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NKS Programme Area:	NKS-R
Research Area:	Organisation and safety culture
Report Number:	NKS-81
Report Title:	Systematic Analysis of Dependent Human Errors From the Maintenance History at Finnish NPPs - A Status Report
Activity Acronym:	SOS-2.2
Authors:	Kari Laakso
Abstract:	Operating experience has shown missed detection events, where faults have passed inspections and functional tests to operating periods after the maintenance activities during the outage. The causes of these failures have often been complex event sequences, involving human and organisational factors. Especially common cause and other dependent failures of safety systems may significantly contribute to the reactor core damage risk. The topic has been addressed in the Finnish studies of human common cause failures, where experiences on latent human errors have been searched and analysed in detail from the maintenance history. The review of the bulk of the analysis results of the Olkiluoto and Loviisa plant sites shows that the instrumentation & control and electrical equipment is more prone to human error caused failure events than the other maintenance and that plant modifications and also predetermined preventive maintenance are significant sources of common cause failures. Most errors stem from the refuelling and maintenance outage period at the both sites, and less than half of the dependent errors were identified during the same outage. The dependent human errors originating from modifications could be reduced by a more tailored specification and coverage of their start-up testing programs. Improvements could also be achieved by a more case specific planning of the installation inspection and functional testing of complicated maintenance works or work objects of higher plant safety and availability importance. A better use and analysis of condition monitoring information for maintenance steering could also help. The feedback from discussions of the analysis results with plant experts and professionals is still crucial in developing the final conclusions and recommendations that meet the specific development needs at the plants.
Publication date:	01 Dec 2002
ISBN:	ISBN: 87-7893-137-1
Number of downloads:	2011
Download:	NKS-81.pdf

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