Monday, October 20, 2014

DNFSB Hearings on Safety Culture, Round Three


DNFSB Headquarters

On October 7, 2014 the Defense Nuclear Facilities Safety Board (DNFSB) held its third and final hearing* on safety culture (SC) at Department of Energy (DOE) nuclear facilities.  The original focus was on the Hanford Waste Treatment Plant (WTP) but this hearing also discussed the Waste Isolation Pilot Plant (WIPP), the Pantex plant and other facilities.  There were three presenters: DOE Secretary Moniz and two of his top lieutenants.  A newspaper article** published the same day reported key points made during the hearing and you should read that article along with this post.  This post focuses on items not included in the newspaper article, including the tone of the hearing and other nuances.  The presenters used no slides and the hearing transcript has not yet been released.  The only current record of the hearing is a DNFSB video.

Secretary Moniz

Moniz has been Secretary for about a year-and-a-half.  In his view, the keys to improving SC are training, consistent senior management attention, and procurement modifications, i.e., DOE’s intent to revise RFP and contracting processes to include SC expectations.  He also said fostering the consideration of SC in all decisions, including resource allocation, is important.  Board member Sullivan asked about the SC issues at Pantex and Moniz provided a generic answer about improving self-assessments and sharing lessons learned but ultimately punted to the next presenter, Ms. Creedon.

Principal Deputy Administrator Creedon, National Nuclear Security Administration (NNSA)

Creedon has been in her position for two months.  She believes NNSA employees get the job done in spite of bureaucracy but they need greater trust in senior management who, in turn, must work harder to engage the workforce.  Returning to the Pantex*** issues, Sullivan asked why the recommendations of the plant’s outside technical advisors had been ignored for years.  Creedon said she would work to improve communications up and down the organization.  In a separate exchange, she provided an example of positive reinforcement where NNSA employees can receive cash awards ($500) for good work. 

Creedon’s  prior position was in the Department of Defense.  To the extent she has the warfighter mentality (“Anything, anywhere, anytime…at any cost”)**** then balancing mission and safety may not be natural for her.  Her response to a question on this topic was not encouraging; she claimed the motto du jour for NNSA (“Mission First, People Always”) adequately addresses safety's prioity but it obviously doesn’t even mention safety.

Acting Assistant Secretary for Environmental Management Whitney

Whitney is also new in his job but not to DOE, coming from DOE Oak Ridge.  He laid out his goals of establishing trust, a questioning attitude and mutual respect.  He was asked about a SC assessment finding that DOE senior managers don’t feel responsible for safety, rather it belongs to the site leads or one of the EM mission support units.  Whitney said that was unacceptable and described the intent to add SC factors to senior management evaluations.  He also repeated the plan to upgrade the WTP contractor evaluation to include SC factors.  He noted that most employees stay at one site for their entire career, making it hard to transfer SC from site to site.

Our Perspective

The overall tone of the hearing was collegial.  The Board expressed support and encouragement for the presenters, all of whom are relatively new in their jobs.  The presenters all stayed on message and reinforced each other.  For example, for WTP one message is “We know there are still significant SC issues at WTP but we have the right team in place and are taking action and making progress.  Changing a decades-old culture takes time.”  Whitney received more of a (polite) grilling probably because the WTP and the WIPP are under his purview.

We are totally supportive of DOE’s stated intent to add SC factors to contracts and senior management evaluations.  When players have skin in the game, the chances of seeing desired behavioral changes are greatly increased.  We are equally supportive of Secretary Moniz’ desire to create a culture that incorporates safety considerations in all decisions.

DOE is trying to make its employees more conscious of safety’s importance; two thousand mangers have gone through SC training and there’s more to come.  Now we’re starting to worry about the drumbeat of SC creating a Weltanschauung where a strong SC is sine quo non for good outcomes and a weak SC is always present when bad outcomes occur.  Organizational reality is more complicated.  An organization with a mediocre SC can achieve satisfactory results if other effective controls and incentives are in place; an organization with a strong SC can still make poor decisions.  And luck can run good or bad for anyone.


