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Title

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Contents
Executive summary...............................................................................................................................1
Introduction...........................................................................................................................................1
Discussion..............................................................................................................................................1
Conclusions............................................................................................................................................6
Recommendations.................................................................................................................................7
References.............................................................................................................................................8

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Executive summary
Chernobyl is termed as the worst nuclear radiation accident in history and is responsible for
the largest radioactivity releases. It caused 31 casualties in the short term due to evacuation
but is expected to cause 4000 deaths in the long-term with the emergence of cancer in
Ukraine and its surrounding areas. The failure of Chernobyl can be termed as a mix of
intermittent and wear-out failures. The initiation of events resulting in the accident begun 24
hours earlier with a safety-related turbine trip experiment followed by a scheduled shutdown.
Shutting down final fail-safe, high reactivity coefficient, crossing the minimum limit of
moderator rods and a series of management errors are responsible for the accident. The
design of RBMK-1000 was faulty causing high reactivity due to steam generation and this
issue was not addressed properly. Nuclear energy is very dangerous against its virtues. There
are several learnings from the incident. Lack of awareness of accountabilities and
responsibilities of a manager and lack of coordination is one of the main causes of the
accident in risk plant. Assigning incompetent inexperience people and lack of knowledge of a
situation handling was another main cause. The corruption and biased decisions of the
authority allowed the faulty reactor design and the continuation of improper practices. As a
whole Chernobyl was a manmade disaster that occurred due to infrastructural problems and a
series of human errors. And it will be considered as a profound example of the extent of the
disaster that can be caused by human ignorance and mismanagement.

Introduction
The accident in the nuclear power plant in Chernobyl on April 25-26, 1986 is responsible for
the largest radioactivity release ever recorded in case of one technological disaster. The
Chernobyl Nuclear Power Plant is a nuclear powerplant in the Pripyat of northern Ukraine.
The construction of the plant and the nearby city for the Pripyat started in 1970. The first,
second, third and fourth reactor we commissioned in 1977, 1978,1981, and 1983 (Gorelik,
2001). The plant consisted of four nuclear reactors each being RBMK-1000 with 1000 MW
electric power (Jacob, 2001). The accident is an example of a worst-case scenario in which a
large portion of the matured nuclear fuel breached the core confinement and also released its
radionuclide inventory up to several percentages (Jargin, 2012). The release was equivalent a
fallout of large nuclear weapon. However, favourable sitting, dry weather, evacuation of
116,000 people, dispersion of releases to the high altitude minimised the casualties to 31
(Mousseau, Nelson and Shestopalov, 2005). The ground deposits, air concentrations reached
as far a 1000-2000 km exceeding protective action guidelines producing 2800 delayed cancer
fatalities in Europe. A series of human and technical errors are perceived to be responsible for
this accident. This case incident report analyses the case of Chernobyl accident by examining
the role of plant and equipment engineering, ongoing operations, management systems,
communications and highlighting the key learnings and recommend for the site and sector.

Discussion
The accident took place in 1:23:48 local time on April 26, 1986. It sheared off 1661 pressure
tubes, discharge hot molten fuel, lifted 1000-ton cover plate (Goldman, 2001). The series of
errors begun at 24-hour earlier when the operators conducted a safety-related turbine trip
experiment and began a scheduled shut down. The motive was to make the reactor stable at
22-30% of the power available along with closing off the supply of steam of one generator
above the areas of positive coefficient if power (Chernobyl: Intangible fallout from reactor,

