tag:blogger.com,1999:blog-4170623839736191950.post3724110105275691167..comments2022-12-03T19:22:46.911-08:00Comments on Safetymatters: Safety culture information, analysis and management: High Reliability Management by Roe and SchulmanBob Cudlinhttp://www.blogger.com/profile/08502712287881656493noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-4170623839736191950.post-76790183775496385562013-10-19T13:55:50.294-07:002013-10-19T13:55:50.294-07:00Great writeup Lew and I'm eagerly awaiting my ...Great writeup Lew and I'm eagerly awaiting my copy so that I can delve into the details.<br /><br />So these comments are preliminary, more lines of inquiry I'll have than anything firm at the moment.<br /><br />Since my experience in the Navy, mode shifts have been central to my conception of how uncertainty and complexity compound during employment of the highly engineered artifacts. Over the course of a 12-15 month deployment cycle, the crew of a submarine will likely encounter upwards of 20 distinct modes. A few of them relate to "all hands on deck" response to high uncertainty or significantly off-normal circumstances - most represent a pre-tailored response pattern that brings extra functional specialists and generalist oversight to bear such as during the Maneuvering Watch when coming in and out of port. <br /><br />Over the operations cycle, there is a recognizable meta-pattern of stepwise approach to peak fitness, as a crew moves its proficiency from operational effectiveness in a repair and refit situation each stage includes drills, classroom study, rehearsals and walk-throughs an typically culminates in a verification exercise. <br /><br />This is one pattern of mode-recognition and response - I anticipate that each recognizable deployment cycle mode would fit clearly in one of the four corners of the author's 2X2 - Variability-Diversity matrix.<br /><br />When we look at the CAISO or the National Air Traffic Control System we can see the same kinds of anticipated variability but these are open systems in continual operation - they generally do not follow the "deployment cycle" pattern of military units. Also the tend to have some goodly degree of hub and spoke structure as opposed to the self-healing, auto-catalytic one of the immune system.<br /><br />It seems to me, from a systems perspective, there is a pattern matching challenge relating the CAISO experience to the domain of mode recognition and management in commercial nuclear power operations. The challenge is to detect which features of the typical NP enterprise appear similar to each different mode category in terms of the range of potential volatility and the provision for sustainment of diverse defense in depth against both anticipated and some more unlikely patterns of events. <br /><br />In the case of a NPP fleet operator like Excelon, Entergy or Duke, a similar identification of similarity exercise would appear to be warranted to the Navy's various nuclear fleet operations experience.<br /><br />On first look, I'm inclined to set aside operational tempo as a primary source of difference. The CAISO reviewers point out that in at least one mode complaisance and inattention to details with know legacy importance is a key analytical feature. This sounds a lot like NASA's loss of corporate memory between Challenger and Columbia.<br /><br />My sense is that while the character of the equipment generally determines the "pace of variation" during "normal operations" it is our brain's tendency to "regularize" every aspect of anticipation to the equipment's master clock (whatever speed that runs at). This seems to make complacency a comparable phenomenon anywhere significant circumstance changes can be anticipated.<br /><br />While I've more thinking to do, I'm leaning toward the notion that it is the critical maintenance and modifications aspects of NPP operations that are the place where considerations of volatility and preservation of diversity will provide highly useful insights from the CAISO to NPP situation. <br /><br />As I was first reading this post, the recent Palisades trip during electrical maintenance and the whole subsequent NSC upgrade saga came to mind - the tell in that one for me has always been the on call Senior Manager's over-engagement in the maintenance planning to the point where he violated the overtime limits - that combined with no one from the Control Room at the work site during the actual repair. Inadequate gear-shifting (vigilance mode upgrading) was never described in the RCA or the NRC's SIT report!Bill Mullinsnoreply@blogger.com