IAEA Safety Standards
for protecting people and the environment
Specific Safety Guide No. SSG-50
Operating Experience
Feedback for Nuclear
Installations
IAEA SAFETY STANDARDS AND RELATED PUBLICATIONS
IAEA SAFETY STANDARDS
Under the terms of Article III of its Statute, the IAEA is authorized to establish or adopt standards of safety for protection of health and minimization of danger to life and property, and to provide for the application of these standards.
The publications by means of which the IAEA establishes standards are issued in the IAEA Safety Standards Series. This series covers nuclear safety, radiation safety, transport safety and waste safety. The publication categories in the series are Safety Fundamentals, Safety Requirements and Safety Guides.
Information on the IAEA’s safety standards programme is available on the IAEA Internet site
http://www-ns.iaea.org/standards/
The site provides the texts in English of published and draft safety standards. The texts of safety standards issued in Arabic, Chinese, French, Russian and Spanish, the IAEA Safety Glossary and a status report for safety standards under development are also available. For further information, please contact the IAEA at: Vienna International Centre, PO Box 100, 1400 Vienna, Austria.
All users of IAEA safety standards are invited to inform the IAEA of experience in their use (e.g. as a basis for national regulations, for safety reviews and for training courses) for the purpose of ensuring that they continue to meet users’ needs. Information may be provided via the IAEA Internet site or by post, as above, or by email to Official.Mail@iaea.org.
RELATED PUBLICATIONS
The IAEA provides for the application of the standards and, under the terms of Articles III and VIII.C of its Statute, makes available and fosters the exchange of information relating to peaceful nuclear activities and serves as an intermediary among its Member States for this purpose.
Reports on safety in nuclear activities are issued as Safety Reports, which provide practical examples and detailed methods that can be used in support of the safety standards.
Other safety related IAEA publications are issued as Emergency Preparedness and Response publications, Radiological Assessment Reports, the International Nuclear Safety Group’s INSAG Reports, Technical Reports and TECDOCs. The IAEA also issues reports on radiological accidents, training manuals and practical manuals, and other special safety related publications.
Security related publications are issued in the IAEA Nuclear Security Series.
The IAEA Nuclear Energy Series comprises informational publications to encourage and assist research on, and the development and practical application of, nuclear energy for peaceful purposes. It includes reports and guides on the status of and advances in technology, and on experience, good practices and practical examples in the areas of nuclear power, the nuclear fuel cycle, radioactive waste management and decommissioning.
OPERATING EXPERIENCE FEEDBACK FOR NUCLEAR
INSTALLATIONS
AFGHANISTAN ALBANIA ALGERIA ANGOLA
ANTIGUA AND BARBUDA ARGENTINA
ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN
BOLIVIA, PLURINATIONAL STATE OF
BOSNIA AND HERZEGOVINA BOTSWANA
BRAZIL
BRUNEI DARUSSALAM BULGARIA
BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA
CENTRAL AFRICAN REPUBLIC CHADCHILE CHINA COLOMBIA CONGO COSTA RICA CÔTE D’IVOIRE CROATIA CUBACYPRUS CZECH REPUBLIC DEMOCRATIC REPUBLIC
OF THE CONGO DENMARK DJIBOUTI DOMINICA
DOMINICAN REPUBLIC ECUADOR
EGYPT EL SALVADOR ERITREA ESTONIA ETHIOPIA FIJIFINLAND FRANCE GABON GEORGIA GERMANY
GHANA GREECE GRENADA GUATEMALA GUYANA HAITI HOLY SEE HONDURAS HUNGARY ICELAND INDIA INDONESIA
IRAN, ISLAMIC REPUBLIC OF IRAQIRELAND
ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA
KOREA, REPUBLIC OF KUWAIT
KYRGYZSTAN
LAO PEOPLE’S DEMOCRATIC REPUBLIC
LATVIA LEBANON LESOTHO LIBERIA LIBYA
LIECHTENSTEIN LITHUANIA LUXEMBOURG MADAGASCAR MALAWI MALAYSIA MALIMALTA
MARSHALL ISLANDS MAURITANIA MAURITIUS MEXICO MONACO MONGOLIA MONTENEGRO MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NEPAL NETHERLANDS NEW ZEALAND NICARAGUA NIGER NIGERIA NORWAY OMANPAKISTAN PALAU
PANAMA
PAPUA NEW GUINEA PARAGUAY PERUPHILIPPINES POLAND PORTUGAL QATAR
REPUBLIC OF MOLDOVA ROMANIA
RUSSIAN FEDERATION RWANDA
SAINT VINCENT AND THE GRENADINES SAN MARINO SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOUTH AFRICA SPAIN SRI LANKA SUDAN SWAZILAND SWEDEN SWITZERLAND
SYRIAN ARAB REPUBLIC TAJIKISTAN
THAILAND
THE FORMER YUGOSLAV REPUBLIC OF MACEDONIA TOGOTRINIDAD AND TOBAGO TUNISIA
TURKEY TURKMENISTAN UGANDA UKRAINE
UNITED ARAB EMIRATES UNITED KINGDOM OF
GREAT BRITAIN AND NORTHERN IRELAND UNITED REPUBLIC
OF TANZANIA
UNITED STATES OF AMERICA URUGUAY
UZBEKISTAN VANUATU
VENEZUELA, BOLIVARIAN REPUBLIC OF
VIET NAM YEMEN ZAMBIA ZIMBABWE The following States are Members of the International Atomic Energy Agency:
The Agency’s Statute was approved on 23 October 1956 by the Conference on the Statute of the IAEA held at United Nations Headquarters, New York; it entered into force on 29 July 1957.
