Severe accidents and lessons learned: design and organizational factors perspective after Fukushima

The Great East Japan Earthquake and the subsequent tsunami on 11 March 2011 initiated accident conditions at several nuclear power plants (NPPs) on the north-east coast of Japan and developed into a severe accident at the Fukushima Daiichi NPP, which highlighted a number of nuclear safety issues. After the Fukushima Daiichi accident, new research and development (R&D) activities have been undertaken by many countries and international organizations relating to severe accidents at NPPs. The IAEA held, in cooperation with the OECD/NEA, the International Experts’ Meeting (IEM) on “Strengthening Research and Development Effectiveness in the Light of the Accident at the Fukushima Daiichi Nuclear Power Plant” at IAEA Headquarters in Vienna, Austria, 16–20 February 2015. The objective of the IEM was to facilitate the exchange of information on these R&D activities and to further strengthen international collaboration among Member States and international organizations. One of the main conclusions of the IEM was that the Fukushima Daiichi accident had not identified completely new phenomena to be addressed, but that the existing strategies and priorities for R&D should be reconsidered. Significant R&D activities had been already performed regarding severe accidents of water cooled reactors (WCRs) before the accident, and the information was very useful for predicting and understanding the accident progression. However, the Fukushima Daiichi accident highlighted several challenges that should be addressed by reconsidering R&D strategies and priorities. Following this IEM, the IAEA invited several consultants to IAEA Headquarters, Vienna, Austria, 12–14 May 2015, and held a meeting in order to discuss proposals on possible IAEA activities to facilitate international R&D collaboration in relation to severe accidents and how to effectively disseminate the information obtained at the IEM. The IAEA also held Technical Meeting (TM) on “Post-Fukushima Research and Development Strategies and Priorities” at IAEA Headquarters, Vienna, Austria, 15–18 December 2015. The objective of this meeting was to provide a platform for experts from Member States and international organizations to exchange perspectives and information on strategies and priorities for R&D regarding the Fukushima Daiichi accident and severe accidents in general. The experts discussed R&D topic areas that need further attention and the benefits of possible international cooperation. This paper discusses lessons learned from the Fukushima Daiichi accident based on the presentations and discussions at the meetings mentioned above, and identifies the needs for further R&D activities to develop WCR technologies to cope with Fukushima Daiichi-type accidents.

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HEPA Filter Clogging and Volatile Material Release Under Solvent Fire Accident in Fuel Reprocessing Facility

Volume 7: Fuel Cycle, Decontamination and Decommissioning, Radiation Protection, Shielding, and Waste Management; Mitigation Strategies for Beyond Design Basis Events ◽

10.1115/icone25-67626 ◽

2017 ◽

Author(s):

Takuya Ono ◽

Koji Watanabe ◽

Shinsuke Tashiro ◽

Yuki Amano ◽

Hitoshi Abe

Keyword(s):

Organic Solvent ◽

High Efficiency ◽

Ventilation System ◽

Lessons Learned ◽

Differential Pressure ◽

Severe Accidents ◽

Combustion Tests ◽

Filter Clogging ◽

Fuel Reprocessing ◽

Fire Accident

The new licensing standards were further improved by taking into account of lessons learned from the Fukushima-Daiichi nuclear accident, and countermeasures against severe accidents were newly required as regulatory items, where severe accidents were defined as serious accidents that occur under conditions exceeding design bases. Organic solvent fire in cell was defined as one of the severe accidents in nuclear fuel reprocessing facilities, which should be investigated, in order to establish methods for evaluating effectiveness of the countermeasures. One of the combustibles in the fire accident at reprocessing facilities is the organic solvent composed of 30% tributyl phosphate (TBP) and 70% dodecane. When the solvent burns, aerosol of soot and radioactive substances are released inside the facility. The aerosol causes a clogging of high-efficiency particulate air filters (HEPA filters) in a ventilation system of the facility, which increases a differential pressure of the filters. We have performed combustion tests simulating the fire accident. As one of interesting results of the tests, we observed, when most of dodecane in the solvent was burned out, a rapid increase in a differential pressure of a HEPA filter, which may cause its rupture. We also found a small amount of RuO4 release from the burning solvent, which can pass through HEPA filters due to its volatility. These phenomena should be adapted in the effectiveness evaluations of the countermeasures against the fire accident.