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1986). A 50% hold on power was ordered to meet the demand of the public delaying the
accident by 9h. When the ramp-down for the 50% power began at 23.10, the operators, due to
improper use of automatic controls, ended up with 1% power on April 26, 0:28 getting
severely poisoned by fission product Xe (Medvedev, Medvedev and Wilson, 1991). When
the operators tried to work against the negative reactivity by Xe, they tried to get the power
back to 22% but only could get 6.3% by 1:19 by withdrawing most of the control rods that
were nonautomatic. Moreover, the cope with the liquid levels and variable pressure, they
turned off the associated automated system, thus, disabling the only thing that could have
prevented the accident. The operation should not have continued as they have the reactor at
the region of positive power coefficient, most of the control rod withdrawn, automatic sacrum
turned off. At 1:22, despite getting immediate shutdown notice by the computer message as
the reactivity coefficient was extremely dangerous, they did not (Braithwaite, 2019). Starting
at 1:23:44, due to the continuous increase of void fraction, the power increased up to 100
times the nominal reactor rating and then destroyed the core via explosions.
After 20 years of the Chernobyl incident, the world health organisation has evaluated the
health of the prole design the radiation. The survey shied that, there was a drastic increase of
thyroid cancer in the children under 15 years with 500 children having operations around the
regions in Chernobyl, Ukraine, and the Republic of Belarus. However, unlike atomic bomb
survivors, there was no increase in Leukaemia patients in infant and adults. It is presumed to
be because the survivors of Hiroshima and Nagasaki were exposed to external radiation
whereas the radiation was internal in case of Chernobyl immediately after the explosion.
Apart from thyroid cancer, demonstration of increased benign diseases, solid cancers, effects
on unborn babies and genetic effects are seen. In the short term, there were cases of death due
to the accident. Just 31 people died on spot due to the blast trauma. However, UN estimates
that it was reasonable to associate only 50 deaths with the incident. It is predicted that 4000
might eventually die because of that radiation exposure. The town of Chernobyl is no longer
habitable and is considered as a ghost town eventually attracting a lot of tourists every year.
Reliability engineering is referred to as the engineering discipline that applies the scientific
know-how to a product, plant, component, the process to form the functions intended in a
specific timeframe in a specific environment (Popentiu, 1990). The life cycle management of
the products that determine the products ability to perform under a specific condition for a
specific period, it’s important that a product can endure different threatening stresses such as
vibration, shock, voltage, temperature and environmental factors. Reliability engineering is
the application of the principles of functional reliability.
The causes of poor reliability are the increase of the complexity of the product,
overemphasized state of the art factor, too many features present in the design of the product
that may affect reliability, more severe and complex environmental changes, interactions, and
field stresses, obsolescence for rapid production, rising customer expectations for endurance
and performance, lack of regulations and penalties for the reliability in performance. The
complexity and too many features of a nuclear powerplant are huge and nobody has a full
grasp of everything. It is known that there were interactional environmental and other
changes in the Chernobyl NPP making it vulnerable to poor reliability (Xia, 2011).
Reliability-based maintenance (RBM) similar to reliability centred maintenance is a
technique that incorporates the managers to attain high standards of maintenance in the plants

