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 in the Latest U.S. Report for the Convention on Nuclear Safety

NUREG-1650 cover

The Nuclear Regulatory Commission (NRC) recently published NUREG-1650, rev. 6, the seventh national report for the Convention on Nuclear Safety.*  The report is prepared for the triennial meeting of the Convention and describes the policies, laws, practices and other activities utilized by the U.S. to meet its international obligations and ensure the safety of its commercial nuclear power plants.  Nuclear Safety Culture (NSC) is one of the topics discussed in the report.  This post highlights NSC changes (new items and updates) from the sixth report (NUREG-1650, rev. 5) which we reviewed on March 26, 2014.  The numbers shown below are section numbers in the current report.

8.1.5  International Responsibilities and Activities 

The NRC’s International Regulatory Development Partnership (IRDP) program supports the safe introduction of nuclear power in “new entrant” countries.  IRDP training addresses many topics including safety culture. (p. 99)

8.1.6.2  Human Resources 

This section was updated to include a reference to the 2015 NRC Safety Culture and Climate Survey.

10.1  Background [for article 10, “Priority to Safety”] 

The report notes “All U.S. nuclear power plants have committed to conducting a safety culture self-assessment every 2 years and have committed to conducting monitoring panels as described in Nuclear Energy Institute (NEI) 09-07, “Fostering a Healthy Nuclear Safety Culture,” dated March 2014.” (p. 120)  We reviewed NEI 09-07 on Jan. 6, 2011.

10.4  Safety Culture

The bulk of the report addressing NSC is in this section and exhibits a significant rewrite from the previous report.  Some of the changes reorganized existing material but there are also new items, discussed below, and additional background information.  Overall, section 10.4 is more complete and lucid than its predecessor.

10.4.1  Safety Culture Policy Statement

This contains material that formerly appeared under 10.4 and has been expanded to include two new safety culture traits, “questioning attitude” and “decisionmaking.”  The NRC worked with licensees and other stakeholders to develop a common language for discussing and assessing NSC; this effort resulted in NUREG-2165, “Safety Culture Common Language.”  We reviewed NUREG-2165 on April 6, 2014.

10.4.2  NRC Monitoring of Licensee Safety Culture 

This section has been edited to improve clarity and completeness, and provide more specific references to applicable procedures.  For example, IP 95003 now includes detailed guidance for NRC inspectors who conduct an independent assessment of licensee NSC.**

New language specifies interventions the NRC may take with respect to licensee NSC: “These activities range from requesting the licensee perform a safety culture self-assessment to a meeting between senior NRC managers and a licensee’s Board of Directors to discuss licensee performance issues and actions to address persistent and continuing safety culture cross-cutting issues.” (p. 128)

10.4.3 The NRC Safety Culture

This section covers the NRC’s efforts to maintain and enhance its own SC.  The section has been rewritten and strengthened throughout.  It discusses the need for continuous improvement and says “Complacency lends itself to a degradation in safety culture when new information and historical lessons are not processed and used to enhance the NRC and its regulatory products.” (p. 130)  That’s true; SC that is not actively maintained will invariably decay.

12.3.5  Human Factors Information System 

This system handles human performance information extracted from NRC inspection and licensee event reports.  The report notes “the database is being updated to include data with a safety culture perspective.” (p. 146)

Institute of Nuclear Power Operations (INPO)

INPO also provides content for the report, basically a description of INPO’s activities to ensure plant safety.  Their discussion includes a section on SC, which is not materially different from their contribution to the previous version of the report.

Our Perspective

Like the sixth national report, this seventh report appears to cover every aspect of the NRC’s operations but does not present any new information.  In other words, it’s a good reference document.

The NSC changes are incremental but move toward increased bureaucratization and intrusive oversight of NSC.  The NRC is certainly showing the hilt of the sword of regulation if not the blade.  We still believe if it reads like a set of requirements, results in enforceable interventions and quacks like the NRC, it’s de facto regulation.


*  NRC NUREG-1650 Rev. 6, “The United States of America Seventh National Report for the Convention on Nuclear Safety” (Oct. 2016).  ADAMS ML16293A104.  The Convention on Nuclear Safety is a legally binding commitment to maintain a level of safety that meets international benchmarks.

**  This detailed guidance is also mentioned in 12.3.6 Support to Event Investigations and For-Cause Inspections and Training (p. 148).

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. 

NRC Staff Review of National Research Council Safety Culture Recommendations Arising from Fukushima

On July 30, 2014 we reviewed the safety culture (SC) aspects of the National Research Council report on lessons learned from the Fukushima nuclear accident.  We said the report’s SC recommendations were pretty limited: the NRC and industry must maintain and monitor a strong SC in all safety-related activities, the NRC must maintain its independence from outside influences, and the NRC and industry should increase their transparency about their SC-related efforts.

The NRC staff reviewed the report’s recommendations, assessed whether the agency was addressing them and documented their results.*  Given the low bar, it’s no surprise the staff concluded “that all NAS’s recommendations are being adequately addressed.” (p.1)  Following is the evidence the staff assembled to show the NRC is addressing the SC recommendations.

Emphasis on Safety Culture (pp. 25-26) 

In 1989, after Peach Bottom plant operators were caught sleeping on the job, the NRC issued a “Policy Statement on the Conduct of Nuclear Power Plant Operations.”   The policy statement focused on personal dedication and accountability but also underscored management’s responsibility for fostering a healthy SC.

In 1996, after Millstone whistleblowers faced retaliation, the NRC issued another policy statement, “Freedom of Employees in the Nuclear Industry to Raise Safety Concerns without Fear of Retaliation.”  This policy statement focused on the NRC’s expectation that all licensees will establish and maintain a safety-conscious work environment (SCWE).

In 2002, after discovery of the Davis-Besse reactor pressure vessel’s degradation, the Reactor Oversight Process (ROP) was strengthened to detect potential SC weaknesses during inspections and performance assessments.  ROP changes were described in Regulatory Issue
Summary 2006-13, “Information on the Changes Made to the Reactor Oversight Process to More Fully Address Safety Culture.”

