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Enhancing Nuclear Safety


Research

Publications

Retour d'expérience incidentel et développement durable

R. Périnet,
Congrès annuel de la Société d'Ergonomie de Langue Française (SELF) sur l'ergonomie et le développement durable, Saint-Denis de la Réunion, 22 septembre 2005,
Rapport DSR 91

Document type > *Report/contribution to WG (paper or CD-Rom), *Congrès/colloque

Keywords > operating feedback

Research Unit > IRSN/DSR/SEFH

Authors > PERINET Romuald

Publication Date > 24/11/2005

Summary

Tchernobyl the 26th of April 1986, AZF the 21st September 2001, Columbia the 1st of February 2003…. These accidents highlight the difficulty even the impossibility to foresee all possible operating future situations. Indeed, these accidents result from a complex process according to whom technical dysfunctions and human errors have been associated to conduct to possible harmful consequences. These accidents reveal situations that can induce human errors and can weaken the parades set up to manage consequences of these errors. In other words, accidents and incidents reveal a need of prevention which has never been yet identified. As a consequence, they also represent the start of an improvement process aiming at preventing similar future situations.

Within today’s studies about durable development, this article concerns method of industrial accident prevention through incidental experience feedback analysis. From one incident analysis, for each step of analysis, it aims at detailing the objectives, the methodological requirements and associated difficulties. For example, it highlights the difficulty to define the investigations framework, to deepen errors analysis and to identify weak signals. These difficulties result from inappropriate methodology and from lack of competence and time for carrying out analyses. It also appears that incident induces protection behaviours from system actors which prevent information feedback and limit the relevance of analyses.

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