Nuclear Safety Culture: Focus on Decision Making

McKinsey Five Fifty cover

We have long held that decision making (DM) is a key artifact reflecting the state of a nuclear organization’s safety culture.

The McKinsey Quarterly (MQ) has packaged a trio of articles* on DM.  Their first purpose is identifying and countering the different biases that lead to sub-optimal, even disastrous decisions.  (When specific biases are widely spread in an organization, they are part of its culture.)  A second purpose is to describe the attributes of more fair, robust and effective DM processes.  The articles’ specific topics are (1) the behavioral science that underlies DM, (2) a method for categorizing and processing decisions and (3) a case study of a major utility that changed its decision culture. 

“The case for behavioral strategy” (MQ, March 2010)

This article covers the insights from psychology that can be used to fashion a robust DM process.  The authors evidence the need for process improvement by reporting their survey research results showing over 50 percent of the variability in decisional results (i.e., performance) was determined by the quality of the DM process while less than 10 percent was caused by the quality of the underlying analysis. 

There are plenty of cognitive biases that can affect human DM.  The authors discuss several of them and strategies for counteracting them, as summarized in the table below.

Type of bias	How to counteract
False pattern recognition (e.g., saliency (overweight recent or memorable events), confirmation, inaccurate analogies)	Require alternative explanations for the data in the analysis, articulate participants’ relevant experiences (which can reveal the basis for their biases), identify similar situations for comparative analysis.
Bias for action	Explicitly consider uncertainty in the input data and the possible outcomes.
Stability (anchoring to an initial value, loss aversion)	Establish stretch targets that can’t be achieved by business as usual.
Silo thinking	Involve a diverse group in the DM process and define specific decision criteria before discussions begin.
Social (conformance to group views)	Create genuine debate through a diverse set of decision makers, a climate of trust and depersonalized discussions.

The greatest problem arises from biases that create repeatable patterns that become undesirable cultural traits.  DM process designers must identify the types of biases that arise in their organization’s DM, and specify debiasing techniques that will work in their organization and embed them in formal DM procedures.

An attachment to the article identifies and defines 17 specific biases.  Much of the seminal research on DM biases was performed by Daniel Kahneman who received a Nobel prize for his efforts.  We have reviewed Prof. Kahneman’s work on Safetymatters; see our Nov. 4, 2011 and Dec. 18, 2013 posts or click on the Kahneman label. 

“Untangling your organization’s decision making” (MQ, June 2017)

While this article is aimed at complex, global organizations, there are lessons here for nuclear organizations (typically large bureaucracies) because all organizations have become victims of over-abundant communications, with too many meetings and low value e-mail threads distracting members from paying attention to making good decisions.

The authors posit four types of decisions an organization faces, plotted on a 2x2 matrix (the consultant’s best friend) with scope and impact (broad or narrow) on one axis and level of familiarity (infrequent or frequent) on the other.  A different DM approach is proposed for each quadrant. 

Big-bet decisions are infrequent and have broad impact.  Recommendations include (1) ensure there’s an executive sponsor, (2) break down the mega-decision into manageable parts for analysis (and reassemble them later), (3) use a standard DM approach for all the parts and (4) establish a mechanism to track effectiveness during decision implementation.

The authors observe that some decisions turn out to be “bet the company” ones without being recognized as such.  There are examples of this in the nuclear industry.  For details, see our June 18,2013 post on Kewaunee (had only an 8 year PPA), Crystal River (tried to cut through the containment using in-house expertise) and SONGs (installed replacement steam generators with an unproven design). 

Cross-cutting decisions are more frequent and have broad impact.  Some decisions at a nuclear power plant fall into this category.  They need to have the concurrence and support of the Big 3 stakeholders (Operations, Engineering and Maintenance).  Silo attitudes are an omnipresent threat to success in making these kinds of decisions.  The key is to get the stakeholders to agree on the main process steps and define them in a plain-English procedure that defines the calendar, handoffs and decisions.  Governing policy should establish the DM bodies and their authority, and define shared performance metrics to measure success. 

