53 Guidelines for Assessing Diagnosis Failures for a Flowchart-Based Diagnostic Procedure (PSAM-0291)
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Published:2006
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In the emergency situations of nuclear power plants (NPPs), diagnosis of the occurring events is crucial for managing or controlling a plant to a safe and stable state. If the operators fail to diagnose the occurring event(s), their responses to a given event can eventually be inappropriate or inadequate.
This paper presents the guidelines for assessing the potential for a diagnosis failure (or misdiagnosis) for the occurring events in nuclear power plants. As the contributing factors to diagnosis failures, three categories of causes such as plant dynamics (PD), operator errors (OE) and instrumentation failures (IF) are identified through the analysis of past events and simulator training records that involve a diagnosis failure. This study provides qualitative and quantitative guidelines for considering these three factors in assessing diagnosis failures.
The paper also presents a case study that applied the proposed method to the small loss of coolant (SLOCA) event of a Korean NPP.