A Nordic Compendium on Nuclear Safety Culture

A new research paper* covers the challenges of establishing and improving nuclear safety culture (NSC) in a dynamic, i.e., project, environment.  The authors are Finnish and Swedish and it appears the problems of the Olkiluoto 3 plant inform their research interests.  Their summary and review of current NSC literature is of interest to us. 

They begin with an overall description of how organizational (and cultural) changes can occur in terms of direction, rate and scale.

Direction

Top-down (or planned) change relies on the familiar unfreeze-change-refreeze models of Kurt Lewin and Ed Schein.  Bottom-up (or emergent) change emphasizes self-organization and organizational learning.  Truly free form, unguided change leads to NSC being an emergent property of the organization.  As we know, the top-down approach is seldom, if ever, 100% effective because of frictional losses, unintended consequences or the impact of competing, emergent cultural currents.  In a nod to a systems perspective, the authors note organizational structures and behavior influence (and are influenced by) culture.

Rate

“Organizational change can also be distinguished by the rate of its occurrence, i.e, whether the change occurs abruptly or smoothly [italics added].” (p. 8)  We observe that most nuclear plants try to build on past success, hence they promote “continuous improvement” programs that don’t rattle the organization.  In contrast, a plant with major NSC problems sometimes receives shock treatment, often in the form of a new senior manager who is expected to clean things up.  New management systems and organizational structures can also cause abrupt change.

Scale

The authors identify four levels of change.  Most operating plants exhibit the least disruptive changes, called fine tuning and incremental adjustment.  Modular transformation attempts to change culture at the department level; corporate transformation is self-explanatory. 

The authors sound a cautionary note: “the more radical types of changes might not be easily initiated – or might not even be feasible, considering that safety culture is by nature a slowly and progressively changing phenomenon. The obvious condition where a safety-critical organization requires radical changes to its safety culture is when it is unacceptably unhealthy.” (p. 9)

Culture Change Strategies

The authors list seven specific strategies for improving NSC:

• Change organizational structures,
• Modify the behavior of a target group through, e.g. incentives and positive reinforcement,
• Improve interaction and communication to build a shared culture,
• Ensure all organizational members are committed to safety and jointly participate in its improvement,
• Training,
• Promote the concept and importance of NSC,
• Recruit and select employees who will support a strong NSC.

This section includes a literature review for examples of the specific strategies.

Project Organizations

The nature of project organizations is discussed in detail including their time pressures, wide use of teams, complex tasks and a context of a temporary organization in a relatively permanent environment.  The authors observe that “in temporary organisations, the threat of prioritizing “production” over safety may occur more naturally than in permanent organizations.” (pp. 16-17)  Projects are not limited to building new plants; as we have seen, large projects (Crystal River containment penetration, SONGS steam generator replacement) can kill operating plants.

The balance of the paper covers the authors’ empirical work.

Our Perspective 

This is a useful paper because it provides a good summary of the host of approaches and methods that have been (and are being) applied in the NSC space.  That said, the authors offer no new insights into NSC practice.

Although the paper’s focus is on projects, basically new plant construction, people responsible for fixing NSC at problem plants, e.g., Watts Bar, should peruse this report for lessons they can apply that might help achieve the step function NSC improvements such plants need.


*  K.Viitanen, N. Gotcheva and C. Rollenhagen, “Safety Culture Assurance and Improvement Methods in Complex Projects – Intermediate Report from the NKS-R SC AIM” (Feb. 2017).  Thanks to Aili Hunt of the LinkedIn Nuclear Safety Culture group for publicizing this paper.

Safety Culture “State of the Art” in 2002 per NUREG-1756

Here’s a trip down memory lane.  Back in 2002 a report* on the “state of the art” in safety culture (SC) thinking, research and regulation was prepared for the NRC Advisory Committee on Reactor Safeguards.  This post looks at some of the major observations of the 2002 report and compares them with what we believe is important today.