The Headquarters of the Agency are situated in Vienna. Its principal objective is “to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world’’.
IAEA SAFETY STANDARDS SERIES No. SSG-50
OPERATING EXPERIENCE FEEDBACK FOR NUCLEAR
INSTALLATIONS
SPECIFIC SAFETY GUIDE
INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA, 2018
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© IAEA, 2018 Printed by the IAEA in Austria
June 2018 STI/PUB/1805
IAEA Library Cataloguing in Publication Data Names: International Atomic Energy Agency.
Title: Operating experience feedback for nuclear installations / International Atomic Energy Agency.
Description: Vienna : International Atomic Energy Agency, 2018. | Series: IAEA safety standards series, ISSN 1020–525X ; no. SSG-50 | Includes bibliographical references.
Identifiers: IAEAL 18-01160 | ISBN 978–92–0–100918–0 (paperback : alk. paper) Subjects: LCSH: Nuclear industry — Safety measures. | Nuclear engineering —
Safety measures. | Nuclear facilities — Accidents.
Classification: UDC 621.039 | STI/PUB/1805
FOREWORD by Yukiya Amano
Director General
The IAEA’s Statute authorizes the Agency to “establish or adopt…
standards of safety for protection of health and minimization of danger to life and property” — standards that the IAEA must use in its own operations, and which States can apply by means of their regulatory provisions for nuclear and radiation safety. The IAEA does this in consultation with the competent organs of the United Nations and with the specialized agencies concerned. A comprehensive set of high quality standards under regular review is a key element of a stable and sustainable global safety regime, as is the IAEA’s assistance in their application.
The IAEA commenced its safety standards programme in 1958. The emphasis placed on quality, fitness for purpose and continuous improvement has led to the widespread use of the IAEA standards throughout the world. The Safety Standards Series now includes unified Fundamental Safety Principles, which represent an international consensus on what must constitute a high level of protection and safety. With the strong support of the Commission on Safety Standards, the IAEA is working to promote the global acceptance and use of its standards.
Standards are only effective if they are properly applied in practice.
The IAEA’s safety services encompass design, siting and engineering safety, operational safety, radiation safety, safe transport of radioactive material and safe management of radioactive waste, as well as governmental organization, regulatory matters and safety culture in organizations. These safety services assist Member States in the application of the standards and enable valuable experience and insights to be shared.
Regulating safety is a national responsibility, and many States have decided to adopt the IAEA’s standards for use in their national regulations. For parties to the various international safety conventions, IAEA standards provide a consistent, reliable means of ensuring the effective fulfilment of obligations under the conventions. The standards are also applied by regulatory bodies and operators around the world to enhance safety in nuclear power generation and in nuclear applications in medicine, industry, agriculture and research.
Safety is not an end in itself but a prerequisite for the purpose of the protection of people in all States and of the environment — now and in the future. The risks associated with ionizing radiation must be assessed and controlled without unduly limiting the contribution of nuclear energy to equitable and sustainable development. Governments, regulatory bodies and operators everywhere must ensure that nuclear material and radiation sources are used beneficially, safely and ethically. The IAEA safety standards are designed to
THE IAEA SAFETY STANDARDS
BACKGROUND
Radioactivity is a natural phenomenon and natural sources of radiation are features of the environment. Radiation and radioactive substances have many beneficial applications, ranging from power generation to uses in medicine, industry and agriculture. The radiation risks to workers and the public and to the environment that may arise from these applications have to be assessed and, if necessary, controlled.
Activities such as the medical uses of radiation, the operation of nuclear installations, the production, transport and use of radioactive material, and the management of radioactive waste must therefore be subject to standards of safety.
Regulating safety is a national responsibility. However, radiation risks may transcend national borders, and international cooperation serves to promote and enhance safety globally by exchanging experience and by improving capabilities to control hazards, to prevent accidents, to respond to emergencies and to mitigate any harmful consequences.
States have an obligation of diligence and duty of care, and are expected to fulfil their national and international undertakings and obligations.
International safety standards provide support for States in meeting their obligations under general principles of international law, such as those relating to environmental protection. International safety standards also promote and assure confidence in safety and facilitate international commerce and trade.
A global nuclear safety regime is in place and is being continuously improved. IAEA safety standards, which support the implementation of binding international instruments and national safety infrastructures, are a cornerstone of this global regime. The IAEA safety standards constitute a useful tool for contracting parties to assess their performance under these international conventions.
THE IAEA SAFETY STANDARDS
The status of the IAEA safety standards derives from the IAEA’s Statute, which authorizes the IAEA to establish or adopt, in consultation and, where appropriate, in collaboration with the competent organs of the United Nations and with the specialized agencies concerned, standards of safety for protection of health and minimization of danger to life and property, and to provide for their application.
With a view to ensuring the protection of people and the environment from harmful effects of ionizing radiation, the IAEA safety standards establish fundamental safety principles, requirements and measures to control the radiation exposure of people and the release of radioactive material to the environment, to restrict the likelihood of events that might lead to a loss of control over a nuclear reactor core, nuclear chain reaction, radioactive source or any other source of radiation, and to mitigate the consequences of such events if they were to occur.