*  DNFSB Oct. 7, 2014 Safety Culture Public Meeting and Hearing.  We posted on the first hearing on June 9, 2014 and the second hearing on Sept. 4, 2014.

**  A. Cary, “Moniz says safety culture at Hanford vit plant led to problems,” Tri-City Herald (Oct. 7, 2014).

***  NNSA's responsibilities include Pantex which has recognized SC issues.

****  See the third footnote in our Sept. 4, 2014 post.

Monday, October 13, 2014

Systems Thinking in Air Traffic Management


A recent white paper* presents ten principles to consider when thinking about a complex socio-technical system, specifically European Air Traffic Management (ATM).  We review the principles below, highlighting aspects that might provide some insights for nuclear power plant operations and safety culture (SC).

Before we start, we should note that ATM is truly a complex** system.  Decisions involving safety and efficiency occur on a continuous basis.  There is always some difference between work-as-imagined and work-as-done.

In contrast, we have argued that a nuclear plant is a complicated system but it has some elements of complexity.  To the extent complexity exists, treating nuclear like a complicated machine via “analysing components using reductionist methods; identifying ‘root causes’ of problems or events; thinking in a linear and short-term way; . . . [or] making changes at the component level” is inadequate. (p. 5)  In other words, systemic factors may contribute to observed performance variability and frustrate efforts to achieve the goal in nuclear of eliminating all differences between work-as-planned and work-as-done.

Principles 1-3 relate to the view of people within systems – our view from the outside and their view from the inside.

1. Field Expert Involvement
“To understand work-as-done and improve how things really work, involve those who do the work.” (p. 8)
2. Local Rationality
“People do things that make sense to them given their goals, understanding of the situation and focus of attention at that time.” (p. 10)
3. Just Culture
“Adopt a mindset of openness, trust and fairness. Understand actions in context, and adopt systems language that is non-judgmental and non-blaming.” (p. 12)

Nuclear is pretty good at getting line personnel involved.  Adages such as “Operations owns the plant” are useful to the extent they are true.  Cross-functional teams can include operators or maintenance personnel.  An effective CAP that allows workers to identify and report problems with equipment, procedures, etc. is good; an evaluation and resolution process that involves members from the same class of workers is even better.  Having someone involved in an incident or near-miss go around to the tailgates and classes to share the lessons learned can be convincing.

But when something unexpected or bad happens, nuclear tends to spend too much time looking for the malfunctioning component (usually human).   “The assumption is that if the person would try harder, pay closer attention, do exactly what was prescribed, then things would go well. . . . [But a] focus on components becomes less effective with increasing system complexity and interactivity.” (p. 4)  An outside-in approach ignores the context in which the human performed, the information and time available, the competition for focus of attention, the physical conditions of the work, fatigue, etc.  Instead of insight into system nuances, the result is often limited to more training, supervision or discipline.

The notion of a “just culture” comes from James Reason.  It’s a culture where employees are not punished for their actions, omissions or decisions that are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated.

Principles 4 and 5 relate to the system conditions and context that affect work.

4. Demand and Pressure
“Demands and pressures relating to efficiency and capacity have a fundamental effect on performance.” (p. 14)
5. Resources & Constraints

“Success depends on adequate resources and appropriate constraints.” (p. 16)

Fluctuating demand creates far more varied and unpredictable problems for ATM than it does in nuclear.  However, in nuclear the potential for goal conflicts between production, cost and safety is always present.  The problem arises from acting as if these conflicts don’t exist.

