<?xml version="1.0" encoding="utf-8"?>
<?xml-stylesheet href="client.xsl" type="text/xsl"?>
<article article-type="other">
<front>
<journal-meta>
<journal-id/>
<issn/>
<banner>
<href>banner.jpg</href>
<size width="100%"/>
</banner>
</journal-meta>
<doi>0728-cd</doi>
<article-meta>
<title-group>
<article-title>An Analysis of Recent Operational Events Involving Errors of Commission</article-title>
</title-group>

<author>Luca Podofillini<sup>a</sup> and Vinh N. Dang<sup>b</sup></author>

<aff>Laboratory for Energy Systems Analysis, Paul Scherrer Institute, Villigen PSI, Switzerland</aff>

<email><a href="mailto:luca.podofillini@psi.ch"><sup>a</sup>luca.podofillini@psi.ch</a></email>

<email><a href="mailto:vinh.dang@psi.ch"><sup>b</sup>vinh.dang@psi.ch</a></email>

</article-meta></front>
<body>
<abstract>
<title>ABSTRACT</title>
<p>Analyses of operational events provide important information on the contextual factors that contribute to human performance issues. This is especially the case for inappropriate operator decisions (typically referred to as Errors of Commissions, EOCs), which frequently result from very specific combinations of factors triggering the decision. Recognizing this, the quantification module of the Commission Error Search and Assessment (CESA-Q) method characterizes the situations possibly leading to inappropriate decisions into a two-layer factor framework, identified and characterized based on analyses of 26 operational events (mostly occurred in the 1990s). The present paper documents the on-going work by the authors to cover more recent operational events. In particular, the CESA-Q analysis of three events is presented and compared with a more typical root cause analysis. Besides demonstrating the CESA-Q method itself, the comparison shows the fundamental difference between the CESA-Q framework, aiming at characterizing the decision situation, and a root cause analysis, aiming at identifying the root causes for failures. The implication of the differences in the factor frameworks for prospective, probabilistic analyses (such as CESA-Q) and retrospective (such as root cause analysis) are discussed.</p>
<p><italic>Keywords: </italic>Probabilistic safety assessment, Human reliability analysis, Errors of commission, Operational events, Commission Error Search and Assessment.</p>
</abstract>
<fpdf>
<href>pdflogo.jpg</href>
<hpdf>0728</hpdf>
</fpdf>
</body>
</article>