应用ECF图对控制棒驱动机构电源全部丧失导致反应堆自动停堆事件分析  

Root Cause Analysis of Reactor Trip Event due to Loss of Power Supply to CRDM by Using ECF Chart

作　　者：焦峰[1] 孙树海[1] 郑丽馨[1] 刘时贤[1] 李华升[1] 段军[1] 

机构地区：[1]环境保护部核与辐射安全中心,北京100082

出　　处：《原子能科学技术》2017年第4期659-665,共7页Atomic Energy Science and Technology

摘　　要：国内某核电厂发生了控制棒驱动机构电源全部丧失导致反应堆自动停堆运行事件,为系统分析导致事件发生的原因,本文运用事件原因因素(ECF)图分析法对其进行了事件调查和原因分析。通过梳理事件序列,确定了事件发展过程中的失效点,通过对各失效点深入分析,确定了事件发生的促成原因和根本原因。发生该事件的根本原因是:隔离经理不了解触碰3RAM601JA可能导致停堆的风险,执行了程序规定以外的动作,在操作过程中未对操作进行自检或采取其他防人因失误方法,工作技能不足;电厂相关人员核安全文化存在缺陷,将尽快恢复电厂运行置于优先位置,主动违反了SOP程序规定。The cause of a reactor trip event occurred in a nuclear power plant due to loss of power supply to the control rod drive mechanism （CRDM） was systematically ana- lyzed. The root cause was investigated and analyzed by using the event and cause factor （ECF） chart analysis method. The sequence of event was established to determine the failure points of the event process. The contributing causes and root causes of the event were determined by deep analysis of each failure point. It is found that the root causes of the event are that the quarantine manager is lack of understanding of risk caused by pressing 3RAM601JA and by implementing action out of program specification, no self- checking methods or other protections from human errors are taken during the operation and the manager is in shortage of job skills. On the other hand, there is a nuclear safety culture deficiency at the power plant, showing that the relevant operator took power recovery as a priority, and actively violated the SOP program.

关 键 词：事件原因因素图分析法 核电厂运行事件 根本原因分析 

分 类 号：TL364.4[核科学技术—核技术及应用]