JAEA-Technology...JAEA-Technology JAEA-Technology 2009-028 Root Cause Analysis Method Applied to...

-TechnologyJAEA-Technology

2009-028

Root Cause Analysis Method Applied to Accidents and Troubles

of Nuclear Research Facilities

原子力研究施設等の事故・故障等に適用した根本原因分析手法

佐藤猛　渡辺憲夫　吉田一雄

大洗研究開発センター安全管理部

Health and Safety DepartmentOarai Research and Development Center

May 2009

Japan Atomic Energy Agency 日本原子力研究開発機構

-Technology 2009-028　原子力研究施設等の事故・故障等に適用した根本原因分析手法

日本原子力研究開発機構

Takeshi SATO, Norio WATANABE and Kazuo YOSHIDA

JAEA- Technology 2009-028

2009 4 10

311-1393 4002

��

JAEA-Technology　2009-028

JAEA- Technology 2009-028

Root Cause Analysis Method Applied to Accidents and Troubles of Nuclear Research Facilities

Takeshi SATO, Norio WATANABE+ and Kazuo YOSHIDA++

Health and Safety Department, Oarai Research and Development Center, Japan Atomic Energy Agency

Oarai -machi, Higashiibaraki-gun, Ibaraki-ken

(Received April 10, 2009)

The importance to make use of lessons learned and knowledge from accidents and troubles in safety management of nuclear research facilities is recognized widely. By the root cause analysis of accidents and troubles, lessons learned and knowledge have been arrived about safety management of facilities. The root cause analysis has been performed for accidents and troubles generated at nuclear research facilities in Japan Atomic Energy Agency (JAEA) from about 1990. Because the analysis is performed for various facilities, anyone have been used the

analysis method of possible of utilize. On this account the analysis method has been developed and adopted an existing analysis method. This report introduces the analysis method that has been used for the root cause analysis of these accidents and troubles. Furthermore, this report apply a generally well known JCO Criticality Accident to each analysis method as an example and explain on the direction for uses.

Keywords: Root Cause Analysis, Nuclear Research Facility, Analysis Method

+ Nuclear Safety Research Center ++ Nuclear Facility Safety Research Unit, Nuclear Safety Research Center

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JAEA-Technology　2009-028

JAEA-Technology 2009-028

��

1. -------------------------------------------------------------------------------------------------------- 2. --------------------------------------------------------------------------------------------

2.1 ---------------------------------------------------------------------- 2.2 ---------------------------------------------------------------------

3. ---------------------------------------- 3.1 ---------------------------------------------------- 3.2 ----------------------------------------------------

4. --------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------- 1 ------------------------------------------------- 2 --------------

Contents

1. Introduction --------------------------------------------------------------------------------------------- 2. Cause analysis method ------------------------------------------------------------------------------

2.1 Cognitive error root cause analysis method ------------------------------------------------ 2.2 4M5E matrix analysis method ------------------------------------------------------------------

3. Explanation of each analysis method assumed JCO Criticality Accident an example -----------------------------------------------------------------------------------------------------------------

3.1 Analysis by Cognitive error root cause analysis method -------------------------------- 3.2 Analysis by 4M5E matrix analysis method ---------------------------------------------------

4. Concluding Remarks ------------------------------------------------------------------------------------- Acknowledgements -------------------------------------------------------------------------------------------- References --------------------------------------------------------------------------------------------------------

Appendix 1 Brief description of taxonomy of causes of error in cognitive behavior ----------------------------------------------------------------------------------------------------

Appendix 2 4M factors classification list and countermeasures classification list on 4M5E matrix analysis method -------------------------------------------------------------------

114899

121213142628

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2007 2 JEAC4111-2003JEAG4121-2005 8.5.2 8.5.3

2) 2007 82008 12

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2002(PWR) Davis Besse

(PWSCC)

(IAEA)ASSET(Analysis and Screening of Safety Events Team)

3) latent weakness

What happened ? or What failed to perform as expected ?

Why did it happen ?Why was it not prevented ?

ASSET Event & Causal Factors Analysis E&CFA Management Oversight & Risk Tree MORT

1 ASSET PROSPER

─ � ─

Rasmussen

5 Table 2.1

(http://www.jaea.go.jp/)4) 2003

Table 2.1 5

2007 2007 6 26

2006 2006 2 13

2005 2005 4 11 JRR-3 S-1

2004 2005 2 19 HTTR2005 2 19

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Rasmussen

Fig. 2.1Rasmussen

4Rasmussen 2.1.3

Table 2.1

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Fig. 2.2

2.1.3 6)

Rasmussen ( Riso J.Rasmussen)

Rasmussen

RasmussenRasmussen

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3.1.31

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- 11 -

Table 2.3

Man Machine Media Management EducationEngineering Enforcement Examples Environment

EdwardsKLM Hawkins SHEL

SHEL Management M- SHELHiyari-Hatto-Guideline for IDeas of Error reduction 1999 H2-GUIDE

(http://www.n-iinet.ne.jp/4m5e.htm)

8) Man MachineMedia Management

Education Engineering EnforcementExample Environment

Table 2.4

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Management2

EducationEngineeringEnforcementExampleEnvironment

Table 2.19),10),11)

3.13.1.1

1999 9 30 10 35

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2010 1 2 30

6 158 50

2.5×1018

1980 111984 20

1999 18.8 380gU/

3 2910

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(UHN) (1986 )

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10 3510 1 2 30 4 00

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Table 3.1

3.1.2Fig. 3.1

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3.1.4Table 3.2

3.2Table 3.3

Man Machine Media ManagementManagement 34

(9 29 13 00 14 30)10

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Table2.1 2007 6

Fig. 4.1

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- 17 -

1) 2007 8

2) (JEAC4111-2003)JEAG4121-2005[2007 2] 2008 2

3) IAEA-ASSETJAERI-Tech 97-036(1997)

4) http://www.jaea.go.jp/(accessed 2009-01-15)

5) 1994 26) J. 19907) 1

JAERI-Review 2002-017 (2002)8) http://www.n-iinet.ne.jp/4m5e.htm

(accessed 2009-01-15)9) 1999 1210) JCO JCO

2005 211) 2000 9

Table 2.2

Fig. 2.2

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Table 2.2

Fig. 2.2

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Table 2.3

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Table 3.2

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Education

Engineering

Enforcement

Example

Environment

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