In 2004, INPO published “Principles for a Strong Nuclear Safety Culture.”  In 2009, an industry/NEI/INPO effort produced a process for monitoring and improving SC, documented in NEI 09-07 “Fostering a Strong Nuclear Safety Culture.”  We reviewed NEI 09-07 on Jan. 6, 2011.

In 2008, the NRC initiated an effort to define and expand SC policy.  The final Safety Culture Policy Statement (SCPS) was published on June 14, 2011.  We posted eight times on the SCPS effort before the policy was issued.  Click on the SC Policy Statement label to see both those posts and subsequent ones that refer to the SCPS. 

An Independent Regulator (pp. 26-27)

The Energy Reorganization Act of 1974 established the NRC.  Principal Congressional oversight of the agency is performed by the Senate Subcommittee on Clean Air and Nuclear Safety, and the House Subcommittee on Energy and the Environment.  It’s not clear how the NRC performing obeisance before these committees contributes to the agency’s independence.

The NRC receives independent oversight from the NRC’s Office of the Inspector General and the U.S. Government Accountability Office.

Perhaps most relevant, the U.S. is a contracting party to the international Convention on Nuclear Safety.  The NRC prepares a periodic report describing how the U.S. fulfills its obligations under the CNS, including maintaining the independence of the regulatory body.  On March 26, 2014 we posted on the NRC’s most recent report.

Industry Transparency (pp. 27-28)

For starters, the NRC touts its SC website which includes the SCPS and SC-related educational and outreach materials.

In March 2014, the NRC published NUREG-2165, “Safety Culture Common Language,” which
documents a common language to describe SC in the nuclear industry.  We reviewed the NUREG on April 6, 2014.

That’s all.

Our Perspective 

We’ll give the NRC a passing grade on its emphasis on SC.  The “evidence” on agency independence is slim.  Some folks believe that regulatory capture has occurred, to a greater or lesser degree.  For what it’s worth, we think the agency is fairly independent.

The support for industry transparency is a joke.  As we said in our July 30, 2014 post, “the nuclear industry’s penchant for secrecy is a major contributor to the industry being its own worst enemy in the court of public opinion.”     


*  NRC Staff Review of National Academy of Sciences Report, “Lessons Learned from theFukushima Dai-ichi Nuclear Accident for Improving Safety of U.S. Nuclear Plants” (Apr. 9, 2015).  ADAMS ML15069A600.  The National Research Council is part of the National Academy of Sciences.

INPO’s View on Fukushima Safety Culture Lessons Learned

In November 2011 the Institute of Nuclear Power Operations (INPO) published a special report* on the March 2011 Fukushima accident.  The report provided an overview and timeline for the accident, focusing on the evolution of the situation during the first several days after the earthquake and tsunami.  Safety culture (SC) was not mentioned in the report.

In August 2012 INPO issued an addendum** to the report covering Fukushima lessons learned in eight areas, including SC.  Each area contains a lengthy discussion of relevant plant activities and experiences, followed by specific lessons learned.  According to INPO, some lessons learned may be new or different from those published elsewhere.  Several caught our attention as we paged through the addendum: Invest resources to assess low-probability, high-consequence events (Black Swans).  Beef up available plant staffing to support regular staff in case a severe, long duration event inconveniently occurs on a weekend.  Evaluate the robustness of off-site event management facilities (TEPCO’s was inaccessible, lost power and did not have filtered ventilation).  Be aware that assigning most decision making authority to the control room crew (as TEPCO did) meant other plant groups could not challenge or check ops’ decisions—efficiency at the cost of thoroughness.  Conduct additional training for a high-dose environment when normal dosage limits are replaced with emergency ones.  Ensure that key personnel have in-depth reactor and power plant knowledge to respond effectively if situations evolve beyond established procedures and flexibility is required.

Focusing on SC, the introduction to this section is clear and unexpectedly strong: “History has shown that accidents and their precursors at commercial nuclear electric generating stations result from a series of decisions and actions that reflect flaws in the shared assumptions, values, and beliefs of the operating organization.” (p. 33)

The SC lessons learned are helpful.  INPO observed that while TEPCO had taken several steps over the years to strengthen its SC, it missed big picture issues including cultivating a questioning attitude, challenging assumptions, practicing safety-first decision making and promoting organizational learning.  In each of these areas, the report covers specific deficiencies or challenges faced at Fukushima followed by questions aimed at readers asking them to consider if similar conditions exist or could exist at their own facilities.

Our Perspective

The addendum has a significant scope limitation: it does not address public policy (e.g., regulatory or governmental) factors that contributed to the Fukushima accident and yielded their own lessons learned.***  However, given the specified scope, a quick read of the entire addendum suggests it’s reasonably thorough, the SC section certainly is.  The questions aimed at report readers are the kind we ask all the time on Safetymatters but we award INPO full marks for addressing these general, qualitative, open-ended subjects.  One question INPO raised that we have not specifically asked is “To what extent are the safety implications considered during enterprise business planning and budgeting?” (italics added)  Another, inferred from the report text, is “How do operators create complex, realistic scenarios (e.g., with insufficient information and/or personnel under stress) during emergency training?”  These are legitimate additions to the repertoire.  

The addendum is not perfect.  For example, INPO trots out the “special and unique” mantra when discussing the essential requirements to maintain core cooling capability and containment integrity (esp. with respect to venting at Fukushima).  This mantra, coupled with INPO’s usual penchant for secrecy, undermines public support for commercial nuclear power.  INPO can be a force for good when its work products, like this report and addendum, are publicly available.  It would be better for the industry if INPO were more transparent and if commercial nuclear power were characterized as a safety-intense industrial process run by ordinary, albeit highly trained, people.

Bottom line, you should read the addendum looking for bits that apply to your own situation.


*  INPO, “Special Report on the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station,” INPO 11-005 Rev. 0 (Nov. 2011).

**  INPO, “Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station,” INPO 11-005 Rev. 0 Addendum (Aug. 2012).  Thanks to Madalina Tronea for publicizing this document.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety discussion group.

