Mashin V.A. Boeing: Two Paths - Two Safety Cultures. Part 2. Manuscript (09.11.2024).
Manuscript. Part 2 (in Russian)
This article examines the fundamental reasons that led to a series of high-profile incidents that have plagued Boeing in recent years. The presented analysis will be useful to domestic aircraft manufacturers seeking to improve the efficiency of aircraft development and production without losing sight of quality and safety issues. Keywords: safety culture, human factor (ergonomics), Boeing company, McDonnell Douglas company, DC-10 crash (1974), Boeing 737 MAX crashes (2018-2019), Boeing 737 MAX 9 (2024).
Mashin V.A. Boeing: Two Paths - Two Safety Cultures. Part 1 // AviaSouz, 2024. No 5 (101), p. 70-75.
The Magazine Article. Part 1 (in Russian)
This article examines the fundamental reasons that led to a series of high-profile incidents that have plagued Boeing in recent years. The presented analysis will be useful to domestic aircraft manufacturers seeking to improve the efficiency of aircraft development and production without losing sight of quality and safety issues. Keywords: safety culture, human factor (ergonomics), Boeing company, McDonnell Douglas company, DC-10 crash (1974), Boeing 737 MAX crashes (2018-2019), Boeing 737 MAX 9 (2024).
Mashin V.A. The Boeing Company: The Evolution of Safety Culture. The manuscript of the article, 05.11.2024.
The manuscript of the article. Part 2 (in Russian)
This article examines the reasons that led to a series of high-profile incidents haunting the Boeing Company in 2024, how its culture focused on engineering, quality and safety changed after the merger in 1997 with McDonnell Douglas, whose culture was based on financial performance and shareholder value. Using the design and production of the Boeing 737 MAX and Boeing 787 as an example, it is shown how the strategy of reducing costs and increasing the profitability of net assets led to the transfer of high-tech enterprises to outsourcing, accelerated design and production, savings on innovation and loss of key competencies, and, ultimately, to a decrease in the safety and quality of manufactured aircraft. The history of the Boeing Company will be useful to enterprises and companies seeking to improve their performance indicators, without losing sight of quality and safety issues. Keywords: safety culture, human factor (ergonomics), Boeing company, McDonnell Douglas company, DC-10 crash 03.03.1974, Boeing 737 MAX crash 10.29.2018, Boeing 737 MAX crash 03.10.2019, Boeing 737 MAX 9 incident 01.05.2024.
Mashin V.A. The process of managing production experience. Normative and terminological reference book (19.03.2024)
Mashin V.A. The Course "The Human Factors and The methods of preventing errors in the work of NPP personnel. Introduction". Introductory course for nuclear industry specialists (5 hours: presentation, case analysis, analysis of real situations). Obninsk Scientific and Research Center «PROGNOZ», 2023
1. The Types of human errors
2. The Causes of human errors
3. Significant Event Precursors
4. Methods of analysis of the causes of human errors
Joint-Stock Company Specialized Research Institute for Instrument Engineering (JSC SNIIP, Rosatom State Corporation). Independent assessment of the Safety Culture. Obninsk Scientific and Research Center «PROGNOZ» (Mashin V.A. - Observations, Interviews, Focus groups, Document analysis). Moscow, 12-13, 18-20.12.2023.
The Angarsk Electrolysis Chemical Combine (The TVEL Fuel Company, The State Atomic Energy Corporation Rosatom). Independent assessment of the Safety Culture. Obninsk Scientific and Research Center «PROGNOZ» (Mashin V.A. - Observations, Interviews, Focus groups, Document analysis). Angarsk, The Irkutsk Region, Russia. 04-08.12.2023.
The Siberian Chemical Combine (The TVEL Fuel Company, The State Atomic Energy Corporation Rosatom). Independent assessment of the Safety Culture. Obninsk Scientific and Research Center «PROGNOZ» (Mashin V.A. - Observations, Interviews, Focus groups, Document analysis). Seversk, The Tomsk Region, Russia. 27.11-01.12.2023.
Mashin V.A. Recommendations for organizing investigations of events and their precursors caused by human factors (25.10.2023)
The JSC Zelenogorsk Electrochemical Plant. Independent assessment of the Safety Culture. Obninsk Scientific and Research Center «PROGNOZ» (Mashin V.A. - Observations, Interviews, Focus groups, Document analysis). Zelenogorsk, Krasnoyarsk Krai, Russia. 02-06.10.2023.
OAO I. I. Afrikantov OKB Mechanical Engineering. Independent assessment of the safety culture (25-29.09.2023). Obninsk Scientific and Research Center «PROGNOZ» (Mashin V.A. - Document analysis).
Mashin V.A. Investigation of events caused by Human Errors. Collection of cases
2nd International Intersectoral Forum on Safety Culture. Training and exchange of experience in the field of safety in various sectors of the economy. St. Petersburg, May 30 - June 2, 2023
Mashin V.A. The Course "Modern methodology for investigating events and tools for identifying and analyzing the causes of events at a nuclear facility. Human Factors". The Siberian Chemical Combine, Seversk (13-17.03.2023)
Module 1. The Types of human errors
Module 2. The Causes of human errors
Module 4. Methods of analysis of the causes of human errors
Mashin V.A. The Course "Modern methodology for investigating events and tools for identifying and analyzing the causes of events at a nuclear facility. Human Factors". Afrikantov OKB Mechanical Engineerin (27.02-03.03.2023)
Module 1. The Types of human errors
Module 2. The Causes of human errors
Mashin V.A. Safety Culture: Significant Event Precursors. Elektricheskie Stantsii (Power Plants), 2023. No. 3, p. 34-48.
The article (in Russian)
Using examples from various industries, transport and nuclear energy, the important role of the Accident Precursor Programs for learning lessons from numerous Near Misses and Low Level Events is considered. Implementation of Accident Precursor Programs contributes to reducing the risk of harm to people, equipment, production processes or the environment, strengthening an atmosphere of trust and openness, as well as developing proactive organizational learning and a high safety culture. Barriers to identifying and reporting Near Misses and Low Level Events by personal as well as the basic principles for the effective implementation and development of Accident Precursor Programs are considered. The presented material will be useful in solving the tasks of implementing and maintaining Accident Precursor Programs both at NPPs and at other types of power plants. Keywords: Safety Culture, Accident Precursor Program, Near Miss, Low Level Event, Unsafe Condition, Unsafe Action.