The standards apply to facilities and activities that give rise to radiation risks, including nuclear installations, the use of radiation and radioactive sources, the transport of radioactive material and the management of radioactive waste.
Safety measures and security measures1 have in common the aim of protecting human life and health and the environment. Safety measures and security measures must be designed and implemented in an integrated manner so that security measures do not compromise safety and safety measures do not compromise security.
The IAEA safety standards reflect an international consensus on what constitutes a high level of safety for protecting people and the environment from harmful effects of ionizing radiation. They are issued in the IAEA Safety Standards Series, which has three categories (see Fig. 1).
Safety Fundamentals
Safety Fundamentals present the fundamental safety objective and principles of protection and safety, and provide the basis for the safety requirements.
Safety Requirements
An integrated and consistent set of Safety Requirements establishes the requirements that must be met to ensure the protection of people and the environment, both now and in the future. The requirements are governed by the objective and principles of the Safety Fundamentals. If the requirements are not met, measures must be taken to reach or restore the required level of safety. The format and style of the requirements facilitate their use for the establishment, in a harmonized manner, of a national regulatory framework. Requirements, including numbered ‘overarching’ requirements, are expressed as ‘shall’ statements. Many requirements are not addressed to a specific party, the implication being that the appropriate parties are responsible for fulfilling them.
1 See also publications issued in the IAEA Nuclear Security Series.
Safety Guides
Safety Guides provide recommendations and guidance on how to comply with the safety requirements, indicating an international consensus that it is necessary to take the measures recommended (or equivalent alternative measures). The Safety Guides present international good practices, and increasingly they reflect best practices, to help users striving to achieve high levels of safety. The recommendations provided in Safety Guides are expressed as ‘should’ statements.
APPLICATION OF THE IAEA SAFETY STANDARDS
The principal users of safety standards in IAEA Member States are regulatory bodies and other relevant national authorities. The IAEA safety standards are also used by co-sponsoring organizations and by many organizations that design, construct and operate nuclear facilities, as well as organizations involved in the use of radiation and radioactive sources.
Part 1. Governmental, Legal and Regulatory Framework for Safety Part 2. Leadership and Management
for Safety Part 3. Radiation Protection and
Safety of Radiation Sources Part 4. Safety Assessment for
Facilities and Activities Part 5. Predisposal Management
of Radioactive Waste Part 6. Decommissioning and
Termination of Activities Part 7. Emergency Preparedness
and Response
1. Site Evaluation for Nuclear Installations 2. Safety of Nuclear Power Plants
2/1 Design 2/2 Commissioning and Operation
3. Safety of Research Reactors
4. Safety of Nuclear Fuel Cycle Facilities 5. Safety of Radioactive Waste
Disposal Facilities 6. Safe Transport of Radioactive Material General Safety Requirements Specific Safety Requirements
Safety Fundamentals Fundamental Safety Principles
Collection of Safety Guides
FIG. 1. The long term structure of the IAEA Safety Standards Series.
The IAEA safety standards are applicable, as relevant, throughout the entire lifetime of all facilities and activities — existing and new — utilized for peaceful purposes and to protective actions to reduce existing radiation risks. They can be used by States as a reference for their national regulations in respect of facilities and activities.
The IAEA’s Statute makes the safety standards binding on the IAEA in relation to its own operations and also on States in relation to IAEA assisted operations.
The IAEA safety standards also form the basis for the IAEA’s safety review services, and they are used by the IAEA in support of competence building, including the development of educational curricula and training courses.
International conventions contain requirements similar to those in the IAEA safety standards and make them binding on contracting parties.
The IAEA safety standards, supplemented by international conventions, industry standards and detailed national requirements, establish a consistent basis for protecting people and the environment. There will also be some special aspects of safety that need to be assessed at the national level. For example, many of the IAEA safety standards, in particular those addressing aspects of safety in planning or design, are intended to apply primarily to new facilities and activities.
The requirements established in the IAEA safety standards might not be fully met at some existing facilities that were built to earlier standards. The way in which IAEA safety standards are to be applied to such facilities is a decision for individual States.
The scientific considerations underlying the IAEA safety standards provide an objective basis for decisions concerning safety; however, decision makers must also make informed judgements and must determine how best to balance the benefits of an action or an activity against the associated radiation risks and any other detrimental impacts to which it gives rise.
DEVELOPMENT PROCESS FOR THE IAEA SAFETY STANDARDS
The preparation and review of the safety standards involves the IAEA Secretariat and five safety standards committees, for emergency preparedness and response (EPReSC) (as of 2016), nuclear safety (NUSSC), radiation safety (RASSC), the safety of radioactive waste (WASSC) and the safe transport of radioactive material (TRANSSC), and a Commission on Safety Standards (CSS) which oversees the IAEA safety standards programme (see Fig. 2).
All IAEA Member States may nominate experts for the safety standards committees and may provide comments on draft standards. The membership of
the Commission on Safety Standards is appointed by the Director General and includes senior governmental officials having responsibility for establishing national standards.
A management system has been established for the processes of planning, developing, reviewing, revising and establishing the IAEA safety standards.
It articulates the mandate of the IAEA, the vision for the future application of the safety standards, policies and strategies, and corresponding functions and responsibilities.
