Human based roots of failures in nuclear events investigations

摘要

This paper aims for improvement of quality of the event investigations in the nuclear industry through analysis of the existing practices, identifying and removing the existing Human and Organizational Factors (HOF) and management related barriers. It presents the essential results of several studies performed by the European Clearinghouse on Operational Experience. Outcomes of studies are based on survey of currently existing event investigation practices typical for nuclear industry of 12 European countries, as well as on insights from analysis of numerous event investigation reports.rnSystem of operational experience feedback from information based on event investigation results is not enough effective to prevent and even to decrease frequency of recurring events due to existing methodological, HOF-related and/or knowledge management related constraints. Besides that, several latent root causes of unsuccessful event investigation are related to weaknesses in safety culture of personnel and managers. These weaknesses include focus on costs or schedule, political manipulation, arrogance, ignorance, entitlement and/or autocracy. Upgrades in safety culture of organization's personnel and its senior management especially seem to be an effective way to improvement. Increasing of competencies, capabilities and level of independency of event investigation teams, elaboration of comprehensive software, ensuring of positive approach, adequate support and impartiality of management could also facilitate for improvement of quality of the event investigations.