Thursday, February 28, 2013

The Safety Culture Common Language Path Forward (Update)

The intent of the NRC's Safety Culture Common Language Path Forward initiative is to describe safety culture (SC) attributes at a more detailed level than the NRC’s SC policy statement.  On January 29-30, 2013 the NRC held a public workshop to finalize the draft SC common language.*  The document they issued after the workshop** contains attribute definitions and examples of behavior and artifacts that support or embody each attribute.  This document will be used by the NRC to develop a NUREG containing the final common language.

Last March we posted on a draft produced by previous workshops, focusing on areas we consider critical for a strong SC: decision making, corrective action, management incentives and work backlogs.  In that post, our opinion was that decision making and corrective action were addressed in a satisfactory manner, the treatment of incentives was minimally acceptable and backlogs were all but ignored.

So, how does the “final” language treat the same subject areas?  Is it better than the draft comments we reviewed last March?  The arrows indicate whether the final version is better
, the same → or worse ↓.

Decision making – Good.  Decision making incorporates “. . . a consistent, systematic approach to make decisions” (p. 51) and a conservative bias, i.e., “. . . decision-making practices that emphasize prudent choices over those that are simply allowable. A proposed action is determined to be safe in order to proceed, rather than unsafe in order to stop.” (p. 52)  In addition, communicating, explaining and justifying individual decisions is mentioned throughout the document. 

Goal conflict is addressed under leader behavior “. . . when resolving apparent conflicts between nuclear safety and production” (p. 12) and leaders “avoid unintended or conflicting messages that may be conveyed by operational decisions” (p. 37); work process “activities are coordinated to address conflicting or changing priorities.” (p. 23) 

Corrective action – Satisfactory
.  The section on problem identification and resolution (pp. 13-17) is suffused with desirable characteristics of corrective actions and the CAP.  A good CAP has a low threshold for identifying issues and problems are thoroughly evaluated.  Corrective actions are timely, effective and prevent recurrence of problems.  Periodic analysis of CAP and other data is used to identify any programmatic or common cause issues.

Management incentives – Unsatisfactory.  The section on incentives appears to focus on workers, not managers: “Leaders ensure incentives, sanctions, and rewards are aligned with nuclear safety policies and reinforce behaviors and outcomes which reflect safety as the overriding priority.” (p. 7)  This is even less complete than the single sentence that appeared in last year's draft: “Senior management incentive program [sic] reflect a bias toward long-term plant performance and safety.”*** The failure to mention the senior management incentive program is a serious shortcoming.

Backlogs – Minimally Acceptable.  Backlogs are specifically mentioned in maintenance and engineering (p. 24) and document changes (p. 25).  In addition, problem evaluation, corrective actions, CAP trending analyses, operating experience lessons and many administrative activities are supposed to be addressed in a “timely” manner.  I hope that implies that backlogs in these areas should not be too large.     

But attention to backlogs is still important.  Repeating what we said last year, “Excessive backlogs are demoralizing; they tell the workforce that accomplishing work to keep the plant, its procedures and its support processes in good repair or up-to-date is not important.  Every “problem plant” we worked on in the late 1990s had backlog issues.”


Overall, this latest document is an improvement over the March 2012 version but still short of what we'd like to see.

*  M.J. Keefe (NRC) to U.S. Shoop (NRC), “Summary of the January 29-30, Workshop to Develop Common Language for Safety Culture” (Feb. 7, 2013)  ADAMS ML13038A059.

**  Nuclear Safety Culture Common Language 4th Public Workshop January 29-31, 2013  ADAMS ML13031A343.

***  U.S. Shoop (NRC) to J. Giitter (NRC), “Safety Culture Common Language Path Forward” (Mar. 19, 2012) p. 12.  ADAMS ML12072A415.

Friday, February 22, 2013

Personal and Organizational Habits: A Threat to Safety Culture?

