at Fukushima Nuclear Power Stationsof Tokyo Electric Power Company--- Recommendations ---Investigation Committee on the Accident at Fukushima Nuclear Power Stations of Tokyo Electric Power CompanyJuly 23, 2012On March 11, 2011, the Fukushima Dai-ichi Nuclear Power Station (“Fukushima Dai-ichi NPS”) and the Fukushima Dai-ni Nuclear Power Station (“Fukushima Dai-ni NPS”) of the Tokyo Electric Power Company (“TEPCO”) were hit and damaged by the Tohoku District - off the Pacific Ocean Earthquake and accompanying tsunami. Particularly at the Fukushima Dai-ichi NPS, a serious severe accident occurred, which was of Level 7 in the International Nuclear Event Scale (INES) of the International Atomic Energy Agency.This Investigation Committee was established on May 24, 2011 by a cabinet decision. Its mission is to make policy recommendations, by investigating the causes of the accident and ensuing damage, on measures to prevent the further spread of damage caused by the accident and a recurrence of similar accidents in the future. The Investigation Committee inspected the accident site including the Fukushima Dai-ichi and Dai-ni NPSs, and interviewed many individuals concerned, including the mayors and residents of relevant municipalities. The number of interviewees reached 772 in total. The Investigation Committee published its Interim Report on December 26, 2011 and its Final Report on July 23, 2012.The Investigation Committee continued its multifaceted analysis, after the publication of the Interim Report, on matters including the then-available accident preventive measures and disaster preparedness, emergency response actions taken on-site and off-site at the accident. The results are contained in the Final Report. It became clear through the investigation that the accident had been initiated on the occasion of a natural disaster of an earthquake and tsunami, but that there had been various complex problems behind this very serious and large scale accident, i.e., the problems in the accident preventive measures and disaster preparedness, in on-site emergency responses to the accident, and in preventive measures against the spread of damage outside the nuclear power station.Examples are: the then-available accident preventive measures and disaster preparedness of TEPCO and the Nuclear Industry and Safety Agency (“NISA”) were insufficient against tsunami and severe accidents; the preparedness for a large-scale complex disaster was insufficient; and they were unprepared for the release of a large amount of radioactive materials into the environment caused by a containment failure. Inadequate TEPCO emergency responses to the accident at the site were also identified. Furthermore, in the preventive measures against the spread of damage taken by the central and local governments, problems were identified which lacked consideration to the victims, such as the radiation monitoring operation, the utilization of the System for Prediction of Environmental Emergency Dose Information (SPEEDI), evacuation instructions to the residents, responses to the people’s radiation exposure, or the provision of information to the nation and outside the country. In addition, problems of the crisis management system of the government came to light, too.The investigation thus far has suggested that radical strengthening revision be required of the measures for preventing a recurrence of a grave accident at the nuclear power station, and for limiting/mitigating the spread of damage. In this context, the Investigation Committee has made a number of recommendations in the Final Report (It also reproduces the recommendations made in the Interim Report).This document excerpts the recommendations which the Investigation Committee made in the Final Report. The Investigation Committee believes that the realization of these recommendations be useful and important for preventing a recurrence of a nuclear disaster and mitigating its damage. The central and local governments concerned, nuclear operators and other relevant organizations are strongly urged to incorporate and act upon these recommendations in their safety measures and disaster preparedness.The English version of the Interim Report of the Investigation Committee and its Executive Summary is available on the Committee’s website (http://icanps.go.jp/eng/). The English version of the Final Report and its Executive Summary will also be uploaded shortly.(1)Recommendations for a basic stance for safety measures and disaster preparednessRecommendations for disaster preparedness in light of complex disasters in mind (Final Report VI. 2. (2))When reviewing the existing safety measures at nuclear power stations, risks of a large scale complex disaster should be sufficiently considered in disaster preparedness.●Recommendations for changing an attitude to see risks (Final Report VI. 2. (3))i.It is necessary to humbly face the reality of natural threats, diastrophism and othernatural disasters, which are sizable in scale and time, keeping in mind that Japan has often had them in its long history.ii.Risk reduction should be tackled in a drastically different approach. In the government as well as in private entities, a new approach to safety measures and disaster preparedness should be established for a disaster which potentially brings about serious damage in broad areas like a gigantic tsunami or the severe accident at the Fukushima Nuclear Power Station, regardless of its probability of occurrence.iii.An institutional framework is needed to ensure continued in-depth examination of “residual risks” or “remaining issues” without leaving them behind beyond the predetermined safety measures and disaster preparedness.●Recommendations for “deficiency analyses from the disaster victims’ standpoint” (FinalReport VI. 2. (4))An accident at a nuclear power station has risks to bring about damage in vast areas.Nuclear operators on one hand, nuclear regulators on the other, should establish a systematic activity to identify all risk potentials from the “disaster victims’ standpoint,” when designing, constructing and operating such nuclear systems, for ensuring credible nuclear safety including evacuation planning in the local society. Such an approach should be practiced.Radioactive materials may scatter over vast areas due to an accident at a nuclear power station. The prefecture and local municipalities involved should closely collaborate in building up an effective system through evacuation planning and its drills for minimizing confusion.●Recommendations for incorporating the latest knowledge in the disaster prevention plan(Final Report VI. 2. (5))i.Scientific knowledge of earthquakes is not sufficient yet. The latest research resultsshould be continually incorporated in disaster preparedness. In other words, a policy/rule concluded at a certain point based on the then-available knowledge shouldbe reviewed with flexibility and revised, without groundless procrastination, when newknowledge of earthquakes and tsunami become available.ii.If an area is excluded, due to limited financial resources or other reasons, from the areas for strengthening disaster preparedness because of low or unknown probabilitiesof occurrence, the damage would be extremely serious once a massive earthquake andtsunami hit the area. Administrative bodies should take initiatives of, for instance,launching research projects on earthquake evaluation in specific areas for which someseismologists warn of risks, even if few in number, or which show traces of massiveearthquakes and gigantic tsunami (tsunami deposits, for instance) from the remotepast; or formulating an innovative disaster prevention plan in full cooperation of publicadministration, residents and experts through disclosing relevant information.iii.Disaster risks in nuclear power plant siting regions should be noted. It was the role of NISA to prepare for nuclear disasters at nuclear power stations. However, the policy ofthe Central Disaster Management Council has strong relevance to the disasterpreparedness at nuclear power stations. The Central Disaster Management Councilshould duly consider the nuclear power stations, too, in its policy making.