ATM has to “cope with variable demand and variable resources,” a situation that is also different from nuclear with its base load plants and established resource budgets.  The authors opine that for ATM, “a rigid regulatory environment destroys the capacity to adapt constantly to the environment.” (p. 2) Most of us think of nuclear as quite constrained by procedures, rules, policies, regulations, etc., but an important lesson from Fukushima was that under unforeseen conditions, the organization must be able to adapt according to local, knowledge-based decisions  Even the NRC recognizes that “flexibility may be necessary when responding to off-normal conditions.”***

Principles 6 through 10 concern the nature of system behavior, with 9 and 10 more concerned with system outcomes.  These do not have specific implications for SC other than keeping an open mind and being alert to systemic issues, e.g., complacency, drift or emergent behavior.

6. Interactions and Flows
“Understand system performance in the context of the flows of activities and functions, as well as the interactions that comprise these flows.” (p. 18)
7. Trade-Offs
“People have to apply trade-offs in order to resolve goal conflicts and to cope with the complexity of the system and the uncertainty of the environment.” (p. 20)
8. Performance variability
“Understand the variability of system conditions and behaviour.  Identify wanted and unwanted variability in light of the system’s need and tolerance for variability.” (p. 22)
9. Emergence
“System behaviour in complex systems is often emergent; it cannot be reduced to the behaviour of components and is often not as expected.” (p. 24)
10. Equivalence
“Success and failure come from the same source – ordinary work.” (p. 26)

Work flow certainly varies in ATM but is relatively well-understood in nuclear.  There’s really not much more to say on that topic.

Trade-offs occur in decision making in any context where more than one goal exists.  One useful mental model for conceptualizing trade-offs is Hollnagel’s efficiency-thoroughness construct, basically doing things quickly (to meet the production and cost goals) vs. doing things well (to meet the quality and possibly safety goals).  We reviewed his work on Jan. 3, 2013.

Performance variability occurs in all systems, including nuclear, but the outcomes are usually successful because a system has a certain range of tolerance and a certain capacity for resilience.  Performance drift happens slowly, and can be difficult to identify from the inside.  Dekker’s work speaks to this and we reviewed it on Dec. 5, 2012.

Nuclear is not fully complex but surprises do happen, some of them not caused by component failure.  Emergence (problems that arise from new or unforeseen system interactions) is more likely to occur following the implementation of new technical systems.  We discussed this possibility in a July 6, 2013 post on a book by Woods, Dekker et al.

Equivalence means that work that results in both good and bad outcomes starts out the same way, with people (saboteurs excepted) trying to be successful.  When bad things happen, we should cast a wide net in looking for different factors, including systemic ones, that aligned (like Swiss cheese slices) in the subject case.

The white paper also includes several real and hypothetical case studies illustrating the application of the principles to understanding safety performance challenges 

Our Perspective 

The authors draw on a familiar cast of characters, including Dekker, Hollnagel, Leveson and Reason.  We have posted about all these folks, just click on their label in the right hand column.

The principles are intended to help us form a more insightful mental model of a system under consideration, one that includes non-linear cause and effect relationships, and the possibility of emergent behavior.  The white paper is not a “must read” but may stimulate useful thinking about the nature of the nuclear operating organization.


*  European Organisation for the Safety of Air Navigation(EUROCONTROL), “Systems Thinking for Safety: Ten Principles” (Aug. 2014).  Thanks to Bill Mullins for bringing this white paper to our attention.

**  “[C]omplex systems involve large numbers of interacting elements and are typically highly dynamic and constantly changing with changes in conditions. Their cause-effect relations are non-linear; small changes can produce disproportionately large effects. Effects usually have multiple causes, though causes may not be traceable and are socially constructed.” (pp. 4-5)

Also see our Oct. 14, 2013 discussion of the California Independent System Operator for another example of a complex system.

***  “Work Processes,” NRC Safety Culture Trait Talk, no. 2 (July 2014), p. 1.  ADAMS ML14203A391.  Retrieved Oct. 8, 2014

Sunday, October 5, 2014

Update on INPO Safety Culture Study

On October 22, 2010 we reported on an INPO study that correlated safety culture (SC) survey data with safety performance measures.  A more complete version of the analysis was published in an academic journal* this year and this post expands on our previous comments.