***  Regulatory, government and corporate governance lessons learned have been publicized by other Fukushima reviewers and the findings widely distributed, including on Safetymatters.  Click on the Fukushima label to see our related posts. 

Update on INPO Safety Culture Study

On October 22, 2010 we reported on an INPO study that correlated safety culture (SC) survey data with safety performance measures.  A more complete version of the analysis was published in an academic journal* this year and this post expands on our previous comments.

Summary of the Paper

The new paper begins with a brief description of SC and related research.  Earlier research suggests that some modest relationship exists between SC and safety performance but the studies were limited in scope.  Longitudinal (time-based) studies have yielded mixed results.  Overall, this leaves plenty of room for new research efforts.

According to the authors, “The current study provides a unique contribution to the safety culture literature by examining the relationship between safety culture and a diverse set of performance measures [NRC industry trends, ROP data and allegations, and INPO plant data] that focus on the overall operational safety of a nuclear power plant.” (p. 39)  They hypothesized small to medium correlations between current SC survey data and eleven then-current (2010) and future (2011) safety performance measures.**

The 110-item survey instrument was distributed across the U.S. nuclear industry and 2876 useable responses were received from employees and contractors representing almost all U.S. plants.  Principal components analysis (PCA) was applied to the survey data and resulted in nine useful factors.***  Survey items that did not have a high factor loading (on a single factor) or presented analysis problems were eliminated, resulting in 60 useful survey items.  Additional statistical analysis showed that the survey responses from each individual site were similar and the various sites had different responses on the nine factors.

Statistically significant correlations were observed between both overall SC and individual SC factors and the safety performance measures.****  A follow-on regression analysis suggested “that the factors collectively accounted for 23–52% of the variance in concurrent safety performance.” (p. 45)

“The significant correlations between overall safety culture and measures of safety performance ranged from -.26 to -.45, suggesting a medium effect and that safety culture accounts for 7–21% of the variance in most of the measures of safety performance examined in this study.” (p. 45)

Here is an example of a specific finding: “The most consistent relationship across both the correlation and regression analyses seemed to be between the safety culture factor questioning attitude, and the outcome variable NRC allegations. . . .Questioning attitude was also a significant predictor of concurrent counts of inspection findings associated with ROP cross-cutting aspects, the cross-cutting area of human performance, and total number of SCCIs. Fostering a questioning attitude may be a particularly important component of the overall safety culture of an organization.” (p. 45)

And another: “It is particularly interesting that the only measure of safety performance that was not significantly correlated with safety culture was industrial safety accident rate.” (p. 46)

The authors caution that “The single administration of the survey, combined with the correlational analyses, does not permit conclusions to be drawn regarding a causal relationship between safety culture and safety performance.  In particular, the findings presented here are exploratory, mainly because the correlational analyses cannot be used to verify causality and the data used represent snapshots of safety culture and safety performance.” (p. 46)

The relationships between SC and current performance were stronger than between SC and future performance.  This should give pause to those who would rush to use SC data as a leading indicator. 

Our Perspective 

This is a dense paper and important details may be missing from this summary.  If you are interested in this topic then you should definitely read the original and our October 22, 2010 post.

That recognizable factors dropped out of the PCA should not be a surprise.  In fact, the opposite would have been the real surprise.  After all, the survey was constructed to include previously identified SC traits.  The nine factors mapped well against previously identified SC traits and INPO principles. 

However, there was no explanation, in either the original presentation or this paper, of why the 11 safety performance measures were chosen out of a large universe.  After all, the NRC and INPO collect innumerable types of performance data.  Was there some cherry picking here?  I have no idea but it creates an opportunity for a statistical aside, presented in a footnote below.*****

The authors attempt to explain some correlations by inventing a logic that connects the SC factor to the performance measure.  But it just speculation because, as the authors note, correlation is not causality.  You should look at the correlation tables and see if they make sense to you, or if some different processes are at work here. 

One aspect of this paper bothers me a little.  In the October 22, 2010 NRC public meeting, the INPO presenter said the analysis was INPO’s while an NRC presenter said NRC staff had reviewed and accepted the INPO analysis, which had been verified by an outside NRC contractor.  For this paper, those two presenters are joined by another NRC staffer as co-authors.  This is a difference.  It passes the smell test but does evidence a close working relationship between an independent public agency and a secretive private entity.


*  S.L. Morrow, G.K. Koves and V.E. Barnes, “Exploring the relationship between safety culture and safety performance in U.S. nuclear power operations,” Safety Science 69 (2014), pp. 37–47.  ADAMS ML14224A131.

**  The eleven performance measures included seven NRC measures (Unplanned scrams, NRC allegations,  ROP cross-cutting aspects,  Human performance cross-cutting inspection findings, Problem identification and resolution cross-cutting inspection findings, Substantive cross-cutting issues in the human performance or problem identification and resolution area and ROP action matrix oversight, i.e., which column a plant is in) and four INPO measures (Chemistry performance, Human performance error rate, Forced loss rate and Industrial safety accident rate.

***  The nine SC factors were management commitment to safety, willingness to raise safety concerns, decision making, supervisor responsibility for safety, questioning attitude, safety communication, personal responsibility for safety, prioritizing safety and training quality.

****  Specifically, 13 (out of 22) overall SC correlations with the current and future performance measures were significant as were 84 (out of 198) individual SC factor correlations.

*****  It would be nice to know if any background statistical testing was performed to pick the performance measures.  This is important because if one calculates enough correlations, or any other statistic, one will eventually get some false positives (Type I errors).  One way to counteract this problem is to establish a more restrictive threshold for significance, e.g., 0.01 vs 0.05 or 0.005 vs. 0.01. This note is simply my cautionary view.  I am not suggesting there are any methodological problem areas in the subject paper.

NRC "National Report" to IAEA

A March 25, 2014 NRC press release* announced that Chairman Macfarlane presented the Sixth National Report for the Convention on Nuclear Safety** to International Atomic Energy Agency (IAEA) member countries.  The report mentions safety culture (SC) several times, as discussed below.  There is no breaking news in a report like this.  We’re posting about it only because it provides an encyclopedic review of NRC activities including a description of how SC fits into their grand scheme of things.  We also tie the report’s contents to related posts on Safetymatters.  The numbers shown below are section numbers in the report.