INTERACTION WITH OTHER INTERNATIONAL ORGANIZATIONS The findings of the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) and the recommendations of international
Secretariat and consultants:
drafting of new or revision of existing safety standard
Draft
Endorsement by the CSS Final draft
Review by safety standards
committee(s) Member States
Comments Draft Outline and work plan prepared by the Secretariat;
review by the safety standards committees and the CSS
FIG. 2. The process for developing a new safety standard or revising an existing standard.
expert bodies, notably the International Commission on Radiological Protection (ICRP), are taken into account in developing the IAEA safety standards. Some safety standards are developed in cooperation with other bodies in the United Nations system or other specialized agencies, including the Food and Agriculture Organization of the United Nations, the United Nations Environment Programme, the International Labour Organization, the OECD Nuclear Energy Agency, the Pan American Health Organization and the World Health Organization.
INTERPRETATION OF THE TEXT
Safety related terms are to be understood as defined in the IAEA Safety Glossary (see http://www-ns.iaea.org/standards/safety-glossary.htm). Otherwise, words are used with the spellings and meanings assigned to them in the latest edition of The Concise Oxford Dictionary. For Safety Guides, the English version of the text is the authoritative version.
The background and context of each standard in the IAEA Safety Standards Series and its objective, scope and structure are explained in Section 1, Introduction, of each publication.
Material for which there is no appropriate place in the body text (e.g. material that is subsidiary to or separate from the body text, is included in support of statements in the body text, or describes methods of calculation, procedures or limits and conditions) may be presented in appendices or annexes.
An appendix, if included, is considered to form an integral part of the safety standard. Material in an appendix has the same status as the body text, and the IAEA assumes authorship of it. Annexes and footnotes to the main text, if included, are used to provide practical examples or additional information or explanation. Annexes and footnotes are not integral parts of the main text. Annex material published by the IAEA is not necessarily issued under its authorship;
material under other authorship may be presented in annexes to the safety standards. Extraneous material presented in annexes is excerpted and adapted as necessary to be generally useful.
CONTENTS
1. INTRODUCTION . . . 1
Background (1.1–1.3) . . . 1
Objective (1.4, 1.5) . . . 2
Scope (1.6–1.9) . . . 2
Structure (1.10) . . . 3
2. OPERATING EXPERIENCE FEEDBACK IN OPERATING ORGANIZATIONS . . . 4
General (2.1–2.6) . . . 4
The management system and the role of management (2.7–2.22) . . . 5
Identification and reporting (2.23–2.30) . . . 10
Screening (2.31–2.39) . . . 11
Investigation (2.40–2.51) . . . 13
Trending and review (2.52–2.58) . . . 15
Corrective actions (2.59–2.67) . . . 17
Communication: Use, dissemination and exchange of information (2.68–2.74) . . . 18
Reviewing the effectiveness of the operating experience programme (2.75–2.78) . . . 19
Documentation (2.79, 2.80) . . . 20
3. ROLE OF THE REGULATORY BODY IN OPERATING EXPERIENCE FEEDBACK . . . 20
General (3.1–3.7) . . . 20
The management system (3.8–3.10) . . . 22
Reporting (3.11–3.14) . . . 24
Screening (3.15–3.18) . . . 24
Investigation (3.19, 3.20) . . . 25
Trending and review (3.21, 3.22) . . . 25
Corrective actions (3.23, 3.24) . . . 26
Communication: Use, dissemination and exchange of information (3.25–3.28) . . . 26
Reviewing the effectiveness of the operating experience programme (3.29, 3.30) . . . 27
Documentation (3.31) . . . 27
APPENDIX: EVENT REPORT TYPES, TIMING, FORMAT AND
CONTENT . . . 29 REFERENCES . . . 33 ANNEX: INTERNATIONAL SYSTEMS FOR THE
PROVISION OF FEEDBACK ON OPERATING
EXPERIENCE . . . 35 CONTRIBUTORS TO DRAFTING AND REVIEW . . . 45
1. INTRODUCTION
BACKGROUND
1.1. IAEA Safety Standards Series No. SSR-2/2 (Rev. 1), Safety of Nuclear Power Plants: Commissioning and Operation [1]; IAEA Safety Standards Series No. SSR-3, Safety of Research Reactors [2]; IAEA Safety Standards Series No. SSR-4, Safety of Nuclear Fuel Cycle Facilities [3]; IAEA Safety Standards Series No. GSR Part 2, Leadership and Management for Safety [4]; and IAEA Safety Standards Series No. GSR Part 1 (Rev. 1), Governmental, Legal and Regulatory Framework for Safety [5] establish safety requirements — based on IAEA Safety Standards Series No. SF-1, Fundamental Safety Principles [6] — for the provision of feedback on operating experience. International conventions such as the Convention on Nuclear Safety [7] (in Article 19) and the Joint Convention on the Safety of Spent Fuel Management and on the Safety of Radioactive Waste Management [8] (in Article 9) also emphasize the importance of providing feedback on operating experience. These safety standards and conventions stress the importance of establishing programmes to collect and analyse relevant operating experience and of acting on the results.
1.2. In 1989, the IAEA issued IAEA Safety Series No. 93, Systems for Reporting Unusual Events in Nuclear Power Plants1. That Safety Guide presented a recommended scheme for the management of safety related operating experience in nuclear power plants that was based on available national practice at the time.