Summary of the Paper

The new paper begins with a brief description of SC and related research.  Earlier research suggests that some modest relationship exists between SC and safety performance but the studies were limited in scope.  Longitudinal (time-based) studies have yielded mixed results.  Overall, this leaves plenty of room for new research efforts.

According to the authors, “The current study provides a unique contribution to the safety culture literature by examining the relationship between safety culture and a diverse set of performance measures [NRC industry trends, ROP data and allegations, and INPO plant data] that focus on the overall operational safety of a nuclear power plant.” (p. 39)  They hypothesized small to medium correlations between current SC survey data and eleven then-current (2010) and future (2011) safety performance measures.**

The 110-item survey instrument was distributed across the U.S. nuclear industry and 2876 useable responses were received from employees and contractors representing almost all U.S. plants.  Principal components analysis (PCA) was applied to the survey data and resulted in nine useful factors.***  Survey items that did not have a high factor loading (on a single factor) or presented analysis problems were eliminated, resulting in 60 useful survey items.  Additional statistical analysis showed that the survey responses from each individual site were similar and the various sites had different responses on the nine factors.

Statistically significant correlations were observed between both overall SC and individual SC factors and the safety performance measures.****  A follow-on regression analysis suggested “that the factors collectively accounted for 23–52% of the variance in concurrent safety performance.” (p. 45)

“The significant correlations between overall safety culture and measures of safety performance ranged from -.26 to -.45, suggesting a medium effect and that safety culture accounts for 7–21% of the variance in most of the measures of safety performance examined in this study.” (p. 45)

Here is an example of a specific finding: “The most consistent relationship across both the correlation and regression analyses seemed to be between the safety culture factor questioning attitude, and the outcome variable NRC allegations. . . .Questioning attitude was also a significant predictor of concurrent counts of inspection findings associated with ROP cross-cutting aspects, the cross-cutting area of human performance, and total number of SCCIs. Fostering a questioning attitude may be a particularly important component of the overall safety culture of an organization.” (p. 45)

And another: “It is particularly interesting that the only measure of safety performance that was not significantly correlated with safety culture was industrial safety accident rate.” (p. 46)

The authors caution that “The single administration of the survey, combined with the correlational analyses, does not permit conclusions to be drawn regarding a causal relationship between safety culture and safety performance.  In particular, the findings presented here are exploratory, mainly because the correlational analyses cannot be used to verify causality and the data used represent snapshots of safety culture and safety performance.” (p. 46)

The relationships between SC and current performance were stronger than between SC and future performance.  This should give pause to those who would rush to use SC data as a leading indicator. 

Our Perspective 


This is a dense paper and important details may be missing from this summary.  If you are interested in this topic then you should definitely read the original and our October 22, 2010 post.

That recognizable factors dropped out of the PCA should not be a surprise.  In fact, the opposite would have been the real surprise.  After all, the survey was constructed to include previously identified SC traits.  The nine factors mapped well against previously identified SC traits and INPO principles. 

However, there was no explanation, in either the original presentation or this paper, of why the 11 safety performance measures were chosen out of a large universe.  After all, the NRC and INPO collect innumerable types of performance data.  Was there some cherry picking here?  I have no idea but it creates an opportunity for a statistical aside, presented in a footnote below.*****

The authors attempt to explain some correlations by inventing a logic that connects the SC factor to the performance measure.  But it just speculation because, as the authors note, correlation is not causality.  You should look at the correlation tables and see if they make sense to you, or if some different processes are at work here. 

One aspect of this paper bothers me a little.  In the October 22, 2010 NRC public meeting, the INPO presenter said the analysis was INPO’s while an NRC presenter said NRC staff had reviewed and accepted the INPO analysis, which had been verified by an outside NRC contractor.  For this paper, those two presenters are joined by another NRC staffer as co-authors.  This is a difference.  It passes the smell test but does evidence a close working relationship between an independent public agency and a secretive private entity.


