IEC 63260

®
Edition 1.0 2020-05

INTERNATIONAL IEEE Std 1082™

STANDARD

Guide for incorporating human reliability analysis into probabilistic risk

assessments for nuclear power generating stations and other nuclear facilities
IEC 60320:2020-05(en) IEEE Std 1082-2017

Authorized licensed use limited to: UNIVERSITY OF BIRMINGHAM. Downloaded on July 25,2020 at 20:57:45 UTC from IEEE Xplore. Restrictions apply.
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 IEC 63260
®
Edition 1.0 2020-05

INTERNATIONAL
A IEEE Std 1082™
STANDARD

Guide for incorporating human reliability analysis into probabilistic risk

assessments for nuclear power generating stations and other nuclear facilities

INTERNATIONAL
ELECTROTECHNICAL
COMMISSION

ICS 27.120.20 ISBN 978-2-8322-7547-4

,(((3')67' ,(((,6%1

Warning! Make sure that you obtained this publication from an authorized distributor.

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International OF BIRMINGHAM.
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 Contents

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2.2 Acronyms and abbreviations .............................................................................................................. 

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3.2 Overall evaluation issues .................................................................................................................... 
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5. Documentation .......................................................................................................................................... 26
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5.2 Structure ............................................................................................................................................. 26

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Annex B (informative) Bibliography ............................................................................................................. 32

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Probabilistic Risk Assessments for Nuclear Power Generating Stations
and Other Nuclear Facilities

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 ,(& ± YLL± IEEE Std 1082™-2017
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IEEE Guide for Incorporating

Human Reliability Analysis into
Probabilistic Risk Assessments for
Nuclear Power Generating Stations
and Other Nuclear Facilities

6SRQVRU

Nuclear Power Engineering Committee

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IEEE Power and Energy Society

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IEEE-SA Standards Board

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 IEC 63260:20
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IEEE Std 1082-2017

Abstract: A structured framework for the incorporation of human reliability analysis (HRA) into
probabilistic risk assessments (PRAs) is provided in this guide. To enhance the analysis of human/
system interactions in PRAs, to help ensure reproducible conclusions, and to standardize the
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framework is developed from standard practices. The HRA framework is neutral with respect to
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Keywords: HRA, human reliability analysis, IEEE 1082™, PRA, probabilistic risk assessment

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IEEE Introduction

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Any process that requires manual control to minimize public risk will require a high level of human reliability.
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However, such an assessment requires a detailed understanding of human performance and human reliability
methods to form a reasonable reliability estimate.

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enterprise. But the methodology—both analyzing human failure events and identifying and incorporating
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for a conference on the human factor issues raised by TMI.2 This conference has subsequently become a series.
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This guide outlines the steps necessary to include human reliability in risk assessments. The intent of the guide
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issues and practices.

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The numbers in brackets correspond to those of the bibliography in Annex B.
2
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4
ASME publications are available from the American Society of Mechanical Engineers (http://www.asme.org/).

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IEEE Guide for Incorporating

Human Reliability Analysis into
Probabilistic Risk Assessments for
Nuclear Power Generating Stations
and Other Nuclear Facilities

1. Overview
1.1 Scope
7KLVJXLGHSURYLGHVDVWUXFWXUHGIUDPHZRUNIRUWKHLQFRUSRUDWLRQRIKXPDQUHOLDELOLW\DQDO\VLV+5$LQWR
SUREDELOLVWLFULVNDVVHVVPHQWV35$V

1.2 Purpose
7KHSXUSRVHRIWKLVJXLGHLVWRHQKDQFHWKHDQDO\VLVRIKXPDQV\VWHPLQWHUDFWLRQVLQ35$VWRKHOSHQVXUH
UHSURGXFLEOHFRQFOXVLRQVDQGWRVWDQGDUGL]HWKHGRFXPHQWDWLRQRIVXFKDVVHVVPHQWV7RGRWKLVDVSHFL¿F
+5$IUDPHZRUNLVGHYHORSHGIURPVWDQGDUGSUDFWLFHVWRVHUYHDVDEHQFKPDUNWRDVVHVVDOWHUQDWLYHZD\VRI
LQFRUSRUDWLQJ+5$LQWR35$

 'H¿QLWLRQVDFURQ\PVDQGDEEUHYLDWLRQV
 'H¿QLWLRQV
)RUWKHSXUSRVHVRIWKLVGRFXPHQWWKHIROORZLQJWHUPVDQGGH¿QLWLRQVDSSO\7KHIEEE Standards Dictionary
OnlineVKRXOGEHFRQVXOWHGIRUWHUPVQRWGH¿QHGLQWKLVFODXVH5

NOTE—6HYHUDOWHUPVXVHGLQWKLVJXLGHDQGLQWKH¿HOGRI+5$DUHLPSRUWDQW\HWDUHDPELJXRXVLQFRPPRQXVDJHRUQRW
XVHGIUHTXHQWO\HQRXJKWREHZHOONQRZQ7KH\DUHGH¿QHGLQWKLVFODXVHIRUWKHXVHLQXQGHUVWDQGLQJDQGIROORZLQJWKLV
guide.6

basic event: An element of the probabilistic risk assessment model for which no further decomposition is
performed because it is at the limit of resolution consistent with available data.

5
IEEE Standards Dictionary Online subscription is available at: http://dictionary.ieee.org.
6
1RWHVLQWH[WWDEOHVDQG¿JXUHVRIDVWDQGDUGDUHJLYHQIRULQIRUPDWLRQRQO\DQGGRQRWFRQWDLQUHTXLUHPHQWVQHHGHGWRLPSOHPHQWWKLV
standard.

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consequences7KHUHVXOWVRILHHYHQWVWKDWIROORZDQGGHSHQGXSRQDVSHFL¿HGHYHQW

cutset: A group of events that, if all occur, would cause occurrence of the top event (the outcome of interest
such as that investigated by means of a fault tree).

dependence: The relationship between two or more human failure events, which may result in an adjustment
to the model or the human error probability.

design-basis accident: A postulated accident that a nuclear facility must be designed and built to withstand
without loss to the systems, structures, and components necessary to help ensure public health and safety.

dominant sequence: A sequence of events that constitutes a dominant contributor to overall risk.

event$$Q\FKDQJHLQFRQGLWLRQVRUSHUIRUPDQFHRILQWHUHVW%$QRFFXUUHQFHDWDVSHFL¿FSRLQWLQWLPH

event tree: A graphical representation of the logical progression of the possible scenarios through a multiple
series of events that may or may not occur.

fault tree: A graphical representation of an analytical technique whereby an undesired state of a system is
VSHFL¿HGDQGWKHSDWWHUQVOHDGLQJWRWKDWVWDWHFDQEHHYDOXDWHGWRGHWHUPLQHKRZWKHXQGHVLUDEOHV\VWHP
failure can occur.

human action: The observable result (often a bodily movement) of a person’s intention.

human error )DLOXUH RI KXPDQ WDVN SHUIRUPDQFH WR PHHW VSHFL¿HG FULWHULD RI DFFXUDF\ FRPSOHWHQHVV
correctness, appropriateness, or timeliness.

human error probability (HEP): The quantitative estimation of the likelihood of a human error.

human failure event (HFE): A basic event that pertains to a human error.

human interaction$KXPDQDFWLRQRUVHWRIDFWLRQVWKDWD൵HFWVHTXLSPHQWUHVSRQVHRIV\VWHPVRURWKHU
human actions.

human reliability analysis (HRA): Any number of formal approaches and methods used to identify sources
of human error and quantify their accompanying human error probabilities.

initiating event: An event either internal or external to the plant that perturbs the steady state operation of the
plant by challenging plant control and safety systems whose failure could potentially lead to core damage or
UHOHDVHRIDLUERUQH¿VVLRQSURGXFWV

operating crew3ODQWSHUVRQQHOZRUNLQJRQVKLIWWRRSHUDWHWKHSODQW7KH\LQFOXGHFRQWUROURRPSHUVRQQHO
and those support personnel who directly support the control room personnel in operating the plant.

performance shaping factor (PSF) $ IDFWRU WKDW LQÀXHQFHV KXPDQ UHOLDELOLW\ WKURXJK LWV H൵HFWV RQ
performance. These include factors such as environmental conditions, human-system interface design,
procedures, training, and supervision.

probabilistic risk assessment (PRA): A qualitative and quantitative assessment of the risk associated with
plant operation and maintenance that is measured in terms of frequency of occurrence of risk metrics, such as


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use in human reliability analysis.

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SUREDELOLVWLFVDIHW\DVVHVVPHQW36$@

recovery $ VHW RI LQWHUDFWLRQV LQWHQGHG WR UHVWRUH IDLOHG HTXLSPHQW RU WR ¿QGD OWHUQDWLYHVW RD FKLHYHLWV
function.

risk3UREDELOLW\DQGFRQVHTXHQFHVRIDQHYHQWDVH[SUHVVHGE\WKHDQVZHUWRWKHIROORZLQJWKUHHTXHVWLRQV
:KDWFDQJRZURQJ"+RZOLNHO\LVLW"DQG:KDWDUHWKHFRQVHTXHQFHVLILWRFFXUV"

screening$W\SHRIDQDO\VLVDLPHGDWHOLPLQDWLQJIURPIXUWKHUFRQVLGHUDWLRQIDFWRUVWKDWDUHOHVVVLJQL¿FDQW
IRUSURWHFWLRQRUVDIHW\LQRUGHUWRFRQFHQWUDWHRQWKHPRUHVLJQL¿FDQWIDFWRUV

screening value$URXJKEXWFRQVHUYDWLYHSRLQWHVWLPDWHRIWKHSUREDELOLW\RIDVSHFL¿FKXPDQIDLOXUHHYHQW

uncertainty interval7KHFRQ¿GHQFHLQWKHKXPDQHUURUSUREDELOLW\HVWLPDWHDVH[SUHVVHGLQDFRQ¿GHQFH
bound around the single-point estimate.

walkthrough: A systematic process by which the actions required of operators are checked against the real
plant or against a model, mock-up, or simulation of the real plant. A walkthrough is typically used to identify
performance shaping factors.

