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A Technique for Human Error Analysis (ATHEANA) RECEIVED JUL 0 2 1996 OSTI NUREG/CR-6350 BNL-NUREG-52467 A Technique for Human Error Analysis (ATHEANA) RECEIVED JUL 0 2 1996 OSTI Technical Basis and Methodology Description Prepared by S. E. Cooper, SAIC A. M. Ramey-Smith, NRC J. Wreathall, WWG G. W. Parry, NUS D. C. Bley, WWG W. J. Luckas, J. H. Taylor, M. T. Barriere, BNL Brookhaven National Laboratory Science Applications International Corporation Halliburton NUS Corporation The WreathWood Group Prepared for U.S. Nuclear Regulatory Commission DISTRiBUTSGM OF WS DOCUKHTTS UHQWTEgP^ AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the following sources: 1. The NRC Public Document Room, 2120 L Street, NW., Lower Level, Washington. DC 20555-0001 2. The Superintendent of Documents, U. S. Government Printing Office, P. O - Box 37082, Washington, DC 20402-9328 3. The National Technical Information Service, Springfield, VA 22161-0002 Although the listing that follows represents the majority of documents cited in NRC publications, it is not in• tended to be exhaustive. Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda; NRC bulletins, circulars, information notices, in• spection and investigation notices; licensee event reports; vendor reports and correspondence; Commission papers; and applicant and licensee documents and correspondence. The following documents In the NUREG series are available for purchase from the Government Printing Office: formal NRC staff and contractor reports, NRC-sponsbred conference proceedings, international agreement reports, grantee reports, and NRC booklets and brochures. Also available are regulatory guides, NRC regula• tions In the Code of Federal Regulations, and Nuclear Regulatory Commission Issuances. Documents available from the National Technical Information Service include NUREG-series reports and tech• nical reports prepared by other Federal agencies and reports prepared by the Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission. Documents available from public and special technical libraries include all open literature items, such as books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries.: Documents such as theses, dissertations, foreign reports and translations, and non-NRC conference pro• ceedings are available for purchase from the organization sponsoring the publication cited. Single copies of NRC draft reports are available free. to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section. U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001. Copies of industry codes and standards used in a substantive manner in the NRC regulatory process are main• tained at the NRC Library, Two White Flint North, 11545 Rockville Pike, Rockville. MD 20852-2738, for use by the public. Codes and standards are usually copyrighted and may be purchased from the originating organiza• tion or, if they are American National Standards. from the American National Standards Institute, 1430 Broad• way, New York, NY 10018-3308. DISCLAIMER NOTICE This report was prepared as an account of work sponsored by an agency of the United States Government. Neither the United States Government nor any agency thereof, nor any of their employees, makes any warranty, expressed or implied, or assumes any legal liability or responsibility for any third party's use, or the results of such use, of any information, apparatus, product, or process disclosed in this report, or represents that its use by such third party would not infringe privately owned rights. NUREG/CR-6350 BNL-NUREG-52467 A Technique for Human Error Analysis (ATHEANA) Technical Basis and Methodology Description Manuscript Completed: April 1996 Date Published: May 1996 Prepared by S. E. Cooper, SAIC A. M. Ramey-Smith, NRC J. Wreathall, WWG G. W. Parry, NUS D. C. Bley, WWG W. J. Luckas, J. H. Taylor, M. T. Barriere, BNL Brookhaven National Laboratory Upton, NY 11973 Subcontractors: Science Applications International Corporation Reston, VA 22090 Halliburton NUS Corporation Gaithersburg, MD 20878 The WreathWood Group Dublin, OH 43016 A. M. Ramey-Smith, NRC Project Manager Prepared for Division of Systems Technology Office of Nuclear Regulatory Research U.S. Nuclear Regulatory Commission Washington, DC 20555-0001 NRC Job Code L2415 ABSTRACT Probabilistic risk assessment (PRA) has become an important tool in the nuclear power industry, both for the Nuclear Regulatory Commission (NRC) and the operating utilities. Human reliability analysis (HRA) is a critical element of PRA; however, limitations in the analysis of human actions in PRAs have long been recognized as a constraint when using PRA. A multidisciplinary