In 2006, the IAEA issued another Safety Guide as IAEA Safety Standards Series No. NS-G-2.11, A System for the Feedback of Experience from Events in Nuclear Installations2. NS-G-2.11 superseded and constituted an update and extension of IAEA Safety Series No. 93.
1.3. This publication is a revision of NS-G-2.11 and supersedes it. This revised Safety Guide updates the recommendations on meeting the obligations, principles and requirements established in international conventions, the Fundamental Safety Principles (SF-1 [6]) and the applicable Safety Requirements publications (Refs [1–5]). This Safety Guide also extends the scope to cover the provision of
1 INTERNATIONAL ATOMIC ENERGY AGENCY, Systems for Reporting Unusual Events in Nuclear Power Plants, IAEA Safety Series No. 93, IAEA, Vienna (1989).
2 INTERNATIONAL ATOMIC ENERGY AGENCY, A System for the Feedback of Experience from Events in Nuclear Installations, IAEA Safety Standards Series No. NS-G-2.11, IAEA, Vienna (2006).
feedback on operating experience throughout the lifetime of nuclear installations, from design to decommissioning, and provides additional guidance on analysing and reporting operating experience, including good practices.
OBJECTIVE
1.4. The objective of this Safety Guide is to provide recommendations for establishing, implementing, assessing and continuously improving an operating experience programme for nuclear installations to prevent or minimize the risk of future events3 by learning from events that have already occurred at the installation or elsewhere.
1.5. This Safety Guide is primarily aimed at operating organizations and regulatory bodies responsible for nuclear installations and describes their roles and responsibilities in the overall operating experience programme. However, this Safety Guide is also of relevance to other organizations involved in the design, construction, commissioning, operation and decommissioning of nuclear installations, including technical support organizations, vendor companies (e.g. designers, engineering contractors, manufacturers), research establishments and universities providing research and safety related services in support of a nuclear facility.
SCOPE
1.6. This Safety Guide is applicable to all types of nuclear installation that are part of the nuclear fuel cycle, except facilities for the mining or processing of uranium ores or thorium ores and disposal facilities for radioactive waste. The types of nuclear installation to which this Safety Guide applies include nuclear power plants, research reactors (including subcritical and critical assemblies) and adjoining radioisotope production facilities, storage facilities for spent fuel, facilities for the enrichment of uranium, nuclear fuel fabrication facilities,
3 In this Safety Guide, an ‘event’ is as defined in the IAEA Safety Glossary [9]: “any occurrence unintended by the operator, including operating error, equipment failure or other mishap, and deliberate action on the part of others, the consequences or potential consequences of which are not negligible from the point of view of protection and safety.” This definition includes initiating events, accident precursors, near misses, accidents (all as defined in the IAEA Safety Glossary [9]), as well as unauthorized acts. Operating experience includes, but is not limited to, experience from such events.
conversion facilities, facilities for the reprocessing of spent fuel, facilities for the predisposal management of radioactive waste arising from nuclear fuel cycle facilities, and nuclear fuel cycle related research and development facilities.
1.7. This Safety Guide is applicable to the design, construction, commissioning, operation and decommissioning stages in the lifetime of nuclear installations.
1.8. This Safety Guide does not address the arrangements for the notification and sharing of information established under the Convention on Early Notification of a Nuclear Accident and the Convention on Assistance in the Case of a Nuclear Accident or Radiological Emergency [10], which place specific obligations relating to a nuclear or radiological emergency on the States Parties to the conventions and on the IAEA. IAEA Safety Standards Series No. GSR Part 7, Preparedness and Response for a Nuclear or Radiological Emergency [11], further addresses the requirements on notification and assistance relating to a nuclear or radiological emergency.
1.9. This Safety Guide does not address operating experience relating to nuclear security, although many of the recommendations in this Safety Guide would be relevant. The main reason that nuclear security related operating experience is not addressed is that some information in the operating experience programme may be subject to confidentiality requirements for security or other reasons established under the Amendment to the Convention on the Physical Protection of Nuclear Material [12]. Guidance on information security is outside the scope of this Safety Guide; such guidance is provided in the IAEA Nuclear Security Series Nos 13, 20 and 23-G [13–15].
STRUCTURE
1.10. Section 2 provides recommendations on the operating experience programme to be established and implemented in the operating organization.
Section 3 provides recommendations on the operating experience programme for the regulatory body. Additional detailed guidance is provided in the Appendix.
Descriptions of the operating experience systems operated by the IAEA are given in the Annex.
2. OPERATING EXPERIENCE FEEDBACK IN OPERATING ORGANIZATIONS
GENERAL
2.1. All organizations with responsibilities for safety should foster mutual understanding and respect through honest and open communication on operating experience as part of a strong safety culture (as indicated by Requirement 12 of GSR Part 2 [4]). This communication should include reporting any deficiencies with potential adverse effects on safety even if they are not covered by formal reporting requirements.
2.2. All organizations with responsibilities for safety should implement or participate in an effective operating experience programme. A graded approach should be applied so that the participation in such a programme is commensurate with the safety significance of the activities at the installation and with the role of the organization.
