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Crisis Management Failures in Japan's Reactors and the BP Spill

A potentially catastrophic technological problem, an incomplete crisis response plan, misleading early information, divided private and public authority, ineffective initial actions.

This could describe the current situation at the Fukushima Daiichi nuclear power plant and its six reactors. But, it also describes what happened after the April 20, 2010 explosion of the Deepwater Horizon oil rig in the Gulf of Mexico.

These two unprecedented events are stark reminders that effective crisis management involving complex science and technology is wholly dependent on well-thought-out — and actively practiced — crisis response plans. Of course, such plans will have to adapt to actual events, but without a robust plan, "seat of the pants" crisis management won't work. This is a lesson of vital importance to business and government in a host of technological activities that are potentially dangerous but economically significant. It is of even greater importance if a major act of terrorism involving nuclear, chemical, biological or cyber weapons occurs, either in private sector facilities or public spaces that impact private employers.

The fact that many of the problems relating to crisis response and crisis management recurred in Japan, with the Gulf spill still freshly in mind, shows how easy it is to talk the talk on these matters of crucial importance, and how difficult to actually execute in the turbulence of low probability but high consequence events.

Although the Japanese nuclear event is not yet a week old and information is impressionistic and fragmentary, it bears a striking resemblance in a number of dimensions to the Gulf spill which occurred almost a year ago and has since been carefully analyzed (see, for example, the Report of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, January 11, 2011):

Response Plan. Neither the Gulf spill nor the problems at the Japan nuclear plants were unthinkable. The possibility of a well blow-out was explicitly addressed by systems, processes and technology. Planning for the possibility of a severe earthquake and a subsequent tsunami were part of Japanese reliance on nuclear power. Yet, neither BP and the U.S. government nor Tokyo Electric Power Company (TEPCO) and the Japanese government had response plans which addressed the sequence of events that, though remote, were arguably foreseeable in environments where dangerous technology was located and which, in particular, addressed the additional issues outlined below.

Public or Private Responsibility? The U.S. government initially left many dimensions of crisis management and response to BP. But, the Gulf spill was a national issue, which required governmental direction, responsibility and accountability. The BP Commission properly criticized the federal government for failing to assume leadership soon enough or to act effectively in coordinating the private sector and public sector (federal, state and local) actors. In Japan, although the government has taken the lead on many aspects of the post-earthquake/tsunami crisis, there has been confusion about who is in charge at the nuclear plants. Where is the central government? Where is the nuclear regulator? As Michiyo Nakamoto pointed out in the Financial Times, the government inititially left many decisions to TEPCO (before forming a "joint" task force) , and then criticized the utility even though this is now a national emergency requiring the exercise of national authority.

Confusing Information. A host of factual questions were raised by Gulf Spill: How much oil was flowing? How could the flow be stopped? Where was the oil going (surface/sub-surface)? How could it be contained or removed? How could damage to environment/people/property be eliminated or mitigated? But for a significant period of time, responses from the company and the government were confusing. The U.S. government needed a central authority which used expert working groups, and which made clear to the public what was known, what was unknown, what process was in place for improving knowledge, and when there would be regular updates on those issues. A similar set of problems bedevils Japan. There are critical questions about condition of the reactors; possible physical and chemical reactions in the reactor areas; actions being take to reduce those risks; radiation releases; health implications. Yet there has been a welter of voices from the government and industry which has left Japanese citizens — and the world — confused. Again, a single central authority needs to have seized control of the information flow and been as candid and explicit as possible about what is known, what isn't known, and how information gaps are being filled.

Decision-Making Processes. As noted, there was substantial confusion for weeks after the Gulf spill about whether the company or different parts of government were making decisions. The decision-making processes on a host of crisis response issues (see preceding paragraph) were not set out clearly for the public — including comparision of options — and led to a perception of drift and lack of direction during a major national catastrophe. A similar concern appears to apply in Japan, where opaqueness prevails about who is making decisions about what options, with what parties at the table, and with which other parties advising (from around the world). This, too, contributes to the growing sense that the public and private authorities do not have the situation in hand (and, in fact, may be losing control).

Implementation and Resources. In the Gulf, there were also serious issues about which private and public sector actors would implement which decisions — and about what resources were necessary. Indeed, just the lack of resource preparedness increased the severity of problems of containment and damage mitigation. In Japan, it is very hard to tell at the moment who is responsible for carrying out which decisions at the nuclear plants as TEPCO has been shifting employees around the plant (leaving, at the moment, 50 heroic technicians to deal with four reactors in stress and two more at risk at the Fukushima Daiichi plant) — and it is far from clear if regulatory experts (from inside or outside Japan) are on or near the site at all.

