NUREG-2198, Figures Final
| ML21134A160 | |
| Person / Time | |
|---|---|
| Issue date: | 05/14/2021 |
| From: | Dejesus-Segarra J NRC/RES/DRA/PRAB |
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| DeJesus, Jonathan - 301 415 1538 | |
| References | |
| NUREG-2198 | |
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Text
Executive Summary Figures
Figure ES-1 2
Human action Tasks and cognitive activities Macrocognitive Functions Processors Cognitive Mechanisms Performance-Influencing Factor Structure Context categories PIFs PIF attributes Cognitive Basis Structure
Figure ES-2 (same as Figure 4-3) 3 Step 1:
Develop scenario narrative Develop scenario timeline Step 1: Determine scenario context Step 1: Identify HFE Step 1: Define HFE PRA model Step 2:
Analyze tasks and identify CT(s) in HFE Step 3: Characterize the CT(s) and select applicable CFMs Step 5: Calculate Step 6: Analyze HFE timeline (subset of scenario timeline, if there are multiple HFEs in the scenario)
Step 4: Assess PIFs applicable to every CFM Step 6: Estimate parameters of distribution Step 6: Estimate parameters of distribution Step 6: Calculate Scenario context and list of applicable PIFs PIF attributes of every CFM for every CT List of CT(s)
HFE and its definition List of applicable CFM(s) for the CT(s) and and Step 7:
Calculate overall HEP
HFE and its definition HFE and its definition Step 8:
Uncertainty and dependency analysis and documentation CFM = cognitive failure mode CT = critical task HEP = human error probability HFE = human failure event PIF = performance-influencing factor PRA = probabilistic risk assessment
= error probability due to CFMs
= error probability due to uncertainty in and
= time available
= time required and = mean and standard deviation of and = mean and standard deviation of
Chapter 1 Figures
IDHEAS General Methodology (NUREG-2198)
IDHEAS for actions outside the control room (e.g., IDHEAS for Event and Condition Assessment)
Literature and human factors practices Cognitive basis framework (NUREG-2114)
IDHEAS Internal At-Power Application (NUREG-2199, Vol. 1)
Other specific HRA applications Plant-specific PRA models Operational experience Existing HRA methods Human error data generalization Figure 1-1
Stage 2 Modeling of important human actions Stage 3 HEP quantification Stage 1 Scenario analysis Stage 4 Integrative analysis Cognition Model Cognitive Basis Structure PIF Structure Human error data IDHEAS-G process Figure 1-2
Chapter 2 Figures
Important Human Action and Context of the Action Cognitive Basis Structure PIF Structure Cognition Model for Human Performance and Reliability Critical Tasks and Cognitive Activities Figure 2-1
Human action Task 1 and cognitive activities Task 2 and cognitive activities Task 3 and cognitive activities Detection Under-standing Decision-making Action execution Interteam coordination Figure 2-2
Task and cognitive activities Cognitive mechanism Cognitive mechanism Cognitive mechanism Cognitive mechanism Cognitive mechanism Cognitive mechanism Processor - D1
Processor - D5 PIF 1 Processor - U1
Processor - U5 Processor - DM1
Processor - DM6 Processor - E1
Processor - E5 Processor - T1
Processor - T7 PIF 2 PIF 3 PIF 17 PIF 18 PIF 19 Macrocognitive functions Processors Cognitive mechanisms PIFs Detection Understanding Decision-making Action execution Interteam coordination Figure 2-3
Detect cues Acquire (gather) information Detection cognitive activities D1. Initiate detection -
Establish the mental model for information to be detected D2. Select, identify, and attend to sources of information D3. Perceive, recognize, and classify information D4. Verify and modify the outcomes of detection D5. Retain, document/record, or communicate the outcomes Detection processors D.a. Mental model of the cues D.b. Perception of sensory information D.c. Attention D.d. Working memory D.e. Vigilance D.f. Information foliage D.g. Pattern recognition D.h. Shared cognition within a team D.i. Infrastructure for exporting the information detected Detection cognitive mechanisms Figure 2-4 Macrocognitive function: Detection
Maintain situational awareness Assess status based on indirect information Diagnose problems and resolve conflicting information Make predictions or form expectations for the upcoming situation development Understanding cognitive activities U1. Assess/select data U2. Select/adapt/develop the mental model U3. Integrate data with the mental model to generate the outcome of understanding (situational awareness, diagnosis, resolving conflicts)
U4. Verify and revise the outcome through iteration of U1, U2, and U3 U5. Export the outcome Understanding processors Understanding cognitive mechanisms Macrocognitive function: Understanding Figure 2-5 U.a. Data U.b. Selection of data U.c. Mental model U.d. Integration of data with mental model U.e. Working memory U.f. Shared cognition within a team