Mashin V.A. The Distance Course "Modern methodology for investigating events and tools for identifying and analyzing the causes of events at a nuclear facility. Human Factors". Afrikantov OKB Mechanical Engineering (31.05-04.06, 07-11.06.2021)
Mashin V.A. The analysis of the actions of the control room personnel during the accident at the power plant. Report. Obninsk Scientific and Research Center «Prognoz», 2022. 26 p.
1. Executive summary
2. Methods for analyzing incorrect actions of operational personnel
3. Initial conditions
4. Chronology of Main Events
5. The analysis of the actions of the control room personnel during the accident
6. The impact of the control room personnel actions on the course of the accident
7. The causal factors for the occurrence and development of the accident
8. Recommendations
Addition 1. General information about the participants in the accident
Addition 2. Diagram of events and causal factors
Mashin V.A. Distance Course on Human Factors. Afrikantov OKB Mechanical Engineering (31.05-04.06, 07-11.06.2021)
Mashin V.A. Safety Culture: Human Factors Engineering. Elektricheskie Stantsii (Power Plants), 2022. No. 3, p. 8-20.
The article (in Russian)
On the example of nuclear power plants (NPPs) incidents, the important role of systematic inclusion of human factors in the development and implementation of projects of human-system interfaces, procedures and training programs for personnel to prevent human errors caused by ergonomic problems is considered. A human factors engineering program (recommended by the US Nuclear Regulatory Commission) is presented, integrated into the design and modification (reconstruction, modernization) processes of structures, systems and components of NPPs, as well as procedures and training programs. The implementation of the human factors engineering program and adherence to the requirements and principles in the field of ergonomics formulated by the IAEA is aimed at creating a strong safety culture and achieving high and sustainable safety and reliability performance of NPP personnel. The presented material will be useful in solving the problems of creating and maintaining a strong safety culture in the field of human factors engineering both at NPPs and at other types of power plants. Keywords: Safety Culture, Human Factors Engineering Program, Ergonomics, Nuclear Power Plants Incidents, Human Errors, Causal Factors.
Mashin V.A. Safety Culture: The principle of organizational learning. Elektricheskie Stantsii (Power Plants), 2021. No. 10, p. 34-50. DOI: 10.34831/EP.2021.1083.10.005
The article (in Russian)
The important role played by the principle of organizational learning in the development of a strong safety culture in nuclear power is considered. Safety is supported and guided by ongoing learning, the organization's ability to accumulate and analyze operational experience, its successes and failures, and learning lessons to improve its performance. Security is determined by the organization's ability to view significant violations and deviations in the operation of an NPP caused by the actions of personnel as an opportunity for learning, and not for blaming individuals for mistakes and imposing disciplinary sanctions on them. From the standpoint of the principle of organizational learning, the results of the investigation of an accident that took place at one of the domestic nuclear power plants are considered. The way in which organizations investigate such incidents has a huge impact on their safety culture. The presented material will be useful in planning and supervising the execution of works, also when investigating incidents and accidents at the enterprises of the electric power industry. Keywords: Safety Culture, Principle of Organizational Learning, Human Errors, Causal Factors, Accident, Electrical Equipment.
Safety Culture Independent Assessment of Akkuyu Nuclear Power Plant (AKKUYU NÜKLEER ANONİM ŞİRKETİ, Turkish). Obninsk Scientific and Research Center «Prognoz». 05-10.07.2021.
Mashin V.A. Occupational Safety and Health Culture // Elektricheskie Stantsii (Power Plants), 2020. No. 11, p. 43-54. DOI: 10.34831/EP.2020.1072.11.006
The Article (in Russian)
On the example of the Arc Flash Accident at Los Alamos National Laboratories (LANL) Technical Area 53 (May 3, 2015), the modern requirements, methods and principles aimed at shaping and maintaining a high culture in the field of Occupational Safety and Health were considered. The role of the Integrated Safety Management System (ISMS) LANL, Operating Experience and Human Factors in the accident is analyzed. The Causal Factors of the accident and the Corrective Actions recommended by the Joint Accident Investigation Team are presented. Some barriers to the formation and maintaining high Safety Culture are considered. The presented material will be useful in planning and supervising the execution of works, also when investigating incidents and accidents at the enterprises of the electric power industry. Keywords: Switchgear, Accident, Safety Culture, Occupational Safety and Health (OSH), Operating Experience, Human Factor.
Mashin V.A. Safety Culture: Introductory seminar. Limited liability company Research and Production Enterprise “Radiation control. Methods and equipment” (LLC RPE RADICO). Obninsk, March 18 марта, 2020.
Mashin V.A. Analysis of the direct, contributing and root causes of events at nuclear power plants due to incorrect human actions. Training course. Bushehr NPP (Iran), December 07-11, 22-26, 2019.
Obninsk Scientific and Research Center «PROGNOZ». Safety Culture Audit of The Novosibirsk Plant of Chemical Concentrates (The TVEL Fuel Company, The State Atomic Energy Corporation Rosatom). Novosibirsk, Russia. 28.10-01.11.2019.
Obninsk Scientific and Research Center «PROGNOZ». Safety Culture Audit of The Siberian Chemical Combine (The TVEL Fuel Company, The State Atomic Energy Corporation Rosatom). Seversk, The Tomsk Region, Russia. 21-25.10.2019.
Obninsk Scientific and Research Center «PROGNOZ». Safety Culture Audit of The Angarsk Electrolysis Chemical Combine (The TVEL Fuel Company, The State Atomic Energy Corporation Rosatom). Angarsk, The Irkutsk Region, Russia. 18-24.05.2019.
