IAEA Working Paper on Safety Culture Traits and Attributes

Working paper cover

The International Atomic Energy Agency (IAEA) has released a working paper* that attempts to integrate (“harmonize”) the efforts by several different entities** to identify and describe desirable safety culture (SC) traits and attributes.  The authors have also tried to make the language of SC less nuclear power specific, i.e., more general and thus helpful to other fields that deal with ionizing radiation, such as healthcare.  Below we list the 10 traits and highlight the associated attributes that we believe are most vital for a strong SC.  We also offer our suggestions for enhancing the attributes to broaden and strengthen the associated trait’s presence in the organization.

Individual Responsibility 

All individuals associated with an organization know and adhere to its standards and expectations.  Individuals promote safe behaviors in all situations, collaborate with other individuals and groups to ensure safety, and “accept the value of diverse thinking in optimizing safety.”

We applaud the positive mention of “diverse thinking.”  We also believe each individual should have the duty to report unsafe situations or behavior to the appropriate authority and this duty should be specified in the attributes.

Questioning Attitude 

Individuals watch for anomalies, conditions, behaviors or activities that can adversely impact safety.  They stop when they are uncertain and get advice or help.  They try to avoid complacency.  “They understand that the technologies are complex and may fail in unforeseen ways . . .” and speak up when they believe something is incorrect.

Acknowledging that technology may “fail in unforeseen ways” is important.  Probabilistic Risk Assessments and similar analyses do not identify all the possible ways bad things can happen. 

Communication

Individuals communicate openly and candidly throughout the organization.  Communication with external organizations and the public is accurate.  The reasons for decisions are communicated.  The expectation that safety is emphasized over competing goals is regularly reinforced.

Leader Responsibility

Leaders place safety above competing goals, model desired safety behaviors, frequently visit work areas, involve individuals at all levels in identifying and resolving issues, and ensure that resources are available and adequate.

“Leaders ensure rewards and sanctions encourage attitudes and behaviors that promote safety.”  An organization’s reward system is a hot button issue for us.  Previous SC framework documents have never addressed management compensation and this one doesn’t either.  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.

Leaders should also address work backlogs.  Backlogs send a signal to the organization that sub-optimal conditions are tolerated and, if such conditions continue long enough,  are implicitly acceptable.  Backlogs encourage workarounds and lack of attention to detail, which will eventually create challenges to the safety management system.  

Decision-Making

“Individuals use a consistent, systematic approach to evaluate relevant factors, including risk, when making decisions.”  Organizations develop the ability to adapt in anticipation of unforeseen situations where no procedure or plan applies.

We believe the decision making process should be robust, i.e., different individuals or groups facing the same issue should come up with the same or an equally effective solution.  The organization’s approach to decision making (goals, priorities, steps, etc.) should be documented to the extent practical.  Robustness and transparency support efficient, effective communication of the reasons for decisions.

Work Environment 

“Trust and respect permeate the organization. . . . Differing opinions are encouraged, discussed, and thoughtfully considered.”

In addition, senior managers need to be trusted to tell the truth, do the right things, and not sacrifice subordinates to evade the managers’ own responsibilities.

Continuous Learning 

The organization uses multiple approaches to learn including independent and self-assessments, lessons learned from their own experience, and benchmarking other organizations.

Problem Identification and Resolution

“Issues are thoroughly evaluated to determine underlying causes and whether the issue exists in other areas. . . . The effectiveness of the actions is assessed to ensure issues are adequately addressed. . . . Issues are analysed to identify possible patterns and trends. A broad range of information is evaluated to obtain a holistic view of causes and results.”

This is good but could be stronger.  Leaders should ensure the most knowledgeable individuals, regardless of their role or rank, are involved in addressing an issue. Problem solvers should think about the systemic relationships of issues, e.g., is an issue caused by activity in or feedback from some other sub-system, the result of a built-in time delay, or performance drift that exceeded the system’s capacities?  Will the proposed fix permanently address the issue or is it just a band-aid?

Raising Concerns

The organization encourages personnel to raise safety concerns and does not tolerate harassment, intimidation, retaliation or discrimination for raising safety concerns. 

This is the essence of a Safety Conscious Work Environment and is sine qua non for any high hazard undertaking.

Work Planning 

“Work is planned and conducted such that safety margins are preserved.”

Our Perspective

We have never been shy about criticizing IAEA for some of its feckless efforts to get out in front of the SC parade and pretend to be the drum major.***  However, in this case the agency has been content, so far, to build on the work of others.  It’s difficult for any organization to develop, implement, and maintain a strong, robust SC and the existence of many different SC guidebooks has never been helpful.  This is one step in the right direction.  We’d like to see other high hazard industries, in particular healthcare organizations such as hospitals, take to heart SC lessons learned from the nuclear industry.

Bottom line: This concise paper is worth checking out.


*  IAEA Working Document, “A Harmonized Safety Culture Model” (May 5, 2020).  This document is not an official IAEA publication.

**  Including IAEA, WANO, INPO, and government institutions from the United States, Japan, and Finland.

***  See, for example, our August 1, 2016 post on IAEA’s document describing how to perform safety culture self-assessments.  Click on the IAEA label to see all posts related to IAEA.

Catching Up with Nuclear Safety Culture’s Bad Boys: Entergy and TVA

Entergy Headquarters

TVA Headquarters

We haven’t reported for awhile on the activities of the two plant operators who dominate the negative news in the Nuclear Safety Culture (NSC) space, viz., Entergy and TVA.  Spoiler alert: there is nothing novel or unexpected to report, only the latest chapters in their respective ongoing sagas.

