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Human Factors
Research and
Nuclear Safety
Neville P. Moray and Beverly M. Huey, editors
Panel on Human Factors Research Needs in Nuclear Regulatory Research
Committee on Human Factors
Commission on Behavioral and Social Sciences and Education
National Research Council
NATIONAL ACADEMY PRESS
Washington, D.C. 1988
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NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils
of the National Academy of Sciences, the National Academy of Engineering, and the
Institute of Medicine. The members of the committee responsible for the report were
chosen for their special competences and with regard to appropriate balance.
This report has been reviewed by a group other than the authors according to
procedures approved by a Report Review Committee consisting of members of the
National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine.
The National Academy of Sciences is a private, nonprofit,' self-perpetu~ting society
of distinguished scholars engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to- their use for the general welfare. Upon
the authority of the charter granted to it by the Congress in 1863, the Academy has
a mandate that requires it to advise the federal government on scenic and recnn~ca~
matters. Dr. Frank Press is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding engineers.
It is autonomous in its administration and in the selection of its members, sharing with
the National Academy of Sciences the responsibility for advising the federal government.
The National Academy of Engineering also sponsors engineering programs aimed at
meeting national needs, encourages education and research, and recognizes the superior
achievements of engineers. Dr. Robert M. White is president of 'tine National Academy
of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in the
examination of policy matters pertaining to the health of the public. The Institute acts
under the responsibility given to the National Academy of Sciences by its congressional
charter to be an adviser to the federal government and, upon its own initiative, to
identify issues of medical care, research, and education. Dr. Samuel 0. Thier is president
of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences
in 1916 to associate the broad community of science and technology with the Academy's
purposes of fathering knowledge and advising the federal government. Functioning in
accordance with general policies determined by the Academy, the Council has become the
principal operating agency of both the National Academy of Sciences and the National
Academy of Engineering in providing services to the government, the public, and the
scientific and engineering communities. The Council is administered jointly by both
Academies and the Institute of Medicine. Dr. Frank Press and Dr. Robert White are
chairman and vice chairman, respectively, of the National Research Council.
This work relates to the Nuclear Regulatory Commission Grant No. NRO-04-86-
301. However, the content toes not necessarily resect the position or the policy of the
Government, and no official endorsement should be inferred.
The United States Government has at least a royalty-free, nonexclusive and ir-
revocable license throughout the world for government purposes to publish, translate,
reproduce, deliver, perform, dispose of, and to authorize others 80 as to do, all or any
portion of this work.
Available from:
Committee on Human Factors
National Research Council
2101 Constitution Avenue N.W.
Washington, D.C. 20418
Printed in the United States of America
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PANE][ ON HUMAN FACTORS R1:SEARCH NEEDS IN
NUCLEAR REGULATORY RES1:ARCH
NEVILLE MORAY (Chair), Department of Industrial
Engineering, University of Toronto
LINDA COHEN, Department of Economics, University of
California, Irvine
RUSSELL DYNES, Department of Sociology, University of
Delaware
HERBERT ESTRADA, MPR Associates, Washington, D.C.
CLAY E. GEORGE, Department of Psychology, Texas Tech
University
PAUL M. HAAS, Advanced Systems Technology, International
Technology Corporation, Oak Ridge, Tennessee
LARRY HIRSCHHORN, Wharton Center for Applied Research,
Philadelphia, Pennsylvania
JOYCE KEEN, Clinical Psychology, Iowa Methodist Medical
Center, Des Moines, Iowa
TODD R. LAPORTE, Institute of Governmental Studies,
University of California, Berkeley
JENS RASMUSSEN, Cognitive Engineering, RISO National
Laboratory and Technical University of Denmark, Roskilde
Denmark
RICHARD SHIKIAR, Battelle Human Affairs Research Centers
Seattle, Washington
J. ED SMITH, J. Ed's Nuclear Service Corporation, Central,
South Carolina
DAVID WARD, E.I. du Pant de Nemours and Company,
Savannah River Laboratory, Aiken, South Carolina
DAVID WOODS, Westinghouse Research and Development
Center, Pittsburgh, Pennsylvania
THOMAS B. SHERIDAN (ex officio), Chair, Committee on
Human Factors
HAROLD P. VAN COTT, Study Director
STANLEY DEUTSCH, Study Director (1985-1987)
BEVERLY M. HUEY, Research Associate/Consultant
9,
·..
111
,,
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COMMITTEE ON HUMAN FACTORS
THOMAS B. SHERIDAN (Chair), Department of Mechanical
Engineering, Massachusetts Institute of Technology
CLYDE H. COOMBS, Department of Psychology, University of
Michigan, Ann Arbor, Michigan
JEROME I. ELKIND, Information Systems, Xerox Corporation,
Palo Alto, California
OSCAR GRUSKY, Department of Sociology, University of
California, Los Angeles
DOUGLAS H. HARRIS, Anacapa Sciences, Santa Barbara,
California
JULIAN HOCHBERG, Department of Psychology, Columbia
University, New York
THOMAS K. LANDAUER, Information Sciences Division, Bell
Communication Research, Morristown, New Jersey
JUDITH REITMAN OLSON, Graduate School of Business
Administration, University of Michigan
CHRISTOPHER I. WICKENS, Aviation Research Institute,
University of Illinois
ROBERT C. WILLIGES, Department of Industrial Engineering
- and Operations Research, Virginia Polytechnic Institute and
State University
HAROLD P. VAN COTT, Study Director
STANI,EY DEUTSCH, Study Director (1984-1987)
1V
.