(2)Recommendations for safety measures regarding nuclear power generation●Recommendations for building disaster prevention measures (Final Report VI 2 (1))Quite a number of issues exist, which need highly specialized nuclear knowledge over a wide range for solving technical and nuclear engineering problems concerning the emergency responses to the accident at TEPCO Fukushima Dai-ichi NPS, and the then-available disaster preparedness by the government, TEPCO and other organizations.These issues should be reviewed and resolved, results being shaped into concrete actions, through competent knowledge by stakeholders in nuclear power generation. In doing so, they should sincerely take into consideration the recommendations the Investigation Committee has made and they should do so with accountability to society for its process and results.●Recommendations for the necessity of comprehensive risk analysis (Final Report VI. 2. (4)a. (b))Nuclear facilities are installed in a natural environment, which is really diversified.Nuclear operators should conduct comprehensive risk analysis encompassing the characteristics of the natural environment including the external events, not only earthquakes and their accompanying events but also other events such as flooding, volcanic activities or fires, even if their probabilities of occurrence are not high, as well as the internal events having been considered in the existing analysis. Nuclear regulators should check the operators’ analysis. Nuclear operators should actively utilize currently available methods in their analyses of such external events, even if the Probabilistic Safety Assessment (PSA) approach is not firmly established for them. The government should consider support to promote relevant research programs for such initiatives.●Recommendations for severe accident management (Final Report VI. 1. (4) a. (c))In order to ensure maintaining nuclear safety at nuclear power stations, vulnerability of individual facilities for a wide range of characteristics of various internal and external events should be identified by comprehensive safety analysis, and appropriate measures (severe accident management) against such vulnerability should be examined and placed in shape, assuming a situation in which the core may have serious damage by an accident far exceeding the design basis. The effectiveness of such severe accident management should be evaluated through the PSA or other means.(3)Recommendations for nuclear disaster response systems●Recommendations for reforming the crisis management system for a nuclear disaster (FinalReport VI. 2. (6))Learning from the experience as a result of the accident at the Fukushima Dai-ichi NPS, the crisis management system for a nuclear disaster should be urgently reformed, in which the nuclear emergency response manual should be revised assuming an occurrence of a complex disaster combining an earthquake/tsunami disaster and a nuclear accident. In its reforming process, the strengthening of response capabilities of off-site centers, which are supposed to serve as the base for response during a nuclear emergency (hereafter simply referred to as “off-site centers”), is needed. In addition, it is also required to build a crisis management system by examining how to respond to a situation which a Local NuclearEmergency Response Headquarters cannot handle by convening personnel from relevant emergency responsebodies.●Recommendations for the nuclear emergency response headquarters (Final Report VI. 2. b.(a))The emergency response headquarters should, in general, be located close to the accident site where the relevant information is easy to obtain in a nuclear emergency, and the activities at the accident site are easy to grasp. To promptly collect accurate information is, needless to say, the fundamental principle in a nuclear emergency. The government emergency response headquarters should be set up in a way which enables the government people access to the necessary information while staying in government facilities like the Prime Minister’s Office, without moving to the nuclear operator’s head office.●Recommendations for off-site centers (Interim Report VII. 3. (1) a.)The Government should take prompt actions to ensure that off-site centers are able to maintain their functions even during a major disaster, learning from the fact that the Off-site Center (in Fukushima) became unusable because the risks of radioactive contamination had not been adequately considered beforehand.●Recommendations for the roles of the prefectural government in nuclear emergencyresponses (Final Report VI. 1. (2) c.)In a nuclear disaster, the prefectural government should take a responsible role in front, because the damage can extend to a regional size. The nuclear disaster prevention plan should take this point into account.(4)Recommendations for damage prevention and mitigation●Recommendations for the provision of information and risk communication (Final ReportVI. 2. (7))It is necessary to build mutual trust between the public and the government and to provide relevant information in an emergency while avoiding societal confusion and mistrust. To this end, a risk communication approach on risks and opinion exchanges thereupon should be adopted for a consensus building among all stakeholders based on mutual trust. The government should examine, by institutionalizing an appropriate body,how to provide relevant information in an emergency to the public, promptly, accurately, and in an easily understandable as well as clear-cut (not misleading) manner. Inappropriate provision of information can lead to unnecessary fear among the nation. Therefore, an expert on crisis communication may be assigned for providing appropriate suggestions to the cabinet secretary responsible for information provision to the public in an emergency.●Recommendations for improving radiation monitoring operations (Interim Report VII. 5.(2) d.)i.To ensure that the monitoring system does not fail at critical moments, and to ensurethe collection of data and other functions, the system should be designed against various possible events, including not only an earthquake but also a tsunami, storm surge, flood, sediment disasters, volcanic eruptions and gale force winds. Measures should be taken to prevent the system from functional failures even in a complex disaster simultaneously involving two or more such events. Furthermore, measures should be developed to facilitate the relocation of monitoring vehicles and their patrols even in a situation where an earthquake has damaged roads.ii.Training sessions and other learning opportunities should be enhanced to raise awareness of the functions and importance of the monitoring system among competent authorities and personnel.