HRA framework has been developed with the objective of providing a structured approach for analyzing operating experience and understanding nuclear plant safety, human error, and the underlying factors that affect them. The concepts of the framework have matured into a rudimentary working HRA method. A trial application of the method has demonstrated that it is possible to identify potentially significant human failure events from actual operating experience which are not generally included in current PRAs, as well as to identify associated performance shaping factors and plant conditions that have an observable impact on the frequency of core damage. A general process was developed, albeit in preliminary form, that addresses the iterative steps of defining human failure events and estimating their probabilities using search schemes. Additionally, a knowledge• base was developed which describes the links between performance shaping factors and resulting unsafe actions. iii NUREG/CR-6350 CONTENTS Page ABSTRACT hi LIST OF FIGURES vii LIST OF TABLES viii EXECUTIVE SUMMARY ix ACKNOWLEDGEMENTS xii ACRONYMS xiii 1. INTRODUCTION 1-1 1.1 Background 1-1 1.2 Human-System Interactions in Real Accidents and Near Misses 1-2 1.3 Deficiencies in Current HRA Methods 1-3 1.4 Overview of Improved HRA Project 1-4 1.5 Report Outline 1-5 2. PRINCIPLES UNDERLYING THE ATHEANA HRA METHOD 2-1 2.1 Introduction 2-1 2.2 Advances in Understanding Human Performance 2-1 2.2.1 Human Errors Are Driven by Context 2-2 2.2.2 Contexts Trigger Error Mechanisms 2-3 2.2.3 Behavioral Models Connect Error Mechanisms and Post-Initiator Operator Actions 2-4 2.3 Marriage of Behavioral Science with PRA, Engineering, and Human Factors: The Multidisciplinary HRA Framework 2-6 2.3.1 Concepts Underlying the Framework 2-6 2.3.2 Framework Description 2-6 2.3.3 Definition of Framework Elements 2-7 2.3.3.1 Error Forcing Context 2-7 2.3.3.2 Human Error 2-9 2.3.3.3 PRA Model 2-10 2.4 Confirmation of Principles from Analyses of Operational Experience 2-11 2.4.1 Confirmation from Analyses Using the Framework 2-11 2.4.2 Confirmation from Other Analyses 2-13 2.5 The HRA/PRA Interface 2-14 2.5.1 PRA Structure 2-14 2.5.2 Definition of Post-Initiator Human Failure Events 2-16 2.5.3 Specifications for HRA/PRA 2-17 3. GENERAL DESCRIPTION OF THE ATHEANA HRA METHOD 3-1 3.1 Introduction 3-1 3.2 Characteristics of the ATHEANA Method 3-1 3.3 The ATHEANA Quantification Model 3-2 3.4 The Tools for Applying ATHEANA 3-3 3.4.1 The Application Process 3-3 3.4.2 The Knowledge-Base 3-5 3.4.3 Information Sources for Quantification 3-6 3.5 Ongoing Development Work 3-6 v NUREG/CR-6350 CONTENTS (Cont'd) Page 4. TRIAL APPLICATIONS OF THE CONCEPTS 4-1 4.1 Introduction 4-1 4.2 Trial Demonstration Resources 4-1 4.3 The Scenario: A PWR Small-Break LOCA 4-2 4.4 Identification of an Error of Commission HFE 4-2 4.5 Identification of an Unsafe Action . 4-4 4.6 Identification of an Error-Forcing Context 4-5 4.7 HFE Quantification . 4-6 4.8 Summary of Trial Search Approach 4-8 4.9 Findings 4-9 5. DEVELOPMENTS IN UNDERSTANDING THE CAUSES OF UNSAFE ACTIONS . 5-1 5.1 Introduction . 5-1 5.2 Understanding Derived from Behavioral Science 5-1 5.2.1 Detection 5-2 5.2.2 Situation Assessment 5-2 5.2.3 Response Planning 5-4 5.2.4 Response Implementation 5-5 5.3 Understanding Derived from Analyses of Operational Events 5-6 5.3.1 Unsafe Actions and Important Error-Forcing Context Elements 5-6 5.3.1.1 Detection Problems 5-7 5.3.1.2 Situation Assessment Problems 5-7 5.3.1.3 Response Planning Problems 5-11 5.3.1.4 Response Implementation Problems 5-13 5.3.1.5 Generic Examples of PSFs 5-14 5.3.2 Identifying Apparent Causes Not Normally Addressed in PRAs 5-17 5.4 Implications of Unsafe Action Causes for HRA 5-18 6. DEVELOPMENTS IN THE PROCESS FOR APPLYING ATHEANA 6-1 6.1 Introduction 6-1 6.2 Defining and Identifying HFEs . 6-2 6.3 Identifying Unsafe Actions and Associated Error-Forcing Contexts 6-3 7. CONCLUSIONS 7-1 8. REFERENCES 8-1 APPENDICES: Appendix A: Human Reliability Analysis Literature Review A-l Appendix B: Multidisciplinary HRA Framework B-l NUREG/CR-6350 LIST OF FIGURES No. Title Page 2.1 Multidisciplinary HRA framework 2-8 3.1 ATHEANA application process flow diagram 3-4 vii NUREG/CR-6350 LIST OF TABLES No. Title Page 4.1 Quantification Demonstration Results 4-7 5.3-1 Examples of Problems in Detection 5-8 5.3-2 Examples of Problems in Situation Assessment 5-9 5.3-3 Examples of Problems in Response Planning 5-12 5.3-4 Examples of Problems in Response Implementation 5-14 5.3-5 Examples of General Burdens on Cognitive and Physical Abilities 5-15 5.3-6 Factors Not Normally Considered in PRAs .
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