IAEA safety report shifts focus from human error to organizational processes and cultural values

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Contribution of human error to the occurrence of events

This week the IAEA released a new report titled Managing Human Performance to Improve Nuclear Facility Operation.

The publication shows the need for additional emphasis on the role of human performance in sustaining and improving performance at nuclear facilities.

According to the report, some 80% of significant events at nuclear industry facilities can be attributed to human error, and only 20% can be attributed to equipment failure.  Additionally, 70% of human errors (or 56% of all events) at nuclear plants were found to be the result of organizational and process weaknesses, not individual behavior.

In the past, great emphasis was placed on designing system hardware and software to intercept and mitigate events that could cause adverse consequences, but in the advent of Three Mile Island, Chernobyl, and Fukushima Daiichi – the impact of the human component has proven to be even more complicated to resolve.

Historically, the industry has assumed that human error is a motivational issue or problem with an individual, however the report highlights that weaknesses in organization processes and cultural values have contributed significantly more to the occurrence of significant events than have individual mistakes.  Still, despite the fact that human errors are inevitable, regardless of training, experience, and punishment, there are still things which can be done to predict, manage, and prevent systemic errors and many random errors from occurring.

The essential first step in effective error prevention is, understanding how and why unsafe acts occur.  How often have we read about licensed nuclear power facilities where repeat errors are made, sometimes even on the same system or piece of equipment?

Now the IAEA is shifting focus and acknowledging that the individual behaviors and processes in place will only be as good as the organizational structure which supports them.

According to the publication, “While these organizational deficiencies are often hidden in management processes, values or organizational structure, they can create workplace conditions that lead to a human error or degradation in the integrity of defenses, such as quality of procedures or reliability of systems.”

The report concludes that it is possible for events to occur even when individuals are capable of performing the work, and proper procedures are in place.  It notes that events may occur because the culture of the organization does not support the right behaviors.

If licensees were to work to resolve these deficiencies in organizational processes and cultural values, the IAEA believes that the effects over time would lead to; a reduction in the number and consequences of significant events, increased involvement by employees in the organization to achieve its goals, improvement of core and supporting processes in the organization, attention to issues at a lower level before they become significant issues, improvement in quality and safety, reduction in total operating costs, and the increased trust of stakeholders in the organization.

The summary of the report also includes a warning, “It is generally postulated that without continuous efforts on human performance improvement, safe performance of nuclear facilities would be unsustainable,” and also adds that the situation can be improved either reactively after an event, or preferably proactively before a problem arises.

Source: IAEA

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