Oil and Nuclear – Again

We saw an essay on Clean Skies that suggests the oil industry could learn from the nuclear industry, in particular, that the oil industry should adopt international standards of practice similar to the nuclear industry’s response to Chernobyl. We totally agree. The one point we would add is that the single most important thing the oil industry could learn from nuclear is the significance of establishing and maintaining an adequate safety culture. Safety culture is the sine qua non of safe, profitable operations in any high-hazard business.

And safety culture has to be real. Beleaguered executives proclaiming that safety is number are simply not convincing when equipment and methods haven’t been tested (or don’t work), and profit has obviously been driving decision-making.

We want to remind the nuclear industry that they are one significant incident away from an even worse political and public relation disaster. As we have said before, the oil industry is not as tightly interwoven in the public mind as nuclear; to date, BP is being vilified in Washington and in the press, but the damage to other companies has been incidental, a temporary stop in issuing drilling permits. The nuclear industry would not get off so relatively easy if an incident of similar magnitude were to occur in their bailiwick.

How Do We Know? Dave Collins, Millstone, Dominion and the NRC

This week the issues being raised by former Dominion engineer David Collins* regarding safety culture at Millstone are receiving increased attention. It appears David is raising two general issues: (1) Is Dominion's safety culture being eroded due to cost and competitive pressures and (2) is the NRC being effective in its regulatory oversight of safety culture?

So far the responses of the various players are along standard lines. Dominion contends it is simply harvesting cost efficiencies in its organization without compromising safety and specific problems are isolated events. The NRC has referred the issues to its Office of Investigation thus limiting transparency. INPO will not comment on its confidential assessments of nuclear owners.

What is one to make of this? First we have no special insights into the bases for the issues being raised by Collins. We have interacted with him in the past on safety culture issues and he is clearly a dedicated and knowledgeable individual with a strong commitment to nuclear safety culture. Thus we would be inclined to give his allegations serious consideration.

On the broader issues we see both opportunities and risks. We have emphasized cost and competitive pressures as a key to understanding how safety culture must balance multiple priorities to assure safety. What we do not see at the moment is how Dominion, the NRC or INPO would be able to determine whether, or to what extent, such pressures might be impacting decisions within Dominion. We doubt whether current approaches to assessing safety culture can be determinative; e.g., safety culture surveys, NRC performance indicators, or INPO assessments. In addition a plant-centric focus is unlikely to reveal systemic interactions or top-down signals that may result in decisional pressure at the plant levels. Recall that a significant exogenous pressure cited in the space shuttle Challenger accident was Congressional political pressure.

So while we understand the nature of the processes underway to evaluate Collins’ issues, it would be helpful if any or all the organizations could explain their methods for assessing these type of issues and the objective evidence to be used in making findings. The risk at this point is that the industry and NRC appear to be more focused on negating the allegations than in taking a hard look at their possible merits, including how exactly to evaluate them.

* Follow the link below for an overview of Collins' issues and other parties' responses.

EUCG Recognizes Safety Culture's Importance

Today's EUCG* press release on their Spring meeting highlights their discussions on, among other topics, safety culture and safety performance. One quote from an EUCG executive caught our attention: "Data are emerging that a company's safety performance correlates strongly with other performance measures such as profitability, customer satisfaction and service reliability."

We are happy to see other organizations recognize the importance of safety culture but their realization of positive correlation among performance measures is hardly new. For example, back in the 1990s we saw that the best nuclear industry plants were top quartile performers in production, cost AND safety. We recommended to our clients that it was reasonable, even essential, for them to aspire to top-level performance in all three dimensions.

* EUCG used to be (and perhaps still is) the Electric Utility Cost Group. Initially, they focused on sharing various cost performance data among their members, now it appears they are also collecting and sharing other data.

Why Nuclear is Better than Oil

Today's New York Times has an article whose title says it all, "Regulator Deferred to Oil Industry on Offshore Rig Safety." It turns out the the Minerals Management Service, an Interior Department agency, is charged both with regulating the oil industry and with collecting royalties from it. The article goes to to say that the trend in other parts of the world is to separate these functions.

