Characteristics of test and maintenance human errors leading to unplanned reactor trips in nuclear power plants

Abstract

The test and maintenance (T&M) human errors involved in unplanned reactor trip events in Korean nuclear power plants were analyzed according to James Reason's basic error types, and the characteristics of the T&M human errors by error type were delineated by the distinctive nature of major contributing factors, error modes, and the predictivity of possible errors. Human errors due to a planning failure where a work procedure is provided are dominated by the activities during low-power states or startup operations, and human errors due to a planning failure where a work procedure does not exist are dominated by corrective maintenance activities during full-power states. Human errors during execution of a planned work sequence show conspicuous error patterns; four error modes such as ‘wrong object’, ‘omission’, ‘too little’, and ‘wrong action’ appeared to be dominant. In view of a human error predictivity, human errors due to a planning failure is deemed to be very difficult to identify in advance, while human errors during execution are sufficiently predictable by using human error prediction or human reliability analysis methods with adequate resources.