Error-Based Accidents and Security Incidents in Nuclear Materials Management

International Nuclear Information System (INIS)

Pond, Daniel J.; Greitzer, Frank L.

2005-01-01

Hazard and risk assessments, along with human error analysis and mitigation techniques, have long been mainstays of effective safety programs. These tools have revealed that worker errors contributing to or resulting in accidents are often the consequence of ineffective system conditions, process features, or individual employee characteristics. At Los Alamos National Laboratory (LANL), security, safety, human error, and organizational analysts determined that the system-induced human errors that make accidents more likely also are contributing to security incidents. A similar set of system conditions has been found to underlie deliberate, non-malevolent deviations from proper security practices - termed breaches - that also can result in a security incident. In fiscal-year (FY) 2002, LANL's Security Division therefore established the ESTHER (Enhanced Security Through Human Error Reduction) program to identify and reduce the influence of the factors that underlie employee errors and breaches and, in turn, security incidents. Recognizing the potential benefits of this program and approach, in FY2004 the Department of Energy (DOE) Office of Security Policy (DOE-SO) funded an expansion of ESTHER implementation to the causal assessment and reporting of security incidents at other DOE sites. This presentation will focus on three applications of error/breach assessment and mitigation techniques. One use is proactive, accomplished through the elimination of contributors to error, whereas two are reactive, implemented in response to accidents or security incidents as well as to near misses, to prevent recurrence. The human performance and safety bases of these techniques will be detailed. Associated tools - including computer-based assessment training and web-based incident reporting modules developed by Pacific Northwest National Laboratory - will be discussed

A study on the operator's errors of commission (EOC) in accident scenarios of nuclear power plants: methodology development and application

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Jung, Won Dea; Park, Jin Kyun; Kang, Da Il

2003-04-01

As the concern on the operator's inappropriate interventions, the so-called Errors Of Commission (EOCs), that can exacerbate the plant safety has been raised, much of interest in the identification and analysis of EOC events from the risk assessment perspective has been increased. Also, one of the items in need of improvement for the conventional PSA and HRA that consider only the system-demanding human actions is the inclusion of the operator's EOC events into the PSA model. In this study, we propose a methodology for identifying and analysing human errors of commission that might be occurring from the failures in situation assessment and decision making during accident progressions given an initiating event. In order to achieve this goal, the following research items have been performed: Firstly, we analysed the error causes or situations contributed to the occurrence of EOCs in several incidents/accidents of nuclear power plants. Secondly, limitations of the advanced HRAs in treating EOCs were reviewed, and a requirement for a new methodology for analysing EOCs was established. Thirdly, based on these accomplishments a methodology for identifying and analysing EOC events inducible from the failures in situation assessment and decision making was proposed and applied to all the accident sequences of YGN 3 and 4 NPP which resulted in the identification of about 10 EOC situations.

Post-event human decision errors: operator action tree/time reliability correlation

International Nuclear Information System (INIS)

Hall, R.E.; Fragola, J.; Wreathall, J.

1982-11-01

This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations

Post-event human decision errors: operator action tree/time reliability correlation

Energy Technology Data Exchange (ETDEWEB)

Hall, R E; Fragola, J; Wreathall, J

1982-11-01

This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations.

Human error and the problem of causality in analysis of accidents

DEFF Research Database (Denmark)

Rasmussen, Jens

1990-01-01

, designers or managers have played a major role. There are, however, several basic problems in analysis of accidents and identification of human error. This paper addresses the nature of causal explanations and the ambiguity of the rules applied for identification of the events to include in analysis......Present technology is characterized by complexity, rapid change and growing size of technical systems. This has caused increasing concern with the human involvement in system safety. Analyses of the major accidents during recent decades have concluded that human errors on part of operators...

The role of usability in the evaluation of accidents: human error or design flaw?

Science.gov (United States)

Correia, Walter; Soares, Marcelo; Barros, Marina; Campos, Fábio

2012-01-01

This article aims to highlight the role of consumer products companies in the heart and the extent of accidents involving these types of products, and as such undesired events take part as an agent in influencing decision making for the purchase of a product that nature on the part of consumers and users. The article demonstrates, by reference, interviews and case studies such as the development of poorly designed products and design errors of design can influence the usage behavior of users, thus leading to accidents, and also negatively affect the next image of a company. The full explanation of these types of questions aims to raise awareness, plan on a reliable usability, users and consumers in general about the safe use of consumer products, and also safeguard their rights before a legal system of consumer protection, even far away by the CDC--Code of Consumer Protection.

Justifications of policy-error correction: a case study of error correction in the Three Mile Island Nuclear Power Plant Accident

International Nuclear Information System (INIS)

Kim, Y.P.

1982-01-01

The sensational Three Mile Island Nuclear Power Plant Accident of 1979 raised many policy problems. Since the TMI accident, many authorities in the nation, including the President's Commission on TMI, Congress, GAO, as well as NRC, have researched lessons and recommended various corrective measures for the improvement of nuclear regulatory policy. As an effort to translate the recommendations into effective actions, the NRC developed the TMI Action Plan. How sound are these corrective actions. The NRC approach to the TMI Action Plan is justifiable to the extent that decisions were reached by procedures to reduce the effects of judgmental bias. Major findings from the NRC's effort to justify the corrective actions include: (A) The deficiencies and errors in the operations at the Three Mile Island Plant were not defined through a process of comprehensive analysis. (B) Instead, problems were identified pragmatically and segmentally, through empirical investigations. These problems tended to take one of two forms - determinate problems subject to regulatory correction on the basis of available causal knowledge, and indeterminate problems solved by interim rules plus continuing study. The information to justify the solution was adjusted to the problem characteristics. (C) Finally, uncertainty in the determinate problems was resolved by seeking more causal information, while efforts to resolve indeterminate problems relied upon collective judgment and a consensus rule governing decisions about interim resolutions

Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

National Research Council Canada - National Science Library

Wiegmann, Douglas; Faaborg, Troy; Boquet, Albert; Detwiler, Cristy; Holcomb, Kali; Shappell, Scott

2005-01-01

... of both commercial and general aviation (GA) accidents. These analyses have helped to identify general trends in the types of human factors issues and aircrew errors that have contributed to civil aviation accidents...

A Human Reliability Analysis of Post- Accident Human Errors in the Low Power and Shutdown PSA of KSNP

Energy Technology Data Exchange (ETDEWEB)

Kang, Daeil; Kim, J. H.; Jang, S. C

2007-03-15

Korea Atomic Energy Research Institute, using the ANS low power and shutdown (LPSD) probabilistic risk assessment (PRA) Standard, evaluated the LPSD PSA model of the KSNP, Yonggwang Units 5 and 6, and identified the items to be improved. The evaluation results of human reliability analysis (HRA) of the post-accident human errors in the LPSD PSA model for the KSNP showed that 10 items among 19 items of supporting requirements for those in the ANS PRA Standard were identified as them to be improved. Thus, we newly carried out a HRA for post-accident human errors in the LPSD PSA model for the KSNP. Following tasks are the improvements in the HRA of post-accident human errors of the LPSD PSA model for the KSNP compared with the previous one: Interviews with operators in the interpretation of the procedure, modeling of operator actions, and the quantification results of human errors, site visit. Applications of limiting value to the combined post-accident human errors. Documentation of information of all the input and bases for the detailed quantifications and the dependency analysis using the quantification sheets The assessment results for the new HRA results of post-accident human errors using the ANS LPSD PRA Standard show that above 80% items of its supporting requirements for post-accident human errors were graded as its Category II. The number of the re-estimated human errors using the LPSD Korea Standard HRA method is 385. Among them, the number of individual post-accident human errors is 253. The number of dependent post-accident human errors is 135. The quantification results of the LPSD PSA model for the KSNP with new HEPs show that core damage frequency (CDF) is increased by 5.1% compared with the previous baseline CDF It is expected that this study results will be greatly helpful to improve the PSA quality for the domestic nuclear power plants because they have sufficient PSA quality to meet the Category II of Supporting Requirements for the post-accident

A Human Reliability Analysis of Post- Accident Human Errors in the Low Power and Shutdown PSA of KSNP

International Nuclear Information System (INIS)

Kang, Daeil; Kim, J. H.; Jang, S. C.

2007-03-01

Korea Atomic Energy Research Institute, using the ANS low power and shutdown (LPSD) probabilistic risk assessment (PRA) Standard, evaluated the LPSD PSA model of the KSNP, Yonggwang Units 5 and 6, and identified the items to be improved. The evaluation results of human reliability analysis (HRA) of the post-accident human errors in the LPSD PSA model for the KSNP showed that 10 items among 19 items of supporting requirements for those in the ANS PRA Standard were identified as them to be improved. Thus, we newly carried out a HRA for post-accident human errors in the LPSD PSA model for the KSNP. Following tasks are the improvements in the HRA of post-accident human errors of the LPSD PSA model for the KSNP compared with the previous one: Interviews with operators in the interpretation of the procedure, modeling of operator actions, and the quantification results of human errors, site visit. Applications of limiting value to the combined post-accident human errors. Documentation of information of all the input and bases for the detailed quantifications and the dependency analysis using the quantification sheets The assessment results for the new HRA results of post-accident human errors using the ANS LPSD PRA Standard show that above 80% items of its supporting requirements for post-accident human errors were graded as its Category II. The number of the re-estimated human errors using the LPSD Korea Standard HRA method is 385. Among them, the number of individual post-accident human errors is 253. The number of dependent post-accident human errors is 135. The quantification results of the LPSD PSA model for the KSNP with new HEPs show that core damage frequency (CDF) is increased by 5.1% compared with the previous baseline CDF It is expected that this study results will be greatly helpful to improve the PSA quality for the domestic nuclear power plants because they have sufficient PSA quality to meet the Category II of Supporting Requirements for the post-accident

Human reliability data, human error and accident models--illustration through the Three Mile Island accident analysis

International Nuclear Information System (INIS)

Le Bot, Pierre

2004-01-01

Our first objective is to provide a panorama of Human Reliability data used in EDF's Safety Probabilistic Studies, and then, since these concepts are at the heart of Human Reliability and its methods, to go over the notion of human error and the understanding of accidents. We are not sure today that it is actually possible to provide in this field a foolproof and productive theoretical framework. Consequently, the aim of this article is to suggest potential paths of action and to provide information on EDF's progress along those paths which enables us to produce the most potentially useful Human Reliability analyses while taking into account current knowledge in Human Sciences. The second part of this article illustrates our point of view as EDF researchers through the analysis of the most famous civil nuclear accident, the Three Mile Island unit accident in 1979. Analysis of this accident allowed us to validate our positions regarding the need to move, in the case of an accident, from the concept of human error to that of systemic failure in the operation of systems such as a nuclear power plant. These concepts rely heavily on the notion of distributed cognition and we will explain how we applied it. These concepts were implemented in the MERMOS Human Reliability Probabilistic Assessment methods used in the latest EDF Probabilistic Human Reliability Assessment. Besides the fact that it is not very productive to focus exclusively on individual psychological error, the design of the MERMOS method and its implementation have confirmed two things: the significance of qualitative data collection for Human Reliability, and the central role held by Human Reliability experts in building knowledge about emergency operation, which in effect consists of Human Reliability data collection. The latest conclusion derived from the implementation of MERMOS is that, considering the difficulty in building 'generic' Human Reliability data in the field we are involved in, the best

Use of a fuzzy decision-making method in evaluating severe accident management strategies

International Nuclear Information System (INIS)

Jae, M.; Moon, J.H.

2002-01-01

In developing severe accident management strategies, an engineering decision would be made based on the available data and information that are vague, imprecise and uncertain by nature. These sorts of vagueness and uncertainty are due to lack of knowledge for the severe accident sequences of interest. The fuzzy set theory offers a possibility of handling these sorts of data and information. In this paper, the possibility to apply the decision-making method based on fuzzy set theory to the evaluation of the accident management strategies at a nuclear power plant is scrutinized. The fuzzy decision-making method uses linguistic variables and fuzzy numbers to represent the decision-maker's subjective assessments for the decision alternatives according to the decision criteria. The fuzzy mean operator is used to aggregate the decision-maker's subjective assessments, while the total integral value method is used to rank the decision alternatives. As a case study, the proposed method is applied to evaluating the accident management strategies at a nuclear power plant

Beyond the organisational accident: the need for "error wisdom" on the frontline.

Science.gov (United States)

Reason, J

2004-12-01

Complex, well defended, high technology systems are subject to rare but usually catastrophic organisational accidents in which a variety of contributing factors combine to breach the many barriers and safeguards. To the extent that healthcare institutions share these properties, they too are subject to organisational accidents. A detailed case study of such an accident is described. However, it is important to recognise that health care possesses a number of characteristics that set it apart from other hazardous domains. These include the diversity of activity and equipment, a high degree of uncertainty, the vulnerability of patients, and a one to one or few to one mode of delivery. Those in direct contact with patients, particularly nurses and junior doctors, often have little opportunity to reform the system's defences. It is argued that some organisational accident sequences could be thwarted at the last minute if those on the frontline had acquired some degree of error wisdom. Some mental skills are outlined that could alert junior doctors and nurses to situations likely to promote damaging errors.

Decision conferencing on countermeasures after a large nuclear accident

International Nuclear Information System (INIS)

French, S.; Walmod-Larsen, O.; Sinkko, K.

1993-01-01

The conference addressed the following objectives. 1. To achieve a common understanding between decision makers and local government officials on the one hand and the radiation protection community on the other of the issues that arise in decisions in the aftermath of a major nuclear accident. 2. To identify issues which need to be considered in preparing guidance on intervention levels. 3. To explore the use of decision conferencing as a format for major decision making. To achieve these objectives the participants were invited to consider a scenario of a hypothetical radiation accident. The scenario assumed that appropriate early protective actions (sheltering, issuing of iodine tablets, etc.) had been taken and that the conference was meet ng some eight days into the accident to consider medium and longer term protective actions, particularly the need for relocation of certain areas. By the end of the conference, considerable consensus on the general form of the strategy had emerged. Moreover, there was a better understanding of the evaluation criteria against which such a strategy needed to be developed. Many felt that it was important to retain flexibility in the strategy of protective actions, even if this increased the uncertainty for the affected population, who would not know exactly what would be done for several months. This emphasised even more the need for good communication and understandable presentations of the adopted strategy. All felt that more research and advice is needed on the psychological effects of such accidents and the effects of protective actions. It was felt that the exercise had illustrated the problems inherent in radiation emergencies. However, a different situation with larger populations could have led to different results. It was agreed that the exercise had been useful in meeting the need to think about the issues before an accident happens. (au) (12 tabs., 5 ills., 8 refs.)

Aircraft accident investigation: the decision-making in initial action scenario.

Science.gov (United States)

Barreto, Marcia M; Ribeiro, Selma L O

2012-01-01

In the complex aeronautical environment, the efforts in terms of operational safety involve the adoption of proactive and reactive measures. The process of investigation begins right after the occurrence of the aeronautical accident, through the initial action. Thus, it is in the crisis scenario, that the person responsible for the initial action makes decisions and gathers the necessary information for the subsequent phases of the investigation process. Within this scenario, which is a natural environment, researches have shown the fragility of rational models of decision making. The theoretical perspective of naturalistic decision making constitutes a breakthrough in the understanding of decision problems demanded by real world. The proposal of this study was to verify if the initial action, after the occurrence of an accident, and the decision-making strategies, used by the investigators responsible for this activity, are characteristic of the naturalistic decision making theoretical approach. To attend the proposed objective a descriptive research was undertaken with a sample of professionals that work in this activity. The data collected through individual interviews were analyzed and the results demonstrated that the initial action environment, which includes restricted time, dynamic conditions, the presence of multiple actors, stress and insufficient information is characteristic of the naturalistic decision making. They also demonstrated that, when the investigators make their decisions, they use their experience and the mental simulation, intuition, improvisation, metaphors and analogues cases, as strategies, all of them related to the naturalistic approach of decision making, in order to satisfy the needs of the situation and reach the objectives of the initial action in the accident scenario.

Decision aids for multiple-decision disease management as affected by weather input errors.

Science.gov (United States)

Pfender, W F; Gent, D H; Mahaffee, W F; Coop, L B; Fox, A D

2011-06-01

Many disease management decision support systems (DSSs) rely, exclusively or in part, on weather inputs to calculate an indicator for disease hazard. Error in the weather inputs, typically due to forecasting, interpolation, or estimation from off-site sources, may affect model calculations and management decision recommendations. The extent to which errors in weather inputs affect the quality of the final management outcome depends on a number of aspects of the disease management context, including whether management consists of a single dichotomous decision, or of a multi-decision process extending over the cropping season(s). Decision aids for multi-decision disease management typically are based on simple or complex algorithms of weather data which may be accumulated over several days or weeks. It is difficult to quantify accuracy of multi-decision DSSs due to temporally overlapping disease events, existence of more than one solution to optimizing the outcome, opportunities to take later recourse to modify earlier decisions, and the ongoing, complex decision process in which the DSS is only one component. One approach to assessing importance of weather input errors is to conduct an error analysis in which the DSS outcome from high-quality weather data is compared with that from weather data with various levels of bias and/or variance from the original data. We illustrate this analytical approach for two types of DSS, an infection risk index for hop powdery mildew and a simulation model for grass stem rust. Further exploration of analysis methods is needed to address problems associated with assessing uncertainty in multi-decision DSSs.

The Sustained Influence of an Error on Future Decision-Making.

Science.gov (United States)

Schiffler, Björn C; Bengtsson, Sara L; Lundqvist, Daniel

2017-01-01

Post-error slowing (PES) is consistently observed in decision-making tasks after negative feedback. Yet, findings are inconclusive as to whether PES supports performance accuracy. We addressed the role of PES by employing drift diffusion modeling which enabled us to investigate latent processes of reaction times and accuracy on a large-scale dataset (>5,800 participants) of a visual search experiment with emotional face stimuli. In our experiment, post-error trials were characterized by both adaptive and non-adaptive decision processes. An adaptive increase in participants' response threshold was sustained over several trials post-error. Contrarily, an initial decrease in evidence accumulation rate, followed by an increase on the subsequent trials, indicates a momentary distraction of task-relevant attention and resulted in an initial accuracy drop. Higher values of decision threshold and evidence accumulation on the post-error trial were associated with higher accuracy on subsequent trials which further gives credence to these parameters' role in post-error adaptation. Finally, the evidence accumulation rate post-error decreased when the error trial presented angry faces, a finding suggesting that the post-error decision can be influenced by the error context. In conclusion, we demonstrate that error-related response adaptations are multi-component processes that change dynamically over several trials post-error.

The Sustained Influence of an Error on Future Decision-Making

Directory of Open Access Journals (Sweden)

Björn C. Schiffler

2017-06-01

Full Text Available Post-error slowing (PES is consistently observed in decision-making tasks after negative feedback. Yet, findings are inconclusive as to whether PES supports performance accuracy. We addressed the role of PES by employing drift diffusion modeling which enabled us to investigate latent processes of reaction times and accuracy on a large-scale dataset (>5,800 participants of a visual search experiment with emotional face stimuli. In our experiment, post-error trials were characterized by both adaptive and non-adaptive decision processes. An adaptive increase in participants’ response threshold was sustained over several trials post-error. Contrarily, an initial decrease in evidence accumulation rate, followed by an increase on the subsequent trials, indicates a momentary distraction of task-relevant attention and resulted in an initial accuracy drop. Higher values of decision threshold and evidence accumulation on the post-error trial were associated with higher accuracy on subsequent trials which further gives credence to these parameters’ role in post-error adaptation. Finally, the evidence accumulation rate post-error decreased when the error trial presented angry faces, a finding suggesting that the post-error decision can be influenced by the error context. In conclusion, we demonstrate that error-related response adaptations are multi-component processes that change dynamically over several trials post-error.

A strategy to the development of a human error analysis method for accident management in nuclear power plants using industrial accident dynamics

International Nuclear Information System (INIS)

Lee, Yong Hee; Kim, Jae Whan; Jung, Won Dae; Ha, Jae Ju

1998-06-01

This technical report describes the early progress of he establishment of a human error analysis method as a part of a human reliability analysis(HRA) method for the assessment of the human error potential in a given accident management strategy. At first, we review the shortages and limitations of the existing HRA methods through an example application. In order to enhance the bias to the quantitative aspect of the HRA method, we focused to the qualitative aspect, i.e., human error analysis(HEA), during the proposition of a strategy to the new method. For the establishment of a new HEA method, we discuss the basic theories and approaches to the human error in industry, and propose three basic requirements that should be maintained as pre-requisites for HEA method in practice. Finally, we test IAD(Industrial Accident Dynamics) which has been widely utilized in industrial fields, in order to know whether IAD can be so easily modified and extended to the nuclear power plant applications. We try to apply IAD to the same example case and develop new taxonomy of the performance shaping factors in accident management and their influence matrix, which could enhance the IAD method as an HEA method. (author). 33 refs., 17 tabs., 20 figs

Analysis and decision making method for radiation accident situation

International Nuclear Information System (INIS)

Jammet, H.; Hamard, J.

1975-01-01

Decisions on the application of countermeasures for accident situations must take into account the cost of these countermeasures and the feasibility of reducing the exposure. A contribution to the solution of this problem, rested on the application of the principle of choice rationalization and optimization of decision making method, is presented [fr

A decision theoretic approach to an accident sequence: when feedwater and auxiliary feedwater fail in a nuclear power plant

International Nuclear Information System (INIS)

Svenson, Ola

1998-01-01

This study applies a decision theoretic perspective on a severe accident management sequence in a processing industry. The sequence contains loss of feedwater and auxiliary feedwater in a boiling water nuclear reactor (BWR), which necessitates manual depressurization of the reactor pressure vessel to enable low pressure cooling of the core. The sequence is fast and is a major contributor to core damage in probabilistic risk analyses (PRAs) of this kind of plant. The management of the sequence also includes important, difficult and fast human decision making. The decision theoretic perspective, which is applied to a Swedish ABB-type reactor, stresses the roles played by uncertainties about plant state, consequences of different actions and goals during the management of a severe accident sequence. Based on a theoretical analysis and empirical simulator data the human error probabilities in the PRA for the plant are considered to be too small. Recommendations for how to improve safety are given and they include full automation of the sequence, improved operator training, and/or actions to assist the operators' decision making through reduction of uncertainties, for example, concerning water/steam level for sufficient cooling, time remaining before insufficient cooling level in the tank is reached and organizational cost-benefit evaluations of the events following a false alarm depressurization as well as the events following a successful depressurization at different points in time. Finally, it is pointed out that the approach exemplified in this study is applicable to any accident scenario which includes difficult human decision making with conflicting goals, uncertain information and with very serious consequences

A Study on an Accident Diagnosis Methodology Using Influence Diagrams

International Nuclear Information System (INIS)

Kang, Kyungmin; Jae, Moosung

2006-01-01

For nuclear power plants, EOPs help operators to diagnose, control and mitigate accidents. However, it is very difficult that operators follow appropriate EOPs for accidents with similar symptoms in a given short period of time. Also EOPs are very complicated to follow and have many procedures to do. Therefore, if operators cannot diagnose correctly, the accident would become severe. Correct diagnostic action depends on the decision making ability of operators. Therefore, the methodology that can diagnose accidents quickly and help operators follow appropriate procedures should be developed. Due to the complexity of the tasks, it is very important to reduce human errors during diagnostic actions. In this study, to minimize human errors an accident diagnosis model has been constructed based on EOPs, accident symptoms and component reliabilities. For construction of model, Influence Diagrams have been applied. This decision-making tool consists of nodes and arcs. It is applicable to complicated situations, such as those required for developing strategies for managing severe accidents in nuclear power plants. And quantification of model has performed with total probability and Bayesian theorem. Through this quantification, the results should help operators diagnose complex situations

[Cognitive errors in diagnostic decision making].

Science.gov (United States)

Gäbler, Martin

2017-10-01

Approximately 10-15% of our diagnostic decisions are faulty and may lead to unfavorable and dangerous outcomes, which could be avoided. These diagnostic errors are mainly caused by cognitive biases in the diagnostic reasoning process.Our medical diagnostic decision-making is based on intuitive "System 1" and analytical "System 2" diagnostic decision-making and can be deviated by unconscious cognitive biases.These deviations can be positively influenced on a systemic and an individual level. For the individual, metacognition (internal withdrawal from the decision-making process) and debiasing strategies, such as verification, falsification and rule out worst-case scenarios, can lead to improved diagnostic decisions making.

Root cause analysis of JCO accident based on decision-making model

International Nuclear Information System (INIS)

Kohda, Takehisa; Inoue, Koichi; Nojiri, Yoshihiko

2000-01-01

This paper discusses root causes of the JCO accident by considering the reasons why the workers made their decision to choose the illegal actions leading to a criticality accident. Analyzing their decision process compared with the normal decision process, the direct cause of their incorrect decision is estimated to be the lack of knowledge about the danger of nuclear materials and the criticality. Further, the lack of knowledge is considered to be due to organizational or environmental factors such as (a) the ignorance of safety by the overall JCO company which pursued low costs and high profit, (b) the JCO's custom and practice of modifying operational rules without permission, and (c) the JCO's inappropriate training or education where the criticality or its danger was not taught. All these background factors are related to the overconfidence of plant safety, a false trust that such a criticality accident will never occur at the plant. Since the recognition of the danger or risk of a system is considered to be the starting point for its safety management and operation, all information about the danger and safety should be correctly communicated to everyone related to the system. (author)

Error affect inoculation for a complex decision-making task.

Science.gov (United States)

Tabernero, Carmen; Wood, Robert E

2009-05-01

Individuals bring knowledge, implicit theories, and goal orientations to group meetings. Group decisions arise out of the exchange of these orientations. This research explores how a trainee's exploratory and deliberate process (an incremental theory and learning goal orientation) impacts the effectiveness of individual and group decision-making processes. The effectiveness of this training program is compared with another program that included error affect inoculation (EAI). Subjects were 40 Spanish Policemen in a training course. They were distributed in two training conditions for an individual and group decision-making task. In one condition, individuals received the Self-Guided Exploration plus Deliberation Process instructions, which emphasised exploring the options and testing hypotheses. In the other condition, individuals also received instructions based on Error Affect Inoculation (EAI), which emphasised positive affective reactions to errors and mistakes when making decisions. Results show that the quality of decisions increases when the groups share their reasoning. The AIE intervention promotes sharing information, flexible initial viewpoints, and improving the quality of group decisions. Implications and future directions are discussed.

Human Factors in Nuclear Reactor Accidents

International Nuclear Information System (INIS)

Mustafa, M.E.

2016-01-01

While many people would blame nature for the disaster of the “Fukushima Daiichi” accident, experts considered this accident to be also a human-induced disaster. This confirmed the importance of human errors which have been getting a growing interest in the nuclear field after the Three Mile Island accident. Personnel play an important role in design, operation, maintenance, planning, and management. The interface between machine and man is known as a human factor. In the present work, the human factors that have to be considered were discussed. The effect of the control room configuration and equipment design effect on the human behavior was also discussed. Precise reviewing of person’s qualifications and experience was focused. Insufficient training has been a major cause of human error in the nuclear field. The effective training issues were introduced. Avoiding complicated operational processes and non responsive management systems was stressed. Distinguishing between the procedures for normal and emergency operations was emphasised. It was stated that human error during maintenance and testing activities could cause a serious accident. This is because safety systems do not cover much more risk probabilities in the maintenance and testing activities like they do in the normal operation. In nuclear industry, the need for a classification and identification of human errors has been well recognised. As a result of this, human reliability must be assessed. These errors are analyzed by a probabilistic safety assessment which deals with errors in reading, listening and implementing procedures but not with cognitive errors. Much efforts must be accomplished to consider cognitive errors in the probabilistic safety assessment. The ways of collecting human factor data were surveyed. The methods for identifying safe designs, helping decision makers to predict how proposed or current policies will affect safety, and comprehensive understanding of the relationship

Decision model support of severity of injury traffic accident victims care by SAMU 192

Directory of Open Access Journals (Sweden)

Rackynelly Alves Sarmento Soares

2013-01-01

Full Text Available Traffic accidents produce high morbidity and mortality in several countries, including Brazil. The initial care to victims of accidents, by a specialized team, has tools for evaluating the severity of trauma, which guide the priorities. This study aimed to develop a decision model applied to pre-hospital care, using the Abbreviated Injury Scale, to define the severity of the injury caused by the AT, as well to describe the features of accidents and their victims, occurred in Joao Pessoa, Paraiba. This is a descriptive epidemiological investigation, sectional, which analyzed all victims of traffic accidents attended by the SAMU 192, João Pessoa-PB, in January, April and June 2010. Data were collected in the medical regulation sheets of SAMU 192. Most of victims were male (76%, aged between 20 and 39 years (60%. Most injuries were classified as AIS1 (62.5%. The model of decision support implemented was the decision tree that managed to correctly classify 95.98% of the severity of injuries. By this model, it was possible to extract 29 rules of gravity classification of injury, which may be used for decision-making teams of the SAMU 192.

Outbreak Column 16: Cognitive errors in outbreak decision making.

Science.gov (United States)

Curran, Evonne T

2015-01-01

During outbreaks, decisions must be made without all the required information. People, including infection prevention and control teams (IPCTs), who have to make decisions during uncertainty use heuristics to fill the missing data gaps. Heuristics are mental model short cuts that by-and-large enable us to make good decisions quickly. However, these heuristics contain biases and effects that at times lead to cognitive (thinking) errors. These cognitive errors are not made to deliberately misrepresent any given situation; we are subject to heuristic biases when we are trying to perform optimally. The science of decision making is large; there are over 100 different biases recognised and described. Outbreak Column 16 discusses and relates these heuristics and biases to decision making during outbreak prevention, preparedness and management. Insights as to how we might recognise and avoid them are offered.

Using HET taxonomy to help stop human error

OpenAIRE

Li, Wen-Chin; Harris, Don; Stanton, Neville A.; Hsu, Yueh-Ling; Chang, Danny; Wang, Thomas; Young, Hong-Tsu

2010-01-01

Flight crews make positive contributions to the safety of aviation operations. Pilots have to assess continuously changing situations, evaluate potential risks, and make quick decisions. However, even well-trained and experienced pilots make errors. Accident investigations have identified that pilots’ performance is influenced significantly by the design of the flightdeck interface. This research applies hierarchical task analysis (HTA) and utilizes the Human Error Template (HET) taxonomy to ...

Analysis of human error in occupational accidents in the power plant industries using combining innovative FTA and meta-heuristic algorithms

Directory of Open Access Journals (Sweden)

M. Omidvari

2015-09-01

Full Text Available Introduction: Occupational accidents are of the main issues in industries. It is necessary to identify the main root causes of accidents for their control. Several models have been proposed for determining the accidents root causes. FTA is one of the most widely used models which could graphically establish the root causes of accidents. The non-linear function is one of the main challenges in FTA compliance and in order to obtain the exact number, the meta-heuristic algorithms can be used. Material and Method: The present research was done in power plant industries in construction phase. In this study, a pattern for the analysis of human error in work-related accidents was provided by combination of neural network algorithms and FTA analytical model. Finally, using this pattern, the potential rate of all causes was determined. Result: The results showed that training, age, and non-compliance with safety principals in the workplace were the most important factors influencing human error in the occupational accident. Conclusion: According to the obtained results, it can be concluded that human errors can be greatly reduced by training, right choice of workers with regard to the type of occupations, and provision of appropriate safety conditions in the work place.

Development of Human Factor Management Requirements and Human Error Classification for the Prevention of Railway Accident

International Nuclear Information System (INIS)

Kwak, Sang Log; Park, Chan Woo; Shin, Seung Ryoung

2008-08-01

Railway accident analysis results show that accidents cased by human factors are not decreasing, whereas H/W related accidents are steadily decreasing. For the efficient management of human factors, many expertise on design, conditions, safety culture and staffing are required. But current safety management activities on safety critical works are focused on training, due to the limited resource and information. In order to improve railway safety, human factors management requirements for safety critical worker and human error classification is proposed in this report. For this accident analysis, status of safety measure on human factor, safety management system on safety critical worker, current safety planning is analysis

Use of decision trees for evaluating severe accident management strategies in nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Jae, Moosung [Hanyang Univ., Seoul (Korea, Republic of). Dept. of Nuclerar Engineering; Lee, Yongjin; Jerng, Dong Wook [Chung-Ang Univ., Seoul (Korea, Republic of). School of Energy Systems Engineering

2016-07-15

Accident management strategies are defined to innovative actions taken by plant operators to prevent core damage or to maintain the sound containment integrity. Such actions minimize the chance of offsite radioactive substance leaks that lead to and intensify core damage under power plant accident conditions. Accident management extends the concept of Defense in Depth against core meltdown accidents. In pressurized water reactors, emergency operating procedures are performed to extend the core cooling time. The effectiveness of Severe Accident Management Guidance (SAMG) became an important issue. Severe accident management strategies are evaluated with a methodology utilizing the decision tree technique.

A novel framework for improvement of road accidents considering decision-making styles of drivers in a large metropolitan area.

Science.gov (United States)

Azadeh, Ali; Zarrin, Mansour; Hamid, Mehdi

2016-02-01

Road accidents can be caused by different factors such as human factors. Quality of the decision-making process of drivers could have a considerable impact on preventing disasters. The main objective of this study is the analysis of factors affecting road accidents by considering the severity of accidents and decision-making styles of drivers. To this end, a novel framework is proposed based on data envelopment analysis (DEA) and statistical methods (SMs) to assess the factors affecting road accidents. In this study, for the first time, dominant decision-making styles of drivers with respect to severity of injuries are identified. To show the applicability of the proposed framework, this research employs actual data of more than 500 samples in Tehran, Iran. The empirical results indicate that the flexible decision style is the dominant style for both minor and severe levels of accident injuries. Copyright © 2015 Elsevier Ltd. All rights reserved.

Relationship Between Technical Errors and Decision-Making Skills in the Junior Resident.

Science.gov (United States)

Nathwani, Jay N; Fiers, Rebekah M; Ray, Rebecca D; Witt, Anna K; Law, Katherine E; DiMarco, ShannonM; Pugh, Carla M

The purpose of this study is to coevaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there would be significant correlations between scenario-based decision-making skills and technical proficiency in central line insertion. We also predict residents would face problems in anticipating common difficulties and generating solutions associated with line placement. Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real-life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario-based decision-making skills. This study was performed at 7 tertiary care centers. Study participants (N = 46) largely consisted of first-year research residents who could be followed longitudinally. Second-year research and clinical residents were not excluded. In total, 6 checklist errors were committed more often than anticipated. Residents committed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44) = 3.82, p technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r (33) = -0.429, p = 0.021, r (33) = -0.383, p = 0.044, respectively). Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision-making skills suggests a critical need to train residents in both technique and error management. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Stakeholder involvement facilitates decision making for UK nuclear accident recovery.

Science.gov (United States)

Alexander, C; Burt, R; Nisbet, A F

2005-01-01

The importance of major stakeholders participating in the formulation of strategies for maintaining food safety and agricultural production following a nuclear accident has been successfully demonstrated by the UK 'Agriculture and Food Countermeasures Working Group' (AFCWG). The organisation, membership and terms of reference of the group are described. Details are given of the achievements of the AFCWG and its sub-groups, which include agreeing management options that would be included in a recovery handbook for decision-makers in the UK and tackling the disposal of large volumes of contaminated milk, potentially resulting from a nuclear accident.

Analysis of Human Errors in Industrial Incidents and Accidents for Improvement of Work Safety

DEFF Research Database (Denmark)

Leplat, J.; Rasmussen, Jens

1984-01-01

Methods for the analysis of work accidents are discussed, and a description is given of the use of a causal situation analysis in terms of a 'variation tree' in order to explain the course of events of the individual cases and to identify possible improvements. The difficulties in identifying...... 'causes' of accidents are discussed, and it is proposed to analyze accident reports with the specific aim of identifying the potential for future improvements rather than causes of past events. In contrast to traditional statistical analysis of work accident data, which typically give very general...... recommendations, the method proposed identifies very explicit countermeasures. Improvements require a change in human decisions during equipment design, work planning, or the execution itself. The use of a model of human behavior drawing a distinction between automated skill-based behavior, rule-based 'know...

Selection of the important performance influencing factors for the assessment of human error under accident management situations in nuclear power plants

International Nuclear Information System (INIS)

Kim, J. H.; Jung, W. J.

1999-01-01

This paper introduces the process and final results of selection of the important Performance Influencing Factors (PIFs) under emergency operation and accident management situations in nuclear power plants for use in the assessment of human errors. We collected two types of PIF taxonomies, one is the full set PIF list mainly developed for human error analysis, and the other is the PIFs for human reliability analysis (HRA) in probabilistic safety assessment (PSA). 5 PIF taxonomies among the full set PIF list and 10 PIF taxonomies among HRA methodologies (CREAM, SLIM, INTENT, were collected in this research. By reviewing and analyzing PIFs selected for HRA methodologies, the criterion could be established for the selection of appropriate PIFs under emergency operation and accident management situations. Based on this selection criteria, a new PIF taxonomy was proposed for the assessment of human error under emergency operation and accident management situations in nuclear power plants

A trend analysis of human error events for proactive prevention of accidents. Methodology development and effective utilization

International Nuclear Information System (INIS)

Hirotsu, Yuko; Ebisu, Mitsuhiro; Aikawa, Takeshi; Matsubara, Katsuyuki

2006-01-01

This paper described methods for analyzing human error events that has been accumulated in the individual plant and for utilizing the result to prevent accidents proactively. Firstly, a categorization framework of trigger action and causal factors of human error events were reexamined, and the procedure to analyze human error events was reviewed based on the framework. Secondly, a method for identifying the common characteristics of trigger action data and of causal factor data accumulated by analyzing human error events was clarified. In addition, to utilize the results of trend analysis effectively, methods to develop teaching material for safety education, to develop the checkpoints for the error prevention and to introduce an error management process for strategic error prevention were proposed. (author)

Application of improved topsis method to accident emergency decision-making at nuclear power station

International Nuclear Information System (INIS)

Zhang Jin; Cai Qi; Zhang Fan; Chang Ling

2009-01-01

Given the complexity in multi-attribute decision-making on nuclear accident emergency, and by integrating subjective weight and impersonal weight of each evaluating index, a decision-making model for emergency plan at nuclear power stations is established with the application of improved TOPSIS model. The testing results indicated that the improved TOPSIS-based multi-attribute decision-making has a better assessment results. (authors)

Techniques and decision making in the assessment of off-site consequences of an accident in a nuclear facility

International Nuclear Information System (INIS)

1987-01-01

This Guide is intended to complement the IAEA's existing technical guidance on emergency planning and preparedness by providing information and practical guidance related to the assessment of off-site consequences of an accident in a nuclear or radioactive materials installation and to the decision making process in implementing protective measures. This Guide contains information on emergency response philosophy, fundamental factors affecting accident consequences, principles of accident assessment, data acquisition and handling, systems, techniques and decision making principles. Many of the accident assessment concepts presented are considerably more advanced than some of those that now pertain in most countries. They could, if properly interpreted, developed and applied, significantly improve emergency response in the early and intermediate phases of an accident. Furthermore, they are considered to be applicable to a broad range of serious nuclear accidents and radiological emergencies. The extent of their application is governed by both the scale of the accident and by the availability of preplanned resources for accident assessment and emergency response. 68 refs, 28 figs, 14 tabs

Scientific decision of the Chernobyl accident problems (results of 1997)

International Nuclear Information System (INIS)

Konoplya, E.F.; Rolevich, I.V.

1998-12-01

In the publication are summarized the basic results of the researches executed in 1997 in the framework of the 'Scientific maintenance of the decision of problems of the Chernobyl NPP accident consequences' of the State program of Republic of Belarus for minimization and overcoming of the Chernobyl NPP accident consequences on 1996-2000 on the following directions: dose monitoring of the population, estimation and forecast of both collective irradiation dozes and risks of radiation induced diseases; development and ground of the measures for increase of radiation protection of the population of Belarus during of the reducing period after the Chernobyl accident; study of influence of radiological consequences of the Chernobyl accident on health of people, development of methods and means of diagnostics, treatment and preventive maintenance of diseases for various categories of the victims; optimisation of the system of measures for preservation of health of the victim population and development of ways for increase of it effectiveness; creation of the effective both prophylactic means and food additives for treatment and rehabilitation of the persons having suffered after the Chernobyl accident; development of complex system of an estimation and decision-making on problems of radiation protection of the population living on contaminated territories; development and optimization of a complex of measures for effective land use and decrease of radioactive contamination of agricultural production in order to reduce irradiation dozes of the population; development of complex technologies and means of decontamination, treatment and burial of radioactive wastes; study of the radioisotopes behaviour dynamics in environment (air, water, ground), ecosystems and populated areas; optimization of the system of radiation ecological monitoring in the republic and scientific methodical ways of it fulfilling; study of effects of low doze irradiation and combined influences, search

Decision support systems for major accident prevention in the chemical process industry : A developers' survey

NARCIS (Netherlands)

Reniers, Genserik L L; Ale, B. J.M.; Dullaert, W.; Foubert, B.

2006-01-01

Solid major accident prevention management is characterized by efficient and effective risk assessments. As a means of addressing the efficiency aspect, decision support analysis software is becoming increasingly available. This paper discusses the results of a survey of decision support tools for

Decision Aids for Multiple-Decision Disease Management as Affected by Weather Input Errors

Science.gov (United States)

Many disease management decision support systems (DSS) rely, exclusively or in part, on weather inputs to calculate an indicator for disease hazard. Error in the weather inputs, typically due to forecasting, interpolation or estimation from off-site sources, may affect model calculations and manage...

New technology for accident prevention

Energy Technology Data Exchange (ETDEWEB)

Byne, P. [Shiftwork Solutions, Vancouver, BC (Canada)

2006-07-01

This power point presentation examined the effects of fatigue in the workplace and presented 3 technologies designed to prevent or monitor fatigue. The relationship between mental fatigue, circadian rhythms and cognitive performance was explored. Details of vigilance related degradations in the workplace were presented, as well as data on fatigue-related accidents and a time-line of meter-reading errors. It was noted that the direct cause of the Exxon Valdez disaster was sleep deprivation. Fatigue related accidents during the Gulf War were reviewed. The effects of fatigue on workplace performance include impaired logical reasoning and decision-making; impaired vigilance and attention; slowed mental operations; loss of situational awareness; slowed reaction time; and short cuts and lapses in optional or self-paced behaviours. New technologies to prevent fatigue-related accidents include (1) the driver fatigue monitor, an infra-red camera and computer that tracks a driver's slow eye-lid closures to prevent fatigue related accidents; (2) a fatigue avoidance scheduling tool (FAST) which collects actigraphs of sleep activity; and (3) SAFTE, a sleep, activity, fatigue and effectiveness model. refs., tabs., figs.

Defining criteria related to wastes for use in multi-criteria decision tool for nuclear accidents

Energy Technology Data Exchange (ETDEWEB)

Silva, Diogo N.G.; Guimaraes, Jean R.D., E-mail: dneves@biof.ufrj.br, E-mail: jeanrdg@biof.ufrj.br [Universidade Federal do Rio de Janeiro (UFRJ), RJ (Brazil). Instituto de Biofisica Carlos Chagas Filho; Rochedo, Elaine R.R.; De Luca, Christiano, E-mail: elainerochedo@gmail.com, E-mail: christiano_luca@hotmail.com [Instituto Militar de Engenharia (IME), Rio de Janeiro, RJ (Brazil). Programa de Engenharia Nuclear; Rochedo, Pedro R.R., E-mail: rochedopedro@gmail.com [Universidade Federal do Rio de Janeiro (UFRJ), RJ (Brazil). Instituto Alberto Luiz Coimbra de Pos-Graduacao e Pesquisa de Engenharia

2013-07-01

The selection of protective measures and strategies for remediation of contaminated areas after a nuclear accident must be based on previously established criteria in order to prevent stress of the population and the unnecessary exposure of workers. After a nuclear accident resulting in environmental contamination, decisions on remediation of areas is complex due to the large numbers of factors involved in decontamination processes. This work is part of a project which aims to develop a multi-criteria tool to support a decision-making process in cases of a radiological or a nuclear accident in Brazil. First, a database of remediation strategies for contaminated areas was created. In this process, the most relevant aspects for the implementation of these strategies were considered, including technical criteria regarding aspects related to the generation of wastes in a reference urban area, which are discussed in this paper. The specific objective of this study is to define criteria for the aspects of radioactive wastes, resulted by the implementation of some urban measures, in order to be incorporated in a multi-criteria decision tool. Main aspects considered were the type, the amount and the type of treatment necessary for each procedure. The decontamination procedures are then classified according to the selected criteria in order to feed the multi-criteria decision tool. This paper describes the steps for the establishment of these criteria and evaluates the potential for future applications in order to improve predictions and to support the decisions to be made. (author)

Defining criteria related to wastes for use in multi-criteria decision tool for nuclear accidents

International Nuclear Information System (INIS)

Silva, Diogo N.G.; Guimaraes, Jean R.D.; Rochedo, Elaine R.R.; De Luca, Christiano; Rochedo, Pedro R.R.

2013-01-01

The selection of protective measures and strategies for remediation of contaminated areas after a nuclear accident must be based on previously established criteria in order to prevent stress of the population and the unnecessary exposure of workers. After a nuclear accident resulting in environmental contamination, decisions on remediation of areas is complex due to the large numbers of factors involved in decontamination processes. This work is part of a project which aims to develop a multi-criteria tool to support a decision-making process in cases of a radiological or a nuclear accident in Brazil. First, a database of remediation strategies for contaminated areas was created. In this process, the most relevant aspects for the implementation of these strategies were considered, including technical criteria regarding aspects related to the generation of wastes in a reference urban area, which are discussed in this paper. The specific objective of this study is to define criteria for the aspects of radioactive wastes, resulted by the implementation of some urban measures, in order to be incorporated in a multi-criteria decision tool. Main aspects considered were the type, the amount and the type of treatment necessary for each procedure. The decontamination procedures are then classified according to the selected criteria in order to feed the multi-criteria decision tool. This paper describes the steps for the establishment of these criteria and evaluates the potential for future applications in order to improve predictions and to support the decisions to be made. (author)

Human errors and mistakes

International Nuclear Information System (INIS)

Wahlstroem, B.

1993-01-01

Human errors have a major contribution to the risks for industrial accidents. Accidents have provided important lesson making it possible to build safer systems. In avoiding human errors it is necessary to adapt the systems to their operators. The complexity of modern industrial systems is however increasing the danger of system accidents. Models of the human operator have been proposed, but the models are not able to give accurate predictions of human performance. Human errors can never be eliminated, but their frequency can be decreased by systematic efforts. The paper gives a brief summary of research in human error and it concludes with suggestions for further work. (orig.)

Planning for large-scale accidents: learning from the Three Mile Island accident

International Nuclear Information System (INIS)

Fischer, D.W.