*  S.L. Morrow, G.K. Koves and V.E. Barnes, “Exploring the relationship between safety culture and safety performance in U.S. nuclear power operations,” Safety Science 69 (2014), pp. 37–47.  ADAMS ML14224A131.

**  The eleven performance measures included seven NRC measures (Unplanned scrams, NRC allegations,  ROP cross-cutting aspects,  Human performance cross-cutting inspection findings, Problem identification and resolution cross-cutting inspection findings, Substantive cross-cutting issues in the human performance or problem identification and resolution area and ROP action matrix oversight, i.e., which column a plant is in) and four INPO measures (Chemistry performance, Human performance error rate, Forced loss rate and Industrial safety accident rate.

***  The nine SC factors were management commitment to safety, willingness to raise safety concerns, decision making, supervisor responsibility for safety, questioning attitude, safety communication, personal responsibility for safety, prioritizing safety and training quality.

****  Specifically, 13 (out of 22) overall SC correlations with the current and future performance measures were significant as were 84 (out of 198) individual SC factor correlations.

*****  It would be nice to know if any background statistical testing was performed to pick the performance measures.  This is important because if one calculates enough correlations, or any other statistic, one will eventually get some false positives (Type I errors).  One way to counteract this problem is to establish a more restrictive threshold for significance, e.g., 0.01 vs 0.05 or 0.005 vs. 0.01. This note is simply my cautionary view.  I am not suggesting there are any methodological problem areas in the subject paper.

Wednesday, September 24, 2014

NAS Safety Culture Lessons Learned from Fukushima—Presentation to NRC

We reviewed the National Academy of Sciences’ (NAS) Fukushima Lessons Learned report on July 30, 2014.  As you recall, we were underwhelmed by the recommendations related to nuclear safety culture (SC).  Basically, the report said the NRC should maintain a strong SC at the facilities it regulates and maintain the agency’s independence.  In addition, the NRC and industry should increase the transparency of their efforts to assess and improve SC.

Two of the report’s authors presented the NAS findings to the NRC on July 31, 2014 as part of a panel of external stakeholders presenting Fukushima lessons learned.  This post, based on the meeting transcript*, reviews the SC-related comments at that meeting.  The NAS presenter repeated the report’s SC recommendations then added some comments about the differences between Japanese and American culture. (pp. 18-19)  He also noted that the SC chapter in the report exhibits a range of views of SC held by different members of the 21-person NAS committee. (p. 24)

The NAS presentation was one of six made by the external panel.  A five-member NRC staff panel reported separately on the agency’s Fukushima-related investigations and activities.  Only the NAS presentation mentioned SC; the other presentations focused on plant hardware, off-site equipment, and state and foreign regulatory activities.

Our Perspective

Although this was a busy meeting with a tight schedule, SC did warrant comments from the Commissioners:

Commissioner Magwood said “. . . I also agree with many of the points the Committee raised about safety culture. I think that the cultural and training issues may actually be more important than some of the hardware issues that we spend a lot of time talking about.  And that is something that has not got enough emphasis.” (p. 57)

Commissioner Svinicki said “I liked the simple statement that was made of nuclear safety culture is a big issue.”  She also appreciated that the committee had a “vibrant” discussion on SC. (pp. 73-74)

Bottom line: Given the number of presentations SC did not get short shrift from the Commission. The Commissioners acknowledged SC’s importance but there was no real discussion of the topic.



*  NRC, “Briefing on the Status of Lessons Learned from the Fukushima Dai-ichi Accident,” meeting transcript (July 31, 2014).  ADAMS ML14217A208.

Wednesday, September 10, 2014

A Safety Culture Guide for Regulators

This paper* was referenced in a safety culture (SC) presentation we recently reviewed.  It was prepared for Canadian offshore oil industry regulators.  Although not nuclear oriented, it’s a good introduction to SC basics, the different methods for evaluating SC and possible approaches to regulating SC.  We’ll summarize the paper then provide our perspective on it.  The authors probably did not invent anything other than the analysis discussed below but they used a decent set of references and picked appropriate points to highlight.

