Training....Yet Again

U.S. Navy SEALS in Training

We have beat the drum on the value of improved and innovative training techniques for improving safety management performance for some time.  Really since the inception of this blog where our paper, “Practicing Nuclear Safety Management,”* was one of the seminal perspectives we wanted to bring to our readers.  We continue to encounter knowledgeable sources that advocate practice-based approaches and so continue to bring them to our readers’ attention.  The latest is an article from the Harvard Business Review that calls attention to, and distinguishes, “training” as an essential dimension of organizational learning.  The article is “How the Navy SEALS Train for Leadership Excellence.”**  The author, Michael Schrage,*** is a research fellow at MIT who reached out to a former SEAL, Brandon Webb, who transformed SEAL training.  The author contends that training, as opposed to just education or knowledge, is necessary to promote deep understanding of a business or market or process.  Training in this sense refers to actually performing and practicing necessary skills.  It is the key to achieving high levels of performance in complex environments. 

One of Webb’s themes that really struck a chord was: “successful training must be dynamic, open and innovative…. ‘It’s every teacher’s job to be rigorous about constantly being open to new ideas and innovation’, Webb asserts.”  It is very hard to think about much of the training in the nuclear industry on safety culture and related issues as meeting these criteria.  Even the auto industry has recently stepped up to require the conduct of decision simulations to verify the effectiveness of corrective actions - in the wake of the ignition switch-related accidents. (see our May 22, 2014 post.)

In particular the reluctance of the nuclear industry and its regulator to address the presence and impact of goal conflicts on safety continues to perplex us and, we hope, many others in the industry.   It was on the mind of Carlo Rusconi more than a year ago when he observed: “Some of these conflicts originate high in the organization and are not really amenable to training per se” (see our Jan. 9, 2014 post.)  However a certain type of training could be very effective in neutralizing such conflicts - practicing making safety decisions against realistic fact-based scenarios.  As we have advocated on many occasions, this process would actualize safety culture principles in the context of real operational situations.  For the reasons cited by Rusconi it builds teamwork and develops shared viewpoints.  If, as we have also advocated, both operational managers and senior managers participated in such training, senior management would be on the record for its assessment of the scenarios including how they weighed, incorporated and assessed conflicting goals in their decisions.  This could have the salutary effect of empowering lower level managers to make tough calls where assuring safety has real impacts on other organizational priorities.  Perhaps senior management would prefer to simply preach goals and principles, and leave the tough balancing that is necessary to implement the goals to their management chain.  If decisions become shaded in the “wrong” direction but there are no bad outcomes, senior management looks good.  But if there is a bad outcome, lower level managers can be blamed, more “training” prescribed, and senior management can reiterate its “safety is the first priority” mantra.


*  In the paper we quote from an article that highlighted the weakness of “Most experts made things worse.  Those managers who did well gathered information before acting, thought in terms of complex-systems interactions instead of simple linear cause and effect, reviewed their progress, looked for unanticipated consequences, and corrected course often. Those who did badly relied on a fixed theoretical approach, did not correct course and blamed others when things went wrong.”  Wall Street Journal, Oct. 22, 2005, p. 10 regarding Dietrich Dörner’s book, The Logic of Failure.  For a comprehensive review of the practice of nuclear safety, see our paper “