An integrated framework to the predictive error analysis in emergency situation

This paper introduces an analysis framework and procedure to predictively analyze human errors in performing emergency tasks, which are mostly composed of cognitive activities, in nuclear power plants. The framework focuses on the cognitive errors and provides a new perspective in the utilization of context factors into cognitive error prediction. The basic viewpoint on the occurrence of cognitive error taken in this paper is that the cognitive function failures occur from the mismatch between operator's cognitive capability and the requirements of a given task and situational condition. In accordance with this viewpoint, performance influencing factors that influence the occurrence of human errors are classified into three groups, i.e. Performance Assisting Factors (PAF), Task Characteristic Factors (TCF), and Situational Factors (SF). This classification helps analysts view the overall task context in an integrative way by considering the level of PAF with the requirements of TCF and SF to predict the possibility of cognitive function failures. Further, it enables analysts to draw specific error reduction strategies. The framework suggested was applied to the analysis of cognitive error potential for the bleed and feed operation of emergency tasks in nuclear power plants.     

A taxonomy of performance influencing factors for human reliability analysis of emergency tasks

This paper introduces the process for, and the result of, the selection of performance influencing factors (PIFs) for the use in human reliability analysis (HRA) of emergency tasks in nuclear power plants. The approach taken in this study largely consists of three steps. First, a full-set PIF system is constructed from the collection and review of existing PIF taxonomies. Secondly, PIF candidates are selected from the full-set PIF system, considering the major characteristics of emergency situations and the basic criteria of PIF for use in HRA. Finally, a set of PIFs is established by structuring representative PIFs and their detailed subitems from the candidates. As a result, a set of PIFs comprised of the 11 representative PIFs and 39 subitems was developed.     

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。     

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.     

Team crystallization (SIO2): Dynamic model of team effectiveness evaluation under the dynamic and tactical environment at nuclear installation

Accident management activities at nuclear power plants require concurrent communication, information sharing, team based decision-making and collective actions under tactical and dynamic environments. Team effectiveness under such environments can be characterized as the performance of team situation awareness with hierarchically distributed information and knowledge susceptible to organizational characteristics and communication quality. This paper proposes a team performance model, called a team crystallization model comprising of four elements: state, information, organization, and orientation and its quantification method using a communication process model based on a receding horizon control approach. The team crystallization model is a holistic approach for evaluating team effectiveness in conjunction with team situation awareness considering physical system dynamics and team behavioural dynamics for a tactical and dynamic task at a nuclear power plant. This model provides a systematic measure to evaluate time-dependent team effectiveness or performance affected by multi-agents such as plant states, communication quality in terms of transferring situation-specific information and strategies for achieving the team task goal at a given time, and organizational factors. To demonstrate the applicability of the proposed model and its quantification method, a case study was carried out using the data obtained from a full-scope power plant simulator for 1000 MW(e) pressurized water reactors with four on-the-job operating groups and one expert group who knew accident sequences.     

导弹核武器核事故应急有关问题研究

对导弹核武器核事故应急的主要任务、特点、组织指挥以及力量运用等问题进行了探讨 ,导弹核武器核事故的应急问题是一项涉及体制、人员、装备、技术、科学理论等方面的复杂系统工程 ,笔者结合实际 ,有针对性的研究了事故应急有关的问题 ,可为导弹核武器核事故应急提供理论指导     

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。     

基于图形熵的化工应急响应预案复杂度评价

面对突发化工事故,应急处理是控制事故后果、减少损失的有效措施,应急响应预案是应急处理的依据和指南。应急处理中人与系统的交互作用对于事故的缓解或恶化起着至关重要的作用,目前在应急人因失误的研究中纷纷强调操作员操作经验的重要性,而忽略了由于预案逻辑结构过于复杂、可读性太差导致操作员因不能完全理解预案而造成的操作失误,因此讨论了预案复杂度的评价方法。基于图形熵的概念,将文本预案转化为相应的图形,通过计算图形的一、二阶熵确定步骤的5个复杂度因子,进而通过合并步骤复杂度计算任务复杂度。最后,以化工＂切换备用泵＂的应急操作实例对计算方法进行了验证和说明,并针对计算结果给出了减小复杂度的具体措施。实践证明,该方法是有效的。     

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”。     

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。     

我国自然灾害类应急预案评价方法研究(Ⅲ):可操作性评价

从预案执行人员的角度出发,将可操作性评价转化为复杂性评价,并以国家地震应急预案为例,构建针对应急预案结构的可操作性评价方法。该方法由3步完成:首先,应急预案具有由描述性语言组成的特点,分析国内现有应急预案的组织结构,采用语句成分分析的方法对预案中的关键信息和行动进行提取与处置;然后,引入软件工程中的程序流转图,将描述性的预案文本转换为包含行动以及它们之间逻辑与层次关系的结构控制图;最后,借鉴度量软件复杂性的方法,定义了结构控制图的内部复杂度和综合复杂度等一系列指标,用于应急预案的复杂性即可操作性评价。评价结果可为完善和修订应急预案提供科学依据。     

Development of statistical models for predicting muscle and mental activities during repetitive precision tasks

This study was conducted to develop muscle and mental activities on repetitive precision tasks. A laboratory experiment was used to address the objectives. Surface electromyography was used to measure muscle activities from eight upper limb muscles, while electroencephalography recorded mental activities from six channels. Fourteen university students participated in the study. The results show that muscle and mental activities increase for all tasks, indicating the occurrence of muscle and mental fatigue. A linear relationship between muscle activity, mental activity and time was found while subjects were performing the task. Thus, models were developed using those variables. The models were found valid after validation using other students’ and workers’ data. Findings from this study can contribute as a reference for future studies investigating muscle and mental activity and can be applied in industry as guidelines to manage muscle and mental fatigue, especially to manage job schedules and rotation.     