The report’s Abstract provides a clear summary of the report’s perspective:  “There is a widespread belief that safety culture is an important contributor to the safety of operations. . . . The commonly accepted attributes of safety culture include good organizational communication, good organizational learning, and senior management commitment to safety. . . . The role of regulatory bodies in fostering strong safety cultures remains unclear, and additional work is required to define the essential attributes of safety culture and to identify reliable performance indicators.” (p. iii) 

General Observations on Safety Performance 

A couple of quotes included in the report reflect views on how safety performance is managed or influenced.

 “"The traditional approach to safety . . . has been retrospective, built on precedents. Because it is necessary, it is easy to think it is sufficient.  It involves, first, a search for the primary (or "root") cause of a specific accident, a decision on whether the cause was an unsafe act or an unsafe condition, and finally the supposed prevention of a recurrence by devising a regulation if an unsafe act,** or a technical solution if an unsafe condition." . . . [This approach] has serious shortcomings.  Specifically, ". . . resources are diverted to prevent the accident that has happened rather than the one most likely to happen."” (p. 24)

“"There has been little direct research on the organizational factors that make for a good safety culture. However, there is an extensive literature if we make the indirect assumption that a relatively low accident plant must have a relatively good safety culture." The proponents of safety culture as a determinant of operational safety in the nuclear power industry rely, at least to some degree, on that indirect assumption.” (p. 37) 

Plenty of people today behave in accordance with the first observation and believe (or act as if they believe) the second one.  Both contribute to the nuclear industry’s unwillingness to consider new ways of thinking about how safe performance actually occurs.

Decision Making, Goal Conflict and the Reward System

Decision making processes, recognition of goal conflicts and an organization’s reward system are important aspects of SC and the report addressed them to varying degrees.

One author referenced had a contemporary view of decision making, noting that “in complex and ill-structured risk situations, decisionmakers are faced not only with the matter of risk, but also with fundamental uncertainty characterized by incompleteness of knowledge.” (p. 43)  That’s true in great tragedies like Fukushima and lesser unfortunate outcomes like the San Onofre steam generators.

Goal conflict was mentioned: “Managers should take opportunities to show that they will put safety concerns ahead of power production if circumstances warrant.” (p.7)

Rewards should promote good safety practices (p. 6) and be provided for identifying safety issues. (p. 37)  However, there is no mention of the executive compensation system.  As we have argued ad nauseam these systems often pay more for production than for safety.

The Role of the Regulator

“The regulatory dilemma is that the elements that are important to safety culture are difficult, if not impossible, to separate from the management of the organization.  [However,] historically, the NRC has been reluctant to regulate management functions in any direct way.” (pp. 37-38)  “Rather, the NRC " . . . infers licensee organization management performance based on a comprehensive review of inspection findings, licensee amendments, event reports, enforcement history, and performance indicators."” (p. 41)  From this starting point, we now have the current situation where the NRC has promulgated its SC Policy Statement and practices de facto SC regulation using the highly reliable “bring me another rock” method.

The Importance of Context when Errors Occur 

There are hints of modern thinking in the report.  It contains an extended summary of Reason’s work in Human Error.  The role of latent conditions, human error as consequence instead of cause, the obvious interaction between producers and production, and the “non-event” of safe operations are all mentioned. (p. 15)  However, a “just culture” or other more nuanced views of the context in which safety performance occurs had yet to be developed.

One author cited described “the paradox that culture can act simultaneously as a precondition for safe operations and an incubator for hazards.” (p. 43)  We see that in Reason and also in Hollnagel and Dekker: people going about business as usual with usually successful results but, on some occasions, with unfortunate outcomes.

Our Perspective

The report’s author provided a good logic model for getting from SC attributes to identifying useful risk metrics, i.e., from SC to one or more probabilistic risk assessment (PRA) parameters.  (pp. 18-20)  But none of the research reviewed completed all the steps in the model. (p. 36)  He concludes “What is not clear is the mechanism by which attitudes, or safety culture, affect the safety of operations.” (p. 43)  We are still talking about that mechanism today.   

But some things have changed.  For example, probabilistic thinking has achieved greater penetration and is no longer the sole province of the PRA types.  It’s accepted that Black Swans can occur (but not at our plant).

