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V Lessons-Learned Processes and Implementing Change
Pages 53-64

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From page 53...
... Bari served on the committee of 24 experts with chair Norman Neureiter, vice chair John Garrick, and study director Kevin Crowley from the NAS Nuclear and Radiation Studies Board.
From page 54...
... Most of the recommendations in the nuclear plant systems category involve the ability to detect, measure, and understand what is occurring during an accident, and to control the system enough to remove the decay heat to the ultimate heat sink. This mitigation step requires direct current power for instrumentation and the ability to maintain real-time monitoring of the plant, even under a loss of power.
From page 55...
... The committee believed it was very important to have clear emergency management responsibilities, to know who is in charge of what when an event occurs. Training should also assess and evaluate emergency preparedness over time and be evaluated continually and revised in case of an extreme external event.
From page 56...
... Immediately after the Fukushima accident, Eletronuclear reacted by establishing a Fukushima Response Management Committee of broad experts to evaluate safety at the site. Working groups of specialists gathered and evaluated information about the Fukushima accident onset, development, and consequences; identified lessons learned applicable to Brazilian nuclear power plants; performed safety assessments; participated in national and international discussion forums on these lessons learned; and submitted a 5-year executive plan to the Comissão Nacional de Energia Nuclear (CNEN, the National Nuclear Energy Commission)
From page 57...
... Secondly, it determines what to do with loose safety systems, and thirdly, it evaluated the response to a broad group of natural disasters using probability approaches for safety margins. Actions range from interconnecting the emergency equipment to using external diesel generators to recharge the batteries and mobile pumps and backup generators for redundancy.
From page 58...
... Extended outages of essential integrated features in the security system were not considered problems. These prolonged outages drove compensatory measures in order to cover the loss of these critical features while the maintenance backlog grew on several different aspects of the integrated security system.
From page 59...
... The security personnel and the management, previously in two different reporting chains to the Department of Energy, became part of one contract, where personnel and systems were managed by a single function. The security maintenance priority system was revamped with the highest priority and immediate attention.
From page 60...
... When the team visited the commercial nuclear power generating plant on the Chesapeake Bay at Calvert Cliffs, Maryland, they saw a culture where employees were encouraged to step beyond their functional responsibilities in order to focus on mission success with security or other operations within the complex. When security professionals saw something that was out of line, even if it was outside of their functional expertise, they were encouraged to report it.
From page 61...
... Two months before the security breach at Y-12, this organization performed a field inspection and graded the complex as having a high probability of detection of intruders. The inspectors did not do a comprehensive evaluation of the entire integrated security system and failed to anticipate the problems, for which there were early indicators: There was a growing backlog of maintenance; there was too much distance between the site federal officer and the contractor; and the main contractor responsible for testing and for security maintenance was not aggregating the shortfalls and performing a risk analysis of what each additional backlog meant for overall security.
From page 62...
... Science officials in the Department of Energy gain experience in a variety of positions and locations, but there was no evidence of security personnel transferring between the field and the headquarters security team. The growing separation between the nuclear laboratories and the production efforts at Pantex Plant and at Y-12 led to a situation where facilities were not implementing common standards in common ways.
From page 63...
... Due to Fukushima's location at the bottom of a large sloping hill, rain flows through the site and into the sea, filtering through the soil and carrying residual radioactive elements into the sea. They have dealt with this issue and with the open pooling, but have yet to deal with waste disposal.
From page 64...
... The major lesson learned is that a lack of robust emergency planning and the presence of lingering effects that drag on and on raise concerns over whether nuclear technology is a worthwhile investment. Fukushima was a very severe accident, not from the standpoint of the radioactivity released and direct health effects, Dr.


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