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Creating Patient Safety with Organizational Learning: A Case-Based Learning Intervention at a Public and Private Hospital

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/154193120204601607 ◽

2002 ◽

Vol 46 (16) ◽

pp. 1438-1442

Author(s):

Amanda Eisenlohr ◽

Marta L. Render ◽

Emily S. Patterson

Keyword(s):

Private Hospital ◽

Program Effectiveness ◽

High Reliability ◽

Organizational Factors ◽

Lessons Learned ◽

Public And Private ◽

Learning Intervention ◽

Case Based Learning ◽

The Individual ◽

Case Based

A critical component of a high reliability organization (HRO) is believed to be a safety culture. Historically, healthcare placed the onus on individuals for perfection in performance of complex work. A six-month, case-based learning intervention at a public and private hospital, Safety Minutes™, attempted to shift the focus from the individual to systems. The intervention is organized in rotating modules of a medical and non-medical incident that exemplify a safety concept, displayed via posters in a staff meeting space, followed by a moderated discussion. Moderators asked how the stories resembled or differed from the nurses' experiences and guided participants away from ingrained “blame” responses in order to look more deeply at systemic and organizational factors. We assessed program effectiveness by ethnographic analysis of written transcripts of the moderated sessions and discuss lessons learned.

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Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework

Journal of Medical Internet Research ◽

10.2196/23775 ◽

2021 ◽

Vol 23 (1) ◽

pp. e23775

Author(s):

Hannah M James ◽

Chrysanthi Papoutsi ◽

Joseph Wherton ◽

Trisha Greenhalgh ◽

Sara E Shaw

Keyword(s):

Health Care ◽

Large Scale ◽

Resistance To Change ◽

Scale Up ◽

Organizational Factors ◽

Lessons Learned ◽

Service Development ◽

Health Administration ◽

Reimbursement Mechanisms ◽

Over Time

Background COVID-19 has thrust video consulting into the limelight, as health care practitioners worldwide shift to delivering care remotely. Evidence suggests that video consulting is acceptable, safe, and effective in selected conditions and settings. However, research to date has mostly focused on initial adoption, with limited consideration of how video consulting can be mainstreamed and sustained. Objective This study sought to do the following: (1) review and synthesize reported opportunities, challenges, and lessons learned in the scale-up, spread, and sustainability of video consultations, and (2) identify transferable insights that can inform policy and practice. Methods We identified papers through systematic searches in PubMed, CINAHL, and Web of Science. Included articles reported on synchronous, video-based consultations that had spread to more than one setting beyond an initial pilot or feasibility stage, and were published since 2010. We used the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework to synthesize findings relating to 7 domains: an understanding of the health condition(s) for which video consultations were being used, the material properties of the technological platform and relevant peripherals, the value proposition for patients and developers, the role of the adopter system, organizational factors, wider macro-level considerations, and emergence over time. Results We identified 13 papers describing 10 different video consultation services in 6 regions, covering the following: (1) video-to-home services, connecting providers directly to the patient; (2) hub-and-spoke models, connecting a provider at a central hub to a patient at a rural center; and (3) large-scale top-down evaluations scaled up or spread across a national health administration. Services covered rehabilitation, geriatrics, cancer surgery, diabetes, and mental health, as well as general specialist care and primary care. Potential enablers of spread and scale-up included embedded leadership and the presence of a telehealth champion, appropriate reimbursement mechanisms, user-friendly technology, pre-existing staff relationships, and adaptation (of technology and services) over time. Challenges tended to be related to service development, such as the absence of a long-term strategic plan, resistance to change, cost and reimbursement issues, and the technical experience of staff. There was limited articulation of the challenges to scale-up and spread of video consultations. This was combined with a lack of theorization, with papers tending to view spread and scale-up as the sum of multiple technical implementations, rather than theorizing the distinct processes required to achieve widespread adoption. Conclusions There remains a significant lack of evidence that can support the spread and scale-up of video consulting. Given the recent pace of change due to COVID-19, a more definitive evidence base is urgently needed to support global efforts and match enthusiasm for extending use.

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Analytical Study on Failure Mechanisms by Extreme Loadings Under Design Extension Conditions

Volume 1B: Codes and Standards ◽

10.1115/pvp2015-45553 ◽

2015 ◽

Author(s):

Hiroshi Ogawa ◽

Hideo Machida ◽

Naoto Kasahara

Keyword(s):

