It is “compiacimento”. Why would I be providing this bit of knowledge? The reason is a recent speech by Commissioner Dale Klein of the NRC to a conference in Rome, Italy. What I found interesting was that once again an NRC Commissioner was sounding the warning about complacency as a latent flaw that can undermine nuclear safety. We have written a number of posts on this blog on the subject and continue to emphasize it as otherwise . . . . we would be complacent.
One of the direct quotes from the speech is, “Complacency is the primary enemy of an effective regulatory program.“ Klein goes on to recount how both the NRC and the industry had grown complacent prior to the TMI accident. As he said it, “success breeds complacency”.
The complacency issue is the takeoff point for Klein to link complacency with safety culture. His point being that a healthy safety culture, one that questions and challenges, is an antidote to complacency. We agree to a point. But a question that we have asked and try to address in our safety management models is, what if complacency in fact erodes safety culture? Has that not been observed in more recent safety failures such as the space shuttle accidents? To us that is the insidious nature of complacency - it can undermine the very process designed to avoid complacency in the first place. From a systems perspective it is particularly interesting (or troubling) because as compla-cency erodes safety culture, results are challenged less and become more acceptable, further reinforcing the sense that everything is OK, and leading to more complacency. It is referred to as a positive reinforcing loop. Positive reinforcing loops have the ability to change system performance very rapidly, meaning an organization can go from success to failure faster than other mechanisms (e.g., safety culture surveys) may be able to detect.
To delve a little deeper into this question, on Slide 10 of the NEI presentation there is a typical summary graphic of assessment results. The chart catalogs the responses of members of the organization by the eight INPO principles of safety culture. This summary indicates a variety of responses to the individual principles – for 3 or 4 of the principles there seems to be a fairly strong consensus that the right things are happening. But 5 of the 8 principles show greater than a 20 score negative responses and 2 of the principles show greater than a 40 score negatives.
First, what can or should one conclude about the overall state of safety culture in this organization given these results? One wonders if these results were shown to a number of experts, whether their interpretations would be consistent or whether they would even purport to associate the results with a finding. As discussed in a prior post, this issue is fundamental to the nature of safety culture, whether it is amenable to direct measurement, and whether assessment results really say anything about the safety health of the organization.
But the more particular question for this post is whether an assessment can detect complacency in an organization and its potential for latent risk to the organization’s safety performance. In a post dated July 30, 2009 I referred to the problems presented by complacency, particularly in organizations experiencing few operational challenges. That environment can be ripe for a weak culture to develop or be sustained. Could that environment also bias the responses to assessment questions, reinforcing the incorrect perception that safety culture is healthy? It may be that this type of situation is of most relevance in today’s nuclear industry where the vast majority of plants are operating at high capacity factors and experiencing few significant operational events. It is not clear to this commentator that assessments can be designed to explicitly detect complacency, and even the use of assessment results in conjunction with other data (data likely to look normal when overall performance is good) may not be credible in raising an alarm.
What is this all about? Reliability is a dynamic non-event [MIT paper pg 5]. It is about complacency. Paradoxically, when incident rates are low for an extended period of time and if management does not maintain a high priority on safety, the organization may slip into complacency as individuals shift their attention to other priorities such as production pressures. The MIT authors note the parallel to the NASA space program where incidents were rare notwithstanding a weak safety culture, resulting in the organization rationalizing its performance as “normal”. (See Dianne Vaughan’s book The Challenger Launch Decision for a compelling account of NASA’s organizational dynamics.) In our paper “Practicing Nuclear Safety Management” we make a similar comparison.
What does this imply about the nuclear industry? Certainly we are in a period where the reliability of the plants is at a very high level and the NRC ROP indicator board is very green. Is this positive for maintaining high safety culture levels or does it represent a potential threat? It could be the latter since the biggest problem in addressing the safety implications of complacency in an organization is, well, complacency.