1981-01-01

Decision-making issues raised at the Three Mile Island nuclear accident in Pennsylvania are explored. The organizations involved, their interconnections, and decisions are described. The underlying issues bearing on allocation of effort to pre-accident planning and actual accident responses are also noted. Finally, a framework from this effort is used for guiding the planning of operations for future accidents. (author)

Evaluation of decision support systems for nuclear accidents

International Nuclear Information System (INIS)

Sdouz, G.; Mueck, K.

1998-05-01

In order to adopt countermeasures to protect the public after an accident in a nuclear power plant in an appropriate and optimum way, decision support systems offer a valuable assistance in supporting the decision maker in choosing and optimizing protective actions. Such decision support systems may range from simple systems to accumulate relevant parameters for the evaluation of the situation over prediction models for the rapid evaluation of the dose to be expected to systems which permit the evaluation and comparison of possible countermeasures. Since the establishment of a decision support systems obviously is also required in Austria, an evaluation of systems available or in the state of development in other countries or unions was performed. The aim was to determine the availability of decision support systems in various countries and to evaluate them with regard to depth and extent of the system. The evaluation showed that in most industrialized countries the requirement for a decision support system was realized, but in only few countries actual systems are readily available and operable. Most systems are limited to early phase consequences, i.e. dispersion calculations of calculated source terms and the estimation of exposure in the vicinity of the plant. Only few systems offer the possibility to predict long-term exposures by ingestion. Few systems permit also an evaluation of potential countermeasures, in most cases, however, limited to a few short-term countermeasures. Only one system which is presently not operable allows the evaluation of a large number of agricultural countermeasures. In this report the different systems are compared. The requirements with regard to an Austrian decision support system are defined and consequences for a possible utilization of a DSS or parts thereof for the Austrian decision support system are derived. (author)

ReSCA: decision support tool for remediation planning after the Chernobyl accident.

Science.gov (United States)

Ulanovsky, A; Jacob, P; Fesenko, S; Bogdevitch, I; Kashparov, V; Sanzharova, N

2011-03-01

Radioactive contamination of the environment following the Chernobyl accident still provide a substantial impact on the population of affected territories in Belarus, Russia, and Ukraine. Reduction of population exposure can be achieved by performing remediation activities in these areas. Resulting from the IAEA Technical Co-operation Projects with these countries, the program ReSCA (Remediation Strategies after the Chernobyl Accident) has been developed to provide assistance to decision makers and to facilitate a selection of an optimized remediation strategy in rural settlements. The paper provides in-depth description of the program, its algorithm, and structure. © Springer-Verlag 2010

Rade-aid a decision support system to evaluate countermeasures after a radiological accident

International Nuclear Information System (INIS)

Wagenaar, G.; Van Den Bosch, C.J.H.; Weger, D. de.

1990-01-01

After Chernobyl the authorities in many countries were overwhelmed by the enormous amount of information that was being generated by measuring and monitoring programs. In making decisions, this information had to be combined with the results of specific countermeasures, in order to determine the optimal strategy with respect to a large number of consequences. The development of RADE-AID, the Radiological Accident Decision AIDing system, is aimed at providing a powerful tool in the decision-making process. RADE-AID is developed by TNO (The Netherlands) in a joint contract with KfK (FRG) and NRPB (UK). In the first phase a demonstration system will be built, called RADE-AID/D. RADE-AID/D will be used as a decision support system in the intermediate and late phase after a radiological accident. RADE-AID/D will consider countermeasures with respect to external exposure and internal exposure by food ingestion. Countermeasures are evaluated considering reduction in doses and in numbers of health effects, costs, and social effects. The paper covers the structure of the program, presentation of data and results, and the decision analysis technique that is being used. This decision analysis part is an important feature of the system; an advanced decision analysis technique is used, that is able to compare data of varying nature. Furthermore the place of RADE-AID in the decision-making process will be treated. RADE-AID/D is an interactive computer program, that offers the user the possibility to enter relevant data and to have data and results displayed in a variety of ways. Furthermore the system contains an advanced decision analysis technique, that is able to compare data of varying nature. Input data for the decision analysis calculations are provided by models from UFOMOD and MARC-codes

Tools to support important technical decisions during accident conditions

International Nuclear Information System (INIS)

Tenschert, J.; Bergiers, C.

2008-01-01

To handle design basis and beyond design basis accidents with intact reactor core, Nuclear Power Plants are using Emergency Operating Procedures (EOP) that they may have developed based on the generic Westinghouse Emergency Response Guidelines. Even though the EOPs are very directive, some questions are left to external support, i.e. to a team of persons constituting the so-called Technical Support Center (TSC). The Pressurized Water Reactor Owner Group (PWROG, previously Westinghouse Owner Group, WOG) has developed a TSC manual to support this group in their decision making process. Because of the specific and particular design of the Beznau NPP (KKB) Safety Systems, development of a plant-specific TSC manual required a lot of additions compared to the generic material. This plant-specific TSC manual is a helpful tool for the Site Emergency Director (SED) of the KKB to better evaluate issues and potential concerns arising while executing the EOPs. The majority of considered issues are relevant for beyond design basis accidents and external events. (orig.)

A Grounded Theory Study of Aircraft Maintenance Technician Decision-Making

Science.gov (United States)

Norcross, Robert

Aircraft maintenance technician decision-making and actions have resulted in aircraft system errors causing aircraft incidents and accidents. Aircraft accident investigators and researchers examined the factors that influence aircraft maintenance technician errors and categorized the types of errors in an attempt to prevent similar occurrences. New aircraft technology introduced to improve aviation safety and efficiency incur failures that have no information contained in the aircraft maintenance manuals. According to the Federal Aviation Administration, aircraft maintenance technicians must use only approved aircraft maintenance documents to repair, modify, and service aircraft. This qualitative research used a grounded theory approach to explore the decision-making processes and actions taken by aircraft maintenance technicians when confronted with an aircraft problem not contained in the aircraft maintenance manuals. The target population for the research was Federal Aviation Administration licensed aircraft and power plant mechanics from across the United States. Nonprobability purposeful sampling was used to obtain aircraft maintenance technicians with the experience sought in the study problem. The sample population recruitment yielded 19 participants for eight focus group sessions to obtain opinions, perceptions, and experiences related to the study problem. All data collected was entered into the Atlas ti qualitative analysis software. The emergence of Aircraft Maintenance Technician decision-making themes regarding Aircraft Maintenance Manual content, Aircraft Maintenance Technician experience, and legal implications of not following Aircraft Maintenance Manuals surfaced. Conclusions from this study suggest Aircraft Maintenance Technician decision-making were influenced by experience, gaps in the Aircraft Maintenance Manuals, reliance on others, realizing the impact of decisions concerning aircraft airworthiness, management pressures, and legal concerns

Challenge and Error: Critical Events and Attention-Related Errors

Science.gov (United States)

Cheyne, James Allan; Carriere, Jonathan S. A.; Solman, Grayden J. F.; Smilek, Daniel

2011-01-01

Attention lapses resulting from reactivity to task challenges and their consequences constitute a pervasive factor affecting everyday performance errors and accidents. A bidirectional model of attention lapses (error [image omitted] attention-lapse: Cheyne, Solman, Carriere, & Smilek, 2009) argues that errors beget errors by generating attention…

Nuclear power plant personnel errors in decision-making as an object of probabilistic risk assessment

International Nuclear Information System (INIS)

Reer, B.

1993-09-01

The integration of human error - also called man-machine system analysis (MMSA) - is an essential part of probabilistic risk assessment (PRA). A new method is presented which allows for a systematic and comprehensive PRA inclusions of decision-based errors due to conflicts or similarities. For the error identification procedure, new question techniques are developed. These errors are shown to be identified by looking at retroactions caused by subordinate goals as components of the overall safety relevant goal. New quantification methods for estimating situation-specific probabilities are developed. The factors conflict and similarity are operationalized in a way that allows their quantification based on informations which are usually available in PRA. The quantification procedure uses extrapolations and interpolations based on a poor set of data related to decision-based errors. Moreover, for passive errors in decision-making a completely new approach is presented where errors are quantified via a delay initiating the required action rather than via error probabilities. The practicability of this dynamic approach is demonstrated by a probabilistic analysis of the actions required during the total loss of feedwater event at the Davis-Besse plant 1985. The extensions of the ''classical'' PRA method developed in this work are applied to a MMSA of the decay heat removal (DHR) of the ''HTR-500''. Errors in decision-making - as potential roots of extraneous acts - are taken into account in a comprehensive and systematic manner. Five additional errors are identified. However, the probabilistic quantification results a nonsignificant increase of the DHR failure probability. (orig.) [de

The Impact of Severe Nuclear Accidents on National Decision for Nuclear Decommissioning

International Nuclear Information System (INIS)

Suh, Young A; Hornibrook, Carol; Yim, Man Sung

2016-01-01

Many researchers have tried to identify the impact of severe nuclear accidents on a country's or international nuclear energy policy [2-3]. However, there is little research on the influence of nuclear accidents and historical events on a country's decision to permanently shutdown an NPP versus international nuclear decommissioning trends. To demonstrate the correlation between a nuclear severe accident and the impact on world nuclear decommissioning, this research reviewed case studies of individual historical events, such as the St. Lucens, TMI, Chernobyl, Fukushima accidents and the series of events leading up to the collapse of the Soviet Union. For validation of the results of these case studies, a statistical analysis was conducted using the R code. This will be useful in explaining how international and national decommissioning strategies are affected by shutdown reasons, i.e. world historical events. The number of permanently shutdown NPPs was selected as an indicator because any relationship between the number of permanently In conclusion, nuclear severe accidents and historical events have an impact on the number of international NPPs that shutdown permanently and cancelled NPP construction. This directly impacts international nuclear decommissioning policy and nuclear energy policy trends. The number of permanently shutdown NPPs was selected as an indicator because any relationship between the number of permanently

Human errors, countermeasures for their prevention and evaluation

International Nuclear Information System (INIS)

Kohda, Takehisa; Inoue, Koichi

1992-01-01

The accidents originated in human errors have occurred as ever in recent large accidents such as the TMI accident and the Chernobyl accident. The proportion of the accidents originated in human errors is unexpectedly high, therefore, the reliability and safety of hardware are improved hereafter, but the improvement of human reliability cannot be expected. Human errors arise by the difference between the function required for men and the function actually accomplished by men, and the results exert some adverse effect to systems. Human errors are classified into design error, manufacture error, operation error, maintenance error, checkup error and general handling error. In terms of behavior, human errors are classified into forget to do, fail to do, do that must not be done, mistake in order and do at improper time. The factors in human error occurrence are circumstantial factor, personal factor and stress factor. As the method of analyzing and evaluating human errors, system engineering method such as probabilistic risk assessment is used. The technique for human error rate prediction, the method for human cognitive reliability, confusion matrix and SLIM-MAUD are also used. (K.I.)

Decision making process and emergency management in different phases of a nuclear accident

International Nuclear Information System (INIS)

Duranova, T.

2005-01-01

EVATECH, Information Requirements and Countermeasure Evaluation Techniques in Nuclear Emergency Management, was a research project in the key action 'Nuclear Fission' of the fifth EURATOM Framework Programme (FP5). The overall objective of the project was to enhance the quality and coherence of response to nuclear emergencies in Europe by improving the decision support methods, models and processes in ways that take into account the expectations and concern of the many different parties involved - stake holders both in managing the emergency response and those who are affected by the consequences of nuclear emergencies. The project had ten partners from seven European countries. The development of the real-time online decision support system RODOS has been one of the major items in the area of radiation protection within the European Commission's Framework Programmes. The main objectives of the RODOS project have been to develop a comprehensive and integrated decision support system that is generally applicable across Europe and to provide a common framework for incorporating the best features of existing decision support systems and future developments. Furthermore the objective has been to provide greater transparency in the decision process to: improve public understanding and acceptance of off-site emergency measures, to facilitate improved communication between countries of monitoring data, predictions of consequences, etc., in the event of any future accident, and to promote, through the development and use of the system, a more coherent, consistent and harmonised response to any future accident that may affect Europe. (authors)

Frame-based safety analysis approach for decision-based errors

International Nuclear Information System (INIS)

Fan, Chin-Feng; Yihb, Swu

1997-01-01

A frame-based approach is proposed to analyze decision-based errors made by automatic controllers or human operators due to erroneous reference frames. An integrated framework, Two Frame Model (TFM), is first proposed to model the dynamic interaction between the physical process and the decision-making process. Two important issues, consistency and competing processes, are raised. Consistency between the physical and logic frames makes a TFM-based system work properly. Loss of consistency refers to the failure mode that the logic frame does not accurately reflect the state of the controlled processes. Once such failure occurs, hazards may arise. Among potential hazards, the competing effect between the controller and the controlled process is the most severe one, which may jeopardize a defense-in-depth design. When the logic and physical frames are inconsistent, conventional safety analysis techniques are inadequate. We propose Frame-based Fault Tree; Analysis (FFTA) and Frame-based Event Tree Analysis (FETA) under TFM to deduce the context for decision errors and to separately generate the evolution of the logical frame as opposed to that of the physical frame. This multi-dimensional analysis approach, different from the conventional correctness-centred approach, provides a panoramic view in scenario generation. Case studies using the proposed techniques are also given to demonstrate their usage and feasibility

Wrong decisions in radiology. Analysis of causes and strategies for error prevention

International Nuclear Information System (INIS)

Lackner, Klaus-Juergen; Krug, Kathrin Barbara

2009-01-01

The book covers observations on errors concerning radiological decisions within a ten-year period. The compiled information is supposed to prevent similar errors in the future. The case studies cover the following issues: cranium, thorax, mamma, abdomen (liver, pancreas, colon), (gastrointestinal tract, urogenital tract), spinal cord, skeleton and blood vessels.

The Impact of Severe Nuclear Accidents on National Decision for Nuclear Decommissioning

Energy Technology Data Exchange (ETDEWEB)

Suh, Young A; Hornibrook, Carol; Yim, Man Sung [KAIST, Daejeon (Korea, Republic of)

2016-05-15

Many researchers have tried to identify the impact of severe nuclear accidents on a country's or international nuclear energy policy [2-3]. However, there is little research on the influence of nuclear accidents and historical events on a country's decision to permanently shutdown an NPP versus international nuclear decommissioning trends. To demonstrate the correlation between a nuclear severe accident and the impact on world nuclear decommissioning, this research reviewed case studies of individual historical events, such as the St. Lucens, TMI, Chernobyl, Fukushima accidents and the series of events leading up to the collapse of the Soviet Union. For validation of the results of these case studies, a statistical analysis was conducted using the R code. This will be useful in explaining how international and national decommissioning strategies are affected by shutdown reasons, i.e. world historical events. The number of permanently shutdown NPPs was selected as an indicator because any relationship between the number of permanently In conclusion, nuclear severe accidents and historical events have an impact on the number of international NPPs that shutdown permanently and cancelled NPP construction. This directly impacts international nuclear decommissioning policy and nuclear energy policy trends. The number of permanently shutdown NPPs was selected as an indicator because any relationship between the number of permanently.

Research trend on human error reduction

International Nuclear Information System (INIS)

Miyaoka, Sadaoki

1990-01-01

Human error has been the problem in all industries. In 1988, the Bureau of Mines, Department of the Interior, USA, carried out the worldwide survey on the human error in all industries in relation to the fatal accidents in mines. There was difference in the results according to the methods of collecting data, but the proportion that human error took in the total accidents distributed in the wide range of 20∼85%, and was 35% on the average. The rate of occurrence of accidents and troubles in Japanese nuclear power stations is shown, and the rate of occurrence of human error is 0∼0.5 cases/reactor-year, which did not much vary. Therefore, the proportion that human error took in the total tended to increase, and it has become important to reduce human error for lowering the rate of occurrence of accidents and troubles hereafter. After the TMI accident in 1979 in USA, the research on man-machine interface became active, and after the Chernobyl accident in 1986 in USSR, the problem of organization and management has been studied. In Japan, 'Safety 21' was drawn up by the Advisory Committee for Energy, and also the annual reports on nuclear safety pointed out the importance of human factors. The state of the research on human factors in Japan and abroad and three targets to reduce human error are reported. (K.I.)

[Recreational boating accidents--Part 1: Catamnestic study].

Science.gov (United States)

Lignitz, Eberhard; Lustig, Martina; Scheibe, Ernst

2014-01-01

Deaths on the water are common in the autopsy material of medicolegal institutes situated on the coast or big rivers and lakes (illustrated by the example of the Institute of Legal Medicine of Greifswald University). They mostly occur during recreational boating activities. Apart from hydro-meteorological influences, human error is the main cause of accidents. Often it is not sufficiently kept in mind whether the boat crew is fit for sailing and proper seamanship is ensured. Drowning (following initial hypothermia) is the most frequent cause of death. Medicolegal aspects are not decisive for ordering a forensic autopsy. As statistics are not compiled in a uniform way, a comparison of the data of different institutions engaged in investigating deaths at sea and during water sports activities is hardly possible, neither on a national nor an international basis--and the reconstruction of aquatic accidents is generally difficult. Fatal accidents can only be prevented by completely clarifying their causes.

Quantifying human and organizational factors in accident management using decision trees: the HORAAM method

International Nuclear Information System (INIS)

Baumont, G.; Menage, F.; Schneiter, J.R.; Spurgin, A.; Vogel, A.

2000-01-01

In the framework of the level 2 Probabilistic Safety Study (PSA 2) project, the Institute for Nuclear Safety and Protection (IPSN) has developed a method for taking into account Human and Organizational Reliability Aspects during accident management. Actions are taken during very degraded installation operations by teams of experts in the French framework of Crisis Organization (ONC). After describing the background of the framework of the Level 2 PSA, the French specific Crisis Organization and the characteristics of human actions in the Accident Progression Event Tree, this paper describes the method developed to introduce in PSA the Human and Organizational Reliability Analysis in Accident Management (HORAAM). This method is based on the Decision Tree method and has gone through a number of steps in its development. The first one was the observation of crisis center exercises, in order to identify the main influence factors (IFs) which affect human and organizational reliability. These IFs were used as headings in the Decision Tree method. Expert judgment was used in order to verify the IFs, to rank them, and to estimate the value of the aggregated factors to simplify the quantification of the tree. A tool based on Mathematica was developed to increase the flexibility and the efficiency of the study

A methodology for supporting decisions on the establishment of protective measures after severe nuclear accidents

International Nuclear Information System (INIS)

Papazoglou, I.A.; Kollas, J.G.

1994-06-01

The objective of this report is to demonstrate the use of a methology supporting decisions on protective measures following severe nuclear accidents. A multicriteria decision analysis approach is recommended where value tradeoffs are postponed until the very last stage of the decision process. Use of efficient frontiers is made to exclude all technically inferior solutions and present the decision maker with all nondominated solutions. A choice among these solutions implies a value trade-off among the multiple criteria. An interactive computer packge has been developed where the decision maker can choose a point on the efficient frontier in the consequence space and immediately see the alternative in the decision space resulting in the chosen consequences. The methodology is demonstrated through an application on the choice among possible protective measures in contaminated areas of the former USSR after the Chernobyl accident. Two distinct cases are considered: First a decision is to be made only on the basis of the level of soil contamination with Cs-137 and the total cost of the chosen protective policy; Next the decision is based on the geographic dimension of the contamination ant the total cost. Three alternative countermeasure actions are considered for population segments living on soil contaminated at a certain level or in a specific geographic region: (a) relocation of the population; (b) improvement of the living conditions; and, (c) no countermeasures at all. This is final deliverable of the CEC-CIS Joint Study Project 2, Task 5: Decision-Aiding-System for Establishing Intervention Levels, performed under Contracts COSU-CT91-0007 and COSU-CT92-0021 with the Commission of European Communities through CEPN

Feasibility of neuro-morphic computing to emulate error-conflict based decision making.

Energy Technology Data Exchange (ETDEWEB)

Branch, Darren W.

2009-09-01

A key aspect of decision making is determining when errors or conflicts exist in information and knowing whether to continue or terminate an action. Understanding the error-conflict processing is crucial in order to emulate higher brain functions in hardware and software systems. Specific brain regions, most notably the anterior cingulate cortex (ACC) are known to respond to the presence of conflicts in information by assigning a value to an action. Essentially, this conflict signal triggers strategic adjustments in cognitive control, which serve to prevent further conflict. The most probable mechanism is the ACC reports and discriminates different types of feedback, both positive and negative, that relate to different adaptations. Unique cells called spindle neurons that are primarily found in the ACC (layer Vb) are known to be responsible for cognitive dissonance (disambiguation between alternatives). Thus, the ACC through a specific set of cells likely plays a central role in the ability of humans to make difficult decisions and solve challenging problems in the midst of conflicting information. In addition to dealing with cognitive dissonance, decision making in high consequence scenarios also relies on the integration of multiple sets of information (sensory, reward, emotion, etc.). Thus, a second area of interest for this proposal lies in the corticostriatal networks that serve as an integration region for multiple cognitive inputs. In order to engineer neurological decision making processes in silicon devices, we will determine the key cells, inputs, and outputs of conflict/error detection in the ACC region. The second goal is understand in vitro models of corticostriatal networks and the impact of physical deficits on decision making, specifically in stressful scenarios with conflicting streams of data from multiple inputs. We will elucidate the mechanisms of cognitive data integration in order to implement a future corticostriatal-like network in silicon

Construction of a technique plan repository and evaluation system based on AHP group decision-making for emergency treatment and disposal in chemical pollution accidents

International Nuclear Information System (INIS)

Shi, Shenggang; Cao, Jingcan; Feng, Li; Liang, Wenyan; Zhang, Liqiu

2014-01-01

Highlights: • Different chemical pollution accidents were simplified using the event tree analysis. • Emergency disposal technique plan repository of chemicals accidents was constructed. • The technique evaluation index system of chemicals accidents disposal was developed. • A combination of group decision and analytical hierarchy process (AHP) was employed. • Group decision introducing similarity and diversity factor was used for data analysis. - Abstract: The environmental pollution resulting from chemical accidents has caused increasingly serious concerns. Therefore, it is very important to be able to determine in advance the appropriate emergency treatment and disposal technology for different types of chemical accidents. However, the formulation of an emergency plan for chemical pollution accidents is considerably difficult due to the substantial uncertainty and complexity of such accidents. This paper explains how the event tree method was used to create 54 different scenarios for chemical pollution accidents, based on the polluted medium, dangerous characteristics and properties of chemicals involved. For each type of chemical accident, feasible emergency treatment and disposal technology schemes were established, considering the areas of pollution source control, pollutant non-proliferation, contaminant elimination and waste disposal. Meanwhile, in order to obtain the optimum emergency disposal technology schemes as soon as the chemical pollution accident occurs from the plan repository, the technique evaluation index system was developed based on group decision-improved analytical hierarchy process (AHP), and has been tested by using a sudden aniline pollution accident that occurred in a river in December 2012

Construction of a technique plan repository and evaluation system based on AHP group decision-making for emergency treatment and disposal in chemical pollution accidents

Energy Technology Data Exchange (ETDEWEB)

Shi, Shenggang [College of Environmental Science and Engineering, Beijing Forestry University, Beijing 100083 (China); College of Chemistry, Baotou Teachers’ College, Baotou 014030 (China); Cao, Jingcan; Feng, Li; Liang, Wenyan [College of Environmental Science and Engineering, Beijing Forestry University, Beijing 100083 (China); Zhang, Liqiu, E-mail: zhangliqiu@163.com [College of Environmental Science and Engineering, Beijing Forestry University, Beijing 100083 (China)

2014-07-15

Highlights: • Different chemical pollution accidents were simplified using the event tree analysis. • Emergency disposal technique plan repository of chemicals accidents was constructed. • The technique evaluation index system of chemicals accidents disposal was developed. • A combination of group decision and analytical hierarchy process (AHP) was employed. • Group decision introducing similarity and diversity factor was used for data analysis. - Abstract: The environmental pollution resulting from chemical accidents has caused increasingly serious concerns. Therefore, it is very important to be able to determine in advance the appropriate emergency treatment and disposal technology for different types of chemical accidents. However, the formulation of an emergency plan for chemical pollution accidents is considerably difficult due to the substantial uncertainty and complexity of such accidents. This paper explains how the event tree method was used to create 54 different scenarios for chemical pollution accidents, based on the polluted medium, dangerous characteristics and properties of chemicals involved. For each type of chemical accident, feasible emergency treatment and disposal technology schemes were established, considering the areas of pollution source control, pollutant non-proliferation, contaminant elimination and waste disposal. Meanwhile, in order to obtain the optimum emergency disposal technology schemes as soon as the chemical pollution accident occurs from the plan repository, the technique evaluation index system was developed based on group decision-improved analytical hierarchy process (AHP), and has been tested by using a sudden aniline pollution accident that occurred in a river in December 2012.

Decision diagram for neutron and photon dose estimation and for classification of persons involved in radiation accident

International Nuclear Information System (INIS)

Anon.

1981-01-01

The relation is described between monitoring and health care measures taken during a radiation accident. The decision-making chart for the assessment of exposure and the classification of people involved are presented, the risks of the respective decision-making are discussed and the flow charts and explanations for the diagrams are given. (H.S.)

'When measurements mean action' decision models for portal image review to eliminate systematic set-up errors

International Nuclear Information System (INIS)

Wratten, C.R.; Denham, J.W.; O; Brien, P.; Hamilton, C.S.; Kron, T.; London Regional Cancer Centre, London, Ontario

2004-01-01

The aim of the present paper is to evaluate how the use of decision models in the review of portal images can eliminate systematic set-up errors during conformal therapy. Sixteen patients undergoing four-field irradiation of prostate cancer have had daily portal images obtained during the first two treatment weeks and weekly thereafter. The magnitude of random and systematic variations has been calculated by comparison of the portal image with the reference simulator images using the two-dimensional decision model embodied in the Hotelling's evaluation process (HEP). Random day-to-day set-up variation was small in this group of patients. Systematic errors were, however, common. In 15 of 16 patients, one or more errors of >2 mm were diagnosed at some stage during treatment. Sixteen of the 23 errors were between 2 and 4 mm. Although there were examples of oversensitivity of the HEP in three cases, and one instance of undersensitivity, the HEP proved highly sensitive to the small (2-4 mm) systematic errors that must be eliminated during high precision radiotherapy. The HEP has proven valuable in diagnosing very small ( 4 mm) systematic errors using one-dimensional decision models, HEP can eliminate the majority of systematic errors during the first 2 treatment weeks. Copyright (2004) Blackwell Science Pty Ltd

Human factors issues in severe accident management: Training for decision-making under stress

International Nuclear Information System (INIS)

Mumaw, R.J.; Roth, E.M.; Schoenfeld, I.

1994-01-01

Training for operator and other technical positions in the commercial nuclear power industry traditionally has focused on mastery of the formal procedures used to control plant systems and processes. However, there is a growing awareness that the decision-making tasks required for selecting appropriate control actions, in addition to guidance from formal procedures, also involve cognitive activities commonly referred to as judgment or reasoning. A project was completed to address the nature of the cognitive skills that may be important to decision-making in the nuclear power plant environment, especially during severe accident management. The project identified a model of decision-making that could account for both rule-based and knowledge-based decision-making and used it to identify cognitive skills for both individuals and operational crews. This analysis was then used to identify existing training techniques for cognitive skills and the general characteristics of successful training techniques

Decision making on population protection in a large-scale radioactive contamination following a nuclear reactor accident

International Nuclear Information System (INIS)

Konstantinov, Yu. O.

1993-01-01

Since the first years of development of nuclear power the most serious attention has been given to the planning of measures of population protection in the event of a radioactive release to atmosphere from a nuclear reactor. In the 60s 'Criteria for urgent decision making in the event of an accidental radioactive release into the environment' were developed in the USSR. When substantiating numerical values of potential radiation doses reasoning the implementation of countermeasures, specific conditions of emergency situations, characteristics of countermeasures and the real possibilities of timely dosimetric estimation of the situation were considered. The 'Criteria' were designed for urgent decision making at an early stage, in the first hours and days following the emergency. After the start of the Chernobyl accident on April 26, 1986, decisions on measures of protection of the population living in proximity to the site of the accident, including relocation of residents of the town of Pripyat on May 27, 1986, were taken on the basis of this document, as well as decisions for iodine prophylaxis and for relocation of other settlements within the 30 km zone. The decisions were taken by the result of the estimation prediction of the radiation situation which showed a possibility of an excess of criteria levels by external gamma radiation and by inhalation of radioiodine

Severe accident analysis methodology in support of accident management

International Nuclear Information System (INIS)

Boesmans, B.; Auglaire, M.; Snoeck, J.

1997-01-01

The author addresses the implementation at BELGATOM of a generic severe accident analysis methodology, which is intended to support strategic decisions and to provide quantitative information in support of severe accident management. The analysis methodology is based on a combination of severe accident code calculations, generic phenomenological information (experimental evidence from various test facilities regarding issues beyond present code capabilities) and detailed plant-specific technical information

Criteria for the decision adoption on participating of Zashchita Special Centre of Emergency Medical (SCEMA) in special medical care at radiation accidents

International Nuclear Information System (INIS)

Bad'in, V.I.; Grachev, M.I.; Kamyshenko, I.D.

1992-01-01

Problem concerning the establishment of criteria for the decision adoption on participating of Zashchita SCEMA in special medical care during radiation accidents is considered as well as intervention level. General reasons used for the establishment of intervention levels of Zashchita SCEMA, dose criteria, decision adoption, assessment of the accident character and scale, need in additional specialists and equipment. Attention is paid to the national and foreign documents on the above problems. 11 refs.; 7 tabs

Review of human error analysis methodologies and case study for accident management

International Nuclear Information System (INIS)

Jung, Won Dae; Kim, Jae Whan; Lee, Yong Hee; Ha, Jae Joo

1998-03-01

In this research, we tried to establish the requirements for the development of a new human error analysis method. To achieve this goal, we performed a case study as following steps; 1. review of the existing HEA methods 2. selection of those methods which are considered to be appropriate for the analysis of operator's tasks in NPPs 3. choice of tasks for the application, selected for the case study: HRMS (Human reliability management system), PHECA (Potential Human Error Cause Analysis), CREAM (Cognitive Reliability and Error Analysis Method). And, as the tasks for the application, 'bleed and feed operation' and 'decision-making for the reactor cavity flooding' tasks are chosen. We measured the applicability of the selected methods to the NPP tasks, and evaluated the advantages and disadvantages between each method. The three methods are turned out to be applicable for the prediction of human error. We concluded that both of CREAM and HRMS are equipped with enough applicability for the NPP tasks, however, compared two methods. CREAM is thought to be more appropriate than HRMS from the viewpoint of overall requirements. The requirements for the new HEA method obtained from the study can be summarized as follows; firstly, it should deal with cognitive error analysis, secondly, it should have adequate classification system for the NPP tasks, thirdly, the description on the error causes and error mechanisms should be explicit, fourthly, it should maintain the consistency of the result by minimizing the ambiguity in each step of analysis procedure, fifty, it should be done with acceptable human resources. (author). 25 refs., 30 tabs., 4 figs

Error begat error: design error analysis and prevention in social infrastructure projects.

Science.gov (United States)

Love, Peter E D; Lopez, Robert; Edwards, David J; Goh, Yang M

2012-09-01

Design errors contribute significantly to cost and schedule growth in social infrastructure projects and to engineering failures, which can result in accidents and loss of life. Despite considerable research that has addressed their error causation in construction projects they still remain prevalent. This paper identifies the underlying conditions that contribute to design errors in social infrastructure projects (e.g. hospitals, education, law and order type buildings). A systemic model of error causation is propagated and subsequently used to develop a learning framework for design error prevention. The research suggests that a multitude of strategies should be adopted in congruence to prevent design errors from occurring and so ensure that safety and project performance are ameliorated. Copyright © 2011. Published by Elsevier Ltd.

Development of the assessment of nuclear accident consequences and decision support system in China: status, requirement and recommendations

International Nuclear Information System (INIS)

Shi Zhongqi; Wang Xingyu

2003-01-01

This paper introduces the status of nuclear accident consequence assessment/development of decision-making support system in China. The basic functions and roles of the consequence assessment/decision-making support system for three levels of nuclear emergency response organization (i.e. national, local offsite and nuclear power plant operator) in China are presented in the paper

A methodology for supporting decisions on the establishment of protective measures after severe nuclear accidents. Final report

International Nuclear Information System (INIS)

Papazoglou, I.A.; Kollas, J.G.

1994-06-01

Full text: The objective of this report is to demonstrate the use of a methodology supporting decisions on protective measures following severe nuclear accidents. A multicriteria decision analysis approach is recommended where value tradeoffs are postponed until the very last stage of the decision process. Use of efficient frontiers is made to exclude all technically inferior solutions and present the decision maker with all non-dominated solutions. A choice among these solutions implies a value trade-off among the multiple criteria. An interactive computer package has been developed where the decision maker can choose a point on the efficient frontier in the consequence space and immediately see the alternative in the decision space resulting in the chosen consequences. The methodology is demonstrated through an application on the choice among possible protective measures in contaminated areas of the former USSR after the Chernobyl accident. Two distinct cases are considered: First a decision is to be made only on the basis of the level of soil contamination with Cs-137 and the total cost of the chosen protective policy; Next the decision is based on the geographic dimension of the contamination and the total cost. Three alternative countermeasure actions are considered for population segments living on soil contaminated at a certain level or in a specific geographic region: (a) relocation of the population; (b) improvement of the living conditions; and, (c) no countermeasures at all. This is the final deliverable of the CEC-CIS Joint Study Project 2, Task 5: Decision-Aiding-System for Establishing Intervention Levels, performed under Contracts COSU-CT91-0007 and COSU-CT92-0021 with the Commission of European Communities through CEPN. (author)

Two heads are better than one: the association between condom decision-making and condom use errors and problems.

Science.gov (United States)

Crosby, R; Milhausen, R; Sanders, S A; Graham, C A; Yarber, W L

2008-06-01

This exploratory study compared the frequency of condom use errors and problems between men reporting that condom use for penile-vaginal sex was a mutual decision compared with men making the decision unilaterally. Nearly 2000 people completed a web-based questionnaire. A sub-sample of 660 men reporting that they last used a condom for penile-vaginal sex (within the past three months) was analysed. Nine condom use errors/problems were assessed. Multivariate analyses controlled for men's age, marital status, and level of experience using condoms. Men's unilateral decision-making was associated with increased odds of removing condoms before sex ended (adjusted odds ratio (AOR) 2.51, p = 0.002), breakage (AOR 3.90, p = 0.037), and slippage during withdrawal (AOR 2.04, p = 0.019). Men's self-reported level of experience using condoms was significantly associated with seven out of nine errors/problems, with those indicating less experience consistently reporting more errors/problems. Findings suggest that female involvement in the decision to use condoms for penile-vaginal sex may be partly protective against some condom errors/problems. Men's self-reported level of experience using condoms may be a useful indicator of the need for education designed to promote the correct use of condoms. Education programmes may benefit men by urging them to involve their female partner in condom use decisions.

Accident and emergency management

International Nuclear Information System (INIS)

Andersen, V.; Moellenbach, K.; Heinonen, R.; Jakobsson, S.; Kukko, T.; Berg, Oe.; Larsen, J.S.; Westgaard, T.; Magnusson, B.; Andersson, H.; Holmstroem, C.; Brehmer, B.; Allard, R.

1988-06-01

There is an increasing potential for severe accidents as the industrial development tends towards large, centralised production units. In several industries this has led to the formation of large organisations which are prepared for accidents fighting and for emergency management. The functioning of these organisations critically depends upon efficient decision making and exchange of information. This project is aimed at securing and possibly improving the functionality and efficiency of the accident and emergency management by verifying, demonstrating, and validating the possible use of advanced information technology in the organisations mentioned above. With the nuclear industry in focus the project consists of five main activities: 1) The study and detailed analysis of accident and emergency scenarios based on records from incidents and rills in nuclear installations. 2) Development of a conceptual understanding of accident and emergency management with emphasis on distributed decision making, information flow, and control structure sthat are involved. 3) Development of a general experimental methodology for evaluating the effects of different kinds of decision aids and forms of organisation for emergency management systems with distributed decision making. 4) Development and test of a prototype system for a limited part of an accident and emergency organisation to demonstrate the potential use of computer and communication systems, data-base and knowledge base technology, and applications of expert systems and methods used in artificial intelligence. 5) Production of guidelines for the introduction of advanced information technology in the organisations based on evaluation and validation of the prototype system. (author)

A decision support system prototype including human factors based on the TOGA meta-theory approach

International Nuclear Information System (INIS)

Cappelli, M.; Memmi, F.; Gadomski, A. M.; Sepielli, M.

2012-01-01

The human contribution to the risk of operation of complex technological systems is often not negligible and sometimes tends to become significant, as shown by many reports on incidents and accidents occurred in the past inside Nuclear Power Plants (NPPs). An error of a human operator of a NPP can derive by both omission and commission. For instance, complex commission errors can also lead to significant catastrophic technological accidents, as for the case of the Three Mile Island accident. Typically, the problem is analyzed by focusing on the single event chain that has provoked the incident or accident. What is needed is a general framework able to include as many parameters as possible, i.e. both technological and human factors. Such a general model could allow to envisage an omission or commission error before it can happen or, alternatively, suggest preferred actions to do in order to take countermeasures to neutralize the effect of the error before it becomes critical. In this paper, a preliminary Decision Support System (DSS) based on the so-called (-) TOGA meta-theory approach is presented. The application of such a theory to the management of nuclear power plants has been presented in the previous ICAPP 2011. Here, a human factor simulator prototype is proposed in order to include the effect of human errors in the decision path. The DSS has been developed using a TRIGA research reactor as reference plant, and implemented using the LabVIEW programming environment and the Finite State Machine (FSM) model The proposed DSS shows how to apply the Universal Reasoning Paradigm (URP) and the Universal Management Paradigm (UMP) to a real plant context. The DSS receives inputs from instrumentation data and gives as output a suggested decision. It is obtained as the result of an internal elaborating process based on a performance function. The latter, describes the degree of satisfaction and efficiency, which are dependent on the level of responsibility related to

Influence diagrams and decision trees for severe accident management

Energy Technology Data Exchange (ETDEWEB)

Goetz, W.W.J.

1996-09-01

A review of relevant methodologies based on Influence Diagrams (IDs), Decision Trees (DTs), and Containment Event Trees (CETs) was conducted to assess the practicality of these methods for the selection of effective strategies for Severe Accident Management (SAM). The review included an evaluation of some software packages for these methods. The emphasis was on possible pitfalls of using IDs and on practical aspects, the latter by performance of a case study that was based on an existing Level 2 Probabilistic Safety Assessment (PSA). The study showed that the use of a combined ID/DT model has advantages over CET models, in particular when conservatisms in the Level 2 PSA have been identified and replaced by fair assessments of the uncertainties involved. It is recommended to use ID/DT models complementary to CET models. (orig.).

Influence diagrams and decision trees for severe accident management

International Nuclear Information System (INIS)

Goetz, W.W.J.; Seebregts, A.J.; Bedford, T.J.

1996-08-01

A review of relevent methodologies based on Influence Diagrams (IDs), Decision Trees (DTs), and Containment Event Trees (CETs) was conducted to assess the practicality of these methods for the selection of effective strategies for Severe Accident Management (SAM). The review included an evaluation of some software packages for these methods. The emphasis was on possible pitfalls of using IDs and on practical aspects, the latter by performance of a case study that was based on an existing Level 2 Probabilistic Safety Assessment (PSA). The study showed that the use of a combined ID/DT model has advantages over CET models, in particular when conservatisms in the Level 2 PSA have been identified and replaced by fair assessments of the uncertainties involved. It is recommended to use ID/DT models as complementary to CET models. (orig.)

Influence diagrams and decision trees for severe accident management

International Nuclear Information System (INIS)

Goetz, W.W.J.

1996-09-01

A review of relevant methodologies based on Influence Diagrams (IDs), Decision Trees (DTs), and Containment Event Trees (CETs) was conducted to assess the practicality of these methods for the selection of effective strategies for Severe Accident Management (SAM). The review included an evaluation of some software packages for these methods. The emphasis was on possible pitfalls of using IDs and on practical aspects, the latter by performance of a case study that was based on an existing Level 2 Probabilistic Safety Assessment (PSA). The study showed that the use of a combined ID/DT model has advantages over CET models, in particular when conservatisms in the Level 2 PSA have been identified and replaced by fair assessments of the uncertainties involved. It is recommended to use ID/DT models complementary to CET models. (orig.)

Factors correlated with traffic accidents as a basis for evaluating Advanced Driver Assistance Systems.

Science.gov (United States)

Staubach, Maria

2009-09-01

This study aims to identify factors which influence and cause errors in traffic accidents and to use these as a basis for information to guide the application and design of driver assistance systems. A total of 474 accidents were examined in depth for this study by means of a psychological survey, data from accident reports, and technical reconstruction information. An error analysis was subsequently carried out, taking into account the driver, environment, and vehicle sub-systems. Results showed that all accidents were influenced by errors as a consequence of distraction and reduced activity. For crossroad accidents, there were further errors resulting from sight obstruction, masked stimuli, focus errors, and law infringements. Lane departure crashes were additionally caused by errors as a result of masked stimuli, law infringements, expectation errors as well as objective and action slips, while same direction accidents occurred additionally because of focus errors, expectation errors, and objective and action slips. Most accidents were influenced by multiple factors. There is a safety potential for Advanced Driver Assistance Systems (ADAS), which support the driver in information assimilation and help to avoid distraction and reduced activity. The design of the ADAS is dependent on the specific influencing factors of the accident type.

A decision support system for emergency response to major nuclear accidents

International Nuclear Information System (INIS)

Papazoglou, I.A.; Christou, M.D.

1997-01-01

A methodology for the optimization of the short-term emergency response in the event of a nuclear accident is presented. The method seeks an optimum combination of protective actions in the presence of a multitude of conflicting objectives and under uncertainty. Conflicting objectives arise in the attempt to minimize simultaneously the potential adverse effects of an accident and the associated socioeconomic impacts. Additional conflicting objectives arise whenever an emergency plan tends to decrease a particular health effect, such as acute deaths, while it increases another, such as latent deaths. The uncertainty is due to the multitude of possible accident scenarios and their respective probability of occurrence, the stochastic variability in the weather conditions, and the variability and/or lack of knowledge of the parameters of the risk assessment models. A multiobjective optimization approach is adopted. An emergency protection plan consists of defining a protective action at each spatial cell around the plant. Three criteria are used as the objective functions of the problem, namely, acute fatalities, latent effects, and socioeconomic cost. The optimization procedure defines the efficient frontier, i.e., all emergency plans that are not dominated by another in all three criteria. No value trade-offs are necessary up to this point. The most preferred emergency plan is then chosen among the set of efficient plans. Finally, the methodology is integrated into a computerized decision support system, and its use is demonstrated in a realistic application

Decision-making guide for management of agriculture in the case of a nuclear accident

International Nuclear Information System (INIS)

Fourrie, Laetitia; Grosjean, Francois; Adam, Didier; Pretet, Caroline; Michel, Aurelie; Fostier, Bernard; Bertrand, Sophie; Cessac, Bruno; Reales, Nicolas IRSN; Aubert, Claude

2007-05-01

For several years, agricultural and nuclear professionals in France have been working on how to manage the agricultural situation in the event of a nuclear accident. This work resulted in measures at both the national (Aube nuclear safety exercises in 2003, INEX3 in 2005) and international levels (EURATOM Programmes). Following on from the European FARMING (FP5) and EURANOS (FP6) works, ACTA', IRSN and six agricultural technical institutes which are specialized in agricultural production and processing network (arable crop [especially cereals, maize, pulses, potatoes and forage crops], fruits and vegetables, vine and wine, livestock farming [cattle, sheep, goats, pigs, poultry]), created a resource adapted to the French context: the Decision-aiding Tool for the Management of Agriculture in case of a Nuclear Accident. Devised for the Ministry of Agriculture services supporting state officials in a radiation emergency, this manual focuses on the early phase following the accident when the state of emergency would make discussion on countermeasures with a large stakeholder panel impossible. Supported by the Ministry of Agriculture and Fisheries and the French Nuclear Safety Authority, this project increased knowledge of post-accident management strategies and made an important contribution to the national think tank set up within the framework of the French Steering Committee for managing the post-event phase of a nuclear accident (CODIRPA). This article describes how the manual evolved throughout the project and the development of new resources

Decision-making guide for management of agriculture in the case of a nuclear accident

International Nuclear Information System (INIS)

Reales, N.; Fourrie, L.; Quinio, C.; Grastilleur, Ch.

2008-01-01

For several years, agricultural and nuclear professionals in France have been working on how to manage the agricultural situation in the event of a nuclear accident. This work resulted in measures at both the national (Aube nuclear safety exercises in 2003, INEX3 in 2005) and international levels (EURATOM Programmes). Following on from the European FARMING (FP5) and EURANOS (FP6) works, ACTA', IRSN and six agricultural technical institutes which are specialized in agricultural production and processing network (arable crop [especially cereals, maize, pulses, potatoes and forage crops], fruits and vegetables, vine and wine, livestock farming [cattle, sheep, goats, pigs, poultry]), created a resource adapted to the French context: the Decision-aiding Tool for the Management of Agriculture in case of a Nuclear Accident. Devised for the Ministry of Agriculture services supporting state officials in a radiation emergency, this manual focuses on the early phase following the accident when the state of emergency would make discussion on countermeasures with a large stakeholder panel impossible. Supported by the Ministry of Agriculture and Fisheries and the French Nuclear Safety Authority, this project increased knowledge of post-accident management strategies and made an important contribution to the national think tank set up within the framework of the French Steering Committee for managing the post-event phase of a nuclear accident (CODIRPA). This article describes how the manual evolved throughout the project and the development of new resources. (authors)

Review of nuclear reactor accidents

International Nuclear Information System (INIS)

Connelly, J.W.; Storr, G.J.

1989-01-01

Two types of severe reactor accidents - loss of coolant or coolant flow and transient overpower (TOP) accidents - are described and compared. Accidents in research reactors are discussed. The 1961 SL1 accident in the US is used as an illustration as it incorporates the three features usually combined in a severe accident - a design flaw or flaws in the system, a circumvention of safety circuits or procedures, and gross operator error. The SL1 reactor, the reactivity accident and the following fuel-coolant interaction and steam explosion are reviewed. 3 figs

Evaluation of decision making in technical support center for effective severe accident management

International Nuclear Information System (INIS)

Huh, C.; Suh, N.

2010-01-01

We have evaluated the technical and organizational aspect of the current SAMG focusing on the decision making process in TSC. Technically, we found that the current SAMG is a good software kind of tool which can help operators to manage the severe accident. But the clear cutting of EOP and SAMG, shift of plant control from MCR to TSC seems to have no firm ground to be accepted as it is. Study on the organizational behavior shows that the group decision under risky situation will be inevitably polarized either toward risky or cautious way. Since the current SAMG makes TSC to evaluate the pros and cons of strategies to be implemented and choose one based on group decision, we are not free of this group polarization phenomenon. We propose that the proven organization of EOP needs to be maintained and also that the SAMG needs to be more proceduralized. (authors)

Use of bayesian operations for diagnosing accidents

International Nuclear Information System (INIS)

Kang, K.M.; Jae, M.; Suh, K.Y.