●Recommendations for the SPEEDI system (Interim Report VII. 5. (3) c.)In order to protect the lives and dignity of residents caught up in a disaster, and to prevent the spread of harm from the disaster, measures should be developed to improve operational guidelines of the SPEEDI system so that crucial information on radiation dose rates is provided promptly in a manner acceptable to the people. Measures, including hardware and infrastructure-related measures should be developed and implemented to ensure that SPEEDI functions remain operable even during a complex disaster.●Recommendations for evacuation procedures of residents (Items i. to iv. in Interim ReportVII. 5. (4) c. and item v. in Final Report VI. 1. (4) b.)i.Activities to raise public awareness in daily lives are needed to provide residents withbasic, practical knowledge of how radioactive substances are released during a major nuclear accident, how they are dispersed by wind and other agents, and how they fallback to the ground, as well as knowledge of howthe exposure to radiation can affect human health.ii.Local government bodies need to prepare evacuation readiness plans that take into account the exceptionally grave nature of a nuclear accident, periodically conduct evacuation drills in a realistic circumstance, and take steps to promote the earnest participation of residents in those drills.iii.It is necessary to complete, during normal times, readiness preparations, such as drafting detailed plans for ensuring means of transportation, traffic control, securing evacuation sites in outlying areas, and securing water and food supplies at the evacuation site, taking into consideration the situation that the evacuees may number in the thousands to over a hundred thousand . It is especially important to develop measures that support the evacuation of the disadvantaged, such as seriously ill or disabled people in medical institutions, homes for the aged, social welfare facilities, or in their own homes.iv.The above types of measures should not be left up to the local municipal governments, but need in addition to involve the active participation of the prefectural and national governments in designing and operating an evacuation plan and a disaster prevention plan, in consideration of the situation that a nuclear emergency would affect a large area.v.The existing Emergency Planning Zone (EPZ) had been set before the accident on the basic assumption of 8 to 10 km from a nuclear power station, so that the situation could be well dealt with even in an incident far exceeding a hypothetical accident. However, the accident has shown the need to reconsider what accidents to assume and how to designate evacuation areas. Furthermore, the roles of the government in a nuclear emergency are so large that the government responses should not be limited to those areas outside nuclear site boundaries such as the residents’ evacuation. It should also be considered what the government should do to cooperate or support the nuclear operator in a nuclear emergency, in consultation with the operator.Recommendations for administering stable iodine tablets (Final Report VI. 1. (3) e. (c)) In the existing emergency preparedness, administration of stable iodine tablets is, inprinciple, subject to the judgment of the government NERHQ. A system which allows local municipalities to independently administer the tablets should be reconsidered, and so is the appropriateness to distribute them in advance to the residents as a precaution.●Recommendations for radiation emergency medical care institutions (Final Report VI. 1. (3)e. (f))A considerable number of medical facilities for initial radiation emergency medicaltreatment should be located in the area which is not likely to be included in an evacuation designated area, so that radiation emergency medical care could be provided even in a severe accident like the accident at Fukushima Dai-ichi NPS. Those medical facilities should not be concentrated in the area close to the nuclear power station. At the same time, such medical care systems in a nuclear emergency would need to be coordinated for collaborating over a wide area across the prefectural borders.●Recommendations for public understanding of radiation effects (Final Report VI. 1. (3) e.(g))As many opportunities as possible should be institutionalized for the public to get knowledge and deepen their understanding of radiation. By doing so, the individuals should be able to judge the radiation risks based on correct information; in other words, they would be freed from unnecessary fears about, or from underestimating, the radiation risks because of the lack of information.●Recommendations for information sharing with, and receiving support from, overseas(Final Report VI. 1. (3) g. (a), (b))Provision of information to overseas countries is equally important as to the Japanese public, especially to neighboring countries or those countries which have many of their nationals residing in Japan. Active and polite responses should be in place for prompt and accurate provision of relevant information with due consideration to language barriers.International support in a nuclear emergency should be accepted and received as early as possible, when offered, for international comity and for urgently meeting national needs. To avoid confusion and inappropriateness experienced in the early stages at the time of the accident in Fukushima, operation manuals of competent ministries, nuclear operator emergency management operation plans and other relevant materials should prescribe howto respond to such international support.(5)Recommendations for harmonization with international practices●Recommendations for harmonization with international practices such as the IAEA safetystandards (Final Report VI. 1. (7))It is necessary to keep the national regulation qualities constantly updated in line with the nuclear knowledge accumulation and technological development in the international and national community. To this end, continuous efforts are needed to keep the national regulatory guides newest and best while monitoring international standards, such as those at the IAEA. Lessons on nuclear safety should be extracted from the accident, and those lessons and relevant knowledge should be provided to the international community so that they could contribute to the prevention of similar accidents, not only in our country but also in other countries. In the process of revising national regulatory guides, international contribution should be pursued by making efforts to propose them to incorporate into the IAEA standards etc., if they turn out to be effective and useful as international standards.