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A foreign specialist commenting on the safety measures put by the JCO factory after the Tokaimura accident said that the plant “had the safety standards of a bakery and not a nuclear facility” (www.joewein.de). Experts, pointing an accusing finger at the management of the plant and government authorities, have echoed these sentiments.
Controversy has raged on over the ethical issues surrounding the Tokaimura accident. These range from the inadequate training of the technician and management. Some obvious questions have been raised.
Were the plant technicians armed with enough skills, experience and diligence to handle this kind of job? Had the management of JCO amply erected the necessary measures, facilities and standards for a plant of such magnitude? Were all the legal standards and regulations complied with, and if not, why?
To determine the ethical issues surrounding the accident, it becomes important to recap the chronology of the events that day and highlight on the obvious mistakes that will demonstrate gross incompetence and blatant disregard of safety standards by the management as well as the ignorance displayed by the technicians. The paper will also propose a number of recommendations on the appropriate measures that can be employed both within the factory and the industry at large to ensure that such accidents find no room in the future.
On September 30, 1999, people in Japan woke up to the news of a severe accident that would have resulted to mass fatalities. The scene of the accident was at JCO, a nuclear fuel plant in Tokaimura over one hundred and thirty kilometers from Tokyo. Two fatalities were recorded although not immediately. This accident, the third most severe having in mind the Chenobyl accident in 1986 and the Three Miles Island in 1979. But unlike these prior accidents, the Tokaimura one was unique in that it was not a nuclear power plant but rather was a fuel factory.
Prior to the accident, three technicians were on the final stages of the fuel-processing unit. They were in haste and ended up decanting Uranyl Nitrate not in the usual recommended tank but in a water container, a gross violation of standards. They filled the precipitation container with quality of around 16kg, 700 percent over what the Science and Technology Agency (STA), Japans regulatory body, had recommended and above what the tank could hold. Such a process was in violation of the factory manual and against the conventional norms and standards that had been in operation since 1940s.
The amount of uranium poured into the tank was too much such that it resulted into a blue flash, a nausea attack and insurmountable pain was experienced by the technicians who were near the tank.The mixture was reacting on its own and the chain of reaction that ensued led to the release of radioactive elements. This would continue for many hours, without the realization that the resultant effect would be harmful. It would take hours before the three workers would move away from the scene of the chain. Medical help was sought for the technicians but still the management had not comprehended the gravity of the situation. It took time the to extinguish the reaction as the factory had to seek for help from outside. No evacuation measures were taken immediately and additionally a number of people were exposed to the radiation; the dose was too high.
The official count of all that had been exposed to the radiation was 667 persons. Radiation level was high at “4.5 mSv/hr for neutrons” and “0.50 mSv/hr for gamma rays.”(Michael E.R., 2001). This was over a 1000 percent of the usual gamma available in the atmosphere. This exposure continues to have devastating effects on the victims’ health (Robert C. Ricks, et al, 2002).
A similar accident had occurred in Tokaimura after an explosion gutted down a demonstration facility. A facility where, according to Hiroshi I:
…Low radioactive nuclear waste water with molten bitumen and evaporates water in a stream-heated extruder at 180 and pours the molten mixture into steel drum to cool down (temp.onlineethics.org/cases/iino.html)
The resultant mixture due to the excessive levels of sodium nitrate oxidation was very likely to explode especially if the temperatures got high.
In this particular incident, the temperature had risen to an alarming level but change would not have been registered as the installed thermometer had earlier in the years malfunctioned. The technicians on the ground raised their concerns with the engineers in charge but they responded after the explosion had occurred and radioactive elements escaped. Luckily, there were no injuries or fatalities but several ethical questions were raised. The competence the engineers came into question as well as the layout or the design of the experiment. The engineers did not respond on time even after being informed of the fire that had been priorly extinguished by the ground technicians. They were not vigilant or curious enough to know what was happening or how the safety control measures were operating. This is because they had given up their core roles on the ground and taken up their role in the offices as managers, with little regard taken to ensure the safety of the workers or the neighboring community, despite the fact that this plant was located in a populated area (T.N. Sasaki, 1998).
