BP's New Safety Division

It looks like oil company BP believes that creating a new, “global” safety division is part of the answer to their ongoing safety performance issues including most recently the explosion of Deepwater Horizon oil rig in the Gulf of Mexico.  An article in the September 29, 2010 New York Times* quotes BP’s new CEO as stating “safety and risk management [are] our most urgent priority” but does not provide many details of how the initiative will accomplish its goal.  Without seeming to jump to conclusions, it is hard for us to see how a separate safety organization is the answer although BP asserts it will be “powerful”. 

Of more interest was a lesser headline in the article with the following quote from BP’s new CEO:

“Mr. Dudley said he also plans a review of how BP creates incentives for business performance, to find out how it can encourage staff to improve safety and risk management.”

We see this as one of the factors that is a lot closer to the mark for changing behaviors and priorities.  It parallels recent findings by FPL in its nuclear program (see our July 29, 2010 post) and warning flags that we had raised in our July 6 and July 9, 2010 posts regarding trends in U.S. nuclear industry compensation.  Let’s see which speaks the loudest to the organization: CEO pronouncements about safety priority or the large financial incentives that executives can realize by achieving performance goals.  If they are not aligned, the new “division of safety” will simply mean business as usual.

*  The original article is available via the iCyte below.  An updated version is available on the NY Times website.

Games Theory

In the September 15, 2010 New York Times there is an interesting article* about the increasing recognition within school environments that game-base learning has great potential.  We cite this article as further food for thought about our initiatives to bring simulation-based games to training for nuclear safety management.

The benefits of using games as learning spaces is based on the insight that games are systems, and systems thinking is really the curriculum, bringing a nuanced and rich way of looking at real world situations. 

“Games are just one form of learning from experience. They give learners well-designed experiences that they cannot have in the real world (like being an electron or solving the crisis in the Middle East). The future for learning games, in my view, is in games that prepare people to solve problems in the world.” **

“A game….is really just a “designed experience,” in which a participant is motivated to achieve a goal while operating inside a prescribed system of boundaries and rules.” ***  The analogy in nuclear safety management is to have the game participants manage a nuclear operation - with defined budgets and performance goals - in a manner that achieves certain safety culture attributes even as achievement of those attributes comes into conflict with other business needs.  The game context brings an experiential dimension that is far more participatory and immersive than traditional training environments.  In the NuclearSafetySim simulation, the players’ actions and decisions also feedback into the system, impacting other factors such as  organizational trust and the willingness of personnel to identify deviations.  Experiencing the loss of trust in the simulation is likely to be a much more powerful lesson than simply the admonition to “walk the talk” burned into a Powerpoint slide.

* Sara Corbett, "Learning by Playing: Video Games in the Classroom," New York Times (Sep 15, 2010).

** J.P. Gee, "Part I: Answers to Questions About Video Games and Learning," New York Times (Sep 20, 2010).

*** "Learning by Playing," p. 3 of retrieved article.

Missing the Mark at SONGS

In our September 13, 2010 post on the current situation at SONGS we commented on the (in our opinion) undue focus on “leadership” as the sine qua non of safety culture.  Delving into the details of the most recent NRC inspection report* we came across another perplexing organizational response.  This time the issue was deliberate non-compliance.  While deliberate violations do not often get a lot of visibility, we find them potentially useful for illustrating safety culture dynamics.

First the SONGS experience.  Recall that it was a series of deliberate violations by fire watch personnel in the 2001-2006 time frame that started to crystallize safety culture concerns.  To address the problem, SCE committed to providing Corporate Ethics training to managers, supervisors and other specified employees.  The training was completed in 2008.  In 2009 additional ethics training was given to all employees including a SONGS-specific case study.  In addition monitoring programs were enhanced to better detect deliberate violations.

How effective was the training?  As reported in the NRC inspection report, between January 2008 and mid-2010, nine additional instances of deliberate non-compliances were identified.  The inspection report went on to say: “In response to these nine deliberate non-compliances, the licensee performed an Apparent Cause Evaluation….This evaluation identified the need to continue the training and monitoring programs which were developed in response to the Confirmatory Order.”

Did the NRC agree?  “The inspectors determined that this large number of deliberate non-compliances indicated that training on ethics and the disciplinary policy had not been fully effective in eliminating deliberate non-compliances.”  But in a bewildering twist, the NRC goes on to sign off on the issue because actions taken to detect and address deliberate violations have been effective...and the licensee intended to continue taking actions to prevent further instances from occurring. 

Perhaps both SCE and the NRC might have found our recent posts on current academic thinking on the subject of teaching ethics to be of value.  The Yale School of Management’s authors [see our August 30,2010 post] indicated: the concern arises when values are taught in the abstract and reliance is placed on commitments to high ethics without the contextual conflicts that will arise in the real world.  And the MIT article cited in our September 1, 2010 post bluntly reminds us “a decision necessarily involves an implicit or explicit trade-off of values.”  and that companies typically drill employees on values statements and codes of conduct, which have a more “symbolic than instrumental effect”.

We don’t have access to the ethics training provided by SCE but our suspicion is that it probably misses the target in the manner described in these management papers.  In the case of deliberate violations can there be any question that a trade-off of values is occurring?  And if trade-offs are occurring, then one has to ask, Why?  If situational forces are driving behavior, and training was not effective the first time, will repeating the training produce a different result?  

