Thursday, July 30, 2009

“Reliability is a Dynamic Non-Event” (MIT #5)

What is this all about?  Reliability is a dynamic non-event [MIT paper pg 5].  It is about complacency.  Paradoxically, when incident rates are low for an extended period of time and if management does not maintain a high priority on safety, the organization may slip into complacency as individuals shift their attention to other priorities such as production pressures.  The MIT authors note the parallel to the NASA space program where incidents were rare notwithstanding a weak safety culture, resulting in the organization rationalizing its performance as “normal”.  (See Dianne Vaughan’s book The Challenger Launch Decision for a compelling account of NASA’s organizational dynamics.)  In our paper “Practicing Nuclear Safety Management” we make a similar comparison.

What does this imply about the nuclear industry?  Certainly we are in a period where the reliability of the plants is at a very high level and the NRC ROP indicator board is very green.  Is this positive for maintaining high safety culture levels or does it represent a potential threat?  It could be the latter since the biggest problem in addressing the safety implications of complacency in an organization is, well, complacency.

Wednesday, July 29, 2009

Self Preservation (MIT #4)

The MIT paper [pg 7] introduces the concept of feedback loops, an essential ingredient of systems dynamics, and critical to understanding the dynamics of safety management.  The MIT authors suggest that there is a “weak balancing loop” associated with individuals responding to a perceived personal threat associated with increased incident rates.  While the authors acknowledge it is a weak feedback, I would add that, at best, it represents an idealized effect and is hard to differentiate from other feedbacks that individuals receive such as management reaction to incidents and pressures associated with cost and plant performance.  The MIT paper [pg 8] goes on to address management actions and states, “When faced with an incident rate that is too high, the natural and most immediately effective response for managers is to focus the blame on individual compliance with rules.”  Note the conditional phrase, “most immediately effective” as it is an example of single loop learning as described in one of my prior posts (MIT #3).  Certainly the fact that procedure adherence is an issue that recurs at many nuclear plants suggests that the “blame game” has limited and short term effectiveness.

My sense is that the self preservation effect is one that exists deeply embedded within the larger safety climate of the organization.  In that climate how strictly is rule adherence observed?  Are procedures and processes of sufficient quality to enhance observance?  If procedures and processes are ambiguous or even incorrect, and left uncorrected, is there a tacit approval of alternate methods?  The reality is self preservation can act in several directions – it may impel compliance, if that is truly the organizational ethic, or it could rationalize non-compliance if that is an organizational expectation.  Life is difficult.

"Beaten to Death by Croutons"

In the July 27, 2009 Wall Street Journal in the Bookshelf column, there is a review of "Say Everything", a book about blogging.  In the review, there is a comment that "reading blogs is like being beaten to death by croutons".  We hope that readers of our blog do not experience such a fate.  The column goes on to note that the best blogs are those that are concise, current, and precisely targeted.  That is the goal for this blog and we hope it is being met.

Single Loop, Double Loop – What Is This All About? (MIT #3)

One of the potential benefits of academic papers is the opportunity for theoretical structure to be put forward to explain a set of observational experience.  The MIT paper [pg 4] provides such a theory regarding organizational learning and safety culture.  They cite the difference between “single loop” and “double loop” learning as vital to the way organizations respond to performance problems.  Single loop learning “represents the immediate and local actions that individuals and organizations take in response to a perceived problem.”  On the other hand, double loop learning “instead of focusing on enforcement…question[s] why rules were not originally followed…”. 

The MIT authors contend that double loop offers the greatest potential benefit to safety, but can be a difficult challenge since “it threatens existing bureaucratic structures”.  And they add an insight that derives from their (and our) view of safety as a dynamic process: “the immediate success of single loop learning can undermine both the motivation and the perceived need to follow through on more substantial improvement efforts…”

How does the theory of single and double loop resonate with your experience?  Do you see single loop being the dominant response within your organization?

