核电厂调试人因事件分析

调试是核电厂建设过程中由建造安装过渡到运行必不可少的重要阶段,调试阶段存在工期紧、大量交叉作业、团队协作活动多、未知风险多等特点,导致人因事件频发。文章基于WANO根本原因及原因因子分类框架,采用屏障分析技术,对我国某核电企业2009-2018年共155份调试人因事件报告中事件失效屏障及其根本原因进行统计分析,结果显示:工作实践、规程制度与文件、人员本身因素、培训授权、监督方法、语言交流是主要的失效屏障；规程没有得到使用、规程不完善、技能不足、岗位培训和岗位经验不足、进程没有得到充分监督、班组间交流不充分等是根本原因。

Statistics and Analysis of Commissioning Human Factor Events in Nuclear Power Plant

Commissioning is an essential and important stage during the transition from installation to operation of nuclear power plants. During commissioning, there are many problems, such as tight schedule, a lot of cross-work, a lot of teamwork activities and unknown risks, which lead to frequent human events. Based on WANO root causes and the classification framework of cause factors, this paper adopts barrier analysis technology to analyze and make statistics on the barriers and root causes of event breakthrough in 155 effective commissioning reports of a nuclear power enterprise in China from 2009 to 2018. Among them, personnel work practices, written procedures and documents, personal factors, training/qualification, supervisory methods, verbal communications are the main barriers to failure. The basic reasons are that required procedures, drawings, or other references are not used, procedures are technically incomplete, skill of the craft is inadequate, on-job training/experience is not enough, progress is not adequately monitored, and inter-team communication is inadequate.