2.3. Requirement 24 of SSR-2/2 (Rev. 1) [1] states that “The operating organization shall establish an operating experience programme to learn from events at the plant”. Paragraph 5.27 of SSR-2/2 (Rev. 1) [1] states further that “[the operating organization] shall obtain and evaluate available information on relevant operating experience at other nuclear installations to draw and incorporate lessons for its own operations”. Similar requirements apply to research reactors (Requirement 88 and para. 7.126 of SSR-3 [2]) and to nuclear fuel cycle facilities (Requirement 73 and para. 9.133 of SSR-4 [3]). Operating experience from other industries with stringent safety requirements (e.g. chemical plants, air or sea transport) should be used, as far as such information can be obtained with commensurate effort.
2.4. An effective operating experience programme should include the following main elements:
(a) Identification and reporting of internal operating experience;
(b) Collection of external operating experience4;
4 In the context of this Safety Guide, ‘external operating experience’ is experience from outside the installation, whether from within the same State or from another State, from installations that use similar technologies or from those that use different technologies.
(c) Screening of operating experience, including immediate review of events of specific interest;
(d) Investigation and in-depth analysis of relevant operating experience;
(e) Trending and review for timely recognition of developing issues;
(f) Management of corrective actions resulting from investigation and analysis of operating experience, including approval, implementation, tracking and evaluation of their effectiveness;
(g) Use, dissemination and exchange of operating experience, including through national and international reporting systems;
(h) Review of the effectiveness of the operating experience programme;
(i) Maintenance of a storage, retrieval and documentation system for operating experience.
A schematic diagram of a typical operating experience programme containing the recommended elements is shown in Fig. 1.
2.5. The organizational framework for an operating experience programme will depend on the operating organization’s structure. An operating organization with a single nuclear installation should perform all functions of the operating experience programme for that installation. An operating organization that has multiple installations may judge it appropriate to centralize some of the operating experience functions5.
2.6. The exchange of experience with national and international systems for the gathering of feedback on operating experience may be supported by external organizations (e.g. there may be industry organizations or other national organizations through which reporting might be routed).
THE MANAGEMENT SYSTEM AND THE ROLE OF MANAGEMENT 2.7. Principle 3 of the Fundamental Safety Principles [6] states that “Effective leadership and management for safety must be established and sustained in
5 Such centralized functions typically include:
(a) Coordination of and support for the handling of internal operating experience to ensure compliance with the organization’s processes;
(b) Screening and analysis of external operating experience and dissemination among the relevant installations;
(c) Training of personnel on the operating experience programme;
(d) Independent investigation of significant events, as necessary.
Internal operating experience identification and reporting Identification and recording of internal operating experience. Operating experience reported as appropriate to the regulatory body and applicable external organizations.
Trac kin g th e wo rkf low and, in pa rtic ula r, the imp lemen tatio n of c orr ectiv e actio ns
External operating experience collection Sources of operating experience from other nuclear installations and external organizations.
Immediate review of events of specific interest Prompt review of significant events to evaluate actual or potential consequences and to identify necessary actions to restore safety and preclude recurrence. Screening Process to determine significance of internal and external operating experience and decide on priority and level of further analysis.
Results of the operating experience programme classified and stored in database for further use.
Investigation and analysis Investigation and in-depth analysis of operating experience, commensurate with the safety significance. Communication: Use, dissemination and exchange of information Arrangements to ensure that operating experience is effectively used within the operating organization and shared with external organizations as appropriate.
Corrective actions Corrective actions to prevent recurrence or reduce the likelihood of recurrence to an acceptable level. Monitoring of corrective action implementation and effectiveness.
Trending and review Process allowing recognition of a developing adverse trend or emerging problem so that proactive measures can be taken.
Rev iewin g th e e ffec tiven ess of th e op era ting ex per ienc e pr ogr amm e
Documentation Issues without significant safety implications (e.g. low level events, near misses) FIG. 1. Typical operating experience programme.
organizations concerned with, and facilities and activities that give rise to, radiation risks”. Paragraph 3.12 of SF-1 [6] further states that “The management system also has to ensure the promotion of a safety culture, the regular assessment of safety performance and the application of lessons learned from experience.”
2.8. In support of Requirement 12 on fostering a culture for safety, para. 5.2 of GSR Part 2 [4] states that:
“Senior managers and all other managers shall advocate and support the following:
…….
(d) The reporting of problems relating to technical, human and organizational factors and reporting of any deficiencies in structures, systems and components to avoid degradation of safety, including the timely acknowledgement of, and reporting back of, actions taken;
(e) Measures to encourage a questioning and learning attitude at all levels in the organization”.
2.9. In support of Requirement 13 on measurement, assessment and improvement of the management system, para. 6.7 of GSR Part 2 [4] states that:
“The management system shall include evaluation and timely use of the following:
(a) Lessons from experience gained and from events that have occurred, both within the organization and outside the organization, and lessons from identifying the causes of events;
…….
(c) Lessons from identifying good practices.”
2.10. Within the management system, management should plan and establish an operating experience programme at the beginning of the lifetime of the installation so that relevant operating experience can be collected, analysed and disseminated throughout the lifetime of the installation, including decommissioning.
Management should ensure that the findings of operating experience are used for learning at all levels of the organization and in all areas important for safety.
The analysis of operating experience should be complemented by a process to synthesize all relevant operating experience data to identify generic lessons and actions for improvement of the management system.
2.11. The management system should include procedures for the provision of feedback on operating experience from activities undertaken at the installation, as part of the operating experience programme implemented to prevent recurrence of events and to enhance safety.
