NUREG-2198, - Figures Final

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NUREG-2198 - Figures Final
ML21134A160
Person / Time
Issue date: 05/14/2021
From: Dejesus-Segarra J
NRC/RES/DRA/PRAB
To:
DeJesus, Jonathan - 301 415 1538
References
NUREG-2198
Download: ML21134A160 (72)
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Text

Executive Summary Figures

Figure ES-1 Human action Tasks and cognitive activities Cognitive Macrocognitive Basis Functions Structure Processors Cognitive Mechanisms Performance-Influencing Factor Structure

  • Context categories
  • PIF attributes 2

Figure ES-2 (same as Figure 4-3) PIF attributes of every CFM Scenario for every CT PRA context and Step 5: Calculate model list of applicable Step 4: Assess PIFs Step 1: Determine PIFs applicable to every scenario context CFM List of Step 1: HFE and its applicable Step 7:

Develop scenario narrative definition CFM(s) for Calculate Develop scenario timeline the CT(s) overall HEP HFE and its Step 2: List of Step 1: Identify HFE definition Analyze tasks CT(s) Step 3: Characterize the CT(s) and select applicable Step 1: Define HFE and identify CFMs CT(s) in HFE HFE and its definition and Step 6: Estimate parameters Step 6: Analyze HFE timeline of distribution (subset of scenario timeline, if there are Step 6: Calculate multiple HFEs in the scenario)

Step 6: Estimate parameters of distribution and Step 8:

Uncertainty and dependency analysis and documentation CFM = cognitive failure mode = error probability due to CFMs CT = critical task = error probability due to uncertainty in and HEP = human error probability = time available HFE = human failure event = time required PIF = performance-influencing factor and = mean and standard deviation of PRA = probabilistic risk assessment and = mean and standard deviation of 3

Chapter 1 Figures

Figure 1-1 Cognitive basis framework (NUREG-2114)

Literature and human factors practices IDHEAS General Human error Methodology data Existing HRA methods (NUREG-2198) generalization Operational experience IDHEAS Internal At-Power IDHEAS for actions outside Other specific HRA Application the control room applications (NUREG-2199, Vol. 1) (e.g., IDHEAS for Event and Condition Assessment)

Plant-specific PRA models

Figure 1-2 Cognitive Basis Structure Cognition Model PIF Structure Human error data Stage 1 Stage 2 Stage 3 Stage 4 Scenario Modeling of HEP Integrative IDHEAS-G process analysis important quantification analysis human actions

Chapter 2 Figures

Figure 2-1 Cognition Model for Human Performance and Reliability Important Critical Cognitive Basis Structure Human Tasks Action and and Cognitive Context of Activities PIF Structure the Action

Figure 2-2 Human action Task 1 Task 2 Task 3 and cognitive activities and cognitive activities and cognitive activities Under- Decision- Action Interteam Detection standing making execution coordination

Figure 2-3 Macrocognitive Cognitive PIFs Processors functions mechanisms Processor - D1 Cognitive Detection mechanism PIF 1 Processor - D5 Cognitive Processor - U1 PIF 2 mechanism Understanding Processor - U5 Cognitive PIF 3 mechanism Task and Processor - DM1 Decision-cognitive activities making Processor - DM6 Cognitive PIF 17 mechanism Processor - E1 Action Cognitive PIF 18 execution Processor - E5 mechanism PIF 19 Processor - T1 Cognitive Interteam mechanism coordination Processor - T7

Figure 2-4 Macrocognitive function: Detection Detection cognitive activities Detection processors Detection cognitive mechanisms D.a. Mental model of the D1. Initiate detection -

cues Establish the mental model for information D.b. Perception of sensory to be detected information D2. Select, identify, and D.c. Attention attend to sources of D.d. Working memory

  • Detect cues information D.e. Vigilance
  • Acquire (gather) D3. Perceive, recognize, information and classify information D.f. Information foliage D4. Verify and modify the D.g. Pattern recognition outcomes of detection D.h. Shared cognition within D5. Retain, a team document/record, or D.i. Infrastructure for communicate the exporting the outcomes information detected

Figure 2-5 Macrocognitive function: Understanding Understanding cognitive activities Understanding processors Understanding cognitive mechanisms U1. Assess/select data

