Investigation of the Contributors to Wrong Unit or Wrong Train Events

摘要

Wrong unit/wrong train events result when actions are performed on the wrong train of systems with redundant trains or on the wrong unit of a multi-unit facility. This type of human error was investigated at 10 plant sites through in-depth interviews with knowledgeable plant personnel and through plant walk-throughs. The purpose of the interviews was to determine the contributors to wrong unit/wrong train human errors in order to develop a strategy to reduce the incidence of such events. Those factors that contributed to wrong unit/wrong train errors are identified and are ranked according to their relative incidence of involvement. Observations pertinent to wrong unit/wrong train events and recommendations for NRC action to reduce the incidence of wrong unit/wrong train events are given.