These are issues which every company with potentially catastrophic processes, products, or plants needs to answer with a special team of "worst case" analysts. Such analysis then has to be transformed into a response plan. Where the issue involves government — and in most cases it will — the company needs to coordinate its planning with federal, state and local authorities. After 9/11, many companies analyzed these issues with respect to terrorist acts at their facilities or terrorist acts which, if not directed at the company, could still have significant impact on people, facilities, information and supply chain.

Yet, many experts in crisis response and crisis management would say that without practice, without simulations, these response plans merely gather dust and are not effective when the hundred-year event occurs. In the military, war games can be a vital tool for learning how to respond to crisis situations. We need a "war game" mentality in the private sector to address the severe conceptual and operational problems in crisis response and crisis management which the Gulf Spill and the Japan nuclear events so starkly illustrate.

Ben W. Heineman, Jr., GE's former Senior Vice President for Law and Public Affairs, is senior fellow at Harvard Law School's Program on the Legal Profession and Program on Corporate Governance and senior fellow at the Kennedy School's Belfer Center for Science and International Affairs. He is author of High Performance with High Integrity (Harvard Business Press, 2008).

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  • Albert 1 month ago
    We have created a myriad of complex systems that are considered extremely safe and have astronomical chances of failure according to the experts. When, against all odds, these systems fail, whether it be a oil rig or a nuclear power plant or safe mortgage bonds, we lack the capability to react effectively to the situation. When the unexpected strikes we are left to improvise. We have so much faith in these systems not failing that it hampers planning for these situations.

    Crisis situations magnify and strain the weak links in an organization. A hallmark of many of these situations is that precious time is squandered during the crises either on inaction, action that is ineffective or action that makes the situation worse. The bottom line is that many organizations are initially failures at crises management.

    The unexpected is inevitable. Planning for every possible failure is impossible. However, creating teams that are trained in the management of crises is possible. Basics principles like timely escalation, effective communication with the public, option analysis, threat identification and risk management need to be commonly available tools that can be called into action effectively. The sophistication and prevalence of the technology we have today exceeds our ability to manage the crisis that may be spawned by the technology. The situation is dangerous given that the technolgy that has been harnessed has the ability to harm life and the environment in an unprecedented manner.

    Education is key to mitigation of this hazard. Training needs to become more widespread in industry and graduates need to have a better foundation in the area of crisis management.
  • Amen to your last paragraph regarding planning. A key problem is the lack of imagination as well as commitment to plan for the very worst thing that could ever happen.

    Ironically, Japan built a 10 meter high wall in the north based on lessons of past Tsunamis. They did not plan for anything beyond past experience.

    No one wants to think the worst can happen. But, as one anonymous pundit said, "When I think of us (sic) human beings, it seems to me that we have a lot of nerve to make fun of an ostrich."

  • Fantastic post, particuarly your last paragraph. One note of clarification, however. What you decribe there is TESTING, not necessarily training. Simulations and war games are designed to test gaps in systems, plans, abilities. Yes, participants learn and are sensitized to crisis situations...but that's a subordinate goal.

    Training accomplishes much more. Here's a post I wrote nearly a year ago on some elements of training that could have applied to both situations: http://www.jamesjdonnelly.com/...
  • Peter Urey 1 month ago
    http://fearlessconsulting.co.u...

    Western leaders, academics, diplomats and politicians have a role to play in persuading their Japanese counterparts that the Asian cultural imperative to remain in denial and avoid shame is not the response that global media are expecting or will tolerate.

    In the immediate short term civil disorder is more dangerous than radiation.

    It's not the fashionable thing to say but life is more at risk from a government in denial and an over speculative media than from a responsible but State controlled (censored) news release programme with advice from US lawyers and media experts.



