The Operators' Non-compliance Behavior to Conduct Emergency Operating Procedures - Comparing with the Complexity of the Procedural Steps

  • Published : 2003.10.01

Abstract

According to the results of related studies, one of the typical factors related to procedure related human errors is the complexity of procedures. This means that comparing the change of the operators' behavior with respect to the complexity of procedures may be meaningful in clarifying the reasons for the operators' non-compliance behavior. In this study, to obtain data related to the operators' non-compliance behavior, emergency training records were collected using a full scope simulator. And three types of the operators' behavior (such as strict adherence, skipping redundant actions and modifying action sequences) observed from the collected emergency training records were compared with the complexity of the procedural steps. As the results, two remarkable relationships are obtained. They are: 1) the operators seem to frequently adopt non-compliance behavior to conduct the procedural steps that have an intermediate procedural complexity, 2) the operators seems to accommodate their non-compliance behavior to the complexity of the procedural steps. Therefore, it is expected that these relationships can be used as meaningful clues not only to scrutinize the reason for non-compliance behavior but also to suggest appropriate remedies for the reduction of non-compliance behavior that can result in procedure related human error.

Keywords

References

  1. A. B. Long, Computerized operator decision aids, Nuclear Safety, 25:4, 512-524 (1984)
  2. G. Guesnier and C. Hebler, Milestones in screen-based process control, Kerntechnik, 60:5-6, 225-231 (1995)
  3. Y. Niwa, E. Hollnagel and M. Green, Guidelines for computerized presentation of emergency operating procedures, Nuclear Engineering and Design, 167, 113-127 (1996) https://doi.org/10.1016/S0029-5493(96)01297-6
  4. H. G. Stassen, G. Johannsen and N. Moray, Internal representation, internal model, human performance model and mental workload, Automatica, 26:4, 811-820 (1990) https://doi.org/10.1016/0005-1098(90)90057-O
  5. A. Degani and E. L. Wiener, Cockpit checklists: concepts, design and use, Human Factors, 35:2, 345-359 (1993)
  6. A. Degani, and E. L. Wiener, Procedures in complex systems: the airline cockpit, IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans, 27:3, 302-312 (1997) https://doi.org/10.1109/3468.568739
  7. International Atomic Energy Agency, Good Practices with Respect to the Development and Use of Nuclear Power Plant Procedures, IAEA-TECDOC-1058 (1998)
  8. U. S. Environmental Protection Agency, New Ways to Prevent Chemical Incidents, EPA 550-B-99-012 (1999)
  9. W. Rankin, R. Hibit, J. Allen and R. Sargent, Development and evaluation of the Maintenance Error Decision Aid (MEDA) process, International Journal of Industrial Ergonomics, 26, 261-276 (2000) https://doi.org/10.1016/S0169-8141(99)00070-0
  10. G. Brito, Towards a model for the study of written procedure following in dynamic environments, Reliability Engineering and System Safety, 75, 233-244 (2002) https://doi.org/10.1016/S0951-8320(01)00097-7
  11. G. T. Klopp, Industry program needed for nuclear accident management, Power Engineering, May, 37-39 (1989)
  12. G. Depond and L. Resse, Operating procedures for emergency situations in EdF PWR plants, In Proceedings of IAEA International Training Course on Accident Management in Nuclear Power Plants, Chicago, USA (1989)
  13. E. M. Dougherty, Is human reliability enhanced by following procedures? In Proceedings of American Nuclear Society Winter Meeting, p. 112-113, Washington D.C (1994)
  14. J. K. Vaurio, Safety-related decision making at a nuclear power plant, Nuclear Engineering and Design, 185, 335-345 (1998) https://doi.org/10.1016/S0029-5493(98)00225-8
  15. Y. Dien, Safety and application of procedures, or 'how do they have to use operating procedures in nuclear power plants?' Safety Science, 29, 179-87 (1998) https://doi.org/10.1016/S0925-7535(98)00021-6
  16. S. Kondo, Lessons learned for PSA from the SGTR incident at Mihama, unit 2, in 1991, Reliability Engineering and System Safety, 45, 57-65 (1994) https://doi.org/10.1016/0951-8320(94)90076-0
  17. U.S. Nuclear Regulatory Commission, Steam Generator Tube Failures, NUREG/CR-6365. Washington D.C (1996)
  18. U.S. Nuclear Regulatory Commission, Indian Point 2 Steam Generator Tube Failure Lessons-Learned Report, Final Report, TAC No. MA9163, Washington, D.C (2000)
  19. U. S. Federal Aviation Administration, The Use and Design of Flightcrew Checklists and Manuals, DOT/FAA/AM-91/7, Washington, D.C (1991)
  20. D. O' Hare, M. Wiggins, R. Batt and D. Morrison, Cognitive failure analysis for aircraft accident investigation, Ergonomics, 38:11, 1855-1869 (1994)
  21. U.S. National Transport Safety Board, A Review of Flightcrew-involved Major Accidents of U.S. Air Carriers, 1978 Through 1990, NTSB/SS-94/01, Washington, D.C (1994)
