中国运行核电厂误碰运行事件分析与预防对策

Cause Analysis and Preventives for Human Accidental Touch Events in Operating Nuclear Power Plant in China

1991年1月至2019年12月期间我国运行核电机组共发生23起误碰运行事件,其绝对数量不多,但其引起的后果较严重(60.9%造成紧急停堆),降低核电厂的安全性和经济性。误碰运行事件具有偶然性和随机性,其发生时间与反应堆投入运行时间的长短没有必然联系,因此,误碰运行事件的经验反馈对于各运行核电厂都是非常重要的。从事电气检修、脚手架搭设或拆除活动是发生误碰较多的时期,占比分别为39.1%和21.7%。误碰运行事件的根本原因可以归为6大类:操作人员原因,组织管理原因,设计原因,规程原因,培训原因,设备安装原因。根据误碰运行事件根本原因,可通过应用防人因失误工具、完善作业流程和作业现场管理、改进系统设施的设计、完善规程编制、优化员工培训、加强经验反馈工作的实效性等防范措施来减少误碰运行事件的发生频率。本文为运行机组降低误碰运行事件发生频率提供了经验反馈和参考。

There were 23 human accidental touch events occurring in commercial operating nuclear power plants from January 1991 to December 2019 in China.Though the absolute number of human accidental touch events is smalL the consequences resulting from these events are severe(60.9%resulting in emergency shutdown)and these events reduce the safety and economy of operating nuclear power plants.The trend of human accidental touch events is a little random and accidental,and the occurring time of human accidental touch events is not necessarily linked with the duration of plant in operation.Therefore,the experience feedback of human accidental touch events is very important for each operating nuclear power plant.Much more human accidental touch events occurred during the periods of electrical maintenance activities and scaffolding erection or dismantling activities,accounting for 39.1%and 21.7%respectively.The root cause of human accidental touch events can be classified into 6 categories:operator causes,organization management causes,design causes,procedure causes>training causes and equipment installation causes.According to the root cause of human accidental touch events>the frequency of human accidental touch events can be reduced by applying preventive measures such as applying anti-human error tools,improving work flow and work site management,improving the design of systems,perfecting the preparations of procedures,optimizing staff training,and strengthening the effectiveness of experience feedback.This paper provides experience feedback and reference to reduce the frequency of human accidental touch events for operating plants.