Situation awareness in outage work – A study of events occurring in U.S. nuclear power plants between 2016 and 2020

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The Influence of Organization and Management on the Safety of NPPS and Other Complex Industrial Systems (Report of an IAEA/IIASA consultants meeting in Laxenburg and Vienna, 18-22 March 1991)

An analysis of causes for human errors reveals that deficiencies in organization and management often provide an environment making errors more likely. There is also a considerable difference between the operational performance of similar industrial plants. A closer analysis often reveals that the differences can be attributed to the managing practices. Accepting organization and management as one important precursor for operational safety, the aim is to identify good managerial structures and practices as well as characteristics of unsafe operational practices. Such information can provide guidance for the operators of the installations and also support regulatory agencies. The ultimate aim should be to detect and correct organizational deficiencies before an incident or accident brings them into the open. It is therefore not sufficient to blame individuals nor training, because management and organization establishes priorities, structures, and practices that enable tasks to be accomplished. A consultants' meeting organized jointly by the International Atomic Energy Agency (IAEA) and the International Institute for Applied Systems Analysis (IIASA) was held in Laxenburg and Vienna, Austria on 18-22 March 1991. The objective of the meeting was to assess the extent to which research within the management sciences -can provide guidance for the practical problems of managing organizations, where safety is the major concern. The influence of organization and management on the safety of complex industrial installations was discussed during the meeting and the exchange of ideas and experience between different industrial sectors and the academia proved fruitful. In spite of the difference among national and company practices it is still expected that there are many possibilities for an exchange of good managerial knowledge, experience, and practices. The report collects both the contributions offered by members of the Expert Task Force and the findings of the discussions that took place during the meeting. Specific reference is in the following text made to the nuclear industry with the understanding that the issues have a wider application to chemical plants, off-shore installations or more generally to industries where safety is a major concern

The organization and management of nuclear power plants

The explanation of aggregate and sectoral investment behavior has been one of the less successful endeavors in empirical economics. Existing econometric models have had little success in explaining or predicting investment spending. This may be because most such models fail to account for the irreversibility of most investment spending. With irreversibility, changes in the riskiness of future cash flows or interest rates should in theory dramatically affect the decision to invest - more so than, say, a change in the levels of interest rates. Here I survey some of the empirical support for this proposition, and discuss the implications for investment modelling.Nuclear power plants are a controversial technology. The future of the industry depends on the ability to manage efficiently and safely, and to effectively manage organizational change as new technologies and practices are introduced and disseminated. This paper provides a conceptual framework and discussion of the management and organization of nuclear power plants around three questions: (1) How should nuclear power plants be organized and managed to ensure that they are operated most safely and efficiently? (2) What does an understanding of the organization and management of nuclear power plants tell us about how they change or resist change? and (3) What indicators or measures of various characteristics and processes of nuclear power plants are needed in order to address the above questions? We review existing literature on the organization and management of nuclear power plants, and suggest how we would structure a research project to address the above questions.Supported by the Center for Energy Policy Research at M.I.T

Civil and Military Airworthiness

Effective safety management has always been a key objective for the broader airworthiness sector. This book is focused on safety themes with implications on airworthiness management. It offers a diverse set of analyses on aircraft maintenance accidents, empirical and systematic investigations on important continuing airworthiness matters and research studies on methodologies for the risk and safety assessment in continuing and initial airworthiness. Overall, this collection of research and review papers is a valuable addition to the published literature, useful for the community of aviation professionals and researchers

Comparative Analysis of Nuclear Event Investigation Methods, Tools and Techniques

Feedback from operating experience is one of the key means of enhancing nuclear safety and operational risk management. The effectiveness of learning from experience at NPPs could be maximised, if the best event investigation practices available from a series of methodologies, methods and tools in the form of a ‘toolbox’ approach were promoted. Based on available sources of technical, scientific, normative and regulatory information, an inventory, review and brief comparative analysis of information concerning event investigation methods, tools and techniques, either indicated or already used in the nuclear industry (with some examples from other high risk industry areas), was performed in this study. Its results, including the advantages and drawbacks identified from the different instruments, preliminary recommendations and conclusions, are covered in this report. The results of comparative analysis of nuclear event investigation methods, tools and techniques, presented in this interim report, are of a preliminary character. It is assumed that, for the generation of more concrete recommendations concerning the selection of the most effective and appropriate methods and tools for event investigation, new data, from experienced practitioners in the nuclear industry and/or regulatory institutions are needed. It is planned to collect such data, using the questionnaire prepared and performing the survey currently underway. This is the second step in carrying out an inventory of, reviewing, comparing and evaluating the most recent data on developments and systematic approaches in event investigation, used by organisations (mainly utilities) in the EU Member States. Once the data from this survey are collected and analysed, the final recommendations and conclusions will be developed and presented in the final report on this topic. This should help current and prospective investigators to choose the most suitable and efficient event investigation methods and tools for their particular needs.JRC.DDG.F.5-Safety of present nuclear reactor

The organization and management of nuclear power plants

Includes bibliographical references (p. 36-44).Support provided by a grant from the Center for Energy Policy Research at M.I.T.John S. Carroll and Peter Cebon

A DATA-INFORMED MODEL OF PERFORMANCE SHAPING FACTORS FOR USE IN HUMAN RELIABILITY ANALYSIS

Many Human Reliability Analysis (HRA) models use Performance Shaping Factors (PSFs) to incorporate human elements into system safety analysis and to calculate the Human Error Probability (HEP). Current HRA methods rely on different sets of PSFs that range from a few to over 50 PSFs, with varying degrees of interdependency among the PSFs. This interdependency is observed in almost every set of PSFs, yet few HRA methods offer a way to account for dependency among PSFs. The methods that do address interdependencies generally do so by varying different multipliers in linear or log-linear formulas. These relationships could be more accurately represented in a causal model of PSF interdependencies. This dissertation introduces a methodology to produce a Bayesian Belief Network (BBN) of interactions among PSFs. The dissertation also presents a set of fundamental guidelines for the creation of a PSF set, a hierarchy of PSFs developed specifically for causal modeling, and a set of models developed using currently available data. The models, methodology, and PSF set were developed using nuclear power plant data available from two sources: information collected by the University of Maryland for the Information-Decision-Action model [1] and data from the Human Events Repository and Analysis (HERA) database [2] , currently under development by the United States Nuclear Regulatory Commission. Creation of the methodology, the PSF hierarchy, and the models was an iterative process that incorporated information from available data, current HRA methods, and expert workshops. The fundamental guidelines are the result of insights gathered during the process of developing the methodology; these guidelines were applied to the final PSF hierarchy. The PSF hierarchy reduces overlap among the PSFs so that patterns of dependency observed in the data can be attribute to PSF interdependencies instead of overlapping definitions. It includes multiple levels of generic PSFs that can be expanded or collapsed for different applications. The model development methodology employs correlation and factor analysis to systematically collapse the PSF hierarchy and form the model structure. Factor analysis is also used to identify Error Contexts (ECs) – specific PSF combinations that together produce an increased probability of human error (versus the net effect of the PSFs acting alone). Three models were created to demonstrate how the methodology can be used provide different types of data-informed insights. By employing Bayes' Theorem, the resulting model can be used to replace linear calculations for HEPs used in Probabilistic Risk Assessment. When additional data becomes available, the methodology can be used to produce updated causal models to further refine HEP values