In April 1995 the American Nuclear Society (ANS) sponsored a nuclear safety culture (SC) conference in Vienna. This was a large undertaking, with over 80 presentations; the proceedings are almost 900 pages in length.* Presenters included industry participants, regulators, academics and consultants. 1995 was early in the post-Soviet era and the new openness (and concerns about Soviet reactors) led to a large number of presenters from Russia, Ukraine and Eastern Europe. This post presents some conference highlights on topics we emphasize on Safetymatters.
For us, decision making should be systemic, i.e., consider all relevant inputs and the myriad ways a decision can affect consequences. The same rigor should be applied to all kinds of decisions—finance, design, operations, resource allocation, personnel, etc. Safety should always have the highest priority and decisions should accord safety its appropriate consideration. Some presenters echoed this view.
“Safety was (and still is) seen as being vital to the success of the industry and hence the analysis and assessment of safety became an integral part of management decision making” (p. 41); “. . . in daily practice: overriding priority to safety is the principle, to be taken into account before making any decision” (p. 66); and “The complexity of operations implies a systemic decision process.” (p. 227)
The relationship between leadership and decisions was mentioned. “The line management are a very important area, as they must . . . realise how their own actions and decisions affect Safety Culture. The wrong actions, or perceived messages could undermine the work of the team leaders” (p. 186); “. . . statements alone do not constitute support; in the intermediate and long-term, true support is demonstrated by behavior and decision and not by what is said.” (p. 732)
Risk was recognized as a factor in decision making. “Risk culture yields insights that permit balanced safety vs.cost decisions to be made” (p. 325); “Rational decision making is based on facts, experience, cognitive (mental) models and expected outcomes giving due consideration to uncertainties in the foregoing and the generally probabilistic nature of technical and human matters. Conservative decision making is rational decision making that is risk-averse. A conservative decision is weighted in favor of risk control at the expense of cost.” (p. 435)
In sum, nuclear thought leaders knew what good decision making should look like—but we still see cases that do not live up to that standard.
Rewards or compensation were mentioned by people from nuclear operating organizations. Incentive-based compensation was included as a key aspect of the TEPCO management approach (p. 551) and a nuclear lab manager recommended using monetary compensation to encourage cooperation between organizational departments. (p. 643) A presenter from a power plant said “A recognition scheme is in place . . . to recognise and reward individuals and teams for their contribution towards quality improvement and nuclear safety enhancement.” (p. 805)
Rewards were also mentioned by several presenters who did not come from power plants. For example, the reward system should stress safety (p. 322); rewards should be given for exhibiting a “caring attitude” about SC (p. 348) and to people who call attention to safety problems. (p. 527) On the flip side, a regulator complained about plants that rewarded behavior that might cause safety to erode. (pp. 651, 656)
Even in 1995 the presentations could have been stronger since INSAG-4** is so clear on the topic: “Importantly, at operating plants, systems of reward do not encourage high plant output levels if this prejudices safety. Incentives are therefore not based on production levels alone but are also related to safety performance.” (INSAG-4, p. 11) Today, our own research has shown that nuclear executives’ compensation often favors production.
We have always favored nuclear organizational mental models that consider feedback loops, time delays, adaptation, evolution and learning—a systems approach. Presenters’ references to a system include “commercial, public, and military operators of complex high reliability socio-technical systems” (p. 260); “. . . assess the organisational, managerial and socio-technical influences on the Safety Culture of socio-technical systems such as nuclear power plants” (p. 308); “Within the complex system such as . . . [a] nuclear power plant there is a vast number of opportunities for failures to stay hidden in the system” (p. 541); and “It is proposed that the plant should be viewed as an integrated sociotechnical system . . .” (p. 541)
There are three system-related presentations that we suggest you read in their entirety; they have too many good points to summarize here. One is by Electricité de France (EdF) personnel (pp. 193-201), another by Constance Perin (pp. 330-336) and a third by John Carroll (pp. 338-345).
Here’s a sample, from Perin: “Through self-analysis, nuclear organizations can understand how they currently respond socially, culturally, and technically to such system characteristics of complexity, density, obscured signals, and delayed feedback in order to assure their capacities for anticipating, preventing, and recovering from threats to safety.” (p. 330) It could have been written yesterday.
The Role of the Regulator
By 1995 INSAG-4 had been published and generally accepted by the nuclear community but countries were still trying to define the appropriate role for the regulator; the topic merited a half-dozen presentations. Key points included the regulator (1) requiring that an effective SC be established, (2) establishing safety as a top-level goal and (3) performing some assessment of a licensee’ safety management system (either directly or part of ordinary inspection duties). There was some uncertainty about how to proceed with compliance focus vs. qualitative assessment.
Today, at least two European countries are looking at detailed SC assessment, in effect, regulating SC. In the U.S., the NRC issued a SC policy statement and performs back-door, de facto SC regulation through the “bring me another rock” approach.
So conditions have changed in regulatory space, arguably for the better when the regulator limits its focus to truly safety-significant activities.
In 1995, some (but not all) people held what we’d call a contemporary view of SC. For example, “Safety culture constitutes a state of mind with regard to safety: the value we attribute to it, the priority we give it, the interest we show in it. This state of mind determines attitudes and behavior.” (p. 495)
But some things have changed. For example, several presentations mentioned SC surveys—their design, administration, analysis and implications. We now (correctly) understand that SC surveys are a snapshot of safety climate and only one input into a competent SC assessment.
And some things did not turn out well. For example, a TEPCO presentation said “the decision making process is governed by the philosophy of valuing harmony highly so that a conclusion preferred by all the members is chosen as far as possible when there are divided opinions.” (p. 583) Apparently harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards.
* A. Carnino and G. Weimann, ed., “Proceedings of the International Topical Meeting on Safety Culture in Nuclear Installations,” April 24-28, 1995 (Vienna: ANS Austria Local Section, 1995). Thanks to Bill Mullins for unearthing this document.
** International Nuclear Safety Advisory Group, “Safety Culture,” Safety Series No. 75-INSAG-4, (Vienna: IAEA, 1991). INSAG-4 included a definition of SC, a description of SC components, and illustrative evidence that the components exist in a specific organization.