IAEA-TECDOC-538 HUMAN ERROR CLASSIFICATION AND DATA COLLECTION REPOR TECHNICAA F TO L COMMITTEE MEETING ORGANIZED BY THE INTERNATIONAL ATOMIC ENERGY AGENCY AND HEL VIENNADN I , 20-24 FEBRUARY 1989 A TECHNICAL DOCUMENT ISSUED BY THE INTERNATIONAL ATOMIC ENERGY AGENCY, VIENNA, 1990 Ti>e ' AHA does not normally maintain stocks of reports in this series. However, microfiche copies of these reports can be obtained from l h IS Clearinghouse Internationa! Atomic Energy Agency VVagramerstrasse5 P.O. Box 100 A-1400 Vienna, Austria Orders shoul accompaniee db prepaymeny db f Austriao t n Schillings 100, fore for e chequ3 ath th f nm IAEf m o n i o r eAo microfiche service coupons whicrs may be ordered separately from the INIS Clearinghouse, HUMAN ERROR CLASSIFICATIO DATD NAN A COLLECTION IAEA, VIENNA, 1990 IAEA-TECDOC-538 ISSN 1011-4289 Printed by the IAEA in Austria January 1990 EDITORIAL NOTE In preparing this material press,the for staff Internationalofthe Atomic Energy Agency have mounted paginatedand originalthe manuscripts submittedas authorsthe givenby and some attention presentation.the to The views expressed in the papers, the statements made and the general style adopted are the responsibility namedofthe authors. necessarily viewsnot The do reflect those governments ofthe of the Member States or organizations under whose auspices the manuscripts were produced. thisin The bookuse of particular designations of countries territoriesor does implynot any judgement by the publisher, the IAEA, as to the legal status of such countries or territories, of their authorities institutions delimitationand the of or theirof boundaries. The mention specificof companies theirof or products brandor names does implynot any endorsement recommendationor IAEA. partthe the of on Authors themselvesare responsible obtainingfor necessarythe permission reproduceto copyright material from other sources. PLEASE BE AWARE THAT MISSINE TH AL F LO G PAGE THIN SI S DOCUMENT WERE ORIGINALLY BLANK CONTENTS 1. HUMAN ERROR CLASSIFICATION AND DATA COLLECTION - GENERAL ..... 9 1.1. Introduction ........................................................................................9 . 1.2. General objective f humao s n error classificatio datd nan a collection ...................0 1 . 1.2.1. Human error classification ............................................................0 1 . 1.2.2. Data collection ...........................................................................1 1 . 1.2.3. Interaction of human error classification and data collection .................... 12 1.3. Specific objective f humao s n error classificatio datd nan a collection ...................2 1 . 1.4. Current situation ..................................................................................4 1 . 1.5. General remarks/possible ways forward ....................................................... 15 . 2 QUALITATIVE DATA COLLECTIO CLASSIFICATIOD NAN N ..........................7 1 . 2.1. Introduction ........................................................................................7 1 . 2.2. Data requirements ................................................................................. 17 2.2.1qualitativy Wh . e human error data shoul collectee db d ..........................7 1 . 2.2.1.1. Plants ...........................................................................8 1 . 2.2.1.2. Researchers ...................................................................9 1 . 2.2.1.3. Community/authorities ....................................................... 20 2.2.2. Data limitations ........................................................................... 21 2.2.3. Factual information .....................................................................2 2 . 2.2.4. Information base subsequenn do t analysi judgemend an s t ......................3 2 . 2.2.5. Collection .................................................................................3 2 . 2.2.6. Classification .............................................................................4 2 . 2.2.7. Feedbac f datko a ........................................................................4 2 . 2.3. Promotio f planno t specific human error reporting ........................................5 2 . 2.3.1. Management culture ..................................................................... 25 2.3.2. Safety awareness training of plant staff .............................................. 26 2.3.3. Repeated management actions to promote reporting .............................. 26 2.3.3.1. Organization of reporting system .......................................... 27 2.3.3.2. Benefit fro reportine mth g system ........................................8 2 . 2.4. Recommendations .................................................................................9 2 . 3. QUANTITATIVE DATA COLLECTION AND CLASSIFICATION ......................... 31 3.1. Introduction ......................................................................................... 31 3.2. Dattechniqued an a s ..............................................................................1 3 . 3.2.1. Techniqu r humaefo n error rate prediction (THERP) ...........................2 3 . 3.2.2. Accident sequence evaluation programme (ASEP) ...............................2 3 . 3.2.3. Human cognitive reliability correlation (HCR) ....................................3 3 . 3.2.4. Maintenance personnel performance simulation (MAPPS) ......................3 3 . 3.2.5. Operational action tree (OAT) ......................................................... 34 3.2.6. Success likelihood index methodology (SLIM) ....................................5 3 . 3.2.7. Socio-technical approach (STAHR) ..................................................5 3 . 3.3. Possible data sources .............................................................................. 35 3.3.1. Nuclear power plant experience ....................................................... 36 3.3.2. Use of simulators ........................................................................ 36 3.3.3. Expert opinion ............................................................................ 37 3.4. Conclusion recommendationd an s s ............................................................7 3 . 3.4.1. AxCtual situation ........................................................................... 37 3.4.2. Suggested future improvements ....................................................... 38 . 4 PROPOSA CO-ORDINATEA R LFO D RESEARCH PROGRAMME ......................0 4 . 4.1. Co-ordinated research programme .............................................................0 4 . 4.2. Overal ..................................................................lP objectiveCR e th f o s 0 4 . 4.3. Researc discussiod han n topics .................................................................1 4 . 4.4. Product f programmo s e ..........................................................................2 4 . APPENDI . X1 FACTOR S AFFECTING HUMAN PERFORMANCE ...........................3 4 . ANNEX. PAPERS PRESENTE MEETINE TH T DA G SSPB activities on analyzing human performance problems ........................................... 47 L. Jacobsson An approach to human error minimization in PHWR safety related operations .................... 51 GovindarajanG. Human errors — human caused, environment caused ................................................... 61 K. C. Subramanya Human reliability data collectio r qualitativnfo e modellin quantitativd gan e assessment .........1 7 . D.A. Lucas, D.E. Embrey, A.D. Livingston Collection, analysi classificatiod san f humano n performance problem Swedise th t sa h nuclear power plants .......................................................................................3 8 . J.-P. Bento Human characteristics affecting nuclear safety ............................................................ 95 M. Skof Human reliability models validation using simulators ................................................... 103 Aguinaga,M.de Garcia,A. Nunez,J. PradesA. Outline of the development of a nuclear power plant human factor data base ..................... Ill Kameda,A. KabetaniT. Human error classificatio datd nan a collectio surve n— Indian a n yi n nuclear power plant ..................................................................................................7 12 . N. Rajasabai, V. Rangarajan, K.S.N. Murthy Possibilitie necessitd san humae th f yo n error data collectio Pake th st n a nuclea r power plant ................................................................................................... 141 T. Szikszai Higher operational safety of nuclear power plants by evaluating the behaviour of operating personnel .....................................................................................7 14 . M. Mertins, . GlasnerP Human reliability data sources — applications and ideas ............................................... 155 P. Pyy, U. Pulkkinen, J.K. Vaurio List of Participants ............................................................................................. 169 1. HUMAN ERROR CLASSIFICATION AND DATA COLLECTION - GENERAL 1.1 Introduction Awareness of human factors and human reliability has increased significantly over the last 10 to 15 years primarily due to major catastrophes that havd significanha e t human error contributions, e.g. Three Mile Island, Challenger space shuttle, Chernobyl. Eac f theso h e and other incidents have identified different types