Extension of TACOM to the complexity of tasks designed for abnormal situations in nuclear power plants

TACOM (TAsk COMplexity) is a measure for evaluating the complexity of tasks prescribed for emergency situations in nuclear power plants. Five sub-measures constituting TACOM represent five different aspects of the task complexity exhibited in operating procedures for emergency situations. The practicality of TACOM has been verified through a series of empirical studies. However, tasks designed for abnormal situations that can significantly affect the safety of nuclear power plants, also need a proper measure for evaluating their complexity. TACOM provides a process, a systematic cognitive task analysis method and a set of guidelines to support its application. Therefore, although the characteristics of abnormal task situations are not the same as those of emergency situations, TACOM seems to be reasonably applied to abnormal situations or at least to offer meaningful insights for developing a measure for evaluating the complexity of tasks in abnormal situations. Thus this study examined the applicability of TACOM to abnormal situations through case studies. Particular attention was paid to the sufficiency and appropriateness of the three methodological tools, which are the process, the cognitive task analysis method and the set of guidelines. Collective consideration of the case studies and the characteristics of tasks prescribed for abnormal situations led us to draw the conclusion that TACOM could be reliably used for abnormal situations as well. This paper reports the process of how to apply TACOM to the tasks of abnormal situations and discusses some lessons learned through this application.     

Ergodynamics and Hybrid Intelligence Systems in the Reliability of Power Plant Operators

Based on ergodynamics and the hybrid intelligence theory, an analysis of the nuclear power plant operator’s performance is given at the levels of strategies, tactics, and actions. Special attention is paid to the strategies used in the course of severe accidents at nuclear power plants. Data from Ukrainian and Russian power plants and training centres and from accidents around the world were collected and processed. It is shown that in an emergency it is essential for the human operator to be flexible. This flexibility includes two main training and personal factors: a large set of strategies and tactics the operator manages to use, and quick transformations between the strategies (tactics). It was also found that some emergency tasks are too complicated: They require simultaneous use of different strategies, with time strictly limited by nuclear power plant dynamics. Those tasks cannot be successfully solved by any individual operator. Hybrid intelligence systems involving different specialists should be used in those cases in order to avoid failures in emergency problem solving.     

计算机仿真事故响应中的班组绩效影响因子研究

在核电站应急事件的工况下,用计算机仿真的人的班组行为模型(IDAC模型)可以预计主控室操作班组人员(决策者、操作者和咨询者组成)的失误概率,为了量化事件过程中人的认知心理活动发生的机理,采用绩效影响因子(PIF)计算班组人员发生失误的概率。讨论PIF的定义、分类以及量化值的确定,描述人的认知心理活动的失误机理与PIF的关系,预计班组失误亊件发生的概率。对50个PIFs中的一些重要因子进行描述,每组中的PIF都是独立于其他组的,但是不同组中的PIF可能存在从属关系。试图基于心理学观察以及各种人的可靠性分析方法的影响路径,合理有效地选择PIF,以实现动态概率风险评价中的人误事件发生概率的量化。     

核电厂核事故应急疏散研究

根据我国法规、标准与美国核管委对核电厂核事故应急疏散的要求,考虑我国核电厂特殊的厂址条件与社会环境,分析核事故应急疏散的可行性。通过应急疏散行为研究、厂区的交通需求估计和路网分析,对不同情境,考虑核事故应急疏散的特殊问题,分别采用人工容量分析与宏观仿真模拟得到应急疏散时间。针对某核电厂,给出核事故应急疏散分析的一般步骤、方法与计算结果。对宏观仿真模型的主要参数进行灵敏度分析,找出影响应急疏散时间的主要因素,提出缩短应急疏散时间的针对性措施。     

A proactive approach to human error detection and identification in aviation and air traffic control