2.2 Acronyms and abbreviations

DOE U.S. Department of Energy

I&C instrumentation and control
,132 ,QVWLWXWHRI1XFOHDU3RZHU2SHUDWLRQV
LOCA loss of coolant accident
15& 861XFOHDU5HJXODWRU\&RPPLVVLRQ

3. Overview of an integrated HRA

3.1 General
3.1.1 Importance of human reliability

In assessing the risk associated with a nuclear power plant, the analyst should consider not only the reliability
of plant hardware systems but also the reliability of people’s interactions with other plant or support personnel
and with the plant’s equipment and systems. The scope of interactions with plant equipment and systems
should include those in the control room and at local control stations and with both manually controlled and
automated systems.

3.1.2 Importance of integrated HRA and PRA

$Q+5$VKRXOGEHDQLQWHJUDOSDUWRID35$,Q35$VWKHTXDOLW\RIWKHDQDO\VLVHJTXDQWL¿FDWLRQRIKXPDQ
error) is dependent upon the analyst’s ability to identify scenarios and the expected human actions. This guide
SURYLGHVDVSHFL¿FDSSURDFKWKDWLIDSSOLHGZLOOVWDQGDUGL]HWKHLQWHJUDWLRQRI+5$LQWRWKH35$SURFHVV7KH
breakdown and order of the steps presented are not so important; all of the steps and their activities, however,
VKRXOGEHIRXQGZLWKLQDQ\+5$7KLVDSSURDFKLVZHOOHVWDEOLVKHGIRUGHVLJQEDVLV35$V7KHDSSURDFK
applies to beyond design-basis analyses such as those used for severe accidents. However, as the uncertainty
and variability of the plant state and accident scenario evolution increase, so too does the complexity of

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performing the analysis. The steps outlined in this guide should be considered at a minimum; additional steps
may be appropriate for certain cases, such as severe accident analyses.

3.2 Overall evaluation issues

7KHIRFXVRIWKLVJXLGHLVUHVWULFWHGWRWKHLQFRUSRUDWLRQRIWKH+5$LQWHJUDOO\LQWRD35$7KLVLQFOXGHVWKH
following issues:

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E 7KHUHODWLRQVKLSEHWZHHQWKHZD\LQZKLFKDQ+5$LVSHUIRUPHGLWVSKLORVRSK\DQGWKHUHVXOWVRU
insights that may be obtained;
F 0DWFKLQJWKHEHVWVXLWHG+5$PHWKRGWRWKHDQDO\VLVUHTXLUHPHQWVDQG
G 7KHOLPLWVRIDQ+5$RULWVUHVXOWV

3.2.1 PRA compatibility

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GH¿QHGWKHQWKLVJXLGDQFHFDQQRWEHDSSOLHGVXFFHVVIXOO\7KHULVNIRFXVRID35$UHTXLUHVWKHTXDQWLWDWLYH
UHVXOWVRIDQ+5$WREHSUREDELOLVWLFLQQDWXUH$SSOLFDWLRQVRI35$VWRULVNPDQDJHPHQWH൵RUWVUHTXLUH
WKDWWKH+5$GRFXPHQWVLQVX൶FLHQWGHWDLOWKHDQDO\VW¶VKXPDQIDFWRUVFRQVLGHUDWLRQVIRUWKHKXPDQIDLOXUH
HYHQWV7KH35$FDQKDYHDGLYHUVHUDQJHRIDSSOLFDWLRQVWKHREMHFWLYHVRIZKLFKPD\QRWEHFRPSOHWHO\
LGHQWL¿HGSULRUWRWKHDVVHVVPHQW7KH+5$SURFHVVVKRXOGEHÀH[LEOHHQRXJKWRDQWLFLSDWHVRPHRIWKHOLNHO\
DSSOLFDWLRQVRIWKHUHVXOWVRIWKH+5$)RUH[DPSOHWKLVPD\LQFOXGHGHVLJQFKDQJHVSURFHGXUHFKDQJHV
WUDLQLQJGHYHORSPHQWVDIHW\HYDOXDWLRQVRUWHFKQLFDOVSHFL¿FDWLRQPRGL¿FDWLRQ

3.2.2 Qualitative HRA

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WKDWWKHUHLVDQLQFUHDVLQJHPSKDVLVRQWKHLPSRUWDQFHRITXDOLWDWLYH+5$>%@LH+5$WKDWGRHVQRW
produce a human error probability, but rather insights into the human’s role and contribution to overall system
SHUIRUPDQFH7KH+5$DSSURDFKLQWKLVJXLGHVXSSRUWVERWKTXDOLWDWLYHDQGTXDQWLWDWLYHDVSHFWVRI+5$
)RU35$WKHTXDQWLWDWLYHDSSURDFKVKRXOGEHDGRSWHG)RUQRQ35$DSSOLFDWLRQVRI+5$VWHSVUHOHYDQWWR
TXDQWL¿FDWLRQVKRXOGEHRPLWWHGDVDSSURSULDWH

3.2.3 The relationship of approach to results

Assumptions made by human reliability analysts about the relative importance of various human activities
ZLOO LQÀXHQFHWKH EUHDGWK DQG GHWDLO RI PRGHOV GHYHORSHG IRU WKH +5$7KH GDWD DQG FKRVHQ PHWKRG RI
TXDQWLI\LQJ KXPDQ LQWHUDFWLRQV ZLOO LQÀXHQFHWKH VSHFL¿FHVWLPDWHV RU UDQJHV RI XQFHUWDLQW\ REWDLQHG
DOWKRXJKWKHUHLVJHQHUDOO\JRRGDJUHHPHQWEHWZHHQ+5$PHWKRGV,IUHVXOWVSRLQWWRWKHQHHGWRLPSURYH
the reliability of selected systems and accompanying human interactions, these improvements should either
EHUHDGLO\LGHQWL¿DEOHIURPWKHGRFXPHQWHG+5$RUVKRXOGEHWKHVXEMHFWRIIXUWKHURUGL൵HUHQWDQDO\WLFDO
PHWKRGVWKDWZLOODOORZLPSURYHPHQWVWREHLGHQWL¿HGDVGHVFULEHGLQPHWKRGVSHFL¿FGRFXPHQWV,QDGGLWLRQ
WRPHWKRGVSHFL¿FJXLGDQFHJHQHUDOJXLGDQFHRQVHOHFWLRQRIDSSURSULDWH+5$DSSURDFKHVFDQEHIRXQGLQ
cross-method overview documents such as >%@, >%@, and >%@7KH+5$DQDO\VWVKRXOGEHPLQGIXORIWKLV
ZKHQFRQVLGHULQJWKHVSHFL¿FDSSURDFKWREHWDNHQ

3.2.4 Matching the method to the application

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RUDSSURDFKHVWKDWDGGUHVVHUURUVRIFRPPLVVLRQ+5$VVKRXOGEHÀH[LEOHHQRXJKWRDFFRPPRGDWHQHZ
¿QGLQJVDQGPRGHOGHYHORSPHQWVZKLOHVWUXFWXUHGHQRXJKWREHUHSHDWDEOHDQGWUDFHDEOH+5$PHWKRGV
ZHUHGHYHORSHGIRUGLIIHUHQWSXUSRVHVDQGWKH\IHDWXUHGLIIHUHQWVWUHQJWKV>%@. One emerging practice is

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WKDWPXOWLSOH+5$PHWKRGVPD\EHXVHGZLWKLQDVLQJOHDQDO\VLVWRUHÀHFWWKHVWUHQJWKVRIWKRVHDSSURDFKHV
and the needs of the analysis >%@7KLVJXLGHUHPDLQVPHWKRGQHXWUDOEXWHQFRXUDJHVDQDO\VWVWREHÀH[LEOHLQ
FRQVLGHULQJWKHEHVW+5$PHWKRGVIRUSDUWLFXODUDSSOLFDWLRQV

3.2.5 Limits

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UROHRISODQWSHUVRQQHOLQDFFLGHQWSUHYHQWLRQDQGPLWLJDWLRQ$FFRUGLQJO\WKHUHVXOWVRIDQ+5$VKRXOGEH
documented in a format such that the basic assumptions, models, and data sources are clearly documented and
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Figure 1—General HRA process

3.3 HRA process

3.3.1 General

$JHQHUDO+5$SURFHVVLVGHSLFWHGLQ)LJXUH,WSDUDOOHOVWKHW\SLFDO35$SURFHVVVHH>%@ and >%@), but

LVQRWRUJDQL]DWLRQDOO\UHODWHGWRLW7KHFKRVHQ+5$SURFHVVLVDQDGDSWDWLRQRIDSURFHVVWKDWKDVEHHQXVHG
LQPDQ\35$VVHH>%@). The general structure is described in 3.3.3WKHVSHFL¿FVWHSVDUHGHVFULEHGLQ3.3.4
and detailed in Clause 4, and the outputs at each step are described in 3.3.5. The timing and level of detail of
WKH+5$VKRXOGV\QFKURQL]HZLWKWKH35$7KHUHIRUHWKH+5$VWUXFWXUHGLVFXVVHGLQWKLVJXLGHVKRXOGEH
DSSOLHGZLWKPRGL¿FDWLRQDVQHHGHG In its general form, )LJXUH can also show the initial portions of the
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DQDO\VWWDNHVWKHLQLWLDWLQJHYHQW+5$DVWKHEDVLVFKHFNVWKHIHDVLELOLW\RIDFWLRQVIRUH[WHUQDODQGDUHDHYHQWVDQGWKHQPRGL¿HVWKH
analyses as necessary.