2005-01-01

In complex systems, it is necessary to model a logical representation of the overall system interaction with respect to the individual subsystems. Operators are allowed to follow EOPs (Emergency Operating Procedures) when reactor tripped because of accidents. But, it's very difficult to diagnose accidents and find out appropriate procedures to mitigate current accidents in a given short time. Even if they diagnose accidents, it also has possibility to misdiagnose. TMI accident is a good example of operators' errors. Methodology using Influence Diagrams has been developed and applied for representing the dependency behaviors and uncertain behaviors of complex systems. An example to diagnose the accidents such as SLOCA and SGTR with similar symptoms has been introduced. From the constructed model, operators could diagnose accidents at any states of accidents. This model can offer the information about accidents with given symptoms. This model might help operators to diagnose correctly and rapidly. It might be very useful to support operators to reduce human error. Also, from this study, it is applicable to diagnose other accidents with similar symptoms and to analyze causes of reactor trip. (authors)

Accident statistics and the human-factor element.

Science.gov (United States)

Shuckburgh, J S

1975-01-01

The number of fatal accidents involving public transport aircraft has increased significantly in recent years and, because more and more "wide-bodied" aircraft have been coming into service, this has resulted in a rapid increase in the number of fatalities. A combined attack on the problem by all concerned with flight safety is required to improve the situation. The collection and analysis of aircraft accident data can contribute to safety in two ways; by giving an indication of where to concentrate future effort and by showing how successful past efforts have been. An analysis of worldwide accident statistics by phase of flight and causal factor show that the largest percentage of accidents occurs in the approach and landing phase and are caused by "pilot error". Further research is needed to find out why pilots make errors and how such errors can be eliminated.

Development of a multi-criteria decision tool for remediation after a nuclear or radiological accident

Energy Technology Data Exchange (ETDEWEB)

Luca, Christiano de; Rochedo, Elaine R.R.; Ferreira, Nadya M.P.D., E-mail: christiano_luca@hotmail.com, E-mail: elainerochedo@gmail.com, E-mail: nadya@ime.eb.br [Instituto Militar de Engenharia (IME), Rio de Janeiro, RJ (Brazil)

2013-07-01

The review of accidents involving Nuclear Power Plants or facilities that use or process radioactive sources have raised issues related to the decision-making processes and to the procedures used to reestablish the normal living conditions in the affected areas. Due to the large complexity of the decision processes after accidents, a multi-criteria approach has been recommended to support the choice among the several procedures that may improve the environmental conditions. As part of the process of developing a multi-criteria decision support tool, a questionnaire was created to be fulfilled by experts to derive the relevance of the technical criteria to be considered in the model. At this stage, only the technical criteria related to radiation protection of the public will be focused; legal aspects, costs and public opinion, although relevant in the decision-making process, are beyond the scope of this work. The questionnaire contains 12 questions, each containing 5 degrees of importance. The answers are statically analyzed to generate a multiplicative factor to be included in the multicriteria model. To facilitate the process of distributing the questionnaire to the selected experts and then for a better processing and ordering of the information gathered, a program based on the Hypertext Preprocessor language (PHP) was created; this methodology has been chosen because of its compatibility and security in existing operating systems. The relevance rank showed the long-term dose reduction and the generation of wastes as the most relevant aspects to be considered in selecting remediation strategies for a contaminated area. (author)

Development of a multi-criteria decision tool for remediation after a nuclear or radiological accident

International Nuclear Information System (INIS)

Luca, Christiano de; Rochedo, Elaine R.R.; Ferreira, Nadya M.P.D.

2013-01-01

The review of accidents involving Nuclear Power Plants or facilities that use or process radioactive sources have raised issues related to the decision-making processes and to the procedures used to reestablish the normal living conditions in the affected areas. Due to the large complexity of the decision processes after accidents, a multi-criteria approach has been recommended to support the choice among the several procedures that may improve the environmental conditions. As part of the process of developing a multi-criteria decision support tool, a questionnaire was created to be fulfilled by experts to derive the relevance of the technical criteria to be considered in the model. At this stage, only the technical criteria related to radiation protection of the public will be focused; legal aspects, costs and public opinion, although relevant in the decision-making process, are beyond the scope of this work. The questionnaire contains 12 questions, each containing 5 degrees of importance. The answers are statically analyzed to generate a multiplicative factor to be included in the multicriteria model. To facilitate the process of distributing the questionnaire to the selected experts and then for a better processing and ordering of the information gathered, a program based on the Hypertext Preprocessor language (PHP) was created; this methodology has been chosen because of its compatibility and security in existing operating systems. The relevance rank showed the long-term dose reduction and the generation of wastes as the most relevant aspects to be considered in selecting remediation strategies for a contaminated area. (author)

Operator errors

International Nuclear Information System (INIS)

Knuefer; Lindauer

1980-01-01

Besides that at spectacular events a combination of component failure and human error is often found. Especially the Rasmussen-Report and the German Risk Assessment Study show for pressurised water reactors that human error must not be underestimated. Although operator errors as a form of human error can never be eliminated entirely, they can be minimized and their effects kept within acceptable limits if a thorough training of personnel is combined with an adequate design of the plant against accidents. Contrary to the investigation of engineering errors, the investigation of human errors has so far been carried out with relatively small budgets. Intensified investigations in this field appear to be a worthwhile effort. (orig.)

Errors in statistical decision making Chapter 2 in Applied Statistics in Agricultural, Biological, and Environmental Sciences

Science.gov (United States)

Agronomic and Environmental research experiments result in data that are analyzed using statistical methods. These data are unavoidably accompanied by uncertainty. Decisions about hypotheses, based on statistical analyses of these data are therefore subject to error. This error is of three types,...

Development of a decision support system for off-site emergency management in the early phase of a nuclear accident

International Nuclear Information System (INIS)

Datta, D.; Sharma, R.M.

2002-01-01

Full text: Experience gained after the Chernobyl accident clearly demonstrated the importance of improving administrative, organizational and technical emergency management arrangements in India. The more important areas where technical improvements were needed were early warning monitoring, communication networks for the rapid and reliable exchange of radiological and other information and decision support systems for off-site emergency management. A PC based artificial intelligent software has been developed to have a decision support system that can easily implement to manage off-site nuclear emergency and subsequently analyze the off-site consequences of the nuclear accident. A decision support tool, STEPS (source term estimate based on plant status), that provides desired input to the present software was developed. The tool STEPS facilitates meta knowledge of the system. The paper describes the details of the design of the software, functions of various modules, tuning of respective knowledge base and overall its scope in real sense in nuclear emergency preparedness and response

Study on Network Error Analysis and Locating based on Integrated Information Decision System

Science.gov (United States)

Yang, F.; Dong, Z. H.

2017-10-01

Integrated information decision system (IIDS) integrates multiple sub-system developed by many facilities, including almost hundred kinds of software, which provides with various services, such as email, short messages, drawing and sharing. Because the under-layer protocols are different, user standards are not unified, many errors are occurred during the stages of setup, configuration, and operation, which seriously affect the usage. Because the errors are various, which may be happened in different operation phases, stages, TCP/IP communication protocol layers, sub-system software, it is necessary to design a network error analysis and locating tool for IIDS to solve the above problems. This paper studies on network error analysis and locating based on IIDS, which provides strong theory and technology supports for the running and communicating of IIDS.

Regulatory approach to enhanced human performance during accidents

International Nuclear Information System (INIS)

Palla, R.L. Jr.

1990-01-01

It has become increasingly clear in recent years that the risk associated with nuclear power is driven by human performance. Although human errors have contributed heavily to the two core-melt events that have occurred at power reactors, effective performance during an event can also prevent a degraded situation from progressing to a more serious accident, as in the loss-of-feedwater event at Davis-Besse. Sensitivity studies in which human error rates for various categories of errors in a probabilistic risk assessment (PRA) were varied confirm the importance of human performance. Moreover, these studies suggest that actions taken during an accident are at least as important as errors that occur prior to an initiating event. A program that will lead to enhanced accident management capabilities in the nuclear industry is being developed by the US Nuclear Regulatory Commission (NRC) and industry and is a key element in NRC's integration plan for closure of severe-accident issues. The focus of the accident management (AM) program is on human performance during accidents, with emphasis on in-plant response. The AM program extends the defense-in-depth principle to plant operating staff. The goal is to take advantage of existing plant equipment and operator skills and creativity to find ways to terminate accidents that are beyond the design basis. The purpose of this paper is to describe the NRC's objectives and approach in AM as well as to discuss several human performance issues that are central to AM

Structural Model Error and Decision Relevancy

Science.gov (United States)

Goldsby, M.; Lusk, G.

2017-12-01

The extent to which climate models can underwrite specific climate policies has long been a contentious issue. Skeptics frequently deny that climate models are trustworthy in an attempt to undermine climate action, whereas policy makers often desire information that exceeds the capabilities of extant models. While not skeptics, a group of mathematicians and philosophers [Frigg et al. (2014)] recently argued that even tiny differences between the structure of a complex dynamical model and its target system can lead to dramatic predictive errors, possibly resulting in disastrous consequences when policy decisions are based upon those predictions. They call this result the Hawkmoth effect (HME), and seemingly use it to rebuke rightwing proposals to forgo mitigation in favor of adaptation. However, a vigorous debate has emerged between Frigg et al. on one side and another philosopher-mathematician pair [Winsberg and Goodwin (2016)] on the other. On one hand, Frigg et al. argue that their result shifts the burden to climate scientists to demonstrate that their models do not fall prey to the HME. On the other hand, Winsberg and Goodwin suggest that arguments like those asserted by Frigg et al. can be, if taken seriously, "dangerous": they fail to consider the variety of purposes for which models can be used, and thus too hastily undermine large swaths of climate science. They put the burden back on Frigg et al. to show their result has any effect on climate science. This paper seeks to attenuate this debate by establishing an irenic middle position; we find that there is more agreement between sides than it first seems. We distinguish a `decision standard' from a `burden of proof', which helps clarify the contributions to the debate from both sides. In making this distinction, we argue that scientists bear the burden of assessing the consequences of HME, but that the standard Frigg et al. adopt for decision relevancy is too strict.

Ergonomic study of biorhythm effect on the 62 occurrence of human errors and accidents in automobile manufacturing industry

OpenAIRE

2012-01-01

Background and Aim: According to the biorhythm theory when the phase shift from positive to negative and vice versa people experience a critical an unstable day that prone them to error and accident. The purpose of this study is to determine this relationship in one of the automobile manufacturing industry. . Materials and Methods: At first 1280 person incident entered the study was reviewed and then the critical days of each biological cycle was determined using the software Easy Biorh...

Development of a multi-criteria tool to support decision-making process on decontamination of urban areas after a nuclear accident

Energy Technology Data Exchange (ETDEWEB)

Rochedo, Elaine R.R.; Luca, Christiano de [Instituto Militar de Engenharia, Pc. Gen. Tiburcio, 80, Praia Vermelha, Rio de Janeiro, 22290-270 RJ (Brazil); Silva, Diogo N.G. [Universidade Federal do Rio de Janeiro, Instituto de Biofisica Carlos Chagas Filho, Rio de Janeiro 21941-902 RJ (Brazil); Wasserman, Maria Angelica V. [Instituto de Engenharia Nuclear, Cidade Universitaria, Ilha do Fundao, 21941-906, Rio de Janeiro RJ (Brazil)

2014-07-01

This work describes the main efforts to derive criteria for classifying technical aspects related to decontamination procedures to feed a multi-criteria tool to support decisions on remediation of urban areas after nuclear accidents. After listing procedures already tested or used in previous accident, technical aspects to be considered were derived. The relevance of each aspect was determined based on questionnaires answered by experts with experience on remediation after an accident. The questionnaire included 12 aspects and for each of them one or more technical criteria where developed to allow the classification of remediation procedures for urban areas. The criteria described in this work relate to the effects of each procedure on doses to the public, doses to remediation workers, waste generation and infrastructure needed. The aim of this project was to increase public concerns by turning the decision making process more reliable and transparent. In this work, the list of criteria and associated values are described. This list is now being included in a previously developed dose assessment computer program to allow the optimization of actions to be used considering all justifiable procedures based on the current experience on dealing with urban areas contamination after a nuclear or radiological accident. (authors)

The relationship between automation complexity and operator error

International Nuclear Information System (INIS)

Ogle, Russell A.; Morrison, Delmar 'Trey'; Carpenter, Andrew R.

2008-01-01

One of the objectives of process automation is to improve the safety of plant operations. Manual operation, it is often argued, provides too many opportunities for operator error. By this argument, process automation should decrease the risk of accidents caused by operator error. However, some accident theorists have argued that while automation may eliminate some types of operator error, it may create new varieties of error. In this paper we present six case studies of explosions involving operator error in an automated process facility. Taken together, these accidents resulted in six fatalities, 30 injuries and hundreds of millions of dollars in property damage. The case studies are divided into two categories: low and high automation complexity (three case studies each). The nature of the operator error was dependent on the level of automation complexity. For each case study, we also consider the contribution of the existing engineering controls such as safety instrumented systems (SIS) or safety critical devices (SCD) and explore why they were insufficient to prevent, or mitigate, the severity of the explosion

Accident management insights after the Fukushima Daiichi NPP accident

International Nuclear Information System (INIS)

Degueldre, Didier; Viktorov, Alexandre; Tuomainen, Minna; Ducamp, Francois; Chevalier, Sophie; Guigueno, Yves; Tasset, Daniel; Heinrich, Marcus; Schneider, Matthias; Funahashi, Toshihiro; Hotta, Akitoshi; Kajimoto, Mitsuhiro; Chung, Dae-Wook; Kuriene, Laima; Kozlova, Nadezhda; Zivko, Tomi; Aleza, Santiago; Jones, John; McHale, Jack; Nieh, Ho; Pascal, Ghislain; ); Nakoski, John; Neretin, Victor; Nezuka, Takayoshi; )

2014-01-01

The Fukushima Daiichi nuclear power plant (NPP) accident, that took place on 11 March 2011, initiated a significant number of activities at the national and international levels to reassess the safety of existing NPPs, evaluate the sufficiency of technical means and administrative measures available for emergency response, and develop recommendations for increasing the robustness of NPPs to withstand extreme external events and beyond design basis accidents. The OECD Nuclear Energy Agency (NEA) is working closely with its member and partner countries to examine the causes of the accident and to identify lessons learnt with a view to the appropriate follow-up actions to be taken by the nuclear safety community. Accident management is a priority area of work for the NEA to address lessons being learnt from the accident at the Fukushima Daiichi NPP following the recommendations of Committee on Nuclear Regulatory Activities (CNRA), Committee on the Safety of Nuclear Installations (CSNI), and Committee on Radiation Protection and Public Health (CRPPH). Considering the importance of these issues, the CNRA authorised the formation of a task group on accident management (TGAM) in June 2012 to review the regulatory framework for accident management following the Fukushima Daiichi NPP accident. The task group was requested to assess the NEA member countries needs and challenges in light of the accident from a regulatory point of view. The general objectives of the TGAM review were to consider: - enhancements of on-site accident management procedures and guidelines based on lessons learnt from the Fukushima Daiichi NPP accident; - decision-making and guiding principles in emergency situations; - guidance for instrumentation, equipment and supplies for addressing long-term aspects of accident management; - guidance and implementation when taking extreme measures for accident management. The report is built on the existing bases for capabilities to respond to design basis

Environmental decision support system on base of geoinformational technologies for the analysis of nuclear accident consequences

International Nuclear Information System (INIS)

Haas, T.C.; Maigan, M.; Arutyunyan, R.V.; Bolshov, L.A.; Demianov, V.V.

1996-01-01

The report deals with description of the concept and prototype of environmental decision support system (EDSS) for the analysis of late off-site consequences of severe nuclear accidents and analysis, processing and presentation of spatially distributed radioecological data. General description of the available software, use of modem achievements of geostatistics and stochastic simulations for the analysis of spatial data are presented and discussed

Comparative evaluation of three cognitive error analysis methods through an application to accident management tasks in NPPs

International Nuclear Information System (INIS)

Jung, Won Dea; Kim, Jae Whan; Ha, Jae Joo; Yoon, Wan C.

1999-01-01

This study was performed to comparatively evaluate selected Human Reliability Analysis (HRA) methods which mainly focus on cognitive error analysis, and to derive the requirement of a new human error analysis (HEA) framework for Accident Management (AM) in nuclear power plants(NPPs). In order to achieve this goal, we carried out a case study of human error analysis on an AM task in NPPs. In the study we evaluated three cognitive HEA methods, HRMS, CREAM and PHECA, which were selected through the review of the currently available seven cognitive HEA methods. The task of reactor cavity flooding was chosen for the application study as one of typical tasks of AM in NPPs. From the study, we derived seven requirement items for a new HEA method of AM in NPPs. We could also evaluate the applicability of three cognitive HEA methods to AM tasks. CREAM is considered to be more appropriate than others for the analysis of AM tasks. But, PHECA is regarded less appropriate for the predictive HEA technique as well as for the analysis of AM tasks. In addition to these, the advantages and disadvantages of each method are described. (author)

Myopia, spectacle wear, and risk of bicycle accidents among rural Chinese secondary school students: the Xichang Pediatric Refractive Error Study report no. 7.

Science.gov (United States)

Zhang, Mingzhi; Congdon, Nathan; Li, Liping; Song, Yue; Choi, Kai; Wang, Yunfei; Zhou, Zhongxia; Liu, Xiaojian; Sharma, Abhishek; Chen, Weihong; Lam, Dennis S C

2009-06-01

To study the effect of myopia and spectacle wear on bicycle-related injuries in rural Chinese students. Myopia is common among Chinese students but few studies have examined its effect on daily activities. Data on visual acuity, refractive error, current spectacle wear, and history of bicycle use and accidents during the past 3 years were sought from 1891 students undergoing eye examinations in rural Guangdong province. Refractive and accident data were available for 1539 participants (81.3%), among whom the mean age was 14.6 years, 52.5% were girls, 26.8% wore glasses, and 12.9% had myopia of less than -4 diopters in both eyes. More than 90% relied on bicycles to get to school daily. A total of 2931 accidents were reported by 423 participants, with 68 requiring medical attention. Male sex (odds ratio, 1.55; P accident, but habitual visual acuity and myopia were unassociated with the crash risk, after adjusting for age, sex, time spent riding, and risky riding behaviors. These results may be consistent with data on motor vehicle accidents implicating peripheral vision (potentially compromised by spectacle wear) more strongly than central visual acuity in mediating crash risk.

[Model of Analysis and Prevention of Accidents - MAPA: tool for operational health surveillance].

Science.gov (United States)

de Almeida, Ildeberto Muniz; Vilela, Rodolfo Andrade de Gouveia; da Silva, Alessandro José Nunes; Beltran, Sandra Lorena

2014-12-01

The analysis of work-related accidents is important for accident surveillance and prevention. Current methods of analysis seek to overcome reductionist views that see these occurrences as simple events explained by operator error. The objective of this paper is to analyze the Model of Analysis and Prevention of Accidents (MAPA) and its use in monitoring interventions, duly highlighting aspects experienced in the use of the tool. The descriptive analytical method was used, introducing the steps of the model. To illustrate contributions and or difficulties, cases where the tool was used in the context of service were selected. MAPA integrates theoretical approaches that have already been tried in studies of accidents by providing useful conceptual support from the data collection stage until conclusion and intervention stages. Besides revealing weaknesses of the traditional approach, it helps identify organizational determinants, such as management failings, system design and safety management involved in the accident. The main challenges lie in the grasp of concepts by users, in exploring organizational aspects upstream in the chain of decisions or at higher levels of the hierarchy, as well as the intervention to change the determinants of these events.

Normal Accident at Three Mile Island.

Science.gov (United States)

Perrow, Charles

1981-01-01

Discusses some aspects of the accident at the Three Mile Island nuclear power plant. Explains a number of factors involved including the type of accident, warnings, design and equipment failure, operator error, and negative synergy. Presents alternatives to systems with catastrophic potential. (MK)

How we learn to make decisions: rapid propagation of reinforcement learning prediction errors in humans.

Science.gov (United States)

Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C

2014-03-01

Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward

Organizational factors and reoccurrence protection on the JCO nuclear critical accident

International Nuclear Information System (INIS)

Takano, Kenichi

2000-01-01

A nuclear critical accident formed at a nuclear fuel conversion factory in Tokai-mura on September, 1999 became gradually clear not to be a simple human error formed at a level of workmen but to be an organizational error or accident relating to various organizational factors. As a nuclear power facility adopts a depth protection system fundamentally, a large accident with serious danger would not form only by a single trouble and a human error and unless some factors overlaps. By reviewing recent serious accidents and troubles, all of them seem to have a keyword of 'organizational factor'. In the JCO accident, there are some organizational factors such as a climate deviating from a manual, insufficient and loose check against change of procedure, reduction of operators from a reason of profit priority, attitude on priority of working efficiency, and so forth, which are partially common to the Chernobyl accident. Recently, accidents and troubles impossible to make them a cause of simple human error by a person but to have to say an organizational error, have increased. This trend seems to depend upon not only complication and scale-up of technology system but also graduate change of social and management systems operating them. Therefore, it seems to be necessary to introduce a concept of depth protection (multiple protection) in order to keep its reliability and safety when complicating and scaling-up of system. (G.K.)

The relationships between organizational and individual variables to on-the-job driver accidents and accident-free kilometres.

Science.gov (United States)

Caird, J K; Kline, T J

2004-12-01

Highway fatalities are the leading cause of fatal work injuries in the US, accounting for approximately 1 in 4 of the 5900 job-related deaths during 2001. The present study focused on the contribution of organizational factors and driver behaviours to on-the-job driving accidents in a large Western Canadian corporation. A structural equation modelling (SEM) approach was used which allows researchers to test a complex set of relationships within a global theoretical framework. A number of scales were used to assess organizational support, driver errors, and driver behaviours. The sample of professional drivers that participated allowed the recording of on-the-job accidents and accident-free kilometres from their personnel files. The pattern of relationships in the fitted model, after controlling for exposure and social desirability, provides insight into the role of organizational support, planning, environment adaptations, fatigue, speed, errors and moving citations to on-the-job accidents and accident-free kilometres. For example, organizational support affected the capacity to plan. Time to plan work-related driving was found to predict accidents, fatigue and adaptations to the environment. Other interesting model paths, SEM limitations, future research and recommendations are elaborated.

The methods, models and information support on administrative decisions on medico-sanitary maintenance of population of Ukraine in the after Chernobyl accident period

International Nuclear Information System (INIS)

Torbin, V.; Babich, A.; Onopchuk, J.

1996-01-01

The liquidation of serious consequences of Chernobyl accident, taking into consideration their character and scale, requires the huge material and human resources. The complexity and plural of factors, affecting on planning and management of measures on medical-sanitarian maintenance of damaged population, requires the processing during acceptance of decisions, large files of information, containing parameters of healths condition of damaged population, information about the level of complex medical-sanitarian maintenance, dynamics of investments and compensation and etc. The instability of economic situation in Ukraine, connected with transition to new forms of managing and formation of political system does not permit to increase the resources on decisions the problems of liquidation of Chernobyl accident, requires the increasing the effectiveness, efficiency and qualities of accepted decisions on control and management of forming situation. (author)

Comparison of HRA methods based on WWER-1000 NPP real and simulated accident scenarios

International Nuclear Information System (INIS)

Petkov, Gueorgui

2010-01-01

Full text: Adequate treatment of human interactions in probabilistic safety analysis (PSA) studies is a key to the understanding of accident sequences and their relative importance in overall risk. Human interactions with machines have long been recognized as important contributors to the safe operation of nuclear power plants (NPP). Human interactions affect the ordering of dominant accident sequences and hence have a significant effect on the risk of NPP. By virtue of the ability to combine the treatment of both human and hardware reliability in real accidents, NPP fullscope, multifunctional and computer-based simulators provide a unique way of developing an understanding of the importance of specific human actions for overall plant safety. Context dependent human reliability assessment (HRA) models, such as the holistic decision tree (HDT) and performance evaluation of teamwork (PET) methods, are the so-called second generation HRA techniques. The HDT model has been used for a number of PSA studies. The PET method reflects promising prospects for dealing with dynamic aspects of human performance. The paper presents a comparison of the two HRA techniques for calculation of post-accident human error probability in the PSA. The real and simulated event training scenario 'turbine's stop after loss of feedwater' based on standard PSA model assumptions is designed for WWER-1000 computer simulator and their detailed boundary conditions are described and analyzed. The error probability of post-accident individual actions will be calculated by means of each investigated technique based on student's computer simulator training archives

Development of integrated accident management assessment technology

International Nuclear Information System (INIS)

Jung, Won Dea; Ha, Jae Joo; Jin, Young Ho

2002-04-01

This project aims to develop critical technologies for accident management through securing evaluation frameworks and supporting tools, in order to enhance capabilities coping with severe accidents. For the research goal, firstly under the viewpoint of accident prevention, on-line risk monitoring system and the analysis framework for human error have been developed. Secondly, the training/supporting systems including the training simulator and the off-site risk evaluation system have been developed to enhance capabilities coping with severe accidents. Four kinds of research results have been obtained from this project. Firstly, the framework and taxonomy for human error analysis has been developed for accident management. As the second, the supporting system for accident managements has been developed. Using data that are obtained through the evaluation of off-site risk for Younggwang site, the risk database as well as the methodology for optimizing emergency responses has been constructed. As the third, a training support system, SAMAT, has been developed, which can be used as a training simulator for severe accident management. Finally, on-line risk monitoring system, DynaRM, has been developed for Ulchin 3 and 4 unit

Theoretical and Experimental Impact Analysis of Decision Support Systems for Advanced MCR Operators

International Nuclear Information System (INIS)

Lee, Seung Jun; Seong, Poong Hyun

2008-01-01

Human error is recognized as one of the main causes of nuclear power plant (NPP) accidents, and there have been efforts to reduce and prevent human errors by developing various operator support systems. Before adapting these support systems to actual NPPs, it is necessary to validate their reliability and to evaluate their effect on operator performance. Particularly for safety-critical systems such as NPPs, the validation and evaluation of support systems is as important as the design of good systems. Such evaluations may be carried out through a theoretical modelling or experimentation. The objective of this study is to investigate the effects of decision support systems on operator performance by both theoretical and experimental methods. The target system is an integrated decision support system including four decision support sub-systems. In the results of both the theoretical and experimental evaluations, the decision support systems revealed positive effects, and several trends were observed. (authors)

Theoretical and Experimental Impact Analysis of Decision Support Systems for Advanced MCR Operators

Energy Technology Data Exchange (ETDEWEB)

Lee, Seung Jun [Korea Atomic Energy Research Institute, 1045 Daedeok-daero, Yuseong-gu, Daejeon, 305-353 (Korea, Republic of); Seong, Poong Hyun [Korea Advanced Institute of Science and Technology, Guseong-dong, Yuseong-gu, Daejeon, 305-703 (Korea, Republic of)

2008-07-01

Human error is recognized as one of the main causes of nuclear power plant (NPP) accidents, and there have been efforts to reduce and prevent human errors by developing various operator support systems. Before adapting these support systems to actual NPPs, it is necessary to validate their reliability and to evaluate their effect on operator performance. Particularly for safety-critical systems such as NPPs, the validation and evaluation of support systems is as important as the design of good systems. Such evaluations may be carried out through a theoretical modelling or experimentation. The objective of this study is to investigate the effects of decision support systems on operator performance by both theoretical and experimental methods. The target system is an integrated decision support system including four decision support sub-systems. In the results of both the theoretical and experimental evaluations, the decision support systems revealed positive effects, and several trends were observed. (authors)

Collection of offshore human error probability data

International Nuclear Information System (INIS)

Basra, Gurpreet; Kirwan, Barry

1998-01-01

Accidents such as Piper Alpha have increased concern about the effects of human errors in complex systems. Such accidents can in theory be predicted and prevented by risk assessment, and in particular human reliability assessment (HRA), but HRA ideally requires qualitative and quantitative human error data. A research initiative at the University of Birmingham led to the development of CORE-DATA, a Computerised Human Error Data Base. This system currently contains a reasonably large number of human error data points, collected from a variety of mainly nuclear-power related sources. This article outlines a recent offshore data collection study, concerned with collecting lifeboat evacuation data. Data collection methods are outlined and a selection of human error probabilities generated as a result of the study are provided. These data give insights into the type of errors and human failure rates that could be utilised to support offshore risk analyses

Decision making strategy on rehabilitation of wide territories of the Republic of Belarus contaminated by long-lived radionuclides following the Chernobyl accident

International Nuclear Information System (INIS)

Kenigsberg, J.; Ternov, V.

2002-01-01

In the remote period following radiation accidents accompanied by wide scaled contamination of the territory by long-lived radionuclides inevitably problem of the territory rehabilitation is raised. Actually, we are speaking about difficulties, for state authorities and for society, in a decision making process aimed at taking out territories, settlements, residing and/or working people from the status of accident and at return to 'normality'. Difficulty in the decision making is caused by insufficient development of dose criteria, levels of intervention when really existing annual effective doses is less than 5 mSv, justification of usage, scales and duration of countermeasures. The laws accepted in Belarus, Russia and Ukraine following the Chernobyl accident are practicing privileges and compensation of damage to population, residing in territories with density of soil contamination by 137 Cs exceeding 37 kBq/sq.m or annual effective dose exceeding 1 mSv. This makes the idea of rehabilitation unattractive. To simplify the process of decisions making perception by society, it is suggested a step by step way of decision making aimed at rehabilitation, based on radiological and non-radiological criteria. As to radiological criteria, it is necessary to refer to a level of annual effective dose and derived values (exposure dose rate, permissible levels of contamination for foodstuffs and environment). Nonradiological criteria include psychological and social-economic factors (attractiveness of rehabilitating territories for residing and making business, reservation of some privileges, maintenance of high level of medical service). (author)

A predictive model of nuclear power plant crew decision-making and performance in a dynamic simulation environment

Science.gov (United States)

Coyne, Kevin Anthony

The safe operation of complex systems such as nuclear power plants requires close coordination between the human operators and plant systems. In order to maintain an adequate level of safety following an accident or other off-normal event, the operators often are called upon to perform complex tasks during dynamic situations with incomplete information. The safety of such complex systems can be greatly improved if the conditions that could lead operators to make poor decisions and commit erroneous actions during these situations can be predicted and mitigated. The primary goal of this research project was the development and validation of a cognitive model capable of simulating nuclear plant operator decision-making during accident conditions. Dynamic probabilistic risk assessment methods can improve the prediction of human error events by providing rich contextual information and an explicit consideration of feedback arising from man-machine interactions. The Accident Dynamics Simulator paired with the Information, Decision, and Action in a Crew context cognitive model (ADS-IDAC) shows promise for predicting situational contexts that might lead to human error events, particularly knowledge driven errors of commission. ADS-IDAC generates a discrete dynamic event tree (DDET) by applying simple branching rules that reflect variations in crew responses to plant events and system status changes. Branches can be generated to simulate slow or fast procedure execution speed, skipping of procedure steps, reliance on memorized information, activation of mental beliefs, variations in control inputs, and equipment failures. Complex operator mental models of plant behavior that guide crew actions can be represented within the ADS-IDAC mental belief framework and used to identify situational contexts that may lead to human error events. This research increased the capabilities of ADS-IDAC in several key areas. The ADS-IDAC computer code was improved to support additional

In-plant considerations for optimal offsite response to reactor accidents

International Nuclear Information System (INIS)

Burke, R.P.; Heising, C.D.; Aldrich, D.C.

1982-11-01

Offsite response decision-making methods based on in-plant conditions are developed for use during severe reactor-accident situations. Dose projections are used to eliminate all LWR plant systems except the reactor core and the spent-fuel storage pool from consideration for immediate offsite emergency response during accident situations. A simple plant information-management scheme is developed for use in offsite response decision-making. Detailed consequence calculations performed with the CRAC2 model are used to determine the appropriate timing of offsite-response implementation for a range of PWR accidents involving the reactor core. In-plant decision criteria for offsite-response implementation are defined. The definition of decision criteria is based on consideration of core-accident physical processes, in-plant accident monitoring information, and results of consequence calculations performed to determine the effectiveness of various public-protective measures. The benefits and negative aspects of the proposed response-implementation criteria are detailed

Restoration of environments affected by residues from radiological accidents: Approaches to decision making

Energy Technology Data Exchange (ETDEWEB)

NONE

2000-05-01

The International Atomic Energy Agency, jointly with the Instituto de Radioprotecao e Dosimetria of the Comissao Nacional de Energia Nuclear (CNEN), Brazil, the Forschungszentrum fuer Umwelt und Gesundheit, Institut fuer Strahlenschutz, Germany, and with the collaboration of the European Commission, held a workshop in Rio de Janeiro and Goiania, Brazil, in August 1994, on the scientific basis for decision-making after radioactive contamination of an urban environment. This volume presents the proceedings of the workshop. Eighty-eight participants from 18 Member States and 39 organizations attended the workshop. The main thrust of the workshop was to foster information exchange on the scientific basis for intervention in a de facto situation created by an accident affecting an urban area and resulting in long term human radiation exposure. The venue of the workshop was particularly appropriate. Some years before, in September 1987, an accident involving a lost radioactive source had occurred in the city of Goiania, causing serious contamination and serious injuries and deaths among members of the public. The IAEA, in close collaboration with the Brazilian authorities and with the help of an international group of senior experts, drew up and published a comprehensive appraisal of that accident so that Member States might benefit from the lessons to be learned. In 1994, seven years after that fateful event, it was felt that the time was ripe to draw further lessons and to facilitate an exchange of ideas among experts.

Restoration of environments affected by residues from radiological accidents: Approaches to decision making

International Nuclear Information System (INIS)

2000-05-01

The International Atomic Energy Agency, jointly with the Instituto de Radioprotecao e Dosimetria of the Comissao Nacional de Energia Nuclear (CNEN), Brazil, the Forschungszentrum fuer Umwelt und Gesundheit, Institut fuer Strahlenschutz, Germany, and with the collaboration of the European Commission, held a workshop in Rio de Janeiro and Goiania, Brazil, in August 1994, on the scientific basis for decision-making after radioactive contamination of an urban environment. This volume presents the proceedings of the workshop. Eighty-eight participants from 18 Member States and 39 organizations attended the workshop. The main thrust of the workshop was to foster information exchange on the scientific basis for intervention in a de facto situation created by an accident affecting an urban area and resulting in long term human radiation exposure. The venue of the workshop was particularly appropriate. Some years before, in September 1987, an accident involving a lost radioactive source had occurred in the city of Goiania, causing serious contamination and serious injuries and deaths among members of the public. The IAEA, in close collaboration with the Brazilian authorities and with the help of an international group of senior experts, drew up and published a comprehensive appraisal of that accident so that Member States might benefit from the lessons to be learned. In 1994, seven years after that fateful event, it was felt that the time was ripe to draw further lessons and to facilitate an exchange of ideas among experts

Errors and violations

International Nuclear Information System (INIS)

Reason, J.

1988-01-01

This paper is in three parts. The first part summarizes the human failures responsible for the Chernobyl disaster and argues that, in considering the human contribution to power plant emergencies, it is necessary to distinguish between: errors and violations; and active and latent failures. The second part presents empirical evidence, drawn from driver behavior, which suggest that errors and violations have different psychological origins. The concluding part outlines a resident pathogen view of accident causation, and seeks to identify the various system pathways along which errors and violations may be propagated

Cognitive decision errors and organization vulnerabilities in nuclear power plant safety management: Modeling using the TOGA meta-theory framework

International Nuclear Information System (INIS)

Cappelli, M.; Gadomski, A. M.; Sepiellis, M.; Wronikowska, M. W.

2012-01-01

In the field of nuclear power plant (NPP) safety modeling, the perception of the role of socio-cognitive engineering (SCE) is continuously increasing. Today, the focus is especially on the identification of human and organization decisional errors caused by operators and managers under high-risk conditions, as evident by analyzing reports on nuclear incidents occurred in the past. At present, the engineering and social safety requirements need to enlarge their domain of interest in such a way to include all possible losses generating events that could be the consequences of an abnormal state of a NPP. Socio-cognitive modeling of Integrated Nuclear Safety Management (INSM) using the TOGA meta-theory has been discussed during the ICCAP 2011 Conference. In this paper, more detailed aspects of the cognitive decision-making and its possible human errors and organizational vulnerability are presented. The formal TOGA-based network model for cognitive decision-making enables to indicate and analyze nodes and arcs in which plant operators and managers errors may appear. The TOGA's multi-level IPK (Information, Preferences, Knowledge) model of abstract intelligent agents (AIAs) is applied. In the NPP context, super-safety approach is also discussed, by taking under consideration unexpected events and managing them from a systemic perspective. As the nature of human errors depends on the specific properties of the decision-maker and the decisional context of operation, a classification of decision-making using IPK is suggested. Several types of initial situations of decision-making useful for the diagnosis of NPP operators and managers errors are considered. The developed models can be used as a basis for applications to NPP educational or engineering simulators to be used for training the NPP executive staff. (authors)

Cognitive decision errors and organization vulnerabilities in nuclear power plant safety management: Modeling using the TOGA meta-theory framework

Energy Technology Data Exchange (ETDEWEB)

Cappelli, M. [UTFISST, ENEA Casaccia, via Anguillarese 301, Rome (Italy); Gadomski, A. M. [ECONA, Centro Interuniversitario Elaborazione Cognitiva Sistemi Naturali e Artificiali, via dei Marsi 47, Rome (Italy); Sepiellis, M. [UTFISST, ENEA Casaccia, via Anguillarese 301, Rome (Italy); Wronikowska, M. W. [UTFISST, ENEA Casaccia, via Anguillarese 301, Rome (Italy); Poznan School of Social Sciences (Poland)

2012-07-01

In the field of nuclear power plant (NPP) safety modeling, the perception of the role of socio-cognitive engineering (SCE) is continuously increasing. Today, the focus is especially on the identification of human and organization decisional errors caused by operators and managers under high-risk conditions, as evident by analyzing reports on nuclear incidents occurred in the past. At present, the engineering and social safety requirements need to enlarge their domain of interest in such a way to include all possible losses generating events that could be the consequences of an abnormal state of a NPP. Socio-cognitive modeling of Integrated Nuclear Safety Management (INSM) using the TOGA meta-theory has been discussed during the ICCAP 2011 Conference. In this paper, more detailed aspects of the cognitive decision-making and its possible human errors and organizational vulnerability are presented. The formal TOGA-based network model for cognitive decision-making enables to indicate and analyze nodes and arcs in which plant operators and managers errors may appear. The TOGA's multi-level IPK (Information, Preferences, Knowledge) model of abstract intelligent agents (AIAs) is applied. In the NPP context, super-safety approach is also discussed, by taking under consideration unexpected events and managing them from a systemic perspective. As the nature of human errors depends on the specific properties of the decision-maker and the decisional context of operation, a classification of decision-making using IPK is suggested. Several types of initial situations of decision-making useful for the diagnosis of NPP operators and managers errors are considered. The developed models can be used as a basis for applications to NPP educational or engineering simulators to be used for training the NPP executive staff. (authors)

Application of fuzzy decision making to countermeasure strategies after a nuclear accident

International Nuclear Information System (INIS)

Liu, X.; Ruan, D.

1996-01-01

In the event of a nuclear accident, any decision on countermeasures to protect the public should be made based upon the basic principles recommended by the International Commission on Radiological Protection. The application of these principles requires that there is a balance between the cost and the averted radiation dose, taking into account many subjective factors such as social/political acceptability, psychological stress, and the confidence of the population in the authorities etc. In the framework of classical methods, it is difficult to quantify human subjective judgements and the uncertainties of data efficiently. Hence, any attempt to find the optimal solution for countermeasure strategies without deliberative sensitivity analysis can be misleading. However, fuzzy sets, with linguistic terms to describe the human subjective judgement and with fuzzy numbers to model the uncertainties of the parameters, can be introduced to eliminate these difficulties. With fuzzy rating, a fuzzy multiple attribute decision making method can rank the possible countermeasure strategies. This paper will describe the procedure of the method and present an illustrative example

Fuzzy Reasoning as a Base for Collision Avoidance Decision Support System

Directory of Open Access Journals (Sweden)

tanja brcko

2013-12-01

Full Text Available Despite the generally high qualifications of seafarers, many maritime accidents are caused by human error; such accidents include capsizing, collision, and fire, and often result in pollution. Enough concern has been generated that researchers around the world have developed the study of the human factor into an independent scientific discipline. A great deal of progress has been made, particularly in the area of artificial intelligence. But since total autonomy is not yet expedient, the decision support systems based on soft computing are proposed to support human navigators and VTS operators in times of crisis as well as during the execution of everyday tasks as a means of reducing risk levels.This paper considers a decision support system based on fuzzy logic integrated into an existing bridge collision avoidance system. The main goal is to determine the appropriate course of avoidance, using fuzzy reasoning.

Accidents and human factors

International Nuclear Information System (INIS)

Nishiwaki, Y.; Kawai, H.; Morishima, H.; Terano, T.; Sugeno, M.

1984-01-01

When the TMI accident occurred it was 4 a.m., an hour when the error potential of the operators would have been very high. The frequency of car and train accidents in Japan is also highest between 4 a.m. and 6 a.m. The error potential may be classified into five phases corresponding to the electroencephalogramic pattern (EEG). At phase 0, when the delta wave appears, a person is unconscious and in deep sleep; at phase I, when the theta wave appears, he is very tired, sleepy and subnormal; at phase II, when the alpha wave appears, he is normal, relaxed and passive; at phase III, when the beta wave appears, he is normal, clear-minded and active; at phase IV, when the strong beta or epileptic wave appears, he is hypernormal, excited and incapable of normal judgement. Should an accident occur at phase II, the brain condition may jump to phase IV. At this phase the error or accident potential is maximum. The response of the human brain to different types of noises and signals may vary somewhat for different individuals and for different groups of people. Therefore, the possibility that such differences in brain functions may influence the mental structure would be worthy of consideration in human factors and in the design of man-machine systems. Human reliability and performance would be affected by many factors: medical, physiological and psychological, etc. The uncertainty involved in human factors may not necessarily be probabilistic, but fuzzy. Therefore, it would be important to develop a theory by which both non-probabilistic uncertainties, or fuzziness, of human factors and the probabilistic properties of machines can be treated consistently. From the mathematical point of view, probabilistic measure is considered a special case of fuzzy measure. Therefore, fuzzy set theory seems to be an effective tool for analysing man-machine systems. To minimize human error and the possibility of accidents, new safety systems should not only back up man and make up for his

Criterion for adoption of urgent decision on population protection measures in case of NPP accident

International Nuclear Information System (INIS)

Konstantinov, Yu.O.

1985-01-01

The main table of a criterion for making decision about population protection measures in case of NPP accident is reconsidered. In comparison with the previous data the table doesn't contain contact irradiation and food-stuff contamination with 90 Sr and 137 Cs because of their insignificance relatively to external irradiation as a result of inert radioactive gaseous and halogen release and internal irradiation by iodine radioisotopes. Defining more exactly the criterion one should pay more attention to the discussion of numerical values of internal irradiation dose of thyroid gland. The choice of hazard-levels giving the foundation for making decision concerning protection measures should be determined both by biological radiation risk and scale of hazard relative protection urgebcy the degree of accuracy of potential irradiation or contamination evaluation by possibilities of measures carried out in time, difficulties, unfavourable psychologic effect and risk for population health. The criterion should permit flexibility in decision making according to concrete conditions

EPRI nuclear fuel-cycle accident risk assessment

International Nuclear Information System (INIS)

Anon.

1981-01-01

The present results of the nuclear fuel-cycle accident risk assessment conducted by the Electric Power Research Institute show that the total risk contribution of the nuclear fuel cycle is only approx. 1% of the accident risk of the power plant; hence, with little error, the accident risk of nuclear electric power is essentially that of the power plant itself. The power-plant risk, assuming a very large usage of nuclear power by the year 2005 is only approx. 0.5% of the radiological risk of natural background. The smallness of the fuel-cycle risk relative to the power-plant risk may be attributed to the lack of internal energy to drive an accident and the small amount of dispersible material. This work aims at a realistic assessment of the process hazards, the effectiveness of confinement and mitigation systems and procedures, and the associated likelihood of errors and the estimated size of errors. The primary probabilistic estimation tool is fault-tree analysis, with the release source terms calculated using physicochemical processes. Doses and health effects are calculated with CRAC (Consequences of Reactor Accident Code). No evacuation or mitigation is considered; source terms may be conservative through the assumption of high fuel burnup (40,000 MWd/t) and short cooling period (90 to 150 d); high-efficiency particulate air filter efficiencies are derived from experiments

Quantification of human errors in level-1 PSA studies in NUPEC/JINS

International Nuclear Information System (INIS)

Hirano, M.; Hirose, M.; Sugawara, M.; Hashiba, T.

1991-01-01

THERP (Technique for Human Error Rate Prediction) method is mainly adopted to evaluate the pre-accident and post-accident human error rates. Performance shaping factors are derived by taking Japanese operational practice into account. Several examples of human error rates with calculational procedures are presented. The important human interventions of typical Japanese NPPs are also presented. (orig./HP)

Licensing decisions and safety research related to LMFBR accidents

International Nuclear Information System (INIS)

Denise, R.P.; Speis, T.P.; Kelber, C.N.; Curtis, R.T.

1977-01-01

The licensing approach which ensures adequate protection of the public health and safety against serious accidents is described. This paper describes the role of core melt and core disruptive accidents in the design, safety research, and licensing processes, using the Clinch River Breeder Reactor (CRBR) as a focal point. Major design attention is placed on the prevention of these accidents so that the probability of core melt accidents is reduced to a sufficiently low level that they are not treated as design basis accidents. Additional requirements are placed upon the design to further reduce residual risk. This licensing process is supported by a confirmatory research program designed to provide an independent basis for licensing judgements. It has as a goal the resolution of generic safety issues prior to the establishment of a commercial LMFBR industry. The program includes accident analysis, experiments in materials interactions, aerosol transport and system integrity and planning for new safety test facilities. The problems are approached in a multi-disciplinary functional manner that identifies key safety issues and centralizes efforts to resolve them. The near term objectives of the program support the licensing of the Clinch River Breeder Reactor (CRBR) and the proposed Prototype Large Breeder Reactor (PLBR). The long term objectives of the program support the licensing of commercial LMFBRs during the late 1980's and beyond. This safety research is designed to provide an independent basis for the licensing judgements which must be made by the Nuclear Regulatory Commission

A study into the consequences of a nuclear accident

International Nuclear Information System (INIS)

Arnott, D.G.

1987-07-01

The nuclear industry in Britain would like to believe, and would like the general public to believe, that major accidents such as that at Chernobyl in 1986, could no happen in Britain, because the design and operating procedure have been made as safe as possible. However, because the designers and operators are human, they can make mistakes. Some of these are mentioned; errors of design, errors of maintenance or inspection and errors of judgement. In spite of protestations to the contrary, a major accident could occur at Sizewell-B reactor. Given that this a real possibility, plans should be drawn up to prepare for the situation. The study considers the possible consequences of a nuclear accident under the headings, human error, how nuclear fission works, radioactivity, the truth about Chernobyl, what patterns of reactor accident are possible, what can be done (this includes meteorological information, the issuing of potassium iodate tables, radiation monitoring and evacuation). Practical issues which should concern the local authorities, especially Wrekin Council, are discussed and a recommendation made for an environmental protection officer to be appointed to keep the matter under continuing review. (U.K.)

