Learning From Events - Experience with an Electronic Tool Supporting the Report of Events, Evaluation, Analysis, and the Corrective Action Program

摘要

To manage the variety of event types like near misses, notices from audits, occupational accidents up to real events or external events and to realize the possibility to learn from them, we developed an electronic tool which covers the comprehensive support of the operating experience management within the nuclear industry. The method enables organizations and their members to capture, manage, analyze and evaluate safety related experiences. The contribution shows the loop of learning supported by the application. It covers the registration of notifications and events. A digital notification system for the plant staff is implemented and promoted by an incentive system. Also anonymous notifications and their processing can be followed up by the sender. The operating experience team decides by various for the most part integrated criteria about the process of the occurrence. Corresponding to the type of event the adequate analyses and reports can be carried out. Here and in all other steps of administration of partial tasks the work flow principle with placing of responsibilities for persons or working teams is helpful. Further the proposals of actions and recommendations start an examination and approval process. Approved proposals lead to a common corrective action data base with necessary functions to control the carrying out, the time limits, and the evaluation of actions. Statistical evaluations, tables, charts, and synopses support the experience management. The experiences in nuclear power plants show that the method helps in ensuring that the collected information is effective analyzed, integrated in the corrective action program, and subjected to the control of time limits and priorities. Further it ensures that the feedback is distributed and easily available for all users. The common use of the method by different departments increases the cooperation of departments related to operating experience management and organizational learning.