European Clearinghouse: Organizational and management-related aspects in nuclear event analysis: Summary Report of a European Clearinghouse Topical Study
The research carried out within the European Clearinghouse on Operational Experience Feedback of the European Commission has paid particular attention to the further increase of the effectiveness of the Operational Experience Feedback (OEF) systems by means of improvements in methodologies for event analysis and coding. The effectiveness of the entire OEF system is strongly dependent on the quality and comprehensiveness of the coding or classification system of causal factors and root causes of events.
The research carried out at the Joint Research Centre (JRC) of the European Commission has highlighted that issues related to human, organizational and managerial factors are typically not well addressed in the event reports, which mainly focus on human errors at the individual operator or worker level. Moreover, in the existing event investigation practices, the taxonomy of human errors mostly is applied to workforce and not to management or design teams. These findings could be due to the limitations of the analysis methodologies and of the coding and classification systems of causal factors and root causes of events.
These observations have brought to concluding the importance of upgrading the coding systems used for the classification of event reports with an enhanced system ideally simple and enabling the identification and appropriate classification of human, organisational and managerial factors in the registered events.
This Summary Report presents the results of a comprehensive study performed by the European Clearinghouse on Operating Experience Feedback, which proposes a new approach for the analysis of the events and for the coding of findings, based on the adaptation of the Human Factors Analysis and Coding System (HFACS), already applied to other industries, to the investigation of Nuclear Events: HFACS-NE.
A comparative analysis of selected IRS and LERs reports has been carried out using both the IRS and HFACS-NE analysis and coding systems, proving the specific advantages of the HFACS-NE system. A conclusion of the study is that the adoption of the suggested HFACS-NE methodology of event analysis and classification could be considered in a project of upgrade or modification of the IRS coding system, which will benefit of a more detailed and comprehensive analysis and classification of the human, organizational and management-related factors.
MANNA Giustino;
2016-02-29
Publications Office of the European Union
JRC100536
978-92-79-56841-1 (print),
978-92-79-56840-4 (online),
1018-5593 (print),
1831-9424 (online),
EUR 27759,
OP LD-NA-27759-EN-C (print),
OP LD-NA-27759-EN-N,
https://publications.jrc.ec.europa.eu/repository/handle/JRC100536,
10.2790/389942 (print),
10.2790/903152 (online),
Additional supporting files
| File name | Description | File type | |
|---|