  22. D. W. Joos, Z. A. Sabri and A. A. Husseiny, Analysis of gross error rates in operating of commercial nuclear power stations, Nuclear Engineering and Design, 52, 265-300 (1979) https://doi.org/10.1016/0029-5493(79)90056-6
  23. U. S. Nuclear Regulatory Commission, Development of a Checklist for Evaluating Emergency Operating Procedures Used in Nuclear Power Plants, NUREG/CR-1970. Washington D.C (1981)
  24. Institute of Nuclear Power Operations, An Analysis of Root Causes in 1983 and 1984 Significant Event Reports, INPO 85-027. Atlanta GA (1985)
  25. P. Marsden, Procedures in the nuclear industry, Human Factors in Nuclear Safety (N. Stanton, Editor). Taylor & Francis (1996)
  26. K. Furuta, K. Sasou, R. Kubota, H. Ujita., Y. Shuto and E. Yagi, Human factor analysis of JCO criticality accident, Cognition, Technology and Work, 2, 182-203 (2000) https://doi.org/10.1007/PL00011501
  27. Y. Hirotsu, K. Suzuki, M. Kojima and K. Takano, Multivariate analysis of human error incidents occurring at nuclear power plants: Several occurrence patterns of observed human errors, Cognition, Technology and Work, 3, 82-91 (2001) https://doi.org/10.1007/PL00011526
  28. U.S. Nuclear Regulatory Commission, The Human Performance Evaluation Process: A Resources for Reviewing the Identification and Resolution of Human Performance Problem, NUREG/CR-6753, Washington D.C (2002)
  29. J. Park, W. Jung and J. Ha, Development of the step complexity measure for emergency operating procedures using entropy concepts, Reliability Engineering and System Safety, 71:2, 115-130 (2001) https://doi.org/10.1016/S0951-8320(00)00087-9
  30. Jinkyun Park, Wondea Jung, Jaewhan Kim, Jaejoo Ha and Yunghwa Shin, The step complexity measure for emergency operating procedures - comparing with simulation data, Reliability Engineering and System Safety, 74:1, 63-74 (2001) https://doi.org/10.1016/S0951-8320(01)00063-1
  31. Jinkyun Park, Wondea Jung, Jaejoo Ha and Changkue Park, The step complexity measure for emergency operating procedures - measure verification, Reliability Engineering and System Safety, 77:1, 45-59 (2002) https://doi.org/10.1016/S0951-8320(02)00028-5
  32. R. R. Fullwood and R. E. Hall, Probabilistic Risk Assessment in the Nuclear Power Industry: Fundamentals and Applications, Pergamon Press (1988)
  33. Y. Dien and R. Montmayeul, Contribution of the Ergonomic Analysis to the Improvement of the Design of Operating Procedures in Nuclear Power Plants, Electricite de France, EdF-93NB00043 (1992)
  34. P. Marsden and M. Green, Optimizing procedures in manufacturing systems, International Journal of Industrial Ergonomics, 17, 43-51 (1996) https://doi.org/10.1016/0169-8141(94)00102-2
  35. U.S. Nuclear Regulatory Commission, Review of Findings for Human Performance Contribution to Risk in Operating Events, NUREG/CR-6753, Washington D.C (2002)
  36. U.S. Nuclear Regulatory Commission, Evaluation of Emergency Operating Procedures for Nuclear Power Plants, NUREG/CR-1875, Washington D.C (1981)
  37. U.S. Nuclear Regulatory Commission, Guidelines for the Preparation of Emergency Operating Procedures, NUREG/CR-0899, Washington D.C (1982)
  38. U.S. Nuclear Regulatory Commission, Checklist for Evaluating Emergency Operating Procedure Used in Nuclear Power Plants, NUREG/CR-2005, Washington D.C (1983)
  39. T. Kontogiannis, Applying information technology to the presentation of emergency operating procedures: implications for usability criteria, Behaviour and Information Technology, 18:4, 261-276 (1999) https://doi.org/10.1080/014492999119011
  40. A. A. Husseiny, Z. A. Sabri, D. Packer, J. W. Holmes, S. K. Adams and R. J. Rodriguez, Operating procedure automation to enhance safety of nuclear power plants, Nuclear Engineering and Design, 110, 277-297 (1989) https://doi.org/10.1016/0029-5493(89)90001-0
  41. A. Macwan and A. Mosleh, A methodology for modeling operator errors of commission in probabilistic risk assessment, Reliability Engineering and System, 45, 139-157 (1994) https://doi.org/10.1016/0951-8320(94)90082-5
  42. N. Morray. Advanced displays, cultural stereotypes and organizational characteristics of a control room. Nuclear Safety: A Human Factors Perspective (J. Misumi, B. Wilpert and R. Miller, Editor). Taylor & Francis (1999)
  43. U.S. Nuclear Regulatory Commission. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications. NUREG/CR-1278. Washington D.C (1982)
  44. D. E. Maurino, J. Reason, N. Johnston and R. B. Lee, Beyond Aviation Human Factors - Safety in High Technology Systems, Ashgate Publishing Company (1995)
  45. H. W. Heinrich, D. Petersen and N. Roos, Industrial Accident Prevention: A Safety Management Approach, 5th Edition, McGraw-Hill (1980)
  46. Jinkyun Park, Wondea Jung, Jaewhan Kim and Jaejoo Ha, The step complexity measure - its meaning and applications, Journal of the Korean Nuclear Society, 35:1, 80-90 (2003)