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«A Systemic Approach to Oversee Human and Organizational Factors in Nuclear Facilities CLAUDIA HUMBEL HAAG1 and BERND LINSENMAIER Psychologist, ...»

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International Journal of Performability Engineering Vol. 10, No. 7, November 2014, pp. 681-689.

© RAMS Consultants

Printed in India

A Systemic Approach to Oversee Human and Organizational

Factors in Nuclear Facilities


Psychologist, Section Human, Organisation and Safety Culture, Swiss Federal Nuclear

Safety Inspectorate ENSI, Industriestrasse 19, CH-5200 Brugg, SWITZERLAND

Accident Investigation Consultant, Kirchstrasse 42, D-71134 Waiblingen, GERMANY (Received on February 14, 2014, revised on September 16, and accepted on September 19, 2014) Abstract: In nuclear facilities, in addition to technical aspects, human and organizational factors (HOF) also influence the plant safety. However, a common understanding of what is meant by the term, HOF, has not yet been reached here. Existing concepts of oversight differ in how humans interact with their environment and how humans are integrated in conditions and processes affecting nuclear safety.

To understand and oversight the humans’ role in nuclear safety, HOF are often considered separately. The view supported here is that HOF should be overseen both in their own right as well as in terms of their interactions and interferences. This implies that a nuclear facility ought to be seen as a socio-technical system, consisting of individuals, technology, and organization, all of which are interrelated or interacting and are embedded in an environment.

This paper provides a basis for integrating a systemic view and approach to this.

Keywords: Human factors (HF), organisational factors (HOF), nuclear power plants, regulatory oversight, Fukushima

1. Introduction A close relationship can be found between the term HOF and the better known term human factors (HF). In the oversight of nuclear installations, aspects like «human error», «human performance» and «human factors» assumed particular importance in the 1980s, with emphasis on control room operations following TMI. These terms draw attention to the fact that besides the purely technical aspects, individuals also have an influence on the operation of a nuclear installation. More recently, the addition of «organization», as it is illustrated by the term HOF, has been extending this perspective to organizational aspects.

So far, no general understanding or application with regard to the terms HF and HOF has been agreed upon in the nuclear safety community. Accidents like the recent example of Fukushima emphasize the great importance of these factors at all levels, including the upper echelons of management. Hence, for oversight activities an understanding of the importance assigned to these factors is crucial.

In this paper, a systemic approach for overseeing human and organizational factors by regulators is proposed.

2. Regulators’ Understanding of HF and HOF Regulatory authorities employ different understanding of the role individuals play in an organized and engineered environment. Similarly, the International Atomic Energy Agency (IAEA) – which supports efforts to coordinate the activities of these authorities – does not

–  –  –

provide a uniform definitiona of HF or HOF and no common paradigm thereto is recognizable.

Article 12 of the Convention on Nuclear Safetyb (CNS) [1] requests from the contracting parties to take the appropriate steps to ensure that the capabilities and limitations of human performance are taken into account throughout the life of a nuclear facility. To prove compliance with this article each contracting party has to submit a report where the measures c taken to implement this obligation are presented. These reports contain a summary of the appropriate measures, but do not usually provide a detailed understanding of human factors.

After a review of the measures stated in the reports however, four different paradigms of the role individuals play in an engineered environment can be identified.

1. Isolation of Individuals from Technology: The individual is viewed in isolation from technology. Human factors are understood as human errors. In an effort to minimize these errors, more traditional psychological measures such as selection and training are performed almost exclusively on the individual himself.

2. Relation of Individuals to Technology: Human factors are understood as the immediate interplay at the man-machine interface. The questions focus on how human performance can be increased and how the impact of possible human failures can be mitigated. In this view individuals and technology are adapted to each other.

3. Separation of Individuals, Organization and Technology: Individuals, organization and technology are considered separately from each other. Therefore, their effect is also studied separately from each other.

4. Integration of Individuals, Organization and Technology: This understanding distances itself from either isolating separating or linking the three components and tries to understand individuals, organization and technology as a whole in a systemic context.

The differences between these views or paradigms are reflected in the question, as to whether individuals act on their environment or whether their environment influences them. Are individuals to be considered as an integrated part of an overall system or are they are only to be regarded in their operating or monitoring function of a self-contained technical system?

May human erroneous actions be seen as an inseparable attribute of human beings or are they to be regarded as avoidable malfunctions of technical systems?

Considering these paradigms, it is not surprising that they lead to different ways of examining the influence of human (and organizational) factors. However, it appears that especially after the Fukushima accidents, the fourth approach, i.e., the integrated or systemic view has been discussed more intensively. In the course of the investigation into accidents, it was pointed out repeatedly that human and organizational factors which have contributed to the accident sequence were not considered in a sufficiently systemic way beforehand. This insight is also supported by one of the conclusions of the official report of the Fukushima a There is no definition of HF or HOF included in the IAEA Safety Glossary – Terminology used in Nuclear Safety and Radiation Protection. 2007 Edition. However, an indirect definition, i.e., Human Factors Engineering is included (Human Factors Engineering = Engineering in which factors that could influence human performance are taken into account), that understands HF as the influences on the human performance.

b The Convention on Nuclear Safety (CNS) was adopted on 17 June 1994 by a Diplomatic Conference convened by the International Atomic Energy Agency at its Headquarters from 14 to 17 June 1994.