In recent years, there has been a realization that total elimination of human error may be difficult to achieve. A further reduction of accidents will require a better understanding of how practitioners manage their errors in ways that consequences are contained or mitigated. With this goal in mind, the present study has set out to propose a framework of cognitive strategies in error detection that would make human performance resilient to changes in work demands. The literature regarded error detection as a spontaneous process that occurs either while an action is executed (action-based detection) or after action feedback (outcome-based detection). To help practitioners maintain a state of mindfulness and introspection, this study proposes several cognitive strategies such as, rehearsing tasks for future execution, bringing into conscious attention routine tasks, seeing how trajectories change over time, and cross-checking data for reliability. Two further detection mechanisms are proposed at the situation assessment and planning stages of performance. Awareness-based detection may include revising a model of the situation, finding hidden assumptions, and testing the plausibility of assumptions. Planning-based detection addresses issues such as, identifying uncertainties in a plan, thinking out possible errors, and deciding when and how often to review task progress. Finally, several attitudinal factors and team factors are presented that affect the processes of error detection and identification. The cognitive strategies in error detection together with the attitudinal and team factors constitute a framework for designing the content of error management training.     

CREAM-based communication error analysis method (CEAM) for nuclear power plant operators’ communication

Communication error has been considered a primary cause of many incidents and accidents in the nuclear industry. In order to prevent these accidents, a method for the analysis of such communication errors is proposed here. This paper presents a qualitative and a quantitative method to analyze communication errors. The qualitative method focuses on finding a root cause of the communication error and predicting the type of communication error which could happen in nuclear power plants. We develop context conditions and antecedent-consequent links of influential factors related to communication errors. The quantitative analysis method focuses on estimating the probability of communication errors. To accomplish the quantification of communication errors, the Cognitive Speaking Process (CSP) is defined and a method to estimate the weighting factors and the probability is suggested. Finally, case studies conducted to validate the applicability of the proposed methods are detailed. From the results, we can foresee the effects of given plant conditions on communication errors and reduce the error occurrences.     

CREAM方法中控制模式分类的模糊方法

认知可靠性与差错分析方法(CREAM)通过对任务环境进行分析从而直接确定人为差错发生概率。该方法提出控制模式的概念,认定不同的任务环境下可能对应不同的控制模式,而人为差错概率直接由控制模式确定。因此,确定控制模式是其中的关键环节。针对该问题,笔者提出了一种模糊方法。通过对性能影响因子进行打分对任务环境进行量化,利用专家打分的方式确定性能影响因子分值对于控制模式的隶属度;通过拟合分析确定性能影响因子的分值对控制模式的隶属函数,得到控制模式与分值之间的对应关系;将该方法应用到两个示例中,其结果与原有方法的结果基本一致。     

复杂人机系统班组人误模型与量化分析

讨论一个班组人员行为模型,即包括:任务模型、事件模型、班组模型和人-机交互模型4个模块,并用其模拟和分析事故状态下的运行班组对异常事故的响应过程;利用班组认知过程流程图模型表征事件发展过程中班组成员对事故的征兆识别、决策、计划和行动执行的响应过程;采用CREAM的量化分析技术,对核电站的蒸汽发生器管道破管事故的班组认知失误事件进行量化分析。     

复杂工业系统中班组人因失误分析

在复杂工业系统中 ,人因可靠性分析 (HRA)是预防和减少人因失误的有效方法。人在复杂工业系统中的生产活动 ,往往是由组织中班组成员集体完成的 ,完整的HRA必须充分考虑班组人误的产生。班组人误的产生有其自身的规律 ,如何合理地定义人员行为形成因子 (PSFs)是班组人因失误分析的难点 ,也是班组人因失误分析的重要手段 ,被广泛应用在核电厂 ,航空和造船工业领域的事故分析中。笔者详细分析和探讨了班组人因失误的定义、产生过程及相关的人的行为形成因子 ,以期能使大规模工业系统中的人因失误分析更加合理和完善。     

