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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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

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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

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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”)

– Country specific efforts (e.g. NRC/USA, IRSN/France, HSE/UK, SKI/Sweden, GRS/Germany) with many different methods

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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

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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

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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)

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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)

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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)