operational safety operations license to operate from regulator dependent on meeting license...

operational Safetyoperational Safety

OperationsOperations

License to Operate from regulator dependent License to Operate from regulator dependent on meeting license conditions (LCs)on meeting license conditions (LCs)

Design supported by Design supported by Safety CaseSafety Case

Construction and Construction and CommissioningCommissioning

پژوهشگاه علوم و فنون هسته ایپژوهشگاه علوم و فنون هسته ای Nuclear Science and Technology InstituteNuclear Science and Technology Institute

پژوهشکده تحقيقات و توسعه راکتورها و شتاب پژوهشکده تحقيقات و توسعه راکتورها و شتاب هاهادهنده دهنده

School of Research and Development Of Nuclear School of Research and Development Of Nuclear Reactors and AcceleratorsReactors and Accelerators

OutlineOutline Operational nuclear safety Operational nuclear safety Focus on nuclear safety and underlying cultural Focus on nuclear safety and underlying cultural

issuesissues safety systems and processes (but not safety cases)safety systems and processes (but not safety cases) Example License Condition requirementsExample License Condition requirements

Operating experience feedback (LC 7)Operating experience feedback (LC 7) Operating rules (LC 23)Operating rules (LC 23) Management of change (LC 36)Management of change (LC 36)

Behavioural interventions to improve performanceBehavioural interventions to improve performance Overall safety management systemOverall safety management system




Operational Nuclear SafetyOperational Nuclear Safety Remaining within the limits of the safety caseRemaining within the limits of the safety case Procedures, monitoring, analysis and learning Procedures, monitoring, analysis and learning

processesprocesses Suitably qualified, experienced and competent Suitably qualified, experienced and competent

staffstaff Good managementGood management Good safety cultureGood safety culture

the right things are done with the right attitude so as the right things are done with the right attitude so as to achieve the right resultsto achieve the right results




Reason’s Swiss Cheese Reason’s Swiss Cheese ModelModel

Defence in depth Defence in depth (many layers)(many layers)

Works most of the Works most of the timetime

All have weaknessesAll have weaknesses Can line up with Can line up with

disastrous resultsdisastrous results




Culture is fundamentalCulture is fundamental

The culture determines the quality of the The culture determines the quality of the safety management processessafety management processes How big the holes in the cheese areHow big the holes in the cheese are How they are monitored and reducedHow they are monitored and reduced Helps ensure they are not alignedHelps ensure they are not aligned




Generic problemGeneric problem

Piper Alpha




Generic problemGeneric problem

Shuttle Chernobyl




FindingsFindings High proportion (by far) of events High proportion (by far) of events

attributed to human factorsattributed to human factors

Top four root causes:Top four root causes: Personnel work practicesPersonnel work practices ProceduresProcedures Verbal communicationsVerbal communications Supervisory methodsSupervisory methods




Event investigationsEvent investigations Often don’t ask ‘why’ enoughOften don’t ask ‘why’ enough Its easiest to focus on the individual Its easiest to focus on the individual

……...but this won’t help to move things ...but this won’t help to move things forward and prevent future eventsforward and prevent future events

Key is know why the individuals behaved Key is know why the individuals behaved as they did – what are the human factors?as they did – what are the human factors?




Human Factors in eventsHuman Factors in events

IndividualCompetence, skills, personality, attitudes, risk perception….

OrganisationCulture, leadership, resources, communications, work patterns....

Job

Task, workload, environment, display and

controls, procedures…




The learning loopThe learning loop

ENABLERS

RESULTS




Closing the learning loopClosing the learning loop

‘To look is one thing, To see what you look at is another. To understand what you see is another.To learn from what you understand is something else.But to act on what you learn is all that really matters.’

