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2 The NRC's Human Factors Research Program RESEARCH IMPETUS Although the 1975 fire at the Browns Ferry nuclear plant and the 1979 accident at Three Mile Island were clear-cut signals that Al was not well with the state of human factors in the nuclear industry, these were not the first nor the only such warnings. In 1972 the Atomic Energy Commissionthe forerunner of the Department of Energy and the Nuclear Regulatory Commission- asserted that insufficient attention was being given to control room design and staffing and operator training and procedures (U.S. Atomic Energy Commission, 1972~. In 1975 a study by Sandia Laboratory identified human factors deficiencies in the de- sign of the engineering safety panels at the Zion plant and others that were visited (Swain, 1975~. In 1976, the Electric Power Re- search Institute the research arm of the electric power industry- published a negative review of the design of five typical control rooms (Electric Power Research Institute, 1976~. Another review of 18 control rooms conducted for the NRC by the Aerospace Corporation in 1977 was equally negative (FinIayson et al., 1977~. Other investigations disclosed that human factors deficiencies were not limited to control rooms but extended to other parts of nu- clear power plants, such as design for maintainability, surveillance, testing, and security. After seven years of repeated investigations and warnings, why had so little attention been paid to the application of human fac- tors knowledge to nuclear power plant design and operation? The 23

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24 principal reason appears to be that, prior to Three Mile Island, the nuclear power industry relied on conventional engineering am preaches to the design and operation of nuclear power plants, as did the architectural and engineering firms and nuclear steam sum ply system and other vendors who supported the industry. Many of these approaches had their origins in earlier engineering prac- tices used in the design of fossil fuel power plants and process control systems. Since these practices had been effective in the past, it was assumed they would be equally effective when applied to nuclear power plants. However, as the accident at Three Mile Island so dramatically demonstrated, this assumption proved to be invalid. Several major investigations that followed Three Mile Island the President's Commission (Kemeny et al., 1979), the Rogovin Report (Rogovin and Hampton, 1980), the Nuclear Safety Analy- sis Center of EPRI report (EPRT, 1979), an NRC report (NUREG- 0585, 1979b), and othersall pointed out clearly and forcefully, as did the NRC's own investigations, that major improvements were needed in the way in which human capabilities and limita- tions were factored into the design, operation, and maintenance of plants, in the training of personnel, in the design of procedures, and in the process of selecting and examining qualified personnel. A theme common to all the investigations wan succinctly stated in the report of the NRC's Office of Inspection and Enforcement (U.S. Nuclear Regulatory Commission, NUREG-0616, 1979a, p.3~:* Human factors played a key role in the precursor events, in the accident scenario, in the response to the accident, and in many other related aspects. Human factors are involved in the perception of the precursor events in the man-machine interface, and in the operators' response to the event. Human factors appears to be a fertile area for consideration....This area, which ~ not well understood, should be better developed. T"lj' lU" ARC! 1~ ~ ~~ ~ " ~= LIT ~ lUC, AA~J lq~ ~ ~1 ~ ~~O Although the NRC had funded research on human factors and human reliability as early as 1972, it had no formal long- * In this report, publications of the U.S. Nuclear Regulatory Commission are referred to in the text by their technical report number and listed in the references by date under "U.S. Nuclear Regulatory Commission.

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25 range human factors program until 1980, a year after Three Mile Island. In that year it formed the Division of Human Factors Safety in the Office of Nuclear Reactor Regulation to deal with short- term problems associated with the response to Three Mile Island, such as the development and application of guidelines and criteria for the human factors review of control rooms and procedures. Later that year it established two units to conduct human factors research. By 1981 the two units had been consolidated into a single branch in the Division of Facilities and Operations in the Office of Nuclear Regulatory Research. In 1983 the NRC published its first long-range human factors research plan (NUREG-0961, 1983c). This program was aimed at providing the technical knowledge base for resolving seven impor- tant regulatory Issues: Upgrading personnel qualifications and examinations; Upgrading operating procedures; The utilization of computers; The impact on safety of organization and management; Human contributions to risk and how to reduce them; Human-machine technology changes that should be con- sidered; and Human factors requirements for severe accident manage- ment. General guidance for the NRC human factors research plan came from several sources: the five NRC commissioners, the ex- ecutive Rector's office, other NRC units, and recommendations of the report of the Study Group of the Human Factors Society (NUREG/CR-2833, 1982b). Guidance was also provided by the Office of Nuclear Reactor Regulation and its Division of Human Factors Safety. In early 1983, the NRC Human Factors Program Area Review Group was formed to help the director of the Office of Nuclear Re- actor Regulation determine whether the program plan was being properly implemented. This review group consisted of represen- tatives from the major offices and divisions of NRC headquarters, its regional offices, and the Office of the Executive Director. In addition, the Advisory Committee on Reactor Safeguards, a com- mittee reporting to the U.S. Congress, provided guidance to the NRC on the program. During the planning and implementation of the program plan,