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3.3.2 Existing versus new HRA

The process outlined in )LJXUHUHSUHVHQWVDQDSSURDFKWKDWPD\EHXVHGWRFUHDWHDQHZ+5$,QFUHDWLQJ

DQHZ+5$WKH+5$VKRXOGEHLQWHJUDWHGLQWRWKH35$SURFHVVDQGQRWYLHZHGDVDQLQGHSHQGHQWDQDO\VLV
IURPWKH35$,QSUDFWLFHLWLVFRPPRQWRVWDUWZLWKDQH[LVWLQJ+5$IRUDVLPLODUV\VWHPRUSODQWDQGWKHQ
UHXVHDQGPRGLI\LWZLWKGHWDLOVVSHFL¿FWRWKHQHZDQDO\VLV7KHSURSHUGRFXPHQWDWLRQRIWKHLQLWLDO+5$
DFURVVDOOVWHSVKHOSVWRHQVXUHWKDWUHXVHLVYLDEOH:KHQUHXVLQJDQGPRGLI\LQJDQH[LVWLQJ+5$DQDO\VWV
should carefully document any changes in assumptions and their consequences in the new analysis. Steps in
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DFFRUGLQJWRWKHW\SHVRIPRGL¿FDWLRQVPDGHWRWKHH[LVWLQJ+5$

3.3.3 HRA structure

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is broad enough to help ensure completeness without including unnecessary details. As the analysis moves
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possible, and breadth can be traded for depth in the analysis. This narrowing of the analysis requires evaluation
DQGMXGJPHQW7KLVIRFXVLQJRIWKHDQDO\VLVLVUHIHUUHGWRDV³VFUHHQLQJ´E\35$SUDFWLWLRQHUV

3.3.4 Summary of HRA steps

7KH+5$SURFHVVGHSLFWHGLQ)LJXUH is a process of eight tasks and two major decisions. These steps are
detailed in Clause 47KHVHVWHSVIRUPDEDVLVIRUDXGLWDEOHGRFXPHQWDWLRQRIWKH+5$,IWKHWHDPFKRRVHVWR
deviate from this process, then the deviations from this framework can also be documented for auditability as
follows:

D 7KH+5$SURFHVVEHJLQVZLWKWKHVHOHFWLRQDQGWUDLQLQJRIWKHMRLQW+5$35$WHDP
b) The team should familiarize itself with the plant and its systems, functions, and procedures.
F 7KH¿UVWPRGHOVRIWKHSODQWVKRXOGEHGHYHORSHGMRLQWO\E\WKHWHDP7KLVPRGHOLGHQWL¿HVWKHPDMRU
human interaction events in functional terms.
d) The results form a list of interactions that are screened by restricting the analysis to candidate- dominant
VHTXHQFHV7KH+5$VXSSRUWVVFUHHQLQJE\SURYLGLQJURXJKEXWFRQVHUYDWLYHSRLQWHVWLPDWHVRIWKH
probabilities of all the human interaction events called “screening values” into the models at this stage.
H +XPDQDFWLRQVZKRVHIDLOXUHVDUHIRXQGWREHVLJQL¿FDQWFRQWULEXWRUVWRULVNDUHWKHQFKDUDFWHUL]HGLQ
GHWDLODVKXPDQIDLOXUHHYHQWVWRVXSSRUWTXDQWL¿FDWLRQDQGDSSOLFDWLRQRIWKH35$UHVXOWV
I (DFKKXPDQIDLOXUHHYHQWLVWKHQTXDQWL¿HG7KHUHVXOWRIWKHTXDQWL¿FDWLRQVWHSRIWHQFKDQJHVWKH
event description or adds a more detailed representation of the event; the result should be incorporated
into the update of the model.
J 'HSHQGHQFHEHWZHHQKXPDQIDLOXUHHYHQWVLVFRQVLGHUHG,IUHFRYHU\HYHQWVDUHLGHQWL¿HGWKHQWKH
models of these events, including the models of the human interactions, are incorporated into the
updated models.
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RSHUDWLRQVVKRXOGRQO\EHFRQ¿UPDWRU\

)LQDOO\WKHGRFXPHQWDWLRQRIWKH+5$OLNHWKHUHVWRIWKH35$LVDFUXFLDOHOHPHQWWKDWLVRQJRLQJWKURXJKRXW
WKH+5$'RFXPHQWDWLRQLVQRWVKRZQRQWKHÀRZFKDUWLQ)LJXUH but is detailed separately in Clause 5.

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3.3.5 Outputs

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OLVWVWKHNLQGVRILQIRUPDWLRQSURGXFHGDWHDFKVWHS*HQHUDOO\DOOVWHSVRIWKH+5$SURFHVVZLOOEHSHUIRUPHG
VLQFHWKH\WRJHWKHUUHSUHVHQWWKHVWHSVQHHGHGWRVXSSRUWD35$

Table 1—Products of the HRA process steps

Step
6HOHFWDQGWUDLQ+5$WHDP
2. Familiarize team with plant
3. Build initial plant model
4. Screen human interactions
5. Characterize human interactions
4XDQWLI\KXPDQLQWHUDFWLRQV
8SGDWHSODQWPRGHOZLWK
dependence and recovery
5HYLHZUHVXOWV
Product
,QWHJUDWHGWHDPZLWKUHTXLVLWH35$DQG+5$VNLOOV
,QLWLDOLGHQWL¿FDWLRQRIKXPDQIXQFWLRQVDQGDFWLYLWLHV3RWHQWLDOKXPDQ
errors can be spotted although without much risk context yet.
All major systems modeled.
6\VWHPLQWHUDFWLRQVLGHQWL¿HG
'HIHQVHEDUULHUVDJDLQVWR൵QRUPDOHYHQWVGHVFULEHG
0RVWNH\KXPDQLQWHUDFWLRQVLGHQWL¿HG
.H\KXPDQLQWHUDFWLRQVLGHQWL¿HGVFUHHQLQJYDOXHV
FKRVHQDQGLQLWLDOTXDQWL¿FDWLRQSHUIRUPHG
)DLOXUHPRGHVPHFKDQLVPVFDXVHVH൵HFWVDQG
LQÀXHQFHVRIWKHNH\KXPDQLQWHUDFWLRQVDUHGHWHUPLQHG
Initial estimates of time required to take action.
Importance ranking, likelihood, and uncertainties
of key human interactions.
Model with recovery actions and dependencies included.
&RQ¿GHQFHWKDWUHVXOWVPDNHVHQVHDQGFDQEHXVHG
E\SODQWVWD൵LQULVNUHGXFWLRQH൵RUWV

4. Details of the HRA process

4.1 General
7KH+5$SURFHVVDVVXPPDUL]HGLQClause 3, is detailed below and includes each step and a statement of
purpose, a description of the step, and a statement of output. A strong technical interface between the human
UHOLDELOLW\DQDO\VWVDQGWKHUHVWRIWKH35$WHDPSHUIRUPLQJWKHHTXLSPHQWUHOLDELOLW\PRGHOLQJLVQHHGHG7KLV
WHDPVKRXOGEHDMRLQWWHDPZKHQHYHUSRVVLEOH7KH+5$35$WHDPPD\EHDVXEVHWRIWKHRYHUDOO35$WHDP
including members specialized in human factors and human reliability.

4.2 Steps in the human reliability analysis (HRA) process

4.2.1 Step 1: Select and train HRA team

4.2.1.1 General

7KH+5$SURFHVVUHTXLUHVFRQWULEXWLRQVIURPDZLGHUDQJHRIVNLOOVLQHQJLQHHULQJSODQWSHUIRUPDQFHKXPDQ
IDFWRUVDQGPDWKHPDWLFDORUVWDWLVWLFDODQDO\VLV,WLVLPSRUWDQWWKDWWKHWHDPWKDWSHUIRUPVWKH+5$SRVVHVVHV
these skills. The number of people on the team and their formal backgrounds are relatively unimportant, so
long as the aggregate represents the skills listed in . A senior person should be appointed from within
WKHRUJDQL]DWLRQWROHDGWKH+5$35$WHDPDQGLQSDUWLFXODUWROHDGWKHLQWHJUDWLRQRIWKHWHDPVNLOOVDQG
FKDPSLRQWKHLULQWHUDFWLRQZLWKWKHEURDGHU35$WHDP7KHUHTXLUHGWUDLQLQJVKRXOGLQFOXGHPHWKRGVIRU
cooperation and communication across disciplines.

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4.2.1.2 Purpose

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LPSRUWDQWVNLOOVDQGGLVFLSOLQHV7KHTXDOLW\RIWKH+5$SRUWLRQRID35$GHSHQGVLQODUJHSDUWRQHQVXULQJ
that the individuals selected as team members possess the necessary technical skills and ability to work and
FRPPXQLFDWHH൵HFWLYHO\DVDWHDP7KLVWHDPZRUNHDUO\LQWKH35$ZLOOIDFLOLWDWHWKHGHYHORSPHQWRIWKH
+5$DQGWKHDFFXUDF\RIWKH35$

4.2.1.3 Description

7KHH[SHUWLVHUHTXLUHGIRUWKH+5$35$WHDPLQFOXGHVLWHPVDWKURXJKJEHORZ7KHVHH[SHUWVLQWHUIDFH

ZLWKRWKHUH[SHUWVRQWKH35$WHDPDQGDWWKHSODQWDVQHHGHG7KLVOLVWGRHVQRWLPSO\WKDWLQGLYLGXDOVLQHDFK
RIWKHVSHFL¿FDUHDVDUHUHTXLUHG,QGLYLGXDOVPD\KDYHPXOWLSOHDUHDVRIH[SHUWLVHHJD35$DQDO\VWZLWK
RSHUDWLRQVEDFNJURXQGZKRLVWUDLQHGLQ+5$PHWKRGV7RKHOSHQVXUHSURSHUFRQVLGHUDWLRQRIKXPDQDVSHFWV
RIULVN+5$H[SHUWLVHVKRXOGEHSDUWRIWKH35$WHDPWKURXJKRXWWKHDQDO\VLV7KHWHDPVKRXOGKDYHWKH
following cumulative experience:

a) Plant operations personnel provide experienced insight into the way(s) in which people conduct
their jobs/tasks in light of training, procedures, and operating experience. As such, they provide
added reality to the analysis of human-system interaction and can identify information about task
requirements that may not be apparent from system operating descriptions and procedures.
b) Human factors engineering personnelSURYLGHLQIRUPDWLRQDERXWWKHH[SHFWHGH൵HFWVRIWDVNDQG
workplace characteristics on human performance, given human capabilities and limitations. Human
factors engineers augment the team by identifying attributes of tasks and task environments that should
be taken into account when evaluating performance shaping factors that contribute to the reliability or
risk of an operation.
c) Human reliability analysts develop or work with the developed detailed qualitative models of the
human-system analysis to provide both qualitative and quantitative estimations of human reliability.
The human reliability analysts work with a variety of quantitative techniques to address performance
shaping factors, time, and training constraints, and their impact on the reliability of human
performance.
d) Nuclear power plant system engineering personnel bring a broad range of knowledge of how the
systems examined are designed, operated, and maintained. These personnel are knowledgeable
of general operating practices and the details of equipment capacities, operating envelopes, and
equipment performance, and they support the analysis of human-system interaction.
e) System safety analysts provide evaluations of system performance and human performance
requirements for situations in which system conditions transition from normal to abnormal and
EH\RQGWHFKQLFDOVSHFL¿FDWLRQRSHUDWLQJHQYHORSHV7KHV\VWHPVDIHW\DQDO\VLVPD\LQFOXGHWKHUPDO
K\GUDXOLFIXHODQG¿VVLRQ SURGXFWEHKDYLRUDQGRWKHUSKHQRPHQRORJLFDODVVHVVPHQWPHWKRGVWR
identify realistic functional requirements and success criteria for the human.
f) Probabilistic risk assessment personnel, who develop equipment reliability models and data,
provide the detailed information on failure rates (or probabilities) for hardware caused by internally
DQGH[WHUQDOO\LQLWLDWHGHYHQWV2XWSXWRIWKH35$FDQFRQVLVWRIIDXOWWUHHVFXWVHWVHYHQWWUHHV
%D\HVLDQQHWZRUNVG\QDPLFHYHQWWUHHVV\VWHPG\QDPLFVPRGHOVRU3HWULQHWVWRZKLFKWKHKXPDQ
reliability analyst provides input to model the role of the human in system operations for the events
under consideration.
g) Engineering personnel provide knowledge about the functioning of controls and other instrumentation
used by operating personnel to control the process(es) of the systems under examination. Since
WKHW\SHVRIFRQWURODQGVDIHW\V\VWHPVHPSOR\HGLQWKHSODQWJHQHUDOO\LQÀXHQFHWKHDELOLW\RIWKH
operating personnel to operate a system, information about instrumentation and control (I&C) is
necessary to identify potential problems with system operation.

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4.2.1.4 Team training

7KH+5$35$WHDPWUDLQLQJVKRXOGEHDLPHGDWWKHGHYHORSPHQWRILQWHJUDWHGZRUNLQJUHODWLRQVKLSVDPRQJ
team members, and at shared understanding of the responsibilities for each member. This training should also
SURYLGHRSSRUWXQLWLHVIRUHDFKPHPEHUWREHFRPHIDPLOLDUZLWKWKHYRFDEXODU\RIWKH+5$SURFHVVDQGZLWK
the skills represented by the other members. The use of sample problem sets, worked on by the entire team, is
RQHH൵HFWLYHZD\RIDFFRPSOLVKLQJWKHVHJRDOV

4.2.1.5 Output

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WHDP7KHTXDOLW\RIWKH+5$ZLOOLQWXUQLQÀXHQFHWKHTXDOLW\RIWKHDVVRFLDWHG35$7KHUHVXOWRIWKH
WHDPVHOHFWLRQDQGWUDLQLQJVWHSVKRXOGEHDZHOOTXDOL¿HGWHDPWKDWEULQJVWRJHWKHUWKHQHHGHGVNLOOVLQD
FRRUGLQDWHGDQGLQWHJUDWHGH൵RUW

4.2.2 Step 2: Familiarize the team with the plant

4.2.2.1 General

4.2.2.1.1 Existing plants

7KH+5$UHTXLUHVFRQVLGHUDEOHJHQHUDODQGVSHFL¿FNQRZOHGJHDERXWDSODQWLQFOXGLQJWKHIROORZLQJ

D 3ODQWV\VWHPVDQGHTXLSPHQWLHKRZLWZRUNVLWVORFDWLRQDQGLWVLQWHUFRQQHFWLRQV
E 3URFHGXUHVDQGRSHUDWLQJSUDFWLFHV
F 7HFKQLFDOVSHFL¿FDWLRQV
d) Control facilities including control room, peripheral control facilities, and control and instrumentation
H 3ODQWW\SH UHIHUHQFH HYHQWV DQG SODQWVSHFL¿F LQLWLDWLQJ HYHQWV ZLWKLQ RU EH\RQG GHVLJQEDVLV DV
required)
f) Training
g) Crew structure

4.2.2.1.2 New plants

)RUQHZSODQWEXLOGVVRPHRIWKLVLQIRUPDWLRQPD\QRWEHIXOO\GH¿QHGGXULQJWKHLQLWLDO+5$GHYHORSPHQW
7KLVLQIRUPDWLRQVKRXOGEH¿OOHGLQDQGWKH+5$VKRXOGEHUH¿QHGDVSODQWDQGRSHUDWLRQDOGHWDLOVEHFRPH
available.

4.2.2.2 Purpose

7KHSXUSRVHRIWKLVVWHSLVWRSURYLGHWKH+5$35$WHDPZLWKNQRZOHGJHRIWKHSODQWDQGLWVRSHUDWLRQV7KH
familiarization proceeds throughout the duration of the project.

4.2.2.3 Description

The team members should become familiar with the plant at the onset of the analysis. The team should
understand the plant layout, its systems, its procedures, its I&C, and the structure of the operating crews.
This familiarization should include visits to and reviews of the plant and its areas where human interaction
takes place. This should include interviews with personnel that perform these interactions to understand their
expectations, knowledge, and typical response to plant actions. Where possible, the use of plant training
simulators to aid in understanding the response of the control room crew to selected scenarios may prove

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,(((*XLGHIRU,QFRUSRUDWLQJ+XPDQ5HOLDELOLW\$QDO\VLVLQWR3UREDELOLVWLF5LVN ,(&
IRU1XFOHDU3RZHU*HQHUDWLQJ6WDWLRQVDQG2WKHU1XFOHDU)DFLOLWLHV ,(((6WG

EHQH¿FLDO$VQRWHGSUHYLRXVO\+5$IRULQLWLDOOLFHQVLQJRIQHZSODQWVPD\QRWEHDEOHWRPDNHXVHRIDOO
desired sources of information.

4.2.2.4 Output

7KHRXWSXWRIWKLVVWHSLVDQ+5$35$WHDPWKDWKDVDNQRZOHGJHEDVHWRDGHTXDWHO\VXSSRUWWKHSURMHFW7KLV
knowledge should directly lead to an ability to identify the following:

a) Human functions and activities that are important to safety

b) Success criteria for these human actions
F 3RWHQWLDOSUREOHPDUHDVLQKXPDQSHUIRUPDQFH

4.2.3 Step 3: Build the initial plant model

4.2.3.1 General

+5$H[SHUWLVHVKRXOGEHLQWHJUDWHGLQWRWKHGHYHORSPHQWRIWKHLQLWLDOSODQW35$PRGHOWRKHOSHQVXUHWKH
completeness of the study.

4.2.3.2 Purpose

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HYHQWV7KH+5$VSHFLDOLVWVVKRXOGZRUNZLWKWKHV\VWHPPRGHOHUVWRKHOSHQVXUHWKDWWKHSODQWPRGHOSURSHUO\
incorporates the human roles and makes sense from an integrated perspective. The human failures that could
SURGXFHLQLWLDWLQJHYHQWVRUD൵HFWWKHSODQW¶VSHUIRUPDQFHLQUHVSRQVHWRSRVWXODWHGR൵QRUPDOFRQGLWLRQV
VKRXOGDOVREHLGHQWL¿HG

4.2.3.3 Description

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SKLORVRSK\RIKXPDQSHUIRUPDQFHDQGWKHWHFKQLTXHVXVHGLQWKH+5$LPSRVHFRQVWUDLQWVRQWKH35$PRGHOV
6LPLODUO\WKHVW\OHDQGPHWKRGVRIWKH35$FKRVHQGLUHFWWKH+5$WRZDUGWKHW\SHVRIHYHQWVWREHLGHQWL¿HG
This guide is intentionally method-neutral, and appropriate method selection guidance may be found in other
sources (e.g., >%@, >%@, >%@, >%@, and >%@). A screening analysis (described in 4.2.4) helps ensure that
WKHKXPDQIDLOXUHHYHQWVDUHPHDQLQJIXOZKHQODWHUDQDO\]HGXVLQJVSHFL¿F+5$PHWKRGV

,QRUGHUWREHFRQVLVWHQWZLWKWKH35$KXPDQIDLOXUHHYHQWVVKRXOGEHFODVVL¿HGLQWRRQHRIWKHIROORZLQJ
main categories:

a) Pre-initiator events. Failures in human activities conducted during normal plant operations that lead
WR LQRSHUDEOH HTXLSPHQW ZLWKRXW FDXVLQJ DQ R൵QRUPDO FRQGLWLRQLQ WKH SODQW7KHVH HYHQWV KDYH
RIWHQEHHQFDOOHG³ODWHQWHYHQWV´VLQFHWKHLUH൵HFWVDUHWROHDYHIDXOWHGHTXLSPHQWLQDQXQGHWHFWHG
XQDYDLODEOHFRQGLWLRQIRUUHVSRQVHGXULQJDWUDQVLHQW7KHVHHUURUVVKRXOGEHLQFOXGHGLQWKH35$DV
a contributor to demand-related unavailability of equipment. An example is leaving a vital system or
component inoperable after maintenance that, in turn, fails a system when it is called upon.
b) Human-induced initiators. Failures in human activities conducted during normal plant operation that
OHDGGLUHFWO\RULQGLUHFWO\WRR൵QRUPDOSODQWFRQGLWLRQVDQGWKXVLQLWLDWHDWUDQVLHQW$KXPDQHUURU
that directly or indirectly causes a high- or low-pressure boundary loss of coolant accident (LOCA)
is an example of such an event. Errors of commission, such as disabling required automation, may be
another type of human-induced initiator.
c) Post-initiator events)DLOXUHVLQKXPDQDFWLYLWLHVLQUHVSRQVHWRDQR൵QRUPDOFRQGLWLRQ2QHW\SLFDO
kind of post-initiator event is the failure of personnel to actuate a needed, manually actuated system.

