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Summary and Recommendations
This report presents the panel's recommendations for an agen-
da of applied research on the human factors issues involved in the
safety of nuclear reactors. It is addressed to all elements of the
nuclear community. However, undertaking such an agenda by a
diverse community requires leadership, and it is clear to the pane!
that responsibility for that leadership should rest with the U.S.
Nuclear Regulatory Commission (NRC). Accordingly, many of the
research topics presented here are ones that the pane] judges to be
most appropriately undertaken by the NRC.
Part ~ of the report presents a context for human factors re-
search on nuclear safety. It cites the charge given to the pane! and
the approach the pane! took to the problem of human factors in
nuclear safety. As background to specific research topics, Part ~
includes a review and discussion of human factors research both
before and after the Three Mile Island accident. An important dis-
cussion of research methodology and management is also included
in Part I. In this section the pane! makes a variety of recommenda-
tions about how to conduct high-quality research that will produce
useful and applicable results.
Part I! of the report contains an agenda of human factors
research needs for the nuclear industry. Topics of higher priority
within this agenda are identified. The panel has made no attempt
to develop a detailed program plan, schedule, or budget; that
is more properly the task of those managers responsible for im-
plementation of the research program. We propose that nuclear
1
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reactor safety and the recommended research be viewed from a
perspective that recognizes the nuclear power plant as an element
of a more extensive sociotechnical system, and we suggest criteria
for managing a human factors research program that are needed to
address the problems existing within the context of this extended
view of the system.
A word about the type of research proposed here is in order.
In some cases we have suggested research in areas with gaps in
knowledge, and research has been proposed to fill these gaps; this
is particularly true with respect to sociotechnical systems, whose
dynamics, though of critical importance to safety, are as yet not
well understood. In other cases the problem is not a deficiency
of knowledge but rather a failure to transfer and adapt existing
knowledge from other disciplines and other related systems. Yet
another type of research calls for empirical studies of innovations
or modifications to existing technology and operational practices;
research of this type is necessary to demonstrate that a change is
workable and worthwhile.
RECOMMENDATIONS
The remainder of this section summarizes the recommenda-
tions of the panel. These recommendations are of two types: (1)
recommendations to facilitate the initiation, planning, manage-
ment, conduct, and use of human factors research and (2) recom-
mendations on specific research topics to be investigated by the
NRC and the rest of the nuclear community. The pane! has not at-
tempted to suggest how the research topics it recommends should
be allocated within this community. Some studies, particularly
those that can provide the basis for improved regulatory analy-
sis and decision making, will be appropriate undertakings for the
NRC. Others may be more appropriately undertaken as individual
or collaborative efforts. Decisions regarding which elements of the
nuclear community should be responsible for which topics, and
whether research will be done on a collaborative basis, are tasks
for the nuclear community and do not fall within the charge of the
panel.
The panel recommends a general agenda of research on the
human factors issues involved in the safety of nuclear reactors. The
proposed agenda is divided into five major topics: human-system
interface design, the personnel subsystem, human performance,
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management and organization, and the regulatory or environmen-
tal context. Each of these areas includes a number of research
topics, some of which have been identified as having higher prior-
ity. The specific issues involved in each proposed research topic
are elements that are necessary to improve design, construction,
performance, operations, maintenance, and regulation to ensure
public safety.
Recommendation 1: Commitment to Hmnm Factors Research
The pane] recommends that the NRC make a firm public com-
mitment to applied behavioral and social science (human factors
safety) research. This would require a decision to increase staffing
and financial support. Without such a commitment, the public
and the nuclear industry can reasonably assume that human fac-
tors is not regarded by the NRC to be a matter of importance, nor
will the NRC be able to attract the highly competent staff it will
need. In addition, the human factors program should be directed
at the level of branch head, not as a subdivision of the reliability
branch.
In our opinion, it is of paramount importance that the NRC
and the nuclear industry recognize that research and develop-
ment (R&D) in human factors safety has to be an integral part of
any continued national programs in nuclear power systems, just
as R&D in materials, radiation protection, severe accident phe-
nomenology, and reactor systems are part of ongoing research pro-
grams. While there have been major advances in nuclear system
human factors since the Three Mile Island accident, the problems
that existed have not and will not be resolved completely by a
program of a few years' duration. Furthermore, new problems
will inevitably arise, especially as new or improved systems are
introduced.
Recommendation 2: Adopting a Systems-Oriented Approach
In recognition of the many ways in which human behavior
can affect nuclear power plant safety, the pane! recommends that
the NRC's research program maintain a broad perspective. The
operator/maintainer-plant interface is extremely important; but
other factors arising from the way in which a plant is organized,
staffed, managed, and regulated and the way it interacts with
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other elements of the industry can also affect human performance,
induce human error, and increase the level of risk of a plant.
The pane! firmly believes that research that recognizes a sys-
tems approach, in which the "system" is broadly defined, has great
potential for delivering results that yield useful recommendations
for safety improvements. The systems approach to safety requires
multidisciplinary teams and close coordination of programs deal-
ing with different levels and facets of the system. As part of
a systems approach, risk assessment results need to be used to
control plant safety by providing a basis to support management
decisions over the total plant life cycle of design. This also means
that safety level indicators need to be developed to measure the
effectiveness of the improvements to plant operations suggested by
research and to support operational risk management.
