核能運轉人因失誤資料之重建

Abstract

核電廠人員作業績效對於核能安全影響甚大。許多重大核能事故與事件皆與人員作業有關。雖然人為疏 失是事件、事故之近因，但是事故肇因分析的結果發現其背後大多因為系統設計的不良所引起，而這些系統 設計的問題又大多淵源於人員與作業間之不協調。因此，如果要提昇核能安全，首要之務乃是探討核能運轉 人因失誤問題，確認其肇因，發展解決方案，回饋於核能安全之設計。 本計畫之主要目的在於建立核電廠之運轉作業人因失誤的資料庫，分析其肇因，依肇因歸類，以對TRR- II的人因工程設計提供設計回饋。其研究步驟包括：(1)從事故、事件檔案中，確認與人員作業績效問題有 關之事故、事件；(2)重建事件經過；(3)進行肇因分析；(4)將肇因歸類；(5)建立人員作業績效問題資料庫 與查核表。研究結果可應用於核電廠人員作業績效改善及TRR-II主控室人因設計獨立驗證與確認之依據(In- dependent Verification and Validation)。

Human performance has a great impact on nuclear safety. Studies have found that most of nuclear accidents and incidents were related to human errors. Although human error is one of the proximal cause for those accidents, it nevertheless is caused by human-tasks mismatches. To enhance nuclear safety, it is important that human performance problems be identified, causes of those errors be analyzed, and finally feedback to the design of new systems. The purpose of this study is to establish the nuclear operational human error database. The research method consists of the following steps: (1)to identify human performance related accidents/incidents, (2)to analyze root causes of these human performance problems, (3)to establish human performance problem tracking system, and (4)feedback to the human-system inter- face design of TRR-II.