Cognitive failures, driving errors and driving accidents

INTRODUCTION: The impact of a driver's cognitive capability on traffic safety has not been adequately studied. This study examined the relationship between cognitive failures, driving errors and accident data. METHOD: Professional drivers from Iran (160 males, ages 18-65) participated in this study. The cognitive failures questionnaire (CFQ) and the driver error questionnaire were administered. The participants were also asked other questions about personal driving information. A principal component analysis with varimax rotation was performed to determine the factor structure of the CFQ. Poisson regression models were developed to predict driving errors and accidents from total CFQ scores and the extracted factors. RESULTS: Total CFQ scores were associated with driving error rates, but not with accidents. However, the 2 extracted factors suggested an increased effect on accidents and were strongly associated with driving errors. DISCUSSION: Although the CFQ was not able to predict driving accidents, it could be used to identify drivers susceptible to driving errors. Further development of a driving-oriented cognitive failure scale is recommended to help identify error prone drivers. Such a scale may be beneficial to licensing authorities or for developing driver selection and training procedures for organizations.     

The research on extracting the information of human errors in the main control room of nuclear power plants by using Performance Evaluation Matrix

Digitalized nuclear instruments and control systems have been the main stream design for the main control room (MCR) of advanced nuclear power plants (NPPs) nowadays. Digitalization of human–system interface (HSI) could improve human performance and, on the other hand, could reduce operators’ situation awareness as well. It might cause that humans make wrong decision during an emergency unintentionally. Besides, digital HSI relies on computers to integrate system information automatically instead of human operation. It has changed the operator’s role from mainly relating operational activity to mainly relating monitoring. However, if the operators omit or misjudge the information on the video display units and wide display panel, the error of omission and error of commission may occur. This study applies Content Category Analysis (CCA) and Performance Evaluation Matrix (PEM) methods to explore the potential problems in the MCR of advanced NPPs which are caused by human errors. The results show that the potential problems that would probably contribute to the human performance of MCR in the advanced NPPs are multiple accidents, pressure level, number of operators, and other factors such as working environmental. The conclusions of this research may be considered to avoid and prevent human errors in the human factor related researches especially in the nuclear safety field.     

RANDAP: An integrated framework for reliability analysis of detailed action plans of combined automatic-operator emergency response taking into account control room operator errors

Automatic process control and control room operators supervision/intervention in an emergency are of critical importance in major hazard industries. These combined operator and automatic actions are defined in Detailed Action Plans (DAP). A framework has been proposed for analyzing the reliability, and hence the likelihood of success, of DAPs. The Reliability Block Diagram technique is utilized for modeling the reliability of integrated automatic-operator emergency actions. The focus is on incorporating operator's operational and cognitive errors in the process/equipment reliability analysis. For this purpose, the human reliability analysis method SPAR-H is utilized. The proposed framework was used for analyzing emergency response DAPs of a real process plant in order to check and improve its applicability. It is argued that the presented framework facilitates the DAP assessment process by performing Task Analysis, modeling the detailed tasks as well as reliability analysis, thereby uncovering the shortcomings of the designed DAPs. Besides, it provides a very effective, transparent tool with insight into improvement areas and directions for improving the reliability of DAPs.     

核电站中处理人的行为问题的系统方法

引发事件的失误原因或者作为行为趋向的一部分统称为人的行为问题.总结出了核电站中处理人的行为问题的系统方法,即从问题的识别与描述、事件调研、原因分析到开发纠正行动这样一个过程.结合核电站实际,着重介绍了人误原因的识别,如根原因分析技术和起因树.     

