Journal of the Ergonomics Society of Korea (대한인간공학회지)

Ergonomics Society of Korea (대한인간공학회)
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Analysis of Fukushima Accident in Resilience Engineering Perspective Using the FRAM (Functional Resonance Analysis Method)

  • Received : 2018.05.04
  • Accepted : 2018.06.01
  • Published : 2018.06.30
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Abstract

Objective: The aim of this study is to investigate the combination of function variability that has affected the development of the Fukushima accident and to identify potential risks of the emergency response system that directly related the Fukushima accident using the functional resonance analysis method. Background: From a traditional perspective (safety-1), safety management is implemented in a way that finds and solves the direct cause of the accident. In the Resilience engineering (safety-2), perspective, accidents or adverse outcomes are considered to emergent from the variability of performance rather than a linear causal relationship. The FRAM is a method of modeling system functions and finding potential risks in the system. Method: This study used the FRAM to analyze the accident response of the Fukushima case. In order to identify the accident response system of the Fukushima, we investigated the existing Fukushima accident reports and analyzed the nuclear power plant structure report. Based on these results, we modeled the accident response system of Fukushima accident. Through the FRAM model, we analyzed the variability of the system functions and identified the risks that the combinations of variability might cause. Results: Through the retrospective analysis, we identified the effect of the combinations of variability of system functions on the accident development process. In this study, we present two instantiations. In addition, we conducted the prospective analysis to identify the potential risks of accident response system of the Fukushima that were not reported in actual Fukushima accident. Conclusion: This study suggested that how the variability of the functions of system connected and contributed to the expansion of the accident. The FRAM can be used to reduce the risk of system-wide hazards through analyzing the combination of variability of system functions, identifying the potential risks related to safety. Application: The FRAM will be a systematic method of analysis for in-depth risk management.

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References

  1. Amano, Y., The Fukushima Daiichi accident. Vienna, Austria, IAEA, 2015.
  2. Costella, F., Saurin, A., Guimaraes, B. and de, M., A method for assessing health and safety management systems from the resilience engineering perspective, Safety Science, 47, 1056-1067, 2009. https://doi.org/10.1016/j.ssci.2008.11.006
  3. EPRI, Technical Report, Severe Nuclear Accidents: Lessons Learned for Instrumentation, Control and Human Factors, 2015.
  4. Frost, B. and Mo, J., System Hazard Analysis of a Complex Socio-Technical System: The Functional Resonance Analysis Method in Hazard Identification, Australian System Safety Conference, Melbourne Australia, 28-30, 2014.
  5. Ham, D.H., Research Trends of Cognitive Systems Engineering Approaches to Human Error and Accident Modelling in Complex Systems, Journal of the Ergonomics Society of Korea, 30, 41-53, 2011. https://doi.org/10.5143/JESK.2011.30.1.41
  6. Hollnagel, E. and Goteman, O., The functional resonance accident model. Cognitive System Engineering in Process Control, 2004.
  7. Hollnagel, E., FRAM: the Functional Resonance Analysis Method, ASHGATE, 2012.
  8. Hollnagel, E. An Application of the Functional Resonance Analysis Method (FRAM) to Risk Assessment of Organisational Change, Swedish Radiation Safety Authority, 2013.
  9. INPO, Special Report, Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station, 2012.
  10. KAERI, Technical Report: Function Analysis of Nuclear Power Plants for developing of Man-Machine Interface System for Korean Next Generation Reactor, 1995.
  11. Lipscy, P., Kushida, K. and Incerti, T., The Fukushima Disaster and Japan's Nuclear Plant Vulnerability in Comparative Perspective, Environmental Science and Technology, 47, 6082-6088, 2013. https://doi.org/10.1021/es4004813
  12. Reason, J., Human Error, Cambridge University Press, New York, 1990.
  13. The National Diet of Japan, The official report of The Fukushima Nuclear Accident Independent Investigation Commission, 2012.