Promotion of plant specific human error reporting

Plant specific human error information has been generally

recognized as a problem. Although reports on safety significant events such as LERs are made, no data on situations where operators have

succeeded in recovering their errors exist in documented form. To

enhance human error reporting the following areas have to be considered:

management culture, safety awareness training of plant staff and repeated emphasis on safety. In the following, these subareas are discussed with practical questions of how to organize the reporting.

2.3.1 Management Culture

Basically, the existence of a safety oriented, and as far as

possible, non-punitive management culture is a necessary precondition of human error reporting. This reporting is generally strongly coupled with the reporting on observed safety hazards (accident precursors), near-miss situations and violations of procedures. Although there may be little to do if the managers do not see the advantages of safety and availability related human error information, practical examples of how reporting could protect plants from e.g. repeated scrams should be given. It should be emphasized that a non-punitive system is the only way to

generate information on non-observable human error, i.e. error with no major consequences.

Another task related to the management culture is to help the

managers to see their role as a part of a plant system. This means that besides plant personnel and technical failures management might also have

25

an impact on disturbances and accidents. Although the organizational contribution might be delayed and vague from a certain event point of view, it can still affect plant safety as a common root cause in several event sequences. This should be taken into account by the management and event investigator, when planning modifications related to e.g.

organization, procedures and plant system documentation.

2.3.2 Safety Awareness Training of Plant Staff

The personnel (shift crews, maintenance personnel) who are expected to report on human errors in SERs, LERs, near misses and accident

precursor reports should be given information on the nature of human error. The training should emphasize the importance of including human error in the safety awareness culture. The general safety attitude

should also include the concept that one should view one's own actions as having a potential for error.

The training programme should include general training on human factors issues, and also specific training on errors and why they occur.

Training on PSA techniques could also be included to exemplify how safety hazards could be identified and reported.

A safety awareness culture that puts an emphasis on analyzing human errors must be well accepted among the plant personnel. A task force could therefore be formed among the operators and maintenance personnel to promote and encourage the reporting.

It is also important to stress that this implementation of a safety awareness culture takes time. When trying to change attitudes, and

especially towards one's own behaviour, one must be given time.

2.3.3 Repeated Management Actions to Promote Reporting

The management must put a continuous and repeated emphasis on the fact that reporting and analyzing human errors is important in keeping and improving the overall safety level. This could be done through encouraging the reporting of general difficulties in handling the equipment. During retraining, repetition of important human error related events should be included. The management should give

non-punitive feedback on the reporting and they must show the personnel that they are not punished for reporting.

Promoting reporting, collecting and analyzing human errors are activities for which resources must be dedicated at the plant, for example by having a full-time coordinator.

2.3.3.1 Organization of Reporting System

Simplicity versus data preservation

The reporting should be simplified and the proforma should be simple to use. However, it is important that whenever possible first hand information should be preserved. Potentially, this might be in the form of free text if a coded format would be too restrictive. As

experience grows in collecting human performance data, it might be clear that certain root causes and/or types of errors appear frequently so that, over time, a form can be developed that is useful to collect data on the large majority of events, and free text descriptions would only be necessary for rare or highly safety significant events.

Anonymity of reports

The management should develop a non-punitive attitude in the case of human errors as indicated above. However, it is suggested that there

is no need to include the name of the person who was involved in the incident in the report. Probably, the head of the operating or maintenance unit or the plant coordinator would keep the information referred to above.

A difficulty with the in-plant coordinator role is that he or she would have to have the trust of the plant staff that their anonymity would be preserved by this person and that he or she could not be

pressured by management or by regulators to reveal identities. Because it was impossible to establish such trust, the Aviation Safety Reporting System (ASRS) asks personnel to send their reports directly to the ASRS and ASRS personnel then telephone the reporters to obtain any additional

information, The ASRS has found this high degree of assurance of

anonymity to be essential to motivating members of the aviation community

27

to report. However, sending the reports off-site for analysis would prevent plant managers from gaining the information to improve plant safety or performance in cases of near-misses, precursors, etc. It would also be difficult to preserve the reporter's anonymity if plant managers have access to all the information abouth the event. Even if they do not know the reporter's name, they could easily obtain it from log books, timecards, work orders, etc.

Follow up action

The nuclear power plant authorities should normally review all the human errors in general and follow up actions benefitting the entire station staff are to be taken by plant management. Some of the suggested follow up actions are given below:

(a) To organize retraining programmes to take care of system modifications, improvements and design changes.

(b) To organize group discussions among the operating staff on incidents where human errors were involved.

(c) To organize training on general human behavioural aspects.

(d) To improve the working environments in the plant.

(e) To review/revise the operating and maintenance procedures, (g) To review the plant operating policies.

2.3.3.2 Benefit From the Reporting System

The plant management should periodically review the human errors and make positive recommendations to avoid the errors in the future.

Positive feedback is to be given to the persons who completed the incident reports.

Incidents with non-safety related consequences are recommended for internal investigation only. These reports although not breaching safety specifications, may provide valuable information regarding human

performance deficiencies which may impact on safety in the future.