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Copyright © 2014
SCK•CEN 1
Mallants Fernand fmallant@sckcen.be
fmallants@gmail.com
Copyright © 2014
SCK•CEN Confidential
SCK•CEN, BR2 Belgium
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Copyright © 2014
SCK•CEN Confidential
Belgian Nuclear Research Centre SCK•CEN BR2
Belgian Reactor 2: high flux material testing reactor
water cooled (low pressure – low temperature)
beryllium and water moderated
BR2’s brothers and sisters at SCK●CEN Belgian Reactor 1: low flux reactor
air cooled
graphite moderated
still original fuel
Belgian Reactor 3: small PWR (11MWe)
first PWR in Western Europe now dismanteld
Guinevere: zero power ADS
fast neutrons
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SCK•CEN Confidential
BR2 reactor
History
first criticality: June 1961
operational: January 1963
refurbishment: 1979-1980 & 1995-1997
2015
Material Testing Reactor
neutron flux production
no electricity production
all produced heat is evacuated through cooling towers
120 staff members/ 120 days >>>32 Reactor operators
( 6 shifts)
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SCK•CEN Confidential
BR2 Irradiation purposes
Research & Development
Materials
fuel
structural materials
instrumentation
Isotope production
applications
nuclear medicine (diagnostic, therapy …)
industry (radiography of welds , sterilization, measurements, …)
Research
Neutron doping of silicon
production of n-type semiconductors
starting material is highly purified silicon
applications: high-grade electronics
power applications
electrical cars
AC-DC converters
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SCK•CEN
Pool-type reactor
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SCK•CEN
Safety in practice
BR2 Lessons learned
Safety Performance Indicators
Mallants Fernand fmallant@sckcen.be
fmallants@gmail.com
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Copyright © 2014
SCK•CEN Confidential
Agenda
Overview & evolution Safety culture at BR2
IMS to a Dynamic safety perspective in practice
Methodology at BR2
Indicators
Leading indicators
Lagging
Actions & planning
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SCK•CEN Confidential
Overview & trend
In the last two decades, organizational and cultural issues have been identified as vital in achieving safe
operation. Safety culture is now a commonly used term.
More and more pressure to assess safety culture
• IAEA GS-R-3 point 6.2 &6.3 “assessments shall be conducted regularly on behalf of senior
management to evaluate the organisation’s safety culture…”
• FANC : IMS shall cover all the activities and processes which can impact the nuclear safety ; Royal
Decree 30/11/1 Safety requirements for nuclear installations
• International trend amongst the nuclear operators to develop methodology for safety culture
assessment
IAEA focus on culture, leadership and management for safety
IAEA Safety culture
• Safety is a Key Factor for Nuclear Organizations.
• An Enhanced Safety Culture is Crucial for Nuclear Safety.
• Safety Culture Enhancement implies in Organizational Changes.
IAEA GS-R-3 >>> GSR Part 2: From IMS to systematic approach for safety
IMS >>> Already implemented on BR2 ( see TECDOC)
TM 2014 : Systemic approach to safety in practice, managing the unexpected
Human , technology and organizational factors
Taking into account interactions between all stakeholders such as operators, regulators, experimenters,
government, contractors….
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SCK•CEN Confidential
Evolution 1
• The nuclear industry has been successful in reducing incident frequency by adopting
improved engineering solutions and sophisticated safety management systems.
• However, safety performance has reached a plateau in many companies: despite all the
money and effort being spent, there is little improvement between one year’s performance
and the next.
How can we achieve further improvements in HSE performance?
Systematic approach
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Evolution 2
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SCK•CEN Confidential
Dynamic interaction
Traditionally, the development of Health, Safety and Environmental Management Systems (IMS) has
concentrated on the facilities and equipment to be used and the management systems themselves.