Entergy

On March 12, 2018 the NRC issued a Confirmatory Order* (CO) to Entergy for violations at the Grand Gulf plant: (1) an examination proctor provided assistance to trainees and (2) nonlicensed operators did not tour all required watch station areas and entered inaccurate information into the operator logs.  The NRC characterized these as willful violations.  As has become customary, Entergy requested Alternative Dispute Resolution (ADR).  Entergy agreed to communicate fleet-wide the company’s intolerance for willful misconduct, evaluate why prior CO-driven corrective actions failed to prevent the current violations, conduct periodic effectiveness reviews of corrective actions, and conduct periodic “organizational health surveys” to identify NSC concerns that could contribute to willful misconduct.

On March 29, 2018 the NRC reported** on Arkansas Nuclear One’s (ANO’s) progress in implementing actions required by a June 17, 2016 Confirmatory Action Letter (CAL).  (We reported at length on ANO’s problems on June 25, 2015 and June 16, 2016.)  A weak NSC has been a major contributor to ANO’s woes.  The NRC inspection team concluded that all but one corrective actions were implemented and effective and closed those items.  The NRC also concluded that actions taken to address two inspection focus areas and two Yellow findings were also satisfactory.

On April 20, 2018 the NRC reported*** on ANO’s actions to address a White inspection finding.  They concluded the actions were satisfactory and noted that ANO’s root cause evaluation had identified nine NSC aspects with weaknesses.  Is that good news because they identified the weaknesses or bad news because they found so many?  You be the judge.

On June 18, 2018 the NRC closed**** ANO's CAL and moved the plant into column 1 of the Reactor Oversight Process Action Matrix.

TVA

The International Atomic Energy Agency (IAEA) conducted an Operational Safety Review Team (OSART) review***** of Sequoyah during August 14-31, 2017.  The team reviewed plant operational safety performance vis-à-vis IAEA safety standards and made appropriate recommendations and suggestions.  Two of the three significant recommendations have an NSC component: (1) “improve the performance of management and staff in challenging inappropriate behaviours” and “improve the effectiveness of event investigation and corrective action implementation . . .” (p. 2)

Focusing on NSC, the team observed: “The procedure for nuclear safety culture self-assessments does not include a sufficiently diverse range of tools necessary to gather all the information required for effective analysis. The previous periodic safety culture self-assessment results were based on surveys but other tools, such as interviews, focus groups and observations, were only used if the survey revealed any gaps.” (p. 60)

On March 14, 2018 the NRC reported^ on Watts Bar’s progress in addressing NRC CO EA-17-022 and Chilling Effect Letter (CEL) EA-16-061, and licensee action to establish and maintain a safety-conscious work environment (SCWE).  (We discussed the CEL on March 25, 2016 and NSC/SCWE problems on Nov. 14, 2016.)  Licensee actions with NSC-related components were noted throughout the report including the discussions on plant communications, training, work processes and independent oversight.  The sections on assessing NSC/SCWE and “Safety Over Production” included inspection team observations (aka opportunities for improvement) which were shared with the licensee. (pp. 10-11, 17, 24-27)  One TVA corrective action was to establish a Fleet Safety Culture Peer Team, which has been done.  The overall good news is the report had no significant NSC-related negative findings.  Focus group participants were generally positive about NSC and SCWE but expressed concern about “falling back into old patterns” and “declaring success too soon.” (p. 27)

Our Perspective

For Entergy, it looks like business as usual, i.e., NSC Whac-A-Mole.  They get caught or self-report an infraction, go to ADR, and promise to do better at the affected site and fleet-wide.  Eventually a new problem arises somewhere else.  The strength of their overall NSC appears to be floating in a performance band below satisfactory but above intolerable.

We are a bit more optimistic with respect to TVA.  It would be good if TVA could replicate some of Sequoyah’s (which has managed to keep its nose generally clean) values and practices at Browns Ferry and Watts Bar.  Perhaps their fleet wide initiative will be a mechanism for making that happen.

We applaud the NRC inspection team for providing specific information to Watts Bar on actions the plant could take to strengthen its NSC.

Bottom line: The Sequoyah OSART report is worth reviewing for its detailed reporting of the team’s observations of unsafe (or at least questionable) employee work behaviors.


*  K.M. Kennedy (NRC) to J.A. Ventosa (Entergy), “Confirmatory Order, NRC Inspection Report 05000416/2017014, and NRC Investigation Reports 4-2016-004 AND 4-2017-021” (Mar. 12, 2018).  ADAMS ML18072A191.

**  N.F. O’Keefe (NRC) to R.L. Anderson (Entergy), “Arkansas Nuclear One – NRC Confirmatory Action Letter (EA-16-124) Follow-up Inspection Report 05000313/2018012 AND 05000368/2018012” (Mar. 29, 2018).  ADAMS ML18092A005.

***  N.F. O’Keefe (NRC) to R.L. Anderson (Entergy), “Arkansas Nuclear One, Unit 2 – NRC Supplemental Inspection Report 05000368/2018040” (Apr. 20, 2018).  ADAMS ML18110A304.

****  K.M. Kennedy (NRC) to R.L. Anderson (Entergy), "Arkansas Nuclear One – NRC Confirmatory Action Letter (EA-16-124) Follow-up Inspection Report 05000313/2018013 AND 05000368/2018013 and Assessment Follow-up Letter" (Jun. 18, 2018)  ADAMS ML18165A206.