  • Johnrstender 1 month ago
    1- water containment, close access to water intake ,use as a resevoir circulate spent water and contaminated water,
    use the exhaust stacks as electromagnet to capture radioactive particles place coils of wire over them
    take microwave dishes facing each other and amplify the super thin field frequency so that the temperature is equalient to sun temp burn of the radioactive particles as the vent
  • Najchapman 1 month ago
    Crisis response/management is an everyday thing. Businesses that can't prioritize their objectives, reach clear decisions efficiently and effectively,and don't use time/dollars and resources well, won't suddenly do so in a crisis. They will struggle under the pressure.
    Therefore, planning and practising for crisis management aren't wasted activities that may never pay off - they are investments for operating a good business all the time. Shareholders and managers should demand it.
  • be it a real crisis in the BP spill or Japan Reactors, it is the same human behaviour re-enacting the scenes like in 2008 with the banking crisis.. leaders are simply not hands on enough to know the ground, neither their Lieutenants, despite these guys being paid millions for the job.
  • Caedmon 1 month ago
    Nobody mentions pumps. Suppose it had been decided that the basic thing was always to have plenty of water no matter what, to cool the rods. You could have installed five different sets of pipes, hoses, any one of which would have been enough, like the five redundant computers in the Space Shuttle or Moon craft. One could have been a simple fire hose. You could have dragged water tankers behind bulldozers to hook up to any of the different hoses or pipes. You could have distributed little trailers for people to drag behind their autos! You could have been prepared to do this for years to come. But no, whatever you do, don't call on people for help! I,John Q Public, have called on girls of eighteen to dig out a bus in a snowstorm!
  • Srjdhartzell 1 month ago
    It is clear that when corporations offer service to a vast percentage of the population, as power companies and oil companies do, there should be a form of 'checks-and balances' by the government. For example, if we look at the financial crisis in the United States it is clear that a lack of government monitoring was a fault. Just as in finance, government must take a more active role in insuring companies have emergency plans in place to avoid disaster. However, there must be a balance as governments have a tendency to over-regulate when they medal in the affairs of the private sector. Let's home these hard lessons allow us to reach that balance to avoid such catastrphies.
  • It appears that the management of the damaged power plant crisis is flawed. The leaders give narrow technical data points but the only real message seems to be remain calm. No one seems able to form what seems to be the key concept.

    All of the assessments to date have in error by being far too optimistic. It seems clear that what ever the cause the decision making process is flawed. It appears that the thinking seems to be to conduct a salvage operation and Humpdy Dumpty will be heroically repaired. The risks for this is simply beyond calculation and could fail incrementally or catastrophically at any point.

    No one seems to put together that that "win" as noble at it seems is not really as important as making as concluding this disaster and starting the recovery process. Entomb all the all of the Humpty Dumpty quickly as an 'abundance of caution' goal.

    Might a leader say, "I know you probably would have heroically succeed fixing Humpty but we must return the country to normal as quickly as possible. You are all hero's and we have no time for fault finding as it simply will impede the heroic rebuilding process."

    Assigning blame for all this is really a foolish exercise. No one did or could have calculated all of the ways things could have gone wrong. We can either spend our lives in analysis paralysis or simply say we are not gods. Our best sometimes is not enough. Uncertainty is simply our temporal reality. This is why some of us ask for the provident care of the Almighty.

    Although I do not agree, unbelievers might be reminded that current cosmological thinking is that there is something rather because of uncertainty. The higgs boson partial was activated by the Heisenberg uncertainty principle and today we are here.

    So there is no reason for anyone to feel bad it simply was a tie game this time. Now clean up the mess.
  • A culture of complacency takes no effort. In good times people and companies can be successful despite themselves; they are anaesthetized to the magnitude and severity of situations that can alter their futures. This crisis of competence is never so more apparent than under situations of actual crisis.

    To me the article says stick to the fundamentals go back to basics, it’s the building blocks and foundation that make you successful. The more prepared you are the more able you’ll be able to handle any situations – so set the bar higher, and make yourself or your company robust.
  • Actually it isn't just in the aftermath of a disaster that the parallels between Japan and BP crop up. In both instances, business leaders fell in love with complexity - which left them, when things went wrong, with organizations they did not know how to manage.
    http://www.bnet.com/blog/busin...
  • One other point about crisis response planning in these cases bears emphasis in light of all three comments. This was not 9/11 which, I would argue, was truly unforeseeable (one didn't design buildings to take direct hits from fully loaded airliners).

    But in these two cases it was foreseeable that oil could escape from a well in an uncontrolled way or that a tsunami might threaten all electrical sources and thus water circulation so critical to reactor cooling. The question is always whether it is worth spending the time and effort on the low probability and high consequence event. The Gulf Spill ad the Japan reactors show that conpanies ignore these issues at their peril,
  • Also this piece only about crisis response and crisis management. But, of course, preventing these events from happening in first place is the key----which in a nutshell involves a safety culture, safety management and safety process driven with intensity from the board and CEO all the way down into the organization,
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