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Failures in contingency actions are often referred to as recovery failure events and are failures in
DFWLYLWLHVUHODWHGWRUHVWRUDWLRQRILQRSHUDEOHHTXLSPHQWRU¿QGLQJRIDOWHUQDWLYHVWRWKHXVHRIIDLOHG
equipment.

4.2.3.4 Output

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35$(DFKHYHQWLVFKDUDFWHUL]HGIXQFWLRQDOO\DQGLVFRUUHODWHGWRWKHFXUUHQWSODQWPRGHO'XULQJWKLVVWHS
WKH+5$WHDPVKRXOGFRQVLVWHQWO\DQGVHQVLEO\LGHQWLI\WKHERXQGDU\FRQGLWLRQVXQGHUZKLFKWKHDFWLRQVZLOO
EHSHUIRUPHGDQGWKHLUVXFFHVVFULWHULDHJXQGHU/2&$FRQGLWLRQVZLWKLQWKH¿UVWPLQ

4.2.4 Step 4: Screen human interactions

4.2.4.1 General

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extensive analyst and computer time and high costs, the models are screened for risk importance to help ensure
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35$ZKHQWKHVFUHHQLQJLVSHUIRUPHG

4.2.4.2 Purpose

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DFWLRQVZKRVHIDLOXUHFDQKDYHVLJQL¿FDQWLPSDFWRQSODQWULVN

4.2.4.3 Description

4.2.4.3.1 General screening approach

,QWKLVVFUHHQLQJVWHSWKHUHVRXUFHVRIWKH+5$35$WHDPVKRXOGEHFRQFHQWUDWHGRQWKRVHHYHQWVLQFOXGLQJ
KXPDQLQWHUDFWLRQVZKLFKDUHOLNHO\FDQGLGDWHVWRFRQWULEXWHVLJQL¿FDQWO\WRWKHDVVHVVHGSODQWULVN7KLV
DOORZVWKH+5$35$WHDPWRPLQLPL]HWKHWLPHDQGUHVRXUFHVWKDWDUHQHHGHGWRDUULYHDWWKHULVNFRQWULEXWLRQ
RIKXPDQLQWHUDFWLRQV:KHQWKH35$WHDPVFUHHQVHYHQWVIRUULVNVLJQL¿FDQFHWKH+5$SURFHVVVKRXOG
support this screening by providing the following:

a) Criteria for ignoring human interactions,

b) Descriptions of human interactions in the event (scenarios), or
c) Conservative estimates of the probabilities of human error to be used in the screening.

These conservative estimates are called screening values.

4.2.4.3.2 Screening for recovery

7KH+5$VKRXOGVXSSRUWWKH35$GXULQJSODQWIDLOXUHPRGHOFRQVWUXFWLRQE\JLYLQJJXLGDQFHUHJDUGLQJZKLFK
KXPDQLQWHUDFWLRQVFDQEHOHIWRXWRIWKHPRGHOHLWKHUEHFDXVHWKH\DUHQRWOLNHO\WREHULVNVLJQL¿FDQWRU
EHFDXVHWKH\FDQEHEHVWLQWURGXFHGZKHQWKH35$PRGHOVKDYHPRUHGH¿QLWLRQ)RUH[DPSOHHYHQWVWKDW35$
analysts have called recovery events are often not included early in the analysis. These events are logically
associated with hardware models that have to be included. The omission of the human interactions is typically
FRQVHUYDWLYHZLWKUHVSHFWWRULVNEHFDXVHGXULQJWKHLQLWLDOVWDJHVRIWKH35$WKHDQDO\VWGRHVQRWWDNHFUHGLW
IRUKXPDQLQWHUYHQWLRQWRUHVWRUHHTXLSPHQWRUPRUHOLNHO\WR¿QGDIXQFWLRQDODOWHUQDWLYH+HQFHWKHRYHUDOO
likelihood of equipment failure increases. Note that this would not be the case with cognitive errors that lead
WRV\VWHPSURSDJDWLRQVZRUVHQLQJWKHVLWXDWLRQ+RZHYHUVXFKIDLOXUHHYHQWVVKRXOGQRWEHLGHQWL¿HGXQWLO
VHTXHQFHGHWDLOVDUHXQGHUVWRRGDQGWKHUHFRYHU\DQDO\VLVLVSHUIRUPHG7KH+5$VKRXOGVXSSRUWWKHUHFRYHU\
DQDO\VLVDVLWGRHVRWKHUSDUWVRIWKH35$

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 6FUHHQLQJTXDQWL¿FDWLRQ

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WKHHYHQWVDWWKLVVWDJH7KHYDOXHVWKDWWKH+5$SURYLGHVWKH35$DWWKLVVWDJHDUHFDOOHGVFUHHQLQJYDOXHV
These screening values are deliberately assigned conservatively so as not to inadvertently omit important parts
RIWKHSODQWPRGHO7KHDVVLJQPHQWRIVFUHHQLQJYDOXHVPD\EHVXSSRUWHGE\DSDUWLFXODU+5$WHFKQLTXHRU
PD\UHTXLUHMXGJPHQWRQWKHSDUWRIWKHWHDP0DQ\HYHQWVWKDWDUHLGHQWL¿HGLQWKHHDUO\PRGHOLQJDFWLYLW\
GRQRWSURYHWREHULVNVLJQL¿FDQWDQGVXEVHTXHQWO\GRQRWKDYHWREHDQDO\]HGLQGHWDLO7KLVFRQVHUYHV+5$
UHVRXUFHVDQGGLUHFWVWKHIRFXVRIWKH+5$WRZDUGWKHHYHQWVWKDWDUHDVVXPHGE\WKH35$PRGHOPRVWOLNHO\
WREHULVNVLJQL¿FDQW+RZHYHUWKHVFUHHQLQJYDOXHVFKRVHQVKRXOGEHFRQVLVWHQWZLWKDQWLFLSDWHGIXUWKHUXVHV
of the analysis.

4.2.4.3.4 Screening for errors of commission

It is important to note that while the typical role of screening is to exclude human interactions that do not have
DVLJQL¿FDQWLPSDFWRQRYHUDOOULVNVFUHHQLQJPD\DOVRVHUYHWRLGHQWLI\HUURUVRIFRPPLVVLRQWKDWZRXOGQRW
EHSDUWRIWKHLQLWLDOVHOHFWLRQRIKXPDQIDLOXUHHYHQWVLQWKH35$)RUH[DPSOHDFULWLFDOSODQWIXQFWLRQWKDWLV
maintained by an automated system may not normally include human interactions, simply because no human
control input is necessary for the successful operation of the system. However, in identifying opportunities
IRUDXWRPDWLRQIDLOXUHLQWKH35$LWPD\EHUHYHDOHGWKDWRQHFDXVHLVLQDGYHUWHQWRULQWHQWLRQDOGLVDEOLQJ
RIWKHDXWRPDWLRQE\DKXPDQRSHUDWRU$VFUHHQLQJDQDO\VLVFDQUHYHDOWKLVFRPPLVVLRQWREHDVLJQL¿FDQW
contributor to overall risk.

4.2.4.4 Output

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the plant model. The result of the screening step is a list of human failure events (except possibly for some
UHFRYHU\HYHQWVWKDWZLOOEHWKHIRFXVRIWKHUHPDLQGHURIWKH+5$$IWHUVFUHHQLQJWKHFDQGLGDWHGRPLQDQW
sequences that survive this screening as potential risk contributors are known. The human interactions that
are not associated with these sequences do not require a detailed analysis. Only the human interactions in the
GRPLQDQWVHTXHQFHVDUHFDUULHGWKURXJKWKHUHVWRIWKH+5$SURFHVV7KHKXPDQDFWLRQVWKDWKDYHVXUYLYHG
the screening process will be evaluated in greater detail next in Step 5 (4.2.5). All the human actions that have
been screened out should be documented in an initial report to help ensure completeness of the work. At this
SRLQWDGHWDLOHG+5$EHJLQV

4.2.5 Step 5: Characterize human interactions

4.2.5.1 General

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sequences. In this step, the human reliability analyst reviews the candidate human failure events that remain in
VX൶FLHQWGHWDLOWRTXDQWLI\WKHPLQWKHQH[WVWHS

4.2.5.2 Purpose

The purpose of this step is to develop enough information to characterize each human failure event so that it
PD\EHTXDQWL¿HG

4.2.5.3 Description

7KHLQLWLDOLGHQWL¿FDWLRQRIWKHKXPDQIDLOXUHHYHQWVLQ6WHS4.2.3) was in functional terms from the plant

model. The events that have been retained in the analysis (e.g., those events that pose a high risk of core melt)
UHTXLUHDGGLWLRQDOGHWDLOHGDQDO\VLVWRGHWHUPLQHVSHFL¿FIDLOXUHPRGHVPHFKDQLVPVFDXVHVDQGH൵HFWV7KH
LQIRUPDWLRQWKDWLVJDWKHUHGVKRXOGEHVX൶FLHQWWRDFFRXQWIRUDOOLPSRUWDQWLQÀXHQFHV>FRPPRQO\FDOOHG
SHUIRUPDQFHVKDSLQJIDFWRUV36)V@RQWKHSUREDELOLW\WKDWWKHRSHUDWLQJFUHZZLOOIDLOWRDFFRPSOLVKWKH
required action. This information is method-dependent and requires knowledge of human factors methods

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such as task analysis and functional requirements analysis, coupled with insights into psychological factors
D൵HFWLQJRSHUDWRUSHUIRUPDQFH

4.2.5.4 Performance shaping factors

$QXPEHURI36)VPD\EHFRQVLGHUHGZKHQHVWLPDWLQJWKHSUREDELOLW\RIIDLOXUHIRUWKHDFWLRQVFRQVLGHUHGLQ
DQ+5$7KH36)VH[SOLFLWO\LQFRUSRUDWHGLQWRWKHPRGHOVVKRXOGLQFOXGHDVDPLQLPXPWKHIROORZLQJ>%@:

a) Training and experience

E 4XDOLW\RISURFHGXUHV
c) Availability of instrumentation
d) Time available
e) Complexity
f) Workload, time pressure, and stress
g) Team and crew dynamics
K $YDLODEOHVWD൶QJDQGUHVRXUFHV
i) Ergonomic quality of the human-system interface
j) Environmental factors
k) Accessibility and operability of equipment
l) Need for any special tools
m) Communications
Q 6SHFLDO¿WQHVVQHHGV

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DQDO\VLVUDWKHUWKHDQDO\VLVVKRXOGJXLGHWKHVHOHFWLRQRIWKHDSSURSULDWH+5$PHWKRGWRWUHDWWKHKXPDQ
interactions adequately.

