alt Hacker NewsIn reality the "swiss cheese" holes for major accidents often turn out to be large holes that were thought to be small at the time.
> [Fukushima] No small alignment of circumstances needed.
The tsunami is what initiated the accident, but the consequences were so severe precisely because of decades of bad decisions, many of which would have been assumed to be minor decisions at the time they were made. E.g.
- The design earthquake and tsunami threat
- Not reassessing the design earthquake and tsunami threat in light of experience
- At a national level, not identifying that different plants were being built to different design tsunami threats (an otherwise similar plant avoid damage by virtue of its taller seawall)
- At a national level, having too much trust in nuclear power industry companies, and not reconsidering that confidence after a number of serious incidents
- Design locations of emergency equipment in the plant complex (e.g. putting pumps and generators needed for emergency cooling in areas that would flood)
- Not reassessing the locations and types of emergency equipment in the plant (i.e. identifying that a flood of the complex could disable emergency cooling systems)
- At a company and national level, not having emergency plans to provide backup power and cooling flow to a damaged power plant
- At a company and national level, not having a clear hierarchy of control and objective during serious emergencies (e.g. not making/being able to make the prompt decision to start emergency cooling with sea water)
Many or all of these failures were necessary in combination for the accident to become the disaster it was. Remove just a few of those failures and the accident is prevented entirely (e.g. a taller seawall is built or retrofitted) or greatly reduced (e.g. the plant is still rendered inoperable but without multiple meltdowns and with minimal radioactive release).
To be blunt; that isn't an appropriate application of the swiss cheese model to Fukushima. It isn't a swiss cheese failure if it was hit by an out-of-design-spec event. Risk models won't help there. Every engineered system has design tolerances. And that system will eventually be hit by a situation outside the tolerances and fail. Risk models aren't to overcome that reality - they are one of a number of tools for making sure that systems can tolerate situations that they were designed for.
If Japan gets traumatised and changes their risk tolerance in response then sure, that is something they could do. But from an engineering perspective it isn't a series of small circumstances leading to a failure - it is a single event that the design was never built to tolerate leading to a failure. There is a lot to learn, but there isn't a chain of small defence failures leading to an unexpected outcome. By choice, they never built defences against this so the defences aren't there to fail.
> Many or all of these failures were necessary in combination for the accident to become the disaster it was.
Most of those items on your list aren't even mistakes. Japan could reasonably re-do everything they did all over again in the same way that they could simply rebuild all the other buildings that were destroyed in much the same way they did the first time. They probably won't, but it is a perfectly reasonable option.
Again I'm going from memory with the numbers but doubling the cost of a rare disaster in a way that injures ... pretty much nobody ... is a great trade for cheap secure energy. It isn't a clear case that anything needs to change or even went wrong in the design process. Massive earthquakes and tsunamis aren't easy to deal with.