Accident Analysis and Barrier Function (AEB) Method. Manual for Incident Analysis

International Nuclear Information System (INIS)

Svenson, Ola

2000-02-01

The Accident Analysis and Barrier Function (AEB) Method models an accident or incident as a series of interactions between human and technical systems. In the sequence of human and technical errors leading to an accident there is, in principle, a possibility to arrest the development between each two successive errors. This can be done by a barrier function which, for example, can stop an operator from making an error. A barrier function can be performed by one or several barrier function systems. To illustrate, a mechanical system, a computer system or another operator can all perform a given barrier function to stop an operator from making an error. The barrier function analysis consists of analysis of suggested improvements, the effectiveness of the improvements, the costs of implementation, probability of implementation, the cost of maintaining the barrier function, the probability that maintenance will be kept up to standards and the generalizability of the suggested improvement. The AEB method is similar to the US method called HPES, but differs from that method in different ways. To exemplify, the AEB method has more emphasis on technical errors than HPES. In contrast to HPES that describes a series of events, the AEB method models only errors. This gives a more focused analysis making it well suited for checking other HPES-type accident analyses. However, the AEB method is a generic and stand-alone method that has been applied in other fields than nuclear power, such as, in traffic accident analyses

Accident Analysis and Barrier Function (AEB) Method. Manual for Incident Analysis

Energy Technology Data Exchange (ETDEWEB)

Svenson, Ola [Stockholm Univ. (Sweden). Dept. of Psychology

2000-02-01

The Accident Analysis and Barrier Function (AEB) Method models an accident or incident as a series of interactions between human and technical systems. In the sequence of human and technical errors leading to an accident there is, in principle, a possibility to arrest the development between each two successive errors. This can be done by a barrier function which, for example, can stop an operator from making an error. A barrier function can be performed by one or several barrier function systems. To illustrate, a mechanical system, a computer system or another operator can all perform a given barrier function to stop an operator from making an error. The barrier function analysis consists of analysis of suggested improvements, the effectiveness of the improvements, the costs of implementation, probability of implementation, the cost of maintaining the barrier function, the probability that maintenance will be kept up to standards and the generalizability of the suggested improvement. The AEB method is similar to the US method called HPES, but differs from that method in different ways. To exemplify, the AEB method has more emphasis on technical errors than HPES. In contrast to HPES that describes a series of events, the AEB method models only errors. This gives a more focused analysis making it well suited for checking other HPES-type accident analyses. However, the AEB method is a generic and stand-alone method that has been applied in other fields than nuclear power, such as, in traffic accident analyses.

A study on industrial accident rate forecasting and program development of estimated zero accident time in Korea.

Science.gov (United States)

Kim, Tae-gu; Kang, Young-sig; Lee, Hyung-won

2011-01-01

To begin a zero accident campaign for industry, the first thing is to estimate the industrial accident rate and the zero accident time systematically. This paper considers the social and technical change of the business environment after beginning the zero accident campaign through quantitative time series analysis methods. These methods include sum of squared errors (SSE), regression analysis method (RAM), exponential smoothing method (ESM), double exponential smoothing method (DESM), auto-regressive integrated moving average (ARIMA) model, and the proposed analytic function method (AFM). The program is developed to estimate the accident rate, zero accident time and achievement probability of an efficient industrial environment. In this paper, MFC (Microsoft Foundation Class) software of Visual Studio 2008 was used to develop a zero accident program. The results of this paper will provide major information for industrial accident prevention and be an important part of stimulating the zero accident campaign within all industrial environments.

Applying Functional Modeling for Accident Management of Nuclear Power Plant

Energy Technology Data Exchange (ETDEWEB)

Lind, Morten; Zhang Xinxin [Harbin Engineering University, Harbin (China)

2014-08-15

The paper investigate applications of functional modeling for accident management in complex industrial plant with special reference to nuclear power production. Main applications for information sharing among decision makers and decision support are identified. An overview of Multilevel Flow Modeling is given and a detailed presentation of the foundational means-end concepts is presented and the conditions for proper use in modelling accidents are identified. It is shown that Multilevel Flow Modeling can be used for modelling and reasoning about design basis accidents. Its possible role for information sharing and decision support in accidents beyond design basis is also indicated. A modelling example demonstrating the application of Multilevel Flow Modelling and reasoning for a PWR LOCA is presented.

Accident progression event tree analysis for postulated severe accidents at N Reactor

International Nuclear Information System (INIS)

Wyss, G.D.; Camp, A.L.; Miller, L.A.; Dingman, S.E.; Kunsman, D.M.; Medford, G.T.

1990-06-01

A Level II/III probabilistic risk assessment (PRA) has been performed for N Reactor, a Department of Energy (DOE) production reactor located on the Hanford reservation in Washington. The accident progression analysis documented in this report determines how core damage accidents identified in the Level I PRA progress from fuel damage to confinement response and potential releases the environment. The objectives of the study are to generate accident progression data for the Level II/III PRA source term model and to identify changes that could improve plant response under accident conditions. The scope of the analysis is comprehensive, excluding only sabotage and operator errors of commission. State-of-the-art methodology is employed based largely on the methods developed by Sandia for the US Nuclear Regulatory Commission in support of the NUREG-1150 study. The accident progression model allows complex interactions and dependencies between systems to be explicitly considered. Latin Hypecube sampling was used to assess the phenomenological and systemic uncertainties associated with the primary and confinement system responses to the core damage accident. The results of the analysis show that the N Reactor confinement concept provides significant radiological protection for most of the accident progression pathways studied

Decision theory, motor planning, and visual memory: deciding where to reach when memory errors are costly.

Science.gov (United States)

Lerch, Rachel A; Sims, Chris R

2016-06-01

Limitations in visual working memory (VWM) have been extensively studied in psychophysical tasks, but not well understood in terms of how these memory limits translate to performance in more natural domains. For example, in reaching to grasp an object based on a spatial memory representation, overshooting the intended target may be more costly than undershooting, such as when reaching for a cup of hot coffee. The current body of literature lacks a detailed account of how the costs or consequences of memory error influence what we encode in visual memory and how we act on the basis of remembered information. Here, we study how externally imposed monetary costs influence behavior in a motor decision task that involves reach planning based on recalled information from VWM. We approach this from a decision theoretic perspective, viewing decisions of where to aim in relation to the utility of their outcomes given the uncertainty of memory representations. Our results indicate that subjects accounted for the uncertainty in their visual memory, showing a significant difference in their reach planning when monetary costs were imposed for memory errors. However, our findings indicate that subjects memory representations per se were not biased by the imposed costs, but rather subjects adopted a near-optimal post-mnemonic decision strategy in their motor planning.

ATHEANA: A Technique for Human Error Analysis: An Overview of Its Methodological Basis

International Nuclear Information System (INIS)

Wreathall, John; Ramey-Smith, Ann

1998-01-01

The U.S. NRC has developed a new human reliability analysis (HRA) method, called A Technique for Human Event Analysis (ATHEANA), to provide a way of modeling the so-called 'errors of commission' - that is, situations in which operators terminate or disable engineered safety features (ESFs) or similar equipment during accident conditions, thereby putting the plant at an increased risk of core damage. In its reviews of operational events, NRC has found that these errors of commission occur with a relatively high frequency (as high as 2 or 3 per year), but are noticeably missing from the scope of most current probabilistic risk assessments (PRAs). This new method was developed through a formalized approach that describes what can occur when operators behave rationally but have inadequate knowledge or poor judgement. In particular, the method is based on models of decision-making and response planning that have been used extensively in the aviation field, and on the analysis of major accidents in both the nuclear and non-nuclear fields. Other papers at this conference present summaries of these event analyses in both the nuclear and non-nuclear fields. This paper presents an overview of ATHEANA and summarizes how the method structures the analysis of operationally significant events, and helps HRA analysts identify and model potentially risk-significant errors of commission in plant PRAs. (authors)

SAMEX: A severe accident management support expert

International Nuclear Information System (INIS)

Park, Soo-Yong; Ahn, Kwang-Il

2010-01-01

A decision support system for use in a severe accident management following an incident at a nuclear power plant is being developed which is aided by a severe accident risk database module and a severe accident management simulation module. The severe accident management support expert (SAMEX) system can provide the various types of diagnostic and predictive assistance based on the real-time plant specific safety parameters. It consists of four major modules as sub-systems: (a) severe accident risk data base module (SARDB), (b) risk-informed severe accident risk data base management module (RI-SARD), (c) severe accident management simulation module (SAMS), and (d) on-line severe accident management guidance module (on-line SAMG). The modules are integrated into a code package that executes within a WINDOWS XP operating environment, using extensive user friendly graphics control. In Korea, the integrated approach of the decision support system is being carried out under the nuclear R and D program planned by the Korean Ministry of Education, Science and Technology (MEST). An objective of the project is to develop the support system which can show a theoretical possibility. If the system is feasible, the project team will recommend the radiation protection technical support center of a national regulatory body to implement a plant specific system, which is applicable to a real accident, for the purpose of immediate and various diagnosis based on the given plant status information and of prediction of an expected accident progression under a severe accident situation.

Medical management of radiological accidents in non-specialized clinics: mistakes and lessons

International Nuclear Information System (INIS)

Jikia, D.

2009-01-01

In 1996-2002 three radiological accidents were developed in Georgia. There were some people injured in those accidents. During medical management of the injured some mistakes and errors were revealed both in diagnostics and scheme of the treatment. The goal of this article is to summarize medical management of the mentioned radiological accidents, to estimate reasons of mistakes and errors, to present the lessons drawn in result of Georgia radiological accidents. There was no clinic with specialized profile and experience. Accordingly due to having no relevant experience late diagnosis can be considered as the main error. It had direct influence on the patients' health and results of treatment. Lessons to be drawn after analyzing Georgian radiological accidents: 1. informing medical staff about radiological injuries (pathogenesis, types, symptoms, clinical course, principles of treatment and etc.); 2. organization of training and meetings in non-specialized clinics or medical institutions for medical staff; 3. preparation of informational booklets and guidelines.(author)

Explaining and predicting workplace accidents using data-mining techniques

International Nuclear Information System (INIS)

Rivas, T.; Paz, M.; Martin, J.E.; Matias, J.M.; Garcia, J.F.; Taboada, J.

2011-01-01

Current research into workplace risk is mainly conducted using conventional descriptive statistics, which, however, fail to properly identify cause-effect relationships and are unable to construct models that could predict accidents. The authors of the present study modelled incidents and accidents in two companies in the mining and construction sectors in order to identify the most important causes of accidents and develop predictive models. Data-mining techniques (decision rules, Bayesian networks, support vector machines and classification trees) were used to model accident and incident data compiled from the mining and construction sectors and obtained in interviews conducted soon after an incident/accident occurred. The results were compared with those for a classical statistical techniques (logistic regression), revealing the superiority of decision rules, classification trees and Bayesian networks in predicting and identifying the factors underlying accidents/incidents.

Explaining and predicting workplace accidents using data-mining techniques

Energy Technology Data Exchange (ETDEWEB)

Rivas, T., E-mail: trivas@uvigo.e [Dpto. Ingenieria de los Recursos Naturales y Medio Ambiente, E.T.S.I. Minas, University of Vigo, Campus Lagoas, 36310 Vigo (Spain); Paz, M., E-mail: mpaz.minas@gmail.co [Dpto. Ingenieria de los Recursos Naturales y Medio Ambiente, E.T.S.I. Minas, University of Vigo, Campus Lagoas, 36310 Vigo (Spain); Martin, J.E., E-mail: jmartin@cippinternacional.co [CIPP International, S.L. Parque Tecnologico de Asturias, Parcela 43, Oficina 11, 33428 Llanera (Spain); Matias, J.M., E-mail: jmmatias@uvigo.e [Dpto. Estadistica e Investigacion Operativa, E.T.S.I. Minas, University of Vigo, Campus Lagoas, 36310 Vigo (Spain); Garcia, J.F., E-mail: jgarcia@cippinternacional.co [CIPP International, S.L. Parque Tecnologico de Asturias, Parcela 43, Oficina 11, 33428 Llanera (Spain); Taboada, J., E-mail: jtaboada@uvigo.e [Dpto. Ingenieria de los Recursos Naturales y Medio Ambiente, E.T.S.I. Minas, University of Vigo, Campus Lagoas, 36310 Vigo (Spain)

2011-07-15

Current research into workplace risk is mainly conducted using conventional descriptive statistics, which, however, fail to properly identify cause-effect relationships and are unable to construct models that could predict accidents. The authors of the present study modelled incidents and accidents in two companies in the mining and construction sectors in order to identify the most important causes of accidents and develop predictive models. Data-mining techniques (decision rules, Bayesian networks, support vector machines and classification trees) were used to model accident and incident data compiled from the mining and construction sectors and obtained in interviews conducted soon after an incident/accident occurred. The results were compared with those for a classical statistical techniques (logistic regression), revealing the superiority of decision rules, classification trees and Bayesian networks in predicting and identifying the factors underlying accidents/incidents.

Revised Severe Accident Research Program plan, FY 1990--1992

International Nuclear Information System (INIS)

1989-08-01

For the past 10 years, since the Three Mile Island accident, the NRC has sponsored an active research program on light-water-reactor severe accidents as part of a multi-faceted approach to reactor safety. This report describes the revised Severe Accident Research Program (SARP) and how the revisions are designed to provide confirmatory information and technical support to the NRC staff in implementing the staff's Integration Plan for Closure of Severe Accident Issues as described in SECY-88-147. The revised SARP addresses both the near-term research directed at providing a technical basis upon which decisions on important containment performance issues can be made and the long-term research needed to confirm and refine our understanding of severe accidents. In developing this plan, the staff recognized that the overall goal is to reduce the uncertainties in the source term sufficiently to enable the staff to make regulatory decisions on severe accident issues. However, the staff also recognized that for some issues it may not be practical to attempt to further reduce uncertainties, and some regulatory decisions or conclusions will have to be made with full awareness of existing uncertainties. 2 figs., 1 tab

Report on a radiotherapy underdose accident

Energy Technology Data Exchange (ETDEWEB)

Christodoulides, G; Christofides, S [Medical Physics Department, Nicosia General Hospital, 1450 Nicosia (Cyprus)

1999-12-31

Reporting information on accidents and incidents involving radiation sources provides a body of knowledge which can help to prevent accidents of a similar nature. Accident information has to be made available to users, manufacturers and regulators; An international effort to pool and analyse incident and accident information will provide more complete and reliable indicators of root causes and trends and recommendations for future accident avoidance. An accident due to human error involving a superficial x-ray therapy machine and patients treated for postoperative breast cancer is reported here. 43 women receiving radiotherapy treatment have received significantly less radiation dose than the prescribed dose. The worst dose percentage within the radiation field was 20% of the prescribed dose. The worst dose percentage on the operation scar of the breast was 52% of the prescribed radiation dose. The response to accidents/incidents in radiotherapy is discussed. (authors) 4 refs., 5 figs., 1 tabs.

Methodological development for selection of significant predictors explaining fatal road accidents.

Science.gov (United States)

Dadashova, Bahar; Arenas-Ramírez, Blanca; Mira-McWilliams, José; Aparicio-Izquierdo, Francisco

2016-05-01

Identification of the most relevant factors for explaining road accident occurrence is an important issue in road safety research, particularly for future decision-making processes in transport policy. However model selection for this particular purpose is still an ongoing research. In this paper we propose a methodological development for model selection which addresses both explanatory variable and adequate model selection issues. A variable selection procedure, TIM (two-input model) method is carried out by combining neural network design and statistical approaches. The error structure of the fitted model is assumed to follow an autoregressive process. All models are estimated using Markov Chain Monte Carlo method where the model parameters are assigned non-informative prior distributions. The final model is built using the results of the variable selection. For the application of the proposed methodology the number of fatal accidents in Spain during 2000-2011 was used. This indicator has experienced the maximum reduction internationally during the indicated years thus making it an interesting time series from a road safety policy perspective. Hence the identification of the variables that have affected this reduction is of particular interest for future decision making. The results of the variable selection process show that the selected variables are main subjects of road safety policy measures. Published by Elsevier Ltd.

Construction of a technique plan repository and evaluation system based on AHP group decision-making for emergency treatment and disposal in chemical pollution accidents.

Science.gov (United States)

Shi, Shenggang; Cao, Jingcan; Feng, Li; Liang, Wenyan; Zhang, Liqiu

2014-07-15

The environmental pollution resulting from chemical accidents has caused increasingly serious concerns. Therefore, it is very important to be able to determine in advance the appropriate emergency treatment and disposal technology for different types of chemical accidents. However, the formulation of an emergency plan for chemical pollution accidents is considerably difficult due to the substantial uncertainty and complexity of such accidents. This paper explains how the event tree method was used to create 54 different scenarios for chemical pollution accidents, based on the polluted medium, dangerous characteristics and properties of chemicals involved. For each type of chemical accident, feasible emergency treatment and disposal technology schemes were established, considering the areas of pollution source control, pollutant non-proliferation, contaminant elimination and waste disposal. Meanwhile, in order to obtain the optimum emergency disposal technology schemes as soon as the chemical pollution accident occurs from the plan repository, the technique evaluation index system was developed based on group decision-improved analytical hierarchy process (AHP), and has been tested by using a sudden aniline pollution accident that occurred in a river in December 2012. Copyright © 2014 Elsevier B.V. All rights reserved.

Complex contexts and relationships affect clinical decisions in group therapy.

Science.gov (United States)

Tasca, Giorgio A; Mcquaid, Nancy; Balfour, Louise

2016-09-01

Clinical errors tend to be underreported even though examining them can provide important training and professional development opportunities. The group therapy context may be prone to clinician errors because of the added complexity within which therapists work and patients receive treatment. We discuss clinical errors that occurred within a group therapy in which a patient for whom group was not appropriate was admitted to the treatment and then was not removed by the clinicians. This was countertherapeutic for both patient and group. Two clinicians were involved: a clinical supervisor who initially assessed and admitted the patient to the group, and a group therapist. To complicate matters, the group therapy occurred within the context of a clinical research trial. The errors, possible solutions, and recommendations are discussed within Reason's Organizational Accident Model (Reason, 2000). In particular, we discuss clinician errors in the context of countertransference and clinician heuristics, group therapy as a local work condition that complicates clinical decision-making, and the impact of the research context as a latent organizational factor. We also present clinical vignettes from the pregroup preparation, group therapy, and supervision. Group therapists are more likely to avoid errors in clinical decisions if they engage in reflective practice about their internal experiences and about the impact of the context in which they work. Therapists must keep in mind the various levels of group functioning, especially related to the group-as-a-whole (i.e., group composition, cohesion, group climate, and safety) when making complex clinical decisions in order to optimize patient outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Investigate the causes of transport and tramming accidents on coal mines.

CSIR Research Space (South Africa)

Rushworth, AM

1999-03-01

Full Text Available Transport and tramming accidents on coal mines in South Africa are a major component in the overall pattern of colliery accidents. Furthermore, there is now a widespread acceptance that human error is a common cause of failure in accident patterns...

Workflow interruptions, cognitive failure and near-accidents in health care.

Science.gov (United States)

Elfering, Achim; Grebner, Simone; Ebener, Corinne

2015-01-01

Errors are frequent in health care. A specific model was tested that affirms failure in cognitive action regulation to mediate the influence of nurses' workflow interruptions and safety conscientiousness on near-accidents in health care. One hundred and sixty-five nurses from seven Swiss hospitals participated in a questionnaire survey. Structural equation modelling confirmed the hypothesised mediation model. Cognitive failure in action regulation significantly mediated the influence of workflow interruptions on near-accidents (p accidents via cognitive failure in action regulation was also significant (p accidents; moreover, cognitive failure mediated the association between compliance and near-accidents (p < .05). Contrary to expectations, compliance with safety regulations was not related to workflow interruptions. Workflow interruptions caused by colleagues, patients and organisational constraints are likely to trigger errors in nursing. Work redesign is recommended to reduce cognitive failure and improve safety of nurses and patients.

Public Speaking Apprehension, Decision-Making Errors in the Selection of Speech Introduction Strategies and Adherence to Strategy.

Science.gov (United States)

Beatty, Michael J.

1988-01-01

Examines the choice-making processes of students engaged in the selection of speech introduction strategies. Finds that the frequency of students making decision-making errors was a positive function of public speaking apprehension. (MS)

Errors, lies and misunderstandings: Systematic review on behavioural decision making in projects

DEFF Research Database (Denmark)

Stingl, Verena; Geraldi, Joana

2017-01-01

limitations—errors), pluralist (on political behaviour—lies), and contextualist (on social and organizational sensemaking—misunderstandings). Our review suggests avenues for future research with a wider coverage of theories in cognitive and social psychology and critical and mindful integration of findings...... in projects and beyond. However, the literature is fragmented and draws only on a fraction of the recent, insightful, and relevant developments on behavioural decision making. This paper organizes current research in a conceptual framework rooted in three schools of thinking—reductionist (on cognitive...

Investigation report on causes of radiation underexposure accident at Yamagata University Hospital and Prevention of Similar accident

International Nuclear Information System (INIS)

2005-01-01

The accident in the title was announced on February 18, 2004 by the hospital, which asked its investigation immediately. The group based on 4 academic societies concerned, thereby started investigations of the in-house reports on the accident and of subsequent hospital visit in March, which involved hearing from personnel concerned, physical/technological examinations and clinical evaluation, with respect to the hospital system for radiation treatment, flow of the treatment, accident details, estimation of the actual expose dose and classification of patients. The investigational group found for the actual number of patients underexposed to be 36 (63, in the in-house report) in 1,377. The cause of the accident was thought essentially the input error for the correct power coefficient 1.032 to be a wrong one 1.320 for 15 x 15 cm 4 MV X-ray. The error had been overlooked by the contract operator from the introduction of the treatment planning equipment in 1999. For prevention, setting up of quality assurance (QA) program by the hospital, the user itself, was pointed out necessary. Making the guideline for introducing the new equipment was conceivably an important work of the trader. (N.I.)

Use of classical criterions of a decision making for choice of measures on decrease of economic damage from nuclear and radiation accidents

International Nuclear Information System (INIS)

Rylov, M.I.; Kamynov, Sh.V.; Mozhaev, A.S.; Anisimov, N.A.; Nikitin, V.S.

2004-01-01

Application of classical criteria of decision making for choice of measures on the decrease of economic damage from possible nuclear and radiation accidents during spent fuel unloading from nuclear submarines and storage in the process of their utilization was demonstrated. Economic damage was chosen as optimization index, three versions of possible accidents and limited number of measures on the decrease of their effect were treated for illustration of the suggested approach. On the base of analysis of classical criteria the optimal strategy for decrease of economic damage was chosen [ru

Utilization of accident databases and fuzzy sets to estimate frequency of HazMat transport accidents

International Nuclear Information System (INIS)

Qiao Yuanhua; Keren, Nir; Mannan, M. Sam

2009-01-01

Risk assessment and management of transportation of hazardous materials (HazMat) require the estimation of accident frequency. This paper presents a methodology to estimate hazardous materials transportation accident frequency by utilizing publicly available databases and expert knowledge. The estimation process addresses route-dependent and route-independent variables. Negative binomial regression is applied to an analysis of the Department of Public Safety (DPS) accident database to derive basic accident frequency as a function of route-dependent variables, while the effects of route-independent variables are modeled by fuzzy logic. The integrated methodology provides the basis for an overall transportation risk analysis, which can be used later to develop a decision support system.

Error Detection and Error Classification: Failure Awareness in Data Transfer Scheduling

Energy Technology Data Exchange (ETDEWEB)

Louisiana State University; Balman, Mehmet; Kosar, Tevfik

2010-10-27

Data transfer in distributed environment is prone to frequent failures resulting from back-end system level problems, like connectivity failure which is technically untraceable by users. Error messages are not logged efficiently, and sometimes are not relevant/useful from users point-of-view. Our study explores the possibility of an efficient error detection and reporting system for such environments. Prior knowledge about the environment and awareness of the actual reason behind a failure would enable higher level planners to make better and accurate decisions. It is necessary to have well defined error detection and error reporting methods to increase the usability and serviceability of existing data transfer protocols and data management systems. We investigate the applicability of early error detection and error classification techniques and propose an error reporting framework and a failure-aware data transfer life cycle to improve arrangement of data transfer operations and to enhance decision making of data transfer schedulers.

ROAD TRANSPORT ACCIDENTS IN NIGERIA AND THE ROLE

Directory of Open Access Journals (Sweden)

Olasunkanmi Oriola AKINYEMI

2016-06-01

Full Text Available Analysis of road traffic accidents revealed that most accidents are as a result of drivers’ errors. Over the years, active safety systems (ASS were devised in vehicle to reduce the high level of road accidents, caused by human errors, leading to death and injuries.This study however evaluated the impacts of ASS inclusions into vehicles in Nigeria road transportation network. The objectives was to measure how ASS contributed to making driving safer and enhanced transport safety. Road accident data were collected, for a period of eleven years, from Lagos State Ministry of Economic Planning and Budget, Central Office of Statistics. Quantitative analysis of the retrospective accident was conducted by computing the proportion of yearly number of vehicles involved in road accident to the total number of vehicles for each year. Results of the analysis showed that the proportion of vehicles involved in road accidents decreased from 16 in 1996 to 0.89 in 2006, the injured persons reduced from 15.58 in 1998 to 0.3 in 2006 and the death rate diminished from 4.45 in 1998 to 0.1 in 2006. These represented 94.4%, 95% and 95% improvement respectively on road traffic safety. It can therefore be concluded that the inclusions of ASS into design of modern vehicles had improved road safety in Nigeria automotive industry.

Analysis of Communication between Main Control Room Operators in Decision-making Process in Steam Generator Tube Rupture Accident

International Nuclear Information System (INIS)

Petkov, M.; Petkov, G.

2006-01-01

The paper presents an investigation results for Main Control Room operators' reliability by Performance Evaluation of Teamwork method, based on FSS-1000 training archives in KNPP in case of Steam Generator Tube Rupture accident. The advantages of operators' teamwork are shown: a) group decision-making vs. individual one: b) positive influence of crew initiated communication consisting of orders and reports that are required by instruction. (authors)

Decisions to shoot in a weapon identification task: The influence of cultural stereotypes and perceived threat on false positive errors.

Science.gov (United States)

Fleming, Kevin K; Bandy, Carole L; Kimble, Matthew O

2010-01-01

The decision to shoot a gun engages executive control processes that can be biased by cultural stereotypes and perceived threat. The neural locus of the decision to shoot is likely to be found in the anterior cingulate cortex (ACC), where cognition and affect converge. Male military cadets at Norwich University (N=37) performed a weapon identification task in which they made rapid decisions to shoot when images of guns appeared briefly on a computer screen. Reaction times, error rates, and electroencephalogram (EEG) activity were recorded. Cadets reacted more quickly and accurately when guns were primed by images of Middle-Eastern males wearing traditional clothing. However, cadets also made more false positive errors when tools were primed by these images. Error-related negativity (ERN) was measured for each response. Deeper ERNs were found in the medial-frontal cortex following false positive responses. Cadets who made fewer errors also produced deeper ERNs, indicating stronger executive control. Pupil size was used to measure autonomic arousal related to perceived threat. Images of Middle-Eastern males in traditional clothing produced larger pupil sizes. An image of Osama bin Laden induced the largest pupil size, as would be predicted for the exemplar of Middle East terrorism. Cadets who showed greater increases in pupil size also made more false positive errors. Regression analyses were performed to evaluate predictions based on current models of perceived threat, stereotype activation, and cognitive control. Measures of pupil size (perceived threat) and ERN (cognitive control) explained significant proportions of the variance in false positive errors to Middle-Eastern males in traditional clothing, while measures of reaction time, signal detection response bias, and stimulus discriminability explained most of the remaining variance.

Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections.

Science.gov (United States)

Bailey, Stephanie L; Bono, Rose S; Nash, Denis; Kimmel, April D

2018-01-01

Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Standard error-checking techniques may not

Status of the Real-time On-line Decision Support (RODOS) system for off-site emergency management after nuclear and radiological accidents

International Nuclear Information System (INIS)

Raskov, W.; Ehrhardt, J.; Landman, C.; Pasler-Sauer, J.

2006-01-01

Under the auspices of its EURATOM Research Framework Programmes, the European Commission (EC) has supported the development of the comprehensive decision support system RODOS (Real-time On-line Decision Support) for off-site emergency management after nuclear accidents for more than a decade. Many national research programmes, research institutes and industrial collaborators contributed to the project, in particular the German Ministry of Environment, Nature Conservation and Reactor Safety (B MU). The RODOS system can be applied to accidental releases into the atmosphere and various aquatic environments within and across Europe. It provides coherent support before, during and after such a release to assist analysis of the situation and decision making about short and long-term countermeasures for mitigating the consequences with respect to health, the environment, and the economy. Appropriate interfaces exist with local and national radiological monitoring data systems, meteorological measurements and forecasts, and for the adaptation to local, regional and national conditions in Europe. Within the European Integrated Project EURANOS of the sixth Framework Programme, the RODOS system is being enhanced, among others, for radiological emergencies such as dirty bombs attacks, transport accidents and satellite crashes by extensions of the nuclide list, the source term characteristics and the atmospheric dispersion model

Adaptive error detection for HDR/PDR brachytherapy: Guidance for decision making during real-time in vivo point dosimetry

DEFF Research Database (Denmark)

Kertzscher Schwencke, Gustavo Adolfo Vladimir; Andersen, Claus E.; Tanderup, Kari

2014-01-01

Purpose:This study presents an adaptive error detection algorithm (AEDA) for real-timein vivo point dosimetry during high dose rate (HDR) or pulsed dose rate (PDR) brachytherapy (BT) where the error identification, in contrast to existing approaches, does not depend on an a priori reconstruction ......, and the AEDA’s capacity to distinguish between true and false error scenarios. The study further shows that the AEDA can offer guidance in decision making in the event of potential errors detected with real-time in vivo point dosimetry....... of the dosimeter position reconstruction. Given its nearly exclusive dependence on stable dosimeter positioning, the AEDA allows for a substantially simplified and time efficient real-time in vivo BT dosimetry implementation. Methods:In the event of a measured potential treatment error, the AEDA proposes the most...

An Approach to Human Error Hazard Detection of Unexpected Situations in NPPs

Energy Technology Data Exchange (ETDEWEB)

Park, Sangjun; Oh, Yeonju; Shin, Youmin; Lee, Yong-Hee [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2015-10-15

Fukushima accident is a typical complex event including the extreme situations induced by the succeeding earthquake, tsunami, explosion, and human errors. And it is judged with incomplete cause of system build-up same manner, procedure as a deficiency of response manual, education and training, team capability and the discharge of operator from human engineering point of view. Especially, the guidelines of current operating NPPs are not enough including countermeasures to the human errors at the extreme situations. Therefore, this paper describes a trial to detect the hazards of human errors at extreme situation, and to define the countermeasures that can properly response to the human error hazards when an individual, team, organization, and working entities that encounter the extreme situation in NPPs. In this paper we try to propose an approach to analyzing and extracting human error hazards for suggesting additional countermeasures to the human errors in unexpected situations. They might be utilized to develop contingency guidelines, especially for reducing the human error accident in NPPs. But the trial application in this study is currently limited since it is not easy to find accidents cases in detail enough to enumerate the proposed steps. Therefore, we will try to analyze as more cases as possible, and consider other environmental factors and human error conditions.

An Approach to Human Error Hazard Detection of Unexpected Situations in NPPs

International Nuclear Information System (INIS)

Park, Sangjun; Oh, Yeonju; Shin, Youmin; Lee, Yong-Hee

2015-01-01

Fukushima accident is a typical complex event including the extreme situations induced by the succeeding earthquake, tsunami, explosion, and human errors. And it is judged with incomplete cause of system build-up same manner, procedure as a deficiency of response manual, education and training, team capability and the discharge of operator from human engineering point of view. Especially, the guidelines of current operating NPPs are not enough including countermeasures to the human errors at the extreme situations. Therefore, this paper describes a trial to detect the hazards of human errors at extreme situation, and to define the countermeasures that can properly response to the human error hazards when an individual, team, organization, and working entities that encounter the extreme situation in NPPs. In this paper we try to propose an approach to analyzing and extracting human error hazards for suggesting additional countermeasures to the human errors in unexpected situations. They might be utilized to develop contingency guidelines, especially for reducing the human error accident in NPPs. But the trial application in this study is currently limited since it is not easy to find accidents cases in detail enough to enumerate the proposed steps. Therefore, we will try to analyze as more cases as possible, and consider other environmental factors and human error conditions

76 FR 55079 - Recreational Vessel Accident Reporting

Science.gov (United States)

2011-09-06

... operators to make decisions aimed at improving boating safety. This information, described in title 33 Code... Coast Guard long after an accident occurs. Incomplete, inaccurate, or late accident information makes... the recreational vessel owner or operator? If so, how many man-hours are required to collect this...

President's Commission and the normal accident

International Nuclear Information System (INIS)

Perrow, C.

1982-01-01

This chapter incorporates the major points of an analysis of the accident at Three Mile Island that I prepared in September 1979. In contrast to the findings of the President's Commission (1979), I did not view the accident as the result of operator error, an inept utility, or a negligent Nuclear Regulatory Commission but as a consequence of the complexity and interdependence that characterize the system itself. I argued that the accident was inevitable-that is, that it could not have been prevented, foreseen, or quickly terminated, because it was incomprehensible. It resembled other accidents in nuclear plants and in other high risk, complex and highly interdependent operator-machine systems; none of the accidents were caused by management or operator ineptness or by poor government regulation, though these characteristics existed and should have been expected. I maintained that the accident was normal, because in complex systems there are bound to be multiple faults that cannot be avoided by planning and that operators cannot immediately comprehend

Evaluation of human error estimation for nuclear power plants

International Nuclear Information System (INIS)

Haney, L.N.; Blackman, H.S.

1987-01-01

The dominant risk for severe accident occurrence in nuclear power plants (NPPs) is human error. The US Nuclear Regulatory Commission (NRC) sponsored an evaluation of Human Reliability Analysis (HRA) techniques for estimation of human error in NPPs. Twenty HRA techniques identified by a literature search were evaluated with criteria sets designed for that purpose and categorized. Data were collected at a commercial NPP with operators responding in walkthroughs of four severe accident scenarios and full scope simulator runs. Results suggest a need for refinement and validation of the techniques. 19 refs

Research on Human-Error Factors of Civil Aircraft Pilots Based On Grey Relational Analysis

Directory of Open Access Journals (Sweden)

Guo Yundong

2018-01-01

Full Text Available In consideration of the situation that civil aviation accidents involve many human-error factors and show the features of typical grey systems, an index system of civil aviation accident human-error factors is built using human factor analysis and classification system model. With the data of accidents happened worldwide between 2008 and 2011, the correlation between human-error factors can be analyzed quantitatively using the method of grey relational analysis. Research results show that the order of main factors affecting pilot human-error factors is preconditions for unsafe acts, unsafe supervision, organization and unsafe acts. The factor related most closely with second-level indexes and pilot human-error factors is the physical/mental limitations of pilots, followed by supervisory violations. The relevancy between the first-level indexes and the corresponding second-level indexes and the relevancy between second-level indexes can also be analyzed quantitatively.

Factors contributing to young moped rider accidents in Denmark.

Science.gov (United States)

Møller, Mette; Haustein, Sonja

2016-02-01

Young road users still constitute a high-risk group with regard to road traffic accidents. The crash rate of a moped is four times greater than that of a motorcycle, and the likelihood of being injured in a road traffic accident is 10-20 times higher among moped riders compared to car drivers. Nevertheless, research on the behaviour and accident involvement of young moped riders remains sparse. Based on analysis of 128 accident protocols, the purpose of this study was to increase knowledge about moped accidents. The study was performed in Denmark involving riders aged 16 or 17. A distinction was made between accident factors related to (1) the road and its surroundings, (2) the vehicle, and (3) the reported behaviour and condition of the road user. Thirteen accident factors were identified with the majority concerning the reported behaviour and condition of the road user. The average number of accident factors assigned per accident was 2.7. Riding speed was assigned in 45% of the accidents which made it the most frequently assigned factor on the part of the moped rider followed by attention errors (42%), a tuned up moped (29%) and position on the road (14%). For the other parties involved, attention error (52%) was the most frequently assigned accident factor. The majority (78%) of the accidents involved road rule breaching on the part of the moped rider. The results indicate that preventive measures should aim to eliminate violations and increase anticipatory skills among moped riders and awareness of mopeds among other road users. Due to their young age the effect of such measures could be enhanced by infrastructural measures facilitating safe interaction between mopeds and other road users. Copyright © 2015 Elsevier Ltd. All rights reserved.

Road Traffic Accidents in Nigeria: A Public Health Problem

African Journals Online (AJOL)

traffic accident as an issue that needs urgent attention aimed at reducing the ... include driver behaviour, visual and auditory acuity, decision making ability and reaction speed. Drug and ... Road traffic accidents have physical, social, emotional.

Do alcohol excise taxes affect traffic accidents? Evidence from Estonia.

Science.gov (United States)

Saar, Indrek

2015-01-01

This article examines the association between alcohol excise tax rates and alcohol-related traffic accidents in Estonia. Monthly time series of traffic accidents involving drunken motor vehicle drivers from 1998 through 2013 were regressed on real average alcohol excise tax rates while controlling for changes in economic conditions and the traffic environment. Specifically, regression models with autoregressive integrated moving average (ARIMA) errors were estimated in order to deal with serial correlation in residuals. Counterfactual models were also estimated in order to check the robustness of the results, using the level of non-alcohol-related traffic accidents as a dependent variable. A statistically significant (P traffic accidents was disclosed under alternative model specifications. For instance, the regression model with ARIMA (0, 1, 1)(0, 1, 1) errors revealed that a 1-unit increase in the tax rate is associated with a 1.6% decrease in the level of accidents per 100,000 population involving drunk motor vehicle drivers. No similar association was found in the cases of counterfactual models for non-alcohol-related traffic accidents. This article indicates that the level of alcohol-related traffic accidents in Estonia has been affected by changes in real average alcohol excise taxes during the period 1998-2013. Therefore, in addition to other measures, the use of alcohol taxation is warranted as a policy instrument in tackling alcohol-related traffic accidents.

Decision analytic methods in RODOS

International Nuclear Information System (INIS)

Borzenko, V.; French, S.

1996-01-01

In the event of a nuclear accident, RODOS seeks to provide decision support at all levels ranging from the largely descriptive to providing a detailed evaluation of the benefits and disadvantages of various countermeasure strategies and ranking them according to the societal preferences as perceived by the decision makers. To achieve this, it must draw upon several decision analytic methods and bring them together in a coherent manner so that the guidance offered to decision makers is consistent from one stage of an accident to the next. The methods used draw upon multi-attribute value and utility theories

A framework for assessing hydrogen management strategies involving multiple decisions

International Nuclear Information System (INIS)

Lee, S.D.; Suh, K.Y.; Park, G.C.; Jae, M.

2000-01-01

An accident management framework consisting of multiple and sequential decisions is developed and applied to a hydrogen control strategy for a reference plant. The compact influence diagrams including multiple decisions are constructed and evaluated with MAAP4 calculations. Each decision variable, represented by a node in the influence diagrams, has an uncertainty distribution. Using the values from the IPE (Individual Plant Examinations) report for the reference plant (UCN 3 and 4), the hydrogen control and accident management strategies are assessed. In this paper, a problem with two decisions is modeled for a simple illustration of the process involved. One decision is whether or not to actuate igniters at the time of core uncovery. Another decision is whether or not to turn on the containment sprays. We chose a small-break loss-of-coolant accident (LOCA) sequence, which was one of the dominant accident sequences in the reference plant. The framework involves the modeling of the decision problem by using decision-making tools, data analysis, and the MAAP4 calculations. It is shown that the proposed framework with a new measure for assessing hydrogen control is flexible enough to be applied to various accident management strategies. (author)

Identifying afterloading PDR and HDR brachytherapy errors using real-time fiber-coupled Al2O3:C dosimetry and a novel statistical error decision criterion

International Nuclear Information System (INIS)

Kertzscher, Gustavo; Andersen, Claus E.; Siebert, Frank-Andre; Nielsen, Soren Kynde; Lindegaard, Jacob C.; Tanderup, Kari

2011-01-01

Background and purpose: The feasibility of a real-time in vivo dosimeter to detect errors has previously been demonstrated. The purpose of this study was to: (1) quantify the sensitivity of the dosimeter to detect imposed treatment errors under well controlled and clinically relevant experimental conditions, and (2) test a new statistical error decision concept based on full uncertainty analysis. Materials and methods: Phantom studies of two gynecological cancer PDR and one prostate cancer HDR patient treatment plans were performed using tandem ring applicators or interstitial needles. Imposed treatment errors, including interchanged pairs of afterloader guide tubes and 2-20 mm source displacements, were monitored using a real-time fiber-coupled carbon doped aluminum oxide (Al 2 O 3 :C) crystal dosimeter that was positioned in the reconstructed tumor region. The error detection capacity was evaluated at three dose levels: dwell position, source channel, and fraction. The error criterion incorporated the correlated source position uncertainties and other sources of uncertainty, and it was applied both for the specific phantom patient plans and for a general case (source-detector distance 5-90 mm and position uncertainty 1-4 mm). Results: Out of 20 interchanged guide tube errors, time-resolved analysis identified 17 while fraction level analysis identified two. Channel and fraction level comparisons could leave 10 mm dosimeter displacement errors unidentified. Dwell position dose rate comparisons correctly identified displacements ≥5 mm. Conclusion: This phantom study demonstrates that Al 2 O 3 :C real-time dosimetry can identify applicator displacements ≥5 mm and interchanged guide tube errors during PDR and HDR brachytherapy. The study demonstrates the shortcoming of a constant error criterion and the advantage of a statistical error criterion.

The Chernobyl reactor accident - a non-accidential accident

International Nuclear Information System (INIS)

Zischka, A.

1987-01-01

Freedom and independence are reserved but for countries constantly succeeding in maintaining their energy supplies without the help of others. Due to the fact that the political decision makers of the Soviet Union, too, are aware of this truth there is more to the Chernobyl reactor accident than the mere effects of the fallout. The real consequences of the reactor accident had already been anticipated beforehand by the media of the Western world. With the voters already rattled the nuclear phaseout is constantly talked about in all political parties. Once again the law of action passes over to politicians instead of to technology and its responsible experts. Zischka proves this phenomenon in the behaviour towards Soviet reactions having been existed before and shows it to be going back to an old tradition: Already in the reign of the czar the Western neighbours were induced to react in an inadequate manner and thus excert a decisive influence on world politics. The emotional effect of Chernobyl dominates. Unless reason will gain the upper hand the dangers of this emotional effect may turn out to be uncontrollable. (orig./HP) [de

Definition of criteria related to occupational exposure for use in multi-criteria decision making process for nuclear accidents in Brazil

International Nuclear Information System (INIS)

Silva, Diogo N.G.; Guimaraes, Jean R.D.; Rochedo, Elaine R.R.

2013-01-01

After the occurrence of nuclear or radiological accidents, the selection of strategies for remediation of contaminated areas and of protective measures for members of public should be based on previously established criteria. Hence, it becomes possible to reduce the stress of population and to prevent the exposure of workers, especially if an implemented measure is not effective in reducing doses for each particular situation. When an accident with radioactive material causes environmental contamination, decisions about remediation of affected areas are complex because there are many factors associated with decontamination processes. Such complexity is related to technical procedures, public acceptance, the feasibility of implementing the measure, costs and legal aspects. This work is part of a project which aims to develop a multi-criteria tool to provide support for decision making processes in cases of nuclear or radiological accidents in Brazil. Primarily, a database containing information about protective and remediation measures for contaminated areas which can be applied nationally was created. Some criteria have already been defined for the classification of these measures regarding aspects of relevance of pathways to public exposure and of the infrastructure necessary to implement the measure. In this paper, the issues related to the exposure of the workforce are assessed and compared to the dose averted to members of the public resulting from the implementation of each remediation procedure. The procedures described in the database are then ranked according to selected criteria. In the next step, these ratings will be incorporated by the multi-criteria tool. (author)

Definition of criteria related to occupational exposure for use in multi-criteria decision making process for nuclear accidents in Brazil

Energy Technology Data Exchange (ETDEWEB)

Silva, Diogo N.G.; Guimaraes, Jean R.D., E-mail: dneves@biof.ufrj.br, E-mail: jeanrdg@biof.ufrj.br [Universidade Federal do Rio de Janeiro (UFRJ), RJ (Brazil). Instituto de Biofisica Carlos Chagas Filho; Rochedo, Elaine R.R., E-mail: elainerochedo@gmail.com [Instituto Militar de Engenharia (IME), Rio de Janeiro, RJ (Brazil). Programa de Engenharia Nuclear

2013-07-01

After the occurrence of nuclear or radiological accidents, the selection of strategies for remediation of contaminated areas and of protective measures for members of public should be based on previously established criteria. Hence, it becomes possible to reduce the stress of population and to prevent the exposure of workers, especially if an implemented measure is not effective in reducing doses for each particular situation. When an accident with radioactive material causes environmental contamination, decisions about remediation of affected areas are complex because there are many factors associated with decontamination processes. Such complexity is related to technical procedures, public acceptance, the feasibility of implementing the measure, costs and legal aspects. This work is part of a project which aims to develop a multi-criteria tool to provide support for decision making processes in cases of nuclear or radiological accidents in Brazil. Primarily, a database containing information about protective and remediation measures for contaminated areas which can be applied nationally was created. Some criteria have already been defined for the classification of these measures regarding aspects of relevance of pathways to public exposure and of the infrastructure necessary to implement the measure. In this paper, the issues related to the exposure of the workforce are assessed and compared to the dose averted to members of the public resulting from the implementation of each remediation procedure. The procedures described in the database are then ranked according to selected criteria. In the next step, these ratings will be incorporated by the multi-criteria tool. (author)

[Diving accidents. Emergency treatment of serious diving accidents].

Science.gov (United States)

Schröder, S; Lier, H; Wiese, S

2004-11-01

Decompression injuries are potentially life-threatening incidents mainly due to a rapid decline in ambient pressure. Decompression illness (DCI) results from the presence of gas bubbles in the blood and tissue. DCI may be classified as decompression sickness (DCS) generated from the liberation of gas bubbles following an oversaturation of tissues with inert gas and arterial gas embolism (AGE) mainly due to pulmonary barotrauma. People working under hyperbaric pressure, e.g. in a caisson for general construction under water, and scuba divers are exposed to certain risks. Diving accidents can be fatal and are often characterized by organ dysfunction, especially neurological deficits. They have become comparatively rare among professional divers and workers. However, since recreational scuba diving is gaining more and more popularity there is an increasing likelihood of severe diving accidents. Thus, emergency staff working close to areas with a high scuba diving activity, e.g. lakes or rivers, may be called more frequently to a scuba diving accident. The correct and professional emergency treatment on site, especially the immediate and continuous administration of normobaric oxygen, is decisive for the outcome of the accident victim. The definitive treatment includes rapid recompression with hyperbaric oxygen. The value of adjunctive medication, however, remains controversial.

Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making

Directory of Open Access Journals (Sweden)

Fisher Helen

2006-11-01

Full Text Available Abstract Background Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty. Methods Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined. Results Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments; subjects examined diagnostic advice only in 177 episodes (30%. Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%; this reduced to 32.7% following system

An Evidential Reasoning-Based CREAM to Human Reliability Analysis in Maritime Accident Process.

Science.gov (United States)

Wu, Bing; Yan, Xinping; Wang, Yang; Soares, C Guedes

2017-10-01

This article proposes a modified cognitive reliability and error analysis method (CREAM) for estimating the human error probability in the maritime accident process on the basis of an evidential reasoning approach. This modified CREAM is developed to precisely quantify the linguistic variables of the common performance conditions and to overcome the problem of ignoring the uncertainty caused by incomplete information in the existing CREAM models. Moreover, this article views maritime accident development from the sequential perspective, where a scenario- and barrier-based framework is proposed to describe the maritime accident process. This evidential reasoning-based CREAM approach together with the proposed accident development framework are applied to human reliability analysis of a ship capsizing accident. It will facilitate subjective human reliability analysis in different engineering systems where uncertainty exists in practice. © 2017 Society for Risk Analysis.

Nuclear Reactor RA Safety Report, Vol. 13, Causes of possible accidents

International Nuclear Information System (INIS)

1986-11-01

This volume includes the analysis of possible accidents on the RA research reaktor. Any unwanted action causing decrease of integrity of any of the reactor safety barriers is considered to be a reactor accident. Safety barriers are: fuel element cladding, reactor vessel, biogical shield, and reactor building. Reactor accidents can be classified in four categories: (1) accidents caused by reactivity changes; (2) accidents caused by mis function of the cooling system; (3) accidents caused by errors in fuel management and auxiliary systems; (4) accidents caused by natural or other external disasters. The analysis of possible causes of reactor accidents includes the analysis of possible impacts on the reactor itself and the environment [sr

Decision analysis and rational countermeasures in radiation protection

International Nuclear Information System (INIS)

Sinkko, K.

1991-09-01

During the past few years several international organizations (ICRP, IAEA, OECD/NEA), in revising their radiation protection principles, have emphasized the importance of the rationalization and planning of intervention after a nuclear accident. An accident itself and the introduction of protective action entails risks to the people affected, monetary costs and social disruption. Thus protective actions, often including objectives which are difficult to control simultaneously, cannot be undertaken without careful contemplation and consideration of the essential consequences of decisions. Often during an accident there is not enough time for careful consideration. Decision analysis is an analyzing and thought guiding method for the definition of objectives and comparison of options. It is an appropriate methodology assisting in rendering explicit and apparent all factors involved and evaluating their relative importance. The planning of intervention with the help of decision analysis is portion of the preparation for accident situations. In this report one of the techniques of decision analysis, multi-attribute utility analysis, is presented, as concerns its application in planning protective actions in the event of radiation accidents. (orig.)

Decisions to Shoot in a Weapon Identification Task: The Influence of Cultural Stereotypes and Perceived Threat on False Positive Errors

OpenAIRE

Fleming, Kevin K.; Bandy, Carole L.; Kimble, Matthew O.

2009-01-01

The decision to shoot engages executive control processes that can be biased by cultural stereotypes and perceived threat. The neural locus of the decision to shoot is likely to be found in the anterior cingulate cortex (ACC) where cognition and affect converge. Male military cadets at Norwich University (N=37) performed a weapon identification task in which they made rapid decisions to shoot when images of guns appeared briefly on a computer screen. Reaction times, error rates, and EEG activ...

A quarter of a century of the DBQ: some supplementary notes on its validity with regard to accidents.

Science.gov (United States)

de Winter, Joost C F; Dodou, Dimitra; Stanton, Neville A

2015-01-01

This article synthesises the latest information on the relationship between the Driver Behaviour Questionnaire (DBQ) and accidents. We show by means of computer simulation that correlations with accidents are necessarily small because accidents are rare events. An updated meta-analysis on the zero-order correlations between the DBQ and self-reported accidents yielded an overall r of .13 (fixed-effect and random-effects models) for violations (57,480 participants; 67 samples) and .09 (fixed-effect and random-effects models) for errors (66,028 participants; 56 samples). An analysis of a previously published DBQ dataset (975 participants) showed that by aggregating across four measurement occasions, the correlation coefficient with self-reported accidents increased from .14 to .24 for violations and from .11 to .19 for errors. Our meta-analysis also showed that DBQ violations (r = .24; 6353 participants; 20 samples) but not DBQ errors (r = - .08; 1086 participants; 16 samples) correlated with recorded vehicle speed. Practitioner Summary: The DBQ is probably the most widely used self-report questionnaire in driver behaviour research. This study shows that DBQ violations and errors correlate moderately with self-reported traffic accidents.

The IDA cognitive model for the analysis of nuclear power plant operator response under accident conditions. Part I: problem solving and decision making model

International Nuclear Information System (INIS)

Smidts, C.; Shen, S.H.; Mosleh, A.

1997-01-01

This paper is the first of a series of papers describing IDA which is a cognitive model for analysing the behaviour of nuclear power plant operators under accident conditions. The domain of applicability of the model is a relatively constrained environment where behaviour is significantly influenced by high levels of training and explicit requirement to follow written procedures. IDA consists of a model for individual operator behaviour and a model for control room operating crew expanded from the individual model. The model and its derivatives such as an error taxonomy and data collection approach has been designed with ultimate objective of becoming a quantitative method for human reliability analysis (HRA) in probabilistic risk assessment (PRA). The present paper gives a description of the main components of IDA such as memory structure, goals, and problem solving and decision making strategies. It also identifies factors that are at the origin of transitions between goals or between strategies. These factors cover the effects of external conditions and psychological state of the operator. The description is generic at first and then made specific to the nuclear power plant environment and more precisely to abnormal conditions

'Misclassification error' greedy heuristic to construct decision trees for inconsistent decision tables

KAUST Repository

Azad, Mohammad; Moshkov, Mikhail

2014-01-01

A greedy algorithm has been presented in this paper to construct decision trees for three different approaches (many-valued decision, most common decision, and generalized decision) in order to handle the inconsistency of multiple decisions in a decision table. In this algorithm, a greedy heuristic ‘misclassification error’ is used which performs faster, and for some cost function, results are better than ‘number of boundary subtables’ heuristic in literature. Therefore, it can be used in the case of larger data sets and does not require huge amount of memory. Experimental results of depth, average depth and number of nodes of decision trees constructed by this algorithm are compared in the framework of each of the three approaches.

Multi-objective evolutionary emergency response optimization for major accidents

International Nuclear Information System (INIS)

Georgiadou, Paraskevi S.; Papazoglou, Ioannis A.; Kiranoudis, Chris T.; Markatos, Nikolaos C.

2010-01-01

Emergency response planning in case of a major accident (hazardous material event, nuclear accident) is very important for the protection of the public and workers' safety and health. In this context, several protective actions can be performed, such as, evacuation of an area; protection of the population in buildings; and use of personal protective equipment. The best solution is not unique when multiple criteria are taken into consideration (e.g. health consequences, social disruption, economic cost). This paper presents a methodology for multi-objective optimization of emergency response planning in case of a major accident. The emergency policy with regards to protective actions to be implemented is optimized. An evolutionary algorithm has been used as the optimization tool. Case studies demonstrating the methodology and its application in emergency response decision-making in case of accidents related to hazardous materials installations are presented. However, the methodology with appropriate modification is suitable for supporting decisions in assessing emergency response procedures in other cases (nuclear accidents, transportation of hazardous materials) or for land-use planning issues.

Development of Traffic Accidents Control System

Directory of Open Access Journals (Sweden)

Andrey Borisovich Nikolaev

2015-05-01

Full Text Available Proposed a structure of traffic accidents control system included three main parts: pre-processing, decision support and monitoring. For decision support systems we propose a method that allows to make decisions on the basis of fuzzy situational management. The advantage of the method: it allows to formalize a set of typical traffic situations, using the theory of fuzzy sets and to carry out selection of the desired management action.

Developing GIS based decision-support tools for agricultural counter-measurements after radiation accident

International Nuclear Information System (INIS)

Kepka, Pavel; Prochazka, Jan; Brom, Jakub; Pecharova, Emilie

2009-01-01

There is a whole variety of possibilities proposed by EURANOS data sheets for agriculture, for mid-term and long-term counter-measures after contamination of crops by radiation. We have developed a set of supportive tools for decision-makers within the project 'Methods of evaluation of contaminated territory after radiation accident - the importance of structure and functioning of a land cover'. Our TM tools are based on ArcGIS platform and Python programming language. We have developed a simple model for estimating the current biomass of the polluted crops. Inputs for this model are: a shape file of land cover data, database table with customisable plant growth characteristics and shape file of polluted areas. The model provides a shape file data set of estimated amounts of biomass of selected crops per hectare for a given day. The results are helpful for better performing of the countermeasure 'Early removal of crops'. The total amount of polluted waste, logistic costs (transport of people and material; required time; other costs) could be estimated only with basic GIS tools. The number of days expected for the harvest can be also calculated and compared with the dose and half-lives of the contaminating radionuclides. This analysis could also lead to a 'Do nothing' decision, especially in case of radionuclides with short times of half-life. (author)

Key Characteristics of Combined Accident including TLOFW accident for PSA Modeling

Energy Technology Data Exchange (ETDEWEB)

Kim, Bo Gyung; Kang, Hyun Gook [KAIST, Daejeon (Korea, Republic of); Yoon, Ho Joon [Khalifa University of Science, Technology and Research, Abu Dhabi (United Arab Emirates)

2015-05-15

The conventional PSA techniques cannot adequately evaluate all events. The conventional PSA models usually focus on single internal events such as DBAs, the external hazards such as fire, seismic. However, the Fukushima accident of Japan in 2011 reveals that very rare event is necessary to be considered in the PSA model to prevent the radioactive release to environment caused by poor treatment based on lack of the information, and to improve the emergency operation procedure. Especially, the results from PSA can be used to decision making for regulators. Moreover, designers can consider the weakness of plant safety based on the quantified results and understand accident sequence based on human actions and system availability. This study is for PSA modeling of combined accidents including total loss of feedwater (TLOFW) accident. The TLOFW accident is a representative accident involving the failure of cooling through secondary side. If the amount of heat transfer is not enough due to the failure of secondary side, the heat will be accumulated to the primary side by continuous core decay heat. Transients with loss of feedwater include total loss of feedwater accident, loss of condenser vacuum accident, and closure of all MSIVs. When residual heat removal by the secondary side is terminated, the safety injection into the RCS with direct primary depressurization would provide alternative heat removal. This operation is called feed and bleed (F and B) operation. Combined accidents including TLOFW accident are very rare event and partially considered in conventional PSA model. Since the necessity of F and B operation is related to plant conditions, the PSA modeling for combined accidents including TLOFW accident is necessary to identify the design and operational vulnerabilities.The PSA is significant to assess the risk of NPPs, and to identify the design and operational vulnerabilities. Even though the combined accident is very rare event, the consequence of combined

PERANCANGAN COMPUTER AIDED SYSTEM DALAM MENGANALISA HUMAN ERROR DI PERKERETAAPIAN INDONESIA

Directory of Open Access Journals (Sweden)

Wiwik Budiawan

2013-06-01

Full Text Available Kecelakaan kereta api (KA yang terjadi secara beruntun di Indonesia sudah berada pada tingkat kritis. Berdasarkan data dari Direktorat Jendral Perkeretaapian, dalam kurun 5 tahun terakhir (2005-2009 total terdapat 611 kecelakaan KA.  Banyak faktor yang berkontribusi menyebabkan terjadinya kecelakaan, antara lain: sarana, prasarana, SDM operator (human error, eksternal, dan alam.  Kegagalan manusia (Human error merupakan salah satu faktor yang berpotensi menyebabkan terjadinya suatu kecelakaan KA dan dinyatakan sebagai faktor utama penyebab terjadinya suatu kecelakaan kereta api di Indonesia. Namun, tidak jelas bagaimana teknik analisis ini dilakukan. Kajian human error yang dilakukan Komite Nasional Keselamatan Transportasi (KNKT masih relatif terbatas, tidak dilengkapi dengan metode yang sistematis. Terdapat beberapa metode yang telah dikembangkan saat ini, tetapi untuk moda transportasi kereta api masih belum banyak dikembangkan. Human Factors Analysis and Classification System (HFACS merupakan metode analisis human error yang dikembangkan dan disesuaikan dengan sistem perkeretaapian Indonesia. Guna meningkatkan keandalan dalam analisis human error, HFACS kemudian dikembangkan dalam bentuk aplikasi berbasis web yang dapat diakses di komputer maupun smartphone. Hasil penelitian ini dapat dimanfaatkan oleh KNKT sebagai metode analisis kecelakaan kereta api khususnya terkait dengan human error. Kata kunci : human error, HFACS, CAS, kereta api   Abstract Train wreck (KA which occurred in quick succession in Indonesia already at a critical level. Based on data from the Directorate General of Railways, during the last 5 years (2005-2009 there were a total of 611 railway accidents. Many factors contribute to cause accidents, such as: facilities, infrastructure, human operator (human error, external, and natural. Human failure (Human error is one of the factors that could potentially cause a train accident and expressed as the main factors causing

Thermal-hydraulic uncertainties affecting severe accident progression

International Nuclear Information System (INIS)

Haskin, F.E.; Behr, V.L.

1984-01-01

To provide the proper technical bases for decisions regarding severe accidents, the US Nuclear Regulatory Commission (NRC) is sponsoring the following activities: (a) a variety of severe accident research programs, combined under the Severe Accident Research Plan; (b) nationwide task forces on containment loading, containment response, and fission product source terms; (c) a review by the American Physical Society of state-of-the-art methods for calculating radiological source terms; and (d) technical exchange meetings with the Industry Degraded Core (IDCOR) program. One of the means for integrating this developing array of technical information is the Severe Accident Risk Reduction Program (SARRP). One of the current SARRP objectives is to utilize insights gained from the activities listed above to characterize the relative likelihoods of competing containment failure modes for core-melt accidents

Opportunities for international cooperation in nuclear accident preparedness and management: Procedural and organizational measures

International Nuclear Information System (INIS)

Lathrop, J.

1989-01-01

In this paper we address a difficult problem: How can we create and maintain preparedness for nuclear accidents? Our research has shown that this can be broken down into two questions: (1) How can we maintain the resources and expertise necessary to manage an accident once it occurs? and (2) How can we develop plans that will help in actually managing an accident once it occurs? It is apparently beyond the means of ordinary human organizations to maintain the capability to respond to a rare event. (A rare event is defined as something like an accident that only happens once every five years or so, somewhere in the world.) Other more immediate pressures tend to capture the resources that should, in a cost/benefit sense, be devoted to maintaining the capability. This paper demonstrates that some of the important factors behind that phenomenon can be mitigated by an international body that promotes and enforces preparedness. Therefore this problem provides a unique opportunity for international cooperation: an international organization promoting and enforcing preparedness could help save us from our own organizational failings. Developing useful accident management plans can be viewed as a human performance problem. It can be restated: how can we support and off-load the accident managers so that their tasks are more feasible? This question reveals the decision analytic perspective of this paper. That is, we look at the problem managing a nuclear accident by focusing on the decision makers, the accident managers: how do we create a decision frame for the accident managers to best help them manage? The decision frame is outlined and discussed. 9 refs

A Preliminary Study on the Measures to Assess the Organizational Safety: The Cultural Impact on Human Error Potential

International Nuclear Information System (INIS)

Lee, Yong Hee; Lee, Yong Hee

2011-01-01

The Fukushima I nuclear accident following the Tohoku earthquake and tsunami on 11 March 2011 occurred after twelve years had passed since the JCO accident which was caused as a result of an error made by JCO employees. These accidents, along with the Chernobyl accident, associated with characteristic problems of various organizations caused severe social and economic disruptions and have had significant environmental and health impact. The cultural problems with human errors occur for various reasons, and different actions are needed to prevent different errors. Unfortunately, much of the research on organization and human error has shown widely various or different results which call for different approaches. In other words, we have to find more practical solutions from various researches for nuclear safety and lead a systematic approach to organizational deficiency causing human error. This paper reviews Hofstede's criteria, IAEA safety culture, safety areas of periodic safety review (PSR), teamwork and performance, and an evaluation of HANARO safety culture to verify the measures used to assess the organizational safety

A Preliminary Study on the Measures to Assess the Organizational Safety: The Cultural Impact on Human Error Potential

Energy Technology Data Exchange (ETDEWEB)

Lee, Yong Hee; Lee, Yong Hee [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2011-10-15

The Fukushima I nuclear accident following the Tohoku earthquake and tsunami on 11 March 2011 occurred after twelve years had passed since the JCO accident which was caused as a result of an error made by JCO employees. These accidents, along with the Chernobyl accident, associated with characteristic problems of various organizations caused severe social and economic disruptions and have had significant environmental and health impact. The cultural problems with human errors occur for various reasons, and different actions are needed to prevent different errors. Unfortunately, much of the research on organization and human error has shown widely various or different results which call for different approaches. In other words, we have to find more practical solutions from various researches for nuclear safety and lead a systematic approach to organizational deficiency causing human error. This paper reviews Hofstede's criteria, IAEA safety culture, safety areas of periodic safety review (PSR), teamwork and performance, and an evaluation of HANARO safety culture to verify the measures used to assess the organizational safety

Development of A Methodology for Assessing Various Accident Management Strategies Using Decision Tree Models

Energy Technology Data Exchange (ETDEWEB)

Kim, Nam Yeong; Kim, Jin Tae; Jae, Moo Sung [Hanyang University, Seoul (Korea, Republic of); Jerng, Dong Wook [Chung-Ang University, Seoul (Korea, Republic of)

2016-05-15

The purpose of ASP (Accident Sequence Precursor) analysis is to evaluate operational accidents in full power and low power operation by using PRA (Probabilistic Risk Assessment) technologies. The awareness of the importance of ASP analysis has been on rise. The methodology for ASP analysis has been developed in Korea, KINS (Korea Institute of Nuclear Safety) has managed KINS-ASP program since it was developed. In this study, we applied ASP analysis into operational accidents in full power and low power operation to quantify CCDP (Conditional Core Damage Probability). To reflect these 2 cases into PRA model, we modified fault trees and event trees of the existing PRA model. Also, we suggest the ASP regulatory system in the conclusion. In this study, we reviewed previous studies for ASP analysis. Based on it, we applied it into operational accidents in full power and low power operation. CCDP of these 2 cases are 1.195E-06 and 2.261E-03. Unlike other countries, there is no regulatory basis of ASP analysis in Korea. ASP analysis could detect the risk by assessing the existing operational accidents. ASP analysis can improve the safety of nuclear power plant by detecting, reviewing the operational accidents, and finally removing potential risk. Operator have to notify regulatory institute of operational accident before operator takes recovery work for the accident. After follow-up accident, they have to check precursors in data base to find similar accident.

Accidents involving specialized aircraft in agriculture aerial spraying

Directory of Open Access Journals (Sweden)

Marcelo Boamorte Ravelli

Full Text Available ABSTRACT: The great challenge for the practice of agricultural aviation has been to avoid accidents. Although, there are technological progress and high resources for safety, accidents continue to occur. The objective of this research was to analyze the influence and occurrence of factors in agricultural aviation accidents in Brazil recently. Based on research and technical - scientific papers written by researchers and aviation authorities, recommendations directed towards reducing the risks associated with this aircraft modality are assessed. The main factors responsible for accidents are normally operational errors and maneuvers that cause flight collisions, engine failures and altitude loss. Professional awareness and qualification converge towards the success of the agricultural pilot in the detection of inherent dangers or occasional in the various systems involved.

Estimating Traffic Accidents in Turkey Using Differential Evolution Algorithm

Science.gov (United States)

Akgüngör, Ali Payıdar; Korkmaz, Ersin

2017-06-01

Estimating traffic accidents play a vital role to apply road safety procedures. This study proposes Differential Evolution Algorithm (DEA) models to estimate the number of accidents in Turkey. In the model development, population (P) and the number of vehicles (N) are selected as model parameters. Three model forms, linear, exponential and semi-quadratic models, are developed using DEA with the data covering from 2000 to 2014. Developed models are statistically compared to select the best fit model. The results of the DE models show that the linear model form is suitable to estimate the number of accidents. The statistics of this form is better than other forms in terms of performance criteria which are the Mean Absolute Percentage Errors (MAPE) and the Root Mean Square Errors (RMSE). To investigate the performance of linear DE model for future estimations, a ten-year period from 2015 to 2024 is considered. The results obtained from future estimations reveal the suitability of DE method for road safety applications.

A Study on the Operation Strategy for Combined Accident including TLOFW accident

International Nuclear Information System (INIS)

Kim, Bo Gyung; Kang, Gook Young; Yoon, Ho Joon

2014-01-01

It is difficult for operators to recognize the necessity of a feed-and-bleed (F-B) operation when the loss of coolant accident and failure of secondary side occur. An F-B operation directly cools down the reactor coolant system (RCS) using the primary cooling system when residual heat removal by the secondary cooling system is not available. The plant is not always necessary the F-B operation when the secondary side is failed. It is not necessary to initiate an F-B operation in the case of a medium or large break because these cases correspond to low RCS pressure sequences when the secondary side is failed. If the break size is too small to sufficiently decrease the RCS pressure, the F-B operation is necessary. Therefore, in the case of a combined accident including a secondary cooling system failure, the provision of clear information will play a critical role in the operators' decision to initiate an F-B operation. This study focuses on the how we establish the operation strategy for combined accident including the failure of secondary side in consideration of plant and operating conditions. Previous studies have usually focused on accidents involving a TLOFW accident. The plant conditions to make the operators confused seriously are usually the combined accident because the ORP only focuses on a single accident and FRP is less familiar with operators. The relationship between CET and PCT under various plant conditions is important to decide the limitation of initiating the F-B operation to prevent core damage

Total Survey Error for Longitudinal Surveys

NARCIS (Netherlands)

Lynn, Peter; Lugtig, P.J.

2016-01-01

This article describes the application of the total survey error paradigm to longitudinal surveys. Several aspects of survey error, and of the interactions between different types of error, are distinct in the longitudinal survey context. Furthermore, error trade-off decisions in survey design and

An Artificial Neural Networks Approach to Estimate Occupational Accident: A National Perspective for Turkey

Directory of Open Access Journals (Sweden)

Hüseyin Ceylan

2014-01-01

Full Text Available Occupational accident estimation models were developed by using artificial neural networks (ANNs for Turkey. Using these models the number of occupational accidents and death and permanent incapacity numbers resulting from occupational accidents were estimated for Turkey until the year of 2025 by the three different scenarios. In the development of the models, insured workers, workplace, occupational accident, death, and permanent incapacity values were used as model parameters with data between 1970 and 2012. 2-5-1 neural network architecture was selected as the best network architecture. Sigmoid was used in hidden layers and linear function was used at output layer. The feed forward back propagation algorithm was used to train the network. In order to obtain a useful model, the network was trained between 1970 and 1999 to estimate the values of 2000 to 2012. The result was compared with the real values and it was seen that it is applicable for this aim. The performances of all developed models were evaluated using mean absolute percent errors (MAPE, mean absolute errors (MAE, and root mean square errors (RMSE.

Factors contributing to young moped rider accidents in Denmark

DEFF Research Database (Denmark)

Møller, Mette; Haustein, Sonja

2016-01-01

Young road users still constitute a high-risk group with regard to road traffic accidents. The crash rate of a moped is four times greater than that of a motorcycle, and the likelihood of being injured in a road traffic accident is 10-20 times higher among moped riders compared to car drivers...... was made between accident factors related to (1) the road and its surroundings, (2) the vehicle, and (3) the reported behaviour and condition of the road user. Thirteen accident factors were identified with the majority concerning the reported behaviour and condition of the road user. The average number...... of accident factors assigned per accident was 2.7. Riding speed was assigned in 45% of the accidents which made it the most frequently assigned factor on the part of the moped rider followed by attention errors (42%), a tuned up moped (29%) and position on the road (14%). For the other parties involved...

Interrogations to Learn from the Fukushima Accident

International Nuclear Information System (INIS)

Gisquet, E.; Jeffroy, F.

2016-01-01

On March 11, 2011, an earthquake in eastern Japan caused the reactors in operation at the Fukushima Daiichi nuclear power plant (NPP) to trip. The emergency generators started and then suddenly failed following the tsunami. The cooling water injection system no longer worked. Suddenly plunged into total darkness, the operators had to manage the accident. Starting from the official reports and testimonies on the Fukushima accident, IRSN has conducted a survey “Human and Organizational Factors Perspective on the Fukushima Nuclear Accident.” Four years after the accident, however, as more witness accounts become available, IRSN feels it useful to return to the human and organizational response to the accident inside the NPP itself. To what extent can the participants act and coordinate their actions when faced with such a dramatic situation? To what degree did their actions contribute to the disaster? Rather than looking at the causes of the accident, this study examines the unfolding of the crisis, particularly in the most urgent early stages, and draws lessons for safety culture from the decisions and actions of key actors. The main results would be presented in three key areas: 1. How to make sense of the situation? People had to make sense of what happened and create new indicators. Since instruments and controls, as well as many communication technologies, were knocked out by the tsunami, all the standard means of determining the status of the reactors were impossible. Although they were under normal circumstances almost completely dependent on these indicators, and although (or because) their lives were most directly at risk, the operators managed this uncertainty through various means that will be successively presented. 2. What are the challenges for the emergency structure? The Emergency Response Center (ERC) operations team was responsible for being in contact with the operators in the control rooms and providing them technical support as needed. The ERC

Decision support system for containment and release management

Energy Technology Data Exchange (ETDEWEB)

Oosterhuis, B [Twente Univ., Enschede (Netherlands). Computer Science Dept.

1995-09-01

The Containment and Release Management project was carried out within the Reinforced Concerted Action Programme for Accident Management Support and partly financed by the European Union. In this report a prototype of an accident management support system is presented. The support system integrates several concepts from accident management research, like safety objective trees, severe accident phenomena, calculation models and an emergency response data system. These concepts are provided by the prototype in such a way that the decision making process of accident management is supported. The prototype application is demonstrated by process data taken from a severe accident scenario for a pressurized water reactor (PWR) that was simulated with the thermohydraulic computer program MAAP. The prototype was derived from a decision support framework based on a decision theory. For established and innovative concepts from accident management research it is pointed out in which way these concepts can support accident management and how these concepts can be integrated. This approach is generic in two ways; it applies to both pressurized and boiling water reactors and it applies to both in vessel management and containment and release management. The prototype application was developed in Multimedia Toolbox 3.0 and requires at least a 386 PC with 4 MB memory, 6 MB free disk space and MS Windows 3.1. (orig.).

Decision support system for containment and release management

International Nuclear Information System (INIS)

Oosterhuis, B.

1995-09-01

The Containment and Release Management project was carried out within the Reinforced Concerted Action Programme for Accident Management Support and partly financed by the European Union. In this report a prototype of an accident management support system is presented. The support system integrates several concepts from accident management research, like safety objective trees, severe accident phenomena, calculation models and an emergency response data system. These concepts are provided by the prototype in such a way that the decision making process of accident management is supported. The prototype application is demonstrated by process data taken from a severe accident scenario for a pressurized water reactor (PWR) that was simulated with the thermohydraulic computer program MAAP. The prototype was derived from a decision support framework based on a decision theory. For established and innovative concepts from accident management research it is pointed out in which way these concepts can support accident management and how these concepts can be integrated. This approach is generic in two ways; it applies to both pressurized and boiling water reactors and it applies to both in vessel management and containment and release management. The prototype application was developed in Multimedia Toolbox 3.0 and requires at least a 386 PC with 4 MB memory, 6 MB free disk space and MS Windows 3.1. (orig.)

Radiological accident 'The Citadel' medical aspects

International Nuclear Information System (INIS)

Cardenas Herrera, Juan; Fernandez, Isis M.; Lopez, Gladys; Garcia, Omar; Lamadrid, Ana I.; Ramos, Enma O.; Villa, Rosario; Giron, Carmen M.; Escobar, Myrian; Zerpa, Miguel; Romero, Argenis H.; Medina, Julio; Laurenti, Zenia; Oliva, Maria T.; Sierra, Nitza; Lorenzo, Alexis

2008-01-01

The work exposes the medical actions carried out in the mitigation of the consequences of the accident and its main results. In a facility of storage of radioactive waste in Caracas, Venezuela, it was happened a radiological accident. This event caused radioactive contamination of the environment, as well as the irradiation and radioactive contamination of at least 10 people involved in the fact, in its majority children. Cuban institutions participated in response to the accident. Among the decisions adopted by the team of combined work Cuban-Venezuelan, we find the one of transferring affected people to Cuba, for their dosimetric and medical evaluation. Being designed a work strategy to develop the investigations to people affected by the radiological accident, in correspondence with the circumstances, magnitude and consequences of the accident. The obtained main results are: 100% presented affectations in its health, not associate directly to the accident, although the accident influenced in its psychological state. In 3 of studied people they were detected radioactive contamination with Cesium -137 with dose among 2.01 X 10-4 Sv up to 2.78 X 10-4 Sv. This accident demonstrated the necessity to have technical capacities to face these events and the importance of the international solidarity. (author)

Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon [KAERI, Daejeon (Korea, Republic of)

2012-10-15

According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail.

Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon

2012-01-01

According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail

Pattern extraction for high-risk accidents in the construction industry: a data-mining approach.

Science.gov (United States)

Amiri, Mehran; Ardeshir, Abdollah; Fazel Zarandi, Mohammad Hossein; Soltanaghaei, Elahe

2016-09-01

Accidents involving falls and falling objects (group I) are highly frequent accidents in the construction industry. While being hit by a vehicle, electric shock, collapse in the excavation and fire or explosion accidents (group II) are much less frequent, they make up a considerable proportion of severe accidents. In this study, multiple-correspondence analysis, decision tree, ensembles of decision tree and association rules methods are employed to analyse a database of construction accidents throughout Iran between 2007 and 2011. The findings indicate that in group I, there is a significant correspondence among these variables: time of accident, place of accident, body part affected, final consequence of accident and lost workdays. Moreover, the frequency of accidents in the night shift is less than others, and the frequency of injury to the head, back, spine and limbs are more. In group II, the variables time of accident and body part affected are mostly related and the frequency of accidents among married and older workers is more than single and young workers. There was a higher frequency in the evening, night shifts and weekends. The results of this study are totally in line with the previous research.

An assessment of the risk significance of human errors in selected PSAs and operating events

International Nuclear Information System (INIS)

Palla, R.L. Jr.; El-Bassioni, A.

1991-01-01

Sensitivity studies based on Probabilistic Safety Assessments (PSAs) for a pressurized water reactor and a boiling water reactor are described. In each case human errors modeled in the PSAs were categorized according to such factors as error type, location, timing, and plant personnel involved. Sensitivity studies were then conducted by varying the error rates in each category and evaluating the corresponding change in total core damage frequency and accident sequence frequency. Insights obtained are discussed and reasons for differences in risk sensitivity between plants are explored. A separate investigation into the role of human error in risk-important operating events is also described. This investigation involved the analysis of data from the USNRC Accident Sequence Precursor program to determine the effect of operator-initiated events on accident precursor trends, and to determine whether improved training can be correlated to current trends. The findings of this study are also presented. 5 refs., 15 figs., 1 tab

The information value of early career productivity in mathematics: a ROC analysis of prediction errors in bibliometricly informed decision making.

Science.gov (United States)

Lindahl, Jonas; Danell, Rickard

The aim of this study was to provide a framework to evaluate bibliometric indicators as decision support tools from a decision making perspective and to examine the information value of early career publication rate as a predictor of future productivity. We used ROC analysis to evaluate a bibliometric indicator as a tool for binary decision making. The dataset consisted of 451 early career researchers in the mathematical sub-field of number theory. We investigated the effect of three different definitions of top performance groups-top 10, top 25, and top 50 %; the consequences of using different thresholds in the prediction models; and the added prediction value of information on early career research collaboration and publications in prestige journals. We conclude that early career performance productivity has an information value in all tested decision scenarios, but future performance is more predictable if the definition of a high performance group is more exclusive. Estimated optimal decision thresholds using the Youden index indicated that the top 10 % decision scenario should use 7 articles, the top 25 % scenario should use 7 articles, and the top 50 % should use 5 articles to minimize prediction errors. A comparative analysis between the decision thresholds provided by the Youden index which take consequences into consideration and a method commonly used in evaluative bibliometrics which do not take consequences into consideration when determining decision thresholds, indicated that differences are trivial for the top 25 and the 50 % groups. However, a statistically significant difference between the methods was found for the top 10 % group. Information on early career collaboration and publication strategies did not add any prediction value to the bibliometric indicator publication rate in any of the models. The key contributions of this research is the focus on consequences in terms of prediction errors and the notion of transforming uncertainty

Impact of accidents on organizational aspects of nuclear utilities

OpenAIRE

Spurgin, A. J.; Stupples, D.

2012-01-01

This paper applies the Beer Viable Systems Model (VSM) approach to the study of nuclear accidents. It relates how organizational structures and rules are affected by accidents in the attempt to improve safety and reduce risk. The paper illustrates this process with reference to a number of accidents. The dynamic cybernetic aspect of the VSM approach to organizations yields a better understanding of the need for good decision-making to minimize risk and how organizations really operate.

Aetiological factors contributing to road traffic accidents in Riyadh City, Saudi Arabia.

Science.gov (United States)

Nofal, F H; Saeed, A A; Anokute, C C

1996-10-01

The study analysed 13,390 police records of road traffic accidents (RTAs) covering a three and a half year period according to different suspected aetiological factors. The majority of the accidents were recorded for vehicles in good condition on well-paved straight roads with well-operating traffic light systems. Adverse weather conditions such as precipitation, fog and dust were of minimal importance, with most of the accidents being reported during sunny days during the rush period of 12 noon to 3 pm. Driver's error was identified as the main contributing factor in about two thirds of all RTAs mainly as reckless driving and excess speeding. About 27% of the drivers were professional drivers and 41% were in the age group 25-35 years in good health with no alcohol or drug intake. Hence, human errors may be attributed to carelessness, experience, lack of knowledge or attention, over-exhaustion or fatigue. The effects of physical stressors on performance of drivers need to be further explored and clarified but this need not underestimate the importance of vehicle and environment since most accidents are multifactoral and a slight change in them may effectively enhance perception and minimise personal error. Recommendations for remedial measures adopting an interdisciplinary approach are presented.

Strategy generation in accident management support

International Nuclear Information System (INIS)

Sirola, M.

1995-01-01

An increased interest for research in the field of Accident Management can be noted. Several international programmes have been started in order to be able to understand the basic physical and chemical phenomena in accident conditions. A feasibility study has shown that it would be possible to design and develop a computerized support system for plant staff in accident situations. To achieve this goal the Halden Project has initiated a research programme on Computerized Accident Management Support (CAMS project). The aim is to utilize the capabilities of computerized tools to support the plant staff during the various accident stages. The system will include identification of the accident state, assessment of the future development of the accident and planning of accident mitigation strategies. A prototype is developed to support operators and the Technical Support Centre in decision making during serious accident in nuclear power plants. A rule based system has been built to take care of the strategy generation. This system assists plant personnel in planning control proposals and mitigation strategies from normal operation to severe accident conditions. The ideal of a safety objective tree and knowledge from the emergency procedures have been used. Future prediction requires good state identification of the plant status and some knowledge about the history of some critical variables. The information needs to be validated as well. Accurate calculations in simulators and a large database including all important information form the plant will help the strategy planning. (author). 12 refs, 2 figs

Decision Making Processes for a Pregnant Woman Admitted to the Accident and Emergency Department Requiring Emergency Diagnostic X-ray – A Case Study

Directory of Open Access Journals (Sweden)

S. Ismanto

2017-07-01

Full Text Available The objective of this study is to apply the decision-making processes for a pregnant woman who was involved in a motor vehicle accident and admitted to a private middle-class hospital in the capital of Indonesia requiring radiologic X-ray examination.  It also aims to examine and evaluate the patient who was in her 20th week of gestation in order to provide her with the best emergency care, diagnostic investigations and treatments.The descriptive, normative and prescriptive models of decision-making are demonstrated. The descriptive model used intuition, while the normative model used decision trees as decision options and lastly the prescriptive decision used the information processing theory (IPT to decide on the best emergency care, diagnostic investigations and treatments for the patient. The IPT dominated the decision-making process; hence an X-ray examination was done that was safe for the fetus and the childbearing mother. Decision option was not used since the patient was in pain and could not understand much of the procedure that was explained.  Intuition helped in the decision-making in order to ensure safe and effective practice.

Dorsal Anterior Cingulate Cortices Differentially Lateralize Prediction Errors and Outcome Valence in a Decision-Making Task

Directory of Open Access Journals (Sweden)

Alexander R. Weiss

2018-05-01

Full Text Available The dorsal anterior cingulate cortex (dACC is proposed to facilitate learning by signaling mismatches between the expected outcome of decisions and the actual outcomes in the form of prediction errors. The dACC is also proposed to discriminate outcome valence—whether a result has positive (either expected or desirable or negative (either unexpected or undesirable value. However, direct electrophysiological recordings from human dACC to validate these separate, but integrated, dimensions have not been previously performed. We hypothesized that local field potentials (LFPs would reveal changes in the dACC related to prediction error and valence and used the unique opportunity offered by deep brain stimulation (DBS surgery in the dACC of three human subjects to test this hypothesis. We used a cognitive task that involved the presentation of object pairs, a motor response, and audiovisual feedback to guide future object selection choices. The dACC displayed distinctly lateralized theta frequency (3–8 Hz event-related potential responses—the left hemisphere dACC signaled outcome valence and prediction errors while the right hemisphere dACC was involved in prediction formation. Multivariate analyses provided evidence that the human dACC response to decision outcomes reflects two spatiotemporally distinct early and late systems that are consistent with both our lateralized electrophysiological results and the involvement of the theta frequency oscillatory activity in dACC cognitive processing. Further findings suggested that dACC does not respond to other phases of action-outcome-feedback tasks such as the motor response which supports the notion that dACC primarily signals information that is crucial for behavioral monitoring and not for motor control.

The use of influence diagrams for evaluating severe accident management strategies

International Nuclear Information System (INIS)

Jae, M.; Apostolakis, G.E.

1992-01-01

In this paper, the influence diagram, a new analytical tool for developing and evaluating severe accident management strategies, is presented. Influence diagrams are much simpler than decision trees because they do not lead to the large number of branches that are generated when decision trees are used in realistic problems; furthermore, they show explicitly the dependencies between the variables of the problem. One of the accident management strategies proposed for light water reactors, flooding the reactor cavity as a means of preventing vessel breach during a short-term station blackout sequence, is presented. The influence diagram associated with this strategy is constructed. Finally, the advantages of using influence diagrams in accident management are explored

Regulatory research of the PWR severe accident information needs and instrumentation availability for hydrogen control and management

Energy Technology Data Exchange (ETDEWEB)

Park, Jae-Hong; Park, Gun-Chul; Suh, Kune Y.; Kang, Yun-Moon; Lee, Un-Jang; Oh, Se-Chul; Lee, Jin-Yong [Seoul Nationl Univ., Seoul (Korea, Republic of)

1998-03-15

During the current research period, we have set forth the methodology for identification of a severe accident, developed a framework for hydrogen management decision trees, and analyzed the literature on hydrogen management and experimental data for hydrogen bum. Specifically, we have summarized me results for information needs in a severe accident obtained in the U.S. and other countries, and applied the methodology to the reference plant YGN 3 and 4 as part of severe accident management. We have also examined the existing instruments in terms of their availability and survivability during a severe accident, and identified additionally needed information needs and instruments. We have identified dominant accident sequences for me reference plant YGN 3 and 4 to construct decision trees, and extracted available data from the IPE study of the plant. Based upon the data we have performed preliminary study on the decision tree and decision node. Last, we have examined various mechanisms for hydrogen generation and reIevant experimental data to predict me amount of hydrogen generation and governing factors in me process. We have also reviewed the hydrogen generation related models in the severe accident analysis.

Decision Making in Action

Science.gov (United States)

Orasanu, Judith; Statler, Irving C. (Technical Monitor)

1994-01-01

The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication

A System Supporting the Analysis of Motorway Traffic Accidents

Directory of Open Access Journals (Sweden)

Davide Anghinolfi

2015-12-01

Full Text Available This work presents a business intelligence tool for monitoring traffic accidents on motorways and supporting decisions relevant to road safety. The system manages information on road characteristics, traffic accidents and traffic volumes and produces reports for monitoring the evolution of key performance indicators for road safety, supporting decisions on actions for risk mitigation and safety improvements for road users. The paper illustrates the different types of analyses performed by the system. Pattern based analysis is used to evaluate safety performance indicators for the road sections matching defined patterns. Two different road segmentation algorithms, used to identify the most critical road sections according to various severity indicators, are presented and discussed. Differential analysis compares the value of selected severity indicators before and after the implementation of an intervention on a road. Finally, a graphical user interface allows the accident locations to be visualized and accidents with specific characteristics to be highlighted. The system was evaluated on the data collected between 2009 and 2011 for the A15 motorway in Italy, connecting Parma to La Spezia.

Accidents - Chernobyl accident; Accidents - accident de Tchernobyl

Energy Technology Data Exchange (ETDEWEB)

NONE

2004-07-01

This file is devoted to the Chernobyl accident. It is divided in four parts. The first part concerns the accident itself and its technical management. The second part is relative to the radiation doses and the different contaminations. The third part reports the sanitary effects, the determinists ones and the stochastic ones. The fourth and last part relates the consequences for the other European countries with the case of France. Through the different parts a point is tackled with the measures taken after the accident by the other countries to manage an accident, the cooperation between the different countries and the groups of research and studies about the reactors safety, and also with the international medical cooperation, specially for the children, everything in relation with the Chernobyl accident. (N.C.)

Decision Making in the Airplane

Science.gov (United States)

Orasanu, Judith; Shafto, Michael G. (Technical Monitor)

1995-01-01

The Importance of decision-making to safety in complex, dynamic environments like mission control centers, aviation, and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. Yet laboratory research on decision making has not proven especially helpful In improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multi-dimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that

An approach for assessing human decision reliability

International Nuclear Information System (INIS)

Pyy, P.

2000-01-01

This paper presents a method to study human reliability in decision situations related to nuclear power plant disturbances. Decisions often play a significant role in handling of emergency situations. The method may be applied to probabilistic safety assessments (PSAs) in cases where decision making is an important dimension of an accident sequence. Such situations are frequent e.g. in accident management. In this paper, a modelling approach for decision reliability studies is first proposed. Then, a case study with two decision situations with relatively different characteristics is presented. Qualitative and quantitative findings of the study are discussed. In very simple decision cases with time pressure, time reliability correlation proved out to be a feasible reliability modelling method. In all other decision situations, more advanced probabilistic decision models have to be used. Finally, decision probability assessment by using simulator run results and expert judgement is presented

Estimation of cost per severe accident for improvement of accident protection and consequence mitigation strategies

International Nuclear Information System (INIS)

Silva, Kampanart; Ishiwatari, Yuki; Takahara, Shogo

2013-01-01

To assess the complex situations regarding the severe accidents such as what observed in Fukushima Accident, not only radiation protection aspects but also relevant aspects: health, environmental, economic and societal aspects; must be all included into the consequence assessment. In this study, the authors introduce the “cost per severe accident” as an index to analyze the consequences of severe accidents comprehensively. The cost per severe accident consists of various costs and consequences converted into monetary values. For the purpose of improvement of the accident protection and consequence mitigation strategies, the costs needed to introduce the protective actions, and health and psychological consequences are included in the present study. The evaluations of these costs and consequences were made based on the systematic consequence analysis using level 2 and 3 probabilistic safety assessment (PSA) codes. The accident sequences used in this analysis were taken from the results of level 2 seismic PSA of a virtual 1,100 MWe BWR-5. The doses to the public and the number of people affected were calculated using the level 3 PSA code OSCAAR of Japan Atomic Energy Agency (JAEA). The calculations have been made for 248 meteorological sequences, and the outputs are given as expectation values for various meteorological conditions. Using these outputs, the cost per severe accident is calculated based on the open documents on the Fukushima Accident regarding the cost of protective actions and compensations for psychological harms. Finally, optimized accident protection and consequence mitigation strategies are recommended taking into account the various aspects comprehensively using the cost per severe accident. The authors must emphasize that the aim is not to estimate the accident cost itself but to extend the scope of “risk-informed decision making” for continuous safety improvements of nuclear energy. (author)

A study on the estimation of economic consequence of severe accident

International Nuclear Information System (INIS)

Hong, Dae Seok; Lee, Kun Jai; Jeong, Jong Tae

1996-01-01

A model to estimate economic consequence of severe accident provides some measure of the impact on the accident and enables to know the different effects of the accident described as same terms of cost and combined as necessary. Techniques to assess the consequences of accidents in terms of cost have many applications, for instance in examining countermeasure options, as part of either emergency planning or decision making after an accident. In this study, a model to estimate the accident economic consequence is developed appropriate to our country focused on PWR accident costs from a societal viewpoint. Societal costs are estimated by accounting for losses that directly affect the plant licensee, the public, the nuclear industry, or the electric utility industry after PWR accident

RA reactor safety analysis, Part II - Accident analysis; Analiza sigurnosti rada Reaktora RA I-III, Deo II - Analiza akcidenta

Energy Technology Data Exchange (ETDEWEB)

Raisic, N; Radanovic, Lj; Milovanovic, M; Afgan, N; Kulundzic, P [Institute of Nuclear Sciences Boris Kidric, Vinca, Beograd (Serbia and Montenegro)

1963-02-15

This part of the RA reactor safety analysis includes analysis of possible accidents caused by failures of the reactor devices and errors during reactor operation. Two types of accidents are analyzed: accidents resulting from uncontrolled reactivity increase, and accidents caused by interruption of cooling.

Lessons from the Fukushima nuclear power accident

International Nuclear Information System (INIS)

Hatamura, Yotaro

2013-01-01

Through the investigation of the Fukushima Nuclear Power Accident as the chairman of the related Government's Committee, many things had been considered. Essence of the accident could be not only what occurred in the Fukushima nuclear power station, but also dispersed radioactive materials forced many residents to move and not to be returned. Such events as indication errors of water level meter occurring in severe accident could no be thought and remote mechanical operation of valves under high radiation environment were not prepared. Contamination by radioactive clouds caused the evacuation of residents for a long period. Lessons learned from the accident were described such as; (1) the verification of the road to failure connecting selected accident sequence and road to success with another supposed choice, (2) considering what might occur and then what should be needed on the contrary, (3) nuclear power, if should be continued, should be used with the premise of its hazards, and (4) advise to nuclear engineer for adequate information dissemination and technical explanation to the public and keeping nuclear technologies alive. (T. Tanaka)

Developing a knowledge base for the management of severe accidents

International Nuclear Information System (INIS)

Nelson, W.R.; Jenkins, J.P.