A book I received as a gift got me thinking about habits: The Power of Habit: Why We Do What We Do in Life and Business by Charles Duhigg.*  Following is a summary of selected points that we can relate to safety culture (SC) and our assessment of the book's usefulness for SC aficionados

Habits are automatic activity sequences people exhibit when they perceive specific triggering cues in the environment.  Habit behavior is learned, and directed toward achieving some reward, which may be physical or psychological.  The brain creates habits to conserve energy and operate more efficiently; without habits people would be overwhelmed by the countless decisions they would have to make to complete the most mundane tasks, e.g., driving to work.

People use habits at work to increase their productivity and get things done.  Unfortunately, habits can allow potential safety threats to slip through the cracks.  How?  Because while Rational Man considers all available alternatives before making a decision, and Satisficing Man consciously picks the first alternative that looks good enough, Habit Man is carrying out his behavior more or less unconsciously.  If the work environment contains weak signals of nascent problems or external environmental threats, then people following their work habits are not likely to pick up such signals.  Bad work habits may be the handmaiden of complacency.

Organizations also have habits (sometimes called routines).  Routines are important because, without them, it would be much more difficult to get work accomplished.  Routines reduce uncertainty throughout the organization and create truces between competing groups and individuals.  Some routines are the result of decisions made long ago, others evolve organically.  They are so embedded in the organization that no one questions them.**

Duhigg includes many case studies involving individuals and organizations.  One organizational case study is worth repeating because it focuses on changing safety habits.

When Paul O'Neill*** became Alcoa CEO in 1987 he made improving worker safety his first initiative.  He believed the habits that led to safety were keystone habits and if they could be changed (improved) then other business routines would follow.  In this case, he was correct.  Proper work routines are also the safest ones; over time quality and productivity improved and the stock price rose.  The new routines resulted in new values, e.g., intolerance for unsafe practices,  becoming ingrained in the culture.

The bottom line

I'd put this book in the self-help category—the strongest sections focus on individuals, how they can be crippled by bad habits, and how they can change those habits.  With the exception of the Alcoa case, this book is not really about SC so I'm not recommending it for our readers but it does stimulate thought about the role of unconscious habits and routines in reinforcing a strong SC, or facilitating its decay.  If work habits or routines become frozen and cannot (or will not) adjust to changes in the external or task environment, then performance problems will almost surely arise.      

*  C. Duhigg,  The Power of Habit: Why We Do What We Do in Life and Business (New York: Random House 2012).  To simplify this post and focus on a linkage to SC, many of the book's concepts are not mentioned in the main text above.  For example, when the brain links the reward back to the cue, it creates a neurological craving; the stronger the craving, the more likely the cue will trigger the activities that lead to the reward.  Bad habits can be changed by inserting a new activity routine between the cue and the reward.  A belief that change is possible is needed before people will attempt to change their habits; willpower and self-discipline are necessary for changes to stick.  A real (or manufactured) crisis can make organizational routines amenable to change.

**  The result can be the worst kind of machine bureaucracy: rigid hierarchies, organizational silos, narrow employee responsibilities, and no information shared or questions asked.

***  O'Neill later served as U.S. Treasury Secretary during 2001-2002.

Sunday, February 10, 2013

Safety Culture - Lessons from the Social Science Literature

In 2011 the NRC contracted with the Pacific Northwest National Laboratory to conduct a review of social science literature related to safety culture (SC) and methods for evaluating interventions proposed to address issues identified during SC assessments.  The resultant report* describes how traits such as leadership, trust, respect, accountability, and continuous learning are discussed in the literature. 

