1. operational Safety  Operations  License to Operate from regulator dependent on meeting license conditions (LCs)  Design supported by Safety Case  Construction and Commissioning پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

2. Outline  Operational nuclear safety  Focus on nuclear safety and underlying cultural issues  safety systems and processes (but not safety cases)  Example License Condition requirements  Operating experience feedback (LC 7)  Operating rules (LC 23)  Management of change (LC 36)  Behavioural interventions to improve performance  Overall safety management system پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

3. Operational Nuclear Safety  Remaining within the limits of the safety case  Procedures, monitoring, analysis and learning processes  Suitably qualified, experienced and competent staff  Good management  Good safety culture  the right things are done with the right attitude so as to achieve the right results پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

4. Reason’s Swiss Cheese Model  Defence in depth (many layers)  Works most of the time  All have weaknesses  Can line up with disastrous results پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

5. Culture is fundamental  The culture determines the quality of the safety management processes  How big the holes in the cheese are  How they are monitored and reduced  Helps ensure they are not aligned پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

6. Generic problem Piper Alpha پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

7. Generic problem Shuttle Chernobyl پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

8. Findings  High proportion (by far) of events attributed to human factors  Top four root causes:  Personnel work practices  Procedures  Verbal communications  Supervisory methods پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

9. Event investigations  Often don’t ask ‘why’ enough  Its easiest to focus on the individual  …...but this won’t help to move things forward and prevent future events  Key is know why the individuals behaved as they did – what are the human factors? پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

10. Human Factors in events Individual Competence, skills, personality, attitudes, risk perception…. Organisation Culture, leadership, resources, communications, work patterns.... Job Task, workload, environment, display and controls, procedures… پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

11. The learning loop ENABLERSENABLERS R E S U LT S پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

12. Closing the learning loop ‘To look is one thing, To see what you look at is another. To understand what you see is another. To learn from what you understand is something else. But to act on what you learn is all that really matters.’ Sir Winston Churchill پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

13. Review findings  Rules were sometimes  not clearly written (poor language, over complex)  contained no operational margin  were not relevant to nuclear safety  Rules “invited” the operators to breach them  Guidance was needed for rewriting the Rules پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

14. Guiding Principles P3  The operating limits set out in the rules should be such that a breach represents a significant erosion of safety, commensurate with the external attention it attracts P10  A clear identification is required of which rules are appropriate to normal steady state conditions and which to other situations (including faults, start-up, post-trip and shut-down situations). P11  Rules should (so far as is practicable) refer only to plant parameters and conditions which can be directly monitored (and preferably be directly controlled) by the station staff. P12  Rules should not require staff to process information presented to them unless the appropriate support is provided. P15  Rules should use derived operating limits which anticipate faults, rather than basic safety limits. پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

15. Outcome  Many principles concerned with making the Rules easier to follow and comply with i.e. making the operators’ job easier  Programme of Rule revision  Very significant reduction in Rule breaches پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

16. Measurable benefit پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

17. Outcome  Many principles concerned with making the Rules easier to follow and comply with i.e. making the operators’ job easier  Programme of Rule revision  Very significant reduction in Rule breaches  Greater credibility of Rules  Greater regulator and public confidence  Greater self awareness and self confidence پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

18. Management of Change  Newest License Condition (LC36)  Introduced to address the increasing instability in UK Nuclear Industry since 1989  Restructuring, privatisation, downsizing, re- organisation (local and corporate), contractorisation, competition  Loss of experience, uncertainty (role, job security)  Requires formal statement of how nuclear safety is ensured during and after the change  Key performance indicators to monitor the change پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

19. Weakness  Too formal/theoretical  Attitudes and morale not properly covered  Teamworking and loyalties  Influx of contractors  Loss of “latent” expertise  New management style  Clash of cultures  People are not components پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

20. Ideal Actual Ideal Actual Safety Management پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

21. Behavioural interventions Behavioural Observation* Standards and Behaviours Booklets STAR – Stop Think Act Review Coaching Conduct of Operations Conduct of Maintenance Competencies – appraisal, appointments Environmental awareness WANO Peer Review (PO+Cs) Safety Culture Tool * Lead Team operators پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators

22. The sharp end ENABLERSENABLERS R E S U LT S پژوهشگاه علوم و فنون هسته ای پژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology Institute Nuclear Science and Technology Institute پژوهشکده تحقيقات و توسعه راکتورها و شتاب دهنده ها School of Research and Development Of Nuclear Reactors and Accelerators School of Research and Development Of Nuclear Reactors and Accelerators