1986-01-01

Prior to the accident at Three Mile Island, little attention was given to the development of procedures for the management of severe accidents, that is, accidents in which the reactor core is damaged. Since TMI, however, significant effort has been devoted to developing strategies for severe accident management. At the same time, the potential application of artificial intelligence techniques, particularly expert systems, to complex decision-making tasks such as accident diagnosis and response has received considerable attention. The need to develop strategies for accident management suggests that a computerized knowledge base such as used by an expert system could be developed to collect and organize knowledge for severe accident management. This paper suggests a general method which could be used to develop such a knowledge base, and how it could be used to enhance accident management capabilities

United States position on severe accidents

International Nuclear Information System (INIS)

Ross, D.F.

1988-01-01

The United States policy on severe accidents was published in 1985 for both new plant applications and for existing plants. Implementation of this policy is in progress. This policy, aided by a related safety goal policy and by analysis capabilities emerging from improved understanding of accident phenomenology, is viewed as a logical development from the pioneering work in the WASH-1400 Reactor Safety Study published by the United States Nuclear Regulatory Commission (NRC) in 1975. This work provided an estimate of the probability and consequences of severe accidents which, prior to that time, had been mostly evaluated by somewhat arbitrary assumptions dating back 30 years. The early history of severe accident evaluation is briefly summarized for the period 1957-1979. Then, the galvanizing action of Three Mile Island Unit 2 (TMI-2) on severe accident analysis, experimentation and regulation is reviewed. Expressions of US policy in the form of rulemaking, severe accident policy, safety research, safety goal policy and court decisions (on adequacy of safety) are discussed. Finally, the NRC policy as of March 1988 is stated, along with a prospective look at the next few years. (author). 19 refs

Hypothetical accidents of light-water moderated nuclear power plants in the framework of emergency planning

International Nuclear Information System (INIS)

1979-07-01

Hypothetical accidents in nuclear power plants are events which by definition can have a devastating impact on the surroundings of the plant. Apart from an adequate plant design, the protection of the population in case of an accident is covered by the emergency planning. Of major importance are the measures for the short-term emergency protection. The decision on whether these measures are applied has to be based on appropriate measurements within the plant. The aim and achieved result of this investigation is to specify accident types. They serve as operational decision making criteria to determine the necessary measurements for analysing the accident in the accident situation, and to provide indications for choosing the suitable strategy for the protection measures. (orig.) [de

Human Error Assessmentin Minefield Cleaning Operation Using Human Event Analysis

Directory of Open Access Journals (Sweden)

Mohammad Hajiakbari

2015-12-01

Full Text Available Background & objective: Human error is one of the main causes of accidents. Due to the unreliability of the human element and the high-risk nature of demining operations, this study aimed to assess and manage human errors likely to occur in such operations. Methods: This study was performed at a demining site in war zones located in the West of Iran. After acquiring an initial familiarity with the operations, methods, and tools of clearing minefields, job task related to clearing landmines were specified. Next, these tasks were studied using HTA and related possible errors were assessed using ATHEANA. Results: de-mining task was composed of four main operations, including primary detection, technical identification, investigation, and neutralization. There were found four main reasons for accidents occurring in such operations; walking on the mines, leaving mines with no action, error in neutralizing operation and environmental explosion. The possibility of human error in mine clearance operations was calculated as 0.010. Conclusion: The main causes of human error in de-mining operations can be attributed to various factors such as poor weather and operating conditions like outdoor work, inappropriate personal protective equipment, personality characteristics, insufficient accuracy in the work, and insufficient time available. To reduce the probability of human error in de-mining operations, the aforementioned factors should be managed properly.

[Frequently accidents and injury at school].

Science.gov (United States)

Gautier Vargas, María; Martínez González, Vanesa

2011-01-01

During the time we have been in a private company that provide schools with medical care, we were surprised by the frequent and constant phone calls received to ask for our services. This fact made us take the decision to carry out a survey to find out the accidents and the most frequent injuries. According to the retrospective study we realized throughout two different academic courses in several schools in Cantabria, the 3.23% of the students have any accidents or injuries. We found out children between 11 and 15 have the highest accident rate, being 10.8 % higher when boys (rather than girls) are involved. The most common injuries are contusions 42.85%, followed by sprains 23.45%, being blows the reason in 42% of the cases, and surprisingly acts of aggression in 1%. It was also unexpected to learn that gyms, where children are taught in physical education, have the highest percent on accident rate. All these inquiries lead us to think that age, play and sports are determinant factors in the accidents happened in the school area.

Decision making under uncertainty: An investigation into the application of formal decision-making methods to safety issue decisions

International Nuclear Information System (INIS)

Bohn, M.P.

1992-12-01

As part of the NRC-sponsored program to study the implications of Generic Issue 57, ''Effects of Fire Protection System Actuation on Safety-Related Equipment,'' a subtask was performed to evaluate the applicability of formal decision analysis methods to generic issues cost/benefit-type decisions and to apply these methods to the GI-57 results. In this report, the numerical results obtained from the analysis of three plants (two PWRs and one BWR) as developed in the technical resolution program for GI-57 were studied. For each plant, these results included a calculation of the person-REM averted due to various accident scenarios and various proposed modifications to mitigate the accident scenarios identified. These results were recomputed to break out the benefit in terms of contributions due to random event scenarios, fire event scenarios, and seismic event scenarios. Furthermore, the benefits associated with risk (in terms of person-REM) averted from earthquakes at three different seismic ground motion levels were separately considered. Given this data, formal decision methodologies involving decision trees, value functions, and utility functions were applied to this basic data. It is shown that the formal decision methodology can be applied at several different levels. Examples are given in which the decision between several retrofits is changed from that resulting from a simple cost/benefit-ratio criterion by virtue of the decision-makinger's expressed (and assumed) preferences

Trial application of a technique for human error analysis (ATHEANA)

International Nuclear Information System (INIS)

Bley, D.C.; Cooper, S.E.; Parry, G.W.

1996-01-01

The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context

Swedish REGULATORY APPROACH TO SAFETY Assessment AND SEVERE ACCIDENT MANAGEMENT

International Nuclear Information System (INIS)

Frid, W.; Sandervaag, O.

1997-01-01

The Swedish regulatory approach to safety assessment and severe accident management is briefly described. The safety assessment program, which focuses on prevention of incidents and accidents, has three main components: periodic safety reviews, probabilistic safety analysis, and analysis of postulated disturbances and accident progression sequences. Management and man-technology-organisation issues, as well as inspections, play a key role in safety assessment. Basis for severe accident management were established by the Government decisions in 1981 and 1986. By the end of 1988, the severe accident mitigation systems and emergency operating procedures were implemented at all Swedish reactors. The severe accident research has continued after 1988 for further verification of the protection provided by the systems and reduction of remaining uncertainties in risk dominant phenomena

Rapid and reliable predictions of the radiological consequences of accidents as an aid to decisions on countermeasures

International Nuclear Information System (INIS)

Kelly, G.N.

1990-01-01

The rapid and reliable assessment of the potential radiological consequences of an accident at a nuclear installation is an essential input to timely decisions on the effective introduction of countermeasures. There have been considerable improvements over the past decade or so in the methods used for such assessments and, in particular, in the development of computerized systems. The need for such systems is described, together with their current state of development and possible future trends. This topic has featured prominently within the CEC's Radiation Protection Research Programme and is likely to do so far the foreseeable future. The main features of this research, its achievements to date and future directions are described

Medication errors: prescribing faults and prescription errors.

Science.gov (United States)

Velo, Giampaolo P; Minuz, Pietro

2009-06-01

1. Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. 2. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. 3. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. 4. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. 5. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.

Development of an Accident Diagnostic Scheme Using Artificial Intelligence Techniques (I)

Energy Technology Data Exchange (ETDEWEB)

Na, M. G.; Lee, S. H.; Kim, D. S.; No, Y. G.; Lee, S. W. [Chosun University, Gwangju (Korea, Republic of); Ahn, K. I. [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2010-06-15

As a means to effectively manage the severe nuclear accidents, it is important to identify and diagnose the accident initiating events during an initial short time interval after the accidents by observing the major controlling parameters. Main objective of this study is to develop the diagnostic approach for the accurate prediction of accident initiating events using artificial intelligence techniques. For this, first, a variety of artificial intelligence techniques such as Finn, Gmbh, and Sm were examined through this study. Among them, Sc and Gmbh model were assessed as a useful approach to predict the break location and the break size of Local. In order to verify the proposed algorithm, the 111 accident simulation data (based on Map) were applied to train the Sc and Gmbh models, and the test data was used to independently verify whether or not the SVC and GMDH models work well. The analysis of the maximum errors and RMS errors, and the performance of the GMDH according to the existence of measurement errors and SIS actuation showed that the proposed SVC and GMDH models can accurately classify the break locations and accurately predict the break size. As the time-integrated signals were used for inputs into the GMDH model within a period of 60 second after a reactor scram, the actuation of the safety systems such as safety injection system (SIS), auxiliary feed water system, and containment spray system, were not considered in this study. It is because the initial 60 second time-integrated signals were used and the safety systems usually start to actuate after a more than 60 second time delay after the reactor scram

Development of an Accident Diagnostic Scheme Using Artificial Intelligence Techniques (I)

International Nuclear Information System (INIS)

Na, M. G.; Lee, S. H.; Kim, D. S.; No, Y. G.; Lee, S. W.; Ahn, K. I.

2010-06-01

As a means to effectively manage the severe nuclear accidents, it is important to identify and diagnose the accident initiating events during an initial short time interval after the accidents by observing the major controlling parameters. Main objective of this study is to develop the diagnostic approach for the accurate prediction of accident initiating events using artificial intelligence techniques. For this, first, a variety of artificial intelligence techniques such as Finn, Gmbh, and Sm were examined through this study. Among them, Sc and Gmbh model were assessed as a useful approach to predict the break location and the break size of Local. In order to verify the proposed algorithm, the 111 accident simulation data (based on Map) were applied to train the Sc and Gmbh models, and the test data was used to independently verify whether or not the SVC and GMDH models work well. The analysis of the maximum errors and RMS errors, and the performance of the GMDH according to the existence of measurement errors and SIS actuation showed that the proposed SVC and GMDH models can accurately classify the break locations and accurately predict the break size. As the time-integrated signals were used for inputs into the GMDH model within a period of 60 second after a reactor scram, the actuation of the safety systems such as safety injection system (SIS), auxiliary feed water system, and containment spray system, were not considered in this study. It is because the initial 60 second time-integrated signals were used and the safety systems usually start to actuate after a more than 60 second time delay after the reactor scram

Compact disk error measurements

Science.gov (United States)

Howe, D.; Harriman, K.; Tehranchi, B.

1993-01-01

The objectives of this project are as follows: provide hardware and software that will perform simple, real-time, high resolution (single-byte) measurement of the error burst and good data gap statistics seen by a photoCD player read channel when recorded CD write-once discs of variable quality (i.e., condition) are being read; extend the above system to enable measurement of the hard decision (i.e., 1-bit error flags) and soft decision (i.e., 2-bit error flags) decoding information that is produced/used by the Cross Interleaved - Reed - Solomon - Code (CIRC) block decoder employed in the photoCD player read channel; construct a model that uses data obtained via the systems described above to produce meaningful estimates of output error rates (due to both uncorrected ECC words and misdecoded ECC words) when a CD disc having specific (measured) error statistics is read (completion date to be determined); and check the hypothesis that current adaptive CIRC block decoders are optimized for pressed (DAD/ROM) CD discs. If warranted, do a conceptual design of an adaptive CIRC decoder that is optimized for write-once CD discs.

Applying Functional Modeling for Accident Management of Nuclear Power Plant

DEFF Research Database (Denmark)

Lind, Morten; Zhang, Xinxin

2014-01-01

Modeling is given and a detailed presentation of the foundational means-end concepts is presented and the conditions for proper use in modelling accidents are identified. It is shown that Multilevel Flow Modeling can be used for modelling and reasoning about design basis accidents. Its possible role...... for information sharing and decision support in accidents beyond design basis is also indicated. A modelling example demonstrating the application of Multilevel Flow Modelling and reasoning for a PWR LOCA is presented...

Applying Functional Modeling for Accident Management of Nucler Power Plant

DEFF Research Database (Denmark)

Lind, Morten; Zhang, Xinxin

2014-01-01

Modeling is given and a detailed presentation of the foundational means-end concepts is presented and the conditions for proper use in modelling accidents are identified. It is shown that Multilevel Flow Modeling can be used for modelling and reasoning about design basis accidents. Its possible role...... for information sharing and decision support in accidents beyond design basis is also indicated. A modelling example demonstrating the application of Multilevel Flow Modelling and reasoning for a PWR LOCA is presented....

Minimizing driver errors: examining factors leading to failed target tracking and detection.

Science.gov (United States)

2013-06-01

Driving a motor vehicle is a common practice for many individuals. Although driving becomes : repetitive and a very habitual task, errors can occur that lead to accidents. One factor that can be a : cause for such errors is a lapse in attention or a ...

Cognitive processes in anesthesiology decision making.

Science.gov (United States)

Stiegler, Marjorie Podraza; Tung, Avery

2014-01-01

The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.

Daytime sleepiness, sleep habits and occupational accidents among hospital nurses.

Science.gov (United States)

Suzuki, Kenshu; Ohida, Takashi; Kaneita, Yoshitaka; Yokoyama, Eise; Uchiyama, Makoto

2005-11-01

This paper reports a study to determine the prevalence of excessive daytime sleepiness and sleep habits among hospital nurses and to analyse associations between excessive daytime sleepiness and different types of medical error. It has been reported that sleep disorders, and the tiredness and sleepiness brought about by sleep disorders may be associated with occupational accidents. However, to our knowledge, there has so far been no report on associations between sleep disorders, excessive daytime sleepiness in particular, and occupational accidents among hospital nurses. The study was a cross-sectional study targeting 4407 nurses working in eight large general hospitals in Japan. An anonymous self-administered questionnaire was used to investigate their sleep patterns and experience of occupational accidents. The data were collected in 2003. The prevalence of excessive daytime sleepiness among hospital nurses in the present study was 26.0%. A statistically significant relationship was observed between having or not having occupational accidents during the past 12 months and excessive daytime sleepiness. Multiple logistic regression analyses on factors leading to occupational accidents during the past 12 months showed statistically significant associations between (1) drug administration errors and (2) shift work and age, between (1) incorrect operation of medical equipment and (2) excessive daytime sleepiness and age, and between needlestick injuries and age. Excessive daytime sleepiness is an important occupational health issue in hospital nurses. It is possible that occupational policies and health promotion measures, such as a provision of sleep hygiene advice and social support at worksites, would be effective in preventing occupational accidents among hospital nurses.

Arabian, Asian, western: a cross-cultural comparison of aircraft accidents from human factor perspectives.

Science.gov (United States)

Al-Wardi, Yousuf

2017-09-01

Rates of aviation accident differ in different regions; and national culture has been implicated as a factor. This invites a discussion about the role of national culture in aviation accidents. This study makes a cross-cultural comparison between Oman, Taiwan and the USA. A cross-cultural comparison was acquired using data from three studies, including this study, by applying the Human Factors Analysis and Classification System (HFACS) framework. The Taiwan study presented 523 mishaps with 1762 occurrences of human error obtained from the Republic of China Air Force. The study from the USA carried out for commercial aviation had 119 accidents with 245 instances of human error. This study carried out in Oman had a total of 40 aircraft accidents with 129 incidences. Variations were found between Oman, Taiwan and the USA at the levels of organisational influence and unsafe supervision. Seven HFACS categories showed significant differences between the three countries (p culture can have an impact on aviation safety. This study revealed that national culture plays a role in aircraft accidents related to human factors that cannot be disregarded.

Industrial Safety and Accidents Prevention

International Nuclear Information System (INIS)

Sajjad Akbar

2006-01-01

Accident Hazards, dangers, losses and risk are what we would to like to eliminate, minimize or avoid in industry. Modern industries have created many opportunities for these against which man's primitive instincts offer no protection. In today's complex industrial environment safety has become major preoccupation, especially after the realization that there is a clear economic incentive to do so. Industrial hazards may cause by human error or by physical or mechanical malfunction, it is very often possible to eliminate the worst consequences of human error by engineering modification. But the modification also needs checking very thoroughly to ensue that it has not introduced some new and unsuspected hazard. (author)

A review of severe accident assessment

International Nuclear Information System (INIS)

Kawashima, Kei

2000-01-01

One of the most difficult problems on evaluation of external costs on nuclear power generation is value on a severe accident risk. Once forming a severe accident, its effect is very important and extends to a wide range, to give a lot of damages. It is a main area of study on externality of energy to compare various risks by means of price conversion at unit kWh. Here was outlined on research examples on main severe accident risks before then. A common fact on estimation cost such research examples is to limit it to direct cost (mainly to health damage) at accident phenomenon. As an actual problem, it is very difficult to substantially quantify such parameters because of basically belonging to social psychology. It is due to no finding out decisive evaluation method on this problem to be adopted conventional EED (Expert Expected Damages) approach in the ExternE Phase III, either. (G.K.)

Nuclear power plant severe accident research plan. Revision 1

International Nuclear Information System (INIS)

Marino, G.P.

1986-04-01

Subsequent to the Three Mile Island Unit 2 accident, recommendations were made by a number of review committees to consider regulatory changes which would provide better protection of the public from severe accidents. Over the past six years a major research effort has been underway by the NRC to develop an improved understanding of severe accidents and to provide a technical basis to support regulatory decisions. The purpose of this report is to describe current plans for the completion and extension of this research in support of ongoing regulatory actions in this area

Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

National Research Council Canada - National Science Library

Shappell, Scott A; Detwiler, Cristy A; Holcomb, Kali A; Hackworth, Carla A; Boquet, Albert J; Wiegmann, Douglas A

2006-01-01

.... The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with 14 CFR Part 121...

A framework for the assessment of severe accident management strategies

International Nuclear Information System (INIS)

Kastenberg, W.E.; Apostolakis, G.; Dhir, V.K.

1993-09-01

Severe accident management can be defined as the use of existing and/or altemative resources, systems and actors to prevent or mitigate a core-melt accident. For each accident sequence and each combination of severe accident management strategies, there may be several options available to the operator, and each involves phenomenological and operational considerations regarding uncertainty. Operational uncertainties include operator, system and instrumentation behavior during an accident. A framework based on decision trees and influence diagrams has been developed which incorporates such criteria as feasibility, effectiveness, and adverse effects, for evaluating potential severe accident management strategies. The framework is also capable of propagating both data and model uncertainty. It is applied to several potential strategies including PWR cavity flooding, BWR drywell flooding, PWR depressurization and PWR feed and bleed

A framework for the assessment of severe accident management strategies

Energy Technology Data Exchange (ETDEWEB)

Kastenberg, W.E. [ed.; Apostolakis, G.; Dhir, V.K. [California Univ., Los Angeles, CA (United States). Dept. of Mechanical, Aerospace and Nuclear Engineering] [and others

1993-09-01

Severe accident management can be defined as the use of existing and/or altemative resources, systems and actors to prevent or mitigate a core-melt accident. For each accident sequence and each combination of severe accident management strategies, there may be several options available to the operator, and each involves phenomenological and operational considerations regarding uncertainty. Operational uncertainties include operator, system and instrumentation behavior during an accident. A framework based on decision trees and influence diagrams has been developed which incorporates such criteria as feasibility, effectiveness, and adverse effects, for evaluating potential severe accident management strategies. The framework is also capable of propagating both data and model uncertainty. It is applied to several potential strategies including PWR cavity flooding, BWR drywell flooding, PWR depressurization and PWR feed and bleed.

Legal responsibility in case of a nuclear accident

International Nuclear Information System (INIS)

Nabhane, M. F.

1988-01-01

Numerous laws have been elaborated in order to determine the legal responsibility in case of a nuclear accident. These laws were made necessary because of intervention of the factor 'error' in the nuclear accident. The legal definition of 'error' assumes that it results from non-respect or negligence of established norms on the part of the persons who manipulate the instruments of radioactive production. Nuclear research should not be undertaken in a country without the formal engagement of the central authorities to take the necessary dispositions to ensure the security and safety of the populations and their possessions. The world community should not admit a scientific activity in the nuclear field in the absence of guarantees for the safety and the security of man. The state that permits the production of nuclear energy is legally responsible for any failure that might result in radioactive spills. Considering the possibility of error and the dangers attached to the manipulation of radioactive material, the legislators have elaborated a series of laws, which take into consideration two principles: a)The inalienable right of man to life as conceived in the monotheistic religions and proclaimed by positive law; and b)The responsibility of the state for the safety and security of its citizens. Of course, error is human; but if man may make an error of judgement in ordinary normal life, he does not have the right to make the least miscalculation when this might lead to a nuclear disaster. (author)

Analysis of Fukushima Daiichi Accident Using HFACS

International Nuclear Information System (INIS)

Mohamed, Saeed Almheiri

2013-01-01

The shadow of Fukushima Daiichi nuclear power plant (NPP) accident is still too big and will last long. On the other hand, it could still teach us lots of lessons to better design and operate nuclear power plants. In this paper, we will be focusing on the Fukushima Daiichi accident, especially on human organizational factors. We will analyze the accident using Human Factors Analysis and Classification System (HFACS) in order to better understand the organizational climate of TEPCO 1 and NISA 2 that led to Fukushima Daiichi Accident. HFACS was developed for the U. S. aviation industry and has been used at many industries like the rail and mining industries. We found that the HFACS to be greatly beneficial in investigating the latent and organizational causes for the accident. The application results show that the causes of Fukushima Daiichi accident were spread out from sharp end (i.e. Unsafe Act) to blunt end (i. e. Organizational Influences). This means that the corresponding countermeasures should cover from front line staff to management. Thus, we managed to develop a better understanding on how to prevent similar errors or violations. The incident and near-miss have a lot of helpful information because it may show the actual and latent deficiencies of complex systems. We applied the HFACS into Fukushima Daiichi accident to better locate the causes related to both sharp and blunt ends of operation of NPP. In order to derive useful lessons from the accident analysis, the analyst should try to find the similarities not differences from the incident. It is imperative that whatever accident/incident analysis systems we use, we should fully utilize the disastrous Fukushima accident

Analysis of Fukushima Daiichi Accident Using HFACS

Energy Technology Data Exchange (ETDEWEB)

Mohamed, Saeed Almheiri [Korea Advanced Institue of Science and Technology, Daejeon (Korea, Republic of)

2013-10-15

The shadow of Fukushima Daiichi nuclear power plant (NPP) accident is still too big and will last long. On the other hand, it could still teach us lots of lessons to better design and operate nuclear power plants. In this paper, we will be focusing on the Fukushima Daiichi accident, especially on human organizational factors. We will analyze the accident using Human Factors Analysis and Classification System (HFACS) in order to better understand the organizational climate of TEPCO{sup 1} and NISA{sup 2} that led to Fukushima Daiichi Accident. HFACS was developed for the U. S. aviation industry and has been used at many industries like the rail and mining industries. We found that the HFACS to be greatly beneficial in investigating the latent and organizational causes for the accident. The application results show that the causes of Fukushima Daiichi accident were spread out from sharp end (i.e. Unsafe Act) to blunt end (i. e. Organizational Influences). This means that the corresponding countermeasures should cover from front line staff to management. Thus, we managed to develop a better understanding on how to prevent similar errors or violations. The incident and near-miss have a lot of helpful information because it may show the actual and latent deficiencies of complex systems. We applied the HFACS into Fukushima Daiichi accident to better locate the causes related to both sharp and blunt ends of operation of NPP. In order to derive useful lessons from the accident analysis, the analyst should try to find the similarities not differences from the incident. It is imperative that whatever accident/incident analysis systems we use, we should fully utilize the disastrous Fukushima accident.

Management of foodstuffs after nuclear accidents

International Nuclear Information System (INIS)

1991-01-01

A model for the management of foodstuffs after nuclear accidents is presented. The model is a synthesis of traditions and principles taken from both radioactive protection and management of food. It is based on cooperation between the Nordic countries and on practical experience gained from the Chernobyl accident. The aim of the model is to produce a basis for common plans for critical situations based on criteria for decision making. In the case of radioactive accidents it is important that the protection of the public and of the society is handled in a positive way. The model concerns production, marketing and consumption of food and beverage. The overall aim is that the radiation doses should be as low and harmless to health for individual members of the public. (CLS) 35 refs

Humans Optimize Decision-Making by Delaying Decision Onset

Science.gov (United States)

Teichert, Tobias; Ferrera, Vincent P.; Grinband, Jack

2014-01-01

Why do humans make errors on seemingly trivial perceptual decisions? It has been shown that such errors occur in part because the decision process (evidence accumulation) is initiated before selective attention has isolated the relevant sensory information from salient distractors. Nevertheless, it is typically assumed that subjects increase accuracy by prolonging the decision process rather than delaying decision onset. To date it has not been tested whether humans can strategically delay decision onset to increase response accuracy. To address this question we measured the time course of selective attention in a motion interference task using a novel variant of the response signal paradigm. Based on these measurements we estimated time-dependent drift rate and showed that subjects should in principle be able trade speed for accuracy very effectively by delaying decision onset. Using the time-dependent estimate of drift rate we show that subjects indeed delay decision onset in addition to raising response threshold when asked to stress accuracy over speed in a free reaction version of the same motion-interference task. These findings show that decision onset is a critical aspect of the decision process that can be adjusted to effectively improve decision accuracy. PMID:24599295

An Assessment for A Filtered Containment Venting Strategy Using Decision Tree Models

International Nuclear Information System (INIS)

Shin, Hoyoung; Jae, Moosung

2016-01-01

In this study, a probabilistic assessment of the severe accident management strategy through a filtered containment venting system was performed by using decision tree models. In Korea, the filtered containment venting system has been installed for the first time in Wolsong unit 1 as a part of Fukushima follow-up steps, and it is planned to be applied gradually for all the remaining reactors. Filtered containment venting system, one of severe accident countermeasures, prevents a gradual pressurization of the containment building exhausting noncondensable gas and vapor to the outside of the containment building. In this study, a probabilistic assessment of the filtered containment venting strategy, one of the severe accident management strategies, was performed by using decision tree models. Containment failure frequencies of each decision were evaluated by the developed decision tree model. The optimum accident management strategies were evaluated by comparing the results. Various strategies in severe accident management guidelines (SAMG) could be improved by utilizing the methodology in this study and the offsite risk analysis methodology

An Assessment for A Filtered Containment Venting Strategy Using Decision Tree Models

Energy Technology Data Exchange (ETDEWEB)

Shin, Hoyoung; Jae, Moosung [Hanyang University, Seoul (Korea, Republic of)

2016-10-15

In this study, a probabilistic assessment of the severe accident management strategy through a filtered containment venting system was performed by using decision tree models. In Korea, the filtered containment venting system has been installed for the first time in Wolsong unit 1 as a part of Fukushima follow-up steps, and it is planned to be applied gradually for all the remaining reactors. Filtered containment venting system, one of severe accident countermeasures, prevents a gradual pressurization of the containment building exhausting noncondensable gas and vapor to the outside of the containment building. In this study, a probabilistic assessment of the filtered containment venting strategy, one of the severe accident management strategies, was performed by using decision tree models. Containment failure frequencies of each decision were evaluated by the developed decision tree model. The optimum accident management strategies were evaluated by comparing the results. Various strategies in severe accident management guidelines (SAMG) could be improved by utilizing the methodology in this study and the offsite risk analysis methodology.

Dual processing and diagnostic errors.

Science.gov (United States)

Norman, Geoff

2009-09-01

In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical, conscious, and conceptual process, called System 2. Exemplar theories of categorization propose that many category decisions in everyday life are made by unconscious matching to a particular example in memory, and these remain available and retrievable individually. I then review studies of clinical reasoning based on these theories, and show that the two processes are equally effective; System 1, despite its reliance in idiosyncratic, individual experience, is no more prone to cognitive bias or diagnostic error than System 2. Further, I review evidence that instructions directed at encouraging the clinician to explicitly use both strategies can lead to consistent reduction in error rates.

Development of severe accident management guidance for Younggwang units 5 and 6

International Nuclear Information System (INIS)

Lee, K. W.; Beon, C. S.; Kim, M. K.; Hong, S. Y.; Park, K. S.

2001-01-01

Severe Accident Management Guidance (SAMG) has been developed for Younggwang Units 5 and 6. It is consisted of Severe Accident Control Room Guideline, Diagnostic Flow Chart, Severe Accident Guideline, Severe Challenge Guideline, TSC Long Term Monitoring, SAMG Termination. Severe Accident Control Room Guideline, which deals with severe accident after finishing Emergency Operation Procedure, consists of acitions before and after TSC actuation. Seven servere accident management strategies are developed. Diagnostic Flow Chart, Severe Accident Guideline, and Severe Challenge Guideline are developed for each strategy, which enables the users to the implementation of strategy easily and systematically. TSC Long Term Monitoring is also developed to monitor long term activities after a particular strategy. Total of 45 set points are developed for decision making during the implementation of the SAMG

Modelling road accidents: An approach using structural time series

Science.gov (United States)

Junus, Noor Wahida Md; Ismail, Mohd Tahir

2014-09-01

In this paper, the trend of road accidents in Malaysia for the years 2001 until 2012 was modelled using a structural time series approach. The structural time series model was identified using a stepwise method, and the residuals for each model were tested. The best-fitted model was chosen based on the smallest Akaike Information Criterion (AIC) and prediction error variance. In order to check the quality of the model, a data validation procedure was performed by predicting the monthly number of road accidents for the year 2012. Results indicate that the best specification of the structural time series model to represent road accidents is the local level with a seasonal model.

Control of Human Error and comparison Level risk after correction action With the SHERPA Method in a control Room of petrochemical industry

Directory of Open Access Journals (Sweden)

A. Zakerian

2011-12-01

Full Text Available Background and aims Today in many jobs like nuclear, military and chemical industries, human errors may result in a disaster. Accident in different places of the world emphasizes this subject and we indicate for example, Chernobyl disaster in (1986, tree Mile accident in (1974 and Flixborough explosion in (1974.So human errors identification especially in important and intricate systems is necessary and unavoidable for predicting control methods.   Methods Recent research is a case study and performed in Zagross Methanol Company in Asalouye (South pars.   Walking –Talking through method with process expert and control room operators, inspecting technical documents are used for collecting required information and completing Systematic Human Error Reductive and Predictive Approach (SHERPA worksheets.   Results analyzing SHERPA worksheet indicated that, were accepting capable invertebrate errors % 71.25, % 26.75 undesirable errors, % 2 accepting capable(with change errors, % 0 accepting capable errors, and after correction action forecast Level risk to this arrangement, accepting capable invertebrate errors % 0, % 4.35 undesirable errors , % 58.55 accepting capable(with change errors, % 37.1 accepting capable errors .   ConclusionFinally this result is comprehension that this method in different industries especially in chemical industries is enforceable and useful for human errors identification that may lead to accident and adventures.

Radiation protection issues on preparedness and response for a severe nuclear accident: experiences of the Fukushima accident.

Science.gov (United States)

Homma, T; Takahara, S; Kimura, M; Kinase, S

2015-06-01

Radiation protection issues on preparedness and response for a severe nuclear accident are discussed in this paper based on the experiences following the accident at Fukushima Daiichi nuclear power plant. The criteria for use in nuclear emergencies in the Japanese emergency preparedness guide were based on the recommendations of International Commission of Radiological Protection (ICRP) Publications 60 and 63. Although the decision-making process for implementing protective actions relied heavily on computer-based predictive models prior to the accident, urgent protective actions, such as evacuation and sheltering, were implemented effectively based on the plant conditions. As there were no recommendations and criteria for long-term protective actions in the emergency preparedness guide, the recommendations of ICRP Publications 103, 109, and 111 were taken into consideration in determining the temporary relocation of inhabitants of heavily contaminated areas. These recommendations were very useful in deciding the emergency protective actions to take in the early stages of the Fukushima accident. However, some suggestions have been made for improving emergency preparedness and response in the early stages of a severe nuclear accident. © The Chartered Institution of Building Services Engineers 2014.

Development of Information Display System for Operator Support in Severe Accident

International Nuclear Information System (INIS)

Jeong, Kwang Il; Lee, Joon Ku

2016-01-01

When the severe accident occurs, the technical support center (TSC) performs the mitigation strategy with severe accident management guidelines (SAMG) and communicates with main control room (MCR) operators to obtain information of plant's status. In such circumstances, the importance of an information display for severe accident is increased. Therefore an information display system dedicated to severe accident conditions is required to secure the plant information, to provide the necessary information to MCR operators and TSC operators, and to support the decision using these information. We setup the design concept of severe accident information display system (SIDS) in the previous study and defined its requirements of function and performance. This paper describes the process, results of the identification of the severe accident information for MCR operator and the implementation of SIDS. Further implementation on post-accident monitoring function and data validation function for severe accidents will be accomplished in the future

Optimized electricity expansions with external costs internalized and risk of severe accidents as a new criterion in the decision analysis

Energy Technology Data Exchange (ETDEWEB)

Martin del Campo M, C.; Estrada S, G. J., E-mail: cmcm@fi-b.unam.mx [UNAM, Facultad de Ingenieria, Departamento de Sistemas Energeticos, Paseo Cuauhnahuac 8532, 62550 Jiutepec, Morelos (Mexico)

2011-11-15

The external cost of severe accidents was incorporated as a new element for the assessment of energy technologies in the expansion plans of the Mexican electric generating system. Optimizations of the electric expansions were made by internalizing the external cost into the objective function of the WASP-IV model as a variable cost, and these expansions were compared with the expansion plans that did not internalize them. Average external costs reported by the Extern E Project were used for each type of technology and were added to the variable component of operation and maintenance cost in the study cases in which the externalises were internalized. Special attention was paid to study the convenience of including nuclear energy in the generating mix. The comparative assessment of six expansion plans was made by means of the Position Vector of Minimum Regret Analysis (PVMRA) decision analysis tool. The expansion plans were ranked according to seven decision criteria which consider internal costs, economical impact associated with incremental fuel prices, diversity, external costs, foreign capital fraction, carbon-free fraction, and external costs of severe accidents. A set of data for the calculation of the last criterion was obtained from a Report of the European Commission. We found that with the external costs included in the optimization process of WASP-IV, better electric expansion plans, with lower total (internal + external) generating costs, were found. On the other hand, the plans which included the participation of nuclear power plants were in general relatively more attractive than the plans that did not. (Author)

Human reliability analysis during PSA at Trillo NPP: main characteristics and analysis of diagnostic errors

International Nuclear Information System (INIS)

Barquin, M.A.; Gomez, F.

1998-01-01

The design difference between Trillo NPP and other Spanish nuclear power plants (basic Westinghouse and General Electric designs) were made clear in the Human Reliability Analysis of the Probabilistic Safety Analysis (PSA) for Trillo NPP. The object of this paper is to describe the most significant characteristics of the Human Reliability Analysis carried out in the PSA, with special emphasis on the possible diagnostic errors and their consequences, based on the characteristics in the Emergency Operations Manual for Trillo NPP. - In the case of human errors before the initiating event (type 1), the existence of four redundancies in most of the plant safety systems, means that the impact of this type or error on the final results of the PSA is insignificant. However, in the case common cause errors, especially in certain calibration errors, some actions are significant in the final equation for core damage - The number of human actions that the operator has to carry out during the accidents (type 3) modelled, is relatively small in comparison with this value in other PSAs. This is basically due to the high level of automation at Rillo NPP - The Plant Operations Manual cannot be strictly considered to be a symptoms-based procedure. The operation Group must select the chapter from the Operations Manual to be followed, after having diagnosed the perturbing event, using for this purpose and Emergency and Anomaly Decision Tree (M.O.3.0.1) based on the different indications, alarms and symptoms present in the plant after the perturbing event. For this reason, it was decided to analyse the possible diagnosis errors. In the bibliography on diagnosis and commission errors available at the present time, there is no precise methodology for the analysis of this type of error and its incorporation into PSAs. The method used in the PSA for Trillo y NPP to evaluate this type of interaction, is to develop a Diagnosis Error Table, the object of which is to identify the situations in

Waste Transfer Leaks Control Decision Record

International Nuclear Information System (INIS)

RYAN, G.W.

2000-01-01

Control decision meetings for Waste Transfer Leaks were held on April 24,25,26, and 27, 2000. The agenda for the control decision meetings is included in Appendix A, and attendee lists are included in Appendix B. The purpose of the control decision meetings was to review and revise previously selected controls for the prevention or mitigation of waste transfer leak accidents. Re-evaluation of the controls is warranted due to revisions in the hazard and accident analysis for these Tank Farm events. In particular, calculated radiological consequences are significantly reduced from those currently reported in the Final Safety Analysis Report (FSAR). Revised hazard and accident analysis and a revised control recommendation will be reflected in an Authorization Basis Amendment to be submitted at the Department of Energy, Office of River Protection's (ORP's) request by June 30, 2000 to satisfy ORP Performance Incentive (PI) 2.1.1, Revision 1, ''Authorization Basis Management Process Efficiency Improvement''. The scope of the control decision meetings was to address all waste transfer leak-related hazardous conditions identified in the Tank Farm hazard analysis database, excluding those associated with the use of the Replacement Cross-Site Transfer System (RCSTS) slurry line and sluicing of Tank 241-C-106, which is addressed in FSAR Addendum 1. The scope of this control decision process does include future waste feed delivery waste transfer operations

Economic development, mobility and traffic accidents in Algeria.

Science.gov (United States)

Bougueroua, M; Carnis, L

2016-07-01

The aim of this contribution is to estimate the impact of road economic conditions and mobility on traffic accidents for the case of Algeria. Using the cointegration approach and vector error correction model (VECM), we will examine simultaneously short term and long-term impacts between the number of traffic accidents, fuel consumption and gross domestic product (GDP) per capital, over the period 1970-2013. The main results of the estimation show that the number of traffic accidents in Algeria is positively influenced by the GDP per capita in the short and long term. It implies that a higher economic development worsens the road safety situation. However, the new traffic rules adopted in 2009 have an impact on the forecast trend of traffic accidents, meaning efficient public policy could improve the situation. This result calls for a strong political commitment with effective countermeasures for avoiding the further deterioration of road safety record in Algeria. Copyright © 2016 Elsevier Ltd. All rights reserved.

Considerations relating to the operation of PWRs after an incident or accident

International Nuclear Information System (INIS)

Porecki, D.; Griffon, M.; Capel, R.

1981-01-01

All safety analysts are agreed that the main cause of the escalation of the Three Mile Island (TMI-2) accident was that the operator failed to diagnose the situation correctly in the first hours of the accident. Human error contributed a great deal to the accident and the underlying reasons for this should be examined. Lack of understanding of the physical phenomena involved was clearly much to blame, but the operator's environment also played a substantial role. The TMI-2 accident serves as a reminder both to designers and operators of the importance of the ''man-machine interface''. Safety analysis should in future pay greater heed to problems arising during operation and to the prevention of human error. This paper summarizes the short- and medium-term steps taken by Electricite de France (EDF) in this direction with regard to the improvement of data processing and presentation, increased reliability of operator action, the training of operating personnel, operating experience feedback and current thinking on the man-machine interface. The company Framatome, the Commissariat a l'energie atomique (CEA) and agencies which specialize in psychology and ergonomics are participating with EDF in this in-depth study. Increasing the reliability of operator action will be the subject of a special exposition dealing with diagnosis of accidents and post-accident behaviour. With regard to the latter, it is planned to update existing procedures and carry out a comprehensive review of their technical and formal presentation. (author)

Considerations relating to the operation of PWRs after an incident or accident

Energy Technology Data Exchange (ETDEWEB)

Porecki, D [Societe Franco-Americaine de Constructions Atomiques (FRAMATOME), 92 - Courbevoie (France); Griffon, M [CEA Centre d' Etudes Nucleaires de Fontenay-aux-Roses, 92 (France). Inst. de Protection et de Surete Nucleaire; Capel, R [Electricite de France, 75 - Paris. Service de la Production Thermique

1981-01-01

All safety analysts are agreed that the main cause of the escalation of the Three Mile Island (TMI-2) accident was that the operator failed to diagnose the situation correctly in the first hours of the accident. Human error contributed a great deal to the accident and the underlying reasons for this should be examined. Lack of understanding of the physical phenomena involved was clearly much to blame, but the operator's environment also played a substantial role. The TMI-2 accident serves as a reminder both to designers and operators of the importance of the ''man-machine interface''. Safety analysis should in future pay greater heed to problems arising during operation and to the prevention of human error. This paper summarizes the short- and medium-term steps taken by Electricite de France (EDF) in this direction with regard to the improvement of data processing and presentation, increased reliability of operator action, the training of operating personnel, operating experience feedback and current thinking on the man-machine interface. The company Framatome, the Commissariat a l'energie atomique (CEA) and agencies which specialize in psychology and ergonomics are participating with EDF in this in-depth study. Increasing the reliability of operator action will be the subject of a special exposition dealing with diagnosis of accidents and post-accident behaviour. With regard to the latter, it is planned to update existing procedures and carry out a comprehensive review of their technical and formal presentation.

Error Tendencies in Processing Student Feedback for Instructional Decision Making.

Science.gov (United States)

Schermerhorn, John R., Jr.; And Others

1985-01-01

Seeks to assist instructors in recognizing two basic errors that can occur in processing student evaluation data on instructional development efforts; offers a research framework for future investigations of the error tendencies and related issues; and suggests ways in which instructors can confront and manage error tendencies in practice. (MBR)

On preparation for accident management in LWR power stations

International Nuclear Information System (INIS)

1996-01-01

Nuclear Safety Commission received the report from Reactor Safety General Examination Committee which investigated the policy of executing the preparation for accident management. The basic policy on the preparation for accident management was decided by Nuclear Safety Commission in May, 1992. This Examination Committee investigated the policy of executing the preparation for accident management, which had been reported from the administrative office, and as the result, it judged the policy as adequate, therefore, the report is made. The course to the foundation of subcommittee is reported. The basic policy of the examination on accident management by the subcommittee conforming to the decision by Nuclear Safety Commission, the measures of accident management which were extracted for BWR and PWR facilities, the examination of the technical adequacy of selecting accident sequences in BWR and PWR facilities and the countermeasures to them, the adequacy of the evaluation of the possibility of executing accident management measures and their effectiveness and the adequacy of the evaluation of effect to existing safety functions, the preparation of operation procedure manual, and education and training plan are reported. (K.I.)

Sensitivity of risk parameters to human errors for a PWR

International Nuclear Information System (INIS)

Samanta, P.; Hall, R.E.; Kerr, W.

1980-01-01

Sensitivities of the risk parameters, emergency safety system unavailabilities, accident sequence probabilities, release category probabilities and core melt probability were investigated for changes in the human error rates within the general methodological framework of the Reactor Safety Study for a Pressurized Water Reactor (PWR). Impact of individual human errors were assessed both in terms of their structural importance to core melt and reliability importance on core melt probability. The Human Error Sensitivity Assessment of a PWR (HESAP) computer code was written for the purpose of this study

Severe accident management guidelines tool

International Nuclear Information System (INIS)

Gutierrez Varela, Javier; Tanarro Onrubia, Augustin; Martinez Fanegas, Rafael

2014-01-01

Severe Accident is addressed by means of a great number of documents such as guidelines, calculation aids and diagnostic trees. The response methodology often requires the use of several documents at the same time while Technical Support Centre members need to assess the appropriate set of equipment within the adequate mitigation strategies. In order to facilitate the response, TECNATOM has developed SAMG TOOL, initially named GGAS TOOL, which is an easy to use computer program that clearly improves and accelerates the severe accident management. The software is designed with powerful features that allow the users to focus on the decision-making process. Consequently, SAMG TOOL significantly improves the severe accident training, ensuring a better response under a real situation. The software is already installed in several Spanish Nuclear Power Plants and trainees claim that the methodology can be followed easier with it, especially because guidelines, calculation aids, equipment information and strategies availability can be accessed immediately (authors)

Dual Processing and Diagnostic Errors

Science.gov (United States)

Norman, Geoff

2009-01-01

In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical,…

ASSESSING ACCIDENT HOTSPOTS BY USING VOLUNTEERED GEOGRAPHIC INFORMATION

Directory of Open Access Journals (Sweden)

Golnoosh

2017-11-01

Full Text Available Due to the ever-increasing number of vehicles, transportation issues, especially transportation safety have gained great importance. One of the social problems in the world, and particularly in developing countries, which each year imposes great casualties, and economic, social and cultural costs on society, is traffic accidents. Traffic accidents cause waste of time and assets and loss of human resources in society, therefore studies and measures to reduce accidents and damage caused by them, particularly in recent decades, has become important. One of the suggested ways to deal with the problem of car accidents is the modeling of accident-prone points, as by identifying these points, factors affecting accidents can be identified, and elimination of these factors leads to a reduction in accidents. Numerous studies have been conducted in this respect, using official police data to identify these points and performing necessary analysis on them. Official data has gaps and shortcomings. Using Volunteered Geographic Information to determine accident-prone venues can be a suitable answer to the problems of using official data. The aim of this study is the use of volunteered geographic information in relation to the accidents and their causes. By taking into account factors affecting traffic accidents in the study area, and determining the importance of each factor, as well as the severity-of-accidents parameter, and using the Expert Choice software, a decision-making software based on the hierarchical analysis, high-risk venues are determined, and the accident-prone points of the study area are specified.

Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event.

Science.gov (United States)

Meurier, C E

2000-07-01

Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.

Application of FFTBM to severe accidents

International Nuclear Information System (INIS)

Prosek, A.; Leskovar, M.

2005-01-01

In Europe an initiative for the reduction of uncertainties in severe accident safety issues was initiated. Generally, the error made in predicting plant behaviour is called uncertainty, while the discrepancies between measured and calculated trends related to experimental facilities are called the accuracy of the prediction. The purpose of the work is to assess the accuracy of the calculations of the severe accident International Standard Problem ISP-46 (Phebus FPT1), performed with two versions of MELCOR 1.8.5 for validation purposes. For the quantitative assessment of calculations the improved fast Fourier transform based method (FFTBM) was used with the capability to calculate time dependent code accuracy. In addition, a new measure for the indication of the time shift between the experimental and the calculated signal was proposed. The quantitative results obtained with FFTBM confirm the qualitative conclusions made during the Jozef Stefan Institute participation in ISP-46. In general good agreement of thermal-hydraulic variables and satisfactory agreement of total releases for most radionuclide classes was obtained. The quantitative FFTBM results showed that for the Phebus FPT1 severe accident experiment the accuracy of thermal-hydraulic variables calculated with the MELCOR severe accident code is close to the accuracy of thermal-hydraulic variables for design basis accident experiments calculated with best-estimate system codes. (author)

Three Mile Island accident

International Nuclear Information System (INIS)

Barre, B.; Olivier, E.; Roux, J.P.; Pelle, P.

