Wednesday, December 21, 2011

From SCWE to Safety Culture—Time for the Soapbox

Is a satisfactory Safety Conscious Work Environment (SCWE) the same as an effective safety culture (SC)?  Absolutely not.  However, some of the reports and commentary we’ve seen on troubled facilities appear to mash the terms together.  I can’t prove it, but I suspect facilities that rely heavily on lawyers to rationalize their operations are encouraged to try to pass off SCWE as SC.  In any case, following is a review of the basic components of SC:

Safety Conscious Work Environment

An acceptable SCWE* is one where employees are encouraged and feel free to raise safety-related issues without fear of retaliation by their employer.  Note that it does not necessarily address individual employees’ knowledge of or interest in such issues.

Problem Identification and Resolution (PI&R)

PI&R is usually manifested in a facility’s corrective action program (CAP).  An acceptable CAP has a robust, transparent process for evaluating, prioritizing and resolving specific issues.  The prioritization step includes an appropriate weight for an issue’s safety-related elements.  CAP backlogs are managed to levels that employees and regulators associate with timely resolution of issues.

However, the CAP often only deals with identified issues.  Effective organizations must also anticipate problems and develop plans for addressing them.  Again, safety must have an appropriate priority.

Organizational Decision Making

The best way to evaluate an organization’s culture, including safety culture, is through an in-depth analysis of a representative sample of key decisions.  How did the decision-making process handle competing goals, set priorities, treat devil’s advocates who raised concerns about possible unfavorable outcomes, and assign resources?  Were the most qualified people involved in the decisions, regardless of their position or rank?  Note that this evaluation should not be limited to situations where the decisions led to unfavorable consequences; after all, most decisions lead to acceptable outcomes.  The question here is “How were safety concerns handled in the decision making process, independent of the outcome?”

Management Behavior

What is management’s role in all this?  Facility and corporate managers must “walk the talk” as role models demonstrating the importance of safety in all aspects of organizational life.  They must provide personal leadership that reinforces safety.  They must establish a recognition and reward system that reinforces safety.  Most importantly, they must establish and maintain the explicit and implicit weighting factors that go into all decisions.  All of these actions reinforce the desired underlying assumptions with respect to safety throughout the organization. 


Establishing a sound safety culture is not rocket science but it does require focus and understanding (a “mental model”) of how things work.  SCWE, PI&R, Decision Making and Management Behavior are all necessary components of safety culture.  Not to put too fine a point on it, but safety culture is a lot more than quoting a survey result that says “workers feel free to ask safety-related questions.”

*  SCWE questions have also been raised on the LinkedIn Nuclear Safety and Nuclear Safety Culture discussion forums.  Some of the commentary is simple bloviating but there are enough nuggets of fact or insight to make these forums worth following.

Thursday, December 8, 2011

Nuclear Industry Complacency: Root Causes

NRC Chairman Jaczko, addressing the recent INPO CEO conference, warned about possible increasing complacency in the nuclear industry.*  To support his point, he noted the two plants in column four of the ROP Action Matrix and two plants in column three, the increased number of special inspections in the past year, and the three units in extended shutdowns.  The Chairman then moved on to discuss other industry issues. 

The speech spurred us to ask: Why does the risk of complacency increase over time?  Given our interest in analyzing organizational processes, it should come as no surprise that we believe complacency is more complicated than the lack of safety-related incidents leading to reduced attention to safety.

An increase in complacency means that an organization’s safety culture has somehow changed.  Causes of such change include shifts in the organization’s underlying assumptions and decay.

Underlying Assumptions

We know from the Schein model that underlying assumptions are the bedrock for culture.  One can take those underlying assumptions and construct an (incomplete) mental model of the organization—what it values, how it operates and how it makes decisions.  Over time, as the organization builds an apparently successful safety record, the mental weights that people assign to decision factors can undergo a subtle but persistent shift to favor the visible production and cost goals over the inherently invisible safety factor.  At the same time, opportunities exist for corrosive issues, e.g., normalization of deviance, to attach themselves to the underlying assumptions.  Normalization of deviance can manifest anywhere, from slipping maintenance standards to a greater tolerance for increasing work backlogs.


An organization’s safety culture will inevitably decay over time absent effective maintenance.  In part this is caused by the shift in underlying assumptions.  In addition, decay results from saturation effects.  Saturation occurs because beating people over the head with either the same thing, e.g., espoused values, or too many different things, e.g., one safety program or similar intervention after another, has lower and lower marginal effectiveness over time.  That’s one reason new leaders are brought in to “problem” plants: to boost the safety culture by using a new messenger with a different version of the message, reset the decision making factor weights and clear the backlogs.

None of this is new to regular readers of this blog.  But we wanted to gather our ideas about complacency in one post.  Complacency is not some free-floating “thing,” it is an organizational trait that emerges because of multiple dynamics operating below the level of clear visibility or measurement.  

*  G.B. Jaczko, Prepared Remarks at the Institute of Nuclear Power Operations CEO Conference, Atlanta, GA (Nov. 10, 2011), p. 2, ADAMS Accession Number ML11318A134.

Monday, December 5, 2011

Regulatory Assessment of Safety Culture—Not Made in U.S.A.

Last February, the International Atomic Energy (IAEA) hosted a four-day meeting of regulators and licensees on safety culture.*  “The general objective of the meeting [was] to establish a common opinion on how regulatory oversight of safety culture can be developed to foster safety culture.”  In fewer words, how can the regulator oversee and assess safety culture?

While no groundbreaking new methods for evaluating a nuclear organization’s safety culture were presented, the mere fact there is a perception that oversight methods need to be developed is encouraging.  In addition, outside the U.S., it appears more likely that regulators are expected to engage in safety culture oversight if not formal regulation.

Representatives from several countries made presentations.  The NRC presentation discussed the then-current status of the effort that led to the NRC safety culture policy statement announced in June.  The presentations covering Belgium, Bulgaria, Indonesia, Romania, Switzerland and Ukraine described different efforts to include safety culture assessment into licensee evaluations.

Perhaps the most interesting material was a report on an attendee survey** administered at the start of the meeting.  The survey covered “national regulatory approaches used in the oversight of safety culture.” (p.3) 18 member states completed the survey.  Following are a few key findings:

The states were split about 50-50 between having and not having regulatory requirements related to safety culture. (p. 7)  The IAEA is encouraging regulators to get more involved in evaluating safety culture and some countries are responding to that push.

To minimize subjectivity in safety culture oversight, regulators try to use oversight practices that are transparent,  understandable, objective, predictable, and both risk-informed and performance-based. (p. 13)  This is not news but it is a good thing; it means regulators are trying to use the same standards for evaluating safety culture as they use for other licensee activities.

Licensee decision-making processes are assessed using observations of work groups, probabilistic risk analysis, and during the technical inspection. (p. 15)  This seems incomplete or even weak to us.  In-depth analysis of critical decisions is necessary to reveal the underlying assumptions (the hidden, true culture) that shape decision-making.

Challenges include the difficulty in giving an appropriate priority to safety in certain real-time decision making situations and the work pressure in achieving production targets/ keeping to the schedule of outages. (p. 16)  We have been pounding the drum about goal conflict for a long time and this survey finding simply confirms that the issue still exists.

Bottom Line

The meeting was generally consistent with our views.  Regulators and licensees need to focus on cultural artifacts, especially decisions and decision making, in the short run while trying to influence the underlying assumptions in the long run to reduce or eliminate the potential for unexpected negative outcomes.

**  A. Kerhoas, "Synthesis of Questionnaire Survey."