4.2.5.5 Output

This step produces a characterization of the original screened human failure event in its likely failure mode.
This representation may be descriptive or graphical. For each failure mode, one or more failure mechanisms
DUHLGHQWL¿HGDVZHOODVWKHOLNHO\IDLOXUHFDXVHV,WWKHQLGHQWL¿HVDOOLQÀXHQFHVRQWKHSDUWLFXODUIDLOXUH
mode’s occurrence probability.

4.2.6 Step 6: Quantify human interactions

4.2.6.1 General

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WKHTXDQWL¿FDWLRQRIWKRVHKXPDQDFWLRQVLGHQWL¿HGLQWKHSUHGH¿QHGDFFLGHQWVHTXHQFHVLQWKHSODQWPRGHO
DQGWKHHYDOXDWLRQRIWKH35$


This list focuses on post-initiator performance shaping factors. Additional factors may be needed to model pre-initiating events. This
list is illustrative but not exhaustive of those factors driving performance. An analyst should determine the appropriate set of factors to
VXSSRUWGL൵HUHQWDSSOLFDWLRQV

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4.2.6.2 Purpose

The purpose of this step is to provide a numerical estimate for each human failure event in candidate- dominant
VHTXHQFHV7KHHVWLPDWHVVKRXOGEHFRQVLVWHQWZLWKWKHQXPHULFDODFFXUDF\UHTXLUHPHQWVRIWKH35$7KLV
DOORZVWKHTXDQWL¿FDWLRQRIWKHGRPLQDQWVHTXHQFHVDQGWKXVULVNDVZHOODVLWVQXPHULFDOXQFHUWDLQW\E\WKH
35$DQDO\VW

4.2.6.3 Description

4.2.6.3.1 Operational data

The numerical estimation of human failure events would be best obtained from a database of appropriate
events. In the absence of empirical data, insights into human error probabilities can be derived through
interviews with operators, simulator training instructors, and maintenance personnel; and from physical
H[DPLQDWLRQVZDONWKURXJKVDQGWDONWKURXJKVRIVSHFL¿FFRQWUROVDQGFRQWURODFWLRQV3ODQWVSHFL¿FKLVWRULFDO
data and operating experience should also be thoroughly reviewed when available. Surrogates to data can also
be used. Simulators are a potential source of surrogate data, and work sponsored by various research institutes
and laboratories has provided usable data. Interviews and walkthroughs are also valuable tools to collect data
WKDWZLOOKHOSLQWKHTXDQWL¿FDWLRQSURFHVV3ODQWVSHFL¿FGDWDVKRXOGEHXVHGZKHQHYHUDYDLODEOH

4.2.6.3.2 Estimation using HRA methods

,QPDQ\FDVHVGDWDZLOOEHXQDYDLODEOHDQGLWLVQHFHVVDU\WRXVHDQ+5$TXDQWL¿FDWLRQWHFKQLTXH7KH
PDMRULW\RI+5$PHWKRGVR൵HUDSSURDFKHVWRHVWLPDWLQJKXPDQHUURU7KHVHDSSURDFKHVLQFOXGHWHFKQLTXHV
VXFKDVPDWFKLQJDQDO\VLVVFHQDULRVWRSUHDQDO\]HGDQGTXDQWL¿HGHUURUW\SHVDGMXVWLQJQRPLQDOKXPDQHUURU
SUREDELOLWLHVWKURXJKPRGL¿HUVVXFKDV36)VVHOHFWLQJDSSURSULDWHSUHTXDQWL¿HGGHFLVLRQWUHHSDWKVRUXVLQJ
H[SHUWHVWLPDWLRQWHFKQLTXHV'XHWRWKHLQKHUHQWXQFHUWDLQW\RIWKLVTXDQWL¿FDWLRQSURFHVVSRLQWHVWLPDWHV
ZLWKRXWDVWDWHPHQWRIXQFHUWDLQW\VKRXOGQRWEHDFFHSWHGIRUXVHLQWKH+5$

4.2.6.3.3 Human error probability range

7KHKXPDQHUURUSUREDELOLW\VKRXOGJHQHUDOO\IDOOZLWKLQWKHUDQJHRIWR(±LH 1×10 − 5 RU

>%@7KLVORZHUERXQGRI(±VHUYHVDVDQDSSUR[LPDWLRQRIEHVWSRVVLEOHKXPDQSHUIRUPDQFHXQGHUDQ\
FLUFXPVWDQFHV:KLOHPDQ\+5$PHWKRGVGRQRWVHWDORZHUERXQGDQDO\VWVVKRXOGDOZD\VFRQVLGHUWKH
reasonableness of their human error probability estimates and set realistic bounds on these values. It is
possible, of course, that lower values may be achieved for human failure events when these events consider
multiple second-checkers and/or hardware safety systems. Lower-than-lower-bound human error probabilities
are the product of modeling-redundant safety systems and personnel; it is unlikely that a single-point failure (a
human failure event attributable to a single human action) could reasonably produce a human error probability
ORZHUWKDQ(±

4.2.6.4 Output

This step adds a numerical estimate in the form of a human error probability, including uncertainty such as
error bounds or probability distribution, to each human failure event and its qualitative characterization.

4.2.7 Step 7: Update plant model with dependence and recovery

4.2.7.1 General

2QFHWKHVHTXHQFHVKDYHEHHQTXDQWL¿HGWKH+5$35$WHDPVKRXOGHYDOXDWHZKHWKHUGHSHQGHQFHVKRXOG
be considered and whether additional recovery actions are possible. Some recovery actions may have been
LQFOXGHGLQWKHLQLWLDOGHYHORSPHQWRIKXPDQIDLOXUHHYHQWVIRUWKH35$PRGHO7KHRXWSXWRIWKLVVWHSLVDVHW
RIKXPDQLQWHUDFWLRQVWKDWLVQHHGHGWRUHÀHFWDGGLWLRQDOKHUHWRIRUHXQPRGHOHGGHSHQGHQFHDQGUHFRYHU\
in the plant model. These human interactions have been qualitatively and numerically characterized by an
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GHSHQGHQFH

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WKHGHSHQGHQFHDQGUHFRYHU\DQDO\VLVLVSHUIRUPHGIRUWKHVLJQL¿FDQWVHTXHQFHV7KHSODQWPRGHOLVWKHQ
XSGDWHGWRUHÀHFWWKH¿QDOKXPDQIDLOXUHHYHQWVDQGWKHLUQXPHULFDOFKDUDFWHULVWLFV

4.2.7.2 Purpose

This task evaluates the potential for including the dependence between human failure events and the recovery
of failed systems and additional human actions and/or systems into the model. The purpose of this step is to
XSGDWHWKHPRGHORIWKHSODQWWRLQFOXGHGHSHQGHQFHDQGUHFRYHU\IRUDOOVLJQL¿FDQWKXPDQIDLOXUHHYHQWV
LGHQWL¿HGRYHUWKHFRXUVHRIWKH+5$

4.2.7.3 Description

4.2.7.3.1 Incorporating dependence

All aspects of the contributions to risk should be included in the updated plant model. Dependence is a result
RIDQHUURULQFUHDVLQJWKHOLNHOLKRRGRIDVXEVHTXHQWHUURU4XDQWLWDWLYHO\GHSHQGHQFHPHDQVWKDWWKHKXPDQ
error probability of human failure events in sequence may be higher than without dependence. Dependencies
DPRQJKXPDQIDLOXUHHYHQWVRUEHWZHHQKXPDQIDLOXUHHYHQWVDQGRWKHUHYHQWVVKRXOGEHFOHDUO\LGHQWL¿HG
DQDO\]HGDQGTXDQWL¿HGLQWKHPRGHOV-XVWL¿FDWLRQIRUGHSHQGHQFHRULQGHSHQGHQFHVKRXOGEHSURYLGHG
(DFKKXPDQIDLOXUHHYHQWLQWKHPRGHOVKRXOGEHLGHQWL¿HGDVWRZKHWKHULWLVTXDQWL¿HGZLWKDVFUHHQLQJ
probability or a detailed analysis.

4.2.7.3.2 Incorporating recovery

2QFHWKHFDQGLGDWHGRPLQDQWVHTXHQFHVDUHLGHQWL¿HGWKRVHDGGLWLRQDOKXPDQUHFRYHU\DFWLRQVDQGV\VWHPV
WKDWFDQSUHYHQWWKHXQGHVLUHGRXWFRPHFDQEHLQFRUSRUDWHGLQWRWKHPRGHO7KHKXPDQIDLOXUHHYHQWVLGHQWL¿HG
VKRXOGEHFKDUDFWHUL]HGDQGTXDQWL¿HGRQDVFHQDULRVSHFL¿FEDVLVVLQFHWKHOLNHOLKRRGRIRSHUDWRUV¶VXFFHVV
is heavily contingent on the plant conditions presented to them. This action is the source of the feedback
LQGLFDWHGLQWKH+5$SURFHVV%\LQFRUSRUDWLQJDOWHUQDWHPHDQVRIPLWLJDWLQJULVNVLJQL¿FDQWHYHQWVWKHULVN
SUR¿OHPD\EHFKDQJHG$VDUHVXOWRIWKHVHUHFRYHU\DFWLRQVWKHRYHUDOOULVNSUR¿OHPD\EHGHFUHDVHGDQGWKH
OLVWRIGRPLQDQWVHTXHQFHVPD\EHDOWHUHG&HUWDLQVHTXHQFHVWKDWZHUHSUHYLRXVO\LGHQWL¿HGDVULVNVLJQL¿FDQW
PD\EHRIOHVVLPSRUWDQFHWRRYHUDOOSODQWULVNZKHQUHFRYHU\DFWLRQVDUHIDFWRUHGLQWRWKHULVNSUR¿OH7KLV
PD\EHHVSHFLDOO\LPSRUWDQWLQFDVHVZKHUHWKHUHVXOWVRIWKH35$DUHEHLQJXVHGWRMXVWLI\PRGL¿FDWLRQVWRWKH
plant.