2010-01-01

Deluded by equivocal instrumentation signals, operators at TMI-2 (Three Mile Island - unit 2) misunderstood what was going on in the reactor and for 2 hours were taking inadequate decisions that turned a reactor incident into a major nuclear event that led to the melting of about one third of the core. The TMI accident had worldwide impacts in the domain of nuclear safety. The main consequences in France were: 1) the introduction of the major accident approach and the reinforcement of crisis management; 2) the improvement of the reactor design, particularly that of the pressurizer valves; 3) the implementation of safety probabilistic studies; 4) a better taking into account of the feedback experience in reactor operations; and 5) a better taking into account of the humane factor in reactor safety. (A.C.)

Development of Information Display System for Operator Support in Severe Accident

Energy Technology Data Exchange (ETDEWEB)

Jeong, Kwang Il; Lee, Joon Ku [KAERI, Daejeon (Korea, Republic of)

2016-05-15

When the severe accident occurs, the technical support center (TSC) performs the mitigation strategy with severe accident management guidelines (SAMG) and communicates with main control room (MCR) operators to obtain information of plant's status. In such circumstances, the importance of an information display for severe accident is increased. Therefore an information display system dedicated to severe accident conditions is required to secure the plant information, to provide the necessary information to MCR operators and TSC operators, and to support the decision using these information. We setup the design concept of severe accident information display system (SIDS) in the previous study and defined its requirements of function and performance. This paper describes the process, results of the identification of the severe accident information for MCR operator and the implementation of SIDS. Further implementation on post-accident monitoring function and data validation function for severe accidents will be accomplished in the future.

Human error views : a framework for benchmarking organizations and measuring the distance between academia and industry

NARCIS (Netherlands)

Karanikas, Nektarios

2015-01-01

The paper presents a framework that through structured analysis of accident reports explores the differences between practice and academic literature as well amongst organizations regarding their views on human error. The framework is based on the hypothesis that the wording of accident reports

Analytical support for SAMG development as a part of accident management

International Nuclear Information System (INIS)

Honcarenko, R.

1999-01-01

The decision to built up and implement a comprehensive Accident Management Program applying best world-wide knowledge made during last year at Temelin. A small group of engineers dedicated to Accident Management was formed at Temelin NPP as a part of the plant organisation scheme. A short summary of these activities performed by this group is presented. (author)

Learned from Chernobyl accident-intervention

International Nuclear Information System (INIS)

Yasuda, Hiroshi

1997-01-01

It is considered that health and social damage as seen in the Chernobyl accident could be avoided by establishing a clear framework for intervention against contamination. The framework must be easy to understand to be accepted by all the people concerned. This study presented a process of decision-making on countermeasures against a regional-scale soil contamination. This process put an emphasis on 1) Clarification of responsibility and intervention principles, 2) Application of probabilistic techniques into individual dose estimation, 3) Reduction of social burden. Examples of decision-making were also presented for a simulated ground surface contamination. (author)

γ radiation level simulation and analysis with MCNP in EPR containment during severe accident

International Nuclear Information System (INIS)

Zeng Jun; Liu Shuhuan; Wang Yang; Zhai Liang

2013-01-01

The γ dosimetry model based on the EPR core structure, material composition and the designed shielding system was established. The γ-ray dose rate distributions in EPR containment under different conditions including normal operation state, loss-of-coolant accident and core melt severe accident were simulated with MCNP5, and the calculation results under normal operation state and severe accident were compared and analyzed respectively with that of the designed limit. The study results may provide some relative data reference for EPR core accident prediction and reactor accident emergency decision making. (authors)

Human errors identification using the human factors analysis and classification system technique (HFACS

Directory of Open Access Journals (Sweden)

G. A. Shirali

2013-12-01

.Result: In this study, 158 reports of accident in Ahvaz steel industry were analyzed by HFACS technique. This analysis showed that most of the human errors were: in the first level was related to the skill-based errors, in the second to the physical environment, in the third level to the inadequate supervision and in the fourth level to the management of resources. .Conclusion: Studying and analyzing of past events using the HFACS technique can identify the major and root causes of accidents and can be effective on prevent repetitions of such mishaps. Also, it can be used as a basis for developing strategies to prevent future events in steel industries.

The expert assistant in accident management

International Nuclear Information System (INIS)

Goddard, A.J.H.; Cannell, R.J.

1990-01-01

In the event of a nuclear accident in proximity to an urban area, the consequences resulting from the complex processes of environmental transport of radioactivity would require complex countermeasures. Emphasis has been placed on either modelling the potential effects of such an event on the population, or on attempting to predict the geographical evolution of the release. Less emphasis has been placed on the development of accident management aids with a in-built data acquisition capability. Given the problems of predicting the evolution of an accidental release of activity, more emphasis should be placed on the development of small regional systems specifically engineered to acquire and display environmental data in the most efficaceous form possible. A wealth of information can be obtained from appropriately-sited outstations which can aid those responsible for countermeasures in their decision making processes. The substantial volume of data which would arrive within the duration and during the aftermath of an accident requires skilled interpretation under conditions of considerable stress. It is necessary that a management aid notonly presents these data in a rapidly assimilable form, but is capable of making intelligent decisions of its own, on such matters as information display priority and the polling frequency of outstations. The requirement is for an expert assistant. The XERSES accident management aid has been designed with the foregoing features in mind. Intended for covering regions up to approximately 100 kms square, it links with between 1 and 64 outstations supplying a variety of environmental data. Under quiescent conditions the system will operate unattended, raising alarms remotely only when detecting abnormal conditions. Under emergency conditions, the system automatically adjusts such operating parameters as data acquisition rate

Accidents - Chernobyl accident

International Nuclear Information System (INIS)

2004-01-01

This file is devoted to the Chernobyl accident. It is divided in four parts. The first part concerns the accident itself and its technical management. The second part is relative to the radiation doses and the different contaminations. The third part reports the sanitary effects, the determinists ones and the stochastic ones. The fourth and last part relates the consequences for the other European countries with the case of France. Through the different parts a point is tackled with the measures taken after the accident by the other countries to manage an accident, the cooperation between the different countries and the groups of research and studies about the reactors safety, and also with the international medical cooperation, specially for the children, everything in relation with the Chernobyl accident. (N.C.)

On systematic and statistic errors in radionuclide mass activity estimation procedure

International Nuclear Information System (INIS)

Smelcerovic, M.; Djuric, G.; Popovic, D.

1989-01-01

One of the most important requirements during nuclear accidents is the fast estimation of the mass activity of the radionuclides that suddenly and without control reach the environment. The paper points to systematic errors in the procedures of sampling, sample preparation and measurement itself, that in high degree contribute to total mass activity evaluation error. Statistic errors in gamma spectrometry as well as in total mass alpha and beta activity evaluation are also discussed. Beside, some of the possible sources of errors in the partial mass activity evaluation for some of the radionuclides are presented. The contribution of the errors in the total mass activity evaluation error is estimated and procedures that could possibly reduce it are discussed (author)

Nuclear power plant Severe Accident Research Plan

International Nuclear Information System (INIS)

Larkins, J.T.; Cunningham, M.A.

1983-01-01

The Severe Accident Research Plan (SARP) will provide technical information necessary to support regulatory decisions in the severe accident area for existing or planned nuclear power plants, and covers research for the time period of January 1982 through January 1986. SARP will develop generic bases to determine how safe the plants are and where and how their level of safety ought to be improved. The analysis to address these issues will be performed using improved probabilistic risk assessment methodology, as benchmarked to more exact data and analysis. There are thirteen program elements in the plan and the work is phased in two parts, with the first phase being completed in early 1984, at which time an assessment will be made whether or not any major changes will be recommended to the Commission for operating plants to handle severe accidents. Additionally at this time, all of the thirteen program elements in Chapter 5 will be reviewed and assessed in terms of how much additional work is necessary and where major impacts in probabilistic risk assessment might be achieved. Confirmatory research will be carried out in phase II to provide additional assurance on the appropriateness of phase I decisions. Most of this work will be concluded by early 1986

Accident Sequence Evaluation Program: Human reliability analysis procedure

International Nuclear Information System (INIS)

Swain, A.D.

1987-02-01

This document presents a shortened version of the procedure, models, and data for human reliability analysis (HRA) which are presented in the Handbook of Human Reliability Analysis With emphasis on Nuclear Power Plant Applications (NUREG/CR-1278, August 1983). This shortened version was prepared and tried out as part of the Accident Sequence Evaluation Program (ASEP) funded by the US Nuclear Regulatory Commission and managed by Sandia National Laboratories. The intent of this new HRA procedure, called the ''ASEP HRA Procedure,'' is to enable systems analysts, with minimal support from experts in human reliability analysis, to make estimates of human error probabilities and other human performance characteristics which are sufficiently accurate for many probabilistic risk assessments. The ASEP HRA Procedure consists of a Pre-Accident Screening HRA, a Pre-Accident Nominal HRA, a Post-Accident Screening HRA, and a Post-Accident Nominal HRA. The procedure in this document includes changes made after tryout and evaluation of the procedure in four nuclear power plants by four different systems analysts and related personnel, including human reliability specialists. The changes consist of some additional explanatory material (including examples), and more detailed definitions of some of the terms. 42 refs

Level 2 PSA methodology and severe accident management

International Nuclear Information System (INIS)

1997-01-01

The objective of the work was to review current Level 2-PSA (Probabilistic Safety Assessment) methodologies and practices and to investigate how Level 2-PSA can support severe accident management programmes, i.e. the development, implementation, training and optimisation of accident management strategies and measures. For the most part, the presented material reflects the state in 1996. Current Level 2 PSA results and methodologies are reviewed and evaluated with respect to plant type specific and generic insights. Approaches and practices for using PSA results in the regulatory context and for supporting severe accident management programmes by input from level 2 PSAs are examined. The work is based on information contained in: PSA procedure guides, PSA review guides and regulatory guides for the use of PSA results in risk informed decision making; plant specific PSAs and PSA related literature exemplifying specific procedures, methods, analytical models, relevant input data and important results, use of computer codes and results of code calculations. The PSAs are evaluated with respect to results and insights. In the conclusion section, the present state of risk informed decision making, in particular in the level 2 domain, is described and substantiated by relevant examples

[A spatially explicit analysis of traffic accidents involving pedestrians and cyclists in Berlin].

Science.gov (United States)

Lakes, Tobia

2017-12-01

In many German cities and counties, sustainable mobility concepts that strengthen pedestrian and cyclist traffic are promoted. From the perspectives of urban development, traffic planning and public healthcare, a spatially differentiated analysis of traffic accident data is decisive. 1) The identification of spatial and temporal patterns of the distribution of accidents involving cyclists and pedestrians, 2) the identification of hotspots and exploration of possible underlying causes and 3) the critical discussion of benefits and challenges of the results and the derivation of conclusions. Spatio-temporal distributions of data from accident statistics in Berlin involving pedestrians and cyclists from 2011 to 2015 were analysed with geographic information systems (GIS). While the total number of accidents remains relatively stable for pedestrian and cyclist accidents, the spatial distribution analysis shows, however, that there are significant spatial clusters (hotspots) of traffic accidents with a strong concentration in the inner city area. In a critical discussion, the benefits of geographic concepts are identified, such as spatially explicit health data (in this case traffic accident data), the importance of the integration of other data sources for the evaluation of the health impact of areas (traffic accident statistics of the police), and the possibilities and limitations of spatial-temporal data analysis (spatial point-density analyses) for the derivation of decision-supported recommendations and for the evaluation of policy measures of health prevention and of health-relevant urban development.

Brazilian emergency planning for radiological accidents

International Nuclear Information System (INIS)

Mendonca, A.H.

1986-01-01

Brazilian emergency planning for radiological accidents is organized to respond promptly to any emergency at nuclear power plants or other installations utilizing nuclear fuel. It consists of several committees: a general coordination committee with representatives from several federal departments, with final decision with the Brazilian Nuclear Energy Commission (CNEN), and the Federal Environmental Protection Agency (SEMA). Some committees conduct support activities. For example, the Operational Coordination Committee supervises the tasks undertaken by the Army, Navy, and Air Force in response to the needs and decisions of the general coordination committee

Cognitive skills and nuclear power plant operational decision-making

International Nuclear Information System (INIS)

Schoenfeld, Isabelle

1998-01-01

The author reports a project research which aimed at identifying cognitive skills required for severe accident management. It is based on an analytical model of decision making for severe accident conditions. Moreover, scenarios were developed to reveal specific decision making difficulties and to test cognitive skills associated with each of the model's elements. The model used to identify cognitive skills comprised six general processes to describe decision-making performance: monitor/detect, interpret current state, determine implications, plan, control, feedback. For each of these processes, situational factors, cognitive limitations and biases, individual cognitive skills and team cognitive skills have been identified

Risk evaluation for protection of the public in radiation accidents

International Nuclear Information System (INIS)

1967-01-01

Evaluation of the risk that would be involved in the exposure of the public in the event of a radiation accident requires information on the biological consequences expected of such an exposure. This report defines a range of reference doses of radiation and their corresponding risks to the public in the event of a radiation accident. The reference doses and the considerations on which they were based will be used for assessing the hazards of nuclear installations and for policy decisions by the authorities responsible for measures taken to safeguards the public in the case of a nuclear accident.

Challenges to decision makers after urban contamination: The Chernobyl experience

International Nuclear Information System (INIS)

Likhtarev, I.; Ilyin, L.

2000-01-01

The real history of the Chernobyl decisions will probably be published in ten or fifty years after the death of the politicians who made those decisions and the soviet scientists who were there creating them. But that is not out of the possibility that real and tragic history will never be published at all. This is mainly because the most hard and responsible Chernobyl decisions which had to be made in the situation of acute time, skill and information deficit, had been marked by the stamp of time and society where all of us, including the authors, were living. Never before, and I hope very much, never in the future, has humanity faced the industrial nuclear-radiation accident with the scale like Chernobyl NPP accident. So it's extremely important to summarise and put together not only the scientific but human experience of the scientists which directly formed the large-scale decisions. It is very important to explain to society not only the scientific background of those decisions but also the scientists' personal views, their personal impressions as at the time of decision making as in eight years after the accident. (author)

49 CFR 655.44 - Post-accident testing.

Science.gov (United States)

2010-10-01

... best information available at the time of the decision, that the covered employee's performance can be... best available information at the time of the determination that the employee's performance could not... test any other covered employee whose performance could have contributed to the accident, as determined...

An investigation on unintended reactor trip events in terms of human error hazards of Korean nuclear power plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Lee, Yong Hee; Jang, Tong Il; Oh, Yeon Ju; Shin, Kwang Hyeon

2014-01-01

Highlights: • A methodology to identify human error hazards has been established. • The proposed methodology is a preventive approach to identify not only human error causes but also its hazards. • Using the HFACS framework we tried to find out not causations but all of the hazards and relationships among them. • We determined countermeasures against human errors through dealing with latent factors such as organizational influences. - Abstract: A new approach for finding the hazards of human errors, and not just their causes, in the nuclear industry is currently required. This is because finding causes of human errors is really impossible owing to the multiplicity of causes in each case. Thus, this study aims at identifying the relationships among human error hazards and determining the strategies for preventing human error events by means of a reanalysis of the reactor trip events in Korea NPPs. We investigated human errors to find latent factors such as decisions and conditions in all of the unintended reactor trip events during the last dozen years. In this study, we applied the HFACS (Human Factors Analysis and Classification System), which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. Using the HFACS framework, we tried to find out not the causations but all of the hazards and their relationships in terms of organizational factors. Through the trial, we proposed not only meaningful frequencies of each hazards also correlations of them. Also, considering the correlations of each hazards, we suggested useful strategies to prevent human error event. A method to investigate unintended nuclear reactor trips by human errors and the results will be discussed in more detail

Psychophysiological and other factors affecting human performance in accident prevention and investigation

International Nuclear Information System (INIS)

Klinestiver, L.R.

1980-01-01

Psychophysiological factors are not uncommon terms in the aviation incident/accident investigation sequence where human error is involved. It is highly suspect that the same psychophysiological factors may also exist in the industrial arena where operator personnel function; but, there is little evidence in literature indicating how management and subordinates cope with these factors to prevent or reduce accidents. It is apparent that human factors psychophysological training is quite evident in the aviation industry. However, while the industrial arena appears to analyze psychophysiological factors in accident investigations, there is little evidence that established training programs exist for supervisors and operator personnel

Failures without errors: quantification of context in HRA

International Nuclear Information System (INIS)

Fujita, Yushi; Hollnagel, Erik

2004-01-01

PSA-cum-human reliability analysis (HRA) has traditionally used individual human actions, hence individual 'human errors', as a meaningful unit of analysis. This is inconsistent with the current understanding of accidents, which points out that the notion of 'human error' is ill defined and that adverse events more often are the due to the working conditions than to people. Several HRA approaches, such as ATHEANA and CREAM have recognised this conflict and proposed ways to deal with it. This paper describes an improvement of the basic screening method in CREAM, whereby a rating of the performance conditions can be used to calculate a Mean Failure Rate directly without invoking the notion of human error

Strategy generator in computerized accident management support system

International Nuclear Information System (INIS)

Sirola, M.

1994-02-01

An increased interest for research in the field of accident management of nuclear power plants can be noted. Several international programmes have been started in order to be able to understand the basic physical and chemical phenomena in accident conditions. A feasibility study has shown that it would be possible to design and develop a computerized support system for plant staff in accident situations. To achieve this goal the Halden Project has initiated a research programme on Computerized Accident Management Support (CAMS project). The aim is to utilize the capabilities of computerized tools to support the plant staff during the various accident stages. The system will include identification of the accident state, assessment of the future development of the accident and planning of accident mitigation strategies. A prototype is developed to support operators and the Technical Support Centre in decision making during serious accidents in nuclear power plants. A rule based system has been built to take care of the strategy generation. This system assists plant personnel in planning control proposals and mitigation strategies from normal operation to severe accident conditions. The idea of a safety objective tree and knowledge from the emergency procedures have been used. Future prediction requires good state identification of the plant status and some knowledge about the history of some critical variables. The information needs to be validated as well. Accurate calculations in simulators and a large database including all important information from the plant will help the strategy planning. (orig.). (40 refs., 20 figs.)

Supporting decision making by a critical thinking tool

NARCIS (Netherlands)

Dongen, C.J.G. van; Schraagen, J.M.C.; Eikelboom, A.; Brake, G.M. te

2005-01-01

Building up situation understanding is one of the most difficult tasks in the beginning stages of largescale accidents. As ambiguous information about the events becomes available, decision-makers are often tempted to quickly develop a particular story to explain the observed events. As the accident

Value Judgements and Trade-Offs in Management of Nuclear Accidents: Using an Ethical Matrix in Practical Decision-Making

International Nuclear Information System (INIS)

Oughton, Deborah; Bay, Ingrid; Forsberg, Ellen-Marie; Kaiser, Matthias

2003-01-01

Experience after the Chernobyl accident has shown that restoration strategies need to consider a wide range of different issues to ensure the long-term sustainability of large and varied contaminated areas. Thus, the criteria by which we evaluate countermeasures needs to be extended from simple cost benefit effectiveness and radiological protection standards to a more integrated, holistic approach, including social and ethical aspects. Within the EU STRATEGY project, the applicability of many countermeasures is being critically assessed using a wide range of criteria, such as practicability, environmental side-effects, public perceptions of risk, communication and dialogue, and ethical aspects such as informed consent and the fair distribution of costs and doses. Although such socio-ethical factors are now the subject of a substantial field of research, there has been little attempt to integrate them in a practical context for decision makers. Within this paper, we suggest practical means by which these can be taken into account in the decision making process, proposing use of an ethical matrix to ensure transparent and systematic consideration of values in selection of a restoration strategy. in selection of a restoration strategy

[Multicenter paragliding accident study 1990].

Science.gov (United States)

Lautenschlager, S; Karli, U; Matter, P

1992-01-01

During the period from 1.1.90 until 31.12.90, 86 injuries associated with paragliding were analyzed in a prospective study in 12 different Swiss hospitals with reference to causes, patterns, and frequencies. The injuries showed a mean score of over 2 and were classified as severe. Most frequent spine injuries (36%) and lesions of the lower extremity (35%) with a high risk of the ankles were diagnosed. One accident was fatal. 60% of the accidents happened during landing, 26% during launching and 14% during flight. Half of the pilots were affected during their primary training course. Most accidents were caused by inflight error of judgement--especially incorrect estimation of wind conditions--and further the choice of unfavourable landing sites. In contrast to previous injury-reports, only one equipment failure could be noted, but often the equipment was not corresponding with the experience and the weight of the pilot. To reduce the frequency of paragliding-injuries an accurate choice of equipment and an increased attention to environmental factors is mandatory. Furthermore an education-program regarding the attitude and intelligence of the pilot should be included in training courses.

Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports.

Science.gov (United States)

Uramatsu, Masashi; Fujisawa, Yoshikazu; Mizuno, Shinya; Souma, Takahiro; Komatsubara, Akinori; Miki, Tamotsu

2017-02-16

We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be

Review of current status for designing severe accident management support system

Energy Technology Data Exchange (ETDEWEB)

Jeong, Kwang Sub

2000-05-01

The development of operator support system (OSS) is ongoing in many other countries due to the complexity both in design and in operation for nuclear power plant. The computerized operator support system includes monitoring of some critical parameters, early detection of plant transient, monitoring of component status, plant maintenance, and safety parameter display, and the operator support system for these areas are developed and are being used in some plants. Up to now, the most operator support system covers the normal operation, abnormal operation, and emergency operation. Recently, however, the operator support system for severe accident is to be developed in some countries. The study for the phenomena of severe accident is not performed sufficiently, but, based on the result up to now, the operator support system even for severe accident will be developed in this study. To do this, at first, the current status of the operator support system for normal/abnormal/emergency operation is reviewed, and the positive aspects and negative aspects of systems are analyzed by their characteristics. And also, the major items that should be considered in designing the severe accident operator support system are derived from the review. With the survey of domestic and foreign operator support systems, they are reviewed in terms of the safety parameter display system, decision-making support system, and procedure-tracking system. For the severe accident, the severe accident management guideline (SAMG) which is developed by Westinghouse is reviewed; the characteristics, structure, and logical flow of SAMG are studied. In addition, the critical parameters for severe accident, which are the basis for operators decision-making in severe accident management and are supplied to the operators and the technical support center, are reviewed, too.

Review of current status for designing severe accident management support system

International Nuclear Information System (INIS)

Jeong, Kwang Sub

2000-05-01

The development of operator support system (OSS) is ongoing in many other countries due to the complexity both in design and in operation for nuclear power plant. The computerized operator support system includes monitoring of some critical parameters, early detection of plant transient, monitoring of component status, plant maintenance, and safety parameter display, and the operator support system for these areas are developed and are being used in some plants. Up to now, the most operator support system covers the normal operation, abnormal operation, and emergency operation. Recently, however, the operator support system for severe accident is to be developed in some countries. The study for the phenomena of severe accident is not performed sufficiently, but, based on the result up to now, the operator support system even for severe accident will be developed in this study. To do this, at first, the current status of the operator support system for normal/abnormal/emergency operation is reviewed, and the positive aspects and negative aspects of systems are analyzed by their characteristics. And also, the major items that should be considered in designing the severe accident operator support system are derived from the review. With the survey of domestic and foreign operator support systems, they are reviewed in terms of the safety parameter display system, decision-making support system, and procedure-tracking system. For the severe accident, the severe accident management guideline (SAMG) which is developed by Westinghouse is reviewed; the characteristics, structure, and logical flow of SAMG are studied. In addition, the critical parameters for severe accident, which are the basis for operators decision-making in severe accident management and are supplied to the operators and the technical support center, are reviewed, too

Economic and social impacts of nuclear accidents on the agricultural sector

International Nuclear Information System (INIS)

Brenot, J.; Hubert, P.

1997-01-01

The economic and social impact of a major nuclear accident on the agricultural sector are reviewed. The associated costs are evaluated by more or less proper methods depending on the duration and severity of the post accident situation. Calculating such costs is necessary in order to allow farmers, farm-food enterprises, and public authorities to define the indemnification levels as well as to identify means of minimizing the accident consequences. The indemnification procedures are described in a section dedicated to liability issues and the costs due to Chernobyl accident. Concerning the limitation of accident consequences the responsibility falls upon the public authorities. In regard for decision making the existent methods vary according to the situation complexity and proposed objectives. Examples are given to point out the costs and social impact

Development and evaluation of a computer-aided system for analyzing human error in railway operations

International Nuclear Information System (INIS)

Kim, Dong San; Baek, Dong Hyun; Yoon, Wan Chul

2010-01-01

As human error has been recognized as one of the major contributors to accidents in safety-critical systems, there has been a strong need for techniques that can analyze human error effectively. Although many techniques have been developed so far, much room for improvement remains. As human error analysis is a cognitively demanding and time-consuming task, it is particularly necessary to develop a computerized system supporting this task. This paper presents a computer-aided system for analyzing human error in railway operations, called Computer-Aided System for Human Error Analysis and Reduction (CAS-HEAR). It supports analysts to find multiple levels of error causes and their causal relations by using predefined links between contextual factors and causal factors as well as links between causal factors. In addition, it is based on a complete accident model; hence, it helps analysts to conduct a thorough analysis without missing any important part of human error analysis. A prototype of CAS-HEAR was evaluated by nine field investigators from six railway organizations in Korea. Its overall usefulness in human error analysis was confirmed, although development of its simplified version and some modification of the contextual factors and causal factors are required in order to ensure its practical use.

Use of simulators in severe accident management

International Nuclear Information System (INIS)

Evans, R.C.

1994-01-01

The U.S. nuclear utility industry is moving in a deliberate fashion through a coordinated industry severe accident working group to study and augment, where appropriate, the existing utility organizational and emergency planning structure to address accident and severe accident management. Full-scope simulators are used extensively to train licensed operators for their initial license examinations and continually thereafter in licensed operator requalification training and yearly examinations. The goal of the training (both initial and requalification) is to ensure that operators possess adequate knowledge, skills and abilities to prevent an event from progressing to core damage. The use of full-scope simulators in severe accident management training is in large part viewed by the industry as being premature. The working group study has not progressed to the point where the decision to employ full-scope simulators can be logically considered. It is not however premature to consider part-task or work station simulators as invaluable research tools to support the industry's study. These simulators could be employed, subject to limitations in the current state of knowledge regarding severe accident progression and phenomenological responses, in the validation and verification (V and V) of severe accident models or codes as they are developed. The U.S. nuclear utility industry has made substantial strides in the past 12 years in the accident prevention, mitigation and management arena. These strides are a product of the industry's preference for a logical and systematic approach to change. (orig.)

An association between dietary habits and traffic accidents in patients with chronic liver disease: A data-mining analysis.

Science.gov (United States)

Kawaguchi, Takumi; Suetsugu, Takuro; Ogata, Shyou; Imanaga, Minami; Ishii, Kumiko; Esaki, Nao; Sugimoto, Masako; Otsuyama, Jyuri; Nagamatsu, Ayu; Taniguchi, Eitaro; Itou, Minoru; Oriishi, Tetsuharu; Iwasaki, Shoko; Miura, Hiroko; Torimura, Takuji

2016-05-01

The incidence of traffic accidents in patients with chronic liver disease (CLD) is high in the USA. However, the characteristics of patients, including dietary habits, differ between Japan and the USA. The present study investigated the incidence of traffic accidents in CLD patients and the clinical profiles associated with traffic accidents in Japan using a data-mining analysis. A cross-sectional study was performed and 256 subjects [148 CLD patients (CLD group) and 106 patients with other digestive diseases (disease control group)] were enrolled; 2 patients were excluded. The incidence of traffic accidents was compared between the two groups. Independent factors for traffic accidents were analyzed using logistic regression and decision-tree analyses. The incidence of traffic accidents did not differ between the CLD and disease control groups (8.8 vs. 11.3%). The results of the logistic regression analysis showed that yoghurt consumption was the only independent risk factor for traffic accidents (odds ratio, 0.37; 95% confidence interval, 0.16-0.85; P=0.0197). Similarly, the results of the decision-tree analysis showed that yoghurt consumption was the initial divergence variable. In patients who consumed yoghurt habitually, the incidence of traffic accidents was 6.6%, while that in patients who did not consume yoghurt was 16.0%. CLD was not identified as an independent factor in the logistic regression and decision-tree analyses. In conclusion, the difference in the incidence of traffic accidents in Japan between the CLD and disease control groups was insignificant. Furthermore, yoghurt consumption was an independent negative risk factor for traffic accidents in patients with digestive diseases, including CLD.

An association between dietary habits and traffic accidents in patients with chronic liver disease: A data-mining analysis

Science.gov (United States)

KAWAGUCHI, TAKUMI; SUETSUGU, TAKURO; OGATA, SHYOU; IMANAGA, MINAMI; ISHII, KUMIKO; ESAKI, NAO; SUGIMOTO, MASAKO; OTSUYAMA, JYURI; NAGAMATSU, AYU; TANIGUCHI, EITARO; ITOU, MINORU; ORIISHI, TETSUHARU; IWASAKI, SHOKO; MIURA, HIROKO; TORIMURA, TAKUJI

2016-01-01

The incidence of traffic accidents in patients with chronic liver disease (CLD) is high in the USA. However, the characteristics of patients, including dietary habits, differ between Japan and the USA. The present study investigated the incidence of traffic accidents in CLD patients and the clinical profiles associated with traffic accidents in Japan using a data-mining analysis. A cross-sectional study was performed and 256 subjects [148 CLD patients (CLD group) and 106 patients with other digestive diseases (disease control group)] were enrolled; 2 patients were excluded. The incidence of traffic accidents was compared between the two groups. Independent factors for traffic accidents were analyzed using logistic regression and decision-tree analyses. The incidence of traffic accidents did not differ between the CLD and disease control groups (8.8 vs. 11.3%). The results of the logistic regression analysis showed that yoghurt consumption was the only independent risk factor for traffic accidents (odds ratio, 0.37; 95% confidence interval, 0.16–0.85; P=0.0197). Similarly, the results of the decision-tree analysis showed that yoghurt consumption was the initial divergence variable. In patients who consumed yoghurt habitually, the incidence of traffic accidents was 6.6%, while that in patients who did not consume yoghurt was 16.0%. CLD was not identified as an independent factor in the logistic regression and decision-tree analyses. In conclusion, the difference in the incidence of traffic accidents in Japan between the CLD and disease control groups was insignificant. Furthermore, yoghurt consumption was an independent negative risk factor for traffic accidents in patients with digestive diseases, including CLD. PMID:27123257

FACTORS AFFECTING ROAD TRAFFIC ACCIDENTS IN BENGHAZI, LIBYA

Science.gov (United States)

Al-Ghaweel, Ibrahim; Mursi, Saleh A.; Jack, Joel P.; Joel, Irene

2009-01-01

Objectives: The aim of the study was to evaluate the factors responsible for road traffic accidents in Benghazi. Material and Methods: Retrospective and descriptive studies were done in the years 2006-2007. The data was collected from Traffic and License Department, Benghazi. The data were analyzed, based on fatalities, the severely handicapped, hit and run victims and were correlated with age, sex, time, environmental factors, type of roads, etc. Results: One-Thousand-Two-Hundred-Sixty-Five accidents occurred between the years 2006-2007 within the Benghazi city limits; 11.14% of the injuries were fatal; 67.35% of the victims had severe injuries and 21.51% escaped with minor injuries. Table 1 shows that 73.04% lost their lives within the city limits, 13.47% on the fly-over, and 2.12% on minor roads connected to main roads within the city limits. The mean of the accidents and its standard deviation were 16.66± 25.67 with a variance of fatality of 1.54. Conclusion: It is concluded from the studies that major road traffic accidents occur because of environmental stress factors. In addition, fatalities and the seriousness of the accidents depend on a number of factors such as the age of the vehicle, safety measures, human error and time and place of accident. PMID:23012183

Consequences in Sweden of the Chernobyl accident

International Nuclear Information System (INIS)

Snihs, J.O.

1986-01-01

It summarizes the consequences in Sweden of the Chernobyl accident, describes the emergency response, the basis for decisions and countermeasures, the measurement strategies, the activity levels and doses and countermeasures and action levels used. Past and remaining problems are discussed and the major investigations and improvements are given. (author)

Sampling for quality assurance of grading decisions in diabetic retinopathy screening: designing the system to detect errors.

Science.gov (United States)

Slattery, Jim

2005-01-01

To evaluate various designs for a quality assurance system to detect and control human errors in a national screening programme for diabetic retinopathy. A computer simulation was performed of some possible ways of sampling the referral decisions made during grading and of different criteria for initiating more intensive QA investigations. The effectiveness of QA systems was assessed by the ability to detect a grader making occasional errors in referral. Substantial QA sample sizes are needed to ensure against inappropriate failure to refer. Detection of a grader who failed to refer one in ten cases can be achieved with a probability of 0.58 using an annual sample size of 300 and 0.77 using a sample size of 500. An unmasked verification of a sample of non-referrals by a specialist is the most effective method of internal QA for the diabetic retinopathy screening programme. Preferential sampling of those with some degree of disease may improve the efficiency of the system.

Development of severe accident management advisory and training simulator (SAMAT)

International Nuclear Information System (INIS)

Jeong, K.-S.; Kim, K.-R.; Jung, W.-D.; Ha, J.-J.

2002-01-01

The most operator support systems including the training simulator have been developed to assist the operator and they cover from normal operation to emergency operation. For the severe accident, the overall architecture for severe accident management is being developed in some developed countries according to the development of severe accident management guidelines which are the skeleton of severe accident management architecture. In Korea, the severe accident management guideline for KSNP was recently developed and it is expected to be a central axis of logical flow for severe accident management. There are a lot of uncertainties in the severe accident phenomena and scenarios and one of the major issues for developing a operator support system for a severe accident is the reduction of these uncertainties. In this paper, the severe accident management advisory system with training simulator, SAMAT, is developed as all available information for a severe accident are re-organized and provided to the management staff in order to reduce the uncertainties. The developed system includes the graphical display for plant and equipment status, the previous research results by knowledge-base technique, and the expected plant behavior using the severe accident training simulator. The plant model used in this paper is oriented to severe accident phenomena and thus can simulate the plant behavior for a severe accident. Therefore, the developed system may make a central role of the information source for decision-making for a severe accident management, and will be used as the training simulator for severe accident management

The relationship between risk factors and aeronautical decision making in the flight training environment

Science.gov (United States)

Wetmore, Michael J.

The purpose of this applied dissertation was to investigate the relationship between risk factors and aeronautical decision making in the flight training environment using a quantitative, non-experimental, ex post facto research design. All 75 of the flight training accidents that involved a fatality from the years 2001-2003 were selected for study from the National Transportation Safety Board (NTSB) aviation accident database. Objective evidence from the Factual Reports was used to construct accident chains and to code and quantify total risk factors and total poor aeronautical decisions. The data were processed using correlational statistical tests at the 1% significance level. There was a statistically significant relationship between total risk factors per flight and poor decisions per flight. Liveware risks were the most prevalent risk factor category. More poor decisions were made during preflight than any other phase of flight. Pilots who made multiple poor decisions per flight had significantly higher risk factors per flight. A risk factor threat to decision making chart is presented for use by flight instructors and/or flight training organizations. The main threat to validity of this study was the NTSB accident investigation team investigative equality assumption.

The cognitive error in decision making

Directory of Open Access Journals (Sweden)

Pier Luigi Baldi

2013-06-01

Full Text Available This issue deals with the partial data of a research in progress on focalization, pseudodiagnosticity and framing- effect in decision making, followed by the most important results of some experiments about the emotional aspects of the choice, and ends by stressing the potential contribution of the artificial neural networks to the medical diagnosis.

An epidemiologic survey of road traffic accidents in Iran: analysis of driver-related factors

Directory of Open Access Journals (Sweden)

Moafian Ghasem

2013-06-01

Full Text Available 【Abstract】Objective: Road traffic accident (RTA and its related injuries contribute to a significant portion of the burden of diseases in Iran. This paper explores the as-sociation between driver-related factors and RTA in the country. Methods: This cross-sectional study was conducted in Iran and all data regarding RTAs from March 20, 2010 to June 10, 2010 were obtained from the Traffic Police Department. We included 538 588 RTA records, which were classified to control for the main confounders: accident type, final cause of accident, time of accident and driver-related factors. Driver-related factors included sex, educational level, license type, type of injury, duration between accident and getting the driving license and driver’s error type. Results: A total of 538 588 drivers (91.83% male, sex ratio of almost 13:1 were involved in the RTAs. Among them 423 932 (78.71% were uninjured; 224 818 (41.74% had a diploma degree. Grade 2 driving license represented the highest proportion of all driving licenses (290 811, 54.00%. The greatest number of accidents took place at 12:00-13:59 (75 024, 13.93%. The proportion of drivers involved in RTAs decreased from 15.90% in the first year of getting a driving license to 3.13% after 10 years’ of driving experience. Ne-glect of regulations was the commonest cause of traffic crashes (345 589, 64.17%. Non-observance of priority and inattention to the front were the most frequent final causes of death (138 175, 25.66% and 129 352, 24.02%, respectively. We found significant association between type of acci-dent and sex, education, license type, time of accident, final cause of accident, driver’s error as well as duration between accident and getting the driving license (all P<0.001. Conclusion: Our results will improve the traffic law enforcement measures, which will change inappropriate be-havior of drivers and protect the least experienced road users. Key words: Accidents, traffic; Automobile

The Development of Marine Accidents Human Reliability Assessment Approach: HEART Methodology and MOP Model

Directory of Open Access Journals (Sweden)

Ludfi Pratiwi Bowo

2017-06-01

Full Text Available Humans are one of the important factors in the assessment of accidents, particularly marine accidents. Hence, studies are conducted to assess the contribution of human factors in accidents. There are two generations of Human Reliability Assessment (HRA that have been developed. Those methodologies are classified by the differences of viewpoints of problem-solving, as the first generation and second generation. The accident analysis can be determined using three techniques of analysis; sequential techniques, epidemiological techniques and systemic techniques, where the marine accidents are included in the epidemiological technique. This study compares the Human Error Assessment and Reduction Technique (HEART methodology and the 4M Overturned Pyramid (MOP model, which are applied to assess marine accidents. Furthermore, the MOP model can effectively describe the relationships of other factors which affect the accidents; whereas, the HEART methodology is only focused on human factors.

Multi-stage ranking of emergency technology alternatives for water source pollution accidents using a fuzzy group decision making tool.

Science.gov (United States)

Qu, Jianhua; Meng, Xianlin; You, Hong

2016-06-05

Due to the increasing number of unexpected water source pollution events, selection of the most appropriate disposal technology for a specific pollution scenario is of crucial importance to the security of urban water supplies. However, the formulation of the optimum option is considerably difficult owing to the substantial uncertainty of such accidents. In this research, a multi-stage technical screening and evaluation tool is proposed to determine the optimal technique scheme, considering the areas of pollutant elimination both in drinking water sources and water treatment plants. In stage 1, a CBR-based group decision tool was developed to screen available technologies for different scenarios. Then, the threat degree caused by the pollution was estimated in stage 2 using a threat evaluation system and was partitioned into four levels. For each threat level, a corresponding set of technique evaluation criteria weights was obtained using Group-G1. To identify the optimization alternatives corresponding to the different threat levels, an extension of TOPSIS, a multi-criteria interval-valued trapezoidal fuzzy decision making technique containing the four arrays of criteria weights, to a group decision environment was investigated in stage 3. The effectiveness of the developed tool was elaborated by two actual thallium-contaminated scenarios associated with different threat levels. Copyright © 2016 Elsevier B.V. All rights reserved.

Summary and conclusions: Specialist Meeting on Severe Accident Management Implementation

International Nuclear Information System (INIS)

1995-01-01

During the first session of this meeting, regulators, research groups, designers/owners' groups and some utilities discussed the critical decisions in SAM (Severe Accident Management), how these decisions were addressed and implemented in generic SAM guidelines, what equipment and instrumentation was used, what are the differences in national approaches, etc. During the second session, papers were presented by utility specialists that described approaches chosen for specific implementation of the generic guidelines, the difficulties encountered in the implementation process and the perceived likelihood of success of their SAM programme in dealing with severe accidents. The third and final sessions was dedicated to discussing what are the remaining uncertainties and open questions in SAM. Experts from several OECD countries presented significant perspectives on remaining open issues

Analysis of human error in occupational accidents in the power plant industries using combining innovative FTA and meta-heuristic algorithms

OpenAIRE

M. Omidvari; M. R. Gharmaroudi

2015-01-01

Introduction: Occupational accidents are of the main issues in industries. It is necessary to identify the main root causes of accidents for their control. Several models have been proposed for determining the accidents root causes. FTA is one of the most widely used models which could graphically establish the root causes of accidents. The non-linear function is one of the main challenges in FTA compliance and in order to obtain the exact number, the meta-heuristic algorithms can be used. ...

Statistical inference of the nuclear accidents occurrence number for the next decade

International Nuclear Information System (INIS)

Felizia, E.R.

1987-01-01

This paper aims to give a response using the classical statistical and bayesian inference techniques regarding the common characteristic in the Harrisburg and Chernobyl nuclear accidents: in both reactors, core fusion occurred. In relation to the last mentioned techniques, the most recent developments were applied, based on the decision theory of uncertainty; among others, the principle of maximum entropy. Besides, as a preliminar information on the accidents occurrence frequency with core fusion, the German risk analysis results were used. The estimations predicted for the next decade an average between one or two accidents with core fusion and low possibilities for the 'no accident' event in the same period. (Author)

THERP and HEART integrated methodology for human error assessment

Science.gov (United States)

Castiglia, Francesco; Giardina, Mariarosa; Tomarchio, Elio

2015-11-01

THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead to patient radiological overexposures. The results allow for the identification of human errors that are necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so that it can be properly monitored and appropriately managed.

Effect of Meteorological Parameters on Accident Rates in Petrochemical Industries

International Nuclear Information System (INIS)

Mansouri, N.; Farsi, E.

2016-01-01

Background and Objective: In this research the effectiveness of weather and climate parameters in incidence of accidents in the petrochemical industry was studied and management strategies to prevent these events have been presented. Method: Two of the petrochemical companies, one of them in Assaluyeh (named Zagros, located in warm climates) and the other one in Tabriz (in cold climates) were selected for pilot study. The required data were collected by questionnaire, interview and walking through under study fields. The analyses of data have been done by Excel, SPSS software and Correlation statistical test. Findings: Climate parameters don’t have a directly impact on the petrochemical occupational accidents and there is no significant relationship between them. Discussion and Conclusion: The role of climatic parameters in the incidence of accidents in the petrochemical industry is indirect. In fact, the thermal stress in the first stage caused unsafe conditions and then unsafe behavior, and finally cause human error and occupational accidents. In this study, appropriate solutions for instance engineering or managerial measures are also suggested in order to prevent accidents and injuries.

Accident hazard evaluation and control decisions on forested recreation sites

Science.gov (United States)

Lee A. Paine

1971-01-01

Accident hazard associated with trees on recreation sites is inherently concerned with probabilities. The major factors include the probabilities of mechanical failure and of target impact if failure occurs, the damage potential of the failure, and the target value. Hazard may be evaluated as the product of these factors; i.e., expected loss during the current...

Accident Sequence Evaluation Program: Human reliability analysis procedure

Energy Technology Data Exchange (ETDEWEB)

Swain, A.D.

1987-02-01

This document presents a shortened version of the procedure, models, and data for human reliability analysis (HRA) which are presented in the Handbook of Human Reliability Analysis With emphasis on Nuclear Power Plant Applications (NUREG/CR-1278, August 1983). This shortened version was prepared and tried out as part of the Accident Sequence Evaluation Program (ASEP) funded by the US Nuclear Regulatory Commission and managed by Sandia National Laboratories. The intent of this new HRA procedure, called the ''ASEP HRA Procedure,'' is to enable systems analysts, with minimal support from experts in human reliability analysis, to make estimates of human error probabilities and other human performance characteristics which are sufficiently accurate for many probabilistic risk assessments. The ASEP HRA Procedure consists of a Pre-Accident Screening HRA, a Pre-Accident Nominal HRA, a Post-Accident Screening HRA, and a Post-Accident Nominal HRA. The procedure in this document includes changes made after tryout and evaluation of the procedure in four nuclear power plants by four different systems analysts and related personnel, including human reliability specialists. The changes consist of some additional explanatory material (including examples), and more detailed definitions of some of the terms. 42 refs.

Radiological aspects of nuclear accident scenarios. Volume 2 the Rade-Aid system post-Chernobyl action

International Nuclear Information System (INIS)

Sinnaeve, J.

1991-01-01

In the event of a nuclear accident, there is a need for a rapid assessment of the resulting levels of environmental contamination in order to facilitate decisions on possible countermeasures. Volume 2 describes the RADE-AID project to develop a computer system which can be used to support the formulation of decisions on countermeasures following an accidental release of radionuclides. The system is intended as an aid following an actual accident and a tool for assistance in planning and training

Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010–2013 national accident reports

Science.gov (United States)

Uramatsu, Masashi; Fujisawa, Yoshikazu; Mizuno, Shinya; Souma, Takahiro; Komatsubara, Akinori; Miki, Tamotsu

2017-01-01

Objectives We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. Design Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. Setting A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. Primary and secondary outcome measures The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. Results Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). Conclusions Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for

Development of the Human Error Management Criteria and the Job Aptitude Evaluation Criteria for Rail Safety Personnel

Energy Technology Data Exchange (ETDEWEB)

Koo, In Soo; Seo, Sang Mun; Park, Geun Ok (and others)

2008-08-15

It has been estimated that up to 90% of all workplace accidents have human error as a cause. Human error has been widely recognized as a key factor in almost all the highly publicized accidents, including Daegu subway fire of February 18, 2003 killed 198 people and injured 147. Because most human behavior is 'unintentional', carried out automatically, root causes of human error should be carefully investigated and regulated by a legal authority. The final goal of this study is to set up some regulatory guidance that are supposed to be used by the korean rail organizations related to safety managements and the contents are : - to develop the regulatory guidance for managing human error, - to develop the regulatory guidance for managing qualifications of rail drivers - to develop the regulatory guidance for evaluating the aptitude of the safety-related personnel.

Development of the Human Error Management Criteria and the Job Aptitude Evaluation Criteria for Rail Safety Personnel

International Nuclear Information System (INIS)

Koo, In Soo; Seo, Sang Mun; Park, Geun Ok

2008-08-01

It has been estimated that up to 90% of all workplace accidents have human error as a cause. Human error has been widely recognized as a key factor in almost all the highly publicized accidents, including Daegu subway fire of February 18, 2003 killed 198 people and injured 147. Because most human behavior is 'unintentional', carried out automatically, root causes of human error should be carefully investigated and regulated by a legal authority. The final goal of this study is to set up some regulatory guidance that are supposed to be used by the korean rail organizations related to safety managements and the contents are : - to develop the regulatory guidance for managing human error, - to develop the regulatory guidance for managing qualifications of rail drivers - to develop the regulatory guidance for evaluating the aptitude of the safety-related personnel

Assessing the association between thinking dispositions and clinical error.