Make a go/no-go decision for a pre-specified action Select among multiple options or strategies Change or add to a pre-existing plan or strategy Develop a new strategy or plan Decisionmaking cognitive activities DM1. Select and implement decisionmaking model DM2. Manage the goals and decision criteria DM3. Acquire and select data for decisionmaking DM4. Make decision (judgment, strategies, plans)
DM5. Simulate or evaluate the decision or plan DM6. Communicate and authorize the decision Decisionmaking processors Decisionmaking cognitive mechanisms Macrocognitive function: Decisionmaking Figure 2-6 DM.a. Decisionmaking model DM.b. Data for decisionmaking DM.c. Selection or judgment DM.d. Cognitive biases DM.e. Deliberation or evaluation of decision DM.f. Team decisiomaking
Execution of a cognitively simple action Execution of a cognitively complex action Long-lasting action Control action Action Execution cognitive activities E1. Assess action plan and criteria E2. Develop or modify action scripts E3. Coordinate and command action implementation E4. Implement action Action Execution processors Action Execution cognitive mechanisms Macrocognitive function: Action Execution Figure 2-7 E.a. Physical movement and motor skills E.b. Mental model of the actions and the systems to be acted on E.c. Working memory E.d. Attention E.e. Vigilance E.f. Sensory feedback of motor movement E.g. Automaticity E.h. Action programming E.i. Executive control E.j. Error monitoring and ti
Communication Cooperation Coordination Interteam coordination activities T1. Establish or adapt interteam coordination infrastructure T2. Manage information T3. Maintain shared situational awareness T4. Manage resources T5. Plan interteam collaborative activities T6. Implement decisions and commands T7. Verify, modify, and control the implementation Interteam coordination processors Interteam coordination cognitive mechanisms Macrocognitive function: Interteam coordination Figure 2-8 T.a. Interteam coordination infrastructure T.b. Command T.c. Control T.d. Line of communication T.e. Data processing and information management T.f. Shared mental model
Central control Interteam coordination High authority Within-team interaction Figure 2-9
Figure 2-10 Emergency Director (in TSC)
- 1. Determines the need to check a symptom in the field (DM1-DM3; D1-D2)
Field Operator (in the field)
- 2. Detects an issue and reports back (D3-D5)
Emergency director (in TSC) supported by technical staff
- 3. Receives the information (D1-D5)
- 4. Integrates the information with other sources of information to form understanding (U1-U5)
- 5. Prioritizes actions addressing this problem (DM1)
- 6. Decides on action to take (this includes developing an action plan and procuring necessary tools and equipment) (DM2-DM5)
- 7. Communicates and seeks higher level management authority (DM6)
- 9. Communicates action plan to operators who will perform action (DM6)
Management (at Utility Headquarters)
- 8. Decides whether to give approval and communicates approval (DM1-DM6)
Operating Crew (in control room)
- 10. Takes actions and reports back (E1-E5)
Sends field operator into field to check on symptom Communicates decision and seeks approval Communicates approval Sends out operating crew to perform action Operating crew reports back
Chapter 3 figures
PIFs System context Event progress Task context Environment and situation context Personnel context
- Event, mission, goals Human action Human action Human action Cognitive mechanisms Processors Macrocognitve functions Success or failure of human actions Figure 3-1
Environment and Situation System Personnel Task
- Accessibility/habitability of workplace including travel paths
- Workplace visibility
- Noise in workplace and communication pathways
- Cold/heat/humidity
- Resistance to physical movement
- Poor lighting in workplace
- Glare or reflection on physical structure
- Smoke or fog-induced low visibility
- System and I&C transparency to personnel
- HSI
- Equipment and tools
- Staffing
- Procedures, guidance, and instructions
- Training
- Team and organization factors
- Work processes
- Information availability and reliability
- Scenario familiarity
- Multitasking, interruptions, and distractions
- Task complexity
- Mental fatigue
- Time pressure and stress
- Physical demands PIF PIF attributes Links to cognitive mechanisms Context
- Tools are difficult to use
- Tools are unfamiliar to personnel
- Tool does not work
- Tool or parts are unavailable
- Document nomenclature does not agree with equipment labels
- Procedure is inadequate
- Procedure is difficult to use
- Procedure is available, but does not fit the situation See Section 3.4 and Appendix B
- Sustained high-demanding cognitive activities
- Long working hours
- Sleep deprivation Figure 3-2 Note: The PIF attributes shown are examples and correspond to the PIFs highlighted in red.