The report is heavily academic but not impenetrable and a good reference work on organizational culture theory and research.  I stumbled on this report in ADAMS and don't know why it hasn't had wider distribution.  Perhaps it's seen as too complicated or, more importantly, doesn't exactly square with the NRC/NEI/industry Weltanschauung when the authors say things like:  

“There is no simple recipe for developing safety culture interventions or for assessing the likelihood that these interventions will have the desired effects.” (p. 2)

“The literature consistently emphasizes that effecting directed behavioral, cognitive, or cultural change in adults and within established organizations is challenging and difficult, requires persistence and energy, and is frequently unsuccessful.” (p. 7)

This report contains an extensive review of the literature and it is impossible to summarize in a blog post.  We'll provide an overview of the content, focusing on interesting quotes and highlights, then revisit Schein's model and close with our two cents worth.

Concept of safety culture

This section begins with the definition of SC and the nine associated traits in the NRC SC policy statement, and compares them with other organizations' (IAEA, NEI, DOE et al) efforts. 

The Schein model is proposed as a way to understand “why things are as they are” as a starting point upon which to build change strategies aimed at improving organizational performance.  An alternative approach is to define the characteristics of an ideal SC, then evaluate how much the target organization differs from the ideal, and use closing the gap as the objective for corrective strategies.  The NEI approach to SC assessment reflects the second conceptual model.  A third approach, said to bridge the difference between the first two, is proposed by holistic thinkers such as Reason who focus on overall organizational culture. 

This is not the usual “distinction without a difference” argument that academics often wage.  Schein's objective is to improve organizational performance; the idealists' objective is to make an organization correspond to the ideal model with an assumption that desired performance will follow. 

The authors eventually settle on the high reliability organization (HRO) literature as providing the best basis for linking individual and organizational assumptions with traits and mechanisms for affecting safety performance.  Why?  The authors say the HRO approach identifies some of the specific mechanisms that link elements of a culture to safety outcomes and identifies important relationships among the cultural elements. (p. 15)  A contrary explanation is that the authors wanted to finesse their observation that Schein (beloved by NRC) and NEI have different views of the the basis that should be used for designing SC improvement initiatives.

Building blocks of culture 

The authors review the “building blocks” of culture, highlighting areas that correspond to the NRC safety culture traits.  If an organization wants to change its culture, it needs to decide which building blocks to address and how to make and sustain changes.

Organizational characteristics that correspond to NRC SC traits include leadership, communication, work processes, and problem identification and resolution.  Leadership and communication are recognized as important in the literature and are discussed at length.  However, the literature review offered thin gruel in the areas of work processes, and problem identification and resolution; in other words, the connections between these traits and SC are not well-defined. (pp. 20-25)

There is an extensive discussion of other building blocks including perceptions, values, attitudes, norms**, beliefs, motivations, trust, accountability and respect.  Implications for SC assessment and interventions are described, where available.  Adaptive processes such as sense making and double-loop learning are also mentioned.

Change and change management

The authors review theories of individual and organizational change and change management.  They note that planned interventions need to consider other changes that may be occurring because of dynamic processes between the organization and its environment and within the organization itself.

Many different models for understanding and effecting organizational change are described.  As the authors summarize: “. . . change is variously seen as either pushed by problems or pulled by visions or goals; as purposive and volitional or inadvertent and emergent; as a one-time event or a continuous process. It is never seen as easy or simple.” (p. 43)

The authors favor Montaño and Kaspryzk’s Integrated Behavioral Model, shown in the figure below, as a template for designing and evaluating SC interventions.  It's may be hard to read here but suffice to say a lot of factors go into an individual's decision to perform a new behavior and most or all of these factors should be considered by architects of SC interventions.  Leadership can provide input to many of these factors (through communication, modeling desired behavior, including decision making) and thus facilitate (or impede) desired behavioral changes.