(6)Recommendations for relevant organizations●Recommendations for the nuclear safety regulating body.i.The need for independence and transparency(Interim Report VII. 8. (2) a.)An organization with regulatory oversight over nuclear safety must be able to makedecisions effectively and independently, and must be able to function separately from anyorganization that could unduly influence its decision-making process. The new nuclearsafety regulatory organization should therefore be granted independence and shouldmaintain transparency.The new nuclear safety regulatory organization must be granted the authority, financialresources and personnel it needs to function autonomously as an entity concerned withnuclear safety and should also be given the responsibility of explaining nuclear safetyissues to the Japanese people.anizational preparedness for swift and effective emergency response (Interim Report VII. 8. (2) b.)In light of the serious impact of a nuclear disaster on the nation, the nuclear safety regulatory organization, which would play a key role in disaster response, should, during normal times, work out a disaster prevention plan and implement emergency response drills to facilitate rapid response if a disaster occurs. Furthermore it should foster the specialized skills to provide individuals and organizations responsible for emergency response with expert advice and guidance, and should foster as well the management potential to utilize organizational resources effectively and efficiently.In addition, the nuclear safety regulatory organization must be well aware that its role is to respond responsibly to crises. It should beforehand prepare systems that can deal with a major disaster if it occurs, and develop partnerships with relevant government ministries and agencies and with relevant local governing bodies to create mechanisms for cross-organizational response, with the role of the nuclear safety regulatory organization clearly demarcated.iii.Recognition of its role as a provider of disaster-related information to Japan and the world (Interim Report VII. 8. (2) c.)The new nuclear safety regulatory organization must be fully conscious that the way it provides information is a matter of great importance, and must also, during normal times, establish an organizational framework that enables it to provide information in a timely and appropriate manner during an emergency.iv.Development of competent human resources and specialized expertise (Interim Report VII. 8. (2) d.)The new nuclear safety regulatory organization should consider establishing a personnel management and planning regime that encourages personnel to develop lifetime careers. For example, it should offer improved working conditions to attract competent human resources with excellent specialized expertise, expand opportunities for personnel to undergo long-term and practical training, and promote personnel interaction with other administrative bodies and with research institutions, including those involved in nuclear energy and radiation.v.Efforts to collect information and acquire scientific knowledge (Interim Report VII. 8.(2) e.)The new nuclear safety regulatory organization to be established should keep abreast of trends embraced by academic bodies and journals in the field (including those in foreign countries) and by regulatory bodies in other countries, in order to continue acquiring knowledge that will contribute to its regulatory activities. It must also understand the implications of that knowledge, systematically share and sufficiently utilize such knowledge, and resulting outcomes should be archived and continually utilized as an organization.vi.Active relationship with international organizations and regulatory bodies of other countries (Final Report VI. 1. (5))The fixed number of personnel at a government administrative organization is a collective issue of the all administrative organizations, and not limited to an issue of NISA, etc. But that of the new regulatory body should be duly considered, because of the importance of nuclear safety. The new regulatory body should secure its personnel, should establish an organizational system competent for international contribution, and develop human resources who can take a role in personnel interaction with international organizations or regulatory bodies of other countries.vii.Strengthening of the regulatory body (Final Report VI. 1. (5))In order to ensure nuclear power safety, responses to individual problems encountered are not sufficient. Continuous efforts are needed to keep national regulatory guides updated at their newest and best qualities, with consideration to international trends of safety regulations and nuclear security, not only to the latest scientific knowledge in the country and overseas. Considering that the impact of a nuclear disaster on society can be sizable, emergency preparedness should be fully established during normal times by formulating a disaster prevention plan or by conducting nuclear emergency response drills so that effective and prompt responses could be taken in an emergency. The regulatory organization should foster the specialized skills to provide individuals and organizations responsible for emergency response with expert advice and guidance and should also foster the management potential to utilize organizational resources effectively and efficiently. Appropriate size of budget and human resources should be duly examined.●Recommendations for TEPCO (Final Report VI. 6. e.)TEPCO bears critical responsibilities to society as a nuclear operator primarily responsible for nuclear power plant safety. Nevertheless, TEPCO was not sufficiently prepared for such an accident, that natural disasters including tsunami may lead to large-scale core damage. Furthermore, TEPCO had not taken adequate preparedness for tsunami risks beyond design basis at the Fukushima Dai-ichi NPS. The accident showed quite a number of problems with TEPCO such as insufficient capability in organizational crisis management; hierarchical organization structure being problematic in emergency responses; insufficient education and training assuming severe accident situations; and apparently no great enthusiasm for identifying accident causes. TEPCO should receive with sincerity the problems which the Investigation Committee raised and should make further efforts for solving these problems and building higher level safety culture on a corporate-wide basis.●Recommendations for rebuilding safety culture (Final Report VI. 2. (8))Well established safety culture is vitally important to people’s lives in the nuclear power industry, which may cause serious situations once an accident occurs. In view of the reality that safety culture was not necessarily established in our country, the Investigation Committee would strongly require rebuilding safety culture of practically every stakeholder in nuclear power generation such as nuclear operators, regulators, relevant institutions, and government advisory bodies.(7)Recommendations for continued investigation of accident causes and damage●Recommendations for continued investigation of accident cause (Final Report VI. 2. (9) a.)The government, nuclear operators, nuclear plant manufacturers, research institutions, academies, all such stakeholders (relevant organizations) involved in nuclear power generation should take active roles in investigating the accident and in fact analyses, and continue, in their respective capacities, their comprehensive and thorough investigations of the remaining unresolved problems. The government, in particular, should not conclude its investigations of the Fukushima nuclear accident at the time when this Investigation Committee or the Fukushima Nuclear Accident Independent Investigation Commission。