Delegated decisions are frequent and low-risk.  They can be effectively handled by an individual or working team, with limited input from others.  The authors note “The role-modeling of senior leaders is invaluable, but they may be reluctant” to delegate.  We agree.  In our experience, many nuclear managers were hesitant to delegate as many decisions as they could have to subordinates.  Their fear of being held accountable for a screw-up was just too great.  However, their goal should have been to delegate all decisions except those for which they alone had the capabilities and accountability.  Subordinates need appropriate training and explicit authority to make their decisions and they need to be held accountable by higher-level managers.  The organization needs to establish a clear policy defining when and how a decision should be elevated to a more senior decision maker. 

Ad hoc decisions are infrequent and low-risk; they were deliberately omitted from the article. 

“A case study in combating bias” (MQ, May 2017)

This is an interview with a senior executive of a German utility that invested €10 billion in conventional power projects, investments that failed when the political-economic environment evolved in a direction opposite to their assumptions.  In their postmortem, they realized they had succumbed to several cognitive biases, including status quo, confirmation, champion and sunflower.  The sunflower bias (groups aligning with their leaders) stretched far down the organizational hierarchy so lower-level analysts didn’t dare to suggest contrary assumptions or outcomes.

The article describes how the utility made changes to their DM practices to promote awareness of biases and implement debiasing techniques, e.g, one key element is officially designated “devil’s advocates” in DM groups.  Importantly, training emphasizes that biases are not some personal defect but “just there,” i.e., part of the culture.  The interviewee noted that the revised process is very time-intensive so it is utilized only for the most important decisions facing each user group. 

Our Perspective 

The McKinsey content describes executive level, strategic DM but many of the takeaways are equally applicable to decisions made at the individual, department and inter-department level, where a consistent approach is perhaps even more important in maintaining or improving organizational performance.

The McKinsey articles come in one of their Five Fifty packages, with a summary you can review in five minutes and the complete articles that may take fifty minutes total.  You should invest at least the smaller amount.


*  “Better Decisions,” McKinsey Quarterly Five Fifty.  Retrieved Nov. 28, 2017.

Any Lessons for Nuclear Safety Culture from VW’s Initiative to Improve Its Compliance Culture?

VW Logo (Source: Wikipedia)

The Wall Street Journal (WSJ) recently published an interview* with the head of the new compliance department in Volkswagen’s U.S. subsidiary.  The new executive outlined the department’s goals and immediate actions related to improving VW’s compliance culture.  They will all look familiar to you, including a new organization (headed by a former consultant) reporting directly to the CEO and with independent access to the board; mandatory compliance training; a new code of conduct; and developing a questioning attitude among employees.  One additional attribute deserves a brief expansion.  VW aims to improve employees’ decision making skills.  We’re not exactly sure what that means but if it includes providing more information about corporate policies and legal, social and regulatory expectations (in other words, the context of decisions) then we approve.

Our Perspective 

These interventions could be from a first generation nuclear safety culture (NSC) handbook on efforts to demonstrate management interest and action when a weak culture is recognized.  Such activities are necessary but definitely not sufficient to strengthen culture.  Some specific shortcomings follow.

First, the lack of reflection.  When asked about the causes of VW’s compliance failures, the executive said “I can’t speculate on the failures . . .”  Well, she should have had something to say on the matter, even party line bromides.  We’re left with the impression she doesn’t know, or care, about the specific and systemic causes of VW’s “Dieselgate” problems that are costing the company tens of billions of dollars.  After all, this interview was in the WSJ, available to millions of critical readers, not some trade rag.

Second, the trust issue.  VW wants employees who can be trusted by the organization, presumably to do “the right thing” as they go about their business.  That’s OK but it’s even more important to have senior managers who can be trusted to do the right thing.  This is especially relevant for VW because it’s pretty clear the cheating problems were tolerated, if not explicitly promoted, by senior management; in other words, there was a top-down issue in addition to lower-level employee malfeasance.

Next, the local nature of the announced interventions.  The new compliance department is for VW-USA only.  The Volkswagen Group of America includes one assembly plant, sales and maintenance support functions, test centers and VW’s consumer finance entity.  It’s probably safe to say that VW’s most important decisions regarding corporate practices and product engineering are made in Wolfsburg, Lower Saxony and not Herndon, Virginia.

