应用屏障分析与ECF图对LNA和LNC变压器供电回路不可用事件分析  

Analysis of Events due to Unavailability of Transformer Power Supply Circuit of LNA and LNC by Using Barrier Analysis and ECF Chart Analysis

作　　者：刘时贤 褚倩倩 刘锐 车树伟 杨未东 Liu Shixian;Chu Qianqian;Liu Rui;Che Shuwei;Yang Weidong(Nuclear and Radiation Safety Center,MEE,Beijing 100082,China)

机构地区：[1]生态环境部核与辐射安全中心,北京100082

出　　处：《核安全》2022年第6期106-113,共8页Nuclear Safety

摘　　要：国内某核电厂发生了大修期间电气系统在线活动不规范导致LNA和LNC变压器供电回路不可用的运行事件,为系统分析事件发生的原因,本文综合使用屏障分析法和事件原因因素(ECF)图分析法对该事件进行了根本原因分析。通过梳理事件序列,确定能够防止事件发生的屏障,并对屏障失效进行深入分析,得出事件发生的根本原因是人员技能不足和行为不规范以及程序不完善。最后根据事件的根本原因提出针对性的改进建议。The cause of event occurred in a domestic nuclear power plant due to unavailability of transformer power supply circuit of LNA and LNC caused by irregular online activities of the electrical system during overhaul was systematically analyzed. The root cause was analyzed by using combination of barrier analysis method and the event and cause factor(ECF) chart analysis method. The sequence of event was established and all barriers that could prevent this event were listed. The root causes of the event were determined by deep analysis of the failure of barriers. It was found out that insufficient job skills and irregular behaviors of staffs and imperfect procedures were the root causes of the event. Finally, based on the root causes, suggestions for improvement were proposed.

关 键 词：运行事件 屏障分析 事件原因因素图分析 根本原因分析 

分 类 号：TL[核科学技术]