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Contents
PREFACE
SUMMARY AND RECOMMENDATIONS
PART I THE CONTEXT FOR HUMAN FACTORS
RESEARCH IN NUCLEAR SAFETY
1 INTRODUCTION
The Panel's Charge, 11
The Definition and Origins of Human Factors, 11
The Panel's Approach: Nuclear Reactor Operation
as a Sociotechnical System, 13
A Scenario, 19
The Need for an Interdisciplinary Approach, 20
2 THE NRC'S HUMAN FACTORS RESEARCH
PROGRAM
Research Impetus, 23
The NRC's Research Plans, 24
A Commitment to Research, 27
RESEARCH METHODOLOGY AND
MANAGEMENT
Applied Research, 30
Recommended Research Approaches, 32
Sources and Use of Existing Knowledge, 35
v
· ~
V11
1
9
11
23
30
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PART II HUMAN FACTORS AND NUCLEAR SAFETY:
AN AGENDA FOR RESEARCH
4 HUMAN-SYSTEM INTERFACE DESIGN
Computer-Based Information and Display Systems, 47
Automation and Computer-Based Human
Performance Aids, 50
Human Factors in Software Development, 56
THE PERSONNEL SUBSYSTEM
Training, 59
Qualifications, 63
Staffing, 67
6 HUMAN PERFORMANCE
Causal Models of Human Error, Especially for
Situations with Unplanned Elements, 76
7 ORGANIZATIONAL ASPECTS OF THE NUCLEAR
INDUSTRY
The Impact of Regulations on the Practice of
Management, 82
Organizational Design and a Culture of Reliability, 83
Operational Decision Making, 85
Timely Recognition of Emergencies, 86
Characteristics of Managers, 87
8 THE REGULATORY ENVIRONMENT
Models of Regulation, 90
Plant Performance Indicators, 94
Conclusion, 97
REFERENCES
APPENDIX
BIOGRAPHICAL SKETCHES
V1
41
46
58
71
80
89
99
109
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Preface
The Panel on Human Factors Research Needs in Nuclear Reg-
ulatory Research was formed by the National Research Council
in response to a request from the U.S. Nuclear Regulatory Com-
mission (NRC). The NRC asked the Research Council to conduct
an independent 18-month study of human factors research needs
for the safe operation of nuclear power plants. This study was
conducted under the auspices of the Cornrnittee on Human Fac-
tors within the Research Council's Commission on Behavioral and
Social Sciences and Education.
The members of the pane} chosen to carry out this charge
represent a diversity of professions and backgrounds: utility plant
managers, nuclear engineers, psychologists, professionalsinhu-
man factors, specialists in management research, economists, and
political and social scientists.
Several members of the committee have research experience
in problems of management and the sociology of large complex or-
ganizations. One member chaired a task force for the President's
Commission on Three Mile Island (the Kemeny Cornm~ssion). An-
other has extensive knowledge of the economics of energy systems.
Two members have conducted research and have been consul-
tants in human factors related to nuclear power plant operation
and regulation in Europe and Canada. One is an expert on the
effects of stress and stress management. Three members have
worked in the nuclear power industry: one as the manager of a
large commercial nuclear power plant for a major utility, one as an
1
·.
V11
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engineering consultant, and one as a scientist who has conducted
cognitive research in the research department of a major vendor of
nuclear steam supply systems. Another member is a professor of
engineering in a university; he has conducted power plant control
room design reviews and advised a utility owners group on human
factors. Still another panelist was an engineer in one of the national
laboratories conducting nuclear human factors research and is
now working in the industry. We were also fortunate in having a
member of the Advisory Committee on Reactor Safeguards as a
pane] member. This diversity of pane} education and experience
helped to ensure a comprehensive approach to the problem at hand
(see the Appendix for biographical sketches of pane! members and
staffs.
The pane} held six meetings over the duration of this project,
one of which included a site visit to Unit 1 of the General Public
Utilities plant at Three Mile Island. We received information and
were briefed by representatives of the NRC, the Department of
Energy, the Electric Power Research Institute, the Institute for
Nuclear Power Operations, and one of the national laboratories
of the Department of Energy. We reviewed past human factors
research conducted by the NRC and other organizations. In ad-
dition, we received information from a major vendor of nuclear
steam supply systems, from members of professional societies in
human factors and nuclear power, from researchers in human phys-
iology, and from the Nuclear Utility Management and Resource
Committee.
This report describes the sociotechnical system implied by
the panel's conception of human factors and outlines the factors
that affect the performance of that system. The panel believes
that this conception is essential to an understanding of how peo-
ple can affect plant safety and what research is needed. We then
review the chronology of the NRC's human factors research from
the year it was initiated in 1981 until it was terminated in 1985.
This history provides a point of departure for the research agenda
that the pane} recommends. Following a brief discussion of re-
search methodology and management, this report identifies a set of
broad research areas and suggested topics within these areas that
the panel judges to be of high priority. Descriptions of these areas
and topics, together with recommendations on the management of
human factors research, form the core of this report. In identify-
ing research needs, the panel used the potential for increased plant
· .—
van
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safety as a criterion against which to evaluate the candidate topics
we considered. Although the agenda proposed is not advanced as
a detailed program plan, it is intended as an initial advisory step
toward a recommended reinitiation of human factors research by
the NRC and its continuation by other elements of the nuclear
· .
community.
We are appreciative of the cooperation we received from the
many individuals and organizations who helped us. We are es-
pecially grateful to Drs. Thomas Ryan and Daniel Jones of the
Nuclear Regulatory Commission for their continuing assistance in
providing extensive information and materials requested by the
pane} in the pursuit of this study.
Neville Moray, Chair
Pane} on Human Factors Research
Needs in Nuclear Regulatory Research
1X
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