核电厂安全文化建设(4)-3

1Page101“”Page1022Page103Page104“”3Page105Page1064Page107Page1085Page109Page110…6Page111Page1127Page113Page1148Page115Page116ØLackedindependentoversight–independentperspectiveØOUnresolvedlongstandingproblems(O-ringfailures)Over-confidenceintheirpastsuccessØPoorcommunicationstoraiseconcernsØTimepressures9Page117“WeareconvincedthatthemanagementpracticesoverseeingtheSpaceShuttleProgramwereasmuchacauseoftheaccidentasthefoamthatstrucktheleftwing.”Page1182010Page119•19912SGTRINES2•1995INES1•1997•1999JCO•2002TEPCO•2004115Page12011Page121Page12212Page123Page12413Page125•••“”•Page126“”“”14Page127Page12815Page129Page130•51916Page131Page13217Page133Page134•1.–1)–2)–318–4)–5•2•3.•4•5.200331718Page135RPN419EC16H:13m:01S.04’’-16H:13m:01S.36’’0.32S16H:13m:01S.56’’-16H:13m:02S.28’’0.72S16H:13m:12S.88’’-16H:13m:14S.86’’1.96S16H:13m:23S.64’’-16H:13m:27S.24’’3.60SRPN420EC16H:12m:09S.08’’-16H:12m:09S.68’’0.60S16H:13m:01S.00’’-16H:13m:02S.32’’1.32S16H:13m:12S.88’’-16H:13m:14S.32’’1.44S16H:13m:23S.64’’-16H:13m:26S.12’’2.48SPage136LPO+TTS6?=0TTSH*ARO.*MICRPN.*R.*SA,SB,SC,SD,G1,G2,N1,N2.*TTS*.*.19Page137••••Page138lllll20Page139lllllllll/lllPage14012lll321Page141456Page142••“”•“”•“”•–“”–“”–“”22Page1435llllllPage1445•••••23Page1455•“”AstepfromdeathThedifferencebetweenaminoreventandahighconsequenceevent,suchasthedeathofaworkerresultingfromanindustrialinjurymustnotjustbeluck.IntheWANOParisCenterregiontherehavebeenseven“minor”eventsthathaveoccurredrecentlywhichcouldhavekilled.Theyhaveinvolvedtheenergizingofdisconnectedcableswithworkinprogress,cuttingoflivecables,cranestouchingoverheadtransmissionlinesandentrytoconfinedspacescontainingnoxiousgases.Itisnotacceptablethatpeopleareinjuredatwork.Haveyoureviewedyournearmissesforthepotentialconsequencesratherthantheactual?Onlybythoroughreportingandanalysiswilltheindustrybeabletosay“whatif?”not“ifonly!!”Theunderlyingcausalfactorsforanearmissareoftenidenticaltothatofamajorincident.Itiseasytobewiseaftertheevent,butitistheresponsibilityofthemanagernottorelyonluck.