Thursday, January 9, 2014

Safety Culture Training Labs

Not a SC Training Lab
This post highlights a paper* Carlo Rusconi presented at the American Nuclear Society meeting last November.  He proposes the use of “training labs” to develop improved safety culture (SC) through the use of team-building exercises, e.g., role play, and table-top simulations.  Team building increases (a) participants' awareness of group dynamics, e.g., feedback loops, and how a group develops shared beliefs and (b) sensitivity to the viewpoints of others, viewpoints that may differ greatly based on individual experience and expectations.  The simulations pose evolving scenarios that participants must analyze and develop a team approach for addressing.  A key rationale for this type of training is “team interactions, if properly developed and trained, have the capacity to counter-balance individual errors.” (p. 2155)

Rusconi's recognition of goal conflict in organizations, the weakness of traditional methods (e.g., PRA) for anticipating human reactions to emergent issues, the need to recognize different perspectives on the same problem and the value of simulation in training are all familiar themes here at Safetymatters.

Our Perspective

Rusconi's work also reminds us how seldom new approaches for addressing SC concepts, issues, training and management appear in the nuclear industry.  Per Rusconi, “One of the most common causes of incidents and accidents in the industrial sector is the presence of hidden or clear conflicts in the organization. These conflicts can be horizontal, in departments or in working teams, or vertical, between managers and workers.” (p. 2156)  However, we see scant evidence of the willingness of the nuclear industry to acknowledge and address the influence of goal conflicts.

Rusconi focuses on training to help recognize and overcome conflicts.  This is good but one needs to be careful to clearly identify how training would do this and its limitations. For example, if promotion is impacted by raising safety issues or advocating conservative responses, is training going to be an effective remedy?  The truth is there are some conflicts which are implicit (but very real) and hard to mitigate. Such conflicts can arise from corporate goals, resource allocation policies and performance-based executive compensation schemes.  Some of these conflicts originate high in the organization and are not really amenable to training per se.

Both Rusconi's approach and our NuclearSafetySim tool attempt to stimulate discussion of conflicts and develop rules for resolving them.  Creating a measurable framework tied to the actual decisions made by the organization is critical to dealing with conflicts.  Part of this is creating measures for how well decisions embody SC, as done in NuclearSafetySim.

Perhaps this means the only real answer for high risk industries is to have agreement on standards for safety decisions.  This doesn't mean some highly regimented PRA-type approach.  It is more of a peer type process incorporating scales for safety significance, decision quality, etc.  This should be the focus of the site safety review committees and third-party review teams.  And the process should look at samples of all decisions not just those that result in a problem and wind up in the corrective action program (CAP).

Nuclear managers would probably be very reluctant to embrace this much transparency.  A benign view is they are simply too comfortable believing that the "right" people will do the "right" thing.  A less charitable view is their lack of interest in recognizing goal conflicts and other systemic issues is a way to effectively deny such issues exist.

Instead of interest in bigger-picture “Why?” questions we see continued introspective efforts to refine existing methods, e.g., cause analysis.  At its best, cause analysis and any resultant interventions can prevent the same problem from recurring.  At its worst, cause analysis looks for a bad component to redesign or a “bad apple” to blame, train, oversee and/or discipline.

We hate to start the new year wearing our cranky pants but Dr. Rusconi, ourselves and a cadre of other SC analysts are all advocating some of the same things.  Where is any industry support, dialogue, or interaction?  Are these ideas not robust?  Are there better alternatives?  It is difficult to understand the lack of engagement on big-picture questions by the industry and the regulator.


*  C. Rusconi, “Training labs: a way for improving Safety Culture,” Transactions of the American Nuclear Society, Vol. 109, Washington, D.C., Nov. 10–14, 2013, pp. 2155-57.  This paper reflects a continuation of Dr. Rusconi's earlier work which we posted on last June 26, 2013.

1 comment:

  1. Lew,

    You observed: "A less charitable view is their lack of interest in recognizing goal conflicts and other systemic issues is a way to effectively deny such issues exist."

    Consider the description (presumably "state of the art" in Vienna) strategy and approach for safety culture here: http://www.iaea.org/nuclearenergy/nuclearknowledge/schools/NEM-school/archive/2011/topics/topic7/09_IAEA_approach_to_IMS_and_SC_V1107_Trieste.pdf

    Monica Haage is one of the "go to" authorities on nuclear safety culture (one wonders why so many of that cadre are women?). Consider the representations on slides, 3, 4, 5, and 34. Each consists of a metaphor of the form, Safety Culture is like a inorganic monolith.

    This denatured view of institutional culture is commonplace in the NSC literature - I've hypothesized that it reflects a deeply embedded blind spot in the collective psychology of the Global Nuclear Energy Enterprise. Any concept must be reduced to some Newtonian mechanical "system" before it can be incorporated into the Myth of Nuclear's Spectacular Exception (or Integrated Management System as it is termed at IAEA).

    I wish I could see even a few exceptions to this rejection of ecological systems thinking as the basis for modeling human interaction in institutions. Stock and flow models are good tools of course, but they are not intended to calculate from laws of nature, only to simulated some of realities aspects. Given the complexity variances from site to site, it is as you know very difficult to convince plant owners that developing management systems Resilience is about the kind of rehearsal of off-normal archetype situations, not creating hard predictions and behavior forecasts.

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