Monday, July 27, 2009

Worth Noting - NRC Chairman's Comments

The link below is to a recent interview with Gregory Jaczko, newly appointed Chairman of the Nuclear Regulatory Commission.  In the interview he indicates that he wants to reinforce the need to maintain a safety culture at the agency and the nuclear industry.  Safety culture has been an ongoing theme of much of Chairman Jaczko's public statements since coming on the Commission four years ago, and still seems to be on his mind.

Link to article

Organizational Learning (MIT #2)

The central question posed in the MIT paper is: What are the contributors to an organization’s ability to learn and sustain a robust safety culture?  According to the authors, “Here, the focus shifts from prescribing elements of an effective safety culture to managers to an examination of why it is that organizations so often fail to learn…. instead of focusing on enforcement, individuals might question why the rules were not originally followed” [p. 4]  In our paper “Practicing Nuclear Safety Management” we ask the same question.  I have reviewed the presentation materials from the NRC’s safety culture meetings earlier this year.  There is almost total emphasis on actions such as safety culture surveys to assess the state of the organization and various remedial measures to correct any deviations from prescribed rules, but no real questioning of what causes personnel to disregard established safety expectations.

If any readers can provide examples, e.g., presentation materials or assessments, where nuclear organizations have attempted to answer the question “Why?”, please provide a comment below along with appropriate links to the references.  It would greatly help the discussion.

Friday, July 24, 2009

Safety Culture Insights from Simulation (MIT #1)

Starting with this post we are reviewing an interesting paper from the Sloan School of Management at MIT - “Preventing Accidents and Building A Culture of Safety: Insights from a Simulation Model.”  While the paper  approaches organizational safety performance on a generic basis – it is not specific to nuclear facilities - it offers many useful insights that are highly applicable to nuclear organizations.  MIT as an institution is known for its work in systems dynamics and simulation modeling.  These disciplines have been used to analyze a variety of safety and accident environments including NASA and nuclear operations.  Also, as you may have noticed on, our development of nuclear safety management simulation models is based on systems dynamics.

Future posts will highlight several of the key insights from this paper and their applicability to issues of nuclear safety management.

Link to paper.

Thursday, July 23, 2009

Can Driving and Texting Coexist?

In the July 18, 2009 online edition of The New York Times, there is an interesting example of the use of a simulation game to illustrate the impact of texting on a driver’s ability to drive safety and react to changing road conditions. Upon completion of the game, the player is provided with a quantification of his driving performance with and without the distraction presented by receiving and sending text messages.

I thought this would be interesting to nuclear safety management practitioners for several reasons. First, it is another illustration of how simulation games can provide realistic experiences of situations they may have to manage in real life - without the risks associated with the real life activity.

Second, this game demonstrates the impact of competing priorities (texting and driving) on the ability of the driver to maintain performance at a consistent level. In the nuclear operations world, safety management failures are often associated with the impact of competing priorities or pressures on the ability of personnel to perform reliably. The driving game suggests that there is always some diminution of performance due to the competing priority of texting. Is that true of nuclear safety management or is it possible, with sufficient training and practice, to manage competing priorities?

Link to article.

Foreign Nuclear Plant Problems Cast a Long Shadow

Recent news items refer to the Swedish power company Vattenfall and problems that have occurred at two of their plants: Ringhals in Sweden and Krummel in Germany.  In both cases the underlying causes of the problems and/or reactions to the events revealed safety culture issues.  These are just two recent examples of the ongoing prevalence of safety culture issues in the global nuclear industry.  Part of the larger picture is the impact on the debate in Germany about any continuing role for nuclear power, even for the existing plants.  The performance of Vattenfall has created political problems for German Chancellor Merkel and the other principals in Germany's nuclear industry.  This highlights the threat of a safety culture failure in one organization to cast a large shadow over the future of the industry.

The situation at Ringhals is discussed here.

There is a lengthy discussion of Krummel on Spiegel Online