 *****  IAEA Operational Safety Review Team (OSART), Report of the Mission to the Sequoyah Nuclear Power Plant Aug. 14-31, 2017, IAEA-NSNI/OSART/195/2017.  ADAMS ML18061A036. The document date in the NRC library is Mar. 2, 2018.

^  A.D. Masters (NRC) to J.W. Shea “Watts Bar Nuclear Plant – Follow-up for NRC Confirmatory Order EA-17-022 and Chilled Work Environment Letter EA-16-061; NRC INSPECTION REPORT 05000390/2017009, 05000391/2017009” (Mar. 14, 2018).  ADAMS ML18073A202.

“New” IAEA Nuclear Safety Culture Self-Assessment Methodology

IAEA report cover

The International Atomic Energy Agency (IAEA) touted its safety culture (SC) self-assessment methodology at the Regulatory Cooperation Forum held during the recent IAEA 61st General Conference.  Their press release* refers to the methodology as “new” but it’s not exactly fresh from the factory.  We assume the IAEA presentation was based on a publication titled “Performing Safety Culture Self-assessments”** which was published in June 2016 and we reviewed on Aug. 1, 2016.  We encourage you to read our full review; it is too lengthy to reasonably summarize in this post.  Suffice to say the publication includes some worthwhile SC information and descriptions of relevant SC assessment practices but it also exhibits some execrable shortcomings.


*  IAEA, “New IAEA Self-Assessment Methodology and Enhancing SMR Licensing Discussed at Regulatory Cooperation Forum” (Sept. 22, 2017).

**  IAEA, “Performing Safety Culture Self-assessments,” Safety Reports Series no. 83 (Vienna: IAEA, 2016).

Learning About Nuclear Safety Culture from the Web, Maybe

The Internet  Source:Wikipedia

We’ve come across some Internet content (one website, one article) that purports to inform the reader about nuclear safety culture (NSC).  This post reviews the content and provides our perspective on its value.

NSC Website

It appears the title of this site is “Nuclear Safety Culture”* and the primary target is journalists who want an introduction to NSC concepts, history and issues.  It is a product of a group of European entities.  It is a professional looking site that covers four major topics; we’ll summarize them in some detail to show their wide scope and shallow depth. 

Nuclear Safety Culture covers five sub-topics:

History traces the shift in attitudes toward and protection from ionizing radiation as the possible consequences became better known but the story ends in the 1950s.  Key actions describe the roles of internal and external stakeholders during routine operations and emergency situations.  The focus is on power production although medicine, industrial uses and weapons are also mentioned.  Definition of NSC starts with INSAG (esp. INSAG-4), then adds INPO’s directive to emphasize safety over competing goals, and a familiar list of attributes from the Nuclear Safety Journal.  As usual, there is nothing in the attributes about executive compensation or the importance of a systems view.  IAEA safety principles are self explanatory.  Key scientific concepts cover the units of radiation for dose, intake and exposure.  Some values are shown for typical activities but only one legal limit, for US airport X-rays, is included.**  There is no information in this sub-topic on how much radiation a person can tolerate or the regulatory limits for industrial exposure.

From Events to Accidents has two sub-topics:

From events to accidents describes the 7-level International Nuclear Event Scale (from a minor anomaly to major accident) but the scale itself is not shown.  This is a major omission.  Defence in depth discusses this important concept but provides only one example, the levels of physical protection between a fuel rod in a reactor and the environment outside the containment.

Controversies has two sub-topics:

Strengths and Weaknesses discuss some of the nuclear industry’s issues and characteristics: industry transparency is a double-edge sword, where increased information on events may be used to criticize a plant owner; general radiation protection standards for the industry; uncertainties surrounding the health effects of low radiation doses; the usual nuclear waste issues; technology evolution through generations of reactors; stress tests for European reactors; supply chain realities where a problem anywhere is used against the entire industry; the political climate, focusing on Germany and France; and energy economics that have diminished nuclear’s competitiveness.  Overall, this is a hodgepodge of topics and a B- discussion.  The human factor provides a brief discussion of the “blame culture” and the need for a systemic view, followed by summaries of the Korean and French document falsification events.

Stories summarizes three events: the Brazilian theft of a radioactive source, Chernobyl and Fukushima.  They are all reported in an overly dramatic style although the basic facts are probably correct.

The authors describe what they call the “safety culture breach” for each event.  The problem is they comingle overarching cultural issues, e.g., TEPCO’s overconfident management, with far more specific failures, e.g., violations of safety and security rules, and consequences of weak NSC, e.g., plant design inadequacies.  It makes one wonder if the author(s) of this section have a clear notion of what NSC is.

It isn’t apparent how helpful this site will be for newbie journalists, it is certainly not a complete “toolkit.”  Some topics are presented in an over-simplified manner and others are missing key figures.  In terms of examples, the site emphasizes major accidents (the ultimate trailing indicators) and ignores the small events, normalization of deviance, organizational drift and other dynamics that make up the bulk of daily life in an organization.  Overall, the toolkit looks a bit like a rush job or unedited committee work, e.g., the section on the major accidents is satisfactory but others are incomplete.  Importantly (or perhaps thankfully) the authors offer no original observations or insights with respect to NSC.  It’s worrisome that what the site creators call NSC is often just the safety practices that evolved as the hazards of radiation became better known. 

NSC Article

There is an article on NSC in the online version of Power magazine.  We are not publishing a link to the article because it isn’t very good; it looks more like a high schooler’s Internet-sourced term paper than a thoughtful reference or essay on NSC.