6.3.11 Public Participation 

This section describes how the NRC engages with stakeholders and the broader public.  As part of such engagement, the NRC says it expects employers to maintain an open environment where workers are free to raise safety concerns. “These expectations are communicated through the NRC’s Safety Culture Policy Statement” and other regulatory directives and tools. (p. 72)  This is pretty straightforward and we have no comment.

8.1.6.2 Human Resources

Section 8 describes the NRC, from its position in the federal government to how it runs its internal activities.  One such activity is the NRC Inspector General’s triennial General Safety Culture and Climate Survey for NRC employees.  Reporting on the most recent (2012) survey, “the NRC scored above both Federal and private sector benchmarks, although in 2012 the agency did not perform as strongly as it had in the past.” (p. 96)  We posted on the internal SC survey back on April 6, 2013; we felt the survey raised a few significant issues.

10.4 Safety Culture

Section 10 covers activities that ensure that safety receives its “due priority” from licensees and the NRC itself.  Sub-section 10.4 provides an in-depth description of the NRC’s SC-related policies and practices so we excerpt from it at length.

The discussion begins with the SC policy statement and the traits of a positive (sic) SC, including Leadership, Problem identification and resolution, Personal accountability, etc.

The most interesting part is 10.4.1 NRC Monitoring of Licensee Safety Culture which covers “the policies, programs, and practices that apply to licensee safety culture.” (p. 118)  It begins with the Reactor Oversight Process (ROP) and its SC-related enhancements.  NRC staff identified 13 components as important to SC, including decision making, resources, work control, etc.  “All 13 safety culture components are applied in selected baseline, event followup, and supplemental IPs [inspection procedures].” (p. 119)

“There are no regulatory requirements for licensees to perform safety culture assessments routinely. However, depending on the extent of deterioration of licensee performance, the NRC has a range of expectations [emphasis added] about regulatory actions and licensee safety culture assessments, . . .” (p. 119)

“In the routine or baseline inspection program, the inspector will develop an inspection finding and then identify whether an aspect of a safety culture component is a significant causal factor of the finding. The NRC communicates the inspection findings to the licensee along with the associated safety culture aspect. 

“When performing the IP that focuses on problem identification and resolution, inspectors have the option to review licensee self-assessments of safety culture. The problem identification and resolution IP also instructs inspectors to be aware of safety culture components when selecting samples.” (p. 119)

“If, over three consecutive assessment periods (i.e., 18 months), a licensee has the same safety culture issue with the same common theme, the NRC may ask [emphasis added] the licensee to conduct a safety culture self-assessment.” (p. 120)

If the licensee performance degrades to Column 3 of the ROP Action Matrix and “the NRC determines that the licensee did not recognize that safety culture components caused or significantly contributed to the risk-significant performance issues, the NRC may request [emphasis added] the licensee to complete an independent assessment of its safety culture.” (p. 120)

For licensees in Column 4 of the ROP “the NRC will expect [emphasis added] the licensee to conduct a third-party independent assessment of its safety culture. The NRC will review the licensee’s assessment and will conduct an independent assessment of the licensee’s safety culture . . .” (p. 120)

ROP SC considerations “provide the NRC staff with (1) better opportunities to consider safety culture weaknesses . . . (2) a process to determine the need to specifically evaluate a licensee’s safety culture . . . and (3) a structured process to evaluate the licensee’s safety culture assessment and to independently conduct a safety culture assessment for a licensee . . . .  By using the existing Reactor Oversight Process framework, the NRC’s safety culture oversight activities are based on a graded approach and remain transparent, understandable, objective, risk-informed, performance-based, and predictable.” (p. 120)

We described this hierarchy of NRC SC-related activities in a post on May 24, 2013.  We called it de facto regulation of SC.  Reading the above only confirms that conclusion.  When the NRC asks, requests or expects the licensee to do something, it’s akin to a military commander’s “wishes,” i.e., they’re the same as orders.

10.4.2 The NRC Safety Culture 

This section covers the NRC’s actions to strengthen its internal SC.  This actions include appointing an SC Program Manager; integrating SC into the NRC’s Strategic Plan; developing training; evaluating the NRC’s problem identification, evaluation and resolution processes; and establishing clear expectations and accountability for maintaining current policies and procedures. 

We would ask how SC affects (and is affected by) the NRC’s decision making and resource allocation processes, work practices, operating experience integration and establishing personal accountability for maintaining the agency’s SC.  What’s good for the goose (licensee) is good for the gander (regulator).

Institute of Nuclear Power Operations (INPO) 

INPO also provided content for the report.  Interestingly, it is a 39-page Part 3 in the body of the report, not an appendix.  Part 3 covers INPO’s mission, organization, etc. and includes a section on SC.

6. Priority to Safety (Safety Culture)

The industry and INPO have their own definition of SC: “An organization’s values and behaviors—modeled by its leaders and internalized by its members—that serve to make nuclear safety the overriding priority.” (p. 230)

“INPO activities reinforce the primary obligation of the operating organizations’ leadership to establish and foster a healthy safety culture, to periodically assess safety culture, to address shortfalls in an open and candid fashion, and to ensure that everyone from the board room to the shop floor understands his or her role in safety culture.” (p. 231)

We believe our view of SC is broader than INPO’s.  As we said in our July 24, 2013 post “We believe culture, including SC, is an emergent organizational property created by the integration of top-down activities with organizational history, long-serving employees, and strongly held beliefs and values, including the organization's “real” priorities.  In other words, SC is a result of the functioning over time of the socio-technical system.  In our view, a CNO can heavily influence, but not unilaterally define, organizational culture including SC.” 

Conclusion

This 341 page report appears to cover every aspect of the NRC’s operations but, as noted in our introduction, it does not present any new information.  It’s a good reference document to cite if someone asks you what the NRC is or what it does.