  • Maintain situational awareness U2. Select/adapt/develop the mental model
  • Assess status based U.a. Data on indirect U3. Integrate data with the mental model to U.b. Selection of data information generate the outcome U.c. Mental model
  • Diagnose problems of understanding and resolve (situational awareness, U.d. Integration of data with conflicting diagnosis, resolving mental model information conflicts) U.e. Working memory
  • Make predictions or U4. Verify and revise the U.f. Shared cognition within form expectations for outcome through a team the upcoming iteration of U1, U2, and situation U3 development U5. Export the outcome

Figure 2-6 Macrocognitive function: Decisionmaking Decisionmaking cognitive activities Decisionmaking processors Decisionmaking cognitive mechanisms DM1. Select and implement decisionmaking model

  • Make a go/no-go DM2. Manage the goals and DM.a. Decisionmaking decision for a pre-decision criteria model specified action DM3. Acquire and select DM.b. Data for
  • Select among data for decisionmaking multiple options or decisionmaking strategies DM.c. Selection or judgment DM4. Make decision
  • Change or add to a DM.d. Cognitive biases (judgment, strategies, pre-existing plan or plans) DM.e. Deliberation or strategy evaluation of decision DM5. Simulate or evaluate
  • Develop a new the decision or plan DM.f. Team decisiomaking strategy or plan DM6. Communicate and authorize the decision

Figure 2-7 Macrocognitive function: Action Execution Action Execution cognitive activities Action Execution processors Action Execution cognitive mechanisms 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

  • Execution of a E1. Assess action plan and E.e. Vigilance cognitively simple criteria E.f. Sensory feedback of action motor movement E2. Develop or modify
  • Execution of a action scripts E.g. Automaticity cognitively complex action E3. Coordinate and E.h. Action programming command action
  • Long-lasting action implementation E.i. Executive control
  • Control action E4. Implement action E.j. Error monitoring and ti

Figure 2-8 Macrocognitive function: Interteam coordination Interteam coordination activities Interteam coordination processors Interteam coordination cognitive mechanisms T1. Establish or adapt interteam coordination infrastructure T.a. Interteam coordination T2. Manage information infrastructure T3. Maintain shared T.b. Command

  • Communication situational awareness T.c. Control
  • Cooperation T4. Manage resources T.d. Line of communication
  • Coordination T5. Plan interteam T.e. Data processing and collaborative activities information T6. Implement decisions and management commands T.f. Shared mental model T7. Verify, modify, and control the implementation

Figure 2-9 High Central authority control Interteam coordination Within-team interaction

Figure 2-10 Sends field operator into field Emergency Director (in TSC) to check on symptom Field Operator (in the field)

1. Determines the need to
2. Detects an issue and check a symptom in the reports back (D3-D5) field (DM1-DM3; D1-D2)

Emergency director (in TSC) supported by technical staff

3. Receives the information (D1-D5)
4. Integrates the information with other sources of Communicates decision Management (at Utility Headquarters) information to form understanding (U1-U5) and seeks approval 8. Decides whether to give approval
5. Prioritizes actions addressing this problem (DM1) and communicates approval (DM1-
6. Decides on action to take (this includes developing an Communicates approval DM6) action plan and procuring necessary tools and equipment) (DM2-DM5)

Sends out operating

7. Communicates and seeks higher level management crew to perform action authority (DM6) Operating Crew (in control room)
9. Communicates action plan to operators who will Operating crew reports 10. Takes actions and reports back (E1-perform action (DM6) back E5)

Chapter 3 figures

Figure 3-1 Environment and situation context Event progress Event, mission, System Human Human Human Personnel goals context action action action context Task context PIFs Cognitive mechanisms Processors Macrocognitve functions Success or failure of human actions

