Tuesday, July 31, 2012

Regulatory Influence on Safety Culture

In September, 2011 the Nuclear Energy Agency (NEA) and the International Atomic Energy (IAEA) held a workshop for regulators and industry on oversight of licensee management.  “The principal aim of the workshop was to share experience and learning about the methods and approaches used by regulators to maintain oversight of, and influence, nuclear licensee leadership and management for safety, including safety culture.”*

Representatives from several countries made presentations.  For example, the U.S. presentation by NRC’s Valerie Barnes and INPO’s Ken Koves discussed work to define safety culture (SC) traits and correlate them to INPO principles and ROP findings (we previously reviewed this effort here).  Most other presentations also covered familiar territory. 

However, we were very impressed by Prof. Richard Taylor’s keynote address.  He is from the University of Bristol and has studied organizational and cultural factors in disasters and near-misses in both nuclear and non-nuclear contexts.  His list of common contributors includes issues with leadership, attitudes, environmental factors, competence, risk assessment, oversight, organizational learning and regulation.  He expounded on each factor with examples and additional detail. 

We found his conclusion most encouraging:  “Given the common precursors, we need to deepen our understanding of the complexity and interconnectedness of the socio-political systems at the root of organisational accidents.”  He suggests using system dynamics modeling to study archetypes including “maintaining visible convincing leadership commitment in the presence of commercial pressures.”  This is totally congruent with the approach we have been advocating for examining the effects of competing business and safety pressures on management. 

Unfortunately, this was the intellectual high point of the proceedings.  Topics that we believe are important to assessing and understanding SC got short shrift thereafter.  In particular, goal conflict, CAP and management compensation were not mentioned by any of the other presenters.

Decision-making was mentioned by a few presenters but there was no substantive discussion of this topic (the U.K. presenter had a motherhood statement that “Decisions at all levels that affect safety should be rational, objective, transparent and prudent”; the Barnes/Kove presentation appeared to focus on operational decision making).  A bright spot was in the meeting summary where better insight into licensees’ decision making process was mentioned as desirable and necessary by regulators.  And one suggestion for future research was “decision making in the face of competing goals.”  Perhaps there is hope after all.

(If this post seems familiar, last Dec 5 we reported on a Feb 2011 IAEA conference for regulators and industry that covered some of the same ground.  Seven months later the bureaucrats had inched the football a bit down the field.)

*  Proceedings of an NEA/IAEA Workshop, Chester, U.K. 26-28 Sept 2011, “Oversight and Influencing of Licensee Leadership and Management for Safety, Including Safety Culture – Regulatory Approaches and Methods,” NEA/CSNI/R(2012)13 (June 2012).


  1. Dr. Reason made a presentation in 2006 - http://www.vtt.fi/liitetiedostot/muut/HFS06Reason.pdf - which clearly predates both of these NEA/IAEA Workshops at Chester. Reviewing these slide Jim was evidently previewing his 2008 book "The Human Contribution."

    I would encourage readers to consider the Reason presentation (or better yet the whole book) as their benchmark for assessment of both the topic of these NEA/IAEA Workshops and their fruit.

    I suggest that Reason offers an "enterprise world view" where as Taylor conformed his remarks to the "Regulatory Approaches and Methods" institutional boundary established for the Workshops.

    Reason's is an approach of considering performance "from all sides" - while he learns from accidents, the goal is to understand the whole of enterprise self-awareness and its influence on decision-making; he notes:

    "Human Factors is about understanding and improving human performance in the workplace - especially in complex systems." In this view, accident avoidance is the product of the same mindful activities that govern meeting the mission objective or recovering from a schedule setback.

    Production and Protection are two sides of the Performance coin - inextricably related. However like most engineered artifacts Performance unfolds on a dynamic terrain even as its components co-evolve to each others outcomes.

    Reading the summary of the Workshop and Dr. Taylor's keynote I am struck almost paragraph by paragraph by the perverse influence of certain flawed assumptions about "how organizations think" - particularly the bias, taken from our friends the engineers and technologists, that integrated institutional performance is reducible to "root causes" and admits of concise modeling in the flat-worlds of engineering drawings and text procedures.

    Put simply, it is not possible to comprehensively model inorganic, co-evolving, intentional Systems of Systems (e.g. the various National Nuclear Energy Enterprises) with Newtonian causal theory.

    This is not a critiques of modeling per se, rather it is a critique of the institutional mindset - seemingly common to Workshop attendees from NEA/IAEA/NRC/INPO etc. - that modeling is an extension of engineering practice.

    One good indicator of how pervasive this self-defeating "reductionist" convention is can be seen by looking at the normative lexicon and the key memes that appear to be a desired outcome of participants.

    Consider this excerpt from the Executive Summary:

    "The following high-level best practice considerations arose from the workshop discussions:

    "1. Encourage an agreed definition of safety culture and maintain its currency.

    "2. Promote regulatory self assessment of LMfS/SC."

    There is something ontologically muddled about the need for an "agreed definition" followed by an injunction that it needs to be kept "current."

    The second item is a fatally ambiguous statement "regulatory self assessment" would seem an oxymoron - such muddled notions have no place in an Executive Summary.

    Those familiar with the multiple authoritative sources on the topic of Nuclear Safety Culture will recognize a lack of consistency in terminology or consensus about the scope and scale of the topic. But that has not precluded, all the Bigs from weighing in with ostensible standards related to the topic.

    To the best of my knowledge, no writing on the topic represents the product of normative consensus technical standard development including rigorous peer review. Rather these documents have been "crowd-sourced" among gathering of "industry experts" (be they licensee or regulatory workers).

  2. Continuing:

    There is a rather obvious answer for this seeming discrepancy about authoritative parentage that seems to elude the Reductionists at conference after conference. That would be this fact: "Culture" is normed for research purposes in the non-technical domains of psychology, sociology, anthropology, history, and literature. These are poorly represented in the "expert crowds."

    In looking through the lists of participants credentials one typically finds only limited participation of non-technical disciplines. Still, the feeling after reading very many of these documents, emerges that there is an enormous - seemingly irresistible - need to "STANDARDIZE this THING."

    There is a very serious problem with that imperative - the THING under the spotlight is EVOLUTION (more accurately co-evolution in complex intentional Systems of Systems). It hasn't succumbed to reductionist interpretation in 150 years - its not going to fall in place because Nuclear Safety Regulators want it to!

    Until there is a sensible unified view of the non-linear character of Complex, High-Consequence Enterprises - and a revised (i.e. not fully Reductionist) grasp of regulation as tempering the rate of system change, meetings like this are driving the Noise to Signal ratio in the adverse direction.


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