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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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