Context PIFs Environment and situation Event scenario Task Detection Understanding Decision-making Action execution Interteam coordination Cognitive mechanism System Task PIF attributes Processor Processor Cognitive mechanism Cognitive mechanism Cognitive mechanism Cognitive mechanism Cognitive mechanism PIF Structure Cognitive Basis Structure Processor Processor Processor Processor Processor Processor Personnel Figure 3-3
Chapter 4 figures
Analyze scenarios and develop operational narrative Identify and define IHAs Analyze and quantify HEP of a human failure event:
- Identify failure modes
- Assess PIFs
- Estimate the HEP Analyze and document uncertainties Identify and analyze tasks Analyze HFE dependency and adjust HEPs Collect data/information and interact with PRA Time and feasibility analysis Figure 4-1
Stage 2 Modeling of important human actions
- Identify and analyze critical tasks
- Identify CFMs
- Develop operational narrative
- Identify event context
- Identify and define important human actions Stage 4 Integrative analysis
- Document uncertainties
- Assess dependencies Figure 4-2
Figure 4-3 (same as Figure ES-2)
Step 1:
Develop scenario narrative Develop scenario timeline Step 1: Determine scenario context Step 1: Identify HFE Step 1: Define HFE PRA model Step 2:
Analyze tasks and identify CT(s) in HFE Step 3: Characterize the CT(s) and select applicable CFMs Step 5: Calculate Step 6: Analyze HFE timeline (subset of scenario timeline, if there are multiple HFEs in the scenario)
Step 4: Assess PIFs applicable to every CFM Step 6: Estimate parameters of distribution Step 6: Estimate parameters of distribution Step 6: Calculate Scenario context and list of applicable PIFs PIF attributes of every CFM for every CT List of CT(s)
HFE and its definition List of applicable CFM(s) for the CT(s) and and Step 7:
Calculate overall HEP
HFE and its definition HFE and its definition Step 8:
Uncertainty and dependency analysis and documentation CFM = cognitive failure mode CT = critical task HEP = human error probability HFE = human failure event PIF = performance-influencing factor PRA = probabilistic risk assessment
= error probability due to CFMs
= error probability due to uncertainty in and
= time available
= time required and = mean and standard deviation of and = mean and standard deviation of
Development of operational narrative Identification of event context Identification of important human actions Figure 4-4
Operational narrative of a human event Baseline scenario Additional scenarios Scenario narrative
- Overview of the event
- Beginning status
- Initiating event
- Initial conditions
- Boundary conditions
- Progression and end state Timeline
- Date/time
- System response, human response, data for situation awareness, and notes Deviations from the baseline scenario Figure 4-5
Figure 4-6 Task Analysis Identification of CFMs Assessment of PIFs
Figure 4-7 Human Event IHA 1 IHA 2 IHA 3 Critical Task 1 Critical Task 2 Critical Task 3 Critical Task Critical Task Macrocognitive functions required for the task
CFM 1 Critical task 1 CFM 2 CFM 6 PIF states Critical task 2 Critical task 3
= (,, )
= (,, )
= (,, )
= (,, )
Time required
Time available HEP of an IHA Figure 4-8
States of Base PIFs HEP E-4 E-3 E-2 E-1 1
PIF1 PIF2 Figure 4-9
IHAs Critical tasks Event scenarios Macro-cognitive functions and CFMs IHA 1 HEP Critical task 2 Critical task 3 HEP Event scenarios Stage 1: Scenario analysis
- Develop operational narrative
- Identify event context
- Identify important human actions Stage 3 - HEP quantification
- Estimation of
- Estimation of Stage 4 - Integrative analysis
- Document uncertainties
- Assess dependencies Stage 2: Modeling of important human actions
- Identify and analyze critical tasks
- Identify applicable CFMs
- Assess PIFs CFM1 CFM2 CFM3 CFM4 HEPs due to CFMs HEP due to time uncertainty Dependency adjustment PIF1 PIF2 PIF3 PIF4 Uncertainty analysis Figure 4-10 IHA 2 IHA 3 Critical task 1 Understanding Detection Decisionmaking Action execution Interteam coordination CFMs CFMs CFMs CFMs CFMs
Chapter 5 figures
=
= 1
> =
1
Figure 5-1 sum over all possible values Note: The area in red corresponds to the value of.
