Advanced SearchSearch Tips
A Revisit to the Recent Human Error Events in Nuclear Power Plants Focused to the Organizational and Safety Culture
facebook(new window)  Pirnt(new window) E-mail(new window) Excel Download
 Title & Authors
A Revisit to the Recent Human Error Events in Nuclear Power Plants Focused to the Organizational and Safety Culture
Lee, Yong-Hee;
  PDF(new window)
Objective: This paper presents additional considerations related to organization and safety culture extracted from recent human error incidents in Korea, such as station blackout(i.e., SBO) in Kori#1. Background: Safety culture has been already highlighted as a major cause of human errors after 1986 Chernobyl accident. After Fukushima accident in Japan, the public acceptance for nuclear energy has taken its toll. Organizational characteristics and culture became elucidated as a major contributor again. Therefore many nuclear countries are re-evaluating their safety culture, and discussing any preparedness and its improvement. On top of that, there was an SBO in 2012 in the Kori#1. Korean public feels frustrated due to the similar human errors causing to a catastrophe like Fukushima accident. Method: This paper reassesses Japan`s incidents, and revisits Korea`s recent incidents. It focuses on the analysis of the hazards rather than the causes of human errors, the derivation of countermeasures, and their implementation. The preceding incidents and conclusions from Japanese experience are also re-analyzed. The Fukushima accident was an SBO due to the natural disaster such as earthquakes and a successive tsunami. Unlike the Fukushima accident, the Kori#1 incident itself was simple and restored without any loss and radioactive release. However, the fact that the incident was deliberately concealed led to massive distrust. Moreover, the continued violation of rules and organized concealment of the accident are serious signs of a new distorted type of human errors, blatantly revealing the cultural and fundamental weakness of the current organization. Result: We should learn from Japanese experiences who had taken pride in its safety technology and fairly high confidence in safety culture. Japan`s first criticality accident in JCO facility splashed cold water on that confidence. It has turned out to be a typical case revealing the problems in the organization and safety culture. Since Japan has failed to gain lessons and countermeasure, the issue persists to the Fukushima incident. Conclusion: Safety culture is not a specific independent element, which makes it difficult to either evaluate it properly or establish countermeasures from the lessons. It may continue to expose similar human errors such as concealment of incident and manipulation of bad data. Application: Not only will this work establish the course of research for organization and safety culture, but this work will also contribute to the revitalization of Korea`s nuclear industry from the disappointment after the export contract to UAE.
Organizational factor;Safety culture;Kori #1;Human error;Station black-out;Nuclear power plants;
 Cited by
Suggestions for More Reliable Measurement of Korean Nuclear Power Industry Safety Culture,;

Journal of the Ergonomics Society of Korea, 2016. vol.35. 2, pp.75-84 crossref(new window)
Cha, J.H., Nuclear Safety: Tokaimura JCO Criticality Accident, KAERI, (reference source -

IAEA, Preliminary International Incident Report, IRS# 8229, 26 April, 2012.

IAEA, The Management System for Facilities and Activities (Safety Requirements), IAEA-GS-R-3; 2006.

KHNP, Loss of Offsite Power and Emergency Diesel Engine Failure, (09 February 2012, Kori Unit 1, KHNP), Interim Report, 17 June 2012.

Kim, S.K. et al., Investigations on Human Error Hazards in Recent Unintended Trip Events of Korean NPPs, Transactions of KNS- 2012-Fall, 2012.

KNS, A Report on Fukushima Accident (summary) (in Korean), 2012.

Lee, Y.H., A Review on the Human Error Research Issues from the Recent Events in Nuclear Industry, Proc. ESK 2011 Spring, 2011.

Lee, Y.H., A Revisit to the Japanese Cases of Nuclear Accidents for Human Error Analysis and Countermeasure Development, Proc. ESK 2012 Fall, 2012.

Lee, Y.H. et al., An approach to find countermeasures against human errors in NPPs, Proc. NPIC&HMIT 2009, USA, 2009.

Lee, Y.H. et al., A Preliminary Study on the Cultural Differences between Korean and Japanese Nuclear Power Plant Organizations, Transactions of KNS Fall, 2011.

NSC, An investigation report on the accident occurred in Tokaimura Uranium Processing Facility (1999.12.24) (in Japanese), NSC, 1999.

Reason, J., Human error. New York: Cambridge Univ. Press, 1990.

Shappell, S. & Wiegmann, D., A human error approach to accident investigation: The taxonomy of unsafe operations. Int. J. of Aviation Psychology, 7, pp.269-291, 1997. crossref(new window)

WANO, Loss of Offsite Power and Emergency Diesel Engine Failure (09 Feb. 2012, Kori Unit 1, KHNP), WANO Event Analysis Report EAR TYO 12-002, 2012.

Web-page (, 1999.