Tuesday, May 26, 2015

Safety Culture “State of the Art” in 2002 per NUREG-1756

Here’s a trip down memory lane.  Back in 2002 a report* on the “state of the art” in safety culture (SC) thinking, research and regulation was prepared for the NRC Advisory Committee on Reactor Safeguards.  This post looks at some of the major observations of the 2002 report and compares them with what we believe is important today.

The report’s Abstract provides a clear summary of the report’s perspective:  “There is a widespread belief that safety culture is an important contributor to the safety of operations. . . . The commonly accepted attributes of safety culture include good organizational communication, good organizational learning, and senior management commitment to safety. . . . The role of regulatory bodies in fostering strong safety cultures remains unclear, and additional work is required to define the essential attributes of safety culture and to identify reliable performance indicators.” (p. iii) 

General Observations on Safety Performance 

A couple of quotes included in the report reflect views on how safety performance is managed or influenced.

 “"The traditional approach to safety . . . has been retrospective, built on precedents. Because it is necessary, it is easy to think it is sufficient.  It involves, first, a search for the primary (or "root") cause of a specific accident, a decision on whether the cause was an unsafe act or an unsafe condition, and finally the supposed prevention of a recurrence by devising a regulation if an unsafe act,** or a technical solution if an unsafe condition." . . . [This approach] has serious shortcomings.  Specifically, ". . . resources are diverted to prevent the accident that has happened rather than the one most likely to happen."” (p. 24)

“"There has been little direct research on the organizational factors that make for a good safety culture. However, there is an extensive literature if we make the indirect assumption that a relatively low accident plant must have a relatively good safety culture." The proponents of safety culture as a determinant of operational safety in the nuclear power industry rely, at least to some degree, on that indirect assumption.” (p. 37) 

Plenty of people today behave in accordance with the first observation and believe (or act as if they believe) the second one.  Both contribute to the nuclear industry’s unwillingness to consider new ways of thinking about how safe performance actually occurs.

Decision Making, Goal Conflict and the Reward System

Decision making processes, recognition of goal conflicts and an organization’s reward system are important aspects of SC and the report addressed them to varying degrees.

One author referenced had a contemporary view of decision making, noting that “in complex and ill-structured risk situations, decisionmakers are faced not only with the matter of risk, but also with fundamental uncertainty characterized by incompleteness of knowledge.” (p. 43)  That’s true in great tragedies like Fukushima and lesser unfortunate outcomes like the San Onofre steam generators.

Goal conflict was mentioned: “Managers should take opportunities to show that they will put safety concerns ahead of power production if circumstances warrant.” (p.7)

Rewards should promote good safety practices (p. 6) and be provided for identifying safety issues. (p. 37)  However, there is no mention of the executive compensation system.  As we have argued ad nauseam these systems often pay more for production than for safety.

The Role of the Regulator

“The regulatory dilemma is that the elements that are important to safety culture are difficult, if not impossible, to separate from the management of the organization.  [However,] historically, the NRC has been reluctant to regulate management functions in any direct way.” (pp. 37-38)  “Rather, the NRC " . . . infers licensee organization management performance based on a comprehensive review of inspection findings, licensee amendments, event reports, enforcement history, and performance indicators."” (p. 41)  From this starting point, we now have the current situation where the NRC has promulgated its SC Policy Statement and practices de facto SC regulation using the highly reliable “bring me another rock” method.

The Importance of Context when Errors Occur 

There are hints of modern thinking in the report.  It contains an extended summary of Reason’s work in Human Error.  The role of latent conditions, human error as consequence instead of cause, the obvious interaction between producers and production, and the “non-event” of safe operations are all mentioned. (p. 15)  However, a “just culture” or other more nuanced views of the context in which safety performance occurs had yet to be developed.

One author cited described “the paradox that culture can act simultaneously as a precondition for safe operations and an incubator for hazards.” (p. 43)  We see that in Reason and also in Hollnagel and Dekker: people going about business as usual with usually successful results but, on some occasions, with unfortunate outcomes.

Our Perspective

The report’s author provided a good logic model for getting from SC attributes to identifying useful risk metrics, i.e., from SC to one or more probabilistic risk assessment (PRA) parameters.  (pp. 18-20)  But none of the research reviewed completed all the steps in the model. (p. 36)  He concludes “What is not clear is the mechanism by which attitudes, or safety culture, affect the safety of operations.” (p. 43)  We are still talking about that mechanism today.   

