COMPARATIVE ANALYSIS OF NUCLEAR EVENT INVESTIGATION METHODS, TOOLS AND TECHNIQUES Interim Technical Report Stanislovas Ziedelis, Marc Noel EUR 24757 EN - 2011 The mission of the JRC-IE is to provide support to Community policies related to both nuclear and non-nuclear energy in order to ensure sustainable, secure and efficient energy production, distribution and use. European Commission Joint Research Centre Institute for Energy Contact information Address: Postbus 2, 1755 ZG Petten, the Netherlands E-mail: [email protected] Tel.: +31-224-565447 Fax: +31-224-565637 http://ie.jrc.ec.europa.eu/ http://www.jrc.ec.europa.eu/ Legal Notice Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of this publication. 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It can be accessed through the Europa server http://europa.eu/ JRC 62929 EUR 24757 EN ISBN 978-92-79-19712-3 ISSN 1018-5593 doi:10.2790/3097 Luxembourg: Publications Office of the European Union © European Union, 2011 Reproduction is authorised provided the source is acknowledged Printed in Luxembourg List of acronyms and definitions AEB Accident evolution and barrier function ASSET Assessment of Safety Significant Event Team ATHEANA A Technique for Human Event Analysis CAS-HEAR Computer Aided System for Human Error Analysis in Railway Operations CCDF Conditional Core Damage Frequency CCDP Conditional Core Damage Probability CCF Common Cause Failure CRT Current Reality Tree ESReDA the European Safety Reliability and Data Association FRAM Functional Resonance Analysis Method HF Human factors HFE Human factors engineering HFIT Human Factors Investigation Tool HPEP Human Performance Evaluation Process HPES Human Performance Enhancement System HPIP Human Performance Investigation Process HRA Human reliability analysis IAEA International Atomic Energy Agency IE Institute for Energy; Initiating Event INES International Nuclear Event Scale IRS Incident Reporting System JRC Joint Research Centre of European Commission LL Lessons Learned MORT Management Oversight and Risk Tree MTO Man, technology, organisation NPP Nuclear Power Plant NRC Safety Nuclear Regulatory Commission OEF Operating Experience Feedback PRCAP Paks Root Cause Analysis Procedure PROSPER Peer Review of the effectiveness of the Operational Safety Performance Experience Review PSA Probabilistic Safety Assessment PWR Pressurised Water Reactor QA, QC Quality assurance, quality control RASP Risk Assessment Program RCA Root Cause Analysis SAR Safety Analysis Report SOL Safety through Organisational Learning STEP Sequential Timed Events Plotting TSO Technical Supports Organisation WANO World Association of Nuclear Operators WGOE Working Group of Operational Experience Feedback 3CA Control Change Cause Analysis The majority of terms and definitions in this report are used in accordance with IAEA documents [1, 2] and/or IAEA glossary [37]. Some specific or newly suggested definitions are discussed and explained in the text of the report. Content Executive summary................................................................................................................................... 6 1. Introduction........................................................................................................................................... 8 1.1. Background............................................................................................................................... 11 1.2. Objectives and scope................................................................................................................. 12 1.3. Structure of the report ............................................................................................................... 13 2. Event investigation methodologies and methods ................................................................. 14 2.1. Root cause analysis methods .................................................................................................... 18 2.1.1. HPES - Human Performance Enhancement System......................................................... 22 2.1.2. MORT - Management Oversight and Risk Tree............................................................... 25 2.1.3. ASSET - Assessment of Safety Significant Event Team.................................................. 28 2.1.4. RCA methods derived from HPES ................................................................................... 34 2.1.4.1. HPIP - Human Performance Investigation Process ................................................. 34 2.1.4.2. MTO - Man-Technology-Organisation Investigation.............................................. 36 2.1.4.3. AEB - Accident evolution and barrier function....................................................... 37 2.1.4.4. PRCAP - The Paks Root Cause Analysis Procedure............................................... 39 2.1.5. SOL - Safety through Organisational Learning...................................................................... 39 2.1.6. TRIPOD .................................................................................................................................. 43 2.1.7. STEP - Sequential Timed Events Plotting.............................................................................. 46 2.1.8. A remedy-oriented event investigation system....................................................................... 48 2.1.9. HF- compatible RCA method ................................................................................................. 50 2.1.10. 3CA - Control Change Cause Analysis ................................................................................ 51 2.1.11. FRAM - Functional Resonance Analysis Method................................................................ 55 2.1.12. CAS-HEAR - Computer-Aided System for Human Error Analysis & Reduction............... 57 2.1.12.1. Underlying model of CAS-HEAR......................................................................... 57 2.1.12.2. Procedure of CAS-HEAR...................................................................................... 59 2.1.13. Apollo root cause analysis .................................................................................................... 66 2.1.14. Other RCA related event investigation methods .................................................................. 67 2.1.15. Apparent Cause Analysis...................................................................................................... 71 2.1.16. HPEP - Human Performance Evaluation Process............................................................. 72 2.1.17. PROSPER - Peer Review of the effectiveness of the Operational Safety Performance Experience Review process .............................................................................................. 74 2.2. PSA based event and precursor analysis methods .................................................................... 76 2.2.1. ATHEANA ............................................................................................................................. 79 2.2.2. RASP....................................................................................................................................... 83 2.2.3. Attributes of PSA and correlation with other event investigation methods............................ 85 2.3. Deterministic safety analyses.................................................................................................... 90 2.4. Safety Culture Impact Assessment ........................................................................................... 94 3. Event investigation tools and techniques .............................................................................. 99 3.1. Event and causal factor charting and analysis ........................................................................ 106 3.2. Cause and effect analysis........................................................................................................ 115 3.3. Interviewing ............................................................................................................................ 117 3.4. Task analysis........................................................................................................................... 120 3.5. Change analysis ...................................................................................................................... 121 3.6. Barrier analysis ....................................................................................................................... 125 3.7. Fault tree analysis ................................................................................................................... 130 3.8. Event tree analysis .................................................................................................................. 134 3.9. Causal factor tree analysis ...................................................................................................... 136 3.10. Kepner-Tregoe Problem Solving and Decision Making......................................................... 140 4 3.11. Interrelationship diagram.......................................................................................................