Abstract
In the operation of commercial nuclear power plants, large guidebooks have been prepared, documenting proper procedures in the event of various hardware or control failures. Although recognized as having a major impact on overall system safety, human error has not received as much attention from the standpoint of anticipating specific errors and designing against them. Using system diagrams constructed from overall plan design diagrams, it was possible to define subsystem dependencies. It was then possible to construct 80 realistic operation and maintenance errors and control malfunctions, to analyze their symptoms and effects, and to construct sequences of actions to mitigate the situation or to prevent serious consequences. Preventative as well as corrective measures were developed. Methods employed in this study appear to have general application in system safety.
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