Human Performance Issues Associated with the Use of Plant Procedures in Selected Operational Events

The United States Nuclear Regulatory Commission (NRC) monitors, reviews, and analyzes operational events at nuclear power plants in the United States and identifies pertinent human performance issues. The assessments resulting from these activities consistently show that plant procedures and associated reference documents play significant roles in many of the operating and shutdown events. Despite the recognized improvements in procedure generation and procedure implementation over recent years, these roles are frequently found to be root causes or important factors relating to events. In particular, procedures continue to play a significant role in event initiation. This paper describes several key human performance issues which are associated with plant procedures and are integral to event initiation scenarios at nuclear power plants in the United States. The following areas of weakness regarding procedures recently exhibited human performance concern and are of particular interest: (1) inadequacy of procedures; (2) failure of personnel to follow procedures (procedure adherence); (3) use of the wrong procedures; (4) failure to properly control or maintain procedures (5); and unintentional personnel error in the use of the correct procedures. These procedure-related human performance issues continue to occur at both Pressurized Water Reactor (PWR) and Boiling Water Reactor(BWR) facilities throughout the United States. In fact, 694 Licensee Event Reports (LERs) were submitted to the NRC regarding procedure-related events that occurred in 1996. Similarly, 278 procedure-related LERs were submitted in the first half of calendar year 1997. In particular, many of the procedure-related human performance problems are prevalent as initiators of both power operation and shutdown events, and frequently precipitate confusion in communications, aggravate system problems and delay recovery. The examples provided in this paper are associated with power reactor licensee events which occurred in 1996 and 1997. (author)