4.2.7.4 Output

The output of this step is a plant model that includes all reasonable sources of dependence between human
failure events and recovery contributors to plant risk.

4.2.8 Step 8: Review results

4.2.8.1 General

$35$LQWHJUDWHVGLYHUVHLQIRUPDWLRQDERXWWKHSODQW$VHQVLWLYLW\DQDO\VLVVKRXOGEHSHUIRUPHGWRFRQVLGHU
risk factors of human origin, to determine their potential impact, and to rank their importance in relation to
DOORWKHULGHQWL¿HGULVNIDFWRUV,WVUHVXOWVGHSHQGRQWKHDFFXUDF\RIWKLVLQIRUPDWLRQDQGWKHDGHTXDF\RIWKH
plant logic model to combine this information into clear and realistic delineation of the scenarios that lead to
WKHXQGHVLUHGHYHQWV$¿QDOUHYLHZRIWKH+5$E\TXDOL¿HGSHRSOHH[WHUQDOWRWKH35$WHDPLVUHTXLUHG

4.2.8.2 Purpose

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its operation.

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4.2.8.3 Description

7KHUHVXOWVRIWKH+5$DQG35$DUHFRQILUPHGDVFUHGLEOHE\RQHRUPRUHPHDQV7KH+5$UHVXOWVVKRXOG
EH reviewed against station tests and by maintenance and operations personnel. Talkthroughs or
walkthroughs of the dominant sequences should be used to validate the decision-making and diagnostic
strategies assumed by WKH+5$IRUHDFKVHTXHQFH:KHQDYDLODEOHVLPXODWRUH[HUFLVHVDUHDSUHIHUDEOHEXW
PRUHFRVWO\PHDQVWRYDOLGDWHWKLVNLQGRILQIRUPDWLRQ6HTXHQFHUHYLHZVVKRXOGEHFRQGXFWHGEHIRUHWKH
ILQDOTXDQWLILFDWLRQVWDJHRIWKH35$7KH+5$35$UHYLHZWHDPVKRXOGLQFOXGHDPHPEHUIDPLOLDUZLWK
SODQW RSHUDWLRQV 2WKHU SODQW RSHUDWLRQV DQG PDLQWHQDQFH SHUVRQQHO VKRXOG EH VROLFLWHG DW WKH HQG RI WKH
DQDO\VLV WR UHYLHZ WKH +5$ UHVXOWV IRU FUHGLELOLW\ DQG LQIRUPDWLRQDO DFFXUDF\ 7KH +5$ SDUW RI D 35$
VKRXOGEHUHYLHZHGE\LQGHSHQGHQW+5$experts.

4.2.8.4 Output

7KHRXWSXWRIWKLVVWHSLVDQ+5$WKDWUHDVRQDEO\UHIOHFWVWKHFRQWULEXWLRQRIKXPDQDFWLRQVWRSODQWULVN
DQGWKDWFDQEHXVHGLQWKHXWLOLW\¶VULVNUHGXFWLRQHIIRUWV7KLVSURYLGHVDWRROWRIRFXVRQFRQWULEXWRUVWR
ULVNDQGhelp justify modifying plant performance.

5. Documentation

5.1 Purpose
7KHREMHFWLYHRI+5$GRFXPHQWDWLRQLVWRSURGXFHDWUDFHDEOHGHVFULSWLRQRIWKHSURFHVVXVHGWRGHYHORS
WKHTXDQWLWDWLYHDVVHVVPHQWVRIKXPDQLQWHUDFWLRQV'RFXPHQWDWLRQLVRYHUDUFKLQJDFURVVDOO+5$SURFHVV
steps detailed in Clause 47KH+5$35$WHDPSURYLGHVWKHGHVFULSWLRQVRIGDWDDVVXPSWLRQVPRGHOVDQG
representations used. In addition, important dependencies and sensitivities that impact the representation or
PRGHOVVKRXOGEHLGHQWLILHGIRULQWHJUDWLRQLQWRWKHXQFHUWDLQW\DQGFRPPRQFDXVHDQDO\VHV

5.2 Structure
The analysis documentation should be organized to help ensure that the information and data are clearly
presented; that the assumptions, data sources, models selected, and criteria for elimination and retention of
KXPDQ IDLOXUHV DUH UHFRUGHG DQG WKDW WKH KXPDQ TXDQWLWDWLYH LPSDFW RQ WKH 35$ PRGHO LV VWDWHG 7KH
RXWSXWLVa report documenting these aspects.

(DFKVWHSRIWKH+5$SURFHVVVKRXOGEHGRFXPHQWHGDQGLQFOXGHWKHIROORZLQJ

D 7KHFRPSRVLWLRQRIWKH+5$WHDP
b) The origin of source data and reasons for selection
c) The nature of the operating history review
d) The operating history reviews applied
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I 7KHUHDVRQVIRUVHOHFWLRQRIWKH+5$PHWKRGVXVHG
J 7KHVSHFL¿FKXPDQIDLOXUHHYHQWVH[SOLFLWO\PRGHOHG
h) The nature of operator interaction analysis performed
i) The types of operator actions modeled implicitly
j) The method of screening and quantitative values
k) A list of the important actions carried out for more detailed analysis

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P 7KHQDWXUHRISODQWVWD൵LQWHUYLHZV
n) The type of control room reviews
o) The limitation (boundary conditions) on use of each value (e.g., just for loss of coolant accidents, just
for low level)

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35$ZLWKDXVDEOHDXGLWDEOHSDSHUWUDLOIRUWKH+5$UHVXOWV$QH[DPSOHDQGGHVFULSWLRQRIDGDWDWDEOHIRU
UHFRUGLQJDQGGRFXPHQWLQJ+5$GDWDLVLQAnnex A7KRURXJK+5$GRFXPHQWDWLRQLVDOVRDQHFHVVDU\VWHS
IRUSRWHQWLDO+5$UHXVH

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Annex A
LQIRUPDWLYH

An example for documenting HRA data

An example data table is presented along with a description of each item, A through T. Each of these elements
VKRXOGEHUHFRUGHGWRKHOSHQVXUHWKDWWKH+5$SURFHVVLVUHSHDWDEOHYHUL¿DEOHLQWHUQDOO\FRQVLVWHQWDQG
XQGHUVWDQGDEOHWRWKHUHJXODWRUXWLOLW\PDQDJHPHQWDQGRWKHU+5$SURIHVVLRQDOV

7DEOH$ displays the minimum data categories that should be recorded and stored.

Each of the items/columns must be addressed so that a traceable record is generated for each human error
SUREDELOLW\+(3DORQJZLWKWKHDSSURSULDWH36)V7KHHOHPHQWVRIWKHWDEOHDUHGH¿QHGDVIROORZV

A. Sequence number. Enter the relative task sequence of a series of important tasks taken from the event tree
DQGRUIDXOWWUHHQRGHGHVLJQDWRULWHP3RI7DEOH$).

Example:
WDVN$
WDVN
WDVN
WDVN

,IDWDVNDQDO\VLVKDVDOUHDG\EHHQFRQGXFWHGDWWKHSODQWWKH+5$35$WHDPPD\FKRRVHWRVHOHFWWKRVHWDVN
LWHPVIURPWKHWDVNDQDO\VLVVKHHWVDQGLQFOXGHRQO\WKRVHWDVNVHTXHQFHVRILQWHUHVWLQWKH+5$GDWD¿OH

B. Task description. Describe each task in the sequence of interest. It should start with who does the task, what
is done, and how it is accomplished.

Example:

The operator Opens valve V612 By turning To the right

a J handle
WHO ACTION OBJECT HOW WHERE

The task description may be derived from the emergency operating procedures or from a task analysis that
PD\KDYHEHHQSHUIRUPHGDWWKHSODQWEHIRUHWKH+5$WHDPZDVDVVHPEOHG,IWKHGDWDIRUWKLVLWHPDUHQRW
available, then a limited-scope task analysis or recorded walkthrough should be conducted.

C. Task purpose6WDWHWKHUHDVRQIRUHDFKWDVNDFWLRQ7KLVLQIRUPDWLRQLWHPV%DQG&LQWKH+5$GDWD¿OH

PD\EHREWDLQHGIURPWKHRSHUDWLQJSURFHGXUHVRSHUDWLRQVVWD൵RUVKLIWVXSHUYLVRU

D. Task initiator. List the task initiator. A task can be initiated, for example, by an alarm, a person (supervisor
request), or a procedure step; or, the task may be self-initiated by the operator.

E. 3ODQWV\VWHPDৼHFWHG/LVWWKHSODQWV\VWHPRUVXEV\VWHPWKDWLVD൵HFWHGE\WKHH[HFXWLRQRIWKHWDVNHJ
WXUQLQJDSXPSRQRUR൵ZRXOGLPSDFWWKHVDIHW\FRROLQJVXEV\VWHPRUFRROLQJÀXLGLQYHQWRU\

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F. Task time required5HFRUGWKHWLPHUHTXLUHGWRSHUIRUPWKLVWDVNDQGFRPSDUHLWZLWKWKHWLPHLWDFWXDOO\

takes to complete. Typically the time is listed in minutes.

* Important performance shaping factors (PSFs) and weight5HFRUGRQO\WKHLPSRUWDQW36)VUHODWHGWRWKH

task and the appropriate weight assigned.

H. Realistic human error description. Describe in detail the important human errors that could propagate into
possible core damage.