We found it a bit odd that the definition of SC in the report is not the definition promulgated in the NRC SC Policy Statement.  Specifically, the report says the NRC uses the 1991 INSAG definition of SC: “that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear safety issues receive the attention warranted by their significance.” (p. 118)

The Policy Statement says “Nuclear safety culture is the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment.”***

Of course, both definitions are different from the INPO definition provided above.  We’ll leave it as an exercise for the reader to figure out what this means.


*  NRC Press Release No: 14-021, “NRC Chairman Macfarlane Presents U.S. National Report to IAEA’s Convention on Nuclear Safety” (Mar. 25, 2014).  ADAMS ML14084A303.

**  NRC NUREG-1650 Rev. 5, “The United States of America Sixth National Report for the Convention on Nuclear Safety” (Oct. 2013).  ADAMS ML13303B021. 

***  NUREG/BR 0500 Rev 1, “Safety Culture Policy Statement” (Dec 2012).  ADAMS ML12355A122.  This definition comports with the one published in the Federal Register Vol. 76, No. 114 (June 14, 2011) p. 34777.

NRC Outreach on the Safety Culture Policy Statement

An NRC public meeting

Last August 7th, the NRC held a public meeting to discuss their outreach initiatives to inform stakeholders about the Safety Culture Policy Statement (SCPS).  A meeting summary was published in October.*  Much of the discussion covered what we'll call the bureaucratization of safety culture (SC)—development of communication materials (inc. a poster, brochure, case studies and website), presentations at conferences and meetings (some international), and training.  However, there were some interesting tidbits, discussed below.

One NRC presentation covered the SC Common Language Initiative.**  The presenter remarked that an additional SC trait, Decision Making (DM), was added during the development of the common language.  In our Feb. 28, 2013 review of the final common language document, we praised the treatment of DM; it is a principal creator of artifacts that reflect an organization's SC.

The INPO presentation noted that “After the common language effort was completed in January, 2013, INPO published Revision 1 of 12-012, which includes all of the examples developed during the common language workshop.” (p. 6)  We reviewed that INPO document here.

But here's the item that got our attention.  During a presentation on NRC outreach, an industry participant cautioned the NRC to not put policy statements into regulatory documents because policy statements are an expectation, not a regulation. The senior NRC person at the meeting agreed with the comment “and the importance of the NRC not overstepping the Commission’s direction that implementing the SCPS is not a regulatory requirement, but rather the Commission’s expectations.” (p. 4)

We find the last comment disingenuous.  We have previously posted on how the NRC has created de facto regulation of SC.***  In the absence of clear de jure regulation, licensees and the NRC end up playing “bring me another rock” until the NRC accepts a licensee's pronouncements, as verified by NRC inspectors.  For an example of this convoluted kabuki, read Bob Cudlin's Jan. 30, 2013 post on how Palisades' efforts to address a plant incident finally gained NRC acceptance, or at least an NRC opinion that Palisades' SC was “adequate and improving.”

We'll keep you posted on SCPS-related activities.


*  D.J. Sieracki to R.P. Zimmerman, “Summary of the August 7, 2013, Public Meeting between the U.S. Nuclear Regulatory Commission Staff  and Stakeholders to  Exchange Information and Discuss Ongoing Education and Outreach Associated with the Safety Culture Policy Statement” (Oct. 1, 2013).  ADAMS ML13267A385.  We continue to find it ironic that the SCPS is administered by the NRC's Office of Enforcement.  Isn't OE's primary focus on people and companies who violate the NRC's regulations?

**  “The common language initiative uses the traits from the SCPS as a basic foundation, and contains definitions and examples to describe each trait more fully.” (p. 3)

***  For related posts, please click the "Regulation of Safety Culture" label.

Leadership, Culture and Organizational Performance

As discussed in our July 18, 2013 post, INPO's position is that creating and maintaining a healthy safety culture (SC) is a primary leadership responsibility.*  That seems like a common sense belief but is it based on any social science?  What is the connection between leader behavior and culture?  And what is the connection between culture and organizational performance? 

To help us address these questions, we turn to a paper** by some Stanford and UC Berkeley academics.  They review the relevant literature and present their own research and findings.  This paper is not a great fit with nuclear power operations but some of the authors' observations and findings are useful.  One might think there would be ample materials on this important topic but “only a very few studies have actually explored the interrelationships among leadership, culture and performance.” (p. 33)

Leaders and Culture

Leaders can be described by different personality types.  Note this does not focus on specific behavior, e.g., how they make decisions, but the attributes of each personality type certainly imply the kinds of behavior that can reasonably be expected.  The authors contend “. . . the myriad of potential personality and value constructs can be reliably captured by five essential personality constructs, the so-called Big Five or the Five Factor Model . . .” (p. 6)  You have all been exposed to the Big 5, or a similar, taxonomy.  An individual may exhibit attributes from more than one type but can be ultimately be classified as primarily representative of one specific type.  The five types are listed below, with a few selected attributes for each.

• Agreeableness (Cooperative, Compromising, Compassionate, Trusting)
• Conscientiousness (Orderly, Reliable, Achievement oriented, Self-disciplined, Deliberate, Cautious)
• Extraversion (Gregarious, Assertive, Energy, Optimistic)
• Neuroticism (Negative affect, Anxious, Impulsive, Hostile, Insecure)
• Openness to Experience (Insightful, Challenge convention, Autonomous, Resourceful)

Leaders can affect culture and later we'll see that some personality types are associated with specific types of organizational culture.  “While not definitive, the evidence suggests that personality as manifested in values and behavior is associated with leadership at the CEO level and that these leader attributes may affect the culture of the organization, although the specific form of these relationships is not clear.” (p. 10)  “. . . senior leaders, because of their salience, responsibility, authority and presumed status, have a disproportionate impact on culture, . . .” (p. 11)

Culture and Organizational Performance

Let's begin with a conclusion: “One of the most important yet least understood questions is how organizational culture relates to organizational performance” (p. 11)

To support their research model, the authors describe a framework, similar to the Big 5 for personality, for summarizing organizational cultures.  The Organizational Culture Profile (OCP) features seven types of culture, listed below with a few selected attributes for each. 