Nuclear Power ◽

Failure Modes ◽

Nuclear Reactor ◽

Failure Mechanisms ◽

Stress Triaxiality ◽

Lessons Learned ◽

Mitigation Measures ◽

Guide Tube ◽

Typical Structure ◽

Severe Accidents

As the important lessons learned from Fukushima-nuclear power plant accident, mitigation of failure consequences and prevention of catastrophic failure were strongly recognized against severe accidents (SA) and excessive earthquake conditions. To improve mitigation measures and accident management, clarification of failure behaviors with locations is premised under design extension conditions (DEC) such as severe accidents and earthquakes. Design extension conditions induce some different failure modes from design conditions. Furthermore, the best estimation for these failure modes is required for preparing countermeasures and management. Therefore, this study focused on identification failure modes under design extension conditions. To realize best estimation, it is prerequisite to clarify failure modes with ultimate structural strength under extreme loadings such as very high temperature, pressure and great earthquakes. The authors attempt to clarify unclear failure mechanisms by extreme loadings under DEC using numerical simulations. In this paper, relations between failure modes and extreme loadings were investigated by the numerical simulation using the cylindrical model which is a typical structure of nuclear reactor structures (for example, Formed Head, Nozzle, Instrument Tube, Guide Tube, Support Skirt, etc.). Moreover, it was shown that failure modes change with an effect of structural discontinuities. Local failure dominates than ductile fracture at locally constraint portions where stress triaxiality becomes high.

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Overview of Revised Level 2 PRA Standard in Japan

10.1115/icone24-61070 ◽

2016 ◽

Author(s):

Koichi Nakamura ◽

Yoshiyuki Narumiya ◽

Yutaka Abe

Keyword(s):

Nuclear Power ◽

Power Plants ◽

Nuclear Power Plants ◽

Technical Committee ◽

Lessons Learned ◽

Severe Accident ◽

Severe Accidents ◽

New Findings ◽

Accident Research ◽

Level 2

In this paper, we introduce the overview of the standard for Procedure of Level 2 Probabilistic Risk Assessment (PRA) for nuclear power plants established and issued by the Atomic Energy Society of Japan (AESJ). The first edition of the standard was published in 2008 through the discussions at the Level 2 Subcommittee under the Risk Technical Committee of the Standards Committee. As an enforcement standard based on the PRA procedure, the standard specifies the requirements which should have the PRA dealing with incidents resulting from internal events at nuclear power plants during power operation, and the concrete methods of meeting it. This new version standard is regular revision. In revising the 2008 version standard, we updated various requirements to reflect advancements in Level 2 PRA techniques based on new technological findings after the publication of the previous standard and to improve the quality and transparency of this standard. In particular, the lessons learned and new findings from the severe accidents of Fukushima Dai-ichi nuclear power plants, which occurred on March 11 of 2011, were significant. The reason was that three cores were melted down and large amounts of FP were released in the accidents. We investigated the latest documents relevant to severe accident research, and the measure against a severe accident established after the severe accidents of Fukushima Dai-ichi nuclear power plants. Furthermore, we extracted the matter, which should be reflected by comparison with international standard for PRA, ASME/ANS standard and IAEA SSG-4. Here, we introduce the outline and the feature of the AESJ standard for level 2 PRA. We also introduce the future renewal plan of the standard including the extension of the scope for external event, such as an earthquake and tsunami.

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Rural Area School Teacher’s Technology Adoption: Lessons Learned from the COVID-19 Phenomenon

Environment-Behaviour Proceedings Journal ◽

10.21834/ebpj.v6i18.3059 ◽

2021 ◽

Vol 6 (18) ◽

Author(s):

Rusnani Mohamad Khalid ◽

Shaherah Abdul Malik ◽

Nurul Aien Abd Aziz ◽

Mohd Hafizan Musa ◽

Noreen Noor Abd Aziz

Keyword(s):

Technology Adoption ◽

Rural Schools ◽

Online Teaching ◽

Publishing House ◽

Organizational Factors ◽

Lessons Learned ◽

Perceived Usefulness ◽

Learning System ◽

Personal Innovativeness ◽

School Learning

The occurrence of Covid-19 has caused the existing school learning system to move to online teaching and learning methods. They are carried out to safeguard the continuity of school learning sessions, attempting to avert dropouts. This paper analyzes the relationships between organizational factors, perceived usefulness, Personal innovativeness, and peers with technology adoption among teachers in rural schools in Segamat District. A total of 117 teachers were involved in this study. The results showed that perceived usefulness, Personal innovativeness, and peers influenced technology adoption among teachers from rural schools. Keywords: Adoption, e-learning, technology eISSN: 2398-4287© 2021. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians/Africans/Arabians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ebpj.v6i18.3059

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Evaluating the effectiveness of care coordination interventions designed and implemented through a participatory action research process: Lessons learned from a quasi-experimental study in public healthcare networks in Latin America

PLoS ONE ◽

10.1371/journal.pone.0261604 ◽

2022 ◽

Vol 17 (1) ◽

pp. e0261604

Author(s):

María-Luisa Vázquez ◽

Andrea Miranda-Mendizabal ◽

Pamela Eguiguren ◽

Amparo-Susana Mogollón-Pérez ◽

Marina Ferreira-de-Medeiros-Mendes ◽

...