Mashin V.A. Monitoring of Safety Culture: Criteria and leading indicators // Elektricheskie Stantsii (Power Plants), 2019. No 8, p. 2-13. DOI: 10.34831/EP.2019.1057.44205
The Article (in Russian)
Criteria and leading indicators of a proactive approach to the management of processes and activities in the field of ensuring the reliability and safety of nuclear power plant personnel, which serve as the basis for monitoring the safety culture formed and maintained in the organization, are considered. Examples of criteria and leading indicators for the process of human factors accounting (prevention of incorrect operations of personnel) and process of an operating experience (prevention of repetition of similar events and causes in the future) are given. The contributing factors to the implementation of a proactive approach to the management of processes and activities in the field of reliability and safety are highlighted. The presented material will be useful for monitoring safety culture and assessing the quality and effectiveness of processes and activities in the field of ensuring the reliability and safety of both nuclear power plants and other types of power plants. Keywords: Safety Culture, Process of Human Factors Accounting, Process of an Operating Experience, Leading Indicators, Proactive Approach.
Mashin V.A. The methodological recommendations on the system-activity analysis of the causes of human performance related events. The Project (13.07.2019, rev. 11).
Mashin V.A. Safety Culture: The proactive approach // The implementation of a nuclear safety culture directed at preventing errors in the work of NPP personnel. WANO - MC Technical Support Mission at South Ukraine Nuclear Power Station. September 3-7, 2018.
The presentation (in Russian)Photo: Yuzhnoukrayinsk, Pivdennyy Buh. 2018.09.03-07
Mashin V.A. Safety culture: Root Cause Analysis // Elektricheskie Stantsii (Power Plants), 2018. No 11, p. 2-14.
The Article (in Russian)
The important role of the root cause analysis for timely identification and resolution of problems that could lead to significant consequences for the operation and safety of nuclear power plants is considered. The root causes of events caused by human activities are determined, first of all, by the shortcomings of programs ensuring the operation and safety of nuclear power plants. On the example of the Reactor Vessel Head Degradation at Davis-Besse Nuclear Power Plant, the root causes that which could result in loss of integrity of the reactor coolant pressure boundary - which is one of three principal barriers to the release of radioactive fission products - were considered. The presented material will be useful for root cause analysis and taking appropriate corrective actions both at nuclear power plants and other types of power plants. Keywords: Safety Culture, Cause Analysis, Root Cause, Apparent Cause, Trend Analysis, Corrective Actions, Davis-Besse Nuclear Power Plant.
Mashin V.A. Safety culture: Trust Permeates the Organization // Elektricheskie Stantsii (Power Plants), 2018. No 9, p. 2-14.
The Article (in Russian)
The important role played in the nuclear power industry by the "Trust Permeates the Organization" principle to achieve a strong culture of nuclear safety is considered. The atmosphere of trust in the organization comes from Safety Conscious Work Environment (SCWE) and Respectful Work Environment when there are no signs of "Chilling Effect", Harassment, Intimidation, Retaliation, or Discrimination (HIRD) of employees raising safety issues. The importance of the "Trust Permeates the Organization" principle is considered on the example of the crisis situation that occurred at the Milestone nuclear power plant in 1996. The presented material will be useful for solving the problems of creating and maintaining a Strong Safety Culture both at nuclear power plants and other types of power plants. Keywords: Safety Culture, Trust Permeates the Organization, Safety Conscious Work Environment (SCWE), Respectful Work Environment, Millstone Nuclear Power Plant.
Mashin V.A. Focus-group: The methods of preventing errors in the work of NPP personnel // Leadership in the area of Safety Culture Management Leningrad NPP. WANO - MC Technical Support Mission at Leningrad NPP. May 13-18, 2018.
The presentation
Mashin V.A. Focus-group: Leadership in the area of Safety Culture Management // Leadership in the area of Safety Culture Management Leningrad NPP. WANO - MC Technical Support Mission at Leningrad NPP. May 13-18, 2018.
The presentation
Mashin V.A. Safety culture: Human Performance Tools // Elektricheskie Stantsii (Power Plants), 2018. No 2.
The Article (in Russian)
The requirements, methods and principles of a strong Human Performance Improvement culture developed in the nuclear power industry are considered. Part of this culture is the use of Human Performance Tools. Based on the five main stages of the process approach to ensuring the Human Performance Improvement, the factors that can adversely affect the formation of a culture of using Human Performance Tools are listed. The presented material will be useful for solving the problems of ensuring the Human Performance Improvement of both nuclear power plants and other types of power plants. Keywords: Safety Culture, Human Performance Improvement, Human Performance Tools.
Mashin V.A. Introduction of Human Performance Tools in the work of NPP personnel // WANO - MC Technical Support Mission at Bushehr NPP (Iran) "Human Performance Tools", October 21-25, 2017.
The presentation
Mashin V.A. Safety culture: The Human Factors Engineering system // Elektricheskie Stantsii (Power Plants), 2017. No 8.
The Article (in Russian)
This article on the example of the Three Mile Island accident (28 March 1979) considers the important role of Human Factors Engineering (Applied Ergonomics) system in the formation and maintenance of a strong safety culture at Nuclear Power Plant (NPP). The Human Factors Engineering is examined on numerous examples of violations of the ergonomics requirements in the design of the NPP control room, development of operational procedures and training and licensing of operators that played a key role in this accident. Shortcomings of requirements, methods and principles of the existing Human Factors Engineering system that led to the fact that a minor incident developed into a major accident. It concludes that it is impossible to reach a strong safety culture at a low Human Factors Engineering culture of regulating board, supplier and utility. Keywords: Safety Culture, Human Factors Engineering, Ergonomics, Regulatory Body, Utility, Supplier, Three Mile Island Accident.
I express my deep gratitude to Michael J. Derivan (Shift Supervisor Davis-Besse Nuclear Power Plant during the incident September 24, 1977) for his assistance in preparing the article. (Michael J. Derivan - http://nukeknews.com/index.html)
Mashin V.A. Safety culture: The operating experience system // Elektricheskie Stantsii (Power Plants), 2017. No 7.
