1. Improving Nuclear Safety Through Operating Experience Feedback NEA/IAEA/WANO- Conference Cologne 29 – 31 May 2006 Human and Organisational Factors Including Methods Developed to Assist in Operational Decision Making Wolfgang Preischl, GRS/CSNI - SEGHOF

2. 2 Do human and organisational factors (HOF) contribute to reported events ? HOF causes are mentioned as contributors in about 50% of the reported events (IRS, average 1998 – 2002) HOF have contributed to safety significant events Many countries have experienced comparable ratios New challenges have appeared (e.g. outsourcing, aging workforce, new technologies) Expectation: HOF will remain an important contributor

3. 3 What efforts are made to support HOF root-cause analysis and decision making process ? (1) Contribution of human activities to reported events has been investigated Human error root-causes have been identified and efficient countermeasures have been developed and implemented Within the last two decades many tools to support the investigation process have been developed

4. 4 What efforts are made to support HOF root-cause analysis and decision making process ? (2) All important international organisations and many countries are offering investigation methods or guidance – IAEA (e.g. IAEA `03 “Guidelines for Describing Human Factors in the Incident Reporting System”) – NEA/CSNI (e.g. CSNI `98 “Improving Reporting on Coding of Human and Organisational Factors in Event Reports”) – WANO (Coding System for Operating Experience), INPO (HPES “Human Performance Evaluation System”) – Country specific efforts (e.g. NRC/USA, IRSN/France, HSE/UK, SKI/Sweden, GRS/Germany) with many different methods

5. 5 What characterizes useful HOF root-cause analysis methods ? (1) Behavioral and ergonomic science present sufficient and broadly accepted knowledge – Methods to develop event and task models – Task analysis process – Broad collection of performance shaping factors, criteria to evaluate, models to structure them and to combine them with event and task models – Definitions (e.g. “human error”) Problem: Knowledge is widely distributed

6. 6 What characterizes useful HOF root-cause analysis methods ? (2) Methods should present this knowledge in a concentrated manner to reach the following goals – Provide needed expertise – Guide the investigation team to promote convergent results – Assure a quality standard (scope, level of detail, documentation) Be aware - Models and methods are leaving things out, developer hopes these omissions are not important - Sometimes additional HOF knowledge have to be used

7. 7 What characterizes useful HOF root-cause analysis methods ? (3) Useful methods are compatible with accepted knowledge and do not leave out important aspects Useful methods provide extensive support, e.g. - Man/Machine-system models including performance shaping factors - Sufficiently detailed and structured representation of the event - Clear definitions - Systematic guidance through all aspects (also organisational factors and work environment/conditions)

8. 8 Can applied HOF root-cause analysis methods be improved further ? Some methods offer a considerable amount of well structured expert knowledge The differences between the methods are very large (too large ?) More attention should be given to - the use specific knowledge (e.g. social sciences) for the analysis and the design of working environment and working conditions - the presentation of supporting information (e.g. definitions, error criterion, supplementary literature)

9. 9 What are useful steps forward to assist HOF experience feedback and operational decision making ? Further development of the applied tools HOF as a “stand alone” reporting criterion (possibly derived from special SMS performance indicators) Integrated systemic approach to the event analysis (MTO-view) Extended use of gained event experience, e.g. - Event specific HOF root-cause detected - Identify generic content (independent of specific context) - Check routinely comparable work situations (check concept needed)