Figure 3-2 Environment Context and Situation System Personnel Task

  • Accessibility/habitability *Staffing *Information availability
  • System and I&C of workplace including *Procedures, guidance, and reliability transparency to *Scenario familiarity travel paths and instructions personnel *Multitasking,
  • Workplace visibility *Training
  • HSI PIF *Noise in workplace and
  • Equipment and
  • Team and organization interruptions, and communication factors distractions tools *Task complexity pathways *Work processes
  • Cold/heat/humidity *Mental fatigue
  • Resistance to physical *Time pressure and movement stress
  • Physical demands PIF *Poor lighting in *Tools are difficult to use
  • Procedure is inadequate *Sustained high-workplace *Tools are unfamiliar to personnel attributes *Glare or reflection *Tool does not work
  • Procedure is difficult to demanding cognitive use activities Note: The PIF attributes on physical structure *Tool or parts are unavailable
  • Procedure is available, but *Long working hours shown are examples and *Smoke or fog- *Document nomenclature does correspond to the PIFs does not fit the situation *Sleep deprivation induced low visibility not agree with equipment labels highlighted in red.

Links to cognitive See Section 3.4 and Appendix B mechanisms

Figure 3-3 PIF Structure Cognitive Basis Structure Context Processor PIFs PIF Cognitive attributes mechanism Processor Detection Environment Cognitive and situation Processor mechanism Understanding System Processor Event Cognitive Task scenario Decision-mechanism Processor making Personnel Cognitive Processor mechanism Action execution Task Cognitive Processor mechanism Interteam Processor coordination Cognitive mechanism

Chapter 4 figures

Figure 4-1 Collect data/information and interact with PRA Analyze scenarios and develop operational Analyze and quantify HEP narrative of a human failure event:

  • Identify failure modes
  • Assess PIFs Identify and define IHAs
  • Estimate the HEP Identify and analyze tasks Analyze HFE dependency Time and feasibility analysis and adjust HEPs Analyze and document uncertainties

Figure 4-2 Stage 1 Stage 2 Stage 3 Stage 4 Scenario analysis Modeling of HEP Integrative

  • Develop operational important quantification analysis narrative human actions
  • Identify event context
  • Document
  • Identify and analyze uncertainties
  • Identify and define critical tasks due to time important human
  • Identify CFMs uncertainties and
  • Assess actions

Figure 4-3 (same as Figure ES-2) PIF attributes of every CFM Scenario for every CT PRA context and Step 5: Calculate model list of applicable Step 4: Assess PIFs Step 1: Determine PIFs applicable to every scenario context CFM List of Step 1: HFE and its applicable Step 7:

Develop scenario narrative definition CFM(s) for Calculate Develop scenario timeline the CT(s) overall HEP HFE and its Step 2: List of Step 1: Identify HFE definition Analyze tasks CT(s) Step 3: Characterize the CT(s) and select applicable Step 1: Define HFE and identify CFMs CT(s) in HFE HFE and its definition and Step 6: Estimate parameters Step 6: Analyze HFE timeline of distribution (subset of scenario timeline, if there are Step 6: Calculate multiple HFEs in the scenario)

Step 6: Estimate parameters of distribution and Step 8:

Uncertainty and dependency analysis and documentation CFM = cognitive failure mode = error probability due to CFMs CT = critical task = error probability due to uncertainty in and HEP = human error probability = time available HFE = human failure event = time required PIF = performance-influencing factor and = mean and standard deviation of PRA = probabilistic risk assessment and = mean and standard deviation of

Figure 4-4 Development of operational narrative Identification of Identification of important human event context actions

Figure 4-5 Scenario narrative

  • Overview of the event
  • Beginning status
  • Initiating event
  • Initial conditions
  • Boundary conditions
  • Progression and end state Baseline scenario Timeline
  • Date/time Operational
  • System response, human narrative of a response, data for human event situation awareness, and notes Deviations from the baseline Additional scenarios scenario

Figure 4-6 Task Analysis Identification of Assessment of CFMs PIFs

Figure 4-7 Human Event IHA 1 IHA 2 IHA 3 Critical Critical Critical Critical Critical Task Task 1 Task 2 Task 3 Task Macrocognitive functions required for the task

Figure 4-8 Time available Time required CFMs PIF states HEP of = ( , ,)

CFM 1 an IHA Critical

= ( , ,)

task 1 CFM 2 Critical = ( , ,)

CFM 3 task 2 Critical = ( , ,)

