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JAEA-Technology JAEA-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 Department Oarai Research and Development Center May 2009 Japan Atomic Energy Agency 日本原子力研究開発機構 Takeshi SATO, Norio WATANABE and Kazuo YOSHIDA

JAEA-Technology...JAEA-Technology JAEA-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

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  • JAEA

    -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

    JAEA

    -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

  • - 1 -

    JAEA- Technology 2009-028

    2009 4 10

    1990

    JCO

    311-1393 4002

    ��

    JAEA-Technology 2009-028

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    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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    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 -------------------------------------------------------------------

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