* Letter dated Aug 30, 2010 from R.E. Lantz (NRC) to R.T. Ridenoure (SCE), subject "SAN ONOFRE NUCLEAR GENERATING STATION – NRC FOCUSED BASELINE INSPECTION OF SUBSTANTIVE CROSS-CUTTING ISSUES INSPECTION REPORT 05000361/2010010 and 05000362/2010010," ADAMS Accession Number ML102420696.

Here We Go Again

Back on March 22, 2010 we posted about the challenge of addressing safety culture issues through one-dimensional approaches such as focusing on leadership or reiterating training materials.  We observed that the conventional wisdom that culture is simply leadership driven does not address the underlying complexity of culture dynamics.  San Onofre may be the most recent case in point.  In 2008 new leadership was brought in to the station in response to ongoing culture issues.  Safety culture improved somewhat, at least according to surveys, then it resumed its decline. Last week leadership was changed again following continued pressure by the NRC on cross cutting issues.  Perhaps ironically, one of the more recent actions taken at the station in response to continuing allegations of a “chilled environment” was….leadership training.*

The evolution of events at San Onofre also reinforces another observation we have made about the reliance on safety culture surveys.  As with just about all similar situations, the prescription for weaknesses in “cornerstone” issues by both licensees and the NRC is: conduct a survey.  Looking back in the San Onofre case, the following was determined in its October 2009 survey:

Overall, the Independent Safety Culture Assessment determined that “the safety culture at SONGS is sufficient to support plant operations”.

SCE also reported to the NRC that the survey showed:

Site management is communicating strong and consistent safety messages, including:

-    Safety is the first priority

-    Site personnel are encouraged and expected to identify and report potential safety concerns**

The NRC then conducted additional inspections in early 2010.  “The inspection team determined that the safety culture at SONGS was adequate; however, several areas were identified that needed improvement .... All of the individuals interviewed expressed a willingness to raise safety concerns and were able to provide multiple examples of avenues available, such as their supervisor, writing a notification, other supervisors/managers, or the Nuclear Safety Concerns Program; however, approximately 25% of those interviewed indicated that they perceived that individuals would be retaliated against if they went to the NRC with a safety concern if they were not satisfied with their management’s response.”***

“When asked about the 2009 nuclear safety culture assessment, all of the individuals interviewed remembered having attended a briefing session on the results. However, only the general result of "safety culture was adequate” was recalled by those interviewed.”***

* "SONGS Hit with Stern NRC Rebuke," San Clemente Times (March 2, 2010).

** Slides presented at Nov 5, 2009 SCE-NRC meeting, attached to NRC Meeting Summary dated Nov 20,2009, ADAMS Accession Number ML093240212.

*** Letter dated Mar 2, 2010 from E. Collins (NRC) to R.T. Ridenoure (SCE), subject "Work Environment Issues at San Onofre Nuclear Generating Station—Chilling Effect," ADAMS Accession Number ML100601272.

Making Values Count

In our August 30, 2010 Experiencing Decisions post we highlighted a Wall Street Journal article with some interesting insights into how teaching values must have a strong “experiential” component.  In the real world experiential means that day-to-day decision making is a contact sport, where values collide with business priorities.  In that article reference was made to another paper from the MIT Sloan Management Review, “How to Make Values Count in Everyday Decisions.”*  This work provides a useful and practical resource for follow up reading and implementation.

The Sloan paper authors come right to the point, stating “...a decision necessarily involves an implicit or explicit trade-off of values.” [p.75].  And “decision making is a trade-off between values….[for example] choosing customer safety over short-term financial performance”, referring to the decision by Johnson & Johnson to pull Tylenol off store shelves in 1982.  This is an important perspective but not necessarily one that is very often part of the dialogue about nuclear safety culture.

“The typical approach of many companies is to drill employees on values statements and codes of conduct, but by themselves such sets of principles do not easily permeate everyday decisions.  Recent research suggests that they usually have a more symbolic than instrumental effect.” [p.76]

The authors suggest the use of “decision maps” which is a device to create a picture of the decision process including choices, consequences, outcomes and values.  Note that a distinction is drawn between short term results of a decision (consequences) and longer term impacts (outcomes).  Identifying the longer term consequences of a decision requires thinking through the dynamics of the whole business “system” over multiple time periods.  Think of a pinball machine, perhaps even a pinball machine where you can’t see inside.

One of the problems cited in the paper is that values articulated at the top of the organization can be subverted by the everyday decisions made by staff members, in effect creating a default alternative value structure.  As a practical matter it is the sum of actual decisions that defines the value structure more than the abstract and idealized statements of values.

What is one to do?  Are decision maps the answer?  We’ll leave that to our readers to decide after reading this paper and examining the example provided.  What we can endorse is the authors’ prescription in the last section of the article.  It is based on a belief that leaders should be teachers, and teaching means explaining how decisions are made and how they reflect the values espoused by the leaders.  Basically, decisions need to be explained, used in training and communicated widely within the organization.  We like the idea of identifying a number of recent decisions and examining how the decisions were made, particularly how choices, consequences, and outcomes were linked to values and how values were balanced and traded-off.  This might not always be comfortable but the willingness to use such a process may say more about an organization’s values than any other action.

* “How to Make Values Count in Everyday Decisions”, J.E. Urbany, T.J. Reynolds and J.M. Phillips, MIT Sloan Management Review, Summer 2008, pp. 75-80.