Analysis and Utilization of Operating Experience for Organizational Learning
Author(s)Weil, R.; Apostolakis, George E.
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 operating experience to identify additional organizational factors and the context within which they influence performance. Furthermore, they should develop performance indicators and measurement instruments for each organizational factor so that plants would be better able to take responsibility to proactively manage their safety culture.
Massachusetts Institute of Technology. Center for Advanced Nuclear Energy Systems. Nuclear Systems Enhanced Performance Program