The Article (in Russian)
This article on the example of the Three Mile Island accident (28 March 1979) considers the important role of operating experience system in the formation and maintenance of a strong safety culture at Nuclear Power Plant. The operating experience is considered at the level of regulating board, supplier and utility in the analysis of their numerous precursor events of that accident. Shortcomings of requirements, methods and principles of the existing operating experience system which didn't allow to prevent and to minimize accident consequences are listed. It concludes that it is impossible to reach a strong safety culture at a low operating experience culture of regulating board, supplier and utility. Keywords: Safety Culture, Operating Experience, Regulatory Body, Utility, Supplier, Three Mile Island Accident.
I express my deep gratitude to Michael J. Derivan (Shift Supervisor Davis-Besse Nuclear Power Plant during the incident September 24, 1977) for his assistance in preparing the article. (Michael J. Derivan - http://nukeknews.com/index.html)
Mashin V.A. Safety Culture: Prevention of human error and minimizing their consequences (Human Factors) // WANO - MC Technical Support Mission at Khmelnitski NPP, Ukraine. November 21-25, 2016.
Materials for the presentation (in Russian)
Mashin V.A. Safety culture: Issues of monitoring and auditing. Elektricheskie Stantsii (Power Plants), 2016. No 9.
Article (in Russian)
This article on the example of JCO criticality accident analysis (Japan, 1999) considers the important role of external and internal monitoring and auditing of nuclear safety, the formation and maintenance of strong nuclear safety culture. The role of external and internal monitoring and auditing is studied at the stages of licensing and execution of works, in the course of determining the necessary requirements, methods and principles of safety, their reflection in production documents, bringing to the personnel and compliance with the performance of work. It concludes that it is impossible to reach a strong nuclear safety culture at a low culture of the monitoring and auditing of nuclear safety. Keywords: Safety Nuclear Culture, Regulatory Authority, Monitoring and Auditing, Criticality Accident, JCO, Tokaimura, Kaizen, Normalization of Deviation.
On the 30th anniversary of the Chernobyl accident
IAEA Summary Report on the Post-accident Review Meeting on the Chernobyl Accident. Report by the International Nuclear Safety Advisory Group. Safety Series № 75-INSAG-1. Vienna, 1988.
INSAG-1 (in Russian)
Mashin V.A. Safety Culture: Human Performance Improvement System // The Seminar «The Concept of Safety Culture in the Nuclear Industry», February 1-5, 2016. CIPK, Obninsk.
Materials for the presentation (in Russian)
Mashin V.A. The modern principles of formation and development of safety culture // Prepared for International Conference on Human and Organizational Aspects of Assuring Nuclear Safety – Exploring 30 Years of Safety Culture. IAEA Headquarters, Vienna, Austria. 22–26 February 2016.
Poster (in English)
Mashin V.A. Bases of formation and development of safety culture: RMP-approach. PJSC «Mashinostroitelny Zavod» of Rosatom's TVEL Fuel Company. Elektrostal, 14-15 December 2015.
Materials for the presentation (in Russian
Mashin V.A. The formation and development of safety culture at Nuclear Power Plants. Elektricheskie Stantsii (Power Plants), 2016. No 8.
The Article (in Russian)
This article considers the approach to the formation and development of safety culture based on the Requirements, Methods and Principles (RMP) that should be identified and supported in the framework of safety processes Integrated Management System of the organization. The formation and development of safety culture is represented as a process of continuous improvement of RMP with the ability to assess its individual stages: planning, organization, implementation, control and correction. Defining and supporting the implementation of all personnel the requirements, methods and principles of safety, we provide thus the formation of the necessary values, attitudes, perceptions and beliefs to meet the strong safety culture. Keywords: Safety Culture, Integrated Management System (IMS), Process Approach, Quality Management System (QMS), Environmental Management System (EMS), Occupational Health and Safety Management System (OHSAS), Operating Experience (OE) Feedback System, Human Performance Improvement (HPI) System, Chernobyl Accident.
Mashin V.A. Safety culture issues during NPP construction phase. IV International Summer School «Safety Culture». ROSATOM; IAEA; CIPK, ROSATOM. Saint Petersburg, 09 July 2015.
Materials for the presentation (in Russian)
Mashin V.A. Safety Culture: The principles of analysis and prevention of events at nuclear power plants. IV International Summer School «Safety Culture». ROSATOM; IAEA; CIPK, ROSATOM. Saint Petersburg, 06 July 2015.
Materials for the presentation (in Russian)
Mashin V.A. Safety Culture: The principles of events analysis at Nuclear Power Plants. Elektricheskie Stantsii (Power Plants), 2015. No 9.
The Article (in Russian)
This article considers the principles of events analysis at NPPs, which are an essential tool to build and maintain a proper safety culture within the organization. The focus is on understanding the nature of human error. The approach to error analysis, which is based on the factors that contribute to unsafe actions, is substantiated. Limitations of causal relationship to human error, which serve as the basis for the search and address its root causes, are considered on real cases. The taxonomy of contributing factors to human error is presented. The main strategies to error reduction, error capturing and error tolerance are considered. Keywords: safety culture, human error, event analysis, root cause, contributing factors, prevention strategies events.
Mashin V.A. Safety culture issues during NPP construction phase. Elektricheskie Stantsii (Power Plants), 2016. No 4.
The Article (in Russian)
The process model of the safety management system ensuring the development of an adequate level of safety culture at all stages of the life cycle of NNP are examined in this article. Development tools of an adequate level of safety culture are the processes of the safety management system: quality management system, risk management system, the system of operating experience, the system of human performance improvement (HPI). From the standpoint of PDCA methodology the characteristics stages of planning, organization, implementation, control and correction for processes of the safety management system were given. Using the proposed model for a safety management system, the problems of quality and safety during the construction of Olkiluoto-3 NPP and related safety culture issues were examined. Keywords: safety culture, safety management system, quality management system, risk management system, the system of operating experience, the system of human performance improvement (HPI).
Mashin V.A. Formation and development of safety culture in the nuclear field // Meeting to share experiences and promote cooperation with RINPO (China), 20.05.2015. Obninsk, 2015.
Presentation (in Russian)
Mashin V.A. The method of analysis and prevention of errors and events caused by human actions // Meeting to share experiences and promote cooperation with RINPO (China), 20.05.2015. Obninsk, 2015.
