On the Root Causes of the Fukushima Daiichi Disaster from the Perspective of High Complexity and Tight Coupling in Large-Scale Systems

This study explores the root causes of the Fukushima Daiichi disaster and discusses how the complexity and tight coupling in large-scale systems should be reduced under emergencies such as station blackout (SBO) to prevent future disasters. First, on the basis of a summary of the published literature on the Fukushima Daiichi disaster, we found that the direct causes (i.e., malfunctions and problems) included overlooking the loss of coolant and the nuclear reactor's failure to cool down. Second, we verified that two characteristics proposed in "normal accident" theory-high complexity and tight coupling-underlay each of the direct causes. These two characteristics were found to have made emergency management more challenging. We discuss how such disasters in large-scale systems with high complexity and tight coupling could be prevented through an organizational and managerial approach that can remove asymmetry of authority and information and foster a climate of openly discussing critical safety issues in nuclear power plants.