Figure 5-2
Start Cue received Crew diagnosis complete Action complete Action no longer beneficial
Chapter 6 figures
Data source 1 Tasks Integrate data for the failure modes and PIFs Context Failure modes PIFs Data source 2 Tasks Context Failure modes PIFs
= ( )
Human error rates of the failure modes Human error rates at the PIF states Generalization Integration Sources of human error data Human error rates at the PIF states Figure 6-1 Human error rates of the failure modes
Human action
/ tasks Context IDHEAS-G CFMs IDHEAS-G PIF Structure HEP Table -
PIF Impact Table -
PIF Interaction Table -
Analyze data source Interpret and represent data Consolidate and document data Figure 6-2
N L M H E States of PIFs PIF weight W1 W2 W3 W4 W5 N: No impact L: Low impact M: Moderate impact H: High impact E: Extreme High impact Figure 6-3
Appendix C figures
41 Figure C-1
Appendix D figures
Figure D-1 No-impact Poor Error rate PIF2 No-impact PIF2 poor Additive Multiplicative Subtractive No-impact Poor No-impact Poor PIF1
Appendix E figures
Operational narrative of a human event Baseline scenario Additional scenarios Scenario narrative
- Overview of the event
- Beginning status
- Initiating event
- Initial conditions
- Boundary conditions
- Progression and end state Timeline
- Date/time
- System response, human response, data for situation awareness, and notes Deviations from the baseline scenario Figure E-1 (NoteThis is the same as Figure 4-4.)
Appendix F figures
47 Figure F-1
Figure F-2 (recreated)
ELAP The whole scenario 19 7
5 2
0 The DC system survived the hazard.
The initial DC load shed is performed in time.
The deep DC load shed is performed in time.
The portable generator is deployed in time.
The generator fuel is replenished in time.
DC Power Available Duration (hr)
Yes No Yes No Yes No Yes No Yes No Note: The time information in the above tree is only to illustrate human actions effects. The values do not represent any plant.
Appendix G figures
Figure G-1 (NoteThis is the same as Figure 4-6.)
Human Event IHA 1 IHA 2 IHA 3 Critical Task 1 Critical Task 2 Critical Task 3 Critical Task Critical Task Macrocognitive functions required for the task
Task 1 Task 1 Task 3 Task 2 Task 4 Task 1 Task 3 Task 2 Task 4 Task 7 Task 6 Task 10 Task 8 Task 9 Task 1 Task 3 Task 2 Task 4 Task 5 Task 6 Task 7 Task 9 Task 10 Task 8 Task 11 Enter the HFE Goal achieved Simple HFE Single task path Parallel or intermingled tasks/paths Alternative tasks/paths Figure G-2 (recreated)
(a)
Task 5 (b)
(c)
(d)
Note: The red font denotes a critical task.
