43 research outputs found
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A Human Reliability-Centered Approach to the Development of Job Aids for Reviewers of Medical Devices That Use Radiological Byproduct Materials.
The U.S. Nuclear Regulatory Commission (NRC) is engaged in an initiative to risk-inform the regulation of byproduct materials. Operating experience indicates that human actions play a dominant role in most of the activities involving byproduct materials, which are radioactive materials other than those used in nuclear power plants or in weapons production, primarily for medical or industrial purposes. The overall risk of these activities is strongly influenced by human performance. Hence, an improved understanding of human error, its causes and contexts, and human reliability analysis (HRA) is important in risk-informing the regulation of these activities. The development of the human performance job aids was undertaken by stages, with frequent interaction with the prospective users. First, potentially risk significant human actions were identified based on reviews of available risk studies for byproduct material applications and of descriptions of events for byproduct materials applications that involved potentially significant human actions. Applications from the medical and the industrial domains were sampled. Next, the specific needs of the expected users of the human performance-related capabilities were determined. To do this, NRC headquarters and region staff were interviewed to identify the types of activities (e.g., license reviews, inspections, event assessments) that need HRA support and the form in which such support might best be offered. Because the range of byproduct uses regulated by NRC is so broad, it was decided that initial development of knowledge and tools would be undertaken in the context of a specific use of byproduct material, which was selected in consultation with NRC staff. Based on needs of NRC staff and the human performance related characteristics of the context chosen, knowledge resources were then compiled to support consideration of human performance issues related to the regulation of byproduct materials. Finally, with information sources and an application context identified, a set of strawman job aids was developed, which was then presented to prospective users for critique and comment. Work is currently under way to develop training materials and refine the job aids in preparation for a pilot evaluation
Human Performance Analysis of Industrial Radiography Radiation Exposure Events
A set of radiation overexposure event reports were reviewed as part of a program to examine human performance in industrial radiography for the US Nuclear Regulatory Commission. Incident records for a seven year period were retrieved from an event database. Ninety-five exposure events were initially categorized and sorted for further analysis. Descriptive models were applied to a subset of severe overexposure events. Modeling included: (1) operational sequence tables to outline the key human actions and interactions with equipment, (2) human reliability event trees, (3) an application of an information processing failures model, and (4) an extrapolated use of the error influences and effects diagram. Results of the modeling analyses provided insights into the industrial radiography task and suggested areas for further action and study to decrease overexposures
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Implications of an HRA framework for quantifying human acts of commission and dependency: Development of a methodology for conducting an integrated HRA/PRA
To support the development of a refined human reliability analysis (HRA) framework, to address identified HRA user needs and improve HRA modeling, unique aspects of human performance have been identified from an analysis of actual plant-specific events. Through the use of the refined framework, relationships between the following HRA, human factors and probabilistic risk assessment (PRA) elements were described: the PRA model, plant states, plant conditions, PRA basic events, unsafe human actions, error mechanisms, and performance shaping factors (PSFs). The event analyses performed in the context of the refined HRA framework, identified the need for new HRA methods that are capable of: evaluating a range of different error mechanisms (e.g., slips as well as mistakes); addressing errors of commission (EOCs) and dependencies between human actions; and incorporating the influence of plant conditions and multiple PSFs on human actions. This report discusses the results of the assessment of user needs, the refinement of the existing HRA framework, as well as, the current status on EOCs, and human dependencies
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The development and evaluation of programmatic performance indicators associated with maintenance at nuclear power plants
This report summarizes the development and evaluation of programmatic performance indicators of maintenance. These indicators were selected by: (1) creating a formal framework of plant processes; (2) identifying features of plant behavior considered important to safety; (3) evaluating existing indicators against these features; and (4) performing statistical analyses for the selected indicators. The report recommends additional testing. This document provides the appendices to the report. These appendices are: synopsis of process model; detailed results of statistical analysis; and signal processing analysis of daily power loss indicator
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A process for application of ATHEANA - a new HRA method
This paper describes the analytical process for the application of ATHEANA, a new approach to the performance of human reliability analysis as part of a PRA. This new method, unlike existing methods, is based upon an understanding of the reasons why people make errors, and was developed primarily to address the analysis of errors of commission
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Trial application of a technique for human error analysis (ATHEANA)
The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context
Toward General Principles for Resilience Engineering
Maintaining the performance of infrastructure‐dependent systems in the face of surprises and unknowable risks is a grand challenge. Addressing this issue requires a better understanding of enabling conditions or principles that promote system resilience in a universal way. In this study, a set of such principles is interpreted as a group of interrelated conditions or organizational qualities that, taken together, engender system resilience. The field of resilience engineering identifies basic system or organizational qualities (e.g., abilities for learning) that are associated with enhanced general resilience and has packaged them into a set of principles that should be fostered. However, supporting conditions that give rise to such first‐order system qualities remain elusive in the field. An integrative understanding of how such conditions co‐occur and fit together to bring about resilience, therefore, has been less clear. This article contributes to addressing this gap by identifying a potentially more comprehensive set of principles for building general resilience in infrastructure‐dependent systems. In approaching this aim, we organize scattered notions from across the literature. To reflect the partly self‐organizing nature of infrastructure‐dependent systems, we compare and synthesize two lines of research on resilience: resilience engineering and social‐ecological system resilience. Although some of the principles discussed within the two fields overlap, there are some nuanced differences. By comparing and synthesizing the knowledge developed in them, we recommend an updated set of resilience‐enhancing principles for infrastructure‐dependent systems. In addition to proposing an expanded list of principles, we illustrate how these principles can co‐occur and their interdependencies.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156462/2/risa13494_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156462/1/risa13494.pd