This publication appeared on a nuclear safety online discussion board.* It is a high-level review of significant commercial nuclear industry incidents and the subsequent development and implementation of related lessons learned. This post summarizes and evaluates the document then focuses on its treatment of nuclear safety culture (SC).
The authors cover Three Mile Island (1979), Chernobyl (1986), Le Blayais [France] plant flooding (1999), Davis-Besse (2002), U.S. Northeast Blackout (2003) and Fukushima-Daiichi (2011). There is a summary of each incident followed by the major lessons learned, usually gleaned from official reports on the incident.
Some lessons learned led to significant changes in the nuclear industry, other lessons learned were incompletely implemented or simply ignored. In the first category, the creation of INPO (Institute of Nuclear Power Operations) after TMI was a major change.** On the other hand, lessons learned from Chernobyl were incompletely implemented, e.g., WANO (World Association of Nuclear Operators, a putative “global INPO”) was created but it has no real authority over operators. Fukushima lessons learned have focused on design, communication, accident response and regulatory deficiencies; implementation of any changes remains a work in progress.
The authors echo some concerns we have raised elsewhere on this blog. For example, they note “the likelihood of a rare external event at some site at some time over the lifetime of a reactor is relatively high.” (p. 16) And “the industry should look at a much higher probability of problems than is implied in the “once in a thousand years” viewpoint.” (p. 26) Such cautions are consistent with Taleb's and Dédale's warnings that we have discussed here and here.
The authors also say “Lessons can also be learned from successes.” (p. 3) We agree. That's why our recommendation that managers conduct periodic in-depth analyses of plant decisions includes decisions that had good outcomes, in addition to those with poor outcomes.
Arguably the most interesting item in the report is a table that shows deaths attributable to different types of electricity generation. Death rates range from 161 (per TWh) for coal to 0.04 for nuclear. Data comes from multiple sources and we made no effort to verify the analysis.***
On Safety Culture
The authors say “. . . a culture of safety must be adopted by all operating entities. For this to occur, the tangible benefits of a safety culture must become clear to operators.” (p. 2, repeated on p. 25) And “The nuclear power industry has from the start been aware of the need for a strong and continued emphasis on the safety culture, . . .” (p. 24) That's it for the direct mention of SC.
Such treatment is inexcusably short shrift for SC. There were obvious, major SC issues at many of the plants the authors discuss. At Chernobyl, the culture permitted, among other things, testing that violated the station's own safety procedures. At Davis-Besse, the culture prioritized production over safety—a fact the authors note without acknowledging its SC significance. The combination of TEPCO's management culture which simply ignored inconvenient facts and their regulator's “see no evil” culture helped turn a significant plant event at Fukushima into an abject disaster.
It's not clear who the intended audience is for this document. It was written by two professors under the aegis of the American Academy of Arts and Sciences, an organization that, among other things, “provides authoritative and nonpartisan policy advice to decision-makers in government, academia, and the private sector.”**** While it is a nice little history paper, I can't see it moving the dial in any public policy discussion. The scholarship in this article is minimal; it presents scant analysis and no new insights. Its international public policy suggestions are shallow and do not adequately recognize disparate, even oppositional, national interests. Perhaps you could give it to non-nuclear folks who express interest in the unfavorable events that have occurred in the nuclear industry.
* E.D. Blandford and M.M. May, “Lessons Learned from “Lessons Learned”: The Evolution of Nuclear Power Safety after Accidents and Near-Accidents” (Cambridge, MA: American Academy of Arts and Sciences, 2012). Thanks to Madalina Tronea for publicizing this article on the LinkedIn Nuclear Safety group discussion board. Dr. Tronea is the group's founder/moderator.
** This publication is a valentine for INPO and, to a lesser extent, the U.S. nuclear navy. INPO is hailed as “extraordinarily effective” (p. 12) and “a well-balanced combination of transparency and privacy; . . .” (p. 25)
*** It is the only content that demonstrates original analysis by the authors.
**** American Academy of Arts and Sciences website (retrieved Jan. 20, 2014).
Tuesday, January 21, 2014
Thursday, January 9, 2014
|Not a SC Training Lab|
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.
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.