However, like the stopped clock that shows the correct time twice per day, there can be a worthwhile nugget in such an article.  After summarizing a research paper that correlated plants’ performance indicators with assessments of their NSC attributes (which paper we reviewed on Oct. 5, 2014), the author says “There are no established thresholds for determining whether a safety culture is “healthy” or “unhealthy.””  That’s correct.  After NSC assessors consolidate their interviews, focus groups, observations, surveys and document reviews, they always identify some improvement opportunities but the usual overall grade is “pass.”***  There’s no point score, meter or gauge.  Perhaps there should be.

Our Perspective

Don’t waste your time with pap.  Go to primary sources; an excellent starting point is the survey of NSC literature performed by a U.S. National Laboratory (which we reviewed on Feb. 10, 2013.)  Click on our References label to get other possibilities and follow folks who actually know something about NSC, like Safetymatters.


*  Nuclear Safety Culture was developed as part of the NUSHARE project under the aegis of the European Nuclear Education Network.   Retrieved June 19, 2017.

**  The airport X-ray limit happens to be the same as the amount of radiation emitted by an ordinary banana.

***  A violation of the Safety Conscious Work Environment (SCWE) regulations is quite different.  There it’s zero tolerance and if there’s a credible complaint about actual retaliation for raising a safety issue, the licensee is in deep doo-doo until they convince the regulator they have made the necessary adjustments in the work environment.

Nuclear Safety Culture at the 2017 NRC Regulatory Information Conference

NRC 2017 RIC

Nuclear Safety Culture (NSC) was assigned one technical session at the 2017 NRC Regulatory Information Conference (RIC).  The topic was maintaining a strong NSC during plant decommissioning.  This post reviews the session presentations and provides our perspective on the topic.

Nuclear Regulatory Commission (NRC)*

The presenter discussed the agency’s expectations that the requirements of the SC Policy Statement will continue to be met during decommissioning, recognizing that plant old-timers may experience issues with trust, commitment and morale while newcomers, often contractors, will need to be trained and managed to meet NSC standards going forward.  The presentation was on-target but contained no new information or insights.

International Atomic Energy Agency (IAEA)**

This presentation covered the IAEA documents that discuss NSC, viz., the General Safety Requirement “Leadership and Management for Safety,” and the Safety Guides “Application of the Management System for Facilities and Activities,” which covers NSC characteristics, and “The Management System for Nuclear Installations,” which covers NSC assessments, plus supporting IAEA Safety Reports and Technical Documents.  There was one slide covering decommissioning issues, none of which was new.

The slides were dense with turgid text; this presentation must have been excruciating to sit through.  The best part was IAEA did not attempt to add any value through some new approach or analysis, which always manages to muck up the delivery of any potentially useful information. 

Kewaunee***

The Kewaunee plant was shut down on May 7, 2013.  The shutdown announcement on Oct. 22, 2012 was traumatic for the staff and they went through several stages of grieving.  Management has worked to maintain transparency and an effective corrective action program, and retain people who can accept changing conditions.  It is a challenge for management to maintain a strong NSC as the plant transitions to long-term SAFSTOR.

It’s not surprising that Kewaunee is making the best of what is undoubtedly an unhappy situation for many of those involved.  The owner, Dominion Resources, has a good reputation in NSC space.

Vermont Yankee****

This plant was shut down on Dec. 29, 2014.  The site continued applying its process to monitor for NSC issues but some concerns still arose (problems in radiation practices, decline in industrial safety performance) that indicated an erosion in standards.  Corrective actions were developed and implemented.  A Site Review Committee provides oversight of NSC.

The going appears a little rougher at Vermont Yankee than Kewaunee.  This is not a surprise given both the plant and its owner (Entergy) have had challenges in maintaining a strong NSC. 

Our Perspective

The session topic reflects a natural life cycle: industrial facilities are built, operate and then close down.  But that doesn’t mean it’s painless to manage through the phase changes. 

In an operating plant, complacency is a major threat.  Complacency opens the door to normalization of deviation and other gremlins that move performance toward the edge of the envelope.  In the decommissioning phase, we believe loss of fear is a major threat.  Loss of fear of dramatic, even catastrophic radiological consequences (because the fuel has been off-loaded and the plant will never operate again) can lead to losing focus, lack of attention to procedural details, short cuts and other behaviors that can have significant negative consequences such as industrial accidents or mishandling of radioactive materials.

In a “Will the last person out please turn off the lights” environment, maintaining everyone’s focus on safety is challenging for people who operated the plant, often spending a large part of their careers there.  The lack of local history is a major reason to transfer work to specialty decommissioning contractors as quickly as possible. 

In 2016, NSC didn’t merit a technical session at the RIC; it was relegated to a tabletop presentation.  As the industry shrinks, we hope NSC doesn’t get downgraded to a wall poster.


*  D. Sieracki, “Safety Culture and Decommissioning,” 2017 RIC (Mar. 15, 2017).

**  A. Orrell, “Safety Culture and the IAEA International Perspectives,” 2017 RIC (Mar. 15, 2017).

***  S. Yeun, “Maintaining a Strong Safety Culture after Shutdown,” 2017 RIC (Mar. 15, 2017).

****  C. Chappell, “Safety Culture in Decommissioning: Vermont Yankee Experience,” 2017 RIC (Mar. 15, 2017).

Nuclear Safety Culture Self-Assessment Guidance from IAEA

IAEA report cover

The International Atomic Energy Agency (IAEA) recently published guidance on performing safety culture (SC) self-assessments (SCSAs).  This post summarizes the report* and offers our perspective on its usefulness.