We wring our hands on this blog about creeping complacency, normalization of deviance, and failure to sufficiently acknowledge conflicting goals in nuclear plant operations. But we don't have to bang the drum about getting a dedicated safety regulator; the NRC was created in 1974 specifically to separate the government's promotional and regulatory roles in the nuclear industry.

Testing Positive - the NRC on Safety Culture

We have been spending some time with the NRC’s draft statement of policy on safety culture published in the Federal Register on November 6, 2009.*

The initial Commission policy statement on safety culture in 1989 simply referred to “safety culture”. The current statement initially refers to the need for a “strong” safety culture (“It is the Commission’s policy that a strong safety culture is an essential element for individuals . . . .”) but then settles on “positive” safety culture as the fundamental expectation of the policy (“licensees . . . should foster a positive safety culture in their organizations and among individuals . . . .”) (p. 57526) The NRC provides its definition of “safety culture” in the draft policy but does not specifically define “strong” or “positive” safety culture. The NRC states that “certain organizational characteristics and personnel attitudes and behaviors are present in a positive safety culture.” (p. 57528) It also notes that “The INSAG definition emphasizes that in a positive safety culture, the goal of maintaining nuclear safety receives the highest priority in the organization’s and individuals’ decision-making and actions when faced with a conflict with other organizational or individual goals.” (p. 57527)

We found the use of the term “positive” potentially ambiguous and decided to explore its possible meaning(s) as applicable to safety culture and what might be the NRC’s intent in using it to describe safety culture.

First of all we note the use of “positive” in this context is as an adjective. Complicating matters a bit from the start is that there are eight definitions of the adjective, positive. A few are readily dismissed such as where positive refers to the charge of electricity associated with a proton or having higher electric potential. But many remain. The definitions of positive that could be applicable to nuclear safety culture include:

• prescribed, or formally laid down and imposed;
• unconditioned or independent of changing circumstances;
• real, not fictitious and being effective in a social circumstance;
• contributing toward or characterized by increase or progression;
• favorable, having a good effect.

Consulting with Black’s Law Dictionary, the term positive is defined as:

“Laid down, enacted, or prescribed. Direct, absolute, explicit.” Sounds close to the first definition above.So what did the NRC intend by the usage of positive to modify “safety culture”? The short answer is we don’t know. The various definitions imply several possible interpretations. Perhaps the more straightforward is the “prescribed” definition. It would require licensees have an explicit and prescribed policy for safety culture at its facilities, and the policy would need to address elements of safety culture as laid out in the policy statement. This interpretation might also imply that the safety culture is unconditioned and independent of changing circumstances; i.e., enduring. The other possibility is that the NRC intends the “favorable” and “increasing and progressing” safety culture. This meaning has more of a dynamic implication and is similar to continuous improvement. The NRC’s alternate use of the term “strong” in the introduction to the policy doesn’t help much either. Strong can mean the “power to resist or endure” so it could be consistent with the first definition that safety culture should be enduring. But it also implies “resistant to change” which could be good or bad, depending on the current state of safety culture and any need to change (improve) it.

Where does this leave us? As a minimum it would appear necessary that the NRC amplify its use of these modifiers of safety culture and the specific meanings that are intended. Better yet, the NRC could not use these terms and simply rely on an old regulatory standby such as “adequate” safety culture.

* Draft Safety Culture Policy Statement: Request for Public Comments NRC-2009-0485-0001

Why is Nuclear Different?

We saw a very interesting observation in a recent World Nuclear News item describing updates to World Association of Nuclear Operators’ structure. The WANO managing director said “Any CEO must ensure their own facilities are safe but also ensure every other facility is safe. [emphasis added] It's part of their commitment to investors to do everything they can to ensure absolute safety and the one CEO that doesn't believe in this concept will risk the investment of every other.” As WNN succinctly put it, “These company heads are hostages of one another when it comes to nuclear safety.”

