Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Systematic biases in event review and their impact

on learning process
Dan Serbanescu
Safety and Risk expert
Drumul Taberei 35A
061538 Bucharest, Romania

Abstract

The paper presents some results from a research on the best approaches to be
adopted in order to avoid the systematic biases in the review of major accidents in
complex systems. The work considers that prevention of systematic biases in the
event review and lessons learnt are very important obstacles in preventing
recurrence and improving learning process. The work approached the issue of
systematic biases in the events review process from a new point of view, i.e.
considering the impact of accidents on the product lifetime, the impact of
sociopolitical environment and systematic scientific biases in drawing conclusions.
A triadic approach to the causes of the learning gaps from major accidents is
proposed.

Keywords: lessons learnt, biased knowledge, paradigm, triadic learning gap

1. Introduction
The review of major technological accidents has many lessons learnt in all cases.
However there is one common feature for most of them that the lessons prove to be
never fully learnt and the events repeat themselves. There are many possible
approaches to explain such situation. One of them is proposed in this paper
considering that there are some general common features of the biases one can
expect in learning lessons.
The paper presents some results on some important factors proposed to be
considered in order to avoid the systematic biases in the review of major accidents in
complex systems. The research is based mainly on details from the nuclear power
plants experience, but makes also reference to other complex technical systems. The
topic is related to the issues of improving the feedback from event review into the
practice of performance for complex systems. It is considered that there are
systematic biases in implementing lessons from the operation feedback process from
accidents/incidents review into practice. Apparently it happens many times that very
important lessons are not learned and /or are forgotten by people, organizations or
society as a whole, situation leading to major obstacles into the improved learning
from experience process.
Evaluation is based on the nuclear power plants experience, with some reference on
other complex technical systems. The main message of the evaluation is that
prevention of systematic biases in the event review and lessons learnt is tightly
connected with the consideration of some aspects, of which three are to be
considered with priority:

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

1. There is a continuous gap between the derived lessons to be learnt from

incidents/accidents and the implementation process in a lifetime of a given
technology, due to high degree to the technology changes and specifics of
implementing such lessons at a later time after the accidents. By the time of
the implementation of the lessons learnt the lifetime status of the technology
requires an approach adapted to its new status.
2. The evaluation of major accidents is rarely considering the fact that the given
complex system subjected to a major accident is part of a more complex
environment (a complex system of a multitude of complex systems
interacting between them). Even if it is done so, the evaluation of
interdependencies is performed not in a systematic manner.
3. The evaluations rarely consider the systematic bias possible to be induced by
the knowledge process itself.

2. Biases in evaluation of accidents

Biases as a triadic learning gap approach due to the need to consider technology
lifecycle, interdependencies between technologies and systematic knowledge biases,
which are specific for complex systems.

2.1 Biases in learning process connected to the product lifetime cycle

Any technological complex system has a certain lifecycle. Therefore if the

implementation of the lessons learnt from major accidents takes significant amount
of time, then it has to be considered the fact that the product is already on another
lifecycle step.

Figure 1 Nuclear Power Plants technology curves (Source IAEA)

The evaluation of the biases induced by this aspect starts from a description of the
technological product performance curve (called s-curve) – an example for Nuclear
Power Plants is presented in [1] – Figure 1. As a result of this aspect, which is

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

considered as an important one, inducing biases in implementation of the lessons

learnt in the operational feedback process, it can be shown as in Figure 2 that there
are significant differences between the ideal s-curve of a technology and the real
one. Every time a major accident and/or technology challenge of any type takes
place the curve is changed as shown in the figures 2, 4 and 5.

Figure 2 Technology S-curve for a complex system-example of a Nuclear Power Plant [1]

The objective functions defined for the evaluation of the degree of safety of the
technical system (as for instance safety margins or risk levels) change also, as shown
in figures 2 to 5.
In addition to this phenomenon there will be initiations of new/updated/improved
versions of the same technology (as for instance NPP generations III or IV or of
complementary energy sources as for instance renewable energy sources [ …])
under design or testing, for which the accidents and any other challenges on the
operating technical systems will have also very high impact.
Therefore the lessons derived as to be learnt after a major accident have to consider
the phase of the technology when they will be implemented, as well as the fact that
each phase is being developed and reviewed under a set of governing set of
paradigms for the objective functions (for instance for safety margins for NPP) as
illustrated in Figures 3-5.

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 3 Technology risk criterion for a complex system- example for a Nuclear Power Plant [1]

Figure 4 Technology and risk criterion for a complex system during its lifetime, considering
accidents impact - example for a Nuclear Power Plant (NPP)[1]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 5 Technology and risk criterion for a complex system considering the switch in paradigms -
example for a Nuclear Power Plant [1]

To illustrate the bias formulated before in implementation of the lessons learnt and
based on the main features of each lifetime phase illustrated in Figure 5 there is a
series of significant safety approaches for this particular system (NPP). As shown in
Figure 5 there were on our view a set of very important changes in safety objectives
paradigms after the major accidents. This finding is illustrated by national and
international documents, standards and changes in policies during the lifetime of
NPP as a complex system. Based on that it can be noted that the existing reports
listed in literature mention already significant switches in paradigms on nuclear
safety after each major accident, including after Fukushima[1]. Based on those
documents and evaluations we can mention some important changes in post
Fukushima case safety paradigms for NPP, as follows:

1. An increased integration of safety as defined for design postulated accidents

and for severe accidents with a target of defining new, extended design basis.
2. A better integration of the issues related to various objective functions
(safety and security, safety and safeguards, safety and radiation protection
etc)
3. A significant review of the methods used for the evaluation of the features
mentioned under points 1 and 2 above (an increased debate over the
methods-deterministic versus probabilistic, operational feedback etc)
4. An increased search for systematic evaluation on possible answers to
questions related to how to perform:

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

i. Integration of safety and other evaluations production/economical,

safeguards, security general emergency plans for a given region local
regional global etc (to be addressed in this paper in the next
paragraph)
ii. Analysis of end of lifetime safety issues for complex technologies
iii. Review of the site conditions and sitting and of the safety objectives
for specific sites
iv. Review of the issues related to the technical solutions for normal and
abnormal decommissioning
v. Adoption of strategies for catastrophic challenges especially for
technologies with less intrinsic protection with an enhanced target of
having complex systems with an increased catastrophe resistance
features.