• Adaptability (Willing to experiment, Taking initiative, Risk taking, Innovative)
• Collaborative (Team-oriented, Cooperative, Supportive, Low levels of conflict)
• Customer-oriented (Listening to customers, Being market driven)
• Detail-oriented (Being precise, Emphasizing quality, Being analytical)
• Integrity (High ethical standards, Being honest)
• Results-Oriented (High expectations for performance, Achievement oriented, Not easy going)
• Transparency (Putting the organization’s goals before the unit, Sharing information freely)

The linkage between culture and performance is fuzzy.  “While the strong intuition was that organizational culture should be directly linked to firm effectiveness, the empirical results are equivocal.” (p. 14)  “[T]he association of culture and performance is not straightforward and likely to be contingent on the firm’s strategy, the degree to which the culture promotes adaptability, and how widely shared and strongly felt the culture is.” (p. 17)  “Further compounding the issue is that the relationship between culture and firm performance has been shown to vary across industries.” (p. 11)  Finally, “although the [OCP] has the advantage of identifying a comprehensive set of cultural dimensions, there is no guarantee that any particular dimension will be relevant for a particular firm.” (p. 18)  I think it's fair to summarize the culture-performance literature by saying “It all depends.” 

Research Results

The authors gathered and analyzed data on a group of high-technology firms: CEO personalities based on the Big 5 types, cultural descriptions using the OCP, and performance data.  Firm performance was based on financial metrics, firm reputation (an intangible asset) and employee attitudes.*** (p. 23-24) 

“[T]he results reveal a number of significant relationships between CEO personality and firm culture, . . . CEOs who were more extraverted (gregarious, assertive, active) had cultures that were more results-oriented. . . . CEOs who were more conscientious (orderly, disciplined, achievement-oriented) had cultures that were more detail-oriented . . . CEOs who were higher on openness to experience (ready to challenge convention, imaginative, willing to try new activities) [were] more likely to have cultures that emphasized adaptability. (p. 26)

“Cultures that were rated as more adaptable, results-oriented and detail-oriented were seen more positively by their employees. Firms that emphasized adaptability and were more detail-oriented were also more admired by industry observers.” (p. 28)

In sum, the linkage between leadership and performance is far from clear.  But “consistent patterns of [CEO] behavior shape interpretations of what’s important [values] and how to behave. . . . Other research has shown that a CEO’s personality may affect choices of strategy and structure.” (p. 31)

Relevance to Nuclear Operations

As mentioned in the introduction, this paper is not a great fit with the nuclear industry.  The authors' research focuses on high technologically companies, there is nothing SC-specific and their financial performance metrics (more important to firms in highly competitive industries) are more robust than their non-financial measures.  Safety performance is not mentioned.

But their framework stimulates us to ask important questions.  For example, based on the research results, what type of CNO would you select for a plant with safety performance problems?  How about one facing significant economic challenges?  Or one where things are running smoothly?  Based on the OCP, what types of culture would be most supportive of a strong SC?  Would any types be inconsistent with a strong SC?  How would you categorize your organization's culture?  

The authors suggest that “Senior leaders may want to consider developing the behaviors that cultivate the most useful culture for their firm, even if these behaviors do not come naturally to them.” (p. 35)  Is that desirable or practical for your CNO?

The biggest challenge to obtaining generalizable results, which the authors recognize, is that so many driving factors are situation-specific, i.e., dependent on a firm's industry, competitive position and relative performance.  They also recognize a possible weakness in linear causality, i.e., the leadership → culture → performance logic may not be one-way.  In our systems view, we'd say there are likely feedback loops, two-way influence flows and additional relevant variables in the overall model of the organization.

The linear (Newtonian) viewpoint promoted by INPO suggests that culture is mostly (solely?) created by senior executives.  If only it were that easy.  Such a view “runs counter to the idea that culture is a social construct created by many individuals and their behavioral patterns.” (p. 10)  We believe culture, including SC, is an emergent organizational property created by the integration of top-down activities with organizational history, long-serving employees, and strongly held beliefs and values, including the organization's “real” priorities.  In other words, SC is a result of the functioning over time of the socio-technical system.  In our view, a CNO can heavily influence, but not unilaterally define, organizational culture including SC.


*  As another example of INPO's position, a recent presentation by an INPO staffer ends with an Ed Schein quote: “...the only thing of real importance that leaders do is to create and manage culture...”  The quote is from Schein's Organizational Culture and Leadership (San Francisco, CA: Jossey-Bass, 1985), p. 2.  The presentation was A. Daniels, “How to Continuously Improve Cultural Traits for the Management of Safety,” IAEA International Experts’ Meeting on Human and Organizational Factors in Nuclear Safety in the Light of the Accident at the Fukushima Daiichi Nuclear Power Plant, Vienna May 21-24, 2013.
 
**  C. O’Reilly, D. Caldwell, J. Chatman and B. Doerr, “The Promise and Problems of Organizational Culture: CEO Personality, Culture, and Firm Performance”  Working paper (2012).  Retrieved July 22, 2013.  To enhance readability, in-line citations have been removed from quotes.

***  The authors report “Several studies show that culture is associated with employee attitudes . . . ” (p. 14)

INPO: Traits of a Healthy Nuclear Safety Culture

The Institute of Nuclear Power Operations (INPO) has released a document* that aims at aligning their previous descriptions of safety culture (SC) with current NRC SC terminology.  The document describes the essential traits and attributes of a healthy** nuclear SC.  “[A] trait is defined as a pattern of thinking, feeling, and behaving such that safety is emphasized over competing priorities. . . . The attributes clarify the intent of the traits.” (p. 3)  While there is an effort to align with NRC, the document remains consistent with INPO policy, viz., SC is a primary leadership responsibility.  Leaders are expected to regularly reinforce SC, measure SC in their organization and communicate what constitutes a healthy SC.

There are ten traits organized into three categories.  Each trait has multiple attributes and each attribute has representative observable behaviors that are supposed to evidence the attribute's existence, scope and strength.  Many of the behaviors stress management's responsibilities.  The report has too much detail to summarize in this post so we'll concentrate on one of the key SC artifacts we have repeatedly emphasized on this blog: decision making.