Presentation (in Russian)
Mashin V.A. The system of psycho-physiological support of NPP personnel // Meeting to share experiences and promote cooperation with RINPO (China), 20.05.2015. Obninsk, 2015.
Presentation (in Russian)
Mashin V.A. Materials for peer review and self-assessment of Safety Culture: Occupational Safety and Health Management System, Operating Experience Feedback, Human Performance Improvement, Quality management system, Environmental management system. 2015.
Mashin V.A. The Taxonomy of Human and Organization Factors Affecting the Performance of Production Activities.
The Seminar «The Analysis of the Causes of Events at Nuclear Power Plants and Work in the Commission to Investigate the Causes of Events at Nuclear Power Plants», February 16-20, 2015. CIPK, Obninsk.
The Table. The Contributing Factors Taxonomy (23.09.2015)
Mashin V.A. The Contributing Factors Taxonomy: A Tool for Analysis and Prevention of errors and human-caused events. 2015.
Table of contents (in Russian)This method is intended for:
the inspectors of regulators for independent oversight of the preparation and execution of the works in the company in order to identify factors (human and organizational) that contribute to errors and human-caused events, as well as to identify strategies to minimize them;
all levels of management of the company for oversight, decision-making, planning, organization and work in order to identify factors (human and organizational) that contribute to errors and human-caused events, as well as to identify strategies to minimize them;
the specialists to perform specific work, to understand the factors that contribute to the commission of mistakes and events, as well as to determine the operational measures to minimize them;
the specialists investigating the causes of events caused by human actions in order to identify factors (human and organizational) that contribute to errors and human-caused events, as well as to identify strategies to minimize them;.
This Tool for Analysis and Prevention of errors and human-caused event, develops the following approaches:
Maintenance Error Decision Aid (MEDA, Boeing) (Boeing, 2003)
Human Factors Analysis and Classification System – Maintenance Extension (HFACS-ME, Naval Aviation in cooperation with the FAA and NASA) (Naval Aviation, FAA, NASA, 2003)
Human Performance Improvement (HPI, INPO) (INPO, 2006)
Mashin V.A. The Development and Improvement Instruments of Safety Culture: Operating Experience. Reference Manual. 2014.
Table of contents (in Russian)
Mashin V.A. The Development and Improvement Instruments of Safety Culture: Operating Experience (Basic Course). 2014.
Short Syllabus (in Russian)
Mashin V.A. The Modern view of the development and improvement of Safety Culture. International Summer School "Safety Culture: The practical management methods". CIPK, ROSATOM. Saint Petersburg, 30 June - 04 July 2014.
Materials for the presentation (in Russian)Table of contents
1. Safety Culture as Safety Ensuring Culture
2. The problem of Safety attitudes
3. Safety Management System and Ensuring Culture
4. The main processes of Safety Management System and Ensuring Culture
5. Culture of Statistical Analysis on the example of Safety Culture Survey
Mashin V.A. The Development and Improvement Instruments of Safety Culture: Human Performance Improvement (HPI). (Basic Course). 2014. Syllabus (in Russian)
Mashin V.A. Just Culture. Culpability Tree. April 16, 2014. CIPK, Obninsk.
Materials for the presentation (in Russian)Table of contents
1. Safety assurance processes and its basic components.
2. Just Culture and Human Performance Improvement (HPI).
3. Just Culture and Operating Experience (OE).
4. Culpability Tree and the unsafe actions examples.
Mashin V.A. Foundations of the concept of development and improvement of Safety Culture in The State Atomic Energy Corporation ROSATOM. The IХ International public forum-dialogue "Atomic Energy, Society, Safety-2014". Moscow, April 10-11, 2014.
Materials for the presentation (in Russian)Table of contents
1. The modern principles of development and improvement of Safety Culture.
2. The Safety Management System as a tool for creating, maintaining and improving Safety Culture.
3. The role of of leading indicators in monitoring and assessing Safety Culture.
4. The strategic objectives of development and improvement of Safety Culture.
Mashin V.A. The modern understanding of NPP Safety Culture (The Design Stage). Moscow, 2014.
Materials for the presentation (in Russian)Table of contents
I. The traditional approach to the concept of "Safety Culture". The main outcomes.
II. Safety Culture as the effectiveness of the safety process.
III. Case studies: The Chernobyl disaster and the RBMK-1000 reactor design, NASA's Space Shuttle Program, The naval nuclear propulsion program USA.
Mashin V.A. Statistical analysis culture and safety culture. The manuscript of the article (2014)
The manuscript of the article (in Russian)
The questions of proper use of statistical analysis methods on the example of evaluation the Nuclear Regulatory Commission (NRC, U.S.) validity and reliability of the safety culture survey developed by the Institute of Nuclear Power Operations (INPO, USA) are discussed in this article. The questions of the minimum representative sample for the study, the choice of statistical tests based on the scale of measure and the type of distribution, the conditions for use of Principal Component Analysis method and Principal Axis Factoring method, verification the multicollinearity between the factors, analysis of correlation coefficients as well as analysis of outliers are considered. The importance of understanding and proper application of statistical methods in the planning study, data processing and presentation of results is emphasized.
Keywords: safety culture, survey, validity, reliability, statistical analysis
Mashin V.A. The modern foundations of the safety culture concept. Elektricheskie Stantsii (Power Plants), 2014. No 10. P. 2-10.
The Article (in Russian)
The contradictions and limitations inherent in the existing concept of safety culture, the foundations of which were laid out in 1991 in the report of the International Nuclear Safety Advisory Group of the IAEA, are examined in this article. A new concept of safety culture is proposed, which is based on the safety process covering the entire life cycle of the
facility. The main stages and elements of this process are identified, their content and the relationship is considered. Safety culture is defined as the performance of the individual elements and the overall process. Highlights of the proposed concept are illustrated by the example of the Chernobyl accident and The Naval Reactor Program (USA).
Keywords: Safety Culture, Safety Process, Risk Management, Chernobyl Accident, Naval Reactor Program
Mashin V.A. The program of the course "Basics of Safety Culture Management", 2013.