Science.gov (United States)

Kinnear, John; Wilson, Nick

2017-08-09

Dual-process theory suggests that type 1 thinking results in a propensity to make 'intuitive' decisions based on limited information. Type 2 processes, on the other hand, are able to analyse these initial responses and replace them with rationalised decisions. Individuals may have a preference for different modes of rationalisation, on a continuum from careful to cursory. These 'dispositions' of thinking reside in type 2 processes and may result in error when the preference is for 'quick and casual' decision-making. We asked clinicians to answer a cognitive puzzle to which there was an obvious, but incorrect, answer, to measure their propensity for 'quick and casual' decision-making. The same clinicians were also asked to report the number of clinical errors they had committed in the previous two weeks. We hypothesised an association between committing error and settling for an incorrect answer, and that the cognitive puzzle would have predictive capability. 90 of 153 (59%) clinicians reported that they had committed error, while 103 (67%) gave the incorrect 'intuitive' answer to the cognitive puzzle. There was no statistically significant difference between clinicians who committed error and answered incorrectly, and those who did not and answered correctly (χ 2 (1, n=1153)=0.021, p=0.885). The prevalence of clinical error in our study was higher than previously reported in the literature, and the propensity for accepting intuitive solutions was high. Although the cognitive puzzle was unable to predict who was more likely to commit error, the study offers insights into developing other predictive models for error. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Research and Application of Auxiliary Optimization Technology of Power Grid Accident Processing Based on the Mode of Regulation and Control Integration

Directory of Open Access Journals (Sweden)

Cui Houzhen

2015-01-01

Full Text Available Accident processing is the most important link of the scheduling of daily monitoring. The improvement of intelligent level is of great significance for improving the efficiency of accident processing scheduling, shortening the time of accident processing and preventing further deterioration of accidents. According to features of accident processing scheduling, this paper puts forward an integrated framework of aid decision-making of online accident processing based on large power grid, and carries out a study from five aspects, namely integrated information support platform, risk perception in advance, online fault diagnosis, aid decision-making afterwards and visual display, so as to conduct real-time tracking on operating state of power grid, eliminate potential safety hazards of power grid and upgrade power grid from “manual analysis” scheduling to “intelligent analysis” scheduling.

Ergonomic study of biorhythm effect on the 62 occurrence of human errors and accidents in automobile manufacturing industry

Directory of Open Access Journals (Sweden)

2012-03-01

Conclusion: This study showed that the frequency of accidents in critical days and negative section of physical cycle was more than expected. Also the frequency of accidents in critical days and negative section of emotional and intellectual cycle was less than expected. Due to the physical nature of the work activities in the automobile manufacturing industry can be stated that the study showed that in physical work activities, frequency of accidents in critical days and negative section of physical cycle in which the person is not physically ready to do the job was more than expected.

The Three Mile Island accident. Diagnosis and prognosis

International Nuclear Information System (INIS)

Toth, L.M.; Malinauskas, A.P.; Eidam, G.R.; Burton, H.M.

1986-01-01

The Three Mile Island accident occurred on March 29, 1979. The decision to hold a symposium on the TMI accident aftermath was reached when it was realized that enough information had been gathered during the past 6 years to provide a fairly complete picture of the damage and of the activities required for eventual recovery. The symposium was organized into three sessions: the first dealt with a description of the accident, the second focused on the chemical aspects involved, and the third addressed the strategy and progress made toward recovery. The symposium was intended to focus on these three subjects and leave the environmental considerations to future meetings and reports. Although it might appear shortsighted to exclude the environmental impact, the exclusion was considered necessary in order to maintain the focus we sought

Application of uncertainty analysis method for calculations of accident conditions for RP AES-2006

International Nuclear Information System (INIS)

Zajtsev, S.I.; Bykov, M.A.; Zakutaev, M.O.; Siryapin, V.N.; Petkevich, I.G.; Siryapin, N.V.; Borisov, S.L.; Kozlachkov, A.N.

2015-01-01

An analysis of some accidents using the uncertainly assessment methods is given. The list of the variable parameters incorporated the model parameters of the computer codes, initial and boundary conditions of reactor plant, neutronics. On the basis of the performed calculations of the accident conditions using the statistical method, errors assessment is presented in the determination of the main parameters comparable with the acceptance criteria. It was shown that in the investigated accidents the values of the calculated parameters with account for their error obtained from TRAP-KS and KORSAR/GP Codes do not exceed the established acceptance criteria. Besides, these values do not exceed the values obtained in the conservative calculations. A possibility in principle of the actual application of the method of estimation of uncertainty was shown to justify the safety of WWER AES-2006 using the thermal-physical codes KORSAR/GP and TRAP-KS, PANDA and SUSA programs [ru

Radioactive waste management after NPP accident: Post-Chernobyl experience

International Nuclear Information System (INIS)

Mikhalevich, A.; Grebenkov, A.

2000-01-01

As a result of the Chernobyl NPP accident a very large amount of so-called 'Chernobyl waste' were generated in the territory of Belarus, which was contaminated much more than all other countries. These wastes relate mainly to two following categories: low-level waste (LLW) and new one 'Conventionally Radioactive Waste' (CRW). Neither regulations nor technology and equipment were sufficiently developed for such an amount and kind of waste before the accident. It required proper decisions in respect of regulations, treatment, transportation, disposal of waste, etc. (author)

Evaluation of severe accident safety system value based on averting financial risks

International Nuclear Information System (INIS)

Hatch, S.W.; Benjamin, A.S.; Bennett, P.R.

1983-01-01

The Severe Accident Risk Reduction Program is being performed to benchmark the risks from nuclear power plants and to assess the benefits and impacts of a set of severe accident safety features. This paper describes the program in general and presents some preliminary results. These results include estimates of the financial risks associated with the operation of six reference plants and the value of severe accident prevention and mitigation safety systems in averting these risks. The results represent initial calculations and will be iterated before being used to support NRC decisions

An epidemiologic survey of road traffic accidents in Iran: analysis of driver-related factors.

Science.gov (United States)

Moafian, Ghasem; Aghabeigi, Mohammad-Reza; Heydari, Seyed Taghi; Hoseinzadeh, Amin; Lankarani, Kamran Bagheri; Sarikhani, Yaser

2013-01-01

Road traffic accident (RTA) and its related injuries contribute to a significant portion of the burden of diseases in Iran. This paper explores the association between driver-related factors and RTA in the country. This cross-sectional study was conducted in Iran and all data regarding RTAs from March 20, 2010 to June 10, 2010 were obtained from the Traffic Police Department. We included 538 588 RTA records, which were classified to control for the main confounders: accident type, final cause of accident, time of accident and driver-related factors. Driver-related factors included sex, educational level, license type, type of injury, duration between accident and getting the driving license and driver's error type. A total of 538 588 drivers (91.83% male, sex ratio of almost 13:1) were involved in the RTAs. Among them 423 932 (78.71%) were uninjured; 224 818 (41.74%) had a diploma degree. Grade 2 driving license represented the highest proportion of all driving licenses (290 811, 54.00%). The greatest number of accidents took place at 12:00-13:59 (75 024, 13.93%). The proportion of drivers involved in RTAs decreased from 15.90% in the first year of getting a driving license to 3.13% after 10 years'of driving experience. Neglect of regulations was the commonest cause of traffic crashes (345 589, 64.17%). Non-observance of priority and inattention to the front were the most frequent final causes of death (138 175, 25.66% and 129 352, 24.02%, respectively). We found significant association between type of accident and sex, education, license type, time of accident, final cause of accident, driver's error as well as duration between accident and getting the driving license (all P less than 0.001). Our results will improve the traffic law enforcement measures, which will change inappropriate behavior of drivers and protect the least experienced road users.

Description of the information and calculation system for combatment of accidents with hazardous materials

International Nuclear Information System (INIS)

Scheur, M.J. van de; Stolk, D.J.

1987-04-01

On request of the Netherlands government by TNO a decision support system is developed for the assessment of the off-site consequences of an accident with toxic or radioactive materials. The interactive system supports the emergency planning in two ways. First, the risk to the residents in the surroundings of the accident is quantified in terms of severity and magnitude. Second, a set of countermeasures is evaluated by which an optimum strategy to reduce the impact of the accident can be determined. At this moment the system is in a development stage. It turned out that even the preliminary system provides information to the decision process that is urgently needed. This specifically refers to the introduction of the time aspects and the quantification of the damage. 7 refs.; 8 figs.; 3 tabs

Recent Perspective on the Severe Accident Management Programme for Nuclear Power Plant

International Nuclear Information System (INIS)

Kim, Manwoong; Lee, Sukho; Lee, Jungjae; Chung, Kuyoung

2017-01-01

Severe Accident Management Guidelines (SAMGs), has been developed to help operators to prevent or mitigate the impacts of accidents at nuclear power plants. Severe accident management was first introduced in the 1990s with the creation of SAMGs following recognition that post-Three Mile Island Emergency Operating Procedures (EOPs) did not adequately address severe core damage conditions. Establishing and maintaining multiple layers of defence against any internal/external hazards is an important measure to reduce radiological risks to the public and environment. This study is intended to suggest future regulatory perspectives to strengthen the prevention and mitigation strategies for severe accidents by review of the current status of revision of IAEA Safety Standard on Severe Accident Management Programmes for Nuclear Power Plants and the combined PWR SAMG. This new IAEA Safety Guide will address guidelines for preparation, development, implementation and review of severe accident management programs during all operating conditions for both reactor and spent fuel pool. This Guide is used by operating organizations of nuclear power plants and their support organizations. It may also be used by national regulatory bodies and technical support organizations as a reference for developing their relevant safety requirements and for conducting reviews and safety assessments for SAMP including SAMG. The Pressurized Water Reactor Owner’s Group (PWROG) is upgrading the original generic Severe Accident Management Guidelines (SAMGs) into single Severe Accident Guidelines (SAGs) for the PWR SAMG aims to consolidate the advantages of each of the separate vendor severe accident (SA) mitigation methods. This new PWROG SAGs changes the SAMG process to be made that can improve SA response. Changes have been made that guidance is available for control room operators when the TSC is not activated thus allowing for timely accident response. Other changes were made to the guidance

Accident management for severe accidents

International Nuclear Information System (INIS)

Bari, R.A.; Pratt, W.T.; Lehner, J.; Leonard, M.; Disalvo, R.; Sheron, B.

1988-01-01

The management of severe accidents in light water reactors is receiving much attention in several countries. The reduction of risk by measures and/or actions that would affect the behavior of a severe accident is discussed. The research program that is being conducted by the US Nuclear Regulatory Commission focuses on both in-vessel accident management and containment and release accident management. The key issues and approaches taken in this program are summarized. 6 refs

A framework for assessing severe accident management strategies

International Nuclear Information System (INIS)

Kastenberg, W.E.; Apostolakis, G.; Dhir, V.K.; Okrent, D.; Jae, M.; Lim, H.; Milici, T.; Park, H.; Swider, J.; Xing, L.; Yu, D.

1991-01-01

Accident management can be defined as the innovative use of existing and or alternative resources, systems and actions to prevent or mitigate a severe accident. Together with risk management (changes in plant operation and/or addition of equipment) and emergency planning (off-site actions), accident management provides an extension of the defense-in-depth safety philosophy for severe accidents. A significant number of probabilistic safety assessments (PSA) have been completed which yield the principal plant vulnerabilities. For each sequence/threat and each combination of strategy there may be several options available to the operator. Each strategy/option involves phenomenological and operational considerations regarding uncertainty. These considerations include uncertainty in key phenomena, uncertainty in operator behavior, uncertainty in system availability and behavior, and uncertainty in available information (i.e., instrumentation). The objective of this project is to develop a methodology for assessing severe accident management strategies given the key uncertainties mentioned above. Based on Decision Trees and Influence Diagrams, the methodology is currently being applied to two case studies: cavity flooding in a PWR to prevent vessel penetration or failure, and drywell flooding in a BWR to prevent containment failure

Circuit board accident--organizational dimension hidden by prescribed safety.

Science.gov (United States)

de Almeida, Ildeberto Muniz; Buoso, Eduardo; do Amaral Dias, Maria Dionísia; Vilela, Rodolfo Andrade Gouveia

2012-01-01

This study analyzes an accident in which two maintenance workers suffered severe burns while replacing a circuit breaker panel in a steel mill, following model of analysis and prevention of accidents (MAPA) developed with the objective of enlarging the perimeter of interventions and contributing to deconstruction of blame attribution practices. The study was based on materials produced by a health service team in an in-depth analysis of the accident. The analysis shows that decisions related to system modernization were taken without considering their implications in maintenance scheduling and creating conflicts of priorities and of interests between production and safety; and also reveals that the lack of a systemic perspective in safety management was its principal failure. To explain the accident as merely non-fulfillment of idealized formal safety rules feeds practices of blame attribution supported by alibi norms and inhibits possible prevention. In contrast, accident analyses undertaken in worker health surveillance services show potential to reveal origins of these events incubated in the history of the system ignored in practices guided by the traditional paradigm.

The psychological background about human error and safety in NPP

International Nuclear Information System (INIS)

Zhang Li

1992-01-01

A human error is one of the factors which cause an accident in NPP. The in-situ psychological background plays an important role in inducing it. The author analyzes the structure of one's psychological background when one is at work, and gives a few examples of typical psychological background resulting in human errors. Finally it points out that the fundamental way to eliminate the unfavourable psychological background of safety production is to establish the safety culture in NPP along with its characteristics

International survey of government decisions and recommendations following Fukushima

International Nuclear Information System (INIS)

Okyar, H.B.

2011-01-01

A key issue in nuclear emergency management is the need to keep decision makers informed of the details of a situation which is evolving quickly. For example, decision makers need the latest information, and periodic updates, when making decisions regarding advice to citizens, policies on the import and export of food and goods, and industries that may be affected. During the 17 March 2011 meeting of the Inter-Agency Committee on Radiological and Nuclear Emergencies (IACRNE), which was the first of a series of meetings following the Fukushima Daiichi nuclear accident, participants discussed the possibility of establishing a 'database' of the decisions and recommendations made by various governments at an early stage of the Fukushima accident, as well as updating and modifying the database as long as it remained of use. The IACRNE agreed that this information would be very useful, and mandated the NEA to try to collect it. In total, 34 countries (26 NEA members) participated in the survey. The survey results were consolidated into a single document indicating the country, the decision taken or recommendation made, the applicable date and the population concerned. It is important to note that countries submitted differing amounts of information at different points in time during the accident's progression. The survey results indicate that an international overview is required to better understand how national governmental decision-making could be further co-ordinated. The NEA has undertaken some initiatives to analyse the types of decisions made, including the information available and necessary to support such decisions, and the implications for co-ordination needs and mechanisms

A Human Error Analysis with Physiological Signals during Utilizing Digital Devices

Energy Technology Data Exchange (ETDEWEB)

Lee, Yong Hee; Oh, Yeon Ju; Shin, Kwang Hyeon [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2011-10-15

The introduction of advanced MCR is accompanied with lots of changes and different forms and features through the virtue of new digital technologies. There are various kinds of digital devices such as flat panel displays, touch screens, and so on. The characteristics of these digital devices give many chances to the interface management, and can be integrated into a compact single workstation in an advanced MCR so that workers can operate the plant with minimum burden during any operating condition. However, these devices may introduce new types of human errors, and thus we need a means to evaluate and prevent such error, especially those related to the digital devices. Human errors have been retrospectively assessed for accident reviews and quantitatively evaluated through HRA for PSA. However, the ergonomic verification and validation is an important process to defend all human error potential in the NPP design. HRA is a crucial part of a PSA, and helps in preparing a countermeasure for design by drawing potential human error items that affect the overall safety of NPPs. Various HRA techniques are available however: they reveal shortages of the HMI design in the digital era. - HRA techniques depend on PSFs: this means that the scope dealing with human factors is previously limited, and thus all attributes of new digital devices may not be considered in HRA. - The data used to HRA are not close to the evaluation items. So, human error analysis is not easy to apply to design by several individual experiments and cases. - The results of HRA are not statistically meaningful because accidents including human errors in NPPs are rare and have been estimated as having an extremely low probability

Proceedings of the specialist meeting on severe accident management implementation

Energy Technology Data Exchange (ETDEWEB)

NONE

1995-07-01

The Niantic Specialist meeting was structured around three main themes, one for each session. During the first session, papers from regulators, research groups, designers/owners groups and some utilities discussed the critical decisions in Severe Accident Management (SAM), how these decisions were addressed and implemented in generic SAM guidelines, what equipment and instrumentation was used, what are the differences in national approaches, etc. During the second session, papers were presented by utility specialists that described approaches chosen to specific implementation of the generic guidelines, the difficulties encountered in the implementation process and the perceived likelihood of success of their SAM program in dealing with severe accidents. The third session was dedicated to discussing what are the remaining uncertainties and open questions in SAM. Experts from several OECD countries presented significant perspectives on remaining open issues

Proceedings of the specialist meeting on severe accident management implementation

International Nuclear Information System (INIS)

1995-01-01

The Niantic Specialist meeting was structured around three main themes, one for each session. During the first session, papers from regulators, research groups, designers/owners groups and some utilities discussed the critical decisions in Severe Accident Management (SAM), how these decisions were addressed and implemented in generic SAM guidelines, what equipment and instrumentation was used, what are the differences in national approaches, etc. During the second session, papers were presented by utility specialists that described approaches chosen to specific implementation of the generic guidelines, the difficulties encountered in the implementation process and the perceived likelihood of success of their SAM program in dealing with severe accidents. The third session was dedicated to discussing what are the remaining uncertainties and open questions in SAM. Experts from several OECD countries presented significant perspectives on remaining open issues

Evaluation of SAMG effectiveness in view of group decision

International Nuclear Information System (INIS)

Huh, Chang Wook; Suh, Nam Duck; Park, Goon Cherl

2012-01-01

We evaluate the technical and organizational aspects of the severe accident management guideline (SAMG), focusing on the decision-making process in the technical support center (TSC). From the technical aspects, we conclude that the present SAMG is a good tool that can assist the TSC in efficiently managing probable severe accidents. However, we suggest that the clear separation of the emergency operating procedure (EOP) and SAMG, which shifts plant control from the main control room (MCR) to the TSC, might not be an effective framework from an organizational perspective. Studies on organizational behavior demonstrate that a group decision made under a risky situation might be polarized in either a risky or cautious way. We recognize that we cannot be free from the polarization effect since the current SAMG recommends that the TSC evaluate the advantages and disadvantages of strategies to be implemented and choose the best one based on a group decision process. Illustrative examples of accident management under risky conditions are recapitulated from previous studies of the authors and we propose that the SAMG should be more proceduralized to remove this polarization from the decision-making process.

Evaluation of SAMG effectiveness in view of group decision

Energy Technology Data Exchange (ETDEWEB)

Huh, Chang Wook; Suh, Nam Duck [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of); Park, Goon Cherl [Seoul National University, Seoul (Korea, Republic of)

2012-08-15

We evaluate the technical and organizational aspects of the severe accident management guideline (SAMG), focusing on the decision-making process in the technical support center (TSC). From the technical aspects, we conclude that the present SAMG is a good tool that can assist the TSC in efficiently managing probable severe accidents. However, we suggest that the clear separation of the emergency operating procedure (EOP) and SAMG, which shifts plant control from the main control room (MCR) to the TSC, might not be an effective framework from an organizational perspective. Studies on organizational behavior demonstrate that a group decision made under a risky situation might be polarized in either a risky or cautious way. We recognize that we cannot be free from the polarization effect since the current SAMG recommends that the TSC evaluate the advantages and disadvantages of strategies to be implemented and choose the best one based on a group decision process. Illustrative examples of accident management under risky conditions are recapitulated from previous studies of the authors and we propose that the SAMG should be more proceduralized to remove this polarization from the decision-making process.

Error correcting coding for OTN

DEFF Research Database (Denmark)

Justesen, Jørn; Larsen, Knud J.; Pedersen, Lars A.

2010-01-01

Forward error correction codes for 100 Gb/s optical transmission are currently receiving much attention from transport network operators and technology providers. We discuss the performance of hard decision decoding using product type codes that cover a single OTN frame or a small number...... of such frames. In particular we argue that a three-error correcting BCH is the best choice for the component code in such systems....

PSA as a tool for decision making

Energy Technology Data Exchange (ETDEWEB)

Niehaus, F; Lederman, L

1986-05-01

The question on ''How safe is safe enough'' is being responded presently by deterministic criteria. Probabilistic criteria in support to more rational and less emotional decisions in regulatory and licensing issues, rationalization of resource allocation and research prioritization, among others, have a potential which is only marginally being explored. This paper discussed PSA limitations and proposes three areas for the use of PSA in decision making, namely: preventing accidents, mitigating accidents, and defining regulatory requirements. Current activities of the International Atomic Energy Agency in these areas are mentioned. PSA studies depict clearly the uncertainties and this is viewed as a positive aspect, which is unique to the use of probabilistic methods.

RODOS and decision conferencing on early phase protective actions in Finland

International Nuclear Information System (INIS)

Haemaelaeinen, R.P.; Lindstedt, M.; Salo, A.

1998-12-01

This work was undertaken in order to study the utilisation of decision conferencing and of the RODOS system when considering early phase protective actions in the case of a nuclear accident. Altogether four meetings with various people were organised. The meetings were attended by competent national safety authorities and technical level decision-makers, i.e., those who are responsible for preparing advice or making presentations of matters for decision-makers responsible for practical implementation of actions. In the first set of meetings the aim was to elicit the factors/attributes that have to be considered when making a decision on sheltering, evacuation and iodine tablets. No uncertainties nor a threat phase were considered but everything was assumed to happen as described in the given scenario. The theme in the second set of meetings was to study the implications of probabilities. All information was calculated with the support of the RODOS system. In the early phases of a nuclear accident time is limited. Prestructured generic value trees or a list of possible attributes can help to save time. A possible approach is to present a large generic value tree. Either the decision-makers select the attributes that are suitable for the case in hand or the facilitator offers a choice between more structured value trees. The decision-makers then just examine the suggested value trees, check the generic tree to make sure that no important factors have been omitted and choose the appropriate one. As in previous RODOS exercises, the participants felt that RODOS could be used for providing information but found it more problematic to use decision analysis methods when deciding on countermeasures in the early phase of a nuclear accident. Furthermore, it was noted that understanding the actual meaning of 'soft' attributes, such as socio-psychological impacts or political cost, was not a straightforward issue. Consequently, the definition of attributes in advance would be

RODOS and decision conferencing on early phase protective actions in Finland

Energy Technology Data Exchange (ETDEWEB)

Haemaelaeinen, R.P.; Lindstedt, M. [Helsinki Univ. of Technology, Espoo (Finland). Systems Analysis Lab.; Sinkko, K.; Ammann, M. [Radiation and Nuclear Safety Authority, Helsinki (Finland); Salo, A

1998-12-01

This work was undertaken in order to study the utilisation of decision conferencing and of the RODOS system when considering early phase protective actions in the case of a nuclear accident. Altogether four meetings with various people were organised. The meetings were attended by competent national safety authorities and technical level decision-makers, i.e., those who are responsible for preparing advice or making presentations of matters for decision-makers responsible for practical implementation of actions. In the first set of meetings the aim was to elicit the factors/attributes that have to be considered when making a decision on sheltering, evacuation and iodine tablets. No uncertainties nor a threat phase were considered but everything was assumed to happen as described in the given scenario. The theme in the second set of meetings was to study the implications of probabilities. All information was calculated with the support of the RODOS system. In the early phases of a nuclear accident time is limited. Prestructured generic value trees or a list of possible attributes can help to save time. A possible approach is to present a large generic value tree. Either the decision-makers select the attributes that are suitable for the case in hand or the facilitator offers a choice between more structured value trees. The decision-makers then just examine the suggested value trees, check the generic tree to make sure that no important factors have been omitted and choose the appropriate one. As in previous RODOS exercises, the participants felt that RODOS could be used for providing information but found it more problematic to use decision analysis methods when deciding on countermeasures in the early phase of a nuclear accident. Furthermore, it was noted that understanding the actual meaning of `soft` attributes, such as socio-psychological impacts or political cost, was not a straightforward issue. Consequently, the definition of attributes in advance would be

Development of a severe accident training simulator using a MELCOR code

International Nuclear Information System (INIS)

Kim, Ko Ryu; Jeong, Kwang Sub; Ha, Jae Joo; Jung, Won Dae

2002-03-01

Nuclear power plants' severe accidents are, despite of their rareness, very important in safety aspects, because of their huge damages when occurred. For the appropriate execution of severe accident strategy, more information for decision-making are required because of the uncertainties included in severe accidents. Earlier NRC raised concerns over severe accident training in the report NUREC/CR-477, and accordingly, developing effective training tools for severe accident were emphasized. In fact the training tools were requested from industrial area, nevertheless, few training tools were developed due to the uncertainties in severe accidents, lacks of analysis computer codes and technical limitations. SATS, the severe accident training simulator, is developed as a multi-purpose tools for severe accident training. SATS uses the calculation results of MELCOR, an integral severe accident analysis code, and with the help of SL-GMS graphic tools, provides dynamic displays of severe accident phenomena on the terminal of IBM PC. It aimed to have two main features: one is to provide graphic displays to represent severe accident phenomena and the other is to process and simulate severe accident strategy given by plant operators and TSC staffs. Severe accident strategies are basically composed of series of operations of available pumps, valves and other equipments. Whenever executing strategies with SATS, the trainee should follow the HyperKAMG, the on line version of the recently developed severe accident guidance (KAMG). Severe accident strategies are closely related to accidents scenarios. TLOFW and LOCA , two representative severe accident scenarios of Uljin 3,4, are developed as a built-in scenarios of SATS. Although SATS has some minor problems at this time, we expect SATS will be a good severe accident training tool after the appropriate addition of accident scenarios. Moreover, we also expect SATS will be a good advisory tool for the severe accident research

A crisis management decision support system to reduce ingestion dose

International Nuclear Information System (INIS)

Schenker-Wicki, A.; Gibbert, R.

1993-01-01

Environmental accidents such as extensive radioactive or chemical contamination can have more serious consequences for a population than any other kind of accidents known before. Owing to the serious consequences and the high number of people who may be affected, the selection of the best countermeasures to ameliorate the imminent impact is very difficult and the political responsibility is enormous. To help overcome such problems the National Emergency Operations Center in Zurich (Switzerland) has developed a decision support system to evaluate acceptable countermeasures for reducing ingestion dose after an accidental release of radioactive material. The system involves all the necessary modules and techniques for efficient decision making, based on the most recent developments in decision theory as well as the necessary structuring of the decision-making process. The decision-making concept comprehends decision making on two different levels, a technical and a political one. (author)

Research on sever accident emergency simulation system for CPR1000

International Nuclear Information System (INIS)

Yang Zhifei; Liao Yehong; Liang Manchun; Li Ke; Yang Jie; Chen Yali

2015-01-01

The enhanced capability to nuclear power plant (NPP) severe accident management and emergency response depends heavily on exercises. Since the exercise scene is usually monotonous and not realistic, and conduct of exercise has a high cost, the effect of enhancing the capability is limited. Thus, the development of a Sever Accident Emergency Simulation System (SAESS) is necessary. SAESS is able to connect NPP simulator, and simulates the process of severe accident management, personnel evacuation, the dispersion of radioactive plume, and emergency response of emergency organizations. The system helps to design several of exercise scenes and optimize the disposal strategy in different severe accidents. In addition, the system reduces the cost of emergency exercise by computer simulation, benefits the research of exercise, increases the efficiency of exercise and enhances the emergency decision-making capability. This paper introduces the design and application of SAESS. (author)

Forecasting Error Calculation with Mean Absolute Deviation and Mean Absolute Percentage Error

Science.gov (United States)

Khair, Ummul; Fahmi, Hasanul; Hakim, Sarudin Al; Rahim, Robbi

2017-12-01

Prediction using a forecasting method is one of the most important things for an organization, the selection of appropriate forecasting methods is also important but the percentage error of a method is more important in order for decision makers to adopt the right culture, the use of the Mean Absolute Deviation and Mean Absolute Percentage Error to calculate the percentage of mistakes in the least square method resulted in a percentage of 9.77% and it was decided that the least square method be worked for time series and trend data.

Medication errors: definitions and classification

Science.gov (United States)

Aronson, Jeffrey K

2009-01-01

To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. PMID:19594526

Introduction of new terms and lessons for radiological protection after Fukushima Dai-Ichi accident

International Nuclear Information System (INIS)

Singh, Vishwanath P.; Managanvi, S.S.; Bhat, H.R.

2012-01-01

The nuclear accidents in the world are very few among various types of operating facilities. However when an accident happened, we have learnt a lot to improve the philosophy, term, definitions, document preparation, equipment's requirement, supporting systems, awareness program and restriction etc. After Fukushima Dai-ichi we have learnt a lot, in this view this paper has been prepared to discuss for radiological protection aspects. Discussion: The probability of nuclear accidents is negligible but when happens, it opens new doors of lessons for radiological protection practices for occupational workers, emergency workers for damage control to prevent catastrophic situation/rescue to life saving actions and the member of the public. The Chernobyl and Three Mile Island accidents have provided a lot experiences for management of emergency situations, documentation, radiation emergency preparedness, emergency equipment's, concept of defense-in-depth, emergency planning zone (EPZ), accidental dose limits, estimation of source term and public dose, intervention levels, decision supporting system, remedial actions in public domain; decontamination of person, houses/building and land and etc. Recent Fukushima Dai-ichi accident in Japan was managed in appreciable manner but still new definitions and lessons for radiological protection have been emerged out. The present paper discusses difficulties w. r. t. the radiological aspects observed/faced by Japanese during nuclear crises. The accident introduced new terms as Natural Dose Rate Unit (NDRU), voluntary evacuation, deliberate evacuation area, restricted area and difference between evacuation zone and EPZ. The Fukushima accident has enforced worldwide regulators and operators to review the individual dose limit and amendment for raise in the dose limit during accident, availability of efficient/adequate quantities of personal dosimeter in public domain, collection arrangement of bulk amount of radioactive wastes

Decision Making in Action: Applying Research to Practice

Science.gov (United States)

Orasanu, Judith; Statler, Irving C. (Technical Monitor)

1994-01-01

The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication

Soft Decision Analyzer

Science.gov (United States)

Lansdowne, Chatwin; Steele, Glen; Zucha, Joan; Schlesinger, Adam

2013-01-01

We describe the benefit of using closed-loop measurements for a radio receiver paired with a counterpart transmitter. We show that real-time analysis of the soft decision output of a receiver can provide rich and relevant insight far beyond the traditional hard-decision bit error rate (BER) test statistic. We describe a Soft Decision Analyzer (SDA) implementation for closed-loop measurements on single- or dual- (orthogonal) channel serial data communication links. The analyzer has been used to identify, quantify, and prioritize contributors to implementation loss in live-time during the development of software defined radios. This test technique gains importance as modern receivers are providing soft decision symbol synchronization as radio links are challenged to push more data and more protocol overhead through noisier channels, and software-defined radios (SDRs) use error-correction codes that approach Shannon's theoretical limit of performance.

An operational centre for managing major chemical industrial accidents.

Science.gov (United States)

Kiranoudis, C T; Kourniotis, S P; Christolis, M; Markatos, N C; Zografos, K G; Giannouli, I M; Androutsopoulos, K N; Ziomas, I; Kosmidis, E; Simeonidis, P; Poupkou, N

2002-01-28

The most important characteristic of major chemical accidents, from a societal perspective, is their tendency to produce off-site effects. The extent and severity of the accident may significantly affect the population and the environment of the adjacent areas. Following an accident event, effort should be made to limit such effects. Management decisions should be based on rational and quantitative information based on the site specific circumstances and the possible consequences. To produce such information we have developed an operational centre for managing large-scale industrial accidents. Its architecture involves an integrated framework of geographical information system (GIS) and RDBMS technology systems equipped with interactive communication capabilities. The operational centre was developed for Windows 98 platforms, for the region of Thriasion Pedion of West Attica, where the concentration of industrial activity and storage of toxic chemical is immense within areas of high population density. An appropriate case study is given in order to illuminate the use and necessity of the operational centre.

[Guilty victims: a model to perpetuate impunity for work-related accidents].

Science.gov (United States)

Vilela, Rodolfo Andrade Gouveia; Iguti, Aparecida Mari; Almeida, Ildeberto Muniz

2004-01-01

This article analyzes reports and data from the investigation of severe and fatal work-related accidents by the Regional Institute of Criminology in Piracicaba, São Paulo State, Brazil. Some 71 accident investigation reports were analyzed from 1998, 1999, and 2000. Accidents involving machinery represented 38.0% of the total, followed by high falls (15.5%), and electric shocks (11.3%). The reports conclude that 80.0% of the accidents are caused by "unsafe acts" committed by workers themselves, while the lack of safety or "unsafe conditions" account for only 15.5% of cases. Victims are blamed even in situations involving high risk in which not even minimum safety conditions are adopted, thus favoring employers' interests. Such conclusions reflect traditional reductionist explanatory models, in which accidents are viewed as simple, unicausal phenomena, generally focused on slipups and errors by the workers themselves. Despite criticism in recent decades from the technical and academic community, this concept is still hegemonic, thus jeopardizing the development of preventive policies and the improvement of work conditions.

Sensitivity of risk parameters to human errors in reactor safety study for a PWR

International Nuclear Information System (INIS)

Samanta, P.K.; Hall, R.E.; Swoboda, A.L.

1981-01-01

Sensitivities of the risk parameters, emergency safety system unavailabilities, accident sequence probabilities, release category probabilities and core melt probability were investigated for changes in the human error rates within the general methodological framework of the Reactor Safety Study (RSS) for a Pressurized Water Reactor (PWR). Impact of individual human errors were assessed both in terms of their structural importance to core melt and reliability importance on core melt probability. The Human Error Sensitivity Assessment of a PWR (HESAP) computer code was written for the purpose of this study. The code employed point estimate approach and ignored the smoothing technique applied in RSS. It computed the point estimates for the system unavailabilities from the median values of the component failure rates and proceeded in terms of point values to obtain the point estimates for the accident sequence probabilities, core melt probability, and release category probabilities. The sensitivity measure used was the ratio of the top event probability before and after the perturbation of the constituent events. Core melt probability per reactor year showed significant increase with the increase in the human error rates, but did not show similar decrease with the decrease in the human error rates due to the dominance of the hardware failures. When the Minimum Human Error Rate (M.H.E.R.) used is increased to 10 -3 , the base case human error rates start sensitivity to human errors. This effort now allows the evaluation of new error rate data along with proposed changes in the man machine interface

Modeling framework for crew decisions during accident sequences

International Nuclear Information System (INIS)

Lukic, Y.D.; Worledge, D.H.; Hannaman, G.W.; Spurgin, A.J.

1986-01-01

The ability to model the average behavior of operating crews in the course of accident sequences is vital in learning on how to prevent damage to power plants and to maintain safety. This paper summarizes the work carried out in support of a Human Reliability Model framework. This work develops the mathematical framework of the model and identifies the parameters which could be measured in some way, e.g., through simulator experience and/or small scale tests. Selected illustrative examples are presented, of the numerical experiments carried out in order to understand the model sensitivity to parameter variation. These examples ar discussed with the objective of deriving insights of general nature regarding operating of the model which may lead to enhanced understanding of man/machine interactions

Consideration of severe accidents in design of advanced WWER reactors

International Nuclear Information System (INIS)

Fedorov, V.G.; Rogov, M.F.; Podshibyakin, A.K.; Fil, N.S.; Volkov, B.E.; Semishkin, V.P.

1998-01-01

Severe accident related requirements formulated in General Regulations for Nuclear Power Plant Safety (OPB-88), in Nuclear Safety Regulations for Nuclear Power Stations' Reactor Plants (PBYa RU AS-89) and in other NPP nuclear and radiation guides of the Russian Gosatomnadzor are analyzed. In accordance with these guides analyses of beyond design basis accidents should be performed in the reactor plant design. Categorization of beyond design basis accidents leading to severe accidents should be made on occurrence probability and severity of consequences. Engineered features and measures intended for severe accident management should be provided in reactor plant design. Requirements for severe accident analyses and for development of measures for severe accident management are determined. Design philosophy and proposed engineered measures for mitigation of severe accidents and decrease of radiation releases are demonstrated using examples of large, WWER-1000 (V-392), and medium size WWER-640 (V-407) reactor plant designs. Mitigation of severe accidents and decrease of radiation releases are supposed to be conducted on basis of consistent realization of the defense in depth concept relating to application of a system of barriers on the path of spreading of ionizing radiation and radioactive materials to the environment and a set of engineered measures protecting these barriers and retaining their effectiveness. Status of fulfilled by OKB Gidropress and other Russian organizations experimental and analytical investigations of severe accident phenomena supporting design decisions and severe accident management procedures is described. Status of the works on retention of core melt inside the WWER-640 reactor vessel is also characterized

An analysis of the human reliability on Three Mile Island II accident considering THERP and ATHEANA methodologies

International Nuclear Information System (INIS)

Fonseca, Renato Alves da; Alvim, Antonio Carlos Marques

2005-01-01

The research on the Analysis of the Human Reliability becomes more important every day, as well as the study of the human factors and the contributions of the same ones to the incidents and accidents, mainly in complex plants or of high technology. The analysis here developed it uses the methodologies THERP (Technique for Human Error Prediction) and ATHEANA (A Technique for Human Error Analysis), as well as, the tables and the cases presented in THERP Handbook and to develop a qualitative and quantitative study of an occurred nuclear accident. The chosen accident was it of Three Mile Island (TMI). The accident analysis has revealed a series of incorrect actions that resulted in the permanent loss of the reactor and shutdown of Unit 2. This study also aims at enhancing the understanding of the THERP and ATHEANA methods and at practical applications. In addition, it is possible to understand the influence of plant operational status on human failures and the influence of human failures on equipment of a system, in this case, a nuclear power plant. (author)

Development of a knowledge-based system for loop diagnosis

International Nuclear Information System (INIS)

Liao, L.Y.; Tang, H.C.; Chen, S.S.

1987-01-01

An accident diagnostic system is developed as an attempt to provide a useful aid for the operators of an experimental loop or a nuclear power plant in the case of emergency condition. Because the current practices in the system diagnosis are not satisfactory, there is an increasing demand on the establishment of various operator decision support systems. The knowledge based system is a new and promising technique which can be used to fulfill this demand. With the capability of automatic reasoning and by incorporating the information about system status, the knowledge based system can simulate the process of human thinking and serve as a good decision support system. This knowledge based decision support system can be helpful for both a fast, violent accident and a slowly developed accident. Specifically, a fast diagnostic report can be provided for a fast and violent accident of which time is the main concern and a complete diagnostic report can be provided for a slowly developed accident of which complexity is the main concern. Such a knowledge based decision support system also provides many other equally important advantages, such as the elimination of human error, the automatic validation of signal readings, the establishment of human error, the automatic validation of signal readings, and the establishment of a simulation environment

The estimation economic impacts from severe accidents of a nuclear power plant

International Nuclear Information System (INIS)

Jeong, J. T.; Jeong, W. D.

2001-01-01

The severe accidents of a nuclear power plant may cause health effects in the exposed population and societal economic impacts or costs. Techniques to assess the consequences of an accident in terms of cost may be applied in studies on the design of plant safety features and in examining countermeasure options as part of emergency planning or in decision making after an accident. In this study, the costs resulting from the severe accidents of a nuclear power plant were estimated for the different combinations of source term release parameters and meteorological data. Also, the costs were estimated for the different scenarios considering seasonal characteristics of Korea. The results can be used as essential inputs in costs/benefit analysis and in developing optimum risk reduction strategies

Decision-making in abnormal radiological situations

International Nuclear Information System (INIS)

Pretre, S.

1998-01-01

General problems associated with social impacts of radiology and decision making is discussed, as the main topics of the meeting. The problem of population is discussed living in areas contaminates with radioactive substances resulting from a major accident or from pest practices. This situation needs decision making process for initiating actions like relocation, resettlement or large-scale decontamination. The roles of various participants in this decision making process and in the communication with the public are considered. (R.P.)

Optimal threshold of error decision related to non-uniform phase distribution QAM signals generated from MZM based on OCS

Science.gov (United States)

Han, Xifeng; Zhou, Wen

2018-03-01

Optical vector radio-frequency (RF) signal generation based on optical carrier suppression (OCS) in one Mach-Zehnder modulator (MZM) can realize frequency-doubling. In order to match the phase or amplitude of the recovered quadrature amplitude modulation (QAM) signal, phase or amplitude pre-coding is necessary in the transmitter side. The detected QAM signals usually have one non-uniform phase distribution after square-law detection at the photodiode because of the imperfect characteristics of the optical and electrical devices. We propose to use optimal threshold of error decision for non-uniform phase contribution to reduce the bit error rate (BER). By employing this scheme, the BER of 16 Gbaud (32 Gbit/s) quadrature-phase-shift-keying (QPSK) millimeter wave signal at 36 GHz is improved from 1 × 10-3 to 1 × 10-4 at - 4 . 6 dBm input power into the photodiode.

Benchmark accident scenarios for nuclear powered warship visits to Australian ports

International Nuclear Information System (INIS)

Frikken, A.J.

1996-01-01

Full text: Port safety arrangements for visits of nuclear powered warships (NPWs) to Australian ports require compliance with a number of Conditions of Entry. One of these Conditions of Entry is the provision of 'an operating safety organisation, competent to produce a suitable radiation monitoring program and able to initiate actions and provide services necessary to safeguard the public in the event of a release of radioactivity following an accident'. The States and Territories which receive NPW visits have the responsibility for this contingency planning, although the Commonwealth provides assistance through the Visiting Ships Panel Nuclear (VSP(N)). The visit of a NPW to an Australian port may only proceed if the VSP(N) is satisfied that the port safety plan has been exercised in sufficient depth to demonstrate its adequacy and efficacy. Emergency exercises are held on a regular basis in Australian ports which have been validated for visits by NPWs to ensure compliance with the Conditions of Entry. Important aspects of these exercises are the procedures for estimating radiation doses to members of the public following an accident, and the process for making decisions on the need for countermeasures based on the results of dose estimates. To exercise these aspects of the emergency response, detailed emergency exercise scenarios, including simulated radiological monitoring data, are required. To date, emergency exercises have usually been based on a severe and highly improbable scenario, termed the Reference Accident, which is used to assess the suitability of ports for visits by NPW's. The repeated adoption of this scenario does not adequately test the flexibility of the emergency plans to cope with all possible accidents, particularly more likely, less severe accidents. At the request of the VSP(N), the Nuclear Safety Bureau has analysed a spectrum of NPW accident scenarios and developed a set of Bench Mark Accident (BMA) scenarios for emergency response

Human performance breakdowns are rarely accidents: they are usually very poor choices with disastrous results

International Nuclear Information System (INIS)

Besco, Robert O.

2004-01-01

When human error is involved in the error chain of accidents in complex systems, the causes of the errors are very seldom the result of: - a random slip,; - one inadvertent oversight,; - a single unintended action,; - one mis-perceived event,; - simple mal-performance of a complex action, or; - a poor training program for the human operators. Invariably, the cause of the break down is in a very poor conscious choice by someone from the operator back through system designer, the supervision, management and leadership through the entire organization. Usually the operator bears the burden of the blame and is either rebuked, retrained or replaced. In systems such as commercial aviation, complex manufacturing systems, power plants, process control systems, information-processing systems and communications networks, the replacement or retraining of individuals or even classes of individuals usually does not result in any long-term improvement of the safety or effectiveness of the system. What is needed is a system that identifies the reasons why the operators made the errors. Further a system is needed that can recommend what can be done to improve the future performance within the system. The professional performance analysis system (PPAS) has been developed and applied to more than 50 major aircraft accidents in the past 30 years. The PPAS is a direct outgrowth of the human performance analysis system developed by Robert Mager over 45 years ago. The PPAS system is applied after a complete and unbiased definition and description of the events of the accident or incident has been developed by the teams of accident investigation and accident reconstruction professionals. The PPAS then uses a systematic protocol and algorithm to determine the reasons as to why the humans committed the errors or why they performed at subnormal performance levels. This process is based on quantitative behavioral science principles and findings that have been demonstrated valid for many

On-site emergency intervention plan for nuclear accident situation at INR-Pitesti TRIGA reactor

International Nuclear Information System (INIS)

Oprea, I.; Margenu, S.; Preda, M.

2001-01-01

A nuclear incident is defined as a series of events leading to release of radioactive materials into the environment of sufficient concentration to make necessary protective actions. The decision to initiate a protective action is a complex process. The benefits of taking the action is weighed against the involved risk and constraints. In addition the decision will be made under difficult emergency conditions, probably with little detailed information available. Therefore, considerable planing is necessary to reduce to manageable levels the types of decisions leading to effective responses to protect the public in the event of a nuclear incident. The sequence of events for developing emergency plans and responding to nuclear incidents will vary according to individual circumstances, because the international recommendations and site-specific emergency plans cannot provide detailed guidance for all accident scenarios and variations in local conditions. Flexibility must be maintained in emergency response to reflect the actual circumstances encountered (e.g. source term characteristics, the large number of possible weather conditions and environmental situation such as time of the day, season of the year, land use and soil types, population distribution and economic structures, uncertainties in the availability of technical and administrative support and the behaviour of the population). This further complicates the decision-making process, especially under accident conditions where there are time pressures and psychological stress. Therefore one the most important problems in the case of a nuclear emergency is quantifying all these very different types of off-site consequences. Last years, and in particular since the Chernobyl accident, there has been a considerable increase in the resources allocated to development of computerised systems which allow for predicting the radiological impact of accidents and to provide information in a manageable and effective form to

A strategy for minimizing common mode human error in executing critical functions and tasks

International Nuclear Information System (INIS)

Beltracchi, L.; Lindsay, R.W.

1992-01-01

Human error in execution of critical functions and tasks can be costly. The Three Mile Island and the Chernobyl Accidents are examples of results from human error in the nuclear industry. There are similar errors that could no doubt be cited from other industries. This paper discusses a strategy to minimize common mode human error in the execution of critical functions and tasks. The strategy consists of the use of human redundancy, and also diversity in human cognitive behavior: skill-, rule-, and knowledge-based behavior. The authors contend that the use of diversity in human cognitive behavior is possible, and it minimizes common mode error

PSA as a tool for decision making

International Nuclear Information System (INIS)

Niehaus, F.; Lederman, L.

1986-01-01

The question on ''How safe is safe enough'' is being responded presently by deterministic criteria. Probabilistic criteria in support to more rational and less emotional decisions in regulatory and licensing issues, rationalization of resource allocation and research prioritization, among others, have a potential which is only marginally being explored. This paper discussed PSA limitations and proposes three areas for the use of PSA in decision making, namely: preventing accidents, mitigating accidents, and defining regulatory requirements. Current activities of the International Atomic Energy Agency in these areas are mentioned. PSA studies depict clearly the uncertainties and this is viewed as a positive aspect, which is unique to the use of probabilistic methods. (orig.)