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Materials - Taylor and Francis: Human Factors and Human Error in Nuclear Power Plant Maintenance
Materials - Taylor and Francis: Human Factors and Human Error in Nuclear Power Plant Maintenance
10.1 Introduction
In nuclear power plant maintenance, human factors play an important role
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ment, and systems with regard to human factors helps to directly or indi-
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1970s when the WASH-1400 Reactor Safety Study criticized the deviation of
controls’ and displays’ design in the commercial nuclear power plants of the
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United States from the human factors engineering-related set standards [1–3].
A number of studies performed over the years clearly indicate that the
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ber of motors ran backward and withdrew rods instead of inserting them
[5]. Needless to say, over the years, the occurrence of many human factors’
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163
164 Safety, Reliability, Human Factors, and Human Error
coding; maintenance stores, supplies, and tools; maintenance errors and acci-
dents; preventive maintenance and malfunction diagnosis; equipment protec-
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and training. The first seven of these groups are described below [6,7].
The equipment maintainability’s most common problem is the placement
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problems belonging to environmental factors are heat stress and a high vari-
ability of illumination. The communications problems include inadequate
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in References 6 and 7.
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maintenance personnel
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There are many human factors methods that can be used to assess and
improve nuclear power plant maintainability. Five of these methods are
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This is one of the most effective methods used for collecting valuable data
concerning maintainability in the shortest possible time. The method
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assumes that personnel such as repair persons, technicians, and their super-
visors close to maintainability-related problems generally provide the most
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meaningful insights into the difficulties involved in carrying out their job
the best possible way. In a structured interview, a fixed set of questions such
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10.4.3 Surveys
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This method is used when the results obtained through the application of
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methods such as structured interviews and task analysis indicate a need for
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This is a quite useful structured approach for assessing the accident, damage,
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or potential error inherent in a stated task. To determine the potential for mis-
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After analyzing all the collected data, appropriate changes to items such as
equipment, facility, and procedures are recommended. Additional informa-
tion on this method is available in References 6 and 9.
Past experiences over the years clearly indicate that maintenance errors’,
accidents’, or near mishaps’ history can provide useful information concern-
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incident technique is considered a very good tool for examining such case
histories from the standpoint of human factors. The application of this tool/
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After analyzing all the collected data, necessary changes for improvements
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References 6 and 9.
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tors were shut down due to maintenance error and caused rolling
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blackouts [14].
• As per Reference 5, a study of nuclear power plant operating-related
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maintenance-related tasks.
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• As per Reference 16, a study of 199 human errors that took place
in Japanese nuclear power plants during the period from 1965–1995
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There are many causes for the human error occurrence in nuclear power
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Five
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maintenance-
related tasks
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FIGURE 10.1
Five maintenance-related tasks most susceptible to human errors in nuclear power plants.
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The Electric Power Research Institute (EPRI) in the United States and the
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tasks and to develop, implement, and evaluate interventions that have a very
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Over the years, various useful guidelines have been proposed for reducing
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There are many methods/models that can be used for performing human
error analysis in the area of nuclear power plant maintenance. Three of these
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able engineering systems, and it can also be used for performing human
error analysis in the area of nuclear power plant maintenance. The method
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Figure 10.2 [10,20]. Numerals in the circle and boxes denote system states.
The following assumptions are associated with the mathematical model:
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λ2 λ1
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FIGURE 10.2
Nuclear power plant system state space diagram.
172 Safety, Reliability, Human Factors, and Human Error
• The failed nuclear power plant system repair rates are constant.
• The repaired nuclear power plant system is as good as new.
j is the nuclear power plant system state j; for j = 0 (nuclear power plant
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Pj(t) is the probability that the nuclear power plant system is in state j at
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state 0.
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θ2 is the nuclear power plant system constant repair rate from state 2
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to state 0.
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dP0 (t)
+ (λ1 + λ2 )P0 (t) = θ1P1(t) + θ2P2 (t) (10.1)
dt
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dP1(t)
or
dP2 (t)
+ θ2P2 (t) = λ2P0 (t) (10.3)
dt
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where
B = θ1 + θ2 + λ1 + λ2 (10.6)
y1 + y 2 = −(θ1 + θ2 + λ1 + λ2 ) (10.8)
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P2 (t) = + e − e (10.10)
y1 y 2 y1( y1 − y 2 )
y 2 ( y1 − y 2 )
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θ1θ2
P0 = (10.11)
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y1 y 2
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λ2θ1
P1 =
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(10.12)
y1 y 2
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λ1θ2
P2 =
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(10.13)
or
y1 y 2
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where
P0, P1, P2 are the steady-state probabilities of the nuclear power plant sys-
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It should be noted that Equation 10.11 is also known as the system steady-
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EXAMPLE 10.1
Assume that for a nuclear power plant system, we have the following
data values
θ1θ2 θ1θ2
P0 = =
y1 y 2 θ1θ2 + λ2θ1 + λ1θ2
(0.06)(0.04)
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=
(0.06)(0.04) + (0.0001)(0.06) + (0.0008)(0.04)
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= 0.9844
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we get
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λ1θ2 λ1θ2
P2 = =
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Thus, the nuclear power plant system steady-state availability and the
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EXAMPLE 10.2
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Assume that a system used in a nuclear power plant can fail due to a
maintenance error caused by any of these four factors: poor system
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tenance manuals. Two major factors for carelessness are time constraints
or poor training. Similarly, two factors for a poor work environment are
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EXAMPLE 10.3
Assume that the occurrence probability of events Y1, Y2, Y3, Y4, Y5 and
Y6 shown in Figure 10.3 is 0.04. For independent events, calculate the
Human Factors and Human Error in Nuclear Power Plant Maintenance 175
design maintenance
manuals
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I1 I2
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Y1
Y6
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Distractions
constraints training lighting
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Y2 Y3 Y4 Y5
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FIGURE 10.3
Fault tree for Example 10.2.
