We cannot justly summarize the entire conference in this space but we can highlight material related to SC factors we’ve emphasized or people we’ve discussed on Safetymatters, or interesting items that merit your consideration.
Topics We Care About
A Systems Viewpoint
Given that the IAEA has promoted a systemic approach to safety and it was a major conference topic it’s no surprise that many participants addressed it. But we were still pleased to see over 30 presentations, posters and dialogues that included mention of systems, system dynamics, and systemic and/or holistic viewpoints or analyses. Specific topics covered a broad range including complexity, coupling, Fukushima, the Interaction between Human, Technical and Organizational Factors (HTOF), error/incident analysis, regulator-licensee relationships, SC assessment, situational adaptability and system dynamics.
Role of Leadership
Leadership and Management for Safety was another major conference topic. Leadership in a substantive context was mentioned in about 20 presentations and posters, usually as one of multiple success factors in creating and maintaining a strong SC. Topics included leader/leadership commitment, skills, specific competences, attributes, obligations and responsibilities; leadership’s general importance, relationship to performance and role in accidents; and the importance of leadership in nuclear regulatory agencies.
Decision Making
This was mentioned about 10 times, with multiple discussions of decisions made during the early stages of the Fukushima disaster. Other presenters described how specific techniques, such as Probabilistic Risk Assessment and Human Reliability Analysis, or general approaches, such risk control and risk informed, can contribute to decision making, which was seen as an important component of SC.
Compensation and Rewards
We’ve always been clear: If SC and safety performance are important then people from top executives to individual workers should be rewarded (by which we mean paid money) for doing it well. But, as usual, there was zero mention of compensation in the conference materials. Rewards were mentioned a few times, mostly by regulators, but with no hint they were referring to monetary rewards. Overall, a continuing disappointment.
Participants Who Have Been Featured in Safetymatters
Over the years we have presented the work of many conference participants to Safetymatters readers. Following are some familiar names that caught our eye. Page numbers refer to the conference “Programme and Abstracts” document.
We have to begin with Edgar Schein, the architect of the cultural construct used by almost everyone in the SC space. His discussion paper (p. 47) argued that the SC components in a nuclear plant depend on whether the executives actually create the climate of trust and openness that the other attributes hinge on. We’ve referred to Schein so often he has his own label on Safetymatters.
Mats Alvesson’s presentation (p. 46) discussed “hyper culture,” the vague and idealistic terms executives often promote that look good in policy documents but seldom work well in practice. This presentation is consistent with his article on Functional Stupidity which we reviewed on Feb. 23, 2016.
Sonja Haber’s paper (p. 55) outlined a road map for the nuclear community to move forward in the way it thinks about SC. Dr. Haber has conducted many SC assessments for the Department of Energy that we have reviewed on Safetymatters.
Ken Koves of INPO led or participated in three dialogue sessions. He was a principal researcher in a project that correlated SC survey data with safety performance measures which we reviewed on Oct. 22, 2010 and Oct. 5, 2014.
Najmedin Meshkati discussed (p. 60) how organizations react when their control systems start to run behind environmental demands using Fukushima as an illustrative case. His presentation draws on an article he coauthored comparing the cultures at TEPCO’s Fukushima Daiichi plant and Tohoku Electric’s Onagawa plant which we reviewed on Mar. 19, 2014.
Jean-Marie Rousseau co-authored a paper (p. 139) on the transfer of lesson learned from accidents in one industry to another industry. We reviewed his paper on the effects of competitive pressures on nuclear safety management issues on May 8, 2013.
Carlo Rusconi discussed (p. 167) how the over-specialization of knowledge required by decision makers can result in pools of knowledge rather than a stream accessible to all members of an organization. A systemic approach to training can address this issue. We reviewed Rusconi’s earlier papers on training on June 26, 2013 and Jan. 9, 2014.
Richard Taylor’s presentation (p. 68) covered major event precursors and organizations’ failure to learn from previous events. We reviewed his keynote address at a previous IAEA conference where he discussed using system dynamics to model organizational archetypes on July 31, 2012.
Madalina Tronea talked about (p. 114) the active oversight of nuclear plant SC by the National Commission for Nuclear Activities Control (CNCAN), the Romanian regulatory authority. CNCAN has developed its own model of organizational culture and uses multiple methods to collect information for SC assessment. We reviewed her initial evaluation guidelines on Mar. 23, 2012.
Our Perspective
Many of the presentations were program descriptions or status reports related to the presenter’s employer, usually a utility or regulatory agency. Fukushima was analyzed or mentioned in 40 different papers or posters. Overall, there were relatively few efforts to promote new ideas, insights or information. Having said that, following are some materials you should consider reviewing.
From the conference participants mentioned above, Haber’s abstract (p. 55) and Rusconi’s abstract (p. 167) are worth reading. Taylor’s abstract (p. 68) and slides are also worth reviewing. He advocates using system dynamics to analyze complicated issues like the effectiveness of organizational learning and how events can percolate through a supply chain.
Benoît Bernard described the Belgian regulator’s five years of experience assessing nuclear plant SC. Note that lessons learned are described in his abstract (p. 113) but are somewhat buried in his presentation slides.
If you’re interested in a systems view of SC, check out Francisco de Lemos’ presentation (p. 63) which gives a concise depiction of a complex system plus a Systems Theoretic Accident Models and Processes (STAMP) analysis. His paper is based on Nancy Leveson’s work which we reviewed on Nov. 11, 2013.
Diana Engström argued that nuclear personnel can put more faith in reported numbers than justified by the underlying information, e.g., CAP trending data, and thus actually add risk to the overall system. We’d call this practice an example of functional stupidity although she doesn’t use that term in her provocative paper. Both her abstract (p. 126) and slides are worth reviewing.
Jean Paries gave a talk on the need for resilience in the management of nuclear operations. The abstract (p. 228) is clear and concise; there is additional information in his slides but they are a bit messy.
And that’s it for this installment. Be safe. Please don’t drink and text.
* International Atomic Energy Agency, International Conference on Human and Organizational Aspects of Assuring Nuclear Safety: Exploring 30 years of Safety Culture (Feb. 22–26, 2016). This page shows the published conference materials. Thanks to Madalina Tronea for publicizing them. Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety Culture discussion group.
ReplyDelete• Involvement of Authority
An inescapable fact is that conditions, behaviors, actions, and inactions were what they were because those in authority wanted them that way, tolerated their being that way, or didn’t know that they were that way. This applies from the work location to the top governance.
Observation: Situational awareness is a prerequisite for accountability.
“What is permitted is promoted.”- Unknown (for now)
Observation: This has yet to be addressed for Fukushima.