Gilsa P. Monteiro*, Paulo Fernando F. Frutuoso e Melo
{"title":"基于风险的决策如何失败:从核电站事故中吸取教训","authors":"Gilsa P. Monteiro*, Paulo Fernando F. Frutuoso e Melo","doi":"10.1021/acs.chas.1c00039","DOIUrl":null,"url":null,"abstract":"<p >In 2002, a large hole was discovered in the reactor vessel head of the Davis-Besse plant located in Ohio, US. Had the reactor pressure vessel ruptured, a major public safety event would have occurred. Further investigations revealed that, by the end of 2001, a shutdown order was drafted by the Regulatory Agency. Nonetheless, through a risk-informed decision-making approach, the Agency changed the decision related to the issuance of the order. Operations were then allowed to continue for six more weeks, despite the high likelihood that the reactor was operating with leaking cracks in the nozzles located at the reactor head. The reactor vessel head wastage, which had evolved unnoticed for years, was primarily due to borated water that leaked through a nozzle crack onto the carbon steel portion of the reactor head, resulting in boric acid corrosion. This paper aims to explore the Agency’s decision-making to identify factors that might have contributed to the flawed decision. A better comprehension on the organizational factors and social processes that can adversely affect risk-informed decisions is crucial to enhance operational safety in high hazard industries. The paper concludes by suggesting possible ways to guard against the identified factors.</p>","PeriodicalId":12,"journal":{"name":"ACS Chemical Health & Safety","volume":"29 2","pages":"192–201"},"PeriodicalIF":2.9000,"publicationDate":"2022-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"How Risk-Informed Decisions Can Fail: Lessons from a Nuclear Power Plant Incident\",\"authors\":\"Gilsa P. Monteiro*, Paulo Fernando F. Frutuoso e Melo\",\"doi\":\"10.1021/acs.chas.1c00039\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p >In 2002, a large hole was discovered in the reactor vessel head of the Davis-Besse plant located in Ohio, US. Had the reactor pressure vessel ruptured, a major public safety event would have occurred. Further investigations revealed that, by the end of 2001, a shutdown order was drafted by the Regulatory Agency. Nonetheless, through a risk-informed decision-making approach, the Agency changed the decision related to the issuance of the order. Operations were then allowed to continue for six more weeks, despite the high likelihood that the reactor was operating with leaking cracks in the nozzles located at the reactor head. The reactor vessel head wastage, which had evolved unnoticed for years, was primarily due to borated water that leaked through a nozzle crack onto the carbon steel portion of the reactor head, resulting in boric acid corrosion. This paper aims to explore the Agency’s decision-making to identify factors that might have contributed to the flawed decision. A better comprehension on the organizational factors and social processes that can adversely affect risk-informed decisions is crucial to enhance operational safety in high hazard industries. The paper concludes by suggesting possible ways to guard against the identified factors.</p>\",\"PeriodicalId\":12,\"journal\":{\"name\":\"ACS Chemical Health & Safety\",\"volume\":\"29 2\",\"pages\":\"192–201\"},\"PeriodicalIF\":2.9000,\"publicationDate\":\"2022-01-20\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"ACS Chemical Health & Safety\",\"FirstCategoryId\":\"1\",\"ListUrlMain\":\"https://pubs.acs.org/doi/10.1021/acs.chas.1c00039\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q2\",\"JCRName\":\"PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"ACS Chemical Health & Safety","FirstCategoryId":"1","ListUrlMain":"https://pubs.acs.org/doi/10.1021/acs.chas.1c00039","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH","Score":null,"Total":0}
How Risk-Informed Decisions Can Fail: Lessons from a Nuclear Power Plant Incident
In 2002, a large hole was discovered in the reactor vessel head of the Davis-Besse plant located in Ohio, US. Had the reactor pressure vessel ruptured, a major public safety event would have occurred. Further investigations revealed that, by the end of 2001, a shutdown order was drafted by the Regulatory Agency. Nonetheless, through a risk-informed decision-making approach, the Agency changed the decision related to the issuance of the order. Operations were then allowed to continue for six more weeks, despite the high likelihood that the reactor was operating with leaking cracks in the nozzles located at the reactor head. The reactor vessel head wastage, which had evolved unnoticed for years, was primarily due to borated water that leaked through a nozzle crack onto the carbon steel portion of the reactor head, resulting in boric acid corrosion. This paper aims to explore the Agency’s decision-making to identify factors that might have contributed to the flawed decision. A better comprehension on the organizational factors and social processes that can adversely affect risk-informed decisions is crucial to enhance operational safety in high hazard industries. The paper concludes by suggesting possible ways to guard against the identified factors.
期刊介绍:
The Journal of Chemical Health and Safety focuses on news, information, and ideas relating to issues and advances in chemical health and safety. The Journal of Chemical Health and Safety covers up-to-the minute, in-depth views of safety issues ranging from OSHA and EPA regulations to the safe handling of hazardous waste, from the latest innovations in effective chemical hygiene practices to the courts'' most recent rulings on safety-related lawsuits. The Journal of Chemical Health and Safety presents real-world information that health, safety and environmental professionals and others responsible for the safety of their workplaces can put to use right away, identifying potential and developing safety concerns before they do real harm.