Finally, the elephant in the room.  There is no mention of VW’s employee reward and recognition system or the senior management compensation program.  We have long argued that employees focus on actions that will secure their jobs (and perhaps lead to promotions) while senior managers focus on what they’re being paid to accomplish.  For the latter group in the nuclear industry, that’s usually production with safety as a should-do but with little, if any, money attached.  We don’t believe VW is significantly different.

Bottom line: If this WSJ interview is representative of the auto industry’s understanding of culture, then once again nuclear industry thought leaders have a more sophisticated and complete grasp of cultural dynamics and nuances.

We have commented before on the VW imbroglio.  See our Dec. 20, 2015 and May 31, 2016 posts or click on the VW label.


*B. DiPietro, “Working to Change Compliance Culture at Volkswagen,” Wall Street Journal (Nov. 16, 2017).

Nuclear Safety Culture: Catching up with the NRC

NRC Building

No big nuclear safety culture (NSC) news has come out of the Nuclear Regulatory Commission (NRC) so far in 2017 but there have been a few minor items worth mentioning.

New Leadership Model for NRC*

In 2015, the NRC staff proposed developing an explicit NRC leadership model that would complement the agency’s existing Principles of Good Regulation and Organizational Values (Principles).  The model’s attributes would include “empowering employees . . . creative thinking, innovation, and informed risk-taking . . . .”  The Commission disagreed, saying staff should focus on the characteristics of the Principles that support the identified organizational attributes.

Subsequent staff research identified performance improvement opportunities in the areas of employee decision-making, empowerment and consensus, employee creativity, informed risk-taking and innovation.  They are re-proposing an explicit leadership model that focuses on “Empowerment & Shared Leadership, Innovation & Risk Tolerance, Participative Decision-Making, Diversity in Thought, Receptivity to New Ideas and Thinking, and Collaboration & Teamwork . . . .”

This was a significant social science project to rationalize development of a highly specified management model.  Could it contribute to improving the agency’s “effectiveness, efficiency, and agility”?  Or is it, in essence, a regulation that would suck energy away from what NRC leaders need to do to succeed in a changing environment?  You be the judge.

NRC Lessons-Learned Program (LLP)**

This program was established after the Davis-Bessie fiasco to review agency, nuclear industry and outside incidents for lessons-learned that verify or could strengthen NRC processes.  Because a recognized lesson-learned leads to an NRC corrective action plan (i.e., resource usage) there is a high threshold for accepting proposed lessons-learned.  In the past year, six incidents ranging from the government response to the Flint, MI water crisis to two gripe papers published by the Union of Concerned Scientists passed a preliminary screen.  Ultimately, none of the items met the LLP minimum criteria although all were addressed by other NRC groups or processes.  

The LLP Oversight Board is considering whether the LLP should be discontinued, the threshold should be lowered, or the status quo approach should be continued.  Our concern is that the hard-headedness which characterizes the nuclear industry has also infected the LLP and prevents them from being open to actually learning anything from the experience of others.

Continued NSC Pressure on Problem Plants

Finally, NRC continues to (rightfully) squeeze plants with recognized NSC problems to fix such problems.  Arkansas Nuclear One (ANO) has a Confirmatory Action Letter (CAL) that requires the plant to implement specific improvement steps, including establishing a NSC Observer function to monitor leader behavior and enhancing decision making to ensure NSC aspects are considered.***  We discussed ANO’s NSC problems at length on June 16, 2016.

Watts Bar received part 2 of an inspection report on plant performance in the areas of NSC and Safety Conscious Work Environment (SCWE).****  It was a continuation of the beat down they received in part 1 (which we reviewed on Nov. 14, 2016).  The major findings were site-wide challenges to Watts Bar’s SCWE and weaknesses in the criteria used to evaluate NSC standards.  The inspection team’s detailed findings were too numerous to list here but included disagreeing with the site’s interpretation of safety “pulsing” data, management relaxing the standards for evaluating NSC data, overly limited assessment of NSC survey results and weaknesses in the training for NSC monitors.  The report is worth reading to show what a diligent inspector sees when looking at the same plant-produced NSC data that management has been cherry-picking for positive results and trends.

