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اسلاید 1 :

  • Design supported by Safety Case
  • Construction and Commissioning

اسلاید 2 :

Outline

  • Operational nuclear safety
  • Focus on nuclear safety and underlying cultural issues
  • safety systems and processes (but not safety cases)
  • Example License Condition requirements
  • Operating experience feedback (LC 7)
  • Operating rules (LC 23)
  • Management of change (LC 36)
  • Behavioural interventions to improve performance
  • Overall safety management system

اسلاید 3 :

Operational Nuclear Safety

  • Remaining within the limits of the safety case
  • Procedures, monitoring, analysis and learning processes
  • Suitably qualified, experienced and competent staff
  • Good management
  • Good safety culture
  • the right things are done with the right attitude so as to achieve the right results

اسلاید 4 :

Reason’s Swiss Cheese Model

  • Defence in depth (many layers)
  • Works most of the time
  • All have weaknesses
  • Can line up with disastrous results

اسلاید 5 :

Culture is fundamental

  • The culture determines the quality of the safety management processes
  • How big the holes in the cheese are
  • How they are monitored and reduced
  • Helps ensure they are not aligned

اسلاید 6 :

Findings

  • High proportion (by far) of events attributed to human factors
  • Top four root causes:
  • Personnel work practices
  • Procedures
  • Verbal communications
  • Supervisory methods

اسلاید 7 :

Event investigations

  • Often don’t ask ‘why’ enough
  • Its easiest to focus on the individual
  • …...but this won’t help to move things forward and prevent future events
  • Key is know why the individuals behaved as they did – what are the human factors?

اسلاید 8 :

Closing the learning loop

‘To look is one thing,

To see what you look at is another.   

To understand what you see is another.

To learn from what you understand is something else.

But to act on what you learn is all that really matters.’

Sir Winston Churchill

اسلاید 9 :

Review findings

  • Rules were sometimes
  • not clearly written (poor language, over complex)
  • contained no operational margin
  • were not relevant to nuclear safety
  • Rules “invited” the operators to breach them
  • Guidance was needed for rewriting the Rules

اسلاید 10 :

Guiding Principles

P3

  • The operating limits set out in the rules should be such that a breach represents a significant erosion of safety, commensurate with the external attention it attracts

P10

  • A clear identification is required of which rules are appropriate to normal steady state conditions and which to other situations (including faults, start-up, post-trip and shut-down situations).

P11 

  • Rules should (so far as is practicable) refer only to plant parameters and conditions which can be directly monitored (and preferably be directly controlled) by the station staff.

P12 

  • Rules should not require staff to process information presented to them unless the appropriate support is provided.

P15 

  • Rules should use derived operating limits which anticipate faults, rather than basic safety limits.
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