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Human and Organisational Factors Including Methods Developed to Assist in Operational

Improving Nuclear Safety Through Operating Experience Feedback NEA/IAEA/WANO- Conference Cologne 29 – 31 May 2006. Human and Organisational Factors Including Methods Developed to Assist in Operational Decision Making Wolfgang Preischl, GRS/CSNI - SEGHOF.

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Human and Organisational Factors Including Methods Developed to Assist in Operational

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  1. Improving Nuclear Safety Through Operating Experience Feedback NEA/IAEA/WANO- Conference Cologne 29 – 31 May 2006 Human and Organisational Factors Including Methods Developed to Assist in Operational Decision Making Wolfgang Preischl, GRS/CSNI -SEGHOF

  2. Do human and organisational factors (HOF) contribute to reported events ? • HOF causes are mentioned as contributors in about 50% of the reported events (IRS, average 1998 – 2002) • HOF have contributed to safety significant events • Many countries have experienced comparable ratios • New challenges have appeared (e.g. outsourcing, aging workforce, new technologies) • Expectation: HOF will remain an important contributor 2

  3. What efforts are made to support HOF root-cause analysis and decision making process ? (1) • Contribution of human activities to reported events has been investigated • Human error root-causes have been identified and efficient countermeasures have been developed and implemented • Within the last two decades many tools to support the investigation process have been developed 3

  4. What efforts are made to support HOF root-cause analysis and decision making process ? (2) • All important international organisations and many countries are offering investigation methods or guidance • IAEA (e.g. IAEA `03 “Guidelines for Describing Human Factors in the Incident Reporting System”) • NEA/CSNI (e.g. CSNI `98 “Improving Reporting on Coding of Human and Organisational Factors in Event Reports”) • WANO (Coding System for Operating Experience), INPO (HPES “Human Performance Evaluation System”) • Countryspecific efforts (e.g. NRC/USA, IRSN/France, HSE/UK, SKI/Sweden, GRS/Germany) with many different methods 4

  5. What characterizes useful HOF root-cause analysis methods ? (1) • Behavioral and ergonomic science present sufficient and broadly accepted knowledge • Methods to develop event and task models • Task analysis process • Broad collection of performance shaping factors, criteria to evaluate, models to structure them and to combine them with event and task models • Definitions (e.g. “human error”) • Problem: Knowledge is widely distributed 5

  6. What characterizes useful HOF root-cause analysis methods ? (2) • Methods should present this knowledge in a concentrated manner to reach the following goals • Provide needed expertise • Guide the investigation team to promote convergent results • Assure a quality standard (scope, level of detail, documentation) • Be aware • Models and methods are leaving things out, developer hopes these omissions are not important • Sometimes additional HOF knowledge have to be used 6

  7. What characterizes useful HOF root-cause analysis methods ? (3) • Useful methods are compatible with accepted knowledge and do not leave out important aspects • Useful methods provide extensive support, e.g. • Man/Machine-system models including performance shaping factors • Sufficiently detailed and structured representation of the event • Clear definitions • Systematic guidance through all aspects (also organisational factors and work environment/conditions) 7

  8. Can applied HOF root-cause analysis methods be improved further ? • Some methods offer a considerable amount of well structured expert knowledge • The differences between the methods are very large (too large ?) • More attention should be given to • the use specific knowledge (e.g. social sciences) for the analysis and the design of working environment and working conditions • the presentation of supporting information (e.g. definitions, error criterion, supplementary literature) 8

  9. What are useful steps forward to assist HOF experience feedback and operational decision making ? • Further development of the applied tools • HOF as a “stand alone” reporting criterion (possibly derived from special SMS performance indicators) • Integrated systemic approach to the event analysis (MTO-view) • Extended use of gained event experience, e.g. • Event specific HOF root-cause detected • Identify generic content (independent of specific context) • Check routinely comparable work situations (check concept needed) 9

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