2.2 Biases in learning process due to interdependencies between technologies

Another source of the biases in the implementation of lessons learnt from major
accidents and/or challenges for a given technology is related to the need to consider
that complex technologies are tightly connected with other complex systems
(technologies, socio-political, economical).
For example in Figure 5 under the time axis of NPP technology and accidents there
is a list of major socio-political, economical events that took place in periods
surprisingly coincident with some of the most challenging accidents in nuclear field.
This simple connexion is also supported by a proposed approach of evaluation of the
safety level (as defined by a safety matrix prior to the event), the vectors of the
safety margins and goals for that complex system and the consideration of the
impact of the major challenge on the new safety matrix of the system. This approach
is in general illustrated in Figures 6 and 7. The approach is similar to the
development of models for consideration of challenges to technical, economical and
sociopolitical systems in previous evaluations related to complex energy systems[5]

Figure 6 Evaluation of the safety objectives considering lifetime phases and external
interdependencies[1]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 7 Matrix to support the evaluation of the safety objectives considering lifetime phases and
external interdependencies [1]

Figure 8. Matrix used to define the reviewed safety goal of NPP considering the target requirements
before an accident and the perturbation due to a serious challenge/accident [1]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 9 Model of the system of energy systems and its parts [5]

The results for the case of post Fukushima type of evaluations on the new priorities
and goals in safety after paradigm changes are presented in the figures 10 and 11.

Figure 10 Matrix of main issues to be implemented in a postFukushima strategy[1]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 11 Matrix of main issues to be implemented in a post Fukushima strategy [1]

2.3 Biases in learning process due to knowledge management process

Another source of the biases in the implementation of lessons learnt from major
accidents / challenges during phases of the evaluation of complex systems risk
objective functions [1,5,6,7].As it was already shown evaluation of the risk as an
objective function of a complex system leads to the construction of algebraic
structures (Figures 12 and 13) for which the features and advantages are presented in
[1,2,4,5,6,7]. These algebraic structures can be built for the cybernetic systems (as
for instance NPP model) for which the evaluation can be translated from the risk-
probability space (highly non linear) to the state - space that is linear and additive.
This makes possible to support the decision process with evaluations in a linear like
space.

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Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 12 Risk goals and objectives for a complex system of NPP type [1,2,4,5,6,7]

Figure 13 Risk model for a complex system of NPP type in risk [1,2,4,5,6,7]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 14 A risk model in a cybernetic format possible to be translated into space risk algebra [7]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

Figure 15 Systematic biases in knowledge process [ 1, 2 ]

In risk analyses as in any evaluations of complex systems the expected results are in
a bounding surface (as shown in Figure 15) and they are highly dependent on the
capability to evaluate the systematic errors in judgments [1,2]

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 Dynamic Learning from Incidents and Accidents – Bridging the Gap between Safety Recommendations and Learning

3. Conclusions
The triadic approach in evaluating biases of the learning process for lessons after
major accidents/challenges of complex systems proved to help the guidance in
searching for solutions of improved strategies for the post severe accidents actions to
be implemented in a complex system.
It was found that the systematic biases in implementing lessons from the operation
feedback process from accidents/incidents review into practice are leading to high
extent to a decrease in the efficiency of the operational feedback process.
The work approached the issue from a new point of view, i.e. considering the impact
of accidents on the product lifetime, from the perspective of the product
technological curve (s-curve) and other objective functions like the risk/safety
impact. The evaluations performed so far on this issue showed that consideration of
the triadic set of biases is leading to improvement in the learning process.

References
[1] Serbanescu, D. Understanding major accidents -Shifting paradigms in safety and
risk Safety Summit Vienna 27-28 Sept 2011, http://www.academia.edu/
3763738/Understanding_major_nuclear_accidents_shifting_in_paradigms_for_safe
ty_and_risk
[2] Serbanescu, D. On some knowledge issues in sciences and society, ECKM2013,
Kaunas 5-6 September 2013
[3] Serbanescu, D., Vetere Arellano, A.L, WP1 – Risk-Informed Decision Making
(RIDM) Safety, Reliability and Risk Analysis: Theory, Methods and Applications –
Martorell et al. (eds) 2009 Taylor & Francis Group, London, ISBN 978-0-415-
48513-5 SIXTH FRAMEWORK PROGRAMME Citizens and governance in a
knowledge-based society COORDINATION ACTION Proposal/Contract no.: FP6-
036720 Comparison of Approaches to Risk Governance
[4] Serbanescu, D., PRA-type study adapted to the multi-crystalline silicon
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Research Centre, Institute for Energy, Petten, The Netherlands B.J.M. Ale TU Delft,
Policy and Management, Delft, The Netherlands
[5] Serbanescu, D., Vetere Arelano, A.L, Colli, A., On some aspects related to the
use of integrated risk analyses for the decision making process, including its use in
the non-nuclear applications, EC DG Joint Research Centre, Institute for Energy,
Petten, Netherlands
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Infrastructures, Vol. 1, Nos. 2/3, 2005 281,2005 Inderscience Enterprises Ltd
[7] Serbanescu,D., vanGraan, H., Ellof, L., Combrink,Y. Some lessons learnt from
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