The Introduction presents some general background on SC and specific considerations to keep in mind when conducting an SCSA, including a “conscious effort to think in terms of the human system (the complex, dynamic interaction of individuals and teams within an organization) rather than the technological system.” (p. 2)  Importantly, an SCSA is not based on technical skills or nuclear technology, nor is it focused on immediate corrective actions for observed problems.

Section 2 provides additional information on SC, starting with the basics, e.g., culture is one way of explaining why things happen in organizations.  The familiar iceberg model is presented, with the observable artifacts above the surface and the national, ethnic and religious values that underlie culture way below the waterline.  Culture is robust (it cannot be changed rapidly) and complicated (subcultures exist).  So far, so good.

Then things start to go off the rails.  The report reminds us that the IAEA SC framework** has five SC characteristics but then the report introduces, with no transition, a four-element model for envisioning SC; naturally, the model elements are different from the five SC characteristics previously mentioned.  The report continues with a discussion of IAEA’s notion of “shared space,” the boundary area where working relationships develop between the individual and other organizational members.  We won’t mince words: the four-component model and “shared space” are a distraction and zero value-added.

Section 3 explores the characteristics of SCSAs.  Initially, an SCSA focuses on developing an accurate description of the current culture, the “what is.”  It then moves on to evaluating a SC’s strengths and weaknesses by comparing “what is” with “what should be.”  An SCSA is different from a typical audit in numerous ways, including the need for specialized training, a focus on organizational dynamics and an understanding of the complex interplay of multicultural dimensions of the organization.

SCSAs require recognition of the biases present when a culture examines itself.  Coupling this observation with an earlier statement that effective SCSAs require understanding of the relevant social sciences, the report recommends obtaining qualified external support personnel (at least for the initial efforts at conducting SCSAs).  In addition, there are many risks (the report comes up with 17) associated with performing an SCSA that have to be managed.  All of these aspects are important and need to be addressed.

Section 4 describes the steps in performing an SCSA.  The figure that purportedly shows all the steps is unapproachable and unintelligible.  However, the steps themselves—prepare the organization, the team and the SCSA plan; conduct the pre-launch and the SCSA; analyze the results; summarize the communicate the findings; develop actions; capture lessons learned; and conduct a follow-up—are reasonable.

The description of SCSA team composition, competences and responsibilities is also reasonable.  Having a team member with a behavioral science background is highly desirable but probably not available internally in other than the largest organizations. 

Section 5 covers SCSA methods: document review, questionnaires, observations, focus groups and interviews.  For each method, the intent, limitations and risks, and intended uses are discussed.  Each method requires specific skills.  The purpose is to develop an overall view of the culture.  Because of the limitations of individual methods, multiple (and preferably all) methods should be used.  Overall, this section is a pretty good high-level description of the different investigative methods.

Section 6 describes how to perform an integrated analysis of the information gathered.  This involves working iteratively with parallel information sets.  There is a lengthy discussion of how to develop cultural themes from the different data sources.  Themes are combined into an overall descriptive view of the culture which can then be compared to the IAEA SC framework (a normative view) to identify relative strengths and weaknesses, and improvement opportunities.

Section 7 describes approaches to communicating the findings and transitioning into action.  It covers preparing the SCSA report, communicating the results to management and the larger organization, possible barriers to implementing improvement initiatives and maintaining continuous improvement in an organization’s SC.

The report has an extensive set of appendices that illustrate how an SCSA can be conducted.  Appendix I is a laundry list of potential areas for inquiry.  Appendices II-VIII present a case study using all the SCSA methods in Section 5, followed by some example overall conclusions.  Appendix IX is an outline of an SCSA final report.  The guidance on using the SCSA methods is acceptably complete and clear.

A 28-page Annex (including 8 pages of references) describes the social science underlying the recommended methodology for performing SCSAs.  It covers too much ground to be summarized here.  The writing is uneven, with some topics presented in a fluid style (probably a single voice) while others, especially those referring to many different sources, are more ragged.  Because of the extensive use of in-line references, the reader can easily identify source materials.   

Our Perspective

There’s good news and bad news in this Safety Report.  The good news is that when IAEA collates and organizes the work of others, e.g., academics, SC practitioners or industry best practices, IAEA can create a readable, reasonably complete reference on a subject, in this case, SCSA.

The bad news is that when IAEA tries to add new content with their own concepts, constructs, figures and such, they fail to add any value.  In fact, they detract from the total package.  It seems to never have occurred to the IAEA apparatchiks to circulate their ideas for new content for substantive review and comment.


*  International Atomic Energy Agency, “Performing Safety Culture Self-assessments,” Safety Reports Series no. 83 (Vienna: IAEA, 2016).  Thanks to Madalina Tronea for publicizing this report.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety Culture discussion group.

**  Interestingly, the IAEA SC framework (SC definition, key characteristics and attributes) is mentioned without much discussion; the reader is referred to other IAEA documents for more details.  That’s OK.  For purposes of SCSA, it’s only important that the organization, including the SCSA team, agree on a SC definition and its associated characteristics and attributes.  This will give everyone involved a shared normative view for linking the SCSA findings to a picture of what the SC should look like.

IAEA Nuclear Safety Culture Conference

The International Atomic Energy Agency (IAEA) recently sponsored a week-long conference* to celebrate 30 years of interest and work in safety culture (SC).  By our reckoning, there were about 75 individual presentations in plenary sessions and smaller groups; dialog sessions with presenters and subject matter experts; speeches and panels; and over 30 posters.  It must have been quite a circus.

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. 

