Analysis and Utilization of Operating Experience for Organizational Learning
Author(s)
Apostolakis, G. E.; Weil, Richard![Thumbnail](/bitstream/handle/1721.1/74996/NSP-001.pdf.jpg?sequence=3&isAllowed=n)
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Massachusetts Institute of Technology. Nuclear Systems Enhanced Performance Program
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The objective of this report is to clarify the ways that organizational factors influence
nuclear power plant performance in order to improve performance. Therefore, this report
studied the nuclear power plant organizational environment by identifying and detailing
its important work processes. These work processes are: the Work Request Work
Process; the Condition Reporting Work Process; the External Operating Experience
Work Process; the Design Change Process; and the Procedure Change Work Process.
Using this information, a methodology of incident investigation that targets
organizational deficiencies contributing to events was developed. Using this
methodology to analyze recent significant incidents, a list of important organizational
factors and the context within which they influence the successful completion of tasks
was identified. These factors are: 1) Communication - Pervasive – Most important
between different units and departments; 2) Formalization -Execution; 3) Goal
Prioritization - Prioritization; 4) Problem Identification - Planning, scheduling, and return
to normal line-up; 5) Roles and Responsibilities - Execution; and 6) Technical
Knowledge (job specific knowledge and broad based knowledge) - Job specific
knowledge – execution/ Broad based knowledge –prioritization, planning, scheduling,
and other tasks.
Although safety culture and organizational learning are not listed, they are important.
The reason for their exclusion is that they are not single organizational factors useful
when cited in incident investigations. Rather, safety culture is a term used to describe all
organizational factors, including organizational structure, that impact performance.
Similarly, organizational learning was excluded because it is a collection of programs,
processes, individual attitudes and culture responsible for learning. Although
organizational learning was not listed, it was studied resulting in the development of the
Utilization of Operating Experience Work Process. The Utilization of Operating
Experience Work Process consists of the following seven steps: 1) Identification; 2)
Screening/Prioritization/Dissemination; 3) Investigation/Evaluation; 4) Development;
ii i
5) Implementation; 6) Closeout; and 7) Verification/Validation. Since prioritization was
identified as important in the above work process and the analysis of significant events, a
methodology for the prioritization of work activities at nuclear power plants was
developed. This methodology produces a prioritization tool that assigns a numerical
performance index to each item requiring prioritization. Applying the methodology at
Seabrook Station produced a tool that allowed those who prioritize external operating
experience to more efficiently and accurately do so. In addition to the success of the
application at Seabrook, a workshop was held at MIT with experts in prioritizing external
operating experience. These experts further validated the methodology and the resulting
tool.
The final piece of work in this report is an analysis of the NRC's revised oversight
process as it relates to safety culture. The performance-based regulatory approach is
appropriate for regulating safety culture. However, the NRC should continue the analysis
of
Date issued
2001-06-01Publisher
Massachusetts Institute of Technology. Center for Advanced Nuclear Energy Systems. Nuclear Systems Enhanced Performance Program
Series/Report no.
MIT-NSP;TR-001