Table of contents (in Russian)Summary
1. The general concept of safety culture
2. The methodological issues of Safety Culture Managemen
3. The management tools of Safety Culture
4. The list of Case-studies.
Mashin V.A. Questions of formation, development and evaluation of NPP Safety Culture.
VIII International Nuclear Forum Safety of nuclear technologies: nuclear installation safety culture 9-13 September, 2013. St. Petersburg Branch of the Central Institute for Continuing Education and Training, St. Petersburg, Russian Federation.
Materials for the presentation (in Russian)Table of contents
I. How can we influence the formation and development of a safety culture, that is on behavior norms, values and ideas that meet the safety objectives?
II. How can we assess the level of safety culture in nuclear power plants?
Mashin V.A. The Safety Management System as a tool for development and improvement of Safety Culture. International Summer School "Safety Culture: The practical management methods". Saint Petersburg, 01-05 July 2013.
Materials for the presentation (in Russian)Table of contents
The myth 1: Safety Culture is the process
The myth 2: The development of Safety Culture through policy and training
The myth 3: Safety is the highest priority
Comments (in Inglish)Conclusions
It is very important appropriate use of the statistical methods in the study.
It is very important account for limitations of the statistical methods and the main assumptions.
Calculation of Sample Size account for Confidence Level, Confidence Interval, Population.
The use of Pearson correlation for ordinal data of Likert scale is not correct.
For the use of Principal Components Analysis (PCA) should be considered:
the multi-variate normal assumption,
factorability of the intercorrelation matrix,
criteria for determining the number of factors.
With ordinal data should be used Rank correlation coefficients for PCA.
For the use of Principal Axis Factoring (PAF) should be considered:
the multi-variate normal assumption,
factorability of the intercorrelation matrix,
criteria for determining the number of factors,
the validity of the factor analysis model.
With ordinal data should be used Rank correlation coefficients for PAF.
Keywords: Nuclear Power Plant, Safety Culture Survey, Factor Analysis, Reliability Analysis, Criterion-Related Validity, Limitations and Assumptions of Statistical Methods. Abbreviation: INPO - Institute of Nuclear Power Operations USA. NRC - Nuclear Regulatory Commission USA.
Mashin V.A. The indicators of managers’ commitment to Safety Culture based on Operating Experience. WANO MC technical support mission at Zaporizhia NPP. 2-7 June 2013.
Materials for the presentation (in Russian)Table of contents
1. Safety Culture: Safety Management System
2. Monitoring of Safety Management System: The indicators
3. The improvement of Safety Culture: Commitment of manageres
4. Operating Experience: The indicators of managers’ commitment to Safety Culture
Mashin V.A. Policies to promote safety culture at nuclear facilities. Draft. (24.04.2013)
The Policies. Draft (in Russian)
Developing Safety Culture on the basis of Safety Management System. Main goals, objectives and requirements. Keywords: safety, safety management system (SMS), reliability and efficiency of the human performance, safety culture.
Mashin V.A. The provisions on "Safety Management System" in the organizations of the State Atomic Energy Corporation ROSATOM. Draft. (23.04.2013)
The provisions. Draft (in Russian)
Safety Management System provides increase of reliability and efficiency of the staff, thereby determining the development and improvement of safety culture of Rosatom organizations. Keywords: safety, safety management system (SMS), reliability and efficiency of the human performance, safety culture, operational experience process, process HPI (Human Performance Improvement), indicators of SMS process and activities.
Mashin V.A. The development of corrective actions following an investigation of safety and reliability significant events of the utilities of potentially dangerous production. The materials for the workshop, 11-15.03.2013. CIPK, Obninsk.
Materials for the presentation (in Russian)
IAEA recommendations on the development of corrective action programme on events at NPPs are provided. The essential characteristics for corrective actions and elements of an effective corrective action programme are described:
1. Addressing the root causes
2. Selecting the corrective actions
3. Conservative decision making
4. Prioritization and implementation for corrective actions
5. Tracking effectiveness of corrective actions
6. Preventing repetition
7. Rally commitments
8. Indicators
The types of unsafe actions, their sources and the points of safety deficits for the development of corrective actions, prioritization for corrective actions are considered.
Keywords: corrective actions, Operating Experience (OE), Low Level Events (LLEs), Near Misses (NMs), precursors to human error, Just Culture, hazards and risks, Indicators of an effective corrective action programme.
Mashin V.A. Safety Management System: The Development and Continuous Improvement of Safety Culture in the Nuclear Fuel Cycle Facilities. Elektricheskie Stantsii (Power Plants), 2014. No 3. P. 2-10.
The Article (in Russian)
The development and continuous improvement of Safety Culture in the nuclear fuel cycle facilities should be based on the establishment of a Safety Management System. The article presents the basic requirements, goals, objectives and principles, elements and activities and methods to ensure the Safety Management. Special attention is paid to the Risk Management, monitoring based on Safety Performance Indicators, Human Performance Improvement (HPI) methods to prevent and minimize the consequences of human errors, the instruments for the active involvement of staff in the process of continuous improvement of the operational safety. Keywords: safety, safety culture, safety management system, safety performance indicators, risk management, HPI.
Mashin V.A. Human Performance Improvement (HPI) and reducing the human errors. Elektricheskie Stantsii (Power Plants), 2013. No 5. P. 2-10.
The Article (in Russian)
Currently, for the domestic nuclear industry is the actual task of creating and implementing an integrated program to improve the reliability of the personnel activity. In this paper, the methodology of reducing the number of errors and violations in the human actions tested in the U.S. nuclear industry and called "Human Performance Improvement" (HPI) is stated. The basic principles and models of HPI approach, methods and tools for the prevention of human errors and reduce consequences, the implementation issues of HPI approach in the domestic nuclear power industry are considered. Keywords: Human Performance Improvement, Active and Latent Errors, Error Precursors, Critical Step, Safety Culture.
Mashin V.A. Human Performance Improvement in the nuclear industry. 2012.
Materials for the presentation for the meeting of NPP Chief Engineers (10-13.04.2012)
Over the past 10 years, the number of violations, related to human errors, remains at the same level in the industry. There is no overall corporate program, supported by the central office and encouraging all plants to further reduce the number of human errors.