52 Chemical release Figure G-3 (recreated)
Detect the chemical release and decide to flee Detect the chemical release and decide to flee Flee from the building Flee from the building All workers are outside 3rd floor workers 4th floor workers
53 Chemical release Figure G-4 (recreated) t0 t0: Cues available t4 t3 t2 t1 t1: 3rd floor workers detect the cue t2: 3rd floor workers start to flee t3: 4th floor workers detect the cue t4: 4th floor workers start to flee All workers are outside
54 Figure G-5
55 Event MCR Response Field Operator
Response
Technician
Response
Fire Brigade
Response
Detects Alert Begins using Alarm
Response
Procedure Consults MCR computer to determine fire location (i.e.,
bank of cabinets)
Dispatches FO to fire location Dispatches tech to fire location Makes decision to de-energize Travels to fire location Begins serving as posted fire watch at identified bank of cabinets Retrieves equipment to locate incipient fire source Travels to fire location Begins using equipment to locate affected cabinet Opens affected cabinet Communicates information about degraded component to MCR Instructs FO to de-energizeg De-energizes Component VEWFD Response Operations Uses equipment to locate degrading component Communicates information about degrading component to FO Operational Goal Locate degraded component and de-energize before flaming fire occurs Alert sounds in MCR Component begins degrading Continues monitoring the MCR computer screen during the field investigation Maintains communication with FO throughout investigation Maintains communication with MCR throughout investigation Figure G-6
Figure G-7 (recreated) 0 OK 7
6 5
4 3
2 1
Enter Path-1 upon automatic reactor trip Enter EPP-4 Reenter Path-1 upon automatic safety injection Identify LOSC from CCW and enter APP-001-D1 Identify loss of seal injection and enter AOP-018 Section C Transfer to Step 10 at Step 2 Open FCV-626 at Step 10 Fail to open FCV-626, execution Fail to transfer to Step 10 of AOP-018 Fail to enter AOP-018 R
57 Figure G-8
Appendix H figures
Failure of Detection Failure of Understanding Failure of Decisionmaking Failure of Action execution Failure of Interteam coordination Failure of D1 D2 D5 (b) Cognition Failure Taxonomy Failure of a Critical Task Detection Understanding Decisionmaking Action execution Interteam coordination D1-D5 DM1-DM6 E1-E5 U1-U5 T1-T7 (a) Macrocogniton Taxonomy Critical Task Macrocognitive Functions Failure of the Processors Failure of the Macrocognitive Functions Processors Figure H-1 Failure of U1 U2 U5 Failure of DM1 DM2 DM6 Failure of E1 E2 E5 Failure of T1 T2 T7 Note: The symbol represents the union (i.e., OR logic) of the events.
Appendix J figures
Figure J-1 (recreated)
Define the expert elicitation Form the expert panel Develop the project plan Planning and preparation Assemble and disseminate the dataset Familiarize and refine the technical issues Conduct training and piloting Pre-elicitation work Elicit expert judgments Integrate expert judgments Elicitation Final documentation and sponsor review Document the process and results, and conduct sponsors technical review Participatory peer review
Appendix K figures
Figure K-1
- 1. Identify the dependency context Consequential dependency Resource-sharing dependency Cognitive dependency Cut set with multiple HFEs (HFE1, HFE2)
- 2. Model the dependency context HFE2lHFE1 Are there changes to HFE2s:
Definition? Time required and time available?
Feasibility?
CFMs?
Critical tasks?
PIF attributes?
HFE1 and HFE2 are independent P(HFE1,HFE2)=
P(HFE1)*P(HFE2)
- 3. Calculate P(HFE2lHFE1) based on context changes to HFE2 and using same method as individual HFEs Any yes?
HFE2lHFE1 means the occurrence of event HFE2 given the occurrence of event HFE1, where HFE1 is the first event and HFE2 is the second event.
All no Yes P(HFE1,HFE2) =
P(HFE1)*P(HFE2lHFE1)
Figure K-2 (recreated)
HFE 1 HFE 2 Time uncertainty HFE 2 definition Critical task 2 Task 3 Task 1 Understanding Detection Decisionmaking Action execution Interteam coordination CFMs CFMs CFMs CFMs CFMs Change?
PIF 1 PIF 2 PIF 3 PIF 4 PIF 5 Success Failure Use HEP 2 Adjust HEP 2 Yes Failure OK (or other events)
Success No
Figure K-3 (recreated) 65 Context of HFE1 HFE1 S
S Success Failure (P1)
HFE2 Success Failure (P2)
F (P1xP2)
Context of HFE2 (a)
(b)
Context of HFE1 HFE1 S
S Success Failure (P1)
HFE2 Success Failure (P2DEP)
F (P1xP2DEP)
Dependent Context of HFE2
Appendix M figures
Figure M-1 67
Figure M-2 68
Figure M-3 69
Figure M-4 70
Figure M-5 (recreated) 71 Start Detect a RCP abnormal alarm Enter AOP-018 Open FCV-626 or Trip RCPs 1 S 2 F 3 F 4 F S
S S
F F
F
Figure M-6 (recreated) 72 Start - Order to deploy FLEX generator per ELAP procedure Transport and stage FLEX generator Connect FLEX generator Operate FLEX generator to power 480 VAC 1 S 2 F 3 F 4 F S
S S
F F
F