Keyword(s):

Action Research ◽

Participatory Action Research ◽

Organizational Factors ◽

Lessons Learned ◽

Future Research ◽

Public Healthcare ◽

Participatory Action ◽

Intermediate Outcomes ◽

Quasi Experimental

Background Despite increasing recommendations for health professionals to participate in intervention design and implementation to effect changes in clinical practice, little is known about this strategy’s effectiveness. This study analyses the effectiveness of interventions designed and implemented through participatory action research (PAR) processes in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay to improve clinical coordination across care levels, and offers recommendations for future research. Methods The study was quasi-experimental. Two comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys of a sample of primary and secondary care doctors (174 doctors/network/year) were conducted using the COORDENA® questionnaire. Most of the interventions chosen were based on joint meetings, promoting cross-level clinical agreement and communication for patient follow-up. Outcome variables were: a) intermediate: interactional and organizational factors; b) distal: experience of cross-level clinical information coordination, of clinical management coordination and general perception of coordination between levels. Poisson regression models were estimated. Results A statistically significant increase in some of the interactional factors (intermediate outcomes) -knowing each other personally and mutual trust- was observed in Brazil and Chile INs; and in some organizational factors -institutional support- in Colombia and Mexico. Compared to CNs in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. In distal outcomes, care consistency items improved in Brazil, Colombia and Uruguay INs; and patient follow-up improved in Chile and Mexico. General perception of clinical coordination increased in Brazil, Colombia and Mexico INs. Compared to CNs in 2017, only Brazil showed significant differences. Conclusions Although more research is needed, results show that PAR-based interventions improved some outcomes regarding clinical coordination at network level, with differences between countries. However, a PAR process is, by definition, slow and gradual, and longer implementation periods are needed to achieve greater penetration and quantifiable changes. The participatory and flexible nature of interventions developed through PAR processes poses methodological challenges (such as defining outcomes or allocating individuals to different groups in advance), and requires a comprehensive mixed-methods approach that simultaneously evaluates effectiveness and the implementation process to better understand its outcomes.

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Technological innovation in a police organization: Lessons learned from the National Police of the Netherlands

Policing A Journal of Policy and Practice ◽

10.1093/police/paab003 ◽

2021 ◽

Author(s):

Sander Ernst ◽

Hanneke ter Veen ◽

Nicolien Kop

Keyword(s):

The Netherlands ◽

Technological Innovation ◽

New Technologies ◽

Organizational Factors ◽

Lessons Learned ◽

Innovative Technology ◽

Police Organization ◽

Social Organizational ◽

Effective Use ◽

National Police

Abstract Police organizations internationally explore and experiment with new technologies to improve their performance and in response to new forms of crime. The police in the Netherlands experiment with various forms of innovative technology. Previous research has shown that social, organizational, and technological factors are important for effective use and deployment of technology by the police. However, the precise factors and mechanisms underlying the promotion or inhibition of technological innovations within the police are not clear. This study aims to provide empirical knowledge about these mechanisms by providing insight into the processes through which technological innovation develops within the police in the Netherlands. From January 2017 to February 2018, 13 technological innovation projects were subjected to a longitudinal process study. The results show that innovation processes within the police organization are often inhibited by organizational factors, whereas social factors can stimulate and promote these processes.

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Study on Buckling Strength and Post Buckling Behaviors of Reactor Vessel Lower Heads

10.1115/icone28-65553 ◽

2021 ◽

Author(s):

Masato Murohara ◽

Akira Yamazaki ◽

Takuya Sato ◽

Naoto Kasahara

Keyword(s):

Structural Design ◽

Nuclear Power ◽

Reactor Vessel ◽

Lessons Learned ◽

Buckling Strength ◽

Severe Accidents ◽

Design Basis ◽

Post Buckling ◽

Fukushima Daiichi ◽

Very High

Abstract As the lessons learned from the Fukushima Daiichi Nuclear Power Plant accident, the importance of controlling the behavior after a failure and mitigating consequences of a failure was recognized. Conventional reactor structural design has been aimed at preventing the occurrence of failure due to Design Basis Events (DBE). This study aims to improve the resilience of the reactor structure under Beyond Design Basis Events (BDBE), such as very high temperatures and excessive earthquakes during severe accidents, by mitigating the consequences after failure.

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