The authors also thank SNL staff members Nancy Lies and Fotini Walton for providing extensive technical editing support during the report preparation process. • Organized and Developed Human Performance and Cask Movement Terminology and...
moreThe authors also thank SNL staff members Nancy Lies and Fotini Walton for providing extensive technical editing support during the report preparation process. • Organized and Developed Human Performance and Cask Movement Terminology and Behavioral Science Items 6 Job aids are repositories for information, processes, or perspectives; they are external to the individual; they support the work and activity to be done; they direct, guide, and enlighten performance; e.g., books, cards, software, alarms, control panels, various displays (Rossett & Gautier-Downes, 1991). : Terminology related to HRA, human performance, and cask 2-2 movement was clarified, customized, and developed to help make important, but often subtle, distinctions in human performance and cask movement activities that may contribute to a cask drop. This included generating terms to describe specific human performance vulnerabilities that help explain why UAs may occur in particular contexts or situations, in a manner easily understood by those who are knowledgeable of DCSOs but who may have limited knowledge of human performance and HRA. As part of organizing and developing the terminology, and in response to feedback from DCSO SMEs, items from the behavioral sciences that form key portions of the technical basis were selected and summarized to benefit readers without expertise in human factors (HFs) and HRA. • Generated Cask Drop Scenarios Using ATHEANA Tasks: The basic qualitative HRA activities recommended in the ATHEANA (A Technique for Human Event Analysis) HRA method were performed across the seven phases of DCSOs to discover opportunities where cask drops might occur and to develop hypothetical scenarios detailing how and why such events might occur. • Generated Recommendations for Avoiding or Mitigating HFEs: Illustrative recommendations and examples for avoiding or mitigating the impact of human actions that may lead to a cask drop were developed based on: (1) the specific human performance vulnerabilities described in the scenarios; (2) various human performance insights gleaned from the information gathered; and (3) the authors' accumulated knowledge and experience related to improving human performance. None of the authors of this report have first-hand experience in performing or observing SFH and cask movement activities. Therefore, much information had to be gathered to learn about the nominal performance of SFH and DCSOs as well as observed variations from typical activities, significant incidents that have occurred, and recent/emerging concerns, voiced by SMEs, that could contribute to a cask drop. The interviews with SMEs were invaluable in providing an understanding of the human performance aspects of DCSOs and in guiding the authors to various information sources describing incidents that provided further insights. The entire range of activities from planning fuel movements, assuring the quality of equipment, moving individual fuel assemblies, loading fuel into casks, moving casks, and storing fuel at an ISFSI for the long term were examined. The scope of the information-gathering activity was much broader than simply understanding how cask movements are conducted inside NPP buildings: (1) it was important to probe planning and preparation activities for conditions that could set the stage for subsequent UAs related to cask drops; and (2) an earlier analysis report required the generation of scenarios ranging from fuel misloads to accelerated degradation of fuel and casks at ISFSIs (NRC, 2010). The sources below provided the foundation for building the content contained in this report: • interviews with SMEs who have first-hand experience in performing SFH, DCSOs, or overseeing those operations, as well as SMEs with experience in quality assurance (QA) activities for NPP and vendor-supplied equipment used during the conduct of DCSOs, In early discussions with SMEs at the NRC, it became apparent that the two DCSSs and plant types mentioned above would be a useful representative subset of environments for caskhandling operations. Analyzing the HI-STORM 100 DCSS typically used in a Mark I BWR was beneficial because it represents a complex sequence of DCSOs involving many manual rigging operations in a plant requiring large vertical and horizontal cask movements relatively close to reactor operations; thus, it represents the most complex operations and largest potential consequences should a cask be dropped during movement. The analysis of the TN-40 DCSS at a PWR represents less complex DCSOs performed in a fuel or auxiliary building outside the reactor containment building; thus, it represents the complexity of operations and potential cask drop consequences typical for most U.S. NPPs. To develop realistic, credible cask drop scenarios broadly relevant to the U.S. nuclear industry, it was essential to thoroughly understand these two DCSO environments. Previous PRAs and other information sources were reviewed, and a unique categorization scheme for the DCSOs spanning seven phases (defined in Section 3.5) was developed and applied to the two environments. The categorization scheme differed significantly from schemes in previous reports because of the desire to emphasize human performance. In particular, the phases of operation were delineated to facilitate analysis of all planning and preparation activities that could "set up" personnel for a cask drop event and show direct, hands-on cask movement operations that reflect actual "hand-offs" between teams of personnel. These hand-offs may differ among plants due to site-specific practices. Section 3 describes the two DCSO environments, develops the new categorization scheme and applies it to the two environments, and provides new terminology that clearly distinguishes between different types of cask drops and other undesirable cask movements. Appendix A details the activities performed in the seven phases. Early in this study, SMEs in DCSOs expressed a desire to better understand the causes of unsafe human actions that could contribute to events such as cask hang-ups and cask drops. During interviews, questions arose such as "How can you anticipate what unsafe actions (UAs) may occur?"; "Why would any reasonable person do that?"; "Isn't it impossible to predict why people would carry out that UA?"; "Aren't some people just error-prone?"; "Is it possible to identify in advance the people who are susceptible to executing UAs?" It was apparent that over the years the SMEs had seen many people make mistakes or violate procedures during DCSOs. Typically, the people were reprimanded, reassigned, or terminated, and often procedures and training were changed. However, after time, it was not unusual to observe different people make similar mistakes or violate procedures in similar ways. The changes made apparently did not have a lasting effect on improving the safety of the system. The SMEs wondered why these situations kept recurring and whether more effective measures could prevent them in the future. Given that DCSO SMEs and others without expertise in the study of human performance often ask such questions and desire to better understand human performance, it was agreed that this report should provide some background material on HRA and behavioral science. Including key portions of the technical basis for understanding and analyzing human performance (especially UAs) provided an opportunity to organize and further develop terminology relating to HRA and human performance. Section B.1 through B.4, Section 5.1.1, Appendix C, and Appendix D provide background material and improved terminology, which are then applied to the scenarios and recommendations in Sections 5 and 6. Furthermore, Sections B.1 through B.4 discuss HRA and the differences in its application in NPP control room activities and SFH activities, human error in general and UAs in nuclear industry crane operations, important mechanisms and taxonomies for understanding skill acquisition and UAs, and factors that influence human performance in specific contexts (examples tie these concepts directly to SFH and DCSOs). Section 5.1 and Appendix C describe human performance vulnerability terms, and Appendix D defines key terms used in the report and serves as a resource for readers from all technical backgrounds as it clarifies distinctions in human performance, HRA, and cask-handling operations. The background material and terminology will benefit readers without expertise in human factors and HRA in understanding how one may predict: (1) the forms that UAs may take in particular contexts; (2) the reasons why those UAs occur; and (3) the techniques that may be effective in avoiding or mitigating the impact of the UAs.