Thursday, September 12, 2013

Bad Eggs?

We’ve often thought that intentional or willful violations of safety/regulatory requirements could provide a useful window into the dynamics of safety culture.  Now the NRC has just issued an Information Notice* listing recent instances of willful violations.  The Notice is titled “Willful Misconduct/Record Falsification and Nuclear Safety Culture” and reports on seven recent instances of such conduct.  From the title and throughout the notice the NRC asserts a link between willful violations and nuclear safety culture.  To wit it states, “An effective safety-culture is essential to nuclear safety at all phases of design, construction and operation and can help prevent willful misconduct by ensuring expectations and consequences are clearly stated and understood.” (p. 5)  The NRC adds, “The above willful misconduct issues and discussion highlights the need... to establish and implement an effective nuclear safety-culture.  This includes training, adequate oversight, and frequent communications especially for workers new to the nuclear industry.” (p. 6)

What we see here is consistent with the NRC’s pro forma approach to organizational safety performance issues.  The problem is culture; the answer is more training, more clarity of expectations, more oversight.**  Oh, and disciplinary actions for the errant individuals.  

Are we to take from this that the individuals involved in these situations are just “bad eggs”?  And the answer is some punishment and re-education?  Is this even consistent with the nature of willful violations and does the sheer number of recent experiences raise more fundamental questions, the most basic of which is “Why?”

Let’s start with what is different about willful violations.  Willful violations are deliberate, intentional and knowing.  In other words the individual knows his/her actions are against established policies or procedures.  This is not a case of carelessness or lack of knowledge of what is expected.  Thus it is hard to understand what would be achieved by more training and reinforcement of expectations.  The prescription for more oversight is also puzzling.  It appears to assume that violations will continue unless there is strict monitoring of behaviors.  Interestingly it is reliance on more oversight by managers who apparently weren’t providing the necessary oversight in the first place.

So on the one hand the corrective actions identified in the these events do not appear well suited to the nature of a willful violation.  Perhaps more importantly this treatment of the problem obscures deeper analysis of why such violations are occurring in the first place.  Why are personnel deciding to intentionally do something wrong?  Often willful acts have their basis in personal gain or covering up some other misdeed.  Nothing in the seven instances in the Notice even hint at this type of motivation.  Could it be an intent to do harm to the organization due to some other personal issue - a problem with a supervisor, being passed by for a promotion, etc?  Hmmm, I guess it’s possible but again there does not appear to be any hint of this in the available documentation. Or could it be that the individuals were responding to some actual or perceived pressure to get something done - more quickly, at less cost, or to avoid raising an issue that itself would cost time or money?  Again there was no exploration of motive for these violations in the NRC’s or licensee’s investigations.***

The apparent failure to fully investigate the motive for these violations is unfortunate as it leaves other critical factors unexplored and untreated.  Goal pressures almost always have their origin higher up in the organization.  Defaulting to reinforcing the culture side of the equation may not be effective due to the inherent contradiction in signals from upper management. 

In a prior post we suggested that safety culture be thought of as a “pressure boundary”, specifically “the willingness and ability of an organization to resist undue pressure on safety from competing business priorities”.   When resistance breaks down it can lead to shading of safety assessments, a decided lack of rigor in pursuing causes and extent of condition - or it can even lead to willful violations.  Relieving business pressure may be the far more effective antidote.

*  NRC Information Notice 2013-15: Willful Misconduct/Record Falsification and Nuclear Safety Culture (Aug. 23, 2013).  ADAMS ML13142A437.

**  In two instances modest civil penalties were also assessed.

***  We would remind our readers of our post dated April 2, 2012 regarding the guilty plea of one of the Massey coal mine supervisors to intentional violations of the law.  The stated reason: following the law would decrease coal production.

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