2.12. The responsibility of management to foster a strong safety culture includes a requirement to advocate and support:
“The reporting of problems relating to technical, human and organizational factors and reporting of any deficiencies in structures, systems and components to avoid degradation of safety, including the timely acknowledgement of, and reporting back of, actions taken” (GSR Part 2 [4], para. 5.2(d)).
Paragraph 5.31 of SSR-2/2 (Rev. 1) [1] states further that:
“The operating organization shall be responsible for instilling an attitude among plant personnel that encourages the reporting of all events, including low level events and near misses, potential problems related to equipment failures, shortcomings in human performance, procedural deficiencies or inconsistencies in documentation that are relevant to safety.”
2.13. Management should foster a ‘just culture’6 in which shortcomings in human performance are used as learning opportunities. The open reporting of potentially useful experience and a questioning attitude should be encouraged and reinforced at all organizational levels.
2.14. Management’s decisions regarding the operating experience programme should be driven by the goal of maintaining and improving safety performance to meet the overriding priority of protecting people and the environment against radiation risks.
2.15. Management should be proactive in identifying drivers of risks at the organizational and management levels and in highlighting the ongoing need to improve safety.
6 A ‘just culture’ is an organizational culture in which front line operators and others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.
2.16. Management should foster a positive environment for creating, maintaining and continuously improving the operating experience programme.
2.17. Management should ensure that the operating experience programme has sufficient dedicated staff with suitable training, qualifications and experience.
2.18. Management should ensure that the operating experience programme is adequately supported, including with the necessary infrastructure and information technology tools to allow all staff easy access to relevant operating experience information.
2.19. Management should ensure that all personnel are informed about the objectives of the operating experience programme and their role in its implementation. Expectations for the identification and reporting of events, performance weaknesses and negative trends should be communicated effectively to ensure that those expectations are met by everyone at the installation, including contractors. Opportunities for improvement and good practices should also be clearly communicated. The expectations should be communicated through formal means, such as briefings and group meetings, written instructions and training;
through informal means, such as newsletters and information systems; and by example, such as through supervision and coaching.
2.20. Management should ensure that corrective actions resulting from the operating experience programme are given appropriate priority within budgetary and staffing plans to ensure that they are implemented, with follow-up to review their effectiveness. This should also include the implementation of corrective actions relating to radioactive waste minimization and the early allocation of adequate funds for decommissioning.
2.21. Management should ensure that records of the operating experience programme are maintained, easily retrievable and retained for an appropriate period (for the life of the installation, if necessary).
2.22. Management should monitor and review the effectiveness of the operating experience programme on a regular basis, at a frequency commensurate with the type of installation and with the number and significance of the operating experience issues arising.
IDENTIFICATION AND REPORTING
2.23. Operating organizations should identify and feed into their operating experience programme all issues such as (a) events, including low level events and near misses; (b) potential problems relating to equipment and human performance; (c) safety related concerns; (d) situations that are likely to give rise to errors and need to be addressed to prevent undesired effects; (e) procedural deficiencies; and (f) inconsistencies in documentation. Opportunities for improvement and good practices that are relevant to safety should also be identified and fed into the programme.
2.24. The sources of operating experience should include (a) documentation relating to the design, construction, commissioning, operation and decommissioning of the installation, to the fabrication, set-up, and dismantlement of equipment, and to the procurement and testing of goods and services;
(b) operational, maintenance and audit records; and (c) results from regulatory inspections and reviews, training sessions, walkdowns, trending, surveillance, benchmarking, peer reviews, self-assessments, and safety and risk analyses.
Issues involving non-conforming, counterfeit, fraudulent or suspect items or parts that have the potential to constitute a substantial safety hazard should also be identified and reported within the operating experience programme.
2.25. Operating organizations should develop procedural guidelines that outline reporting criteria appropriate for the type of installation being operated and consistent with national regulatory requirements. Further guidance on reporting is given in the Appendix.
2.26. Issues should be identified and reported promptly to facilitate timely screening and the implementation of any immediate actions necessary for safety and follow-up.
2.27. The identification and reporting of low level events and near misses should be encouraged and included in the operating experience programme, since such events can provide valuable lessons to help avoid more significant events.
2.28. Everyone in the operating organization should be able to report any issues that they encounter. The operating experience reporting system should be easily accessible to all personnel within the operating organization; the system should be user friendly, and computerized whenever possible. Contractor personnel should have access to the operating experience reporting system when relevant
for them. Even if accountability is encouraged by recording who reports an event, anonymous reporting should also be possible.
2.29. Individuals who report issues should receive feedback, due acknowledgement, and recognition from management to encourage future reporting. Good examples of reporting should be widely communicated within the installation to encourage future reporting and a questioning attitude.
2.30. An immediate review of events with significant challenges for the safety of the installation should be undertaken by the operating organization to ensure that appropriate immediate actions are taken to restore a safe state and to preclude recurrence. A process should be put in place to ensure that preliminary reports on such events are reported to the regulatory body and to relevant external organizations in a timely manner.
SCREENING
2.31. In order to apply a graded approach to operating experience, identified issues should be screened in a timely manner to evaluate their significance on the basis of their actual or potential consequences for safety. Written guidance with established criteria for significance should be used for the screening process. The screening process should determine the type of investigation or level of analysis for all reported issues, and necessary compensating or mitigating actions should be initiated commensurate with the significance of the issues.
