Wednesday, May 8, 2013

Safety Management and Competitiveness

Jean-Marie Rousseau
We recently came across a paper that should be of significant interest to nuclear safety decision makers.  “Safety Management in a Competitiveness Context” was presented in March 2008 by Jean-Marie Rousseau of the Institut de Radioprotection et de Surete Nucleaire (IRSN).  As the title suggests the paper examines the effects of competitive pressures on a variety of nuclear safety management issues including decision making and the priority accorded safety.  Not surprisingly:

“The trend to ignore or to deny this phenomenon is frequently observed in modern companies.” (p. 7)

The results presented in the paper came about from a safety assessment performed by IRSN to examine safety management of EDF [Electricite de France] reactors including:

“How real is the ‘priority given to safety’ in the daily arbitrations made at all nuclear power plants, particularly with respect to the other operating requirements such as costs, production, and radiation protection or environmental constraints?” (p. 2)

The pertinence is clear as “priority given to safety” is the linchpin of safety culture policy and expected behaviors.  In addition the assessment focused on decision-making processes at both the strategic and operational levels.  As we have argued, decisions can provide significant insights into how safety culture is operationalized by nuclear plant management. 

Rousseau views nuclear operations as a “highly complex socio-technical system” and his paper provides a brief review of historical data where accidents or near misses displayed indications of the impact of competing priorities on safety.  The author notes that competitiveness is necessary just as is safety and as such it represents another risk that must be managed at organizational and managerial levels.  This characterization is intriguing and merits further reflection particularly by regulators in their pursuit of “risk informed regulation”.  Nominally regulators apply a conceptualization of risk that is hardware and natural phenomena centric.  But safety culture and competitive pressures also could be justified as risks to assuring safety - in fact much more dynamic risks - and thus be part of the framework of risk informed regulation.*  Often, as is the case with this paper, there is some tendency to assert that achievement of safety is coincident with overall performance excellence - which in a broad sense it is - but notwithstanding there are many instances where there is considerable tension - and potential risk.

Perhaps most intriguing in the assessment is the evaluation of EDF’s a posteriori analyses of its decision making processes as another dimension of experience feedback.**   We quote the paper at length:

“The study has pointed out that the OSD***, as a feedback experience tool, provides a priori a strong pedagogic framework for the licensee. It offers a context to organize debates about safety and to share safety representations between actors, illustrated by a real problematic situation. It has to be noticed that it is the only tool dedicated to “monitor” the safety/competitiveness relationship.

"But the fundamental position of this tool (“not to make judgment about the decision-maker”) is too restrictive and often becomes “not to analyze the decision”, in terms of results and effects on the given situation.

"As the existence of such a tool is judged positively, it is necessary to improve it towards two main directions:
- To understand the factors favouring the quality of a decision-making process. To this end, it is necessary to take into account the decision context elements such as time pressure, fatigue of actors, availability of supports, difficulties in identifying safety requirements, etc.
- To understand why a “qualitative decision-making process” does not always produce a “right decision”. To this end, it is necessary to analyze the decision itself with the results it produces and the effects it has on the situation.” (p. 8)

We feel this is a very important aspect that currently receives insufficient attention.  Decisions can provide a laboratory of safety management performance and safety culture actualization.  But how often are decisions adequately documented, preserved, critiqued and shared within the organization?  Decisions that yield a bad (reportable) result may receive scrutiny internally and by regulators but our studies indicate there is rarely sufficient forensic analysis - cause analyses are almost always one dimensional and hardware and process oriented.  Decisions with benign outcomes - whether the result of “good” decision making or not - are rarely preserved or assessed.  The potential benefits of detailed consideration of decisions have been demonstrated in many of the independent assessments of accidents (Challenger, Columbia, BP Texas Oil Refinery, etc.) and in research by Perin and others. 

We would go a step further than proposed enhancements to the OSD.  As Rousseau notes there are downsides to the routine post-hoc scrutiny of actual decisions - for one it will likely identify management errors even in the absence of a bad decision outcome.  This would be one more pressure on managers already challenged by a highly complex decision environment.  An alternative is to provide managers the opportunity to “practice” making decisions in an environment that supports learning and dialogue on achieving the proper balances in decisions - in other words in a safety management simulator.  The industry requires licensed operators to practice operations decisions on a simulator for similar reasons - why not nuclear managers charged with making safety decisions?

*  As the IAEA has noted, “A danger of concentrating too much on a quantitative risk value that has been generated by a PSA [probabilistic safety analysis] is that...a well-designed plant can be operated in a less safe manner due to poor safety management by the operator.”  IAEA-TECDOC-1436, Risk Informed Regulation of Nuclear Facilities: Overview of the Current Status, February 2005.

**  EDF implemented safety-availability-Radiation-Protection-environment observatories (SAREOs) to increase awareness of the arbitration between safety and other performance factors. SAREOs analyze in each station the quality of the decision-making process and propose actions to improve it and to guarantee compliance with rules in any circumstances [“Nuclear Safety: our overriding priority” EDF Group‟s file responding to FTSE4Good nuclear criteria] 

***  Per Rousseau, “The OSD (Observatory for Safety/Availability) is one of the “safety management levers” implemented by EDF in 1997. Its objective is to perform retrospective analyses of high-stake decisions, in order to improve decision-making processes.” (p. 7)

1 comment:

  1. This review by French regulatory authorities offers a too rarely gained insight into the mindset that is characteristically behind the concepts and precepts of "risk-informed decision-making" as articulated in the TECDOC 1436 footnoted.

    Rare that is because current thinking in regulatory agency thinking continues to presume that adequate protection can be achieved without regard to the ability of licensed enterprises to sustain themselves economically.

    The term "competition" as used in this account seems to be driven by the onset of French national policy to open electricity markets to less control by government-owned and rate regulated monopoly enterprise.

    There seems to be a presumption in the design of the assessment that in the future plant owners and operators will be under external pressure to conform with market pricing.

    It seems significant that the regulatory authority offers no preconditional analysis of the regulator's own sense of how this change in national policy will impact its concept of responsibility for assurance of adequate protection given any tacit expectation by the public that perhaps a low margin of safety is acceptable in return for reduced cost of supply.

    From the report I conclude the regulatory authorities anticipate that whatever transfers of risk share might occur during privatization and price deregulation that the regulatory system is unaffected. Perhaps not a surprising stance, but a crucial one nonetheless - particularly if a taken-for-granted one.

    In reviewing the TECDOC 1436 I was struck by how thoroughly persuaded the guidance developers seem to be that the design and conduct of regulation exists apart from the enterprises conducting regulated activity.

    So long as the LNTH and the ALARA Principle enable the establishment of arbitrary and uncosted consequence findings, reference in 1436 to "Integrated Decision Making for Plant Safety Issues" will be problematic.

    The elaborate and in-depth dissociation of the social/cultural and technical aspects of nuclear energy enterprises in effect contradicts national policy tending toward more Whole-Risk Reckoned and performance-based sense and decision-making.

    TECDOC 1436 notes the distinction among regulatory regimes with some being highly prescriptive and others taking a more goal-setting, tailored and performance-based strategy to achievement of basic protection principles.

    The TECDOC seems to suggest that Integrated Decision Making approaches to "risk-informed regulation" is applicable to both strategies. I would be more sanguine about this conclusion if the French approach to assessment for "competition" resilience of safety decision making were to become a normative approach.

    This conclusion is based in part upon the complete absence of reference to production efficiency (short term or long term) in the literature of "risk-informed regulation" - that combined with the presumption that a collection of regulators are suited by experience and competence to assess processes related to balancing both nuclear safety and other enterprise risk factors.


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