Another incident in point that occurred in Japan was in Morju, Tsuruga City, on December 8, 1995. Here, as in the case above, a fire razed a prototype reactor after sodium leak. This reactor was a responsibility of the Power reactor and Nuclear fuel development (PNC), an organization that was further controlled by the government of Japan.
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Sodium coolant is under no circumstances radioactive, but in this case when it leaked, there were huge delays in shutting it down. This resulted to a chain of chemical reactions. The quality of this nuclear plant was put into question especially as new details emerged of the shoddy engineering work done at the factory.
A number of fundamentals rules of chemistry and obvious reactions had been ignored. The engineers had used a “sharp edge cut design” which possibly resulted to increased stress that led to breakage and leakage. Rather than using a rounded design (temp.onlineethics.org). There were other evident obvious design flaws that may have been overlooked. Earlier on, queries had been raised by anti nuclear movements on the safety level of the plant and PNC had reacted to the affirmative. Again, the competence of the engineers was put in to question. They had not taken diligent and reasonable care in the plant design or taken the necessary effort to inform the public of the leakages, despite having been aware of it. No manuals were evident to detail the necessary procedure to be taken in case such a leakage occurred. The engineers or the technicians on the ground were not also amply skilled to make any reasonable professional judgment on how such a catastrophe could have been reversed.
The reactor had been around for 18 years with no mishap, the pioneer of the plant had all along left the factory and a new breed brought in. This new generation had overlooked the system thinking it was an easy operation only to be overwhelmed when the leakage occurred. The engineers had misled the public by insisting that the reactor was safe, when it is common knowledge that no nuclear plant can be said to be fault free.
Majority of nuclear plants accidents that have occurred are as a result of human errors. The Tokaimura incident is no exception. The three workers made a grave technical and rudimentary mistake. They poured 19 percent enriched uranium to a tank that under normal circumstances was used for precipitation. Such a mistake was not only as a result of the workers own incompetence and ignorance but also stemmed from far. As afore mentioned, the procedure of mixing the material was not adhered to. The factory was not supposed to deal with such highly enriched uranium and it was not well equipped for such a venture. There was no foresight for such accident as can be seen from the internal structure and controls in the plant. There were no elaborate depressurization pumps or shielding containers befitting a nuclear plant.
One factor that points towards lack of these facilities would be the immense and unreasonable urge to cut on cost on the side of the management. The fuel industry in Japan had been under pressure especially as a result of the competition rocking the industry. Plutonium had ceased to become a reliable source of energy. In an effort to contain the costs, the management had circumvented the required procedures advising the workers to use containers that were larger than the recommended size to increase the production process. The low enriched uranium posed no threat of any fatality. At 3%, the workers were not exposing themselves to any accident, but the facilities used were meant for highly enriched uranium and it is evident that the workers did so with no prior appreciation of the risks they were exposing themselves to.
They had not envisioned a situation where by “a mass of nuclear material is more likely to go critical if the container geometry boosts the probability of neutrons colliding with atoms”. (Staging.spectrum.odaly.com)
There are three errors by the workers that point a finger at gross incompetence
- They failed to use the dissolving tank choosing instead to use the 10 liters containers when oxidizing the acid in their bid to speed up the reaction.
- They surpassed the authorized ratio of uranium by seven times.
- The precipitation tank used lacked the geometric characteristics necessary to prevent the reaction from reaching the critical mass level.
The incident not withstanding, the technicians were not in the right attire for the task. They had not been supplied with the necessary protective clothing.It is said that they were in t-shirts and without the right instruments to measure radioactive fluctuations. There were apparent flaws on how the technicians were trained; there was a blatant ignorance and disregard of the relationship between mass and the amount of concentration of the uranium that could turn fatal. Hiroshi Iino (Pg 4) notes that, in this incident there were qualified and competent engineers who could have overseen the activities on the ground but they were unavailable.