日本国会福岛核事故独立调查委员会正式报告环保部核与辐射安全中心政策法规研究所译校2012.7日本国会福岛核事故独立调查委员会（NAIIC）主席：Kiyoshi Kurokawa医学博士，国家政策研究院专业会员，日本科学理事会前总裁成员：Katsuhiko Ishibashi地震学专家，神户大学名誉教授Koichi Tanaka 化学专家，岛津公司Kenzo Oshima日本国际协力事业团主席顾问，前日本驻美国大使Mitsuhiko Tanaka 科学记者Hisako Sakiyama医学博士，国立放射线综合研究所前主席Shuya Nomura中央大学法学院教授，律师Masafumi Sakurai律师，名古屋公共检察官办公室前首席检察官；国防部督察长办公室前法律合规总督察Reiko Hachisuka福岛Okuma镇商会主席Yoshinori Yokoyama社会学家，东京大学执行管理项目主任委员会顾问Itsuro Kimura Tatsuhiko Kodama Tatsuo Hatta审查者Takao IidaMakoto SaitoJun SugimotoIsao NakajimaTakeshi Matsuoka行政办公室Toru Anjo主任Sakon Uda调查常务主任目录主席致辞 (1)概述 (3)委员会的使命 (3)事故 (6)结论和建议 (10)调查结果概要 (21)1 事故可以避免吗 (22)2 事故的扩大 (25)3 事故的应急响应 (28)4 危害的扩散 (34)5 事故防范和响应的组织问题 (39)6 法律体系 (43)附录 (45)福岛核事故人员疏散调查 (45)对福岛核电站工作人员的调查 (62)委员会会议报告 (74)术语表 (93)致：Takahiro Yokomichi先生众议院议长Kenji Hirata先生参议院总裁日本国会下述报告的主题是2011年3月11日突发的核事故，我们将此报告提交给日本国会以审查。

