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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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2 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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3 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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4 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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6 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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7 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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