The nuclear incident "cannot be regarded as a natural disaster," the NAIIC panel's chairman, Tokyo University professor emeritus Kiyoshi Kurokawa, wrote in the inquiry report. "It was a profoundly man-made disaster -- that could and should have been foreseen and prevented. And its effects could have been mitigated by a more effective human response." "Governments, regulatory authorities and Tokyo Electric Power [TEPCO] lacked a sense of responsibility to protect people's lives and society," the Diet's Fukushima Nuclear Accident Independent Investigation Commission said. "They effectively betrayed the nation's right to be safe from nuclear accidents. Therefore, we conclude that the accident was clearly 'man-made'," it said. The nuclear incident was the result of poor earthquake-safety planning and faulty post-tsunami communication. As a result of collusion between the facility's operator Tokyo Electric Power Co. (TEPCO), regulators, and the Japanese government, the nuclear crisis at the Fukushima Daiichi power plant unfolded as a "man-made disaster". The report attributed the cause of the failings to Japan's culture of "reflexive obedience", noted that there was no separation between atomic regulation and promotion, and described a Japan in which nuclear power became "an unstoppable force, immune to scrutiny by civil society." The parliamentary report suggests that Reactor No. 1 in particular might have suffered earthquake damage, including the possibility that pipes burst from the shaking, leading to a loss of coolant even before the tsunami hit the plant about 30 minutes after the initial earthquake. The report emphasized that a full assessment would require better access to the inner workings of the reactors, which may not be possible for years. “However,” the report said, “it is impossible to limit the direct cause of the accident to the tsunami without substantive evidence. The commission believes that this is an attempt to avoid responsibility by putting all the blame on the unexpected (the tsunami),” the report continued, adding, “and not on the more foreseeable quake.” The commission accused the Japanese government, TEPCO and nuclear regulators of failing to carry out basic safety measures despite being aware of the risks posed by earthquakes, tsunamis and other events that might cut off power systems. For example, the government-appointed Nuclear Safety Commission revised earthquake resistance standards in 2006 and ordered nuclear operators around the country to inspect their reactors, but TEPCO did not carry out any checks, and regulators did not conduct follow ups. TEPCO “manipulated its cozy relationship with regulators to take the teeth out of regulations,” the report said. Nuclear power plants should have been made more quake-proof, but Japan's nuclear bloc, while reassuring the nation about its safe atomic plants, ignored safeguards that would have helped strengthen the Fukushima facility against a massive, but foreseeable earthquake. The Nuclear and Industrial Safety Agency (NISA) did not press TEPCO to prepare for a so-called full station blackout — the loss of main and backup power — because the “probability was small.” NISA instead asked TEPCO to explain why new prevention measures would not be necessary. Regulators and nuclear operators went to painstaking lengths to ignore safety risks at the plant or cover them up. They disregarded earlier warnings from outside watchdog groups that earthquakes posed a significant safety risk to the nuclear plants, and by doing so they “effectively betrayed the nation’s right to be safe from nuclear accidents.” The report said "it is considered that TEPCO management knew about delays in anti-quake works and postponement of tsunami measures and were aware that the Fukushima Daiichi was vulnerable". TEPCO also failed to act promptly, the panel concluded, but added: "This should not be attributed to individuals … at the plant but the structural problems of TEPCO." The NAIIC blamed lax safety measures on what it called the country's powerful and “collusive” decision-makers and on a conformist culture that allowed them to operate with little scrutiny. “What must be admitted — very painfully — is that this was a disaster ‘Made in Japan,’” investigation chairman Kiyoshi Kurokawa wrote in the introduction to the report. “Its fundamental causes are to be found in the ingrained conventions of Japanese culture: our reflexive obedience; our reluctance to question authority; our devotion to ‘sticking with the program’; our
groupism; and our insularity.”
Chain of command was disrupted amidst the crisis, creating confusion, while communication failures about critical decisions undermined trust between the different parties. The prime minister’s office waited too long to declare a state of emergency. TEPCO’s disaster-response manuals were out of date and were missing key diagrams, while TEPCO was too slow to relay information to the government. The administration of then prime minister
Naoto Kan hampered operations as the disaster unfolded, the report said, and did not use a logical chain of command. "The prime minister's office was supposed to contact the plant operator through an on-the-spot task force. But … issued direct instructions to TEPCO head office and the accident site, confusing the command line." Then-Prime Minister Naoto Kan traveled to the plant mid-meltdown and “diverted the attention and time of the on-site operational staff and confused the line of command,” the report said. “Had the head office of TEPCO actively communicated the on-site situation from the start, and explained the severity of the situation to the other parties,” the report said, “there is a possibility that the distrust — and the confusion in the chain of command that followed — could have been prevented.” ==Commission Recommendations==