Analysis of recent operational events involving inappropriate actions: influencing factors and root causes

The Human Reliability Analysis (HRA) of inappropriate actions (Errors Of Commission, EOCs) still suffers from technical gaps, especially for with decision-related motivations. Traditional, factor-based HRA methods often fail to address these Holistic analyses frameworks have been developed (namely, ATHEANA and MERMOS), but rely on strong analyst expertise require large efforts make traceable. This paper presents the application factor framework underlying quantification module Commission Error Search Assessment (CESA-Q) method. is applied fourteen operational events period 2000–2016, not used development. gives chance confirm validity CESA-Q represent adequately diverse situations influencing decisions in real events. In majority events, triggering condition decision information available operators, typically procedural guidance, Human-Machine Interface, experience training. cases, dominant factors (positively negatively) identified through analysis relate verification appropriateness decision. For another set was driven by prospect other benefits (e.g. simplifying plant control).