Bottom line: Every student of SC should take a look at this.  It includes a good survey of 20th century SC-related research in the nuclear industry and it’s part of our basic history.

“Those who cannot remember the past are condemned to repeat it.” — George Santayana (1863-1952)


*  J.N. Sorensen, “Safety Culture: A Survey of the State-of-the-Art,” NUREG-1756 (Jan. 2002).  ADAMS ML020520006.  (Disclosure: I worked alongside the author on a major nuclear power plant litigation project in the 1980s.  He was thoughtful and thorough, qualities that are apparent in this report.)

**  We would add “or reinforcing an existing regulation through stronger procedures, training or oversight.”

Safety Culture at the 2015 NRC Regulatory Information Conference

NRC Public Meeting

The Nuclear Regulatory Commission (NRC) held its annual Regulatory Information Conference (RIC) on March 10-12, 2015.  As usual, safety culture (SC) played a minor supporting role: it was the topic of one technical session out of 37 total.  The SC session focused on assessing and/or measuring SC.  It featured a range of presentations—from NRC, Duke Energy, DOE and a SC consultant—which are summarized below.*

NRC

This presentation consisted of one (sic) slide recounting the NRC’s SC outreach program during the past year including the Trait Talk brochures, SC case studies and meetings with other nuclear regulatory bodies.

Duke Energy

The presenter provided a list of internal (CAP, Employee Concerns Program )and external (INPO, NRC) information, and management activities (Nuclear SC Monitoring Panel, Site Leadership team, Corporate Nuclear SC Monitoring Panel, Fleet Nuclear SC Monitoring Panel, Executive Nuclear Safety Council) that are used to assess equipment, processes and people across the Duke fleet.  There was no information on how these activities are integrated to describe plant or fleet SC, or if any SC issues have been identified or corrective actions taken; the slides were basically a laundry list.

Department of Energy (DOE)

The speaker was from DOE’s Office of Environment, Health, Safety and Security.  He reviewed the safety mission and goals related to DOE’s Integrated Safety Management program, DOE’s SC focus areas (leadership, employee/worker engagement and organizational learning) and SC-related activities (extent of condition reviews, self‐assessments, sustainment plans, independent assessments and the SC Improvement Panel.) 

The presentation covered the challenges in relating SC to safety management performance (mostly industrial safety metrics) and in implementing cultural changes.  Factors that make SC improvement difficult include production vs. safety goal conflict, fiscal pressures, leadership changes and internal inertia (resistance to change).

This presentation covered the basics of SC, as customized for DOE, but had no supporting details or any mention of the SC issues that have arisen at various DOE facilities, e.g., Hanford, Pantex and the Waste Isolation Pilot Plant.  We have posted many times on DOE SC; please click on the DOE label to retrieve these posts.

SC Consultant

The presenter was Sonja Haber.  She reviewed the fundamentals of the linkage between culture, behavior and ultimate performance, and the Schein three-level model of culture.

She also covered the major considerations for conducting SC assessments including having a diversity of expertise in assessing culture, using multiple methods of data collection, understanding how cultural complexity impacts performance and considering the interaction of human, organizational and technological factors.

Our Perspective

This was thin gruel compared to the 2014 RIC SC session (which we reviewed April 25, 2014).  Based on the slides, there was not much “there” there at this session.  The speaker who offered the most was Dr. Haber, not a surprise given that she has been involved in SC evaluations at various DOE facilities and testified at a Defense Nuclear Facilities Safety Board hearing on SC (which we reviewed June 9, 2014).

If a webcast of the SC technical session becomes available, we will review it to see if any useful additional information was presented or arose during the discussion.


*  The SC technical session presentations are available on the NRC website.

NRC Chairman Macfarlane's Speech to the National Press Club

As you know, Chairman Allison Macfarlane will be leaving the NRC and starting a new academic job in January.  Today she made a relatively lengthy speech* reviewing her tenure at NRC.  Her remarks touched on all the NRC’s major work areas, including the following comments on safety culture (SC).