Sir Winston Churchill




Review findingsReview findings Rules were sometimes Rules were sometimes

not clearly written (poor language, over complex)not clearly written (poor language, over complex) contained no operational margincontained no operational margin were not relevant to nuclear safetywere not relevant to nuclear safety

Rules “invited” the operators to breach themRules “invited” the operators to breach them

Guidance was needed for rewriting the RulesGuidance was needed for rewriting the Rules




Guiding PrinciplesGuiding PrinciplesP3 P3

The operating limits set out in the rules should be such that a breach The operating limits set out in the rules should be such that a breach represents a significant erosion of safety, commensurate with the represents a significant erosion of safety, commensurate with the external attention it attracts external attention it attracts

P10 P10 A clear identification is required of which rules are appropriate to normal A clear identification is required of which rules are appropriate to normal

steady state conditions and which to other situations (including faults, steady state conditions and which to other situations (including faults, start-up, post-trip and shut-down situations). start-up, post-trip and shut-down situations).

P11P11 Rules should (so far as is practicable) refer only to plant parameters and Rules should (so far as is practicable) refer only to plant parameters and

conditions which can be directly monitored (and preferably be directly conditions which can be directly monitored (and preferably be directly controlled) by the station staff. controlled) by the station staff.

P12P12 Rules should not require staff to process information presented to them Rules should not require staff to process information presented to them

unless the appropriate support is provided. unless the appropriate support is provided. P15P15

Rules should use derived operating limits which anticipate faults, rather Rules should use derived operating limits which anticipate faults, rather than basic safety limits.than basic safety limits.




OutcomeOutcome Many principles concerned with making Many principles concerned with making

the Rules easier to follow and comply with the Rules easier to follow and comply with i.e. making the operators’ job easieri.e. making the operators’ job easier

Programme of Rule revisionProgramme of Rule revision Very significant reduction in Rule breachesVery significant reduction in Rule breaches




Measurable benefitMeasurable benefit

02468

101214161820

1992 1993 1994 1995 1996

Breaches




OutcomeOutcome Many principles concerned with making the Many principles concerned with making the

Rules easier to follow and comply with i.e. Rules easier to follow and comply with i.e. making the operators’ job easiermaking the operators’ job easier

Programme of Rule revisionProgramme of Rule revision Very significant reduction in Rule breachesVery significant reduction in Rule breaches Greater credibility of RulesGreater credibility of Rules Greater regulator and public confidence Greater regulator and public confidence Greater self awareness and self Greater self awareness and self

confidenceconfidence




Management of ChangeManagement of Change Newest License Condition (LC36)Newest License Condition (LC36) Introduced to address the increasing instability in Introduced to address the increasing instability in

UK Nuclear Industry since 1989UK Nuclear Industry since 1989 Restructuring, privatisation, downsizing, re-Restructuring, privatisation, downsizing, re-

organisation (local and corporate), contractorisation, organisation (local and corporate), contractorisation, competitioncompetition

Loss of experience, uncertainty (role, job security)Loss of experience, uncertainty (role, job security) Requires formal statement of how nuclear safety Requires formal statement of how nuclear safety

is ensured during and after the changeis ensured during and after the change Key performance indicators to monitor the Key performance indicators to monitor the

changechange




WeaknessWeakness Too formal/theoreticalToo formal/theoretical

Attitudes and morale not properly coveredAttitudes and morale not properly covered Teamworking and loyaltiesTeamworking and loyalties Influx of contractorsInflux of contractors Loss of “latent” expertiseLoss of “latent” expertise New management styleNew management style Clash of culturesClash of cultures

People are not componentsPeople are not components




Ideal

Actual

Ideal

Actual

Safety ManagementSafety Management




BehaviouralBehavioural interventions interventions

Behavioural Observation*

Standards and Behaviours Booklets

STAR – Stop Think Act Review

Coaching

Conduct of Operations

Conduct of Maintenance

Competencies – appraisal, appointments

Environmental awareness

WANO Peer Review (PO+Cs)

Safety Culture Tool *

Lead Team

operators




The sharp endThe sharp end

ENABLERS

RESULTS




operational safety operations license to operate from regulator dependent on meeting license...

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