Thursday, August 10, 2017

Nuclear Safety Culture: The Threat of Bureaucratization

We recently read Sidney Dekker’s 2014 paper* on the bureaucratization of safety in organizations.  It’s interesting because it describes a very common evolution of organizational practices, including those that affect safety, as an organization or industry becomes more complicated and formal over time.  Such evolution can affect many types of organizations, including nuclear ones.  Dekker’s paper is summarized below, followed by our perspective on it. 

The process of bureaucratization is straightforward; it involves hierarchy (creating additional layers of organizational structure), specialized roles focusing on “safety related” activities, and the application of rules for defining safety requirements and the programs to meet them.  In the safety space, the process has been driven by multiple factors, including legislation and regulation, contracting and the need for a uniform approach to managing large groups of organizations, and increased technological capabilities for collection and analysis of data.

In a nutshell, bureaucracy means greater control over the context and content of work by people who don’t actually have to perform it.  The risk is that as bureaucracy grows, technical expertise and operational experience may be held in less value.

This doesn’t mean bureaucracy is a bad thing.  In many environments, bureaucratization has led to visible benefits, primarily a reduction in harmful incidents.  But it can lead to unintended, negative consequences including:

  • Myopic focus on formal performance measures (often quantitative) and “numbers games” to achieve the metrics and, in some cases, earn financial bonuses,
  • An increasing inability to imagine, much less plan for, truly novel events because of the assumption that everything bad that might happen has already been considered in the PRA or the emergency plan.  (Of course, these analyses/documents are created by siloed specialists who may lack a complete understanding of how the socio-technical system works or what might actually be required in an emergency.  Fukushima anyone?),
  • Constraints on organizational members’ creativity and innovation, and a lack of freedom that can erode problem ownership, and
  • Interest, effort and investment in sustaining, growing and protecting the bureaucracy itself.
Our Perspective

We realize reading about bureaucracy is about as exciting as watching a frog get boiled.  However, Dekker does a good job of explaining how the process of bureaucratization takes root and grows and the benefits that can result.  He also spells out the shortcomings and unintended consequences that can accompany it.

The commercial nuclear world is not immune to this process.  Consider all the actors who have their fingers in the safety pot and realize how few of them are actually responsible for designing, maintaining or operating a plant.  Think about the NRC’s Reactor Oversight Process (ROP) and the licensees’ myopic focus on keeping a green scorecard.  Importantly, the Safety Culture Policy Statement (SCPS) being an “expectation” resists the bureaucratic imperative to over-specify.  Instead, the SCPS is an adjustable cudgel the NRC uses to tap or bludgeon wayward licensees into compliance.  Foreign interest in regulating nuclear safety culture will almost certainly lead to its increased bureaucratization.  

Bureaucratization is clearly evident in the public nuclear sector (looking at you, Department of Energy) where contractors perform the work and government overseers attempt to steer the contractors toward meeting production goals and safety standards.  As Dekker points out, managing, monitoring and controlling operations across an organizational network of contractors and sub-contractors tends to be so difficult that bureaucratized accountability becomes the accepted means to do so.

We have presented Dekker’s work before, primarily his discussion of a “just culture” (reviewed Aug. 3, 2009) that tries to learn from mishaps rather than simply isolating and perhaps punishing the human actor(s) and “drift into failure” (reviewed Dec. 5, 2012) where a socio-technical system can experience unacceptable performance caused by systemic interactions while functioning normally.  Stakeholders can mistakenly believe the system is completely safe because no errors have occurred while in reality the system can be slipping toward an incident.  Both of these attributes should be considered in your mental model of how your organization operates.

Bottom line: This is an academic paper in a somewhat scholarly journal, in other words, not a quick and easy read.  But it’s worth a look to get a sense of how the tentacles of formality can wrap themselves around an organization.  In the worse case, they can stifle the capabilities the organization needs to successfully react to unexpected events and environmental changes.

*  S.W.A. Dekker, “The bureaucratization of safety,” Safety Science 70 (2014), pp. 348–357.  We saw this paper on Safety Differently, a website that publishes essays on safety.  Most of the site’s content appears related to industries with major industrial safety challenges, e.g., mining.