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by sound guidance (Zhang and Nakamura, 2005). The RBM is mainly dependent upon three
factors the age of the components or the machine, its replacement cost, the safety and cost
consequences of system failure. The major contributing factor is poor component quality. The
failures rate that happens in the payments normally abides by the bathtub model (Bidram and
Nadarajah, 2015). When there is an initial trial of the model, there are many initial failures
due to poor workmanship, design, assembly errors. In the second phase, the errors are
normally random failures and normal failures. The major contributing factor is the stresses
like operating stresses, operator abuse and accidents. In the last phase, there are wear-out
failures. Ageing, weak design, fatigue failure and insulation breakdowns are some of the
causes. The accident of Chernobyl can be contributed two both first and second phase error
making a product of poor design, workmanship as well as accidents and operator abuse.
Slowly, the rate decreases as the replacement and improvement occur but increases in the last
once again, just like the slope of a bathtub. The principals of reliability engineering are
function-oriented and ways to preserve equipment function and system, a group focused and
involves maintenance of a group of devices, reliability engineering is an actuarial manner to
look at the relationship between failure and operating age (Zhang and Nakamura, 2005). It is
to be not that RBM is not concerned with simple failures. The failure of rates specific ages is
applied here. Failures of plants and equipment normally divided into three categories.
They’re induced, intermittent, wear out. Induced failures about an outside force causing the
failure. Intermittent failures are random failures that cannot be predetermined and there is no
effectively planned and scheduled solution. Process monitoring and predictive maintenance
can help to some extent in that case. Wearout failures are predictive failures what occurs
when in the useful life of a component (Wilkinson, 1993).
Infrastructural and fuel handling and storage perspective, the failure of Chernobyl is a mix of
intermittent and wear-out failure. Because all the operating procedures of operating it were
not validated yet. There was a lack of knowledge about the plant. The accidents were caused
by these errors and design flaw but the accident was unexpected and couldn’t be prevented
with a pre-planned response.
The single most important design factor that caused the accident is a positive void coefficient.
The design feature of RMBK is that the steam generated in the channels cause an increase in
reactivity in an unstable manner. For that, the unknown trolled power increase is possible.
There was a positive void coefficient in Chernobyl. Concerns about the safeguarding the key
infrastructures from damages and attacks are long thought. Activities addressing these issues
are called critical infusoria protection (CIP).
Unlike other energy sources nuclear energy source is very dangerous because of its chemical
and radiological hazards causing waste and nuclear fuel. The feeling of nuclear refuelling is
infrequent (every 18 months or so). However, the handling and storage of this fuel are to be
handled very carefully (Nissan and Galperin, 1998). Most of the anything reactors are
massive structures capable of withstanding massive impacts. They are constructed
considering earthquakes, plane crashes, terrorist analytics etc. But the Chernobyl power plant
can be identified as an exception. However, a concern is the relatively less well-defended
research-based facilities. They can be situated in a heavily populated area used to reach
purposes but may not have safety issues. The fuel is highly radioactive in case of spent
fuel(95/00908 Nuclear electric's radioactive waste management and decommissioning
strategy, 1995). They are placed to dissipate the heat they accumulated due to fission and are

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paced for disposal at dry storage. As par management disposal is not practised yet, the waste
stays in the plant. Reprocessing facilities separate plutonium from the spent nuclear fuel rods.
Sometimes, proliferation is done to collect the materials present in the waste that can be of
use to create nuclear weapons (O'Reilly, 2012). To ensure proper safety, the physical
structure of the plant is normally protected by guards, guns and gates properly. As there is no
guarantee that an attack can be prevented, there needs to be always an emergency response
and restoration plans in plant ready to go. The associated personnel also need to be associated
with the backup and safety measures. Despite these recommended guidelines, there was an
anomaly in the management and operating procedures of Chernobyl, for this, there was much
infrastructural damage done. This was also partially due to the lack of knowledge of the
workers.
The accident sheared off 1661 pressure tubes, discharge hot molten fuel, lifted 1000-ton
cover plate. The series of errors begun at 24-hour earlier when the operators conducted a
safety-related turbine trip experiment and began a scheduled shut down(Aitsi-Selmi and
Murray, 2016). The motive was to make the reactor stable at 22-30% of the power available
along with closing off the supply of steam of one generator above the areas of the positive
coefficient of power. A 50% hold on power was ordered to meet the demand of the public
delaying the accident by 9h (Aitsi-Selmi and Murray, 2016). When the ramp-down for the
50% power began at 23.10, the operator's oversight due to improper use of automatic controls
and ended up with 1% power on April 26, 0:28 getting the reactor got severely poisoned by
fission product Xe. When the operators tried to work against the negative reactivity by Xe,
they tried to get the power back to 22% but only could get 6.3% by 1:19 by withdrawing
most of the control rod that was nonautomatic. Moreover, to cope with the liquid levels and
variable pressure, they turned off the associated automated system, thus, disabling the only
thing that could have prevented the accident (Rich, 1986). The operation should not have
continued as they have the reactor at the positive power coefficient, most of the control rod
withdrawn, automatic sacrum turned off. At 1:22, despite getting immediate shutdown notice
by the computer message as the reactivity coefficient was extremely dangerous, they did not.
Starting at 1:23:44, due to the continuous increase of void fraction, the continuous increase of
void fraction, the power increased up to 100 times the nominal reactor rating and then
destroyed the core via explosions.
It was supposed that there were no possibilities of this scale of the explosion in the RBMK-
1000 reactor core. That’s why no equipment that is radiometric measurement equipment was
available in the facility. Also, no control equipment was there to measure mixed radiation that
aware created with alpha, beta, gamma. The main drawback of the RBMK 1000 reactor was
the increase of reactivity from the insertion of control and protection rods into the core and
low speed of reactor protection system operation. The accident happened during the tests
that were scheduled for oversupply mode if there is any external sources loss. The test was
for the situation where the reactor capacity drops by 30% with cooling system shutdown. The
physical and constructed properties of the RBMK-1000 reactor didn’t allow it to operate in
that level. Inserting a protection rod in the reactor core didn’t help to bring the reactor to a
halt in the low reactivity level. On the other hand, it caused a sharp increase in the case in
reactivity, reactor power growth and also heated the reactor gifts causing an explosion. For,
the explosion and ejection of 10 days straight, 70 tons of active materials were rejected in the
environment by the exploded reactor. So about 50 tons of nuclear fuel and 8000 tons of