IAEA Urges Stronger Nuclear Safety Culture in Japan

Fukushima

The International Atomic Energy Agency (IAEA) recently completed a peer review of Japan's Nuclear Regulation Authority (NRA), a regulatory agency established in the aftermath of the 2011 Fukushima disaster.  Highlights of the review were discussed at an IAEA press conference.*

The IAEA review team praised the NRA’s progress in various areas, such as demonstrating independence and transparency, and made suggestions and recommendations for further improvement, primarily in the area of NRA staff recruiting and development.

The IAEA team also mentioned safety culture (SC), recommending “the NRA and nuclear licensees ‘continue to strengthen the promotion of safety culture, including by fostering a questioning attitude’.”

Our Perspective

We look forward to the IAEA’s final report which is due in about three months.  We are especially interested in seeing if there is comprehensive discussion and specific direction with respect to “fostering a questioning attitude.”  The Japanese nuclear industry in general and TEPCO (Fukushima’s owner) in particular certainly need to cultivate employees’ willingness to develop and consider open-ended questions such as “what if?” and “what can go wrong?”

More importantly, they also need to instill the necessary backbone to stand up in front of the bosses and ask tough questions and demand straight answers.  Lots of folks probably knew the Fukushima seawall wasn’t high enough and the emergency equipment in the basement was subject to flooding but everyone went along with the program.  That’s what has to change to create a stronger SC.


*  “IAEA praises reform of Japan's nuclear regulator,” World Nuclear News (Jan. 22, 2016).

IAEA International Conference on Operational Safety, including Safety Culture

IAEA Building

Back in June, the International Atomic Energy Agency (IAEA) hosted an International Conference on Operational Safety.*  Conference sessions covered Peer Reviews, Corporate Management, Post-Fukushima Improvements, Operating Experience, Leadership and Safety Culture and Long Term Operation.  Later, the IAEA published a summary of conference highlights, including conclusions in the session areas.**  It reported the following with respect to safety culture (SC):

“No organization works in isolation: the safety culture of the operator is influenced by the safety culture of the regulator and vice versa. Everything the regulator says or does not say has an effect on the operator. The national institutions and other cultural factors affect the regulatory framework. Corporate leadership is integral to achieving and improving safety culture, the challenge here is that regulators are not always allowed to conduct oversight at the corporate management level.”

Whoa!  This is an example of the kind of systemic thinking that we have been preaching for years.  We wondered who said that so we reviewed all the SC presentations looking for clues.  Perhaps not surprisingly, it was a bit like gold-mining: one has to crush a lot of ore to find a nugget.

Most of the ore for the quote was provided by a SC panelist who was not one of the SC speakers but a Swiss nuclear regulator (and the only regulator mentioned in the SC session program).  Her slide bullets included “The regulatory body needs to take different perspectives on SC: SC as an oversight issue, impact of oversight on licensees’ SC, the regulatory body’s own SC, [and] Self-reflection on its own SC.”  Good advice to regulators everywhere.

As far as we can tell, no presenter made the point that regulators seldom have the authority to oversee corporate management; perhaps that arose during the subsequent discussion.

SC Presentations

The SC presentations contained hearty, although standard fare.  A couple were possibly more revealing, which we’ll highlight later.

The German, Japanese and United Kingdom presentations reviewed their respective SC improvement plans.  In general these plans are focused on specific issues identified during methodical diagnostic investigations.  The plan for the German Philippsburg plant focuses on specific management responsibilities, personnel attitudes and conduct at all hierarchy levels, and communications.  The Japanese plan concentrates on continued recovery from the Fukushima disaster.  TEPCO company-wide issues include Safety awareness, Engineering capability and Communication ability.  The slides included a good system dynamics-type model.  At EDF’s Heysham 2 in the UK, the interventions are aimed at improving management (leadership, decision-making), trust (just culture) and organizational learning.  As a French operator of a UK plant, EDF recognizes they must tune interventions to the local organization’s core values and beliefs.

The United Arab Emirates presentation described a model for their new nuclear organization; the values, traits and attributes come right out of established industry SC guidelines.

The Entergy presenter parroted the NRC/INPO party line on SC definition, leadership responsibility, traits, attributes and myriad supporting activities.  It’s interesting to hear such bold talk from an SC-challenged organization.  Maybe INPO or the NRC “encouraged” him to present at the conference.  (The NRC is not shy about getting licensees with SC issues to attend the Regulatory Information Conference and confess their sins.)

The Russian presentation consisted of a laundry list of SC improvement activities focused on leadership, personnel reliability, observation and cross-cultural factors (for Hanhikivi 1 in Finland).  It was all top-down.  There was nothing about empowering or taking advantage of individuals’ knowledge or experience.  You can make your own inferences.

Management Presentations

We also reviewed the Management sessions for further clues.  All the operator presenters were European and they had similar structures, with “independent” safety performance advisory groups at the plant, fleet and corporate levels.  They all appeared to focus on programmatic strengths and weaknesses in the safety performance area.  There was no indication any of the groups opined on management performance.  The INPO presenter noted that SC is included in every plant and corporate evaluation and SC issues are highlighted in the INPO Executive Summary to a CEO.

Our Perspective

The IAEA press release writer did a good job of finding appealing highlights to emphasize.  The actual presentations were more ordinary and about what you’d expect from anything involving IAEA: build the community, try to not offend anyone.  For example, the IAEA SC presentation stressed the value in developing a common international SC language but acknowledged that different industry players and countries can have their own specific needs.

Bottom line: Read the summary and go to the conference materials if something piques your interest—but keep your expectations modest.