Accidents emerge from the dynamic interactions within and between the factors
Although human error has been recognised as part of the risk contribution, the root causes
associated with particular types of human error have been difficult to address
Human factors
Organizational factors
Technical factors
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SCK•CEN Confidential
Practice & methodology
Define indicators
Proactive versus reactive safety policy
Leading versus lagging indicators (Make the results measurable)
Training, inspections… versus actions after an incident, loss or NCR ( number of NCR’s)
Reactice indicators should follow the proactive (leading) indicators
BR2 context
Human factors performance indicators. The Swiss
Cheese model of accident causation is a model used in
the risk analysis and risk management of human systems
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SCK•CEN Confidential
Some exemples of lagging BR2 indicators
% Working versus number of unexpected stops
Number of NCR’s
Frequency rate of work accidents
Radiological dose >> see presentation SVD
Emissions >> see presentation SVD
Instrument : Analysing NCR’s
Period 01/04/2011-01/04/2014
Number of NCR’s versus Safety NCR’s
Among non conformities concerning safety we mean:
Violation of procedures, consigns or insufficient knowledge of it
Behavioral deficits - no procedures or orders where necessary
Human factor NCR's
Near misses and accidents
Training shortages
Errors in communication
Violation of technical specifications
Industrial & nuclear safety
Environment
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SCK•CEN Confidential
Unexpected stops versus working time
Technical versus safety problem
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1998-2013
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SCK•CEN Confidential
Working accidents
Frequenty rate: Number of accidents affecting X 1,000,000 / number of hours of exposure to the risk
SCK
2011 9
2012 4
2013 3
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The frequency is low
Expected in nuclear because of the implementation of safety culture
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SCK•CEN Confidential 17
Association of industrial enterprises of Antwerp
Copyright © 2014
SCK•CEN Confidential
NCR’s overview
820
840
860
880
900
920
940
960
04/2011-04/2012
04/2012-04/2013
04/2013-04/2014
Increasing the number of NCR’s in 2014
• Splitting of safety-related NCR's
• Better attention so better and more reported
• More NCR's
See the next slides
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NCR issue
0
100
200
300
400
500
600
700
15: Technisch 12: Safety 17: Proces 13: Kwaliteit 18: Security
04/2011-04/2012
04/2012-04/2013
04/2013-04/2014
Increasing the number of safety NCR’s in 2014: Splitting of safety-related NCR's
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NCR detail
0
10
20
30
40
50
60
70
04/2011-04/2012
04/2012-04/2013
04/2013-04/2014
Increasing by splitting of NCR’s:
Bel V: Nuclear safety and radiological safety
Inspection body Vincotte: Industrial safety
IPBW: Industrial safety and Housekeeping
Extra attention to human factors, third parties, communication and procedures
Better judgment
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Conclusion NCRMS
Change in the assessment of the issues and the details have influenced the analysis
NCR’s ( nuclear incidents) with impact on the reactor are treated in INES or INRIBUAN application
Not the number of NCR's or suggestions is important >>> <<< most important is the risk factor >>>
finally define actions to improve response to the safety analysis
Safety performance can never be fully assessed on the basis of 'lagging' indicators (statistics). The
combination with 'leading' is a must
Positive Negative
Not only for safety problems
Technical: Maintenance, infrastructure, inspection
Human: man, org, third,
Organizational Management
Positive experience is not included
Attention to assessment by 10 am meeting Some NCR's are very difficult to judge. Choice among
several aspects ( problem and detail)
Open discussion (shyness disappears) What with multiple errors
Powerful communication tool
Identifies recurring errors
Historical overview of the installation
Base for actions and improvements
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BR2 leading indicators
Leading instrument: Much more difficult to use
QA objective: KPI: If these are not met, there is something wrong with
the security
Other proposals of leading indicators
percentage NCR finished within deadline
Audit of the safety management system
Training results
Risk analyzes
SO/040 (orders = work permit)
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NCR closing time
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NCR closing time
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0
10
20
30
40
50
60
70
80
90
100
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
< 75 days
Due date versus closing time of NCR’s:
maximum running time of NCR = cycle + sd period = +- 60 days
Conclusion :certain NCR remain open because
• they are not relevant
• have a limited impact
• a change process must go through
SPI: based on previous years: with 75% completed within 75 days
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SCK•CEN Confidential
Examples
modification to the installation SF/O/008 and
SF/O/013
work orders and risk analysis
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Conclusion
• Increasing number of applications,
reports, risk analysis ...
• positive evolution
• Increasing awareness of safety
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SCK•CEN Confidential
Indicators
Training
Demand = 10 days or 80 hours / year / ROP member
2013: + - 15 days per member ROP
OJT: extra effort
Safety audit
Intern : NS2 & IDPBW & CPBW ( follow up by NCRMS)
Extern : BelV/ FANC/ Clients/ Insurance/ Inspection bodies/ ISO 9001
Positive result
SF/O/008 & 13
Increasing documentation ( quality >< quantity)
Workorders & risk-analysis
Increasing documentation
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Immediate actions
Systemic approach on safety
Focus on leading indicators
Third parties
Training( contractors, external BR2 and SCK workers )
BR2 Contact-person
Human aspects: start with working group ( OJT is put on the agenda >> actions
started)
10 o'clock meeting: instrument for judgment each NCR.
Improved judgment system NCRMS (human /technical / organizational aspects)
Priority and importance of the NCR
Every NCR on human factors needs an additional analysis ~risk analysis
Always and always repeat, animate so that the involvement of middle
management and workers in the process increases
Improve risk analysis
Concentrate on preventive ( pro-active) actions
Posters
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Long term actions
Topics PSR 2016
Safety culture
Human factors : Tool HEART
SPI
Based on lagging ( NCRMS, ALARA, incidents..) and leading indicators
Organization
Upgrade tool risk analyzis
Integrate BR2 IMS in SCK IMS
DMS non standard documents in ALEXANDRIA
Plant Asset Management (PAM) unit Manages Long Term Operation plan of BR2 by
systematic analysis of ageing risks
BEX group ( experiments) In charge of safety and quality of experimental infrastructure
and projects
Systemic approach to safety in practice
Daily practice
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