ASN’s work on human and organisational factors (HOF)

in nuclear safety after Fukushima

André-Claude LACOSTEformer Chairman of ASN

President of the CNS 6th review meeting (2014)

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ContentWhy are HOF

a concern?

How can we work and progress on this issue?

General statements

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Variability of context

Requiring the workers to adapt the way they work to attain the expected outcome. This adaptation has a cost (in terms of fatigue, stress, health, etc)

The situations actually encountered by individuals in the field vary constantly(equipment which does not react as expected, night-work, inexperienced colleague,

varying levels of urgency, labour disputes, etc.)

It is the licensee’s responsibility to ensure that workers are placed in satisfactory working conditions and have the possibility to adapt the way they are carrying out

their tasks (room of manoeuvre) at an acceptable cost

General statements

HOF and risk

Progress

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Inappropriate resources can lead to risks. For instance :

inadequate tools, poor design of man-machine interfaces,

cramped or poorly lit working environment,

Inadequate selection of individualsinsufficient training or practice,

professional teams destabilised by organisational change, under-manning or insufficient time allocated for tasks

Human cost

A slight variation in the context or change of a member of personnel can be enough to prevent the required performance level from

being reached

An operating situation in which performance is satisfactory but in which this was obtained at very high human cost to those involved is a source of risk

HOF and risk

ProgressMaterial

Environment

Organisation

General statements

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The operator as the unreliable factor ?

(too) often considered as the weakest link in the organization Limitation of the operator’s contribution (mechanisation)

The operator as the reliability vector ?

Detect / correct deficiencies Recovers from degraded situationsBypass or compensate inefficient rules / process Creates solutions

The operator, a reliability vector, & sometimes an unreliable factor

HOF and risk

Progress

General statements

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HOF – where and when ?

• Human and organisational factors are not only interactions between individuals, but to a large extent interactions between an individual and a culture, a system, a working environment, a machine, a tool. Therefore, a very broad picture has to be drawn in order to capture the important issues

• Normal operation (or outage) vs. Emergency situationIn most cases, an accident is created within a common state of the reactor, possibly triggered by a human factor issue. HOF should be tackled both for normal and emergency situations.

• HOF outside the plant : on corporation levels / within the commanding structures, HOF play a part as well

General statements

HOF and risk

Progress

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Prepare to be unprepared

• Whatever the situation, a proper working environment, training, tools, communication means etc. will be crucial in case of an unpredicted situation. Therefore, there are indeed actions to be taken to « prepare the unprepared » : ensure the proper working environment and organisation in order to affect positively the « knowledge-based » decisions of the workers on the field

• In other words : get rid of the superman fallacy. Even the best worker won’t be able to make the right decisions if he hasn’t eaten in 3 days, doesn’t have light on his working place, and doesn’t know who to report to. Human factor is not a matter of selection, but of working conditions.don’t try to hire supermen, but give normal workers super working conditions. They’ll make the right actions

HOF and risk

Progress

General statements

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Safety culture and regulatory body

• The stress tests performed by the licensees after Fukushima Daiichi nuclear accident and reviewed by the regulators lead, in most countries, to numerous new requirements, and to strong requests from the public to the regulators

Nonetheless, beware of the risk of a responsibility shift from the licensees to the regulators. Both the regulator and the licensee should bear this risk in mind. The regulator oversees the licensees, who have the best knowledge about the facilities. For instance :1. The regulator shall determine objectives, and the licensee the means to achieve

them2. The regulator shall leave enough space for licensees’ initiatives : a too tightened

regulation will tighten the licensees’ efforts3. The regulator has to stay unbiased in the relations with the licensees, but

improvements of nuclear safety won’t be achieved without some trust between the actors. Trust is based on respect, fairness, and stability. Control is complementary to trust.

4. The regulator shall carry out thorough inspections in order to control the actions performed by the licensee, both on the field and in the documents.

HOF and risk

Progress

General statements

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Main conclusions of French stress tests on HOF

• Human and organisational factors (which were part of the French « stress-tests ») are essential for safety

• ASN pointed out 3 priorities :– The renewal of the licencees’ staff and skills, facing a massive retirement and

considerable work after the stress tests ;– The organisation of the use of contractors. The supervision of the contractors has

to be strengthened ;– The research on these issues

• ASN called upon a pluralistic group in order to formulate the right questions, and try to address them.

General statements

HOF and risk

Progress

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Social, organisational and human factors steering committee

• Pluralistic approach (alike steering committee for Post Nuclear Accident Management or waste management)

• Participants– the licensees– the trade unions– NGO representatives– the French High Committee for Transparency and Information on Nuclear Security– the Ministry for Labour and the Ministries in charge of nuclear safety– HOF experts and researchers

• 3 working groups started in January 2013– Using contractors in normal operating situations: work organisation and conditions– Use of subcontracting: legal aspects– Management of emergency situations

HOF and risk

Progress

General statements

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Social, organisational and human factors steering committee (2)

• Topics/Considerations on– The renewal of the licensee workforces and skills,

which is a fundamental point at a time when a new generation of staff is taking over a more experienced one,

– Evaluation of the feasibility of the human interventions planned to ensure an optimal management of emergency situations

– The pros and cons and the complementarities of “rule-based safety” –which aims at confining the risks by settling the practices through the formulation of rules or procedures – vs. “adaptative safety” – which is based, on the contrary, on the capacities of initiative of the workers to face the unpredictable and the natural variability of the reality

– Using contractors in normal operating situations: work organisation and conditions, legal aspects

– Etc.

HOF and risk

Progress

General statements

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Conclusions– Inappropriate resources lead to risks, in normal

operation and in emergency situations– The adaptation of the individual has a high cost

– Don’t assimilate human factor to individual skills– Beware of underrating the role of the licensees

– The topics to address are not easy to define– Need for a pluralistic approach

Why are HOF a concern?

How can we work and progress on this issue?

General statements