CFM 6 task 3

Figure 4-9 PIF2 PIF1 1

E-1 HEP E-2 E-3 E-4 States of Base PIFs

Figure 4-10 Event Stage 1: Scenario analysis Event scenarios

  • Develop operational narrative scenarios
  • Identify event context
  • Identify important human actions IHAs IHA 1 IHA 2 IHA 3 Critical Critical task 1 Critical task 2 Critical task 3 Stage 2: Modeling of tasks important human actions
  • Identify and analyze critical Macro-tasks
  • Identify applicable CFMs cognitive Action Interteam functions Detection Understanding Decisionmaking execution coordination
  • Estimation of CFM2 PIF2
  • Estimation of HEP due to time HEP HEP CFM3 PIF3 uncertainty Stage 4 - Integrative analysis Dependency CFM4 PIF4
  • Document uncertainties
  • Assess dependencies adjustment

Chapter 5 figures Figure 5-1 Note: The area in red corresponds to the value of . = = 1

> = 1 sum over all possible values >

Figure 5-2 Cue Crew Start received Action Action diagnosis complete no longer complete beneficial

Chapter 6 figures Sources of human error Data source 1 Data source 2 data Tasks Context Tasks Context Failure PIFs Failure PIFs Generalization modes modes Human error Human error Human error Human error rates of the rates at the rates of the rates at the failure modes PIF states failure modes PIF states Integrate data for the failure modes and PIFs Integration Figure 6-1

= ( )

Figure 6-2 Analyze data Interpret and Consolidate and source represent data document data Human action IDHEAS-G CFMs HEP Table -

/ tasks IDHEAS-G PIF PIF Impact Table -

Context Structure PIF Interaction Table -

Figure 6-3 W5 PIF weight W4 N: No impact L: Low impact W3 M: Moderate impact H: High impact W2 E: Extreme High impact W1 N L M H E States of PIFs

Appendix C figures Figure C-1 41

Appendix D figures Figure D-1 Additive Multiplicative Subtractive Error rate PIF2 poor PIF2 No-impact PIF1 No- Poor No- Poor No- Poor impact impact impact

Appendix E figures Figure E-1 (NoteThis is the same as Figure 4-4.)

Scenario narrative

  • Overview of the event
  • Beginning status
  • Initiating event
  • Initial conditions
  • Boundary conditions
  • Progression and end state Baseline scenario Timeline
  • Date/time Operational
  • System response, human narrative of a response, data for human event situation awareness, and notes Deviations from the baseline Additional scenarios scenario

Appendix F figures Figure F-1 47

Figure F-2 (recreated)

The initial DC load shed The portable generator is performed in time. is deployed in time.

The DC system The deep DC load shed The generator fuel is DC Power Available survived the hazard. is performed in time. replenished in time. Duration (hr)

ELAP The whole scenario Yes Yes Yes Yes Yes 19 No No 7

No 5

No 2

No 0

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 Critical Critical Critical Critical Task Task 1 Task 2 Task 3 Task Macrocognitive functions required for the task

Figure G-2 (recreated)

Simple Enter Task 1 Goal (a)

HFE the HFE achieved Single (b) Task 1 Task 2 Task 3 Task 4 task path Task 1 Task 2 Task 3 Task 4 Parallel or (c) intermingled Task 5 Task 6 Task 7 Task 10 tasks/paths Task 8 Task 9 Task 1 Task 2 Task 3 Task 4 Alternative (d) tasks/paths Task 5 Task 6 Task 7 Task 8 Task 9 Task 10 Task 11 Note: The red font denotes a critical task.

Figure G-3 (recreated) 3rd floor workers Detect the Flee from the chemical release building and decide to flee Chemical All workers release are outside 4th floor workers Detect the Flee from the chemical release building and decide to flee 52

Figure G-4 (recreated) t0: Cues t1: 3rd floor t2: 3rd floor t3: 4th floor t4: 4th floor available workers workers workers workers detect the start to flee detect the start to flee cue cue All Chemical workers release t0 t1 t2 t3 t4 are outside 53

