Human Based Roots of Failures in Nuclear Events Investigations

Objective: Improvement of quality of the event investigations in the nuclear industry through analysis of the existing practices, identifying and removing the existing Human and Organizational Factors (HOF) and management related barriers. Background: Accidents are still recurring despite the plenty of efforts to prevent them because human and organizational factors' issues are typically not well addressed. Methods: Survey based study of human and organizational factors limiting the effectiveness currently existing event investigation practices typical for nuclear industry of 12 European countries. Results: System of operational experience feedback from information based on event investigation results is not enough effective to prevent and even to decrease frequency of recurring events. The latent root causes of failures found through investigation are related to weaknesses in safety culture of personnel and managers. These weaknesses include focus on costs or schedule, political manipulation, arrogance, ignorance, entitlement and/or autocracy. The potential improvements could be targeted to increasing competencies and capabilities of event investigation teams, elaboration of comprehensive software, increasing level of independency of investigation, ensuring of positive approach, adequate support and impartiality of management. Conclusion: Effectiveness of event investigation and operational experience feedback process is not perfect mainly due to existing methodological, HOF-related and/or knowledge management related constraints. Upgrades in safety culture of organization’s personnel and its senior management especially seem to be an effective way to improvement. Application: Results of this study could be applicable in nuclear power plants as well as in other high-risk industries.JRC.F.5-Nuclear Reactor Safety Assessmen