Recommendation 3: Peer Review and Enhanced Access to
Nuclear Power Research Facilities and Personnel
The panel recommends that the NRC involve a diverse group
of knowledgeable researchers in planning, conducting, and evalu-
ating its research program. In addition, peer review of proposals
and of draft reports by behavioral science experts is needed to
ensure the quality of sponsored research.
One of the barriers to effective human factors research has to
do with providing behavioral science researchers access to realistic
settings,~to facilities such as simulators, and to people such as
experienced operators. While the pane! recognizes the practical
difficulties involved, we strongly urge the NRC and the nuclear
industry to take significant steps that enhance researchers' access
to these facilities and people. One step to achieve this goal would
be to create a national research facility for the study of human
factors in nuclear power systems.
Recommendation 4: Continuity in the Research Program
The human-factors-related activities carried out by the NRC
in the past have been of two types. Work by the Office of Nuclear
Reactor Regulation (NRR), typically called "technical assistance,"
has been concerned with short-term solutions to specific problems
or with support to regulatory analysis and decision making. Hu-
man factors work within the Office of Nuclear Reactor Research
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s
(RES) has been concerned with longer-term research issues. While
this may have been a useful and practical separation of functions
that may be appropriate to retain, the pane! is concerned about
the ejects of the short-term priorities of NRR on the longer-term
research programs of RES. For the research programs to produce
useful, practical results, continuity on important issues is essential.
To be effective, a research program must operate coherently for an
extended period rather than change in response to each new, im-
mediate, external demand. Since effective research is cumulative,
continuity is as important as level of expenditure.
Recommendation 5: Transfer of Enowledge
The panel recommends that the NRC take the greatest pos-
sible advantage of existing research in the behavioral and social
sciences by increasing the transfer of knowledge to the nuclear in-
dustry. To this end, the pane} recommends that the NRC publish
an annual review of the human factors research relevant to the
nuclear power industry.
Recommendation 6: Dissemination of Human Factors
Research by the Nuclear Country
The panel has observed that several problems exist in the
usability and transfer of human factors research reports prepared
by the NRC, its contractors, the national laboratories, and other
elements working on human factors research related to nuclear
power that should be addressed.
One unpediment is the difficulty in searching for and retriev-
ing human factors research reports. We are not aware that any
central bibliographic data base or search service exists to abstract,
index, and make available bibliographic or full text information,
including NRC human factors publications. We recommend that
mechanisms to improve the dissemination of human factors re-
sults throughout the industry be developed. One element is to
use or develop a bibliographic search service. As a first step the
pane] recommends the development of a bibliographic system for
NRC-supported human factors reports.
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Recommendation 7: A Human Factors ResearEh Agenda
Based on the panel's approach to the interaction of the human
and technical systems, the research agenda has been organized
into major areas. The pane] followed three criteria in determining
higher priority research topics within these areas. First, some
research topics may have a critical impact on safety and thus
must be addressed immediately. Second, in some areas research is
needed as a basis for evaluation. Third, a particular research topic
may be an essential building block for a long-term program. In all
cases research should be aimed at management, maintenance, and
other ancillary workers, as well as control room operators.
The five major areas of the panel's recommended research
agenda appear below.
(1) Human-System Interface Design. Research on the human-
system interface design seeks to improve the interface between in-
dividuals and the technical system. With the rapid advances in
computer technology, automation, and software, the panel believes
that research on computer-based control and display, automation,
and computer-based performance aids and the human factors as-
pects of software are of particular importance. The highest priority
research topic in this area is:
.
Automation and computer-based job performance aids
(2) Personnel Subsystem. Research on the personnel sum
system is concerned with the design of jobs and the development
of systems to ensure that personnel assigned to those jobs are
sufficient in number and have the requisite training and qualifica-
tions to perform them. The pane! placed higher priority on three
personnel subsystem topics:
Maintenance and enhancement of operational skill (new
training approaches)
Improvements in licensing examinations
Shift scheduling and vigilance
(3) Human Performance. The ability to measure and pre-
dict human performance within the system is fundamental for the
meaningful design and operation of a sociotechnical system. The
panel recognizes a critical need to establish an integrated research
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program, to develop the methodology and data for characteriza-
tion, measurement, and prediction of human performance. The
highest priority research topic is:
. Causal models of human error, especially for situations
with unplanned elements
(4) Management and Organization. This area deals with
the effects of organizational design and management decisions on
safety. Areas for priority attention include:
~ The impact of regulations on the practice of management
Organizational design and a culture of reliability
(5) The Regulatory Environment. This area focuses on the
actions of regulatory bodies and the interactions between regula-
tors and utilities that affect safety, both directly and indirectly.
The highest priority research topics are:
The appropriate mix of government regulation and indus-
try self-regulation
Developing and tracking a wide array of performance indi-
cators
More details of these research priorities are given in the body
of the report.
CONCLUSION
The panel is encouraged by the initiative shown by the NRC
to develop and fund a new human factors research program. If this
plan is implemented in 1988, receives the strong support of the
NRC and of the industry, is managed by a qualified human factors
specialist, is staffed by a team of multidisciplinary scientists, and
is organized as a separate branch rather than as a subdivision of
the reliability branch, then the initial steps of leadership required
of the NRC in this critical area will have been taken. Further steps
will be taken as the NRC and the industry review and implement
the recommendations made by the panel.
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Representative terms from entire chapter:
priority research