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graphite were burned up due to explosion in the reactor. Gamma radiation due to the
explosion were prevalent as dose rate that 10 days (Makhon'ko, 1996).
Normally nuclear fuel contains materials that are fissile and highly activation and fission
products after irradiation expired (95/03647 The nuclear engineering world nuclear industry
handbook, 1995). The most important factor of fuel handling and stage systems in the power
plants are that ensures the proper receive, handling, storage and received without the undue
risk of environment safety and health (Saegusa, 2008). The features of the design of the
nuclear power plants are associated with the assurance of the integrity of the fuel, calling
reading fuel, ensuring safety and radiation protection in accordance with the basic safety
requirements. Fuel handling and storage system are associated with the reactor design and
plant layout with different fundamental approaches. There are two types of storage or wet
storage implying the dry environment and wet environment. A wet storage system is usually
used in case of irradiated fuel. Apparently, it is stated that there was no clear indication of
faulty fuel storage and fuel handling in case of Chernobyl.
A safety management system can be referred as the arrangements made by the organisations
of safety to achieve good safety performance (Sivaramakrishna, Nagaraj and
Madhusoodanan, 2014). The safety is initially the responsibilities of the organisations
operating the plants. The deployed system needs to comply with the requirements of the
legislation and the government's relevant regulatory bodies. There are different safety
policies of a power plant. In case of a nuclear power plant, the nuclear power plant operators
are to give the highest priorities and the commitment can be expressed in the business aims of
the organisations. The organisations need to define expectations for the arrangements in case
of deploying safety standards that define the expectations for the arrangements that are
significant for implementing safety policy (Sivaramakrishna, Nagaraj and Madhusoodanan,
2014). The management system needs to be clearly defined to support the organisation
properly.
In the case of a work management system, these tasks involving safety needs to be identified
prioritized and executed properly. In Chernobyl, security knowledge and safety guidelines.
wasn’t known to the manager which was his responsibility that led to many problems
onwards. Assigning important task is in the hands of the inexperienced incompetent people
was what happened in the night of the accident. A 25-year old trainee was assigned to reduce
the power level out pouty with others helping and contemplating him. Dyatlov assigned the
outage mission on things of such teams who were inexperienced in these types of safety tests
and got out of the experiment room. The line manager is normally responsible for
maintaining the safety of the operations that are under their control. However, it is imperative
that the exact management structure also reflects on specific requirements of the powerplant
for safety. It’s also needed that the managers and their units have clearly defined and
compatible work arrangements.
Moreover, especially in the case of Chernobyl, there were corruption and bias in different
levels that are unacceptable. The USSR deployed RBMK reactors despite knowing its risk of
harming 900000 people (OTSUKA, 1987). The state has a major share of guilt in the tragedy
for wrong power distribution. A scientific paper presenting the faults of RBMK reactors was
censored and the reactor structure part was cut out which indicates a huge lack of morality of
the designers. The level of radiation was understated in front of the citizens in certain parts