*  International Atomic Energy Agency, International Conference on Operational Safety, June 23-26, 2015, Vienna.

**  IAEA press release, “Nuclear Safety is a Continuum, not a Final Destination” (July 3, 2015).

Defense in Depth and Safety Culture from an IAEA Conference

A 2013 IAEA conference focused on the concept of Defense in Depth (DID) and its implementation at nuclear facilities.  It was a large-scale event with almost 50 presentations and papers.  The published proceedings* run over 350 pages.  This post focuses on the treatment of safety culture (SC) by the authors and presenters.  The proceedings started off well: SC was explicitly mentioned as a cross-cutting issue in the implementation of DID. (p. 1)  In addition, the conference itself was predicated on Fukushima lessons learned which, as everyone now knows, included SC shortcomings in both licensee and government organizations.

But on the whole the treatment of SC was something of a disappointment.  The presentations from Argentina, Pakistan and Vietnam mentioned SC in passing.  The presentation from Egypt discussed the regulator’s role in SC oversight at length. (pp. 302-304)  Only the following three presentations gave SC a featured role.

SC in WANO

The World Association of Nuclear Operators (WANO) presenter said this about SC: “Safety supposes that no operator feels isolated, or refuses openness and permanent self-questioning; it requests as well for WANO to ensure that cultural and sometimes political barriers do not hinder safety culture . . . . In WANO, we believe that management system and practices are at the centre of safety culture, and a full involvement of top management (CEOs) of our members is absolutely requested.”**

SC in Indonesia

Two papers discussed SC at different nuclear facilities in Indonesia.  Desirable SC characteristics at both facilities were based on INSAG-4.

The Experimental Fuel Element Installation (EFEI)

The abstract of this paper*** highlighted SC’s role at this facility.  “The application of safety culture in a nuclear facility is one way of DID implementation.  Safety culture aims at the performance of safe works, the prevention of deviation, and the accomplishment of quality operation.  It is in accordance with the first level of DID concept which is the prevention of abnormal operation and failures that is done through conservative design and high quality in construction and operation. . . The objective of safety culture implementation in the EFEI is to encourage workers to have a stronger sense of responsibility on safety and to contribute actively for its development”  The paper presented a laundry list of strategies used to strengthen SC including briefings, workshops, training, senior management visits, integration of safety into work processes, self-assessments, open reporting on safety incidents, open and timely reporting to the regulator, evaluation of safety performance indicators and an annual SC questionnaire.

The authors displayed a bit of realism when they said “Leaders cannot completely control safety culture, but they may influence it.” (p. 179)  They also said their questionnaire results indicated that EFEI SC is at Stage 2 (from IAEA-TECDOC-1329) where “Safety becomes an organizational goal.”  They want SC to evolve to Stage 3 where the organization believes “Safety can always be improved.” (pp. 187-188)

Kartini Research Reactor

This paper**** reported the findings of a SC self-assessment.  The method consisted of questionnaire responses reviewed by experts.  The assessment identified several good current practices in maintaining the safety status of Kartini reactor.  As supporting evidence, the authors noted the number of inspection/audit findings from the regulator went down while reactor utilization and operating hours increased over the past several years.  One opportunity for improvement was the need for more frequent dialogues between employees and managers.

Our Perspective

There is not much SC substance here.  The recitations on SC repeated familiar stuff you’ve seen in lots of places.  In other words, zero new information or insight.  The single page WANO presentation indicates their lowest common denominator audience is even lower than IAEA’s.  Perhaps there were technical issues discussed at the conference that are of interest to you.  Otherwise, don’t invest your coffee break in going through this lengthy document.

*  IAEA, International Conference on TopicalIssues in Nuclear Installation Safety: Defence in Depth — Advances andChallenges for Nuclear Installation Safety, Oct. 21-24, 2013 ConferenceProceedings, IAEA-TECDOC-CD-1749 (Vienna, 2014).  We are grateful to Madalina Tronea for publicizing this material.  Dr. Tronea is the founder and moderator of the LinkedIn Nuclear Safety Culture forum.

**  J. Regaldo, “WANO Actions to Reinforce the Operators’ Safety Culture Worldwide,” p. 147.

***  H. Hardiyanti, B. Herutomo and G. K. Suryaman, “Safety Culture as a Pillar of Defense-in-Depth Implementation at the Experimental Fuel Element Installation, Batan, Indonesia,” pp. 173-188.

****  S. Syarip, “Safety Management and Safety Culture Self Assessment of Kartini Research Reactor,” pp. 321-326.

IAEA Training Workshop on Leadership and Safety Culture for Senior Managers, Nov. 18-21, 2014

IAEA Building

The International Atomic Energy Agency (IAEA) recently conducted a four-day workshop* on leadership and safety culture (SC).  “The primary objective of the workshop [was] to provide an international forum for senior managers to share their experience and learn more about how safety culture and leadership can be continuously improved.” (Opening, Haage)  We don’t have all the information that was shared at the workshop but we can review the workshop facilitators’ presentations.  The facilitators were John Carroll, an MIT professor who is well-known in the nuclear SC field; Liv Cardell, Swedish management consultant; Stanley Deetz, professor at the University of Colorado; Michael Meier, Regulatory Affairs VP at Southern Nuclear OpCo; and Monica Haage, IAEA SC specialist and the workshop leader.  Their presentations follow in the approximate order they were made at the workshop, based on the published agenda.

Shared Space, Haage

The major point is how individual performance is shaped by experience in the social work space shared with others, e.g., conversations, meetings, teams, etc.  Haage described the desirable characteristics of such “shared space” including trust, decrease of power dynamics, respect, openness, freedom to express oneself without fear of recrimination, and dialogue instead of argumentation. 

