Experience feedback from incidents: methodological and cultural aspects

EdF has designed some provisions to improve the reliability of human interventions: an increased number of training simulators, management of the quality of interventions, implementation of human factor consultants on each site, improvement in user documentation, development of communication practices, etc. However, despite efforts made in the right direction, the complexity of human behaviour and organisations make it obligatory to follow up the efficacy of these provisions over time in order to ensure that they produce the expected results on work practices. The in-depth analysis by IRSN of events that are significant for safety shows that experience feedback from incidents constitutes a real opportunity to ensure this follow-up. It also highlights the difficulty for licensees to define the temporal context of investigations to carry out, analysing errors committed more in depth and identifying ensuing problems. This article shows that these difficulties are the result of inappropriate methodologies and a lack of skills and availability to carry out the analysis. Finally, it shows that the incident leads to defensive behaviour among those participating in the system that blocks the compilation of information and limits the relevance of analyses. (author)