Copyright © 2014

SCK•CEN 1

Mallants Fernand fmallant@sckcen.be

fmallants@gmail.com

Copyright © 2014

SCK•CEN Confidential

SCK•CEN, BR2 Belgium

2

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

3

Copyright © 2014

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)

4

Copyright © 2014

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

5

Copyright © 2014

SCK•CEN

Pool-type reactor

6

Copyright © 2014

SCK•CEN

Safety in practice

BR2 Lessons learned

Safety Performance Indicators

Mallants Fernand fmallant@sckcen.be

fmallants@gmail.com

7

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

8

Copyright © 2014

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….

9

Copyright © 2014

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

10

Copyright © 2014

SCK•CEN Confidential

Evolution 2

11

Copyright © 2014

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

12

Copyright © 2014

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

13

Copyright © 2014

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

14

Copyright © 2014

SCK•CEN Confidential

Unexpected stops versus working time

Technical versus safety problem

15

1998-2013

Copyright © 2014

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

16

The frequency is low

Expected in nuclear because of the implementation of safety culture

Copyright © 2014

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

18

Copyright © 2014

SCK•CEN Confidential

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

19

Copyright © 2014

SCK•CEN Confidential

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

20

Copyright © 2014

SCK•CEN Confidential

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

21

Copyright © 2014

SCK•CEN Confidential

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)

22

Copyright © 2014

SCK•CEN Confidential

NCR closing time

23

Copyright © 2014

SCK•CEN Confidential

NCR closing time

24

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

Copyright © 2014

SCK•CEN Confidential

Examples

modification to the installation SF/O/008 and

SF/O/013

work orders and risk analysis

25

Conclusion

• Increasing number of applications,

reports, risk analysis ...

• positive evolution

• Increasing awareness of safety

Copyright © 2014

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

26

Copyright © 2014

SCK•CEN Confidential

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

27

Copyright © 2014

SCK•CEN Confidential

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

28