I. Rationale for human error. For each human error described in item H, provide a rationale (e.g., the operator
may fail to activate the correct pump because the pump is not called out by name in the procedure or the pump
labeling designator is obscured by a maintenance tag hanging above it. In addition, the training program does
QRWVSHFL¿FDOO\DGGUHVVWKLVDFWLRQUHODWHGWRWKHWDVNDQGWKHRSHUDWRUZKRSURYLGHGWKHZDONWKURXJKZDV
XQDEOHWR¿QGWKHFRUUHFWVZLWFK7KHRSHUDWRUKDGWRDVNWKHVKLIWVXSHUYLVRUZKHUHLWZDVORFDWHG

-+XPDQHQJLQHHULQJGH¿FLHQFLHV+('V/LVWDQ\+('VWKDWPD\LPSHGHWKHWDVNRUPDNHLWGL൶FXOWWR¿QG

RURSHUDWHHJWKHOLJKWLQJRQWKLVSDQHOLVEHORZWKHYDOXHVSHFL¿HGLQ185(*>%@ and MIL-STD
*>%@, and the instrument is physically located outside the optimal range of viewing).

K. Training module and quality. Complete this item after reviewing the applicable training modules
DVVRFLDWHGZLWKHDFKLPSRUWDQWRSHUDWRUWDVN6XPPDUL]HWKH¿QGLQJVFRQFHUQLQJGLVFUHSDQFLHVQRWHGGXULQJ
the assessment of training materials and course content along with the relevant criteria used during the review.
7KHFULWHULDIRUWKLVDVVHVVPHQWPD\EHGUDZQIURPVHYHUDOVRXUFHVLQFOXGLQJWKH861XFOHDU5HJXODWRU\
&RPPLVVLRQ15&WKH86'HSDUWPHQWRI(QHUJ\'2((OHFWULF3RZHU5HVHDUFK,QVWLWXWH(35,DQG
,QVWLWXWHRI1XFOHDU3RZHU2SHUDWLRQV,132

L. Procedure number, name, and rated quality5HFRUGWKHSURFHGXUHQXPEHULIDQ\DVVRFLDWHGZLWKWKHWDVN

under review, the name of the procedure, and the criteria used for the assessment.

M. Operator experience and background5HFRUGLQIRUPDWLRQFRQFHUQLQJWKHOHDVWH[SHULHQFHGRSHUDWRUDW

the plant who will be expected to perform this task. Any background factors such as vision, hearing, general
KHDOWKHWFVKRXOGDOVREHOLVWHG'XULQJWKH+5$LWVKRXOGEHDVVXPHGWKDWWKHZHDNHVWKXPDQOLQNUHJDUGLQJ
prior experience) will be called to execute the task under a worst-case scenario. The reason for this approach is
to provide a conservative (from a safety perspective) human error estimate.

N. Environmental factors. List the relevant factors and quantitative measures for items such as heat, noise,
LOOXPLQDWLRQUDGLDWLRQOHYHODQGKXPLGLW\LIWKHVHIDFWRUVPD\LQÀXHQFHWKHH[HFXWLRQRIWKHWDVNLQWHUPVRI
completion times or probability of error.

O. List of past errors related to this task. Describe any past human errors that have occurred regarding this
WDVN DQG HYHQW VFHQDULR 'DWD VRXUFHV VXFK DV OLFHQVHH HYHQW UHSRUWV /(5V XQXVXDO RFFXUUHQFH UHSRUWV
825VRURWKHULQWHUQDOSODQWUHFRUGVPD\EHXVHGIRUWKLVSXUSRVHLIWKHLQIRUPDWLRQH[LVWV,IWKHUHDUHQR
written records available, then attempt to interview a cross-section of operators to obtain their opinions and
experiences. Include “near miss” information if it is available.

3 Event tree and/or fault tree node designator5HFRUGWKHHYHQWDQGRUIDXOWWUHHQRGHGHVLJQDWRUGHVFULSWLRQ

associated with the task under study so that others may quickly trace the task back to the appropriate document
and element on the event tree.

4 Previous event outcome 3DVW HYHQWV VKRXOG EH UHYLHZHG DQG UHFRUGHG LQ RUGHU WR DVFHUWDLQ H[SHFWHG
occurrence frequency and expected consequence. Any problems in task execution should be noted along with
the frequency of occurrence. This information will be valuable in determining past events’ likelihood and their
SRVVLEOHLQÀXHQFHLQVKDUSHQLQJRSHUDWRUVNLOOVXQGHUSUHVVXUH,IWKLVLQIRUPDWLRQLVXQDYDLODEOHWU\WRDVVHVV
the frequency with which drills are performed that simulates this event.

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5 Management/organization control factors5HFRUGFRQFOXVLRQVDQGFULWHULDXVHGWRDVVHVVWKHLPSDFWRI

various management /supervisor controls over the task from a safety perspective.

S. Human error probability (HEP) with upper and lower bounds/LVWWKHDFWXDOFDOFXODWHG+(3DORQJZLWKWKH

upper and lower uncertainty bounds.

T. Human error probability (HEP) rationale summary5HFRUGDVVXPSWLRQVXVHGDQGDTXDQWLWDWLYHVXPPDU\

RI WKH UDWLRQDOH EHKLQG WKH +(3 FDOFXODWLRQ DQG GRFXPHQW WKH 36) ZHLJKWV XVHG IRU WKH FDOFXODWLRQ7KH
SXUSRVHKHUHLVWRKHOSHQVXUHWKDWWKHQXPEHUVXVHGDUHYHUL¿DEOHUHSHDWDEOHDQGRSHQWRSXEOLFVFUXWLQ\
(understandable).

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 Table A.1—HRA data elements
(Include title of event)
A B C D E F G H I J
Important
probabilistic
risk 5HDOLVWLF Human
,(&

assessments human engineering

Sequence Task 3ODQWV\VWHP Task time 36)VDQG error 5DWLRQDOHIRU GH¿FLHQF\
,(((6WG

number description Task purpose Task initiator D൵HFWHG required weight description human error (HED)

K L M N O P Q R S T
Human error
3URFHGXUH List of past Event tree and/ Management/ probability Human error
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Annex B
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Bibliography
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ASME publications are available from the American Society of Mechanical Engineers (http://www.asme.org/).

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The IEEE standards or products referred to in Annex B are trademarks owned by The Institute of Electrical and Electronics Engineers,
Incorporated.

IEEE publications are available from The Institute of Electrical and Electronics Engineers (http://standards.ieee.org/).

MIL publications are available from the U.S. Department of Defense (http://quicksearch.dla.mil/).

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Annex &

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IEEE list of participants

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Ronald L. Boring, Chair

Andreas Bye 5REHUW+DOO 3DPHOD1HOVRQ

'DYLG5'HVDXOQLHUV Teri Hamlin +pOqQH3HVPH
Stephen Fleger -UJHQ+DUWXQJ /XFD3RGR¿OOLQL
'DYLG*HUWPDQ Xuhong He Claire Taylor
.DWULQD*URWK -DURVODY+ROê April Whaley

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following membership, including corresponding members (CM) and honorary members (HM):

Stephen Fleger, Chair

Tom Koshy, Vice Chair
Daryl Harmon, Secretary
George Ballassi, Past Chair

Satish Aggarwal 5REHUW)XOG&0 Ken Miller

Iiaz Ahmad &KULV*HRUJHVRQ Michael H. Miller
*HRUJH$WWDULDQ -DPHV*OHDVRQ Edward Mohtashemi
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Mark Bowman %ULW*ULPP+0 :DUUHQ52GHVV*LOOHWW
Daniel Brosnan (CM) 5REHUW+DOO -DPHV3DUHOOR&0
Keith Bush David Herrell 7HG5LFFLR
5REHUW&&DUUXWK Dirk Hopp Mitchell Staskiewicz
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Suresh Channarasappa Steven Hutchins -RKQ6WHYHQV
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Tom Crawford Chris Kerr Marek Tengler
Dennis Dellinger Wolfgang Koenig Sudhir Thakur
David Desaulniers 5REHUW.RQQLN -LP7KRPDV
-RKQ'LVRVZD\ -DPHV./LPLQJ Masafumi Utsumi
Walter Emerson (CM) Bruce Lord <YRQQH:LOOLDPV
Kenneth Fleischer -RKQ0DF'RQDOG 3DXO/<DQRV\6U
5REHUW-)OHWFKHU Scott Malcom Michael Waterman
5REHUW)UDQFLV Alexander Marion (CM) -RKQ:KLWH

The following members of the individual balloting committee voted on this guide. Balloters may have voted
for approval, disapproval, or abstention.

Satish Aggarwal Neal Dowling <RRQLN.LP

5REHUW$LHOOR Donald Dunn Thomas Koshy
*HRUJH%DOODVVL Stephen Fleger -RKQ0DFGRQDOG
H. Stephen Berger 5REHUW)XOG Andrew Nack
5RQDOG/%RULQJ 'DOH*RRGQH\ Michael Newman
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Nissen Burstein $MLW*ZDO -DQ3LUURQJ
5REHUW&&DUUXWK -RKQ+DUDX] 5D\PRQG6HQHFKDO
Tom Crawford Daryl Harmon -RKQ$6WHYHQV
3DXO&UROO Hamidreza Heidarisafa Eugene Stoudenmire
Matthew Davis 5D\PRQG+HUE -RKQ9HUJLV
-RKQ'LVRVZD\ Werner Hoe zl <YRQQH:LOOLDPV
*DU\'RQQHU Shuhui Zhang
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membership:

Jean-Philippe Faure, Chair

*DU\+R൵PDQ Vice Chair
John D. Kulick, Past Chair
Konstantinos Karachalios, Secretary

Chuck Adams Thomas Koshy 5REE\5REVRQ

Masayuki Ariyoshi -RVHSK/.RHS¿QJHU Dorothy Stanley
Ted Burse Kevin Lu Adrian Stephens
Stephen Dukes Daleep Mohla Mehmet Ulema
Doug Edwards Damir Novosel 3KLO:HQQEORP
-7UDYLV*UL൶WK 5RQDOG&3HWHUVHQ Howard Wolfman
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