福島原子力事故調査報告書（中間報告書 別冊）平成23年12月2日東京電力株式会社はじめに○ 福島原子力事故調査報告書（中間報告書）の本編の繰り返しとなりますが、本年３月１１日の大震災により被災された方々に、衷心より、お見舞い申し上げます。

また、福島第一原子力発電所における放射性物質を外部に放出させるという大変重大な事故により、発電所の周辺地域そして福島県民の皆さま、更に広く社会の皆さまに、大変なご迷惑とご心配をおかけしていることに対し、心より深くお詫び申し上げます。

避難されている方々の一日も早いご帰宅を実現するとともに、国民の皆さまに安心していただけるよう、福島第一原子力発電所における原子炉の安定的冷却や放射性物質の放出抑制に向け、引き続き、全力で取り組んでまいります。

○ さて、福島原子力事故調査報告書（中間報告書）の本編では、津波により被った設備被害、事故の進展状況等につき、事実を整理、評価・分析するとともに、設備面を中心に再発防止に向けた対策を検討いたしました。

一方、一連の事故経緯等を調査する過程で、特定の論点に焦点を当てた「個別項目」として明らかになって来た事項も、多数出て参りました。

具体的な記載としては、報告書本編で記載している事項につき、特定の論点に絞る形で詳細に記載している項目や、また本編報告書に記載はないものの、経緯として明らかにした方が良いと考えられるもの等があり、事故に係わる事実を正確にお伝えするという観点では、重要な要素であるため、今回は、別冊として、現時点までで整理できた事項を、抽出・記載した次第です。

○ 具体的には、「津波対策やアクシデントマネージメント（ＡＭ）策の整備の経緯等」、「地震の襲来によるプラントへの影響評価」のほか、「津波襲来以降の時系列に基づく個別項目の整理」等々に言及していますが、今回の事故全般を概観した報告書本編と異なり、特定の論点に絞り、「個別項目」ごとに整理するといった本編と違ったアプローチをしています。

·动 态·IAEA发布福岛核事故国际实情调查团报告 国际原子能机构(IAE A)继事故当下向日本派遣专家组后,于2011年5月24日—6月2日又派出由其职员和国际专家组成的实情调查团,对福岛核事故进行初步评价。

在日本期间,调查团得到了包括政府、审管机构和运行方在内的多方配合,考察了福岛第一、第二核电站和东海第二核电站。

调查团的活动涉及自然外部事件、安全评价与纵深防御、地震与海啸后的响应、严重事故、设施严重受损条件下的乏燃料管理、应急准备和响应、辐射后果等方面,分外部危害、安全评价与管理以及监测、应急准备和响应三个小组进行。

6月20—24日,IAE A在维也纳召开部长级核安全大会,调查团向大会报告了其成果,即《IAE A International Fact Finding Expert Mission of the Fuku-shima Dai-ichi NPP Accident Following the Great East Japan Earthquake and Tsunami)》,敦促国际社会以这次事故为契机,汲取教训,进一步提升核安全水平。

报告所述成果分结论和事故教训两个方面,分述如下。

调查结论(1)以福岛核事故的情况而论,IAE A基本安全原则仍是坚固基础,涵盖事故教训的方方面面。

(2)考虑到该事故的极端情形,发生地的事故管理已经做得尽善尽美了,符合IAE A基本安全原则之三(领导与管理)的要求。

(3)对海啸危害没有足够的纵深防御考虑,特别是:①低估了海啸之危害—尽管场址评估和核电站设计中均考虑了海啸危害,2002年后预期海啸高度还被提升到了5.7m;②鉴于事故所及核电站事实上无法免于水患,应2002年之后的评估而采取的补充预防措施,不足以应对如此高的海啸以及相伴的所有危险现象(水动力作用和能量很高的大块儿残骸的动力学冲击);③上述补充措施亦没有经过审管当局的评审和批准;④建(构)筑物、系统和部件(SSC)面对洪水的失效一般无以复加,电站未能抵御超过预估高度海啸的后果;⑤严重事故管理的准备,不足以应对多机组失效之情形。

⽇本福岛核电站事故分析报告⽇本福岛核电站事故分析报告论软件⼯程管理常见问题事件回顾:当地时间3⽉11⽇14时46分,⽇本发⽣⾥⽒9级地震,震中位于宫城县以东的太平洋海域,震源深度20公⾥.地震引发的10⽶浪⾼⼤海啸随后横扫沿海地区.地震发⽣后,宫城县、福岛县的数所核电站⾃动关闭。

虽然核裂变被终⽌，但核反应堆还需要数天的冷却才可以完全关闭。

⽽随后⽽来的海啸损坏了福岛核电站冷却系统的紧急供电系统，导致反应堆冷却系统失效。

当地时间3⽉12⽇下午15时36分左右，福岛第⼀核电站1号机组发⽣爆炸，4⼈受伤，反应堆燃料可能发⽣熔化，官⽅要求⽅圆10公⾥范围内的居民紧急疏散，晚些时候将范围扩⼤到20公⾥。

当地时间3⽉14⽇上午11时左右3号机组发⽣爆炸。

当地时间3⽉15⽇晨6时10分左右，2号机组发⽣爆炸。

当地时间3⽉15⽇11时左右3号机组再次发⽣爆炸，4号机组起⽕，造成⼤量辐射物泄露。

到⽬前为⽌，⽇本还在积极处理此次核事故。

看到这些，我们可以说这是⼀次天灾。

但我更觉得这个是⼀次“⼈祸”，中间有许多设计和实施上的缺陷，导致此次事故的扩⼤。

由此我想到我们在实施⼀个⼤型软件项⽬的时候，我们也会经常遇到的⼀些问题，我把它罗列出来，⼀⼀加以说明。

1、架构选型发⽣事故的福岛核电站是当今世界上最⼤的核电站，位于⽇本福岛⼯业区，由福岛⼀站、福岛⼆站组成，共有10台机组，⼀站6台，⼆站4台，均为沸⽔堆，总输出功率为9096兆⽡。

福岛⼀站1号机组于1967年9⽉动⼯，1970年11⽉并⽹，福岛⼆站4号机组于1987年投⼊运⾏。

简单介绍下核电的知识，核电的核⼼核反应堆⽬前主要有压⽔堆和沸⽔堆两种。

压⽔堆有两个回路，⼀回路⾥的⽔被核燃料直接加热，然后流到热交换器⾥，冷却后再流回到反应堆来冷却核燃料，如此循环，不断带⾛核燃料产⽣的热。

通过热交换器⼀回路⾥的⾼温去加热⼆回路⾥的⽔，使其产⽣蒸汽来驱动涡轮发电机来发电。

⼀回路⾥是有辐射性的，⽽⼆回路⾥是没有辐射性的。

福岛核事故调查报告
福岛核事故调查报告
背景信息
•事故发生时间：2011年3月11日
•事故地点：日本福岛县
•事故原因：地震引发的海啸导致核电站设施损坏，引发核泄漏事故概述
•核电站概况：福岛第一核电站是一座由6个核反应堆组成的核电站，事故发生时其中4个堆已投入运营。

•地震与海啸：2011年3月11日发生的东北地方太平洋沖地震引发了10米高的海啸，严重损害了核电站的设施。

•核泄漏：海啸造成核电站的冷却系统严重受损，导致核反应堆过热并发生氢气爆炸，引发核泄漏。

事故调查与分析
•事故根本原因：事故的根本原因在于核电站对地震和海啸的防护措施不足，未能预防海啸对设施的破坏。

•事后调查：事故发生后，福岛核电站事故调查委员会进行了详细调查，分析了事故发生及其原因。

•调查结论：调查报告指出，核电站的设计未考虑到可能发生的大型海啸，且应急反应措施不完备，导致事故发生及其严重后果。

事故的教训与影响
•核能安全规范：福岛核事故引起了全球对核能安全的广泛关注，各国纷纷加强核电站的安全规范，提高对地震和海啸等自然灾害的抵抗能力。

•代价与后果：事故导致数千人死亡、失踪以及核辐射对环境的长期影响，同时也给日本经济和能源政策带来了巨大的冲击。

•反思与改进：事故促使日本重新审视并改善其核能发展战略，重视安全问题，加快发展可再生能源，减少对核能的依赖。

总结与展望
福岛核事故是人类历史上最严重的核事故之一，其给人们带来了深刻的反思和警醒。

各国应共同努力，加强核能安全管理和应急响应能力，以确保人类的生命和环境不受核能发展的副作用影响。

同时，也要推动可再生能源的发展，实现清洁、可持续的能源未来。

IAEA专家组对福岛核事故的调查报告国际原子能机构（IAEA）派遣的专家组对2024年福岛核事故进行了调查和评估，并于最终版报告中总结了他们的发现和建议。

该调查报告包含了事故的原因、影响和吸取的教训，对于日本政府和国际社会都具有重要的参考价值。

调查报告首先指出，福岛核事故是由于地震和海啸导致核电站失去冷却功能而发生的。

事故暴露了日本核电站在面对这种自然灾害时的脆弱性和缺乏应急准备措施。

报告指出，对于核电站的设计和建设，需要对地震和海啸的潜在影响进行更全面和准确的评估。

此外，报告还强调，核电站应该制定针对自然灾害的详细应急计划，并进行定期训练和演习。

报告还指出，福岛核事故造成了广泛的环境和人类健康影响。

事故导致了大量的核辐射释放，造成附近地区的严重污染。

报告建议，政府应加强对受影响地区的监测和治理措施，确保核辐射的最小化和公众的安全。

此外，报告还建议加强与国际社会的合作，分享有关核辐射的信息和经验，以提高核灾害应对能力。

在教训和改进方面，报告提出了一系列建议。

首先，报告强调了核安全文化的重要性，强调核电站人员的培训和安全意识的提高。

其次，报告建议加强监管机构的角色和责任，确保核电站的运营和管理符合国际标准。

此外，报告还呼吁加强核事故应对和紧急情况的合作，并提供国际援助和支持。

最后，报告总结道，福岛核事故是一次引人深思的事件，对于全球核能行业和核安全事务具有重要的启示。

报告指出，核能是一种重要的清洁能源，但同时也伴随着风险和挑战。

因此，全球需要加强对核电站的管理和监管，并推动技术的发展和创新，以提高核能的安全性和可持续性。

总的来说，IAEA专家组对福岛核事故的调查报告提供了一个全面而深入的分析，对于吸取教训、改进核电站的安全性和应对核灾害具有重要的指导意义。

同时，报告也强调了国际合作和共享信息的重要性，以共同应对核能发展中的挑战和风险。

有关日本东部大地震和海啸引发的核事故的IAEA国际事实发现专家调查团东京，日本福岛第一核电站、福岛第二核电站和东海核电站初步总结IAEA专家调查团——日本行初步总结2011年6月2011年3月11日日本东部9级大地震导致一系列海啸巨浪，日本宫古岛（Miyako）的Aneyoshi最高浪高达到38.9米，海啸侵袭日本东海岸。

地震和海啸巨浪给日本大范围地区造成广泛灾难，14000多人丧生。

此外，至少10000人失踪，当城镇和村庄被毁或被冲，还有更多的人流离失所。

日本基础设施的很多方面都被这一灾难和所造成的损失破坏。

其它行业和一些核电站设施也受到严重地震和海啸巨浪的影响：东海、东村, 女川和东京电力公司福岛第一核电站和福岛第二核电站。

这些核电站的运行机组由于自动系统都成功实现停堆，自动系统是核电站为检测地震本来就有的设计范围。

但是，海啸的巨浪都不同程度地影响到上述核电站设施，其中东京电力公司福岛第一核电站遭受到的破坏最严重。

尽管地震发生时所有厂外电都失去了，东京电力公司第一核电站自动系统在检测到地震时，成功将所有控制棒插入三台正在运行的反应堆，正如设计那样，现有所有应急柴油发电机系统都投入运行。

地震约46分钟后海啸的一系列巨浪的第一个浪头冲击到东京电力公司福岛第一核电站。

这些海啸波浪冲垮了东京电力公司福岛第一核电站设施的所有屏障，这些屏障的设计只能阻挡最高海啸浪高为5.7米及以下的波浪。

当天影响福岛第一核电站的最高浪高估计高于14米。

海啸波浪淹没核电机组纵深区域，造成除了1台应急柴油发电机（6B，移动）以外的所有电力的丧失，厂内或厂外没有其他任何重要的电力来源，外部援助的希望更是渺茫。

东京电力公司福岛第一核电站的电站停电和海啸影响导致1到4号反应堆的仪控系统全部失效，6B应急柴油发电机为5、6号机组同时供应应急电源。

海啸以及随即而来的大量碎片对福岛第一核电站大量构筑物、门、路、箱体和其它现场基础设施造成大范围破坏，包括热阱的丧失。

福岛核事故的调查报告•事故概述•事故原因分析•事故应对措施与救援•事故后果与社会影响•事故调查与总结经验教训•相关责任追究与法律程序•前瞻性研究与发展建议目录事故发生时间与地点2011年3月11日，日本福岛县发生地点福岛第一核电站7级核事故，属于国际最高级别核事故之一。

事故规模影响范围影响时间放射性物质泄漏至大气中，影响到周边地区，包括日本其他县市，甚至影响到邻国。

持续数月，对周边地区的环境和人类健康造成了长期影响。

030201事故的规模与影响福岛核电站设有预警系统，但预警系统在事故发生时没有正常工作。

预警系统日本政府和核电站运营方对核事故的应对准备不足，缺乏应对大规模核事故的经验和措施。

准备不足政府部门和运营方在事故发生后未能及时向公众通报事故情况，导致公众对信息的获取不及时、不充分。

信息沟通不畅事故前的预警与准备福岛核电站设备存在老化和磨损的问题，这使得设备在地震和海啸的冲击下更容易发生故障。

设备老化核电站设备需要定期维护和检查，但实际上，设备的维护并不到位，这使得设备在关键时刻容易出问题。

维护不当设备老化与维护不当地震影响福岛核电站所在地区曾发生过大地震，这使得核电站设备受到严重损坏，进而导致事故的发生。

海啸冲击福岛核电站所在地区也是海啸的多发区，然而，核电站并未针对可能发生的海啸进行充分的预防和应对措施，导致海啸对核电站造成了严重的影响。

地震与海啸的冲击福岛核电站的设计存在一些缺陷，例如安全壳结构不合理、冷却系统失效等，这些因素都增加了事故发生的可能性。

福岛核电站的安全标准并未达到国际先进水平，这也为事故的发生埋下了隐患。

核电站设计与安全缺陷安全标准不足设计问题在事故发生过程中，操作人员的判断失误、操作不当等问题也是导致事故扩大的原因之一。

操作失误核电站的指挥系统也存在一些问题，例如信息传递不畅、决策不及时等，这些问题都影响了事故的应对和处置。

指挥不当人员操作失误与指挥不当紧急疏散与撤离计划紧急疏散在事故发生后，福岛核电站周边地区的居民被紧急疏散，以避免放射性物质泄漏可能带来的伤害。

IAEA公布福岛核事故报告
王海丹
【期刊名称】《国外核新闻》
【年(卷),期】2015(0)9
【摘要】【国际原子能机构网站2015年8月31日报道】2015年8月31日,国际原子能机构(IAEA)理事会发布了《福岛第一核电厂事故——总干事的报告》(以下简称《总干事的报告》)。

《总干事的报告》是根据总干事在2012年9月原子
能机构大会上提出的'原子能机构将编写一份关于福岛第一核电厂事故的报告,该报告将是权威性、符合事实和均衡的评定,并涉及事故的原因和后果及所汲取的教训'要求编写的。

【总页数】7页(P21-27)
【关键词】核事故;国际原子能机构;IAEA;辐射剂量;纵深防御;辐射照射;辐射防护;设计基准事故;有效剂量;乏
【作者】王海丹
【作者单位】
【正文语种】中文
【中图分类】TM623.8
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2.IAEA发布福岛核事故国际实情调查团报告 [J],
3.世界卫生组织公布福岛核事故健康风险报告 [J], 伍浩松（译）;
4.IAEA公布福岛第一核电站中长期退役路线图的同行评审报告 [J], 伍浩松;
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