2.32. Management should assign a suitably experienced, knowledgeable, multidisciplinary team to the screening task. The team should include personnel with knowledge of relevant technical matters and of human and organizational factors. The screening team should have management support and the authority to allocate the responsibilities necessary to carry out the investigation and analysis of the issues or events.
2.33. Screening criteria should include the actual or potential consequences of reported issues for nuclear safety, radiation protection, protection of the environment and non-radiation-related safety.
2.34. Screening should include consideration of the possible implications of an issue for other areas of the installation or operating organization from those in which the issue was reported.
2.35. Screening should include identifying and prioritizing any immediate actions that might be necessary, in accordance with the safety significance and potential for recurrence of a particular issue or in accordance with the significance of a developing adverse trend.
2.36. External operating experience (from other nuclear installations and interested parties, such as vendors, suppliers, designers and research institutions) should also be identified and screened for applicability to the installation and significance for safety. Such operating experience should not be dismissed solely, for example, on the basis of differences in design or equipment; all relevant aspects should be considered. Screening for applicability should include consideration of aspects such as the following:
(a) Whether immediate actions are necessary in response to significant external operating experience;
(b) Whether there are generic implications that may apply to the installation;
(c) Whether there is similar equipment at the installation;
(d) The possibility of the occurrence of a similar event at the installation;
(e) Whether reported corrective actions are applicable to the installation;
(f) Whether similar environmental conditions exist;
(g) Whether similar management expectations, personnel behaviours, practices or processes (i.e. organizational factors) have been observed in the organization.
2.37. In operating organizations with nuclear installations in several locations, a centralized group may be considered to conduct screening of external operating experience.
2.38. When external operating experience is determined to be significant but not applicable to the installation, the basis for this decision should be documented.
2.39. The results from the screening of all operating experience (internal and external) should be recorded and may be used for evaluation in subsequent self-assessments, periodic safety assessments or peer reviews.
INVESTIGATION
2.40. Paragraph 5.28 of SSR-2/2 (Rev. 1) [1] states that:
“Events with safety implications shall be investigated in accordance with their actual or potential significance. Events with significant implications for safety shall be investigated to identify their direct and root causes, including causes relating to equipment design, operation and maintenance, or to human and organizational factors. The results of such analyses shall be included, as appropriate, in relevant training programmes and shall be used in reviewing procedures and instructions. Plant event reports and non-radiation-related accident reports shall identify tasks for which inadequate training may be contributing to equipment damage, excessive unavailability of equipment, the need for unscheduled maintenance work, the need for repetition of work, unsafe practices or lack of adherence to approved procedures.”
Similar requirements apply to research reactors (para. 7.127 of SSR-3 [2]) and to nuclear fuel cycle facilities (para. 9.134 of SSR-4 [3]).
2.41. The operating organization should implement procedures with criteria specifying the type of investigation that is appropriate for any category of event.
The type of investigation should be commensurate with the actual or potential consequences of an event and the likelihood of its recurrence. Events should be investigated using appropriate analysis techniques.
2.42. The level of investigation and analysis applied should be commensurate with the significance of the event. For example:
(a) In the case of an event with the potential to provide major lessons (e.g. an event with severe actual or potential consequences, or significant consequences and a high likelihood of repetition), a formal root cause analysis, tailored to the type of event, should be performed. The root cause analysis should be conducted by a team with appropriate skills and knowledge relevant to the nature of the event.
(b) For an event providing fewer and/or less important lessons (e.g. an event with moderate actual or potential consequences), the apparent causes should be identified and corrected.
(c) Adverse trends, including those consisting of minor issues, should be reviewed for safety significance and, when necessary, investigated using appropriate techniques to identify causes and generic implications.
2.43. Management should assign to investigations individuals with the necessary technical knowledge and with skills in investigation techniques. At least one individual on each team conducting root cause analysis should have received formal training (and regular retraining) in root cause analysis and have recent experience in conducting root cause analysis in investigations.
2.44. Procedures should be developed and implemented setting out how investigations should be conducted, including defining the scope and mandate of the investigation, the methodology to be followed, the time frame, the specific techniques and tools to be used, the composition of the investigation team and the format of the final report.
2.45. Investigations should be performed without undue managerial or organizational influence over the results. Events with significant implications for safety should be investigated by a team with sufficient independence from the line management to identify and address organizational issues objectively. The objective of the investigation of an event is the prevention of future events. This activity should focus on fact finding and should not be used to assign blame or liability.
2.46. The investigation should be started as soon as practicable, consistent with maintaining the safety of the installation, to ensure that important information is not lost, invalidated or removed.
2.47. In the case of events for which root cause analysis is necessary, the analysis should document the following:
(a) The complete event sequence (what happened, including how the event developed);
(b) A cause analysis identifying technical, human and organizational factors and other contributing factors (why it happened);
(c) An assessment of the safety significance (what could have happened);
(d) An evaluation of the immediate or compensatory actions taken;
(e) Corrective actions identified to prevent recurrence;
(f) A strategy for the determination of effectiveness of the corrective actions;
(g) An evaluation of the extent to which similar conditions are present in other structures, systems and components or processes at the installation, or in human performance in the organization (‘extent of condition’);
(h) An evaluation of the extent to which similar specific root or underlying causes could affect the safety of other structures, systems and components