Our Perspective

The first calendar quarter of 2017 looks like business as usual at the NRC, at least when it comes to NSC.  That’s probably as it should be; we really don’t want them to be too distracted by the downsizing and problems occurring in the U.S. commercial nuclear industry.  The agency is trying to figure out how to be more agile and, without saying so, looking forward to having to do the same work with fewer resources.  (While some costs, e.g., plant inspection activities, are variable and can scale down with the industry, our guess is much of their work/cost structure is more-or-less fixed.)

There was a safety culture session at the recent Regulatory Information Conference, which we will separately review.


*  Memo from V.M. McCree to NRC Commissioners, “Re-Examination of the Need for a U.S. Nuclear Regulatory Commission Leadership Model” (Feb. 6, 2017).  ADAMS ML16348A323.

**  Memo from V.M. McCree to NRC Commissioners, “Annual Report on the Lessons-Learned Program” (Feb. 17, 2017).  ADAMS ML16231A323.

***  Letter from T.R. Farnholtz (NRC) to R. Anderson (ANO), “Arkansas Nuclear One – NRC Component Design Bases Inspection and Confirmatory Action Letter Follow-up Inspection Report 05000313/2016008 AND 05000368/2016008” (Feb. 28, 2017), pp. A3-5/-6.  ADAMS ML17059D000.

****  Letter from J.T. Munday (NRC) to J.W. Shea (TVA), “Watts Bar Nuclear Plant – NRC Problem Identification and Resolution Inspection (Part 2); and Safety Conscious Work Environment Issue of Concern Follow-up; NRC Inspection Report 05000390/2016013, 05000391/2016013” (March 10, 2017), pp. 2, 13-16.  ADAMS ML17069A133.

Leadership, Decisions, Systems Thinking and Nuclear Safety Culture

AcciMap Excerpt

We recently read a paper* that echoes some of the themes we emphasize on Safetymatters, viz., leadership, decisions and a systems view.  Following is an excerpt from the abstract:

“Leadership is progressively being recognized as a key** factor in supporting successful performance across a range of domains. . . . the decisions and actions that characterize safety leadership thus become important emergent properties in the prevention of incidents, which should be considered within the context of the broader organizational system and not merely constrained to understanding events or conditions that shape performance at the ‘sharp end’.”  [emphasis added]

The authors go on to analyze decisions and actions after a mining incident (landslide) using a combination of three different schemes: Rasmussen’s Risk Management Framework (RMF) and corresponding AcciMap, and the Critical Decision Method (CDM).

The RMF describes work systems as comprised of various levels and argues that safety performance is affected by decisions and actions at all levels from politicians in the external environment down through company executives and managers and finally to individual workers.  Rasmussen’s AcciMap is an expansive causal diagram for an accident or incident that displays the contributions (or omissions) at each level in the RMF and their connections.

CDM uses semi-structured interviews to obtain information about how individuals formulate their decisions, including context such as background knowledge and immediate influencing factors.  Consistent with the RMF, case study interviews were conducted with individuals at different organizational levels.  CDM data were used to construct the AcciMap.

We won’t go into the details of the analysis but it identified over a dozen key decisions made at different organizational levels before and during the incident; most were connected to at least one other key decision.  The AcciMap illustrates decisions and communications across multiple levels and thus provides a useful picture of how an organization anticipates and responds to an unusual situation.

Our Perspective

The authors argue, and we agree, that this type of analysis provides greater detail and insight into the performance of an organization’s safety management system than traditional accident investigations (especially those focused on finding someone to blame).

This article does not specifically discuss culture.  But the body of decisions an organization produces is the strongest evidence and most visible artifact of its culture.  Organizational decisions are far more important than responses to surveys or interviews where people can report what they believe (or hope) the culture is, or what they think their audience wants to hear.

We like that RMF and AcciMap are agnostic: they can be used to analyze either “what went wrong” or “what went right” scenarios.  (The case study was in the latter category because no one was hurt in the incident.)  If an assessor is looking at a sample of decisions to infer a nuclear organization’s culture, most of those decisions will have had positive (or at least no negative) consequences.

The authors are Australian academics but this short (8 pages total) paper is quite readable and a good introduction to CDM and Rasmussen’s constructs.  The references include people whose work we have positively reviewed on Safetymatters, including Dekker, Hollnagel, Leveson and Reason.

