Identifying resilience in proceduralised accident management activity of NPP operating crews

Abstract This paper reports a study in which the usage of emergency operating procedures (EOP) in a simulated accident scenario in a nuclear power plant was carefully analysed. The background assumption was that in an accident situation, even within the closely defined envelope of the EOPs, crews may act differently. The empirical findings demonstrate the variance in the operating performance of twelve professional crews all complying with the EOP. The variance was identified by analysing how crews acted in situations and what particular meanings they associated to the situations. Variance was identified in six tasks: information usage, situation identification, dealing with automation, decision making, communication, and leadership. Corresponding habits, the operationalizations of practices, were identified in the analysis. The discovered operating practices in EOP usage were analysed from the point of view of increasing system level resilience. For example, a strong inclination towards connecting operations with process responses will eventually increase the capability of the whole system to adapt to external disturbances. The conclusion is that on a micro-level the activities of crews are different even within EOP following and also, that some practices seem to have more capability produce resilience in the system. A practical implication is that in the training of proceduralized work, attention should be paid to integrating the EOP usage to the operating work, not only to adherence to the procedure. The contribution of the paper is the insight into the role of proceduralized tasks in the construction of resilient emergency operating activity.

[1]  Sidney Dekker,et al.  Drift into Failure: From Hunting Broken Components to Understanding Complex Systems , 2011 .

[2]  Isaac José Antonio Luquetti dos Santos,et al.  A computerized tool to evaluate the cognitive compatibility of the emergency operational procedures task flow , 2009 .

[3]  W. Skipper,et al.  Shouldering Risks: The Culture of Control in the Nuclear Power Industry , 2006 .

[4]  J. M. Jones,et al.  Situation awareness and trust in computer-based procedures in nuclear power plant operations , 2006 .

[5]  Tarcisio Abreu Saurin,et al.  Assessing the compatibility of the management of standardized procedures with the complexity of a sociotechnical system: case study of a control room in an oil refinery. , 2013, Applied ergonomics.

[6]  Yves Dien Safety and application of procedures, or `how do `they' have to use operating procedures in nuclear power plants?' , 1998 .

[7]  Gabrielle de Brito Towards a model for the study of written procedure following in dynamic environments , 2002, Reliab. Eng. Syst. Saf..

[8]  Katya Le Blanc,et al.  Model of Procedure Usage – Results from a Qualitative Study to Inform Design of Computer-Based Procedures , 2012 .

[9]  Maaria Nuutinen,et al.  Expert Identity in Development of Core-Task-Oriented Working Practices for Mastering Demanding Situations , 2006 .

[10]  K. Rudnick The Essential Peirce: Selected Philosophical Writings , 1993 .

[11]  Emilie M. Roth,et al.  An empirical investigation of operator performance in cognitively demanding simulated emergencies , 1994 .

[12]  Davide Nicolini Practice Theory, Work, and Organization: An Introduction , 2013 .

[13]  Martha S. Feldman,et al.  Designing routines: On the folly of designing artifacts, while hoping for patterns of action , 2008, Inf. Organ..

[14]  Paula Savioja,et al.  Functional situation models in analyses of operating practices in complex work , 2012, ECCE.

[15]  M. Feldman A performative perspective on stability and change in organizational routines , 2003 .

[16]  Charles S. Peirce,et al.  The essential Peirce , 1992 .

[17]  H. Dashti,et al.  Expression of E-cadherin in human colorectal cancer. , 2003, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[18]  Markus C. Becker Organizational routines: a review of the literature , 2004 .

[19]  Jinkyun Park Complexity of Proceduralized Tasks , 2009 .

[20]  Tarcisio Abreu Saurin,et al.  RETRACTED: Identification of non-technical skills from the resilience engineering perspective: A case study of an electricity distributor , 2013 .

[21]  Ann Blandford,et al.  A resilience markers framework for small teams , 2011, Reliab. Eng. Syst. Saf..

[22]  S. Dekker Failure to adapt or adaptations that fail: contrasting models on procedures and safety. , 2003, Applied ergonomics.

[23]  R Flin,et al.  Teaching surgeons about non-technical skills. , 2007, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[24]  K. J. Vicente,et al.  Cognitive Work Analysis: Toward Safe, Productive, and Healthy Computer-Based Work , 1999 .

[25]  J. Dewey Human Nature and Conduct , 1921 .

[26]  Gudela Grote,et al.  Safety management in different high-risk domains - All the same? , 2012 .

[27]  John McCarthy,et al.  Analysis of Procedure Following as Concerned Work , 2003 .

[28]  Ann Blandford,et al.  Resilience Markers for Safer Systems and Organisations , 2008, SAFECOMP.

[29]  Leena Norros,et al.  Analysis of work practices from the resilience engineering perspective , 2012 .

[30]  M. Feldman,et al.  Reconceptualizing Organizational Routines as a Source of Flexibility and Change , 2003 .

[31]  Paula Savioja,et al.  Using operating procedures in NPP process control , 2009, ECCE.

[32]  Paula Savioja,et al.  Operators' conceptions of Procedure Guidance in NPP Process Control , 2013 .

[33]  Paulo Victor Rodrigues de Carvalho,et al.  Ergonomic field studies in a nuclear power plant control room , 2006 .

[34]  Rhona Flin,et al.  Rating non-technical skills: developing a behavioural marker system for use in anaesthesia , 2004, Cognition, Technology & Work.

[35]  R. Flin,et al.  Identifying and training non-technical skills for teams in acute medicine , 2004, Quality and Safety in Health Care.

[36]  T. Ormerod,et al.  Naturalistic Decision Making and Macrocognition , 2012 .

[37]  John M. O'Hara,et al.  Computer-Based Procedure Systems: Technical Basis and Human Factors Review Guidance , 2000 .

[38]  Tarcisio Abreu Saurin,et al.  Identification of non-technical skills from the resilience engineering perspective: a case study of an electricity distributor. , 2012, Work.

[39]  E. Hutchins Cognition in the wild , 1995 .

[40]  David Woods,et al.  Resilience Engineering: Concepts and Precepts , 2006 .

[41]  Gudela Grote,et al.  Diagnosis of safety culture: A replication and extension towards assessing “safe” organizational change processes , 2008 .