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endangering their lives. These types of ignorant and irresponsible behaviour came from the
thought that there was no possibility of the accident.
Activities with a high level of risk need to carried by a specialised type of operators such as
reactor operator. A system needs to be established to identify the required training for all
hired employees. The training needed to change with the change in plant and processes.
Formal qualification, assessment of technical skill and authorisation of many of the activities
and employees are needed. It is known that during the accident when there is at least a
requirement of 28 rods in the reaction, the workers only left 18 and pulled out 211 which
clearly shows the point.
The action of the line managers, supervisors and team leaders have a strong influence on the
safety culture of the organisation (FUNABASHI, 2012). Correction for practises and
promotion of safe working environment need to be ensured. There was a clear indication of
bad organisational culture in Chernobyl NPP. People were bullied to do their job which
indicates bad organisational culture. The manager was reported to threaten employees to do
illogical activities by imposing his power upon the employees as they were afraid to lose the
jobs in Chernobyl. Around 60 people of the plant were exposed to lethal radiation due to the
accident and died after a few days. Dyatlov had placed his interest on the priority and want to
climb the chain of command. His ambition generated the difference to the teamwork and
utility firms. That enabled him to lose a large-scale long-term picture of the project.

Conclusions
After analysing the whole incident from different perspectives, some key findings can be
drawn out. The managers are not properly aware of the responsibilities and accountabilities of
the post he is in and can't work with the employees properly, that may cause big disasters and
safety issues (Learning from Chernobyl, 2006). These types of issues contributed a lot in
Chernobyl disaster. Then, if the work instructions and control documentation are not
incorporated in the risk assessment, there is a chance that the regular workers will have hard
times handling and responding properly in a possibility of a calamity (Jacob, 2001). The tests
and experiments of the operations need an expert or a well-educated employee to carry out
who knows his/her staff (Suzuki, 2007). Otherwise, he cannot handle any unwanted situation
that is not mentioned in the basic instructions. Assigning inexperience incompetent people in
case of safety management and lack of proper supervising increase the chance of failure in
responding to possible deviations. The security risks of plant increase if the authority is
reluctant in monitoring the safety standards (The Lancet, 2020). Lack of sense of security
risks and improper attitude of the employees neglecting the thought of probable danger can
be one of the strongest factors causing disaster through a chain of events. The riskiest and
serious mechanical failure is shutting down of the most basic operations of monitoring,
ventilation and cooling (Yan et al., 2014). They must be continued and run flawlessly and
backed up with emergency power to ensure safety. Positive power coefficient is one thing to
look for and managed properly in case of a nuclear powerplant. This may work as a trigger
and enforcer to potential accidents rather than being a cause. Lack of knowledge about fail-
safes among the employees is a big risk and if solved can contribute in preventing a disaster
in its initiation (Cassel and Leaning, 1989). Endorsements of faulty designs and lack of
proper research for any type of economic or strategic advantage may backfire at a huge scale
especially in the case of high-risk industries. Corruption and lack of transparency from the
government like censoring scientific articles can lead to ignorance and lack of initiative in
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safety improvement. Proper evacuation and safety measures of the civil people can help a lot
in reducing the death tools and long term fatalities which is very common in case of nuclear
accidents(Nukatsuka, Watanabe and Ohba, 2007). Overall, the Chernobyl cannot be referred
to as a natural disaster, rather it was a mand made disaster. When the management is not
functioning properly, mistakes can happen and can lead to severe problems. However, when
the management fails, it is often the employees of the organisation who meet the challenge
and correct the problems. According to PMI, the cleaning up of this worst nuclear accident in
history took for more than 30 years and took a group of high-risk projects. The final phase of
remediation couldn't be complete until 10 years when a Safe Confinement was finished
building with an expense of a US$1.6 billion. The incident shows why it is always better to
be safe than sorry. However, Chernobyl disaster has played a great role as a learning point for
building, implementing and maintaining powerplants. It also shows why it is important to
shift to renewable power to avoid this type of large-scale accidents in future. On the whole, it
can be perceived that the use of a nuclear power plant can be continued but with proper safety
measures and a properly functioning management supervising skilled workers in a good
organisational culture.