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26 management and technical exchanges occurred between the NRC, the Electric Power Research Institute, and the Institute of Nuclear Power Operations. Thm was arranged to help ensure that each organization was aware of the other's activities and to exchange research results of common interest. Exchanges also occurred with nuclear steam supply system vendor companies, with the national laboratories of the Department of Energy, with other countries engaged in human factors research, and with the Halden Project in Norway a multinational research group established by its supporting member nations to conduct research on nuclear power plant design and safety. Some NRC research projects were even conducted in cooperation with utilities and utility owners groups; one study made use of a utility-owned training simulator and licensed personnel. In 1985 the NRC's human factors program was terminated. In light of the data (e.g., Trager, 1985) that shows the significant contribution of the human element to nuclear safety and risk, this action was not a sign of the leadership that is required of the NRC. In June 1987, after a two-year suspension of human factors research, the NRC began the development of a new program plan, which is scheduled for implementation over a period of three years (fiscal 1987 to fiscal 1989~. Copies of the new plan in draft form -were provided to the panel for its examination near the end of the panel's term. The draft contains three sets of research recom- mendations: a Human Factors Safety Program Plan (dated June I, 1987, 1987b) prepared by RES; a Human Reliability Research Plan (dated July 16, 1987, 1987c) also prepared by RES; and a Prioritized List of Human Factors Research Topics (dated Novem- ber 9, 1987, 1987d) prepared by NRR. The NRC plans to integrate these and other elements into a final plan. We are encouraged by the initiative shown by the NRC in 1987 to develop and fund a new human factors research program plan. If this plan is implemented in 1988; receives the strong support of NRC management; is appropriately staffed by a team of multidis- ciplinary specialists; establishes a link to leading behavioral and social scientists for ongoing advice on program planning, proposal evaluation, and review of research results; and is managed at the level of branch chief or higher by a person with training in human factors, the initial steps to provide the leadership required of the NRC in this critical area will have been taken.

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27 TABLE 1 Summary of Nuclear Regulatory Commission Research Organization and management 8 Training simulators 7 Emergency preparedness Operating procedures (including emergency operating procedures) Operator errors Displays and SPDS Selection Job and task analysis Allocation of function 4 10 14 22 8 2 Qualifications and licensing 23 Performance measurement Training Operator behavior, STA Control room design evaluation Maintenance Human error probability and PRA 8 9 6 13 27 Note: This table, based on list of NUREGe and NUREG/CRe provided by the NRC, shows the number of reports that have been published since 1975 on each topic of research. In some cases, reports have been included in more than one category because of the nature of the work. A COMMITMENT TO RESEARCH In the ten-year period between 1977 and 1987, the NRC funded 125 human factors research projects, studies, and related efforts. Table 1 shows a breakdown by topic of the NRC's human factors projects from 1975 to the present. Until 1979, the year of the Three Mile Island accident, the funding was quite limited: $340,000 in 1977 and $345,000 in 1978. Funding was increased in 1979 to $1 million; in 1981 to $4 minion; and in 1982 funding reached $5.5 million. In 1982, when human factors research funding was at its peak, it accounted for 2.2 percent of the NRC's total research budget. After September 1985, when the human factors program was termunated, human factors research was sharply curtailed, and by 1987 was hmited entirely to studies of human reliability. The reasons for this reduction in NRC support of human factors research are not clear. Overall cuts in federal spending, a lack of conviction of the value of human factors research by NRC management, possible disappointment in the usefulness of research results in regulatory decision making, and the assumption by some NRC executives that within a five-year period following

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28 Three Mile Island the major human factors problems in nuclear plants had been resolved are some of the explanations the pane} heard. In its review and evaluation of the NRC safety research pro- gram for fiscal 1986 and 1987, the Advisory Committee on Reac- tor Safeguards (NUREG-1105, 1985m, p.36) took exception to the NRC's decision to fund no human factors research in 1986: We believe that while the industry and other public insti- tutions can do much of the research, the NRC must take a leadership responsibility, just as it has in the past in other technical areas. Therefore, we believe that a substantial pros gram of human factors research, of the order of $2 million to $3 million per year, should be funded in RES in FY 1986 and in ensuing years. This program should address longer range needs and should not be constrained by unmediate user needs and the Human Factors Program Plan. The pane! agrees with the observations of the advisory committee and with its emphasis on long-range research needs. We also believe that short-range needs should be addressed as well. Although the panel applauds the NRC's recent decision to reinitiate research on human factors in fiscal 1988, the collapse of the program since 1985 is one of many signs of historically uncertain support in this important area. In the past, many projects particularly longer-term projects as opposed to technical assistance have been curtailed or postponed in rn~-course. This history establishes the view that support for the human factors program is weak. If the industry is to take the interaction of the human and technical systems seriously, then we believe that a signal must be sent to all the relevant professional communities that strong, stable, and sustained support for a human factors program, broadly defined, will be providecl. The NRC, in its organization of its research programs within the Office of Nuclear Reactor Regulation (NRR) and the Office of Nuclear Reactor Research (RES), has distinguished research that might be thought to be narrowly concerned with regulatory a~aly- sis and decision making from research on the broader problems of rendering nuclear power plants safe. The former type of research we call "technical assistance," and the latter we call applied re- search. It is useful to think of NRR as undertaking reactive studies and RES undertaking longer-term generic or confirmatory studies.

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29 If the NRC is to understand the human issues related to nu- clear power plant safety, it needs to institute a comprehensive progrmn of behavioral science research. The data obtained from this research wiD be applicable to both current and future prom lems and may be user} to evaluate potential improvements to safety and to guide future direction. We believe that by drawing on other disciplines and adopting new methods and by focusing not only on the human-mach~ne interface but on the larger sociotechnical sys- tem in which it is embedded, the demands of the nuclear industry to enhance safety can be met.