I think it's true that nuclear operators are joined at the wallet, but why? In most industries, a problem at one competitor creates opportunities for others. Why is the nuclear industry so tightly coupled and at constant risk of contagion? Is it the mystery and associated fears, suspicion and, in some cases, local visibility that attends nuclear?

Coal mining and oil exploration exist in sharp contrast to nuclear. "Everyone knows" coal mining is dirty and dangerous but bad things only happen, with no wide-ranging effects, to unfortunate folks in remote locations. Oil exploration is somewhat more visible: people will be upset for awhile over the recent blow-out in the Gulf of Mexico, offshore drilling will be put on a temporary hold, but things will eventually settle down. In the meantime, critics will use BP as a punching bag (again) but there will be no negative spillover to, say, Chevron.

Safety Culture: Cause or Context (part 2)

In an earlier post, we discussed how “mental models” of safety culture affect perceptions about how safety culture interacts with other organizational factors and what interventions can be taken if safety culture issues arise. We also described two mental models, the Causal Attitude and Engineered Organization. This post describes a different mental model, one that puts greater emphasis on safety culture as a context for organizational action.

Safety Culture as Emergent and Indeterminate

If the High Reliability Organization model is basically optimistic, the Emergent and Indeterminate model is more skeptical, even pessimistic as some authors believe that accidents are unavoidable in complex, closely linked systems. In this view, “the consequences of safety culture cannot be engineered and only probabilistically predicted.” Further, “safety is understood as an elusive, inspirational asymptote, and more often only one of a number of competing organizational objectives.” (p. 356)* Safety culture is not a cause of action, but provides the context in which action occurs. Efforts to exhaustively model (and thus eventually manage) the organization are doomed to failure because the organization is constantly adapting and evolving.

This model sees that the same processes that produce the ordinary and routine stuff of everyday organizational life also produce the messages of impending problems. But the organization’s necessary cognitive processes tend to normalize and homogenize; the organization can’t very well be expected to treat every input as novel or not previously experienced. In addition, distributed work processes and official security policies can limit the information available to individuals. Troublesome information may be buried or discredited. And finally, “Dangers that are neither spectacular, sudden, nor disastrous, or that do not resonate with symbolic fears, can remain ignored and unattended, . . . . “ (p. 357)

We don’t believe safety significant events are inevitable in nuclear organizations but we do believe that the hubris of organizational designers can lead to specific problems, viz., the tendency to ignore data that does not comport with established categories. In our work, we promote a systems approach, based on system dynamics and probabilistic thinking, but we recognize that any mental or physical model of an actual, evolving organization is just that, a model. And the problem with models is that their representation of reality, their “fit,” can change with time. With ongoing attention and effort, the fit may become better but that is a goal, not a guaranteed outcome.

Lessons Learned

What are the takeaways from this review? First, mental models are important. They provide a framework for understanding the world and its information flows, a framework that the holder may believe to be objective but is actually quite subjective and creates biases that can cause the holder to ignore information that doesn’t fit into the model.

Second, the people who are involved in the safety culture discussion do not share a common mental model of safety culture. They form their models with different assumptions, e.g., some think safety culture is a force that can and does affect the vector of organizational behavior, while others believe it is a context that influences, but does not determine, organizational and individual decisions.

Third, safety culture cannot be extracted from its immediate circumstances and examined in isolation. Safety culture always exists in some larger situation, a world of competing goals and significant uncertainty with respect to key factors that determine the organization’s future.

Fourth, there is a risk of over-reliance on surveys to provide some kind of "truth" about an organization’s safety culture, especially if actual experience is judged or minimized to fit the survey results. Since there is already debate about what surveys measure (safety culture or safety climate?), we advise caution.

Finally, in addition to appropriate models and analyses, training, supervision and management, the individual who senses that something is just not right and is supported by an organization that allows, rather than vilifies, alternative interpretations of data is a vital component of the safety system.


* This post draws on Susan S. Silbey, "Taming Prometheus: Talk of Safety and Culture," Annual Review of Sociology, Volume 35, September 2009, pp. 341-369.