Introduction to SC and its Importance

 
The paper provides some background on SC, its origins and definition, then covers the Schein three-tier model of culture and the difference between SC and safety climate.  The last topic is covered concisely and clearly: “. . . safety climate is an outward manifestation of culture. Therefore, safety culture includes safety climate, but safety culture uniquely includes shared values about risk and safety.” (p. 11)  SC attributes (from the Canadian Nuclear Safety Commission) are described.  Under attributes, the authors stress one of our basic beliefs, viz., “The importance of safety is made clear by the decisions managers make and how they allocate resources.” (p. 12)  The authors also summarize the characteristics of High Reliability Organizations, Low Accident Organizations, and James Reason’s model of SC and symptoms of poor SC.

The chapter on SC as a causal factor in accidents contains an interesting original analysis.  The authors reviewed reports on 17 offshore or petroleum related accidents (ranging from helicopter crashes to oil rig explosions) and determined for each accident which of four negative SC factors (Normalization of deviance, Tolerance of inadequate systems and resources, Complacency, Work pressure) were present.  The number of negative SC factors per accident ranged from 0 (three instances) to 4 (also three instances, including two familiar to Safetymatters readers: BP Texas City and Deepwater Horizon).  The negative factor that appeared in the most accidents was Tolerance of inadequate systems and resources (10) and the least was Work pressure (4).

Assessing SC

 
The authors describe different SC assessment methods (questionnaires, interviews, focus groups, observations and document analysis) and cover the strengths and weaknesses of each method.  The authors note that no single method provides a comprehensive SC assessment and they recommend a multi-method approach.  This is familiar ground for Safetymatters readers; for other related posts, click on the “Assessment” label in the right hand column.

A couple of highlights stand out.  Under observations the authors urge caution:  “The fact that people are being observed is likely to influence their behaviour [the well-known Hawthorne Effect] so the results need to be treated with caution. The concrete nature of observations can result in too much weight being placed on the results of the observation versus other methods.“ (p. 37)  A strength of document analysis is it can evidence how (and how well) the organization identifies and corrects its problems, another key artifact in our view.

Influencing SC

This chapter covers leadership and the regulator’s role.  The section on leadership is well-trod ground so we won’t dwell on it.  It is a major (but in our opinion not the only) internal factor that can influence the evolution of SC.  The statement that “Leaders also shape the safety culture through the allocation of resources” (p. 42) is worth repeating.

The section on regulatory influence is more informative and describes three methods: the regulator’s practices, promotion of SC, and enforcement of SC regulations.  Practices refer to the ways the regulator goes about its inspection and enforcement activities with licensees.  For example, the regulator can promote organizational learning by requiring licensees to have effective incident investigation systems and monitoring how effectively such systems are used in practice. (p. 44)  In the U.S. the NRC constantly reinforces SC’s importance and, through its SC Policy Statement, the expectation that licensees will strive for a strong SC.

Promoting SC can occur through research, education and direct provision of SC-related services.  Regulators in other countries conduct their own surveys of industry personnel to appraise safety climate or they assess an organization’s SC and report their findings to the regulated entity.**  (pp. 45-46)  The NRC both supports and cooperates with industry groups on SC research and sponsors the Regulatory Information Conference (which has a SC module).

Regulation of SC means just what it says.  The authors point out that direct regulation in the offshore industry is controversial. (p. 47)  Such controversy notwithstanding, Norway has developed  regulations requiring offshore companies to promote a positive SC.  Norway’s experience has shown that SC regulations may be misinterpreted or result in unintended consequences. (pp. 48-50)  In the nuclear space, regulation of SC is a popular topic outside the U.S.; the IAEA even has a document describing how to go about it, which we reviewed on May 15, 2013.  More formal regulatory oversight of SC is being developed in Romania and Belgium.  We reported on the former on April 21, 2014 and the latter on June 23, 2014.