Recommendations
The learnings from the accidents of the Chernobyl is just synonymous to recommendations.
By analysing we get to know about some things that need to be done and things that need to
be avoided. About management, it is important that the manager can ensure that the person
vested withy responsibilities and accountabilities have proper resources to discharge those
duties. They also need to inform the staffs, make them aware and accept the responsibilities.
The responsibilities and roles of the external supporting organisations such as technical
support organizations, plant vendors, research institutes and external maintenance
organizations, needs to be clearly defined in a plant. It is imperative to make sure that the
overall safety and responsibilities are in the hands of licensees. To handle any emergencies
and other issues, the high-risk plants need to ensure enough adequacy of arrangements in case
of any types of change. Staffs need to know the change that may take place in their future
responsibilities before and after the change. Planning and control are the effective support
that is given to ensure that the activities are carried out effectively and safely. Safety
significance of any type of change needs to be ceased before any type of change according to
guidelines. The results of risk assessment are incorporated with work instructions or control
documentation. The plant's authority needs to ensure that the safety activities and initiatives
are regulated properly and taken care of. It is a known fact that the accident was a case by a
series of human errors aligning with failed management. Activities like tests and experiments
need to be authorised in paper and get a permit from the work system. It is important to
arrange hold points and verification stages in case of complex tasks and control of test
equipment and stores items. The process of carrying out in case of any type of abnormal
situation needs to be documented and integrated into the quality assurance programme.
Appropriate arrangements need to be there for the placement and selection of employees.
Effective communication systems are a must if safety arrangements and policy are to be
continuously implemented and arranged. Open communication about safety in the
organisation is very much needed. Both formal mechanisms and informal mechanisms such
as feedback to the line managers are to be arranged. Constructive and labour management
policies are required to make sure that the work teams can work with each other and the
managers can work with their employees. Good communication with the outside of the

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organisation is also important to be established like open communication channels with
regulatory business, trade bodies and unions to coordinate the operations and handle
situations better. The authority needs to monitor the safety performance of the organisations
so that safety standards are performed and maintained. The monitoring system must have the
capability of determining whether the safety system is deteriorating or improving or
remaining the same. Protective measures are needed to be taken to ensure that the
achievement of plans and the compliance safety information can be put in the use and can be
used to improve the performance. Employees attitudes over health and safety is another thing
that needs to be assessed. Review and audit of the overall safety measures provide with the
evaluation of effectiveness and scopers of improvement in the organisations’ safety measures.
Quality audits and management reviews, safety management, reviewing safety culture,
routine review and safety case reviews of system reliability are some of the examinations of
people of audit and review. Review by independent and international agencies like IAEA by
the World Association of Nuclear Operators (WANO), Operational Safety Review Teams
(OSARTs needs to be done. There needed to be initiated to apply those appropriate corrective
actions in responses to the audit and review. Most importantly, the safety system needs to be
recognised as a coherent part of the organisation. In the event of a power shut down, it is very
important that the power supply required for safety functions such as ventilation, cooling,
monitoring could be running flawlessly. There is the need for a systemic analysis for different
types of seismic events like dropped loads, pool wall failure, displacement of solid Neutron
absorbers etc. The way fuel handling and storage buildings may be affected by tornadoes and
high winds or missile must be evaluated where relevant. Factors that may have a very bad
effect on the irradiated and fresh fuel should be evaluated with importance. Application of
probabilistic safety analysis and engineering judgement should take place.

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