Decision making (DM) is one of the ten traits.  DM has three attributes: a consistent process, conservative bias and single-point accountability.  Risk insights are incorporated as appropriate.  Observable behaviors include: the organization establishes a well-defined DM process; individuals demonstrate an understanding of the DM process; leaders seek inputs from different work groups or organizations; when previous decisions are called into question by new facts, leaders reevaluate these decisions; conservative assumptions are used when determining whether emergent or unscheduled work can be conducted safely; leaders take a conservative approach to DM, particularly when information is incomplete or conditions are unusual; managers take timely action to address degraded conditions; executives and senior managers reinforce the expectation that the reactor will be shut down when procedurally required, when the margin for safe operation has degraded unacceptably, or when the condition of the reactor is uncertain; individuals do not rationalize assumptions for the sake of completing a task; and the organization ensures that important nuclear safety decisions are made by the correct person at the lowest appropriate level. (pp. 19-20)  That's quite a mouthful but it's not all of the behaviors and some of the included ones have been shortened to fit.

In addition to the above, communicating, explaining, challenging and justifying individual decisions are mentioned throughout the document.  Finally, “Leaders demonstrate a commitment to safety in their decisions and behaviors.” (p. 15)

Our perspective

On the positive side, the INPO treatment of DM is much more comprehensive than what we've seen in the NRC Common Language Path Forward materials released to date.

But the DM example illustrates a major problem with this type of document: a lengthy laundry list of observable behaviors that can morph into de facto requirements.  Now INPO says “. . . this document is not intended to be used as a checklist. It is encouraged that this document be considered for inclusion and use in self-assessments, root cause analyses, and training content, as appropriate.” (p. 3)  But while the observable behaviors may be intended as representative or illustrative, in practice they are likely to become first expectations then requirements.  An overall tone of absolutism reinforces this possibility.

The same tone is evident in the discussion of DM's larger context.  For example, INPO asserts that SC is a board and corporate responsibility but explicit or implicit priorities from above can create constraints on plant management's DM flexibility.  INPO also says “Executives and senior managers ensure sufficient corporate resources are allocated to the nuclear organization for short- and long-term safe and reliable operation” (p. 15) but the top and bottom of the organization may not agree on what level of resources is “sufficient.”

Another problem is the lack of priorities or relative importance.  Are all the traits equally important?  How about the attributes?  And the observable behaviors?  Is it up to, say, a team of QA assessors to determine what they need to include or do they only look at what the boss says or do they try to evaluate everything even remotely related to the scope of their inquiry?

But our biggest difficulty is with this statement: “These traits and attributes, when embraced, will be reflected in the values, assumptions, behaviors, beliefs, and norms of an organization and its members.” (p. 3)  This is naïve absolutism at its worst.  While some members of an organization may incorporate new values, others may comply with the rules and exhibit the desired behavior based on other factors, e.g., fear, peer pressure, desire for recognition or power, or money.  And ultimately, who cares why they do it?  As Commissioner Apostolakis said during an NRC meeting when the proposed SC policy was being discussed: “[W]e really care about what people do and maybe not why they do it. . . .”  (See our Feb. 12, 2011 post.)

We could not say it better ourselves.


*  Institute of Nuclear Power Operations (INPO), “Traits of a Healthy Nuclear Safety Culture”  INPO 12-012, Rev. 1 (April 2013).  The report has two addenda.  One describes nuclear safety behaviors and actions that contribute to a healthy nuclear SC by organizational level and the other provides cross-references to other INPO documents, the NRC ROP cross-cutting area components and the IAEA SC characteristics.  Thanks to Madalina Tronea for making these documents available.

** INPO refers to SC “health” while the NRC refers to SC “strength.”

NRC Regulatory Information Conference (RIC) - Safety Culture Preview

The RIC is this week, March 12-14.  The teaser on the NRC blog says the technical sessions will include safety culture (SC) policies.  Let's look at the program agenda and see what's in store for SC.

There will be 36 technical sessions.  I reviewed all the titles and drilled down into sessions that might make some mention of SC, e.g.,  T4 - Construction Inspection Experience–The First Year and T7 - Human Impacts.  However, I could find no mention of SC in any of the currently available slide presentations.

That left the last technical session on the agenda: TH36 - The NRC’s Safety Culture Policy Statement–Domestic and International Initiatives.  Following is a summary of the available presentations for this session.

The introductory remarks summarize the development of the SC policy statement and its implementation.  There is no news here.

The SC common language presentation reviews the history of this initiative (which we have previously reviewed here and here).  The presentation has one quotable statement: “NRR will work to incorporate language into the ROP guidance documents and inspection procedures, as appropriate.”  Does that sound like back door regulation of SC to you?

A presentation on domestic and international cooperation reviews the relationship between NRC and INPO, NRC and IAEA, and others.  As an example of cooperation, the authors summarize the INPO SC survey data that were collected from operating plants and then analyzed by INPO (and later NRC) to show “statistically significant relationships between safety culture survey results and measures of plant performance.”  We commented on this work when it first appeared in 2010, congratulating INPO for making the effort and agreeing with some of the findings but finally concluding that the analysis was incomplete and potentially misleading.   

An industry presentation by Nuclear Fuel Services Inc. (NFS) describing their SC improvement program is worth a look.  It lists almost two dozen program components, none of which is a trivial undertaking, which suggest how much work is involved in changing an existing SC.  (I have no idea if NFS is actually pursuing the listed activities or how well they're doing.)

All in all, it's probably not worth traveling to Bethesda if you're seeking enlightenment about SC. 

Schein at INPO in 2003

In November 2003 Professor Edgar Schein gave a speech at the INPO CEO conference.*  It was not a lengthy academic lecture but his focus on managing culture, as opposed to changing or creating it, was interesting.  At the time Schein was doing some work for ConEd and had a notion of nuclear plant culture, which he divided into four sub-cultures: engineering, hourly, operator and executive, each with its own underlying assumptions and values.