Bottom line: There is nothing about culture or nuclear here, but the overall message reinforces our beliefs about how to think about Nuclear Safety Culture.


*  S-L Donovana, P.M. Salmonb and M.G. Lennéa, “The leading edge: A systems thinking methodology for assessing safety leadership,” Procedia Manufacturing 3 (2015), pp. 6644–6651.  Available at sciencedirect.com; retrieved Jan. 19, 2017.

**  Note they do not say “one and only” or even “most important.”

Leadership and Safety Culture

Cover of the first issue

It’s an election year in America and voters are assessing candidates who all claim they can provide the leadership the country needs.  A recent article* in The New Yorker offers a primer on the nature of leadership.  The article is engaging because we talk a lot about leadership in the nuclear industry in areas ranging from general management to molding or influencing culture.**  Following are some highlights from the article.

For starters, leadership can mean different things to different people.  The article cites a professor who found more than 200 definitions in the modern leadership literature.  Of necessity, the author focused on a small subset of the literature, starting with sociologist Max Weber who distinguished between “charismatic” and “bureaucratic” leadership.

The charismatic model is alive and well; it’s reflected in the search for CEOs with certain traits, e.g., courage, decisiveness, intelligence or attractiveness, especially during periods of perceived crisis.  Unfortunately, the track record of such people is mixed; according to one researcher, “The most powerful factor determining a company’s performance is the condition of the market in which it operates.” (p. 67)

The bureaucratic model focuses on process, i.e., what a leader actually does.  Behaviors might include gathering information on technology and competitors, setting goals, assembling teams and tracking progress, in other words, the classic plan, organize, staff, direct and control paradigm.  But a CEO candidate’s actual process might not be visible or not what he says it is.  And, in our experience, if the CEO cannot bring strategic insight or a robust vision to the table, the “process” is a puerile exercise.

So how does one identify the right guy or gal?  Filtering is one method to reduce risk in the leader selection process.  Consider the nuclear industry’s long infatuation with admirals.  Why?  One reason is they’ve all jumped through the same hoops and tend to be more or less equally competent—a safe choice but one that might not yield out-of-the-ballpark results.  A genuine organizational crisis might call for an unfiltered leader, an outsider with a different world view and experience, who might deliver a resounding success (e.g., Abraham Lincoln).  Of course, the downside risk is the unfiltered leader may fail miserably.

If you believe leadership is learnable, you’re in luck; there is a large industry devoted to teaching would-be leaders how to empower and inspire their colleagues and subordinates, all the while evidencing a set of pious virtues.  However, one professor thinks this is a crock and what the leadership industry actually does is “obscure the degree to which companies are poorly and selfishly run for the benefit of the powerful people in charge.” (p. 68)

The author sees hope in approaches that seek to impart more philosophy or virtue to leaders.  He reviews at length the work of Elizabeth Samet, an English professor at the U.S. Military Academy (West Point).  She presents leadership through a wide-angle lens, from General Grant’s frank memoirs to a Virginia Woolf essay.  To gain insight into ambition, her students read “Macbeth.”  (Ooops!  I almost typed “MacTrump.”)    

Our Perspective

The New Yorker article is far from a complete discussion of leadership but it does spur one to think about the topic.  It’s worth a quick read and some of the author’s references are worth additional research.  If you want to skip all that, what you should know is “. . . leaders in formal organizations have the power and responsibility to set strategy and direction, align people and resources, motivate and inspire people, and ensure that problems are identified and solved in a timely manner.”***

At Safetymatters, we believe effective leadership is necessary, but not sufficient, to create a strong safety culture (SC).  Not all aspects of leadership are important in the quest for a strong SC.  Leaders need some skills, e.g., the ability to communicate their visions, influence others and create shared understanding.  But the critical aspects are decision-making and role modeling.

Every decision the leader makes must show respect for the importance of safety.  The people will be quick to spot any gap between words and decisions.  Everyone knows that production, schedule and budget are important—failure to perform eventually means jobs and careers go away—but safety must always be a conscious and visible consideration.

Being a role model is also important.  Again, the people will spot any disregard or indifference to safety considerations, rules or practices.

