Japanese newspapers quoted officials from the JCO Co. as saying at a news conference, "The nuclear chain reaction began around 10:35 a.m. 30 September when workers skipped a key step that would have prevented the start of the reaction. They apparently used buckets to transfer a uranium solution into a mixing tank. Because the employees were doing the job by hand, instead of using a required apparatus, they mistakenly loaded 16 kilograms of uranium into a container, nearly eight times the normal amount. They also appear to have transferred the uranium solution to the wrong tank." (Adapted from the website news of CNN.)
The above report gives us an impression that the accident was entirely caused by the workers' error, but fullest consideration should be given to the more basic reason that lead the human error to the disaster. Is it not a gross administrative failure to permit the establishment of a nuclear fuel plant without any fail-safe system against the fission chain reaction?
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