For operators of nuclear research facilities, it is of particular
importance to investigate minor incidents: indeed, as safety
demonstrations are generally based on the presence of several
independent "lines of defence", only through attentive investigation of
every occurrence, usually minor and of no consequence, can the level of
trust placed in each of these defensive lines be confirmed, or the
potential risks arising out of a possible weakness in the system be
anticipated.
The efficiency of the system is based on a rigorous procedure: stringent
attention to all incidents, consideration of the potential consequences
of the incidents in their most pessimistic scenarios, and promotion of a
broad conception of transpositions of the events, in time and space, for
experience feedback.
This efficiency presumes motivation on the part of all those involved,
hence the importance of dissociating from the concept of an "incident"
any notion of "error" or "blame" both in internal analysis and in public
communications.
The nuclear industry has developed some very progressive tools for
experience feedback, which could interest also management of other
technological risks.
This book presents the proceedings of a NATO Advanced Workshop dedicated
to this important matter of concern.