数字化核电站SGTR事故操纵员认知分析

核电站主控室数字化后的人因特征包括数字化规程、警报系统、操作班组信息共享、界面管理任务,它们对操纵员认知可靠性都有重要影响。IDA认知模型把操纵员认知过程分为信息(Information)、诊断(Diagnosis)/决策(Decision)、执行(Action)3个阶段。按IDA模型把数字化核电站主控室操纵员SGTR事故认知过程分为3个阶段,对每个阶段进行操作分析,找到操纵员在SGTR事故认知过程各阶段最容易发生的失误和主要失误。操纵员认知失误发生的原因在于界面管理任务增大了认知难度以及数字化后缺乏情景意识等。     

基于任务特征的电网企业应急预案体系重构*

为解决目前电网企业应急预案体系建设存在的内容泛化、管理成本高等问题，提出基于任务特征的应急预案体系重构思路，运用情景构建方法，开展电网企业突发事件影响场景和处置任务分析，得出7个影响场景、10类处置任务和38项子任务。结果表明:电网企业应急处置任务具有收敛性特征。通过应急预案与处置任务匹配，重构应急预案体系结构和预案定位，构建以通用性部门应急预案及现场处置方案为建设重点的新型应急预案体系，形成“通用性预案工具箱”，实现预案衔接“无缝化”、预案内容“本地化”、管理成本“聚焦化”。     

基于人因失误分析的医院电气安全管理研究

医院是重点用电单位,用电的安全性和供电可靠性都比较高,但因不可抗力、供电系统故障、医院管理问题、人为失误等方面的原因,仍存在发生各类电气突发事件的风险。其中,由人的误操作或不安全行为因素而诱发的电气方面的突发事件已成为医院非医疗事故的主要原因。文章针对医院电气安全操作方面的人因失误,从个人和组织两个角度进行了失误原因的分析,认为人的失误既受个体因素的影响,也受环境、制度和管理水平的影响。在此基础上,提出完善相关规章制度建设、加强教育与培训等,从组织制度建设、人员技术素质提高等方面,提出预防与减少人因失误的措施与方法,提高供配电质量,为医院医疗工作提供有效的电气安全后勤保障。     

Job requirements for control room jobs in nuclear power plants

Together with other variables, human factors play a central role in the safety of highly complex technical systems such as nuclear power plants. However, despite the unquestionable importance of human factors, little information is available about relevant ability requirements for control room jobs in nuclear power plants. The purpose of this study was to close this gap, to provide specific information about ability requirements for such jobs, and to evaluate how several hypothesized factors (ability domain, type of job, and operating condition) contribute to ability requirements. We found that high levels of cognitive as well as social/interpersonal abilities are needed for control room jobs, and that ability requirements increase with the hierarchical job level for these two domains but decrease for psychomotor/physical abilities and for sensory/perceptual abilities. Furthermore, specifically concerning jobs with a leadership function, we found some differences between incidents and normal operations regarding requirements for social/interpersonal abilities, indicating that the former require a different leadership style than the latter.     

On the operator action analysis to reduce operational risk in research reactors

Human errors during operation and the resulting increase in operational risk are major concerns for nuclear reactors, just as they are for all industries. Additionally, human reliability analysis together with probabilistic risk analysis is a key element in reducing operational risk. The purpose of this paper is to analyze human reliability using appropriate methods for the probabilistic representation and calculation of human error to be used alongside probabilistic risk analysis in order to reduce the operational risk of the reactor operation. We present a technique for human error rate prediction and standardized plant analysis risk. Human reliability methods have been utilized to quantify different categories of human errors, which have been applied extensively to nuclear power plants. The Tehran research reactor is selected here as a case study, and after consultation with reactor operators and engineers human errors have been identified and adequate performance shaping factors assigned in order to calculate accurate probabilities of human failure.     

面向核应急响应的S-BOX集成模型

核事故引发的应急任务往往需要集成多个部门应急资源和能力来协同响应。这些海量核应急信息、知识汇聚于网络,其固有异构性限制了跨部门核应急集成的能力。为解决此问题,基于语义X列表理论提出核应急集成框架;以“事件-任务-资源”为主线构建本体结构列表和集成推理规则;给出假定核事故场景和资源、任务信息,搭建S-BOX模型和响应决策推理实验,验证了本方法可有效表达异构核应急信息与知识,实现按需集成。