Analysis of trouble events caused by the problems in operation manuals

Takashi Matsubara, Akio Gofuku

Research output: Contribution to journalArticlepeer-review

3 Citations (Scopus)


Up to now, few studies have been devoted to investigate all the steps from the creation to the application of operation manuals and to consider human factors of operators in order to prevent the troubles caused by the problems of operation manuals. This paper deals with the steps and the human factors. It this study, the troubles caused by the problems are examined and the causes of these troubles are investigated. Here, the general procedure for creating an operation manual from the experiences of authors to create some operation manuals is first summarized and the method of analyzing the tendency of troubles and their causes is considered. From this consideration, it is concluded that there are several steps that cause a trouble in the creation of operation manuals and it is necessary to analyze the causes of a trouble from the viewpoints of creators and operators of operation manuals. Next, in this study, the troubles reported in Nuclear Information Archives (NUCIA) as an example of real trouble data bases are analyzed, a list of trouble causes related to the problems of operation manuals is made, and using this list, the causes of troubles reported in NUCIA are categorized. From analysis results, it is concluded that there are some steps that cause troubles in creating operation manuals, that the creation of a checklist and the description of necessary information are sometimes missing, and that operators take operations following operation manuals but sometimes do not understand the contents of operation manuals and/or have little knowledge for operations.

Original languageEnglish
Pages (from-to)62-76
Number of pages15
JournalTransactions of the Atomic Energy Society of Japan
Issue number1
Publication statusPublished - Mar 2012


  • General procedure
  • Human factor
  • Operation manual
  • Trouble event

ASJC Scopus subject areas

  • Nuclear Energy and Engineering
  • Safety, Risk, Reliability and Quality


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