Our Perspective

 
This paper is written by academics but intended for a more general audience; it is easy reading.  The authors score points with us when they say: “Importantly, safety culture moves the focus beyond what happened to offer a potential explanation of why it happened.” (p. 7)  Important factors such as management decision making and work backlogs are mentioned.  The importance of an effective CAP is hinted at.

The paper does have some holes.  Most importantly, it limits the discussion on influencing SC to leadership and regulatory behavior.  There are many other factors that can affect an organization’s SC including existing management systems; the corporate owner’s culture, goals, priorities and policies; market factors or economic regulators; and political pressure.  The organization’s reward system is referred to multiple times but the focus appears to be on lower-level personnel; the management compensation scheme is not mentioned.

Bottom line: This paper is a good introduction to SC attributes, assessments and regulation.


*  M. Fleming and N. Scott, “A Regulator’s Guide to Safety Culture and Leadership” (no date).

**  No regulations exist in these cases; the regulator assesses SC and then uses its influence and persuasion to affect regulated entity behavior.

Thursday, September 4, 2014

DNFSB Hearings on Safety Culture, Round Two

DNFSB Headquarters
On August 27, 2014 the Defense Nuclear Facilities Safety Board (DNFSB) convened the second of three hearings “to address safety culture at Department of Energy defense nuclear facilities and the Board’s Recommendation 2011–1, Safety Culture at the Waste Treatment and Immobilization Plant.”*  The first hearing was held on May 28, 2014 and heard from industry and federal government safety culture (SC) experts; we reviewed that hearing on June 9, 2014.  The second hearing received SC expert testimony from the U.S. Navy, the U.S. Chemical Safety and Hazard Investigation Board and academia.  The following discussion reviews the presentations in the order they were made to the board. 


Adm. Norton's (Naval Safety Center) presentation** on the Navy’s SC programs was certainly comprehensive with 32 slides for a half-hour talk (plus 22 backup slides).  It appears the major safety focus has been on aviation but the Center’s programs also address the afloat communities (surface, submarine and diving) and Marines.  The programs make heavy use of surveys and unit visits in addition to developing and presenting training and workshops.  Not surprisingly, the Navy stresses the importance of leadership, especially personal involvement and commitment, in creating a strong SC.  They recognize that implementing a strong SC faces a direct challenge from other organizational values such as the warfighter mentality*** and softer challenges in areas such as IT (where there are issues with multiple systems and data problems).

Program strengths include the focus on leadership (leadership drives climate, climate drives cultural change) and the importance of determining why mishaps occurred.  The positive influence of a strong SC on decision making is implied.

Program weaknesses can be inferred from what was not mentioned.  For example, there was no discussion of the importance of fixing problems or identifying hard-to-see technical problems.  More significantly, there was no mention of High Reliability Organization (HRO) attributes, a real head-scratcher given that some of the seminal work on HROs was conducted on aircraft carriers. 

Adm. Eccles' (Navy ret.) presentation**** basically reviews the Navy’s SUBSAFE program and its focus on compliance with program requirements from design through operations.  Eccles notes that ignorance, arrogance and complacency are challenges to maintaining an effective program.


Mr. Griffon's (Chemical Safety Board Member) presentation***** illustrates the CSB’s straightforward approach to investigating incidents, as reflected in the following quotes:

“Intent of CSB investigations are to get to root cause(s) and make recommendations toward prevention.” (p. 3)

While searching for root causes the CSB asks: “Why conditions or decisions leading to accident were seen as normal, rational, or acceptable prior to the accident.” (p. 4)


CSB review of incident-related artifacts includes two of our hot button issues, Process Safety Management action item closure (akin to a CAP) and the repair backlog. (p. 5)  Griffon reviews major incidents, e.g., Texas City and Deepwater Horizon.  For Deepwater, he notes how certain decisions were (deliberately) incompletely informed, i.e., did not utilize readily available relevant information, and thus are indicative of an inadequate SC. (p. 16)  Toward the end Griffon observes that “Safety culture study/change must consider inequalities of power and authority.” (p. 19)  That seems obvious but it doesn’t often get said so clearly.