From Montaño and Kaspryzk
Resistance to change can be wide-spread.  Effective leadership is critical to overcoming resistance and implementing successful cultural changes.  “. . . leaders in formal organizations have the power and responsibility to set strategy and direction, align people and resources, motivate and inspire people, and ensure that problems are identified and solved in a timely manner.” (p. 54)

Lessons from initiatives to create other specific organizational cultures

The authors review the literature on learning organizations, total quality management and quality organizations, and sustainable organizations for lessons applicable to SC initiatives.  They observe that this literature “is quite consistent in emphasizing the importance of recognizing that organizations are multi-level, dynamic systems whose elements are related in complex and multi-faceted ways, and that culture mirrors this dynamic complexity, despite its role in socializing individuals, maintaining stability, and resisting change.” (p. 61)

“The studies conducted on learning, quality, and sustainable organizations and their corresponding cultures contain some badly needed information about the relationship among various traits, organizational characteristics, and behaviors that could help inform the assessment of safety cultures and the design and evaluation of interventions.” (p. 65)  Topics mentioned include management leadership and commitment, trust, respect, shared vision and goals, and a supportive learning environment.

Designing and evaluating targeted interventions 

This section emphasizes the potential value of the evaluation science*** approach (used primarily in health care) for the nuclear industry.  The authors go through the specific steps for implementing the evaluation science model, drilling down in spots to describe additional tools, such as logic modeling (to organize and visualize issues, interventions and expected outcomes), that can be used.  There is a lot of detail here including suggestions for how the NRC might use backward mapping and a review of licensee logic models to evaluate SC assessment and intervention efforts.  Before anyone runs off to implement this approach, there is a major caveat:

“The literature on the design, implementation, and evaluation of interventions to address identified shortcomings in an organization’s safety culture is sparse; there is more focus on creating a safety culture than on intervening to correct identified problems.” (p. 67)

Relation to Schein

Schein's model of culture (shown on p. 8) and prescriptions for interventions are the construct most widely known to the nuclear industry and its SC practitioners.  His work is mentioned throughout the PNNL report.  Schein assumes that cultural change is a top-down effort (so leadership plays a key role) focused on individuals.  Change is implemented using an unfreeze—replace/move—refreeze strategy.  Schein's model is recommended in the program theory-driven evaluation science approach.  The authors believe Schein's “description of organizational culture and change does one of the best jobs of conveying the “cultural” dimensions in a way that conveys its embeddedness and complexity.” (p. 108)  The authors note that Schein's cultural levels interact in complex ways, requiring a systems approach that relates the levels to each other, SC to the larger organizational culture, and culture to overall organizational functioning.

So if you're acquainted with Schein you've got solid underpinnings for reading this report even if you've never heard of any of the over 300 principal authors (plus public agencies and private entities) mentioned therein.  If you want an introduction to Schein, we have posted on his work here and here.


This is a comprehensive and generally readable reference work.  SC practitioners should read the executive summary and skim the rest to get a feel for the incredible number of theorists, researchers and institutions who are interested in organizational culture in general and/or SC in particular.  The report will tell you what a culture consists of and how you might go about changing it.

We have a few quibbles.  For example, there are many references to systems but very little to what we call systems thinking (an exception is Senge's mention of systems thinking on p. 58 and systems approach on p. 59).  There is no recognition of the importance of feedback loops.

The report refers multiple times to the dynamic interaction of the factors that comprise a SC but does not provide any model of those interactions.  There is limited connectivity between potentially successful interventions and desired changes in observable artifacts.  In other words, this literature review will not tell you how to improve your plant's decision making process or corrective action program, resolve goal conflicts or competing priorities, align management incentives with safety performance, or reduce your backlogs.

*  K.M. Branch and J.L. Olson, “Review of the Literature Pertinent to the Evaluation of Safety Culture Interventions” (Richland, WA: Pacific Northwest National Laboratory, Dec. 2011).  ADAMS ML13023A054

**  The authors note “The NRC safety culture traits could also be characterized as social norms.” (p. 28)

***  “. . . evaluation science focuses on helping stakeholders diagnose organization and social needs, design interventions, monitor intervention implementation, and design and implement an evaluation process to measure and assess the intended and unintended consequences that result as the intervention is implemented.” (p. 69)