Wednesday, June 30, 2010

Can Safety Culture Be Regulated? (Part 2)

Part 1 of this topic covered the factors important to safety culture and amenable to measurement or assessment, the “known knowns.”   In this Part 2 we’ll review other factors we believe are important to safety culture but cannot be assessed very well, if at all, the “known unknowns” and the potential for factors or relationships important to safety culture that we don’t know about, the “unknown unknowns.”

Known Unknowns

These are factors that are probably important to regulating safety culture but cannot be assessed or cannot be assessed very well.  The hazard they pose is that deficient or declining performance may, over time, damage and degrade a previously adequate safety culture.

Measuring Safety Culture

This is the largest issue facing a regulator.  There is no meter or method that can be applied to an organization to obtain the value of some safety culture metric.  It’s challenging (impossible?) to robustly and validly assess, much less regulate, a variable that cannot be measured.  For a more complete discussion of this issue, please see our June 15, 2010 post

Trust

If the plant staff does not trust management to do the right thing, even when it costs significant resources, then safety culture will be negatively affected.  How does one measure trust, with a survey?  I don’t think surveys offer more than an instantaneous estimate of any trust metric’s value.

Complacency

Organizations that accept things as they are, or always have been, and see no opportunity or need for improvement are guilty of complacency or worse, hubris.  Lack of organizational reinforcement for a questioning attitude, especially when the questions may result in lost production or financial costs, is a de facto endorsement of complacency.  Complacency is often easy to see a posteriori, hard to detect as it occurs.  

Management competence

Does management implement and maintain consistent and effective management policies and processes?  Is the potential for goal conflict recognized and dealt with (i.e., are priorities set) in a transparent and widely accepted manner?  Organizations may get opinions on their managers’ competence, but not from the regulator.

The NRC does not evaluate plant or owner management competence.  They used to, or at least appeared to be trying to.  Remember the NRC senior management meetings, trending letters, and the Watch List?  While all the “problem” plants had material or work process issues, I believe a contributing factor was the regulator had lost confidence in the competence of plant management.  This system led to the epidemic of shutdown plants in the 1990s.*   In reaction, politicians became concerned over the financial losses to plant owners and employees, and the Commission become concerned that the staff’s explicit/implicit management evaluation process was neither robust and nor valid.

So the NRC replaced a data-informed subjective process with the Reactor Oversight Program (ROP) which looks at a set of “objective” performance indicators and a more subjective inference of cross-cutting issues: human performance, finding and fixing problems (CAP, a known), and management attention to safety and workers' ability to raise safety issues (SCWE, part known and part unknown).  I don’t believe that anyone, especially an outsider like a regulator, can get a reasonable picture of a plant’s safety culture from the “Rope.”  There most certainly are no leading or predictive safety performance indicators in this system.

External influences

These factors include changes in plant ownership, financial health of the owner, environmental regulations, employee perceptions about management’s “real” priorities, third-party assessments, local socio-political pressures and the like.  Any change in these factors could have some effect on safety culture.

Unknown Unknowns

These are the factors that affect safety culture but we don’t know about.  While a lot of smart people have invested significant time and effort in identifying factors that influence safety culture, new possibilities can still emerge.

For example, a new factor has just appeared on our radar screen: executive compensation.  Bob Cudlin has been researching the compensation packages for senior nuclear executives and some of the numbers are eye-popping, especially in comparison to historical utility norms.  Bob will soon post on his findings, including where safety figures into the compensation schemes, an important consideration since much executive compensation is incentive-based.

In addition, it could well be that there are interactions (feedback loops and the like), perhaps varying in structure and intensity over time, between and among the known and unknown factors, that have varying impacts on the evolutionary arc of an organization’s safety culture.  Because of such factors, our hope that safety culture is essentially stable, with a relatively long decay time, may be false; safety culture may be susceptible to sudden drop-offs. 

The Bottom Line

Can safety culture be regulated?  At the current state of knowledge, with some “known knowns” but no standard approach to measuring safety culture and no leading safety performance indicators, we’d have to say “Yes, but only to some degree.”  The regulator may claim to have a handle on an organization’s safety culture through SCWE observations and indirect evidence, but we don’t think the regulator is in a good position to predict or even anticipate the next issue or incident related to safety culture in the nuclear industry. 

* In the U.S. in 1997, one couldn’t swing a dead cat without hitting a shutdown nuclear power plant.  17 units were shutdown during all or part of that year, out of a total population of 108 units. 

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