In the area of current plant performance, she expressed a concern that the lowest performing plants seem to stay in that category for extended periods rather than fixing their problems and moving on.  She says “Poor management is easy to spot from the lack of safety culture and other persistent problems at plants.  I believe that solid leadership from the top – and not just attention to the bottom line – is necessary to ensure consistent plant performance.” (p. 5)  While we believe leadership is a necessary (but not sufficient) condition for success, her general observation is similar to what we saw back in the “problem plant” era of the 1990s.  A significant difference is there are far fewer plants in trouble these days.

Under new plant construction she observed that “today’s component manufacturers have had to adjust their safety culture practices to accommodate the rigorous, often unique, requirements presented by nuclear construction.  Some parts of the industry continue to struggle with these issues.” (p. 5)

At the NRC’s Regulatory Information Conference (RIC) back in March, three entities (two plants, one contractor) that have been in trouble because of SC issues made presentations detailing their problems and corrective actions.  We reviewed their RIC presentations on April25, 2014.

Our Perspective

As a matter of course, speeches like this emphasize the positive and the progress but it is interesting to note all the activities in which the NRC has its fingers.  It’s worth flipping through the pages just to reinforce that perspective.


*  Prepared Remarks of Chairman Allison M. Macfarlane, National Press Club, Washington, DC (Nov. 17, 2014).

Uh-oh, Delays at Vogtle

This Wall Street Journal article* reports that the new Vogtle units may be in construction schedule trouble. The article notes that the new, modular construction techniques being employed were expected to save time and dollars but may be having the opposite effect. In addition, and somewhat incredibly, the independent monitor is citing design changes as another cause of delays. Thought that lesson had been learned a hundred times in the nuclear industry.

Then there is the inevitable finger pointing:

“The delays and cost pressures have created friction between the construction partners and utility companies that will serve as the plant's owners, escalating into a series of lawsuits totaling more than $900 million.”

The Vogtle situation also serves as a reminder that nuclear safety culture (NSC) is applicable to the construction phase though to our recollection, there was not a lot of talk about it during the NRC’s policy statement development process. The escalating schedule and cost pressures at Vogtle also serve to remind us of how significant a factor such pressures can be in a “massive, complex, first-of-a-kind project” (to quote the Westinghouse spokesman). These situational conditions will be challenging construction workers and management who may not possess the same level of NSC experience or consciousness as nuclear operating organizations.

* R. Smith, “New Nuclear Plant HitsSome Snags,” Wall Street Journal online (Dec. 23, 2012).

NEA 2008-2011 Construction Experience Report: Not Much There for Safety Culture Aficionados.

This month the Nuclear Energy Agency, a part of the Organization for Economic Co-Operation and Development, published a report on problems identified and lessons learned at nuclear plants during the construction phase.  The report focuses on three plants currently under construction and also includes incidents from a larger population of plants and brief reviews of other related studies. 

The report identifies a litany of problems that have occurred during plant construction; it is of interest to us because it frequently mentions safety culture as something that needs to be emphasized to prevent such problems.  Unfortunately, there is not much usable guidance beyond platitudinous statements such as “Safety culture needs to be established prior to the start of authorized activities such as the construction phase, and it is applied to all participants (licensee, vendor, architect engineer, constructors, etc.)”, “Safety culture should be maintained at very high level from the beginning of the project” and, from an U.K. report, “. . . an understanding of nuclear safety culture during construction must be emphasized.”*

These should not be world-shaking insights for regulators (the intended audience for the report) or licensees.  On the other hand, the industry continues to have problems that should have been eliminated after the fiascos that occurred during the initial build-out of the nuclear fleet in the 1960s through 1980s; maybe it does need regular reminding of George Santayana’s aphorism: “Those who cannot remember the past are condemned to repeat it.” 


*  Committee on Nuclear Regulatory Activities, Nuclear Energy Agency, “First Construction Experience Synthesis Report 2008-2011,” NEA/CNRA/R(2012)2 (May 3, 2012), pp. 8, 16 and 41.