Event investigations at nuclear power plants in Sweden: Reflections about a method and some associated practices

Safety Science

Volumn 49, Issue 1, 2011, Pages 21-26

  Rollenhagen, Carl ^a  

^a RINGHALS AB   (Sweden)

Author keywords

Accident investigation; Accidents; Experience feedback; MTO

Indexed keywords

ACCIDENT INVESTIGATION; ACCIDENT MODELS; EXPERIENCE FEEDBACK; FUTURE APPLICATIONS; IN-DEPTH INVESTIGATION; MTO; PROBLEM IDENTIFICATION; REMEDIAL ACTIONS; SAFETY CULTURE;

NUCLEAR ENERGY; NUCLEAR INDUSTRY; NUCLEAR POWER PLANTS; PROBLEM SOLVING;

NUCLEAR REACTOR ACCIDENTS;

ACCIDENT PREVENTION; ARTICLE; MAN MACHINE INTERACTION; MANAGER; NUCLEAR ACCIDENT; NUCLEAR INDUSTRY; NUCLEAR POWER PLANT; NUCLEAR SAFETY; OCCUPATIONAL SAFETY; PRIORITY JOURNAL; RISK ASSESSMENT; RISK MANAGEMENT; SWEDEN;

EID: 77957016345     PISSN: 09257535     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ssci.2009.12.012     Document Type: Article

References (25)

1. Alicke M.D. Culpable control and the psychology of blame. Psychological Bulletin 2000, 126(4):556-574.
2. Amalberti R. The paradoxes of almost totally safe transportation systems. Safety Science 2001, 37:109-126.
3. Andersson, O., Rollenhagen, C., 2002. The MTO concept and organisational learning at Forsmark NPP, Sweden. In: Paper Presented at IAEA International Conference on Safety Culture in Nuclear Installations, Rio de Janeiro, Brazil, 2-6 December, 2002.
4. Andersson R.E., Rollenhagen C. System grupper och innovativ problemlösning. (System groups and innovative problem solving) 2003, Studentlitteratur, Lund.
5. Bedau M.A. Weak emergence. Philosophical Perspectives: Mind, Causation, and World 1997, vol. 11:375-399. Blackwell Publishers. J. Tomberlin (Ed.).
6. Bellamy L.J., Ale B.J.M., Geyer T.A.W., Goossens L.H.J., Hale A.R., Oh J., Mud M., Bloemhof I.A., Papazogulu J.Y., Whiston J.Y. Storybuilder - a tool for the analysis of accident report. Reliability Engineering and System Safety 2007, 92:735-744.
7. Cross N. Expertise in design: an overview. Design Studies 2004, 25(5):427-441.
8. Dekker S.W.A. Ten Questions About Human Error: A New View of Human Factors and System Safety 2004, Lawrence Erlbaum, Mahwah, NJ.
9. Evenéus, P., Rollenhagen, C., 2007. In-depth investigation based on a systemic MTO perspective in Vattenfall hydro plants. In: The 4th EADAC Symposium, Chengdu, China, October 13-18, 2007.
10. Guldenmund F.W. The use of questionnaires in safety culture research - an evaluation. Safety Science 2007, 45:723-743.
11. Hale A.R. Culturés confusion. Editorial/Safety Science 2000, 1-14.
12. Hale A.R., Ale B.J.M., Goossens L.H.J., Heijer T., Bellamy L.J., Mud M.L., Roelen A., Baksteen H., Post J., Papazoglou I.A., Blooemhoff A., Oh J.I.H. Modelling accidents for prioritizing prevention. Reliability Engineering and System Safety 2007, 92:1701-1715.
13. Hollnagel E. Barriers and Accident Prevention 2004, Ashgate, Aldershot, UK.
14. Johnson C.W. What are emergent properties and how do they affect the engineering of complex systems?. Reliability Engineering and System Safety 2006, 91:1475-1481.
15. Johnson W.G. MORT Safety Assurance System 1980, Marcel Dekker, New York.
16. Leveson, N., 2001. Evaluating accident models using recent aerospace accidents. Technical Report, MIT Department of Aeronautics and Astronautics.
17. Perrow C. Normal Accidents: Living with High Risk Technology 1984, Basic Books Inc., New York.
18. Rochlin G.I. Safe operation as a social construct. Ergonomics 1999, 42:1549-1560.
19. Rollenhagen C. Can focus on safety culture become an excuse for not rethinking design of technology?. Safety Science 2010, 48:268-278.
20. Rollenhagen C. Att utreda olycksfall: teori och praktik (To investigate accidents: theory and practice) 2003, Studentlitteratur, Lund, Sweden.
21. Rollenhagen, C., 2003b. Safety management as problem identification and problem solving. In: European Commission 5th Euratom Framework Programme 1982-2002, Nuclear Fission, PLEM, Learnsafe - P004.
22. Rollenhagen, C., Evenéus, P., 2007. Development of a systemic MTO perspective on dam safety management. In: International Symposium on Modern Technology of Dams. The 4th EADAC Symposium, Chengdu, China, October 13-18, 2007.
23. Sklet S. Safety barriers: definition, classification, and performance. Journal of loss Prevention in the Process Industries 2005, 19(5):494-506.
24. Svenson O. Accident and incident analysis based on the accident evolution and barrier function (AEB) model. Cognition, Technology and Work 2001, 3(1):42-52.
25. Woods D.D., Cook R.I. Nine steps to move forward from error. Cognition, Technology and Work 2002, 4:137-144.