This presentation shows the methodology of reducing human errors is based on the principles of Human Performance Improvement (HPI) approach. This approach proposed by the Institute of Nuclear Power Operations (INPO) are built on an analysis of the Human Nature and includes a wide range of methods and tools aimed at reducing human errors.
Keywords: human errors, Human Performance Improvement, Human Nature, Error Precursors, Critical Step, Just Culture
Mashin V.A. The Safety Culture and System for Collecting, Recording, Classifying and Analyzing Low Level Events at NPPs. Elektricheskie Stantsii (Power Plants), 2012. No 8. P. 20-28.
The Article (in Russian)
In connection with the introduction of the corporate system for collecting, recording, classifying and analyzing low level events at Nuclear Power Plants of Rosenergoatom Concern OJSC, the role of this system in terms of current trends in the development of Safety Culture concept is analyzed. A close connection with Reporting Culture and Learning Culture is showed. The important factors in determining the efficiency of the voluntary reporting system are considered. Particular attention is paid to creating Just Culture in organizations. Keywords: Safety Culture, Reporting Culture, Just Culture, accounting system of low level events.
Mashin V.A. Incidents at Nuclear Power Plants Caused by the Human Factor. Power Technology and Engineering. Vol. 46, No. 3, September, 2012. p. 215-220.
The Article (in English)
Psychological analysis of the causes of incorrect actions by personnel is discussed as presented in the report "Methodological guidelines for analyzing the causes of incidents in the operation of nuclear power plants." The types of incorrect actions and classification of the root causes of errors by personnel are analyzed. Recommendations are made for improvements in the psychological analysis of causes of incorrect actions by personnel. Keywords: nuclear power plant, personnel, incidents, human factor, types of error, psychological analysis.
Mashin V.A. The psychological analysis method of the causes of the erroneous human actions. An analytical review. The Report of a workshop "Working psychologist in the commission to investigate violations in NPP, related the erroneous human actions", 14.02-17.02.2012. CIPK, Obninsk.
The Presentation (in Russian)
The psychological analysis method for investigating the human factors causes of accidents and incidents, presented in "Methodological guidelines for the investigation of the accident and incident causes in nuclear power plants", are considered using modern approaches. The types and root causes of human errors, used in the psychological analysis method, are analyzed. The recommendations to improve the psychological analysis method for investigating the human factors causes of accidents and incidents are proposed. Presents the examples of classifications and causes of human errors in terms of current approaches in this area.
Keywords: analysis of accident and incident causes, human factor, types of human errors, root causes of human errors.
Mashin V.A. Human Factors. Optimization of teamwork (Basic Course, 2011)
Table of contents (in Russian)
The main characteristics of the human influencing on efficiency and security of operation and maintenance NPP.
Mashin V.A. Human Factors. Introductory Course (2011).
Table of contents (in Russian)
The main characteristics of the human influencing on efficiency and security of operational activities.
The BNPP Staff Code of Professional Ethics (The project manager is Mashin V.A., 2011).
Table of contents (in Russian)
The BNPP Staff Code of Professional Ethics was developed to form the effective Organizational Cultures. The Organizational Cultures should ensure suitable the reliability and the efficiency of BNPP operation.
The Proverbs: The Values and Standards of Conduct in the Folk Wisdom (Compiled by Mashin V.A., 2011).
The Proverbs (in Russian)
Annex to "The BNPP Staff Code of Professional Ethics".
Mashin V.A. The Cross-cultural features of iranian personnel. 2011.
Recommendations for russian personnel (in Russian)
The basic values, the cultural features of behaviors are considered for effective interaction with iranian personnel.
Mashin V.A. The general procedure of personnel cohesiveness estimation (2011).
The underlying principles (in Russian)
The definition of the 'group cohesiveness' are presented. The basic factors affecting on the group cohesiveness, the external criterions of the group cohesiveness and the methods for theirs estimation are considered.
Mashin V.A. The Estimation of Test Procedures Which are Used for Personnel Assessment (2010).
Presentation for seminar (in Russian)
The main psychometrical demands to test pprocedures (representativeness, reliability, validity, discriminativeness) are presented. The factors which have an influence on test pprocedures are concedired. The basic types of reliability and validity of test procedures for personnel selection are described. The examples of methods for reliability and validity estimation are given.
Mashin V.A. The System of Psychological Support of NPP Human Resource Management. Selection (2010).
Presentation for seminar (in Russian)
The process of psychological selection of personnel are presented. The process includes the assessment of 4 critical s (the through competencies): (1) the personality domain (motivation, attitudes), (2) the cognitive domain (perception, attention, memory, thinking), (3) the physiological domain (functional states, emotional stability), (4) the command interaction (group work, leadership skills). The personnel solution algorithm for the process of psychological selection has been developed. The process of psychological selection bases on concepts of systematic and competencies models.
Mashin V.A. The Method of Human Factors Accident Investigation. (Rev. 2011.01.11).
The Human Error Analysis (in Russian)
Human error analysis approach was proposed. The method develop the following concepts and frameworks: Perceptual Control Theory (Powers W.T., 1973), Model of Information Processing (Hendy K.C., Farrell P.S., 1997), SHEL Model (Edwards E., 1988), Latent Failures Model (Reason J., 1990), The Human Factors Analysis and Classification System - HFACS (Shappell S.A., Wiegmann D.A., 2000), Systematic Error and Risk Analysis - SERA (Hendy K.C., 2003), A Systems Approach to the Investigation of Human Factors in Accidents and Incidents (ICAO, 2000). As an example, the method was used for Three Mile Island NPP accident investigation (TMI-2, USA, 1979).
Mashin V.A. The analysis of questionnaire data of personnel with the view of development and introduction of «The Code of Business Ethics». 2009.
Table of contents (in Russian)
The reliability of questionnaire as measuring tool was analysed. The statistical analysis of general data and data of working groups was
performed for each items of questionnaire. The most strained areas of professional activity were marked out due to the analysis data.
Mashin V.A. The methodological guideline for estimation and improvement of reliability, validity and discriminatory power of personnel tests (The assessment tasks). 2008.