The engineering culture emphasizes elegant, possibly expensive designs that minimize the role of error-prone humans.  Engineers want and value respect from other engineers, including those outside the plant (an external orientation). 

The hourly culture (which I think means maintenance) values teamwork and has an experience-based perspective on safety.  They want job security, fair wages, good equipment, adequate training and respect from their peers and supervisors.

The operator culture values teamwork and open communications.  They see the invaluable contributions they make to keeping the plant running safely and efficiently.  They want the best equipment, training and to be recognized for their contributions.

The executive culture is about money.  They want productivity, cost control, safety and good relations with their boards of directors (another external orientation).

These sub-cultures are in conflict because they all can't have everything they want.  The executive needs to acknowledge that cultural differences exist and each sub-culture brings certain strengths to the table.  The executive's role is to create a climate of mutual respect and to work toward aligning the sub-cultures to achieve common goals, e.g., safety.  The executive should not be trying to impose the values of a single sub-culture on everyone else.  In other words, the executive should be a culture manager, not a culture changer.

This was a brief speech and I don't want to read too much into it.  There are dysfunctional or no longer appropriate cultures and they have to be reworked, i.e., changed.  But if many things are working OK, then build on the existing strengths.**

This was not a speech about cultural interventions.  At the beginning, Schein briefly described his tri-level cultural model and noted if the observed artifacts match the espoused values, then there's no need to analyze the underlying assumptions.  This is reminiscent of Commissioner Apostolakis' comment that “. . . we really care about what people do and maybe not why they do it . . . .”


*  E.H. Schein, “Keeping the Edge: Enhancing Performance Through Managing Culture,” speech at INPO CEO Conference (Nov. 7, 2003).  I came across this speech while reviewing the resources listed for a more contemporary DOE conference.

**  Focusing on strengths (and not wasting resources trying to shore up weaknesses unless they constitute a strategic threat) is a management prescription first promoted by Peter Drucker.

Confusion of Properties and Qualities

Dave Snowden

In this post we highlight a provocative, and we believe, accurate criticism of the approach taken by many management scientists in focusing on behaviors as the determinant of desired outcomes.  The source is Dave Snowden, a Welsh lecturer, consultant and researcher in the field of knowledge management.  For those of you interested in finding out more about him, the website http://cognitive-edge.com/main for Cognitive Edge, founded by Snowden, contains an abundant amount of accessible content.

Snowden is a proponent of applying complexity science to inform managers’ decision making and actions.  He is perhaps best known for developing the Cynefin framework which is designed to help managers understand their operational context - based on four archetypes: simple, complicated, complex and chaotic. In considering the archetypes one can see how various aspects of nuclear operations might fit within the simple or complicated frameworks; frameworks where tools such as best practices and root cause analysis are applicable.  But one can also see the limitations of these frameworks in more complex situations, particularly those involving nuanced safety decisions which are at the heart of nuclear safety culture.  Snowden describes “complex adaptive systems” as ones where the system and its participants evolve together through ongoing interaction and influence, and system behavior is “emergent” from that process.  Perhaps most provocatively for nuclear managers is his contention that CDA systems are “non-causal” in nature, meaning one shouldn’t think in terms of linear cause and effect and shouldn’t expect that root cause analysis will provide the needed insight into system failures.

With all that said, we want to focus on a quote from one of Snowden’s lectures in 2008 “Complexity Applied to Systems”.*  In the lecture at approximately the 15:00 minute mark, he comments on a “fundamental error of logic” he calls “confusion of properties and qualities”.  He says:

“...all of management science, they observe the behaviors of people who have desirable properties, then try to achieve those desirable properties by replicating the behaviors”.

By way of a pithy illustration Snowden says, “...if I go to France and the first ten people I see are wearing glasses, I shouldn’t conclude that all Frenchmen wear glasses.  And I certainly shouldn’t conclude if I put on glasses, I will become French.”

For us Snowden’s observation generated an immediate connection to the approach being implemented around the nuclear enterprise.  Think about the common definitions of safety culture adopted by the NRC and industry.  The NRC definition specifies “... the core values and behaviors…” and “Experience has shown that certain personal and organizational traits are present in a positive safety culture. A trait, in this case, is a pattern of thinking, feeling, and behaving that emphasizes safety, particularly in goal conflict situations, e.g., production, schedule, and the cost of the effort versus safety.”**

The INPO definition defines safety culture as “An organization's values and behaviors – modeled by its leaders and internalized by its members…”***

In keeping with these definitions the NRC and industry rely heavily on the results of safety culture surveys to ascertain areas in need of improvement.  These surveys overwhelmingly focus on whether nuclear personnel are “modeling” the definitional traits, values and behaviors.  This seems to fall squarely in the realm described by Snowden of looking to replicate behaviors in hopes of achieving the desired culture and results.  Most often, identified deficiencies are subject to retraining to reinforce the desired safety culture traits.  But what seems to be lacking is a determination of why the traits were not exhibited in the first place.  Followup surveys may be conducted periodically, again to measure compliance with traits.  This recipe is considered sufficient until the next time there are suspect decisions or actions by the licensee. 

Bottom Line

The nuclear enterprise - NRC and industry - appear to be locked into a simplistic and linear view of safety culture.  Values and traits produce desired behaviors; desired behaviors produce appropriate safety management.  Bad results?  Go back to values and traits and retrain.  Have management reiterate that safety is their highest priority.  Put up more posters. 

But what if Snowden’s concept of complex adaptive systems is really an applicable model, and the safety management system is a much more complicated, continuously, self-evolving process?  It is a question well worth pondering - and may have far more impact than much of the hardware centric issues currently being pursued.

Footnote: Snowden is an immensely informative and entertaining lecturer and a large number of his lectures are available via podcasts on the Cognitive Edge website and through YouTube videos.  They could easily provide a stimulating input to safety culture training sessions.

*  Podcast available at http://cognitive-edge.com/library/more/podcasts/agile-conference-complexity-applied-to-systems-2008/. 

**  NRC Safety Culture Policy Statement (June 14, 2011).

***  INPO Definition of Safety Culture (2004).