Lessons Learned and other countries

experiences
National Workshop on Overseeing Manufacturing and Construction
IAEA / NPPA, Cairo, Egypt, 19-22 September 2022

Pirjo Knuuttila
Quality Professional
Konsultointi Knuuttila Oy
Tel. + 358 40 759 1841
Email: pirjo.knuuttila@konsultointi-knuuttila.fi
https://www.linkedin.com/in/pirjo-knuuttila-22b25730/
Table of Content
1. Introduction
2. Simplified process
 Identify
 Screen
 Analyze
 Act
 Share

3. Workshop example
4. Summary

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Lessons learned from different sources

External
experiences

Internal Selected experiences

experiences processed to
Lessons
Learned

Benchmarking

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International guidelines
 The operating organization shall establish an operating experience programme to learn from
events at the plant
 Source: Safety of Nuclear Power Plants: Commissioning and Operation IAEA Safety Standards Series
No. SSR-2/2 (Rev. 1), req. 24

 IAEA Safety Guide SSG-50: Operating Experience Feedback for Nuclear Installations
 WANO Guidelines GL 2003-1 Rev 1: Guidelines for Operating Experience at Nuclear Power
Plants
 Available only for the members of WANO (World Association of Nuclear Operators)

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Learning from experience program
 The purpose of learning from experience is to use and share knowledge derived from
internal, external and benchmarking experiences
 Systematic approach to identify, obtain, maintain and analyze internal and external data in order
to define and implement appropriate corrective and development actions
 Actions to collect and utilize experiences gained through benchmarking
 Graded approach applied
 Selection, analyses and actions
 Objective is to utilize lessons learned from internal and external sources to prevent similar
events and improve safety, reliability and efficiency of the NPP
 Involve the Plant Supplier and its supply chain
 Share experiences and lessons learned within the organization
 Applicable tools and a database is needed for effective experience processing
 Define methods to find relevant LL’s for specific purposes

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Program acc. SSG-50 fig 1

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Lessons Learned process in a nutshell

Identify Screen Analyze Act Share

Document results into the database!

Event reporting during NPP operation often have more strict requirements,
e.g. Finnish YVL A.10 Operating experience feedback of a nuclear facility
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Lessons Learned process - Identify

Identify Screen Analyze Act Share

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Identify
 Important to select sources and prioritize
 Sources from where to look for experiences
 Internal events and observations, projects
 Construction project and the supply chain
 VVER fleet
 Other PWR’s
 NPP construction projects
 IRS database (IAEA)
 WANO
 Other industries
 Different sources can be used for different life-cycle phases

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Lessons Learned - Screen

Identify Screen Analyze Act Share

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Relevance of experiences to be screened
 The team to screen identified experiences and decide which ones are analyzed further
 Define competences you need in the team – facilitator + experts form relevant departments
 The team could include members also from the Plant Supplier, General designer or Main contractor
 Examples of screening criteria (Source: IAEA SSG 50)
 Immediate actions necessary
 Generic implications that may apply to the NPP
 Similar equipment at our NPP
 Applicability of reported corrective actions to the NPP.
 Similarity of environmental conditions
 Applicability to the organization
 Similar events already occurred in the project
 Similarity with the design, if design was a contributor
 Define responsible persons for analyzing the event in detail
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Lessons Learned - Analyze

Identify Screen Analyze Act Share

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Analyzing
 Review the event report and indicate relevant measures concerning
 Plant, Organization, Project
 Document results carefully and justify
 For internal events you might need to use root cause methods
 Define SMART actions and schedule them
 SMART= specific, measurable, achievable, relevant and timely
 Some of experiences are not relevant now, define when they should be revisited
 Consider the level of approval of actions – commitment is needed
 SSG 50 para 2.63
 Senior management should review and approve (a) major corrective* actions resulting from internal
events with significant implications for safety and (b) external operating experience providing
major lessons
 *Major corrective actions’ include those actions taken to prevent the recurrence of internal events
with significant implications for safety or the occurrence of major external event

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Lessons Learned - Act

Identify Screen Analyze Act Share

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Corrective actions
 Lessons learned from internal and external operating experience should be implemented in
 relevant processes, such as training, revision of procedures, work management
 design and modification of the installation
 Implementation to be followed as any open item or task
 Major corrective actions that have not been completed should be assessed periodically
 To identify whether the risk is still acceptable
 Extensions to deadlines for, or the modification or cancellation
 The effectiveness of major corrective actions should be reviewed after their completion
 The effectiveness of the operating experience programme should be assessed
 E.g., by self-assessment, benchmarking and peer review
 Carried out on a regular basis
Source: IAEA SSG 50
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Lessons Learned - Share

Identify Screen Analyze Act Share

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Sharing and communication
 Relevant operating experience should be made readily accessible in a user friendly form to
the personnel for use in their work
 Leaflets shared regularly
 Safety briefings, bulletins
 Consider extending this to the entire project, especially at construction site
 Regular progress reporting
 Relevant operating experience should be shared with other organizations in a timely manner
at appropriate levels
 International channels

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Example LL workshop
 Team of experts Results / category
 Brainstorming issues / good practices
 Grouping them to categories Problem statement / Opportunity
 Summarized results / category
Causes / Enablers
 Categories
 Communication, People, Process, Product, Tools Actions
 Classification of action
 A=critical that should be implemented asap
 B=not crucial, but include places for improvement
 C=to be considered during regular development activities
/trending
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Summary – Lessons Learned
 Experiences to be gathered from internal and external sources
 Sources to be prioritized
 Simplified process: Identify, Screen, Analyze, Act, Share
 Process has similarities with nonconformity management
 Screening team should include facilitator and relevant experts
 Involve supply chain members
 Share defined lessons learned
 For effective LL management a database is needed
 Workshop e.g., after a project is a good method to gather lessons learned
 Process also good practices!

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 Thank You!

Questions & Comments

Pirjo Knuuttila
Quality Professional
Konsultointi Knuuttila Oy
Tel. + 358 40 759 1841
Email: pirjo.knuuttila@konsultointi-knuuttila.fi
https://www.linkedin.com/in/pirjo-knuuttila-22b25730/

pirjo.knuuttila@konsultointi-knuuttila.fi Lessons Learned and other countries experiences 2022-09-22 20