The goal is to tap into the knowledge, experience and insight in the organization, and to build shared understandings that support safe behaviors and good performance.  In a visual of an iceberg, shared understanding is at the bottom, topped by values, which underlie attitudes, and visible behavior is above the waterline.

Leadership for Safety, Carroll and Haage

Haage covered the basics from various IAEA documents: “management” is a function and “leadership” is a relation to influence others and create shared understanding.  Safety leadership has to be demonstrated by managers at all levels.  There is a lengthy list of issues, challenges and apparent paradoxes that face nuclear managers.

Carroll covered the need for leaders who have a correct view of safety (in contrast to, e.g., BP’s focus on personal safety rather than systemic issues) and can develop committed employees who go beyond mere compliance with requirements.  He provided an interesting observation that culture is only one perspective (mental model) of an organization; alternative perspectives include strategic design (which views the organization as a machine) and political (which focuses on contests to set priorities and obtain resources).  He mentioned the Sloan management model (sensemaking, visioning, relating and implementing).  Carroll reviewed the Millstone imbroglio of the 1990s including his involvement, situational factors and the ultimate resolution then used this as a workshop exercise to identify root causes and develop actionable fixes.  He showed how to perform a stakeholder assessment to identify who is likely to lead, follow, oppose or simply bystand when an organization faces a significant challenge.

Management for Safety, Haage

This presentation had an intro similar to Leadership followed by a few slides on management.  Basically, the management system is the administrative structure and associated functions (plan, organize, direct, control) that measures and ensures progress toward established safety goals within rules and available resources and does not allow safety to be trumped by other requirements or demands.

Concept of Culture, Deetz

Culture is of interest to managers because it supports the hope for invisible control with less resistance and greater commitment.  Culture is a perspective, a systemic way to look at values, practices, etc. and a tacit part of all choices.  Culture is seen as something to be influenced rather than controlled.  Cultural change can be attempted but the results to not always work out as planned.  The iceberg metaphor highlights the importance of interpretation when it comes to culture, since what we can observe is only a small part and we must infer the rest.

Culture for Safety, Meier

This is a primer on SC definition, major attributes and organizational tactics for establishing, maintaining and improving SC.  One key attribute is that safety is integrated into rewards and recognitions.  Meier observed that centralization ensures compliance while decentralization [may] help to mitigate accident conditions.

Systemic Approach to Safety, Haage

A systemic approach describes the interaction between human, technical and organizational (HTO) factors.  Haage noted that the usual approach to safety analysis is to decompose the system; this tends to overemphasize technical factors.  A systemic approach focuses on the dynamics of the HTO interactions to help evaluate their ability to produce safety outcomes.  She listed findings and recommendations from SC researchers, including HRO characteristics, and the hindsight bias vs. the indeterminacy of looking ahead (from Hollnagel).

Being Systemic, Deetz

This short presentation lists the SC Challenges faced by workshop participants as presented by groups in the workshop.  The 16-item list would look familiar to any American nuclear manager; most of you would probably say it’s incomplete.

Cultural Work in Practice, Cardell

Cardell’s approach to improving performance starts by separating the hard structural attributes from the softer cultural ones.  An organization tries to improve structure and culture to yield organizational learning.  Exaggerating the differences between structure and culture raises consciousness and achieves balance between the two aspects.

Culture comes from processes between people; meetings are the cradle of culture (this suggests the shared space concept).  Tools to develop culture include dialogue, questioning, storytelling, involving, co-creating, pictures, coaching and systemic mapping.  Cardell suggested large group dialogs with members from all organizational elements.  This is followed by a cookbook of suggestions (tools) for improving cultural processes and attributes. 

Our Perspective

It’s hard to avoid being snarky when dealing with IAEA.  They aim their products at the lowest common denominator of experience and they don’t want to offend anyone.  As a result, there is seldom anything novel or even interesting in their materials.  This workshop is no exception.

The presentations ranged from the simplistic to the impossibly complicated.  There was scant reference to applicable lessons from other industries (which subtly reinforces the whole “we’re unique” and “it can’t happen here” mindset) or contemporary ideas about how socio-technical systems operate.  The strategic issue nuclear organizations face is goal conflict: safety vs production vs cost.  This is mentioned in the laundry lists of issues but did not get the emphasis it deserves.  Similar for decision making and resource allocation.  The primary mechanism by which a strong SC identifies and permanently fixes its problems (the CAP) was not mentioned at all.  And for all the talk about a systemic approach, there was no mention of actual system dynamics (feedback loops, time delays, multi-directional flows) and how the multiple interactions between structure and culture might actually work.

Bottom line: There was some “there” there but nothing new.  I suggest you flip through the Carroll and Cardell presentations for any tidbits you can use to spice up or flesh out your own work.

  

A Compendium was sent to the attendees before the workshop.  It contained facilitator biographies and some background information on SC. It included a paper by Prof. Deetz on SC change as a rearticulation of relationships among concepts.  It is an attempt to get at a deeper understanding of how culture fits and interacts with individuals’ sense of identity and meaning.  You may not agree with his thesis but the paper is much more sophisticated than the materials shared during the workshop.

*  IAEA Training Workshop on Leadership and Safety Culture for Senior Managers, Nov. 18-21, 2014, Vienna.  The presentations are available here.  We are grateful to Madalina Tronea for publicizing this material.  Dr. Tronea is the founder and moderator of the LinkedIn Nuclear Safety Culture forum.