There is no guarantee that even the most gifted leader can deliver a stronger SC.  Although the leader may create a vision for strong SC and attempt to direct behavior toward that vision, the dynamics of SC are complex and subject to multiple factors ranging from employees’ most basic values to major issues that compete for the organization’s attention and resources. 

To close on a more upbeat note, effective leadership is open to varying definitions and specifications but, to borrow former Supreme Court Justice Potter Stewart’s famous phrase, we know it when we see it.****


*  J. Rothman, “Shut Up and Sit Down,” The New Yorker (Feb. 29, 2016), pp. 64-69.

**  For INPO, leadership is sine qua non for an effective nuclear organization.

***  This quote is not from The New Yorker article.  It is from a review of SC-related social science literature that we posted about on Feb. 10, 2013.

****  Justice Stewart was talking about pornography but the same sort of Kantian knowing can be applied to many topics not amenable to perfect definition.

The Dark Side of Culture Management: Functional Stupidity

Culture is the collection of values and assumptions that underlie organizational decisions and other actions.  We have long encouraged organizations to develop strong safety cultures (SC).  The methods available to do this are widely-known, including visible leadership and role models; safety-related policies, practices and procedures; supportive structures like an Employee Concerns Program; the reward and recognition system; training and oversight; and regulatory carrots and sticks.

Because safety performance alone does not pay the bills, organizations also need to achieve their intended economic goals (i.e., be effective) and operate efficiently.  Most of the methods that can be used to promote SC can also be used to promote the overall performance culture.

What happens when the organization goes too far in shaping its culture to optimize performance?  One possibility, according to a 2012 Journal of Management Studies article*, is a culture of Functional Stupidity.  The Functional part means the organization meets its goals and operates efficiently and Stupidity “is an organizationally supported inability or unwillingness to mobilize one’s cognitive capacities.” (p. 1199)**

More specifically, to the extent management, through its power and/or leadership, willfully shapes an organization’s value structure to achieve greater functionality (conformity, focus, efficiency, etc.) they may be, consciously or unconsciously, creating an environment where employees ask fewer questions (and no hard ones), seek fewer justifications for the organization’s decisions or actions, focus their intelligence in the organization’s defined areas, do not reflect on their roles in the organization’s undertakings, and essentially go along with the program.  Strong leaders set the agenda and the true followers, well, they follow.

In the name of increased functionality, such actions can create a Weltanschauung that is narrowly focused and self-justifying.  It may result in soft biases, e.g., production over safety, or ignoring problematic aspects of a situation, e.g., Davis-Besse test and inspection reports.

Fortunately, as the authors explain, a self-correcting dynamic may occur.  Initially, improved functionality contributes to a sense of certainty about the organization’s and individuals’ places in the world, thus creating positive feedback.  But eventually the organization’s view of the world may increasingly clash with reality, creating dissonance (a loss of certainty) for the organization and the individuals who inhabit it.  As the gap between perception and reality grows, the overall system becomes less stable.  When people realize that description and reality are far apart, the organization’s, i.e., management’s, legitimacy collapses.

However, in the worst case “increasingly yawning gaps between shared assumptions and reality may eventually produce accidents or disasters.” (p. 1213)  Fukushima anyone?

Our Perspective

Management is always under the gun to “do better” when things are going well or “do something” when problems occur.  In the latter case, one popular initiative is to “improve” the culture, especially if a regulator is involved.  Although management’s intentions may be beneficent, there is an opportunity for invidious elements to be introduced and/or unintended consequences to occur.

Environmental factors can encourage stupidity.  For example, quarterly financial reporting, an ever shortening media cycle and the global reach of the Internet (especially it’s most intellectually challenged component, the Twitterverse) pressure executives to project command of their circumstances and certainty about their comprehension, even if they lack adequate (or any) relevant data.

The nuclear industry is not immune to functional stupidity.  Not to put too fine a point on it, but the industry's penchant for secrecy creates an ideal Petri dish for the cultivation of stupidity management.

The authors close by saying “we hope to prompt wider debate about why it is that smart organizations can be so stupid at times.” (p. 1216)  For a long time we have wondered about that ourselves.


*  M. Alvesson and A. Spicer, “A Stupidity-Based Theory of Organizations,” Journal of Management Studies 49:7 (Nov. 2012), pp. 1194-1220.  Thanks to Madalina Tronea for publicizing this document.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety Culture discussion group.