But some things have changed.  For example, probabilistic thinking has achieved greater penetration and is no longer the sole province of the PRA types.  It’s accepted that Black Swans can occur (but not at our plant).

Bottom line: Every student of SC should take a look at this.  It includes a good survey of 20th century SC-related research in the nuclear industry and it’s part of our basic history.

“Those who cannot remember the past are condemned to repeat it.” — George Santayana (1863-1952)

*  J.N. Sorensen, “Safety Culture: A Survey of the State-of-the-Art,” NUREG-1756 (Jan. 2002).  ADAMS ML020520006.  (Disclosure: I worked alongside the author on a major nuclear power plant litigation project in the 1980s.  He was thoughtful and thorough, qualities that are apparent in this report.)

**  We would add “or reinforcing an existing regulation through stronger procedures, training or oversight.”


  1. Lew,

    Thanks for bring forward this still significant document. I wish that I felt celebratory about the progress made in the institutionalization of a just and whole-risk competent cultural practice in either the Global or US National Nuclear Energy Enterprise - that I'm not able to muster.

    In this document considerable attention is given to INSAG and particularly INSAG-4. To my reading a proper attention to INSAG-4 would directly engage the roles, duties, and incentives to prudent risk-reckoning of those senior managers and executives; those whom you accurately point out are still not given appropriate weighting in the scheme of nuclear safety culture expectations as those have unfolded since 2002.

    In the NUREG this is what appears in the first reference to the contribution of top management:

    "Requirements imposed on managers include providing clear lines of responsibility and authority, defining and controlling work practices, ensuring appropriate qualifications and adequate training for staff, and providing a system of rewards and sanctions that promotes good safety practices." (p.6)

    This is "requirements/compliance-speak." In this critical summary there is a sort of standard Reg Guide recitation of expectations; it is devoid of any explicit emphasis on the non-delegable Duty of Ultimate Care that executives and those who establish their incentives carry toward prevention of the Fukushima Sea Wall type tragedy and leadership fiasco (from IAEA on down).

    In practice JN Sorenson, the Report's author, it appears to me, ultimately remains captive of his prior experience writing similar over-arching reports for NRC audiences; I infer from your disclosure that he has worked for NRC, or at least in licensing practice, for a long time. That frame invariably sees the Commission at the top of a Do Safety hierarchy which is steadfast to this day in relying primarily upon post-event examinations as justification to take a firm position on a licensee's overall Duty of Care.

    This report, and all the US hoopla regarding NSC since its publication, has hewn to the artificial division of responsibility between the two aspects of Whole Performance - Yield on Societal investment (primarily via Production of Electricity) and Yield on Protection from unacceptable adverse Societal consequences (primarily determined by license development and compliance therewith).

    As you've often indicated the portfolio of risks for which licensee directors and executives must exercise due care under their basic corporate fiduciary accountabilities is much broader than those addressed in the FSAR.

    I've no difficulty coming to the conclusion that the INSAG-4 emphasis on effective issues management would lead to an encompassing suite of Whole Performance indicators, including ones indicative of how carefully the balance is being tended between Production and Protection specific risks. NRC's exaggerated confusion about the difference between decision-making autonomy and independence from integrated performance messiness is the chief barrier here.

    Given the amount of solid study that has been conducted by the authors frequently highlighted in Safety Matters, it sure would be nice if this report were to be updated and that the investigation be done by persons with more distributed credentials - or we could just all carefully read the reports of the Columbia Accident Investigation, that of Deepwater Horizon, or the Japanese Diet's NAIC Report.

  2. Is Safety Culture fading into the background with other temporary notions that have their day in the sun and then become historical curiosities?

    Will safety culture be seen as a red herring that distracted the industry from its failure to display competence, compliance, integrity, and transparency?

    1. I don’t believe “safety culture” is going away anytime soon; it’s just too useful. In general applications, it’s an easy way for politicians, critics and the media to point out and communicate a plausible cause for a wide range of accidents, incidents, lapses, disasters and other bad outcomes that emerge from organizational activity. In the nuclear industry, it’s a way for the NRC to implicitly evaluate and squeeze licensee management in the absence of specific regulations.

    2. Has safety culture been a red herring that distracted the industry from its failure to display competence, compliance, integrity, and transparency?


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