A Systemic Approach to Oversee Human and Organizational Factors in Nuclear Facilities 683 Nuclear Independent Investigation Commission [2]. It states: «the root causes were the organizational and regulatory systems that supported faulty rationales for decisions and actions rather than issues relating to the competency of any specific individual.» The commission has discovered that operator, regulatory bodies and government body failed to correctly develop the most basic safety requirements and gives detailed examples in the report [2].

3. General Systemic Approach to HF and HOF Based on an integrated perspective which attempts to focus on the overall system, this section

develops answers to the following questions:

• What is the understanding of an overall system?

• What are human and organizational factors and what is their role within an overall system?

To answer these questions, an individual is first described in its surrounding environment.

Every individual exists in a surrounding environment with which it is constantly interacting. Here, the environment is anything outside the skin of the individual in the focus.

Therefore, the individual is influenced by its environment (external influence). He behaves in this environment and he acts upon it and on himself. Under this premise, every action of an individual on its environment and on himself is called human factor or human factors (HF).

This ordinary observation in nature and society illustrates that a human factor is actually an old traditional concept that represents the relation of an individual with its environment.

Figure 1 visualizes this concept with the help of an interaction/interference-schema.

Figure 1: Individual-Environment Interference/Interaction-Schema (Source: Traditional View) In order to demonstrate the interaction and interference of an individual with his environment, the question first investigated here relates to, how the action of an individual emerges and develops. The answer to this question will provide further details of the individual-environment interference/interaction-schema.

Every individual possesses human attributes. Human attributes are inherent characteristics of each individual. They exist – at the moment of observation – independently of the individual’s environment and form the necessary basis for the environment-dependent abilities that an individual develops in exchange with his environment (external influence).

Claudia Humbel Haag and Bernd Linsenmaier The abilities of an individual are determined by his human attributes and the external influences.

Further, each individual has an inner drive (motivation) to behave and act in a certain manner.

This motivation is regulated by his perception of his own abilities as well as by the task to be performed. The task can be set externally or fully/partly by the individual himself. The task set externally represents an external influence. Because of its special importance for the motivation it is mentioned here separately from the other influences of the environment.

Since the abilities – as described above – represent the human attributes as a function of

the external influences, the following relationship is derived for the motivation:

The motivation of the individual is influenced by his abilities, the external influences as well as the task in a given situation.

This definition takes into account that abilities and motivation are not independent from each other, but rather have a mutual influence on each other (e.g., increase of the own abilities through experiences of success).

Abilities and motivation are the determinants of the individual’s action in a given situation.

If these determinants are reduced to their origins, i.e., the abilities of the individual, their external influences and the tasks, the following relationship may be derived for the human


The behaviour and action of the individual is determined by the attributes of the individuals, the external influences that are acting upon it as well as the task in a given situation.

This relationship is shown in the expanded individual-environment interference /interaction-schema in Figure 2.

Figure 2: Expanded Individual-Environment Interference/Interaction-Schema

These considerations lead to the understanding that the action and behaviour of the individual, the influence of the individual on his environment as well as the human factor can be considered as synonymous terms for one and the same concept. This results, therefore, in the

following summarizing definition of human factors:

Human factors (HF) are the individual’s action on himself or his environment. HF are determined by the individual’s attributes, the external influences that have an A Systemic Approach to Oversee Human and Organizational Factors in Nuclear Facilities 685 impact on him and the task at hand. HF can be observed in the action and behaviour of the individual as well as in the effects this action and behaviour cause on himself and on his environment.

The individual influences himself as well as his environment. His action and behaviour are the HF. These HF can be detected either directly by the action and behaviour of the individual or indirectly by the impact of his action and behaviour in the environment or on himself.

Causes of HF, however, can be found within the individual, but just as well in the environment, in the interaction and interference between individual and environment as well as in the task set. Anything that can influence human action or behaviour must be considered as a possible cause for HF and needs to be considered as well as its consequences. Thus, in the systemic understanding of the individual-environment interference/interaction-schema the HF are not the explanatory causes for their effects. They are merely human action and behaviour which take place under the conditions of the individual-environment interference/interaction-schema, see Figure 3.

Figure 3: Causes and Effects of Human Factors in the Individual-Environment Interference/InteractionSchema Therefore, the clarification of the causes of a particular human behaviour or its consequences always requires considering of the overall interference/interaction-schema. Approaches that split this schema and consider its components in an independent way take a knowledge loss with respect to the overall arrangement of cause and consequences into account.

Compared with the term HF, the term HOF stresses the organizational measures as a part of the environment of an individual in a distinct way. Analogous to the definition of HF, the

term HOF can be defined as:

Human and Organizational Factors (HOF) are the individual’s action on himself or his environment together with the effect of the organizational measures on the individual, on other environmental aspects as well as on themselves.

Consequently, addressing HF and HOF for oversight, requires the same systemic approach which can be understood with the help of individual-environment interference/interactionClaudia Humbel Haag and Bernd Linsenmaier schema, which has been developed in the course of this section.

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