核应急公众洗消时间评估问题研究

去污洗消是核泄漏应急撤离工作中的重要环节之一,我国在相关规定中主要明确的是人员洗消的适用时段以及原则,各拥有核电的省份在省级核电站场外应急程序中,设定了人员洗消站点的配置方案,但对方案可能存在的风险缺乏进一步研究。根据某核电站场外应急撤离程序中的居民数量、撤离路线、风向风力等信息,构建3种污染场景,利用系统动力学模型,按照洗消站点建设方案,对公众洗消进行仿真。研究结果表明:利用现有洗消站点设备配置进行人员洗消,时间过长,不利于稳定撤离群众的情绪;同时,需要重新审视现有洗消站点的选址及设备配置数量的合理性。因此,建议开展应急撤离程序的洗消站配置方案风险性评估,并进一步制定我国公众洗消站的配置标准。     

应急决策的理论与方法探讨

围绕基于模板的规划、组织决策协调与基于Agent系统的协调机制以及马尔可夫决策规划等应急决策的关键理论与方法,对国内外相关研究进行分析与总结;提出以决策理论规划为应急决策研究的主要建模和分析框架;采用逻辑程序与规划相结合的思想,研究基于应急预案模板的应急决策规划方法;基于应急处置任务的时间、资源约束关系,研究应急处置任务的多Agent马尔可夫决策建模及求解方法。基于决策理论规划的应急决策理论可以很好地用于应急决策的多阶段动态过程建模,而且能够利用预案模板降低模型求解的难度。上述研究完善和丰富了应急决策的理论和方法,为科学的应急决策实践以及应急决策支持系统提供了一种理论和方法。     

Measuring maintenance culture and maintenance core task with CULTURE-questionnaire––a case study in the power industry

Organisational culture has become a focus of much attention in industry in general and the nuclear industry in particular. In maintenance work, the research has addressed mainly human error issues or strategic decision making and optimisation. The present study utilises the CULTURE-questionnaire that is designed to measure the different cultural aspects of complex organisations. Functioning of the questionnaire and the results obtained in a case study at a maintenance organisation of a nuclear power plant are reported in this paper. The questionnaire consisted of four instruments: measures of values, psychological job characteristics, individual perceptions and organisational core task. Three of the instruments were factor analysed and 13 summated scales were formed. The core task instrument was used in a cluster analysis to separate the respondents into groups on the basis of their orientation towards the maintenance work. Differences between the work tasks, section, age and length of service were studied. Hierarchical position in the company influenced perceptions of values. Core task orientation influenced the perception and subjective feelings towards one's organisation. Several partially overlapping subcultures were thus identified. The implications of the different work orientations for effective maintenance are discussed.     

On the origins of informal hierarchy: The interactive role of formal leadership and task complexity

Informal hierarchies are a common and important feature of many groups, yet we know little about the antecedent conditions that determine the strength of such hierarchies. Building on theory that has depicted hierarchy as a mechanism for reducing uncertainty and creating structure, we posit that informal hierarchies emerge most strongly in situations that are ambiguous, ill‐defined, and unstructured. Three independent studies confirm this notion, demonstrating that groups develop particularly strong informal hierarchies in situations characterized by both a lack of strong formal leadership and high task complexity. These findings support the theoretical notion that formal and informal hierarchies are closely related, but only under conditions of high task complexity in which the structuring functions of hierarchies are most crucial.     

重大道路交通事故救援“任务—职责—履责”探讨

突发事件应对中因救援任务不明确、应对主体职责不清、履责路径不通畅而导致事态扩大和严重问责的情况时有发生,这已成为应急绩效评估中常见的、亟需解决的问题。以某次特别重大道路交通事故应急为切入点,借助高速公路特殊路段典型交通事故救援演练实践,梳理了道路交通事故救援任务单元,匹配了各任务单元的责任主体和应急职责,并析出基于各责任主体应急角色交互的履责路径。该研究对提升当地道路交通事故应急救援整体水平具有借鉴价值。     

城市重大事故应急演习方法研究---演习目标及其评价准则

应急演习是城市开展重大事故应急准备过程的主要任务之一,应急演习目标是检查演习效果,评价应急组织、人员应急准备状态和能力的指标.本文介绍了可供选择的十八项演习目标和各项目标的评价准则,同时介绍了分组选择演习目标的方法.     

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。     

应急准备任务设置与应急响应能力建设——基于情景-任务-能力应急预案编制技术研究之二

应急准备任务设置和应急响应能力建设是应急管理中重要内容,是突发事件应急预案编制前置条件和基础。基于情景-任务-能力应急预案管理思想,描述了突发事件应急准备任务和应急响应能力的概念、方法和内容,提出了突发事件应急准备的共同任务和职责任务的一览表,并对共同任务中应急准备一项的内容做了具体介绍。在提出应急响应能力一览表的同时,论述了其功能及发展。