We like the CSB’s approach.  There is no new information here but it’s a quick read of what basic SC should and shouldn’t be.

Prof. Meshkati's (Univ. of S. Cal.) presentation^ compares the cultures at TEPCO’s Fukushima Daiichi plant and Tohoku Electric’s Onagawa plant.  It is mainly a rehash of the op-ed Meshkati co-authored back in March 2014 (and we reviewed on March 19, 2014.)  The presentation adds something we pointed out as an omission in that op-ed, viz., that TEPCO’s Fukushima Daini plant eventually managed to shut down safely after the earthquake and tsunami.  Meshkati notes approvingly that Daini personnel exhibited impromptu, but prudent, decision-making and improvisation, e.g., by flexibly applying emergency operation procedures. (p. 37)

Prof. Sutcliffe (John Hopkins Univ.) co-authored an important book on High Reliability Organizations (which we reviewed on May 3, 2013) and this academically-oriented presentation^^ draws on her earlier work.  It begins with a familiar description of culture and how its evolution can be influenced.  Importantly it shows rewards (including money) as a key input affecting the link between leaders’ philosophy and employees’ behavior. (p. 6) 

Sutcliffe discusses how failure to redirect action (in a situation where a change is needed) can result from failure of foresight or sensemaking, or being overcome by dysfunctional momentum.  She includes a lengthy example featuring wildland firefighters that illustrates the linkages between cues, voiced concerns, search for disparate perspectives, situational reevaluation and redirected actions.  It’s worth a few minutes of your time to flip through these slides.

Our Perspective

For starters, the Naval Safety Center's
activities may be too bureaucratic, with too many initiatives and programs, and focused mainly on compliance with procedures, rules, designs, etc.  It’s not clear what SC lessons can be learned from the Navy experience beyond the vital role of leadership in creating a cultural vision and attempting to influence behavior toward that vision.

The other presenters added nothing that was not already available to you, either through Safetymatters or from observing SC tidbits in the information soup that flows by everyone these days.

Subsequent to the first hearing we reported that Safety Conscious Work Environment (SCWE) issues exist at multiple DOE sites (see our July 8, 2014 post).  This should increase the sense of urgency associated with strengthening SC throughout DOE.  However, our bottom line remains the same as after the first hearing: “The DNFSB is still trying to figure out the correct balance between prescription and flexibility in its effort to bring DOE to heel on the SC issue.  SC is a vital part of the puzzle of how to increase DOE line management effectiveness in ensuring adequate safety performance at DOE facilities.” 


*  DNFSB Aug. 27, 2014 Public Hearing on Safety Culture and Board Recommendation 2011-1.  There is a video of the hearing available.

**  K.J. Norton (U.S. Navy), “The Naval Safety Center and Naval Safety Culture,“ presentation to DNFSB (Aug. 27, 2014).

***  “Anything, anywhere, anytime…at any cost”—desirable warfighter mentality perceived to conflict with safety.” (p. 11)

****  T. J. Eccles (U.S. Navy ret.), “A Culture of Safety: Submarine Safety in the U. S. Navy,” presentation to DNFSB (Aug. 27, 2014).

*****  M.A. Griffon (Chem. Safety Bd.), “CSB Investigations and Safety Culture,” presentation to DNFSB (Aug. 27, 2014).

^  Najm Meshkati, “Leadership and Safety Culture: Personal Reflections on Lessons Learned,” presentation to DNFSB (Aug. 27, 2014).  Prof. Meshkati was also the technical advisor to the National Research Council’s safety culture lessons learned from Fukushima report which we reviewed on July 30, 2014.

^^  K.M. Sutcliffe, “Leadership and Safety Culture,” presentation to DNFSB (Aug. 27, 2014).