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occurrence probability of the top event T (i.e., nuclear power plant sys-
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By using Chapter 4 and the given data values, we obtain the values of
I1, I2 and T as follows:
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= 0.0784
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where
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P(I1), P(Y2), and P(Y3) are the occurrence probabilities of events I1, Y2,
and Y3, respectively.
where
P(I2), P(Y4), and P(Y5) are the occurrence probabilities of events I2, Y4
and Y5, respectively.
By using the above calculated and given data values and Chapter 4,
we get
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where
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P(T), P(Y1) and P(Y6) are the occurrence probabilities of events T, Y1,
and Y6, respectively.
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Thus, the occurrence probabilities of events T, I1, and I2 are 0.2172, 0.0784,
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and 0.0784, respectively. Figure 10.3 fault tree with specified and calcu-
lated fault event occurrence probability values is shown in Figure 10.4.
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0.2172 T
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0.0784 0.0784
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0.04 I1 I2 0.04
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Y1 Y6
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Y2 Y3 Y4 Y5
FIGURE 10.4
A fault tree with given and calculated fault occurrence probability values.
Human Factors and Human Error in Nuclear Power Plant Maintenance 177
measures [23]. The development of this model was sponsored by the U.S.
NRC, and the main objective for its development was the pressing need
for and lack of a human reliability-related data bank pertaining to nuclear
power plant maintenance activities for use in conducting probabilistic risk
assessment studies [23].
Some of the performance measures estimated by the MAPPS model are
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identification of the most and least likely error-prone sub elements, prob-
ability of successfully accomplishing the task of interest, probability of an
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undetected error, the task duration time, and maintenance team stress pro-
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10.10 Problems
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plant maintenance.
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systems.
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3. What are the elements relating to human performance that can con-
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5. Discuss at least five facts, figures, and examples that are directly
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6. What are the main causes for the occurrence of human error in
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References
1. Reactor Safety Study: An Assessment of Accident Risks in U.S. Commercial
Nuclear Power Plants, Report No. WASH-1400, United States Nuclear
Regulatory Commission, Washington, DC, 1975.
2. Seminara, J. L., Gonzalez, W.R., Parsons, S.O., Human Factors Review of
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Nuclear Power Plant Control Room Design, Report No. EPRI NP-309, Electric
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power plants, using root cause analysis, Applied Ergonomics, Vol. 20, No. 2, 1989,
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pp. 115–121.
5. Nuclear Power Plant Operating Experiences, from the IAEA/NEA Incident
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6. Seminara, J.L., Parsons, S.O., Human factors engineering and power plant
maintenance, Maintenance Management International, Vol. 6, 1985, pp. 33–71.
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Proceedings of the 27th Annual Canadian Nuclear Society Conference, pp. 1–11.
9. Seminara, J.L., Human Factors Methods for Assessing and Enhancing Power
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10. Dhillon, B.S., Human Reliability, Error, and Human Factors in Engineering
Maintenance: with reference to aviation and power generation, CRC Press, Boca
l or
Nuclear Europe Worldscan, Vol. 17, No. 5–6, 1997, pp. 35–36.
12. Pyy, P., Laakso, K., Reimann, L., A study of human errors related to NPP
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13. Pyy, P., An analysis of maintenance failures at a nuclear power plant, Reliability
Engineering and System Safety, Vol. 72, 2001, pp. 293–302.
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17. Isoda, H., Yasutake, J.Y., Human factors interventions to reduce human errors
and improve productivity in maintenance tasks, Proceedings of the International
Conference on Design and Safety of Advanced Nuclear Power Plants, 1992, pp.
34.4-1–34.4-6.
18. Khalaquzzaman, M., Kang, H.G., Kim, M.C., Seong, P.H., A model for estima-
tion of reactor spurious shutdown rate considering maintenance human errors
inrReactor protection system of nuclear power plants, Nuclear Engineering
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19. DPPS Maintenance Manual, Ulchin Nuclear Power Plant Unit No. 586,
Document No. 9-650-Z-431-100, Westinghouse Corporation, Butler County,
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Pennsylvania, 2002.
20. Dhillon, B.S., Engineering Maintenance: A Modern Approach, CRC Press, Boca
ig
21. Dhillon, B.S., Singh, C., Engineering Reliability: New Techniques and Applications,
John Wiley & Sons, New York, 1981.
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22. Dhillon, B.S., Human Reliability: with Human Factors, Pergamon Press, Inc., New
York, 1986.
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Conference on Nuclear Power Plant Aging, Availability Factor and Reliability Analysis,
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