**  Following are additional definitions, with italics added, “functional stupidity is inability and/or unwillingness to use cognitive and reflective capacities in anything other than narrow and circumspect ways.” (p. 1201)  “stupidity management . . . involves the management of consciousness, clues about how to understand and relate to the world, . . .” (p. 1204)  “stupidity self-management  [consists of] the individual putting aside doubts, critique, and other reflexive concerns and focusing on the more positive aspects of organizational life which are more clearly aligned with understandings and interpretations that are officially sanctioned and actively promoted.” (p. 1207)

A Nuclear Safety Culture for Itinerant Workers

IAEA has published “Radiation Protection of Itinerant Workers”* a report that describes management responsibilities and practices to protect and monitor itinerant workers who are exposed to ionizing radiation.  “Itinerant workers” are people who work at different locations “and are not employees of the management of the facility where they are working. The itinerant workers may be self-employed or employed by a contractor . . .” (p. 4)  In the real world, such employees have many different names including nuclear nomads, glow boys and jumpers.

The responsibility for itinerant workers’ safety and protection is shared among various organizations and the individual.  “The primary responsibility for the protection of workers lies with the management of the operating organization responsible for the facilities . . . however, the employer of the worker (as well as the worker) also bear certain responsibilities.” (p. 2)

Safety culture (SC) is specifically mentioned in the IAEA report.  One basic management responsibility is to promote and maintain a robust SC at all organizational levels. (p. 11)  Specific responsibilities include providing general training in SC behavior and expectations (p. 131) and, where observation or problems reveal specific needs, targeted individual (or small group) SC training. (p. 93)

Our Perspective

This publication is hardly a great victory for SC; the report provides only the most basic description of the SC imperative.  Its major contribution is that it recognizes that itinerant nuclear workers deserve the same safety and protection considerations as other workers at a nuclear facility. 

Back in the bad old days, I was around nuclear organizations where their own employees represented the highest social class, contractors were regarded as replaceable parts, and nomadic workers were not exactly expendable but were considered more responsible for managing their own safety and exposure than permanent personnel.

One can make some judgment about a society’s worth by observing how it treats its lowest status members—the poor, the homeless, the refugee, the migrant worker.  Nuclear itinerant workers deserve to be respected and treated like the other members of a facility’s team.


*  International Atomic Energy Agency, “Radiation protection of itinerant workers,” Safety reports series no. 84 (Vienna, 2015).

Cultural Tidbits from McKinsey

We spent a little time poking around the McKinsey* website looking for items that could be related to safety culture and found a couple.  They do not provide any major insights but they do spur us to think of some questions for you to ponder about your own organization.

One article discussed organizational redesign** and provided a list of recommended rules, including establishing metrics that show if success is being achieved.  Following is one such metric.

“One utility business decided that the key metric for its efficiency-driven redesign was the cost of management labor as a proportion of total expenditures on labor.  Early on, the company realized that the root cause of its slow decision-making culture and high cost structure had been the combination of excessive management layers and small spans of control.  Reviewing the measurement across business units and at the enterprise level became a key agenda item at monthly leadership meetings.” (p. 107)

What percent of total labor dollars does your organization spend on “management”?  Could your organization’s decision making be speeded up without sacrificing quality or safety?  Would your organization rather have the “right” decision (even if it takes a long time to develop) or no decision at all rather than risk announcing a “wrong” one?

A second article discussed management actions to create a longer view among employees,*** including clearly identifying and prioritizing organizational values.  Following is an example of action related to values.

“The pilots of one Middle East–based airline frequently write incident reports that candidly raise concerns, questions, and observations about potential hazards.  The reports are anonymous and circulate internally, so that pilots can learn from one another and improve—say, in handling a particularly tricky approach at an airport or dealing with a safety procedure.  The resulting conversations reinforce the safety culture of this airline and the high value it places on collaboration.  Moreover, by making sure that the reporting structures aren’t punitive, the airline’s executives get better information and can focus their attention where it’s most needed.”