Figure G-5 54

Figure G-6 VEWFD Response Operations Event Field Operator Technician Fire Brigade Operational MCR Response Response Response Response Goal Detects Alert Travels to fire Retrieves Component begins location equipment to degrading locate incipient Begins using fire source Alarm Begins serving Response as posted fire Procedure watch at Travels to fire Alert identified bank location sounds in of cabinets MCR Consults MCR Begins using computer to equipment to determine fire locate affected location (i.e., cabinet bank of Locate cabinets) degraded component and Opens affected de-energize cabinet before flaming Dispatches FO fire occurs to fire location Uses equipment to locate Dispatches tech degrading to fire location component Continues Communicates monitoring the information MCR computer about screen during degrading the field component to investigation FO Maintains Maintains communication communication with FO with MCR throughout throughout investigation investigation Communicates information Makes decision about degraded to de-energize component to MCR Instructs FO to De-energizes de-energizeg Component 55

Figure G-7 (recreated)

Identify loss of Enter Path-1 Reenter Path-1 Identify LOSC from Transfer to Open FCV-626 seal injection and upon automatic Enter EPP-4 upon automatic CCW and enter Step 10 at at Step 10 enter AOP-018 reactor trip safety injection APP-001-D1 Step 2 Section C 0 1 2 3 4 5 6 OK Fail to open FCV-626, execution R Fail to transfer to 7 Step 10 of AOP-018 Fail to enter AOP-018

Figure G-8 57

Appendix H figures (a) Macrocogniton Taxonomy (b) Cognition Failure Taxonomy Failure of the Failure of the Macrocognitive Processors Macrocognitive Processors Functions Functions Detection D1-D5 Failure of Failure of D1 D2 D5 Detection Understanding U1-U5 Failure of Failure of U1 U2 U5 Understanding Failure of Critical Task Decisionmaking DM1-DM6 a Critical Task Failure of Failure of DM1 DM2 DM6 Decisionmaking Action execution E1-E5 Failure of Failure of E1 E2 E5 Action execution Interteam coordination T1-T7 Failure of Interteam Failure of T1 T2 T7 coordination Note: The symbol represents the union (i.e., OR logic) of the events.

Figure H-1

Appendix J figures Figure J-1 (recreated)

Final documentation Planning and preparation Pre-elicitation work Elicitation and sponsor review Assemble and Define the expert disseminate the elicitation dataset Elicit expert judgments Document the Familiarize and process and results, Form the expert and conduct refine the technical panel sponsors technical issues Integrate expert review judgments Develop the project Conduct training and plan piloting Participatory peer review

Appendix K figures Figure K-1

1. Identify the dependency context Cut set with
  • Consequential dependency multiple HFEs (HFE1, HFE2)
  • Resource-sharing dependency
  • Cognitive dependency HFE1 and HFE2 are 2. Model the dependency context HFE2lHFE1 independent All no Any Are there changes to HFE2s:

Definition? Time required and time available?

P(HFE1,HFE2)= yes?

Feasibility? CFMs?

P(HFE1)*P(HFE2) Critical tasks? PIF attributes?

Yes

3. Calculate P(HFE2lHFE1) based on P(HFE1,HFE2) =

context changes to HFE2 and using P(HFE1)*P(HFE2lHFE1) same method as individual HFEs 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.

Figure K-2 (recreated)

Success Success OK HFE 1 HFE 2 (or other events)

Failure Failure Use HEP 2 HFE 2 definition Time uncertainty Task 1 Critical task 2 Task 3 No Interteam Change?

Action Detection Understanding Decisionmaking execution coordination CFMs CFMs CFMs CFMs CFMs Yes Adjust PIF 1 PIF 2 PIF 3 PIF 4 PIF 5 HEP 2

Figure K-3 (recreated)

(a) Context Success HFE1 S of HFE1 Failure (P1)

Success Context HFE2 S of HFE2 Failure (P2)

F (P1xP2)

(b) Context Success HFE1 S of HFE1 Failure (P1)

Dependent Success Context of HFE2 S HFE2 Failure (P2DEP)

F (P1xP2DEP) 65

Appendix M figures Figure M-1 67

Figure M-2 68

Figure M-3 69

Figure M-4 70

Figure M-5 (recreated)

Detect a RCP S S Open FCV-626 S Start Enter AOP-018 1S abnormal alarm or Trip RCPs F F F 2F 3F 4F 71

Figure M-6 (recreated)

Start - Order to Transport and S S Operate FLEX S deploy FLEX Connect stage FLEX generator to 1S generator per FLEX generator generator power 480 VAC ELAP procedure F F F 2F 3F 4F 72

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