How to extract the hidden lessons from a small incident on a nuclear research facility

Abstract

As the operator of approximately 70 highly diverse nuclear facilities, the CEA attaches particular importance to experience feedback on 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. © 2006 Springer.