The methodological guideline (in Russian)
In given guide the main accent is made on practical techniques and procedures of estimation and improvement of reliability, validity and discriminatory power of tests for the selection and assessment of individual performance of personnel.
Mashin V.A. The development proposals of Psycho-Physiological Support of Human Resource Management System of NPP. 2008. Text (on English)
The main tasks, functions, procedures of psycho-physiological support of Human Resource Management System of Nuclear Power Plants (NPP) as well as personnel, workrooms, equipments, software requirements are considered.
Mashin V.A. A manual for development of the competency models. 2008. Table of contents (in Russian)
Given document describes the structure and procedure for development of the competency models, the
systematic approach for identifying the competencies needed by NPP personnel.
This document describes also how appropriate personnel competencies can be used for the selection
(which includes recruitment, promotion and succession personnel),
development (personnel development programmes including formal training, job rotation, on the job
training, mentonng, and outside assignments) and assessment of individual performance of
NPP personnel. As example the management competencies for NPP managers at all levels are used.
MABP360man.exe - The program for performance appraisal on basis of the competency model of NPP managers (Nuclear Electric Ltd., UK).
Mashin V.A. A methodical manual for development and use of the structured interviews for identifying the competencies and behavioral indicators. 2008. Table of contents (in Russian)
In this document the questions of development and use of the structured interview for
identifying the behavioral events (McClelland D.C.), the structured behavioral interview of Jon Doe,
the questions of behavioral interview of William W. Larson and the bank of competency based
interview questions are considered.
Mashin V.A. A manual for Nominal Group Technique (NTG). 2008.
Table of contents (in Russian)
Given manual describes the general concepts and procedure of Nominal Group Technique (NGT)
for organizational decision making and problem solving (including identifying the competencies needed by NPP personnel).
Mashin V.A. A manual for Repertory Grid Technique: assessment tasks. 2008. Table of contents (in Russian)
Given manual describes the general concepts and procedure of Repertory Grid Technique (Kelly G.)
for identifying the competencies and behavioral standards needed by NPP personnel.
Mashin V.A. The psychophysiological assessment of operations, control and maintenance personnel of OAO «AK «Transneft». The general requirements. 2006. Table of contents (in Russian)
The general requirements (goals and objectives, fuctions) of the psychophysiological assessment system of OAO «AK «Transneft» personnel
are described. The normative, methodical, technical and employment questions of making of the psychophysiological assessment system of OAO «AK «Transneft» personnel are considered.
Mashin V.A. A methodical manual for development and performance of psychophysiological selection of NPP personnel: the systematic approach. 2006.
Table of contents (in Russian) A methodical manual (in Russian)
Given document describes the general demands for development of the psychophysiological selection process of NPP personnel on basis of the systematic and competency approaches. This manual is intended for the specialists on Human Resource Management questions including the professional selection, annual psychophysiological examination.
Mashin V.A., Nikitin V.P. The Concept of safety culture. The Human factor. Elektricheskie Stantsii (Power Plants), 1997, No 4, p. 18-22. The Article (in Russian)
The central positions of safety culture NPP are considered from the viewpoint of human factor. The thesis that achievement of high safety culture on home NPP must are guided by national traditions and particularities of development of home atomic energy is substantiated. The need of development and realization of programs of qualitative realignment of system and methods of control NPP, professional development of personnel NPP, analysis and eliminating the root reasons of accidents and incidents in accordance with human factor is formulated. In the first place the human facility, personnel, style and methods of personnel control, social-psychological climate in work groups must be in the highlight of safety culture. In process of shaping of safety culture must be involved whole personnel, including high administrative level.
Mashin V.A. Support computer systems of operators NPP (Psychological problems). Elektricheskie Stantsii (Power Plants), 1995, No 7, p. 2-7. The Article (in Russian)
With the general positions of safety of exploitation and management NPP the psychological problems, which appear at development and application the support computer systems of operators on NPP and possible negative consequences when disregarding these problems are considered. The active forms of operator activity and ways of maintenance of functions a decision making for operators in conditions of automaticed management NPP are received the central attention. The importance in development stages of of support systems to define the areas of operator competency and automation competency and provide in projects the conditions for compensation of redistribution the part of problems from operator to automaticed systems is noted.
Mashin V.A. About psychological providing exploitation and management NPP. Elektricheskie Stantsii (Power Plants), 1994, No 3. p. 36-39. The Article (in Russian)
In proposed article with positions of psychological analysis the reserves of increasing of safety NPP, depended on "human factor", are considered. Based on the results of studies, which are conducted in psychophysiological laboratory of Atom Energy Training Center, Novovoronezh, Russia, the professional development model of operative personnel and most important for safety NPP psychological change, which are accompanied the main stages of professional development of operator, are described. Two opposite directions in professional development: 'descending' and 'ascending', are substantiated. In canvas of analysis the levels of operator behaviour activities: individually ("passive") and personal ('active') are introduced. Only personal ('active') forms of activity in conditions of NPP can provide the constant self-development of operators and, therefore, high level of safety, reliability and efficiency of its actions are proved. The system of conditions for maintenance and development of personal activity forms of operators on the length of the whole professional way, directed on provision safe, reliable and efficient exploitation and management NPP is formulated. In conclusion article the proposals about development of psychological provision of exploitation and management NPP are presented. About significant reserves, which are hidden in decision of this problem, is inferred.
Mashin V.A. Concerning two levels of psychic regulation in human behavior. Voprosy Psikhologii, 1994 May-June; 3:144-149. The Article (in Russian)
The notion of two levels of psychic regulation in human behavior is analysed. The main difference lies in different sources of balance breach: outer source, when the subject reacts, inner one, when the subject is active in search of new relations, new communications. The analysis lets to see the two levels correspondence to basic psychological concepts – individual and personality.
Mashin V.A. Professionalism of personality in mature age (Operator activities). Doctoral Dissertation of Psychology. Moscow State University, Psychological Department, Moscow, 1994, 170 p. (in Russian)
Mashin V.A. A methodical manual "The general questions of making and operation of the psychophysiological examinations of NPP personnel". 1991. Table of contents (in Russian)
The methodological and methodical questions of making and operation of the psychophysiological examinations of NPP personnel are considered.