How do your operators and other professionals share experiences and learning opportunities among themselves at your site?  How about throughout your fleet?  Does documenting anything that might be construed as weakness require management review or approval?  Is management (or the overall organization) so fearful of such information being seen by regulators or the public, or discovered by lawyers, that the information is effectively suppressed?  Is your organization paranoid or just applying good business sense?  Do you have a culture that would pass muster as “just”?

Our Perspective

Useful nuggets on management or culture are where you find them.  Others’ experiences can stimulate questions; the answers can help you better understand local organizational phenomena, align your efforts with the company’s needs and build your professional career.


*  McKinsey & Company is a worldwide management consulting firm.

**  S. Aronowitz et al, “Getting organizational redesign right,” McKinsey Quarterly, no. 3 (2015), pp. 99-109.

***  T. Gibbs et al, “Encouraging your people to take the long view,” McKinsey Quarterly (Sept. 2012).

Corrosion in the Culture of the DNFSB?

We have posted many times on the Defense Nuclear Facilities Safety Board’s (DNFSB) efforts to get the Department of Defense (DOE) to confront and resolve its safety culture (SC) issues.  Now it appears the DNFSB has management and cultural issues of its own.  In a stinging report* by an outside consultant, DNFSB board members are said to have a “divisive and dysfunctional relationship” and the organizational culture is called “toxic.” (p. iii)  This post highlights the cultural aspects of selected issues and the proposed fixes.

Major issues that can affect culture are the board itself, the negative tone of oral and written communications, and the performance recognition system.

DNFSB is a small agency (100+ people) and most work in the same office.  There is no place to hide from the effects of troubles at the top.  The Board’s basic problem is that the members don’t have a shared mental model of the DNFSB’s mission and strategies.  And, because the members are political appointees representing both major parties, creating some kind of unity is a major challenge.  The report contains many recommendations related to improving board functioning but the reality is it’s mainly a political issue.  Board dysfunctionality is a cultural issue because hydra-headed leadership distracts, confuses and ultimately demoralizes the agency staff.  Most alarming to us, to the extent investigations are driven by board members’ interests rather than by science and safety considerations (a perception reported by some staff), the board’s shortcomings can impinge on the agency’s SC. 

Communications problems start at the board level and permeate the agency. Negative communications, e.g., condescending language and personal attacks, lead to a culture of disrespect.  The recommendations for communications include “Immediately ensure a professional tone in all communications, both among board members and throughout the Agency.  Consider use of an internal communication code of conduct.” (p. 3-2)  In our view, business communications should focus on the issues, be respectful and exhibit a modicum of integrity.

Performance recognition recommendations include “Assess staff sentiment with regard to priorities for nonmonetary incentives, and develop offerings accordingly.” (p. 3-5)  Nonmonetary recognition was mentioned by an employee committee tasked with identifying underlying causes for DNFSB’s declining scores on the periodic federal employee viewpoint survey.  We’re not sure why monetary recognition is off the table, perhaps because of perceived budget problems.  Our feeling is if some type of above-and-beyond behavior is worth recognizing, then an organization should be willing to pay something for it.

There are also a couple of more straightforward management issues: frequent disruptive organizational changes, and the lack of management and leadership competence.  If not addressed, such issues can certainly weaken culture but they are not as important as the ones described previously.

Change management recommendations include “Develop a change management organizational competency . . .  [and] a change management plan, . . .” (p. 3-3)  As an aside, the NRC Inspector General (IG) provides IG services to the DNFSB; an October 2014 IG report** identified change management as a serious challenge facing the agency.

Increasing competence corrective actions include “Institute tailored management and supervisory training for technical staff management and supervisors. . . .” (p. 3-3)  This is not controversial; it simply needs to be accomplished.

Our Perspective 

If the report accurately describes DNFSB’s reality, it looks like a bit of a mess.  The board’s chairman recently retired so the President has an opportunity to nominate someone who is willing and able to clean it up.  Absent competent leadership from the top, the report’s recommendations may make a dent in the problems but will not be a cure-all.

We wish them well.  If the DNFSB’s focus wanes, it bodes ill for efforts to spur DOE to increase its management competence and strengthen its SC.


*  J. O'Hara and P.M. Darmory, “Assessment of the Defense Nuclear Facilities Safety Board Workforce and Culture,” Report DNF40T1 (Dec. 2014).  Thanks to Bill Mullins for recommending this report.

**H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.