In-depth Analysis of Human Error Incidents in Nuclear Power Plants

• Main Authors: Chang-Ching Lee, 李長慶
• Other Authors: Chia-Fen Chi, Ph.D.
• Format: Others
• Language: zh-TW
• Published: 2004
• Online Access: http://ndltd.ncl.edu.tw/handle/50889655890720160999

碩士 === 國立臺灣科技大學 === 工業管理系 === 92 === ABSTRACT It is our need and expectation to maintain a safety operation for a nuclear power plant. Nowadays under supervision of civilian people, any negligence in nuclear operation especially on human error will give people a negative impression/perception on the nuclear safety. Therefore, to inhibit “human error” is an important target for a safety of nuclear operation. The method of “human error inhibition” is to focus on not only guiding better understanding and carrying out protective measures but also doing the research/analysis on past cases through which we will take precaution for the future. This paper based on a research on Taipower three (3) nuclear power plants ( 6 units in total) covers occurrences of 92 RER (Reportable Event Report) sample cases arising from human error. An integral event description of the RER was in a form of writing. Today we have transformed “word” into “Code” to facilitate our analytical work. Thus “Survey Form for Human Error RER” is established on the basis of codes utilized in the Survey Form for TPC-HPES(Taiwan Power Company-Human Performance Evaluation System) “Status Analytical Table” and “Operation Procedure Analytical Table”. The selection of the codes has been appropriately modified and principally enables to reflect RER. There are twenty-four (24) categories in “Survey Form for Human Error RER”. Each Category is divided into some selected items; and all words are transformed into codes. Using the above mentioned coding method, the ninety-two (92) cases were accomplished and an investigation is to be performed according to the distribution of the selected items under each category and the cross analysis between the selected items. A report in regard to the relation between the meaning of the distribution and the cross analysis between the selected items will be provided for case discussion and analysis. In addition, a confrontation of difficulty to transform “words” into “codes” as well as the future research direction is also reported in the paper that provides a ground with proposing improvement suggestions for the coding method in order to reduce the probability of “human error” to a minimum. Key word : RER(Reportable Event Report) TPC-HPES (Taiwan Power Company-Human Performance Evaluation System) Suvery Form For Human Error RER