Power Point Presentation Case Failure Of Tokai Mura Accident

Final Presentation:

1.            The presentation is presenting the  case analysis as a power point presentation. So the presentation will cover only part 1 of your final paper.

Use that as a guideline in making your presentations.

3.            You have the following options for the presentation:


a.            PowerPoint with annotated slides: In this option you make the slides and add notes to it (in the notes area of each slide). These notes must help the audience understand your case analysis. The notes must also be succinct.


PART I: Tokaimura Criticality Accident 1999





Would you go to work if you thought you had a chance of dying?

NO! These workers who were killed during the Tokai-mura accident didn’t think so either. However, how would you feel if I told you that their deaths were preventable? Pretty upsetting right? The cause of the accident was based on "human error and serious breaches of safety principles," according to the International Atomic Energy Agency (IAEA)(Nighswonger, 1999) The headline statement from the IAEA really jumped out at me especially when safety should be priority when dealing with radiation and nuclear facilities. Throughout my term paper, I will identify and describe appropriate managerial principles to solve technical management challenges that the Tokaimura facility faced as key failures identified by the Nuclear Regulatory Commission. These failures were very SIMPLE and PREVENTABLE issues that could have saved and prevented death and injury that these three workers sustained that

day on September 30th, 1999 at the Tokaimura facility.


Background of Failure

On September 30, 1999, an accident occurred at a uranium fuel conversion test facility of JCO Co., Ltd. Tokaimura, Japan.  JCO has operated mainly conversion facilities to produce uranium oxide powder or uranyl nitrate solution from low enriched uranium hexafluoride. The accident was triggered by pouring a sufficient amount of the 18.8% enriched uranium solution into a precipitation vessel, causing a high-level reaction, and was terminated after approximately 19 hours by draining the cooling water around the vessel, which acted as a neutron reflector to maintain the condition. As a result, this accident gave serious radiation doses to 3 employees and fatal doses to 2 of them; further, neutrons and gamma-rays emitted by the accident caused doses to many residents, JCO employees, and emergency personnel who attempted to terminate the

condition and to rescue the 3 employees. The dominant dose for the residents and the JCO employees was caused by neutrons and gamma-rays produced in the precipitation vessel. The individual dose was estimated for 234 residents, 169 JCO employees and 260 emergency personnel, respectively. (Tanaka, 2002) The Tokaimura accident of 1999 is the third most serious accident in the history of nuclear power, after the 1986 Chernobyl accident and the 1979 Three Mile Island accident but unlike the other cases, the Tokaimura accident did not involve a nuclear power station but a nuclear fuel factory where no nuclear chain reaction should ever happen. (Hoover, 2011)  The accident happened when workers preparing nuclear fuels mixed uranium oxide with nitric acid using a stainless-steel container instead of a mixing apparatus. The shortcut was described in an illegal operating manual drafted by the company. The manual had never been approved by the supervising ministry, as was legally required.

The procedure violated some of the most basic safety requirements that were well known in the nuclear industry since the early 1940's. Safety in the nuclear fuel cycle has always been focused on reactor operations, where a huge amount of energy is released continuously in a small volume of material, and where there are substantial amounts of radioactive materials which would be very hazardous if released to the biosphere. The investigations of the accident revealed that JCO allowed unsafe procedures in order to save time and money. In addition, the workers had no proper qualifications and had not received proper training. Moreover, no emergency routines had been prepared, as criticality events were considered unrealistic. The poor crisis management and restrictive information policy during and after the accident were criticized by scientists, politicians and reporters.. With all of this identified,

I will continue to analyze the failures from this report.

Analysis of Failure using the Management Functions

This objective of this paper will consist of analyzing the failures by listing and applying the functions of engineering management decisions with the accident using the five management functions. The Nuclear Regulatory Committee analyzes the failure of management in this accident that led to a few by conclusions drawn by the investigations conducted by the Government of Japan. It revealed that there were three general root causes involved with the Tokai-mura criticality accident: The report from the NRC addressed failures that led to the cause of the accident, which included: inadequate regulatory oversight; overall lack of an appropriate safety culture at the JCO facility and inadequate worker training and qualification. (NRC Review, 2000) I think that most of these failures led to human factors issues. The procedure verification and validation

wasn’t happening both from the employees nor supervisors.  Operational management deficiencies related to operational control as well as operator training and qualification that presented as lacking as well as  approval for transfer of nuclear material. There should have been supervisory authorization of solution transfers, however supervisors were not present. Technical management of the preparation, review and approval of operating procedures, specifically highlighting the failure to require and obtain approval of the safety management group were neglected. Business management in that the company did not pay full attention to a process involving the manufacturing of special products in small quantities on an irregular basis and a licensing process that did not consider a criticality accident to be credible. Lastly, the safety regulation process did not include appropriate inspections.The ah-ha moments that occurred to me wastrying to understand how long supervisors

allowed these kinds of acts to keep occurring. Why hadn’t another authority caught these kinds of unsafe acts and rituals??? How long had this been occurring? Why were inspections not being done? What really surprised me after all this was the little changed in terms of a nuclear safety culture, as the meltdowns of the Fukushima reactor in 2011 painfully demonstrated.Analyzing the management’s decision based on the accident and proposing  effective and possible  solutionsto presented problems and using the management functions listed below is categorized by using the acronym POSDCORB. (Bonoma, T, & Slevin, 1978) We can use these categories to progress on the proposed plan as well to discuss the way ahead for JCO to prevent and mitigate an accident like Tokaimura from happening again.

·         Planning: planning the way ahead to prevent an accident like this from happening again I believe will

take ALL aspects of management and outside agencies to help assist with policy. Anticipating problems and preventing accidents from reoccurring will be top managements priority and goal.


·          Organizing: management will establish structures and systems that will address the response of specific objectives to meet the need in case an emergency arises.


·         Staffing: will ensure the company has adequate staffing to meet the demand of isotope and nuclear production safely and effectively. This will include selecting and training staff and maintaining safe work conditions and ensure all certifications and responsibilities are met.


·         Directing: management will need to make appropriate, effective and safe decisions and set the example by leading and directing what right looks



·         Coordinating: this will take JCO and several other agencies to come in and set up remedial training and continuing to conduct routine audits and inspections of the facility to ensure employee safety is being met and short-cuts are avoided.


·         Reporting: criticality drills will be rehearsed and everyone will report and UNSAFE acts to their immediate supervisors.

·         Budgeting: this will be an initial burden due to the accident; however will be management’s responsibility to invest the money into shielding barriers and lead PPE that will satisfy the safety requirement for employees.


Text Box: 2. Choice of controls:  Consider the controls in the form of rules or work procedures needed to achieve process goals while controlling the process.

width="259" height="116">Text Box: 1. Process Designer:   Define processes, scenarios. Performance goals and hazards associated with worker activities.Moving forward and implementing some kind of organizational strategy for both short and long term plans I developed this flow chart to help JCO consider moving forward.
























Analysis of Failure using the Balanced Scorecard Approach





Expense of safety equipment installation

Safety measures implemented (physical barriers)



Trusted processes

QA/QC inspection

Employee Satisfaction

Routine Audits





Management improvement


Follow up and monitoring


Communicate risks effectively




Innovation and Learning



Employee education



Skills assessed of handling radioactive material

Process improvement with functional excellence

Risk Management: Through the use of a Balanced Scorecard (Kaplan, 1992) an analysis of a management plan can be obtained, ideally alleviating some risks that may arise and outline goals and measures for the Tokaimura facility.



The criticality accident was the violation of procedural regulations, but revealed in itself a simple accident. However, it is by no means simple from the standpoint of prevention of similar accidents discussing the lessons learned from JCO accident, it is one of the most thought-provoking experiences in a nuclear energy related facility, not only in Japan but also in the world. It caused fatalities

among employees as well as emergency evacuation of neighboring residents. It posed a lot of issues which should be discussed not only among nuclear fuel processing industries but also among other nuclear industries and among those who handle radioactive materials. What has really been learned is that another significant event can still happen anywhere and at any time if a strong vigilance of maintaining safety is not exercised by highest priority. Recommendations will place heavy responsibilities upon those who are expected to carry them out and will take extraordinary efforts from the management of the facility. I recommend that the Tokaimura facility be inspected and audited routinely to foster a safe work environment and to avoid shortcuts.




href="http://www.ehstoday.com/author/todd-nighswonger">Todd Nighswonger, Nov 17, 1999, http://www.ehstoday.com/news/ehs_imp_32563

2.)    S. Tanaka, "Summary of the JCO Criticality Accident in Tokai-Mura and a Dose Assessment," J. Radiat. Res. 42, Suppl., S1 (2001).

3.)    W. D. Hoover, Historical Dictionary of Postwar Japan (Scarecrow Press, 2011).

4.)    NRC Review of Tokai-mura Criticality accident , April 2000 Division of Fuel Cycle Safety and Safeguards Office of Nuclear Material Safeguards US Nuclear Regulatory Commission (pg. 3)  https://www.nrc.gov/reading-rm/doc-collections/commission/secys/2000/secy2000-0085/attachment1.pdf

5.)    Bonoma, T, & Slevin, D. P.

(1978). Executive survival manual. Boston: CBI Publishing Company


6.)    Kaplan, R., Norton, D. (1992). The Balanced Scorecard-Measures that Drive Performance. Harvard Business Review, January-February Edition, 69-80.

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