Cover of TEPCO Self-Assessment |
The TEPCO Self-Assessment
Comments with actual or potential relevance for culture appear throughout the 20-page SA report and are summarized below. It appears about half of the SA findings and concrete action plans could have some connection to organizational culture.
Scores of employees have received awards for achieving goals related to stronger nuclear safety culture (NSC) and senior managers have been emphasizing nuclear safety but weaknesses still exist in implementing all the traits of a strong NSC. Unsafe behaviors with respect to industrial safety are being corrected and the need for stronger nuclear safety is being established. However, communications to the worker level with respect to nuclear safety may be insufficient. The importance of nuclear safety is emphasized in new employee training and in meetings with contractor representatives. (pp. 4-5) This is a mixed bag in the part of the SA most likely to be concerned with SC, viz., “Management Reforms Prioritizing Nuclear Safety.”
The company is working on strengthening work processes to improve risk management but employees report processes are unchanged and no clear priorities are established, factors that may increase fatigue and decrease motivation, both of which challenge the development of NSC. (p. 6)
Stricter safety regulations are being implemented and are no longer resisted based on their cost or operating impact. At Fukushima, the emphasis when performing work has shifted from speed to risk reduction to proceed safely. (pp. 8-9) All good news.
Daily meetings share information on operating experience and near-misses but the overall information set is not leveraged because it is not managed to lead to long-term improvements. (p. 10) In other words, continuous improvement is still a goal, not a reality.
Training is good for teaching employees how to complete tasks but the curriculum is insufficient to cultivate and inculcate a high level of safety performance. The need for a more systematic approach to training is recognized but has not been realized. (pp. 12-13)
Overall findings of the SA emphasize the need to enhance a questioning attitude, strengthen supervision, and upgrade education and training. (p. 20)
NRMC Report and Cover Letter
The NRMC reviewed the SA in a 7-page report.** One improvement noted by the NRMC was “Safety culture awareness has permeated throughout the organization and has improved significantly.” However, the first three items on the list of nine Recommendations deal with NSC:
“Consistent efforts should be made to build a strong nuclear safety culture and instill the nuclear safety culture in an organizational culture. The need for formal training and/or professional facilitation for the managers should be evaluated to instill a strong safety culture in the organization. . . . a safety culture program should be developed to the same standards” for contractors. (p. 5)
There is also a one-page cover letter to the report. Its primary focus is SC:
“TEPCO has made significant progress but must not become complacent . . . . TEPCO should instill . . . a strong safety culture throughout the organization, . . . TEPCO is encouraged to take further actions for the safety culture alignment at all levels of the organization . . .”
Our Perspective
SC and NSC occupy much of the space in all these documents. What should we make of that, if anything? One possibility is SC is acceptable but can always be improved or strengthened. After all, as the NRMC notes “any self-assessment process must be critical by nature and therefore should identify areas for future improvement.”
A darker possibility is that TEPCO’s SC is still weak. The NRMC’s report doesn’t have the language we usually see in the typical U.S. NSC report which says or implies “The plant is operating safely (indicating the NSC is at least minimally acceptable) but has improvement opportunities.” We have to ask the NRMC: Is TEPCO’s current NSC acceptable or not? Everyone understands Fukushima Daiichi is not operating, in fact, it’s still a mess where finding a lost fuel rod is world-wide news, but are current clean-up efforts occurring in an adequately safety-conscious environment? The disaster occurred in 2011; some of the shortcomings noted in the SA should have been squared away by now.
On a different note, how does the SA address some topics dear to us? Goal conflict is addressed when safety is mentioned as the primary goal and improvements are being made without cost being a major consideration. The corrective action program (CAP) is mentioned but only as a tool for implementing improvement in the operating experience program. Decision making is not mentioned at all so we don’t know how safety is being integrated into the decision making process at any level. Another mixed bag.
Bottom line: Is SC front and center in all these documents because it is not yet acceptable?
* “Report on TEPCO’s Self-Assessment of Progress” (Jan. 2017).
** Nuclear Reform Monitoring Committee, “Review of the TEPCO’s Self-Assessment Effort on Nuclear Safety Reform,” (Jan. 30, 2017).
*** Nuclear Reform Monitoring Committee, Cover letter to "Review of the TEPCO's Self-Assessment Effort on Nuclear Safety Reform," (Jan. 30, 2017). The public versions of all these TEPCO documents are copy protected so quotes have been retyped.
Lesson to be Learned (LTBL): Most harmful conditions, behaviors, actions, and inactions that are attributed to culture and/or found to be part of the culture are also noncompliances and/or nonconformances.
ReplyDeleteRecognized and Generally Accepted Good Investigation Practice (RAGAGIP): When harmful conditions, behaviors, actions, and inactions are attributed to culture and/or found to be part of the culture look for the corresponding noncompliances and/or nonconformances.