
One system where we see this openness is the air transport industry—the air carriers and the Federal Aviation Administration (FAA). The FAA has two programs for self-reporting of incidents and problems: the Voluntary Disclosure Reporting Program (VDRP) and the Aviation Safety Action Program (ASAP). These programs are discussed in a recent report* by the FAA’s Office of Inspector General (OIG) and are at least superficially similar to the NRC’s Licensee Event Reporting and Employee Concerns Program.
What’s interesting is that VDRP is receptive to the reporting of both individual and systemic issues. The OIG report says the difference between individual and systemic is “important because if the issue is systemic, the carrier will have to develop a detailed fix to address the system as a whole—whereas if the issue is more isolated or individual, the fix will be focused more at the employee level, such as providing counseling or training.” (p. 7) In addition, it appears both FAA programs are imbued with the concept of a “just culture,” another topic we have posted about on several occasions and which is often associated with a systems view. A just culture is one where people are encouraged to provide essential safety-related information, the blame game is aggressively avoided, and a clear line exists between acceptable and unacceptable behavior.
Now the implementation of the FAA programs is far from perfect. As the OIG points out, the FAA doesn't ensure root causes are identified or corrective actions are sufficient and long-lived, and safety data is not analyzed to identify trends that represent risks. Systemic issues may not always be reported by the carriers or recognized by the FAA. But overall, there appears to be an effort at open, comprehensive communication between the regulator and the regulated.
So why does the FAA encourage a just culture while the nuclear industry seems fixated on a culture of blame? One factor might be the NRC’s focus on hardware-centric performance measures. If these are improving over time, one might infer that any incidents are more likely caused by non-hardware, i.e., humans.
But perhaps we can gain greater insight into why one industry is more accepting of systemic issues by looking at system-level factors, specifically the operational (or actual) coupling among industry participants versus their coupling as perceived by external observers.**
As a practical matter, the nuclear industry is loosely coupled, i.e., each plant operates more or less independently of the others (even though plants with a common owner are subject to the same policies as other members of the fleet). There is seldom any direct competition between plants. However, the industry is viewed by many external observers, especially anti-nukes, as a singular whole, i.e, tightly coupled. Insiders reinforce this view when they say things like “an accident at one plant is an accident for all.” And, in fact, one incident (e.g., Davis-Besse) can have industry-wide implications although the physical risk may be entirely local. In such a socio-political environment, there is implicit pressure to limit or encapsulate the causes of any incidents or irregularities to purely local sources and avoid the mention of possible systemic issues. The leads to a search for the faulty component, the bad employee, a failure to update a specific procedure or some other local problem that can be fixed by improved leadership and oversight, clearer expectations, more attention to detail, training etc. The result of this approach (plus other industry-wide factors, e.g., the lack of transparency in certain oversight practices*** and the “special and unique” mantra) is basically a closed system whose client, i.e., the beneficiary of system efforts, is itself.
In contrast, the FAA’s world has two parts, the set of air carriers whose relationship with each another is loosely coupled, similar to the nuclear industry, and the air traffic control (ATC) sub-system, which is more tightly coupled because all the carriers share the same airspace and ATC. Because of loose coupling, a systemic problem at a single carrier affects only that carrier and does not infect the rest of the industry. What is most interesting is that a single airline accident (in the tightly coupled portion of the system) does not lead to calls to shut down the industry. Air transport has no organized opposition to its existence. Air travel is such an integral part of so many people’s lives that pressure exists to keep the system running even in the face of possible hazards. As a consequence, the FAA has to occasionally reassert its interest in keeping safety risks from creeping into the system. Overall, we can say the air transport industry is relatively open, able to admit the existence of problems, even systemic ones, without taking an inadvertent existential risk.
The foregoing is not intended to be a comprehensive comparison of the two industries. Rather it is meant to illustrate how one can apply a simple systems concept to gain some insights into why participants in different industries behave differently. While both the FAA and NRC are responsible for identifying systemic issues in their respective industries, it appears FAA has an easier time of it. This is not likely to change given the top-level factors described above.
* FAA Office of Inspector General, “Further Actions are Needed to Improve FAA’s Oversight of the Voluntary Disclosure Reporting Program” Report No. AV-2014-036 (April 10, 2014). Thanks to Bill Mullins for pointing out this report to us.
“VDRP provides air carriers the opportunity to voluntarily report and correct areas of non-compliance without civil penalty. The program also provides FAA important safety information that might not otherwise come to its attention.“ (p. 1) ASAP “allows individual aviation employees to disclose possible safety violations to air carriers and FAA without fear that the information will be used to take enforcement or disciplinary action against them.” (p. 2)
** “Coupling” refers to the amount of slack, buffer or give between two items in a system.
*** For example, INPO’s board of directors is comprised of nuclear industry CEOs, INPO evaluation reports are delivered in confidence to its members and INPO has basically unfettered access to the NRC. This is not exactly a recipe for gaining public trust. See J.O. Ellis Jr. (INPO CEO), Testimony before the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (Aug. 25, 2010). Retrieved from NEI website May 27, 2014.