Whereas majority of the mistakes may be traced to the management, there is no evidence of strict adherence to professional ethics. The engineers had failed to point out the apparent flaws. This could extend to even those who were not charged with the responsibility of overseeing the operation. This duty was left to the incompetent technician who were trying to improve the situation the only way they could, without the engineers raising an eyebrow. The manual too that was being used had not been approved as per the legal requirements, neither had it been revisited or updated despite the knowledge that it was obsolete. This was management flaw.
Possible course of action
More questions than answers are raised upon the analysis of the Tokaimura accident as well as other nuclear reaction related accidents in the world. These questions revolve around management and professional ethics. It is more than apparent that TCO was negligent and for the better part liable for the fatalities. While the importance of plutonium has to be underscored, it is important to outlaw any experiments involving the mixing plutonium and uranium to reduce the risks of a similar incident.
More efforts should be geared towards improving the safety of the workers through refresher courses and further training. Introducing a safety culture through massive campaigns within an organization can achieve this. Defense and safety measures should be introduced at all the four levels: The individual, managerial, internal as well as external level. This revolves around the detection of errors. If the individual personnel on the ground are unable to detect the flaws, then the supervisors will. The internal regulators in the industry and the government agencies also have a role to play.
The competence and qualifications of all employees and technicians handling the volatile chemicals should be thoroughly scrutinized on a regular basis and any violators penalized to reduce chances of a similar occurrence. It is also important that the regulatory bodies carry out inspections to all nuclear plants to establish that engineers and the management of such factories adhere to the laid down standards. This should be done yearly.
Tokaimura accident has not been an isolated case but rather there has been a string of such incidents involving accidental release of radioactive elements. Chernobyl nuclear reactor accident is a good example. Most of these accidents have been as a result of management and professional negligence. Had there been more diligence and dutiful care from the engineers involved, some of these accidents could not have happened. The government must be more vigilant, through the relevant agencies, in enforcing the legislations on the standards of handling radioactive elements, as well as ensuring that the safety and evacuation measures are put in place in case a repeat scenario emerges (Toshiyashu H., Makoto A., 2002).
The first priority of the engineers, supervisors or any ground technicians is to ensure the safety of the public and should in no way compromise the publics’ interest for any material gain (George D. Catalano, 2006). In doing so, all reasonable care should be employed. Professionals should also be at the forefront in informing the public on the appropriateness of the security measures employed to ensure the safety of the public. In the vicinity of any danger, the public should be made aware the soonest possible so that evacuation can start immediately. In case of any malpractice or any evidence that a standard has been violated, it is important that the respective workers raise their concerns with the relevant authorities on the matter. Safety should not under any circumstances be compromised for material gain.
Hiroshi Lino, 2001. Teaching Engineering Ethics in Japan. Session 8D2. International conference on engineering education.. p. 4. Web.
Jenis Wilkinson. Questions on the Tokaimura Accident.
T.N. Sasaki, T. Koyama, E. Omori, Amaki and T Yamaniuchi, 1998. “study on the cause of the fire and explosion incident at bituminisation demonstration facility at PNC Tokai works” spectrum 798, Denver, Colorado U.S.A 13-18.
Michael E. Ryan, 2001.The Tokaimura Accident.
George D. Catalano, 2006.Engineering Ethics: Peace, Justice and the earth. Morgan & Claypool publishers.
Robert C. Ricks, Mary Ellen Berger, Fredrick Michael O Hara, 2002.The medical basis for radiation-accident preparedness. The clinical care of victims. Taylor & Francis
Toshiyashu Hirama, Makoto Akashi, 2002.Book review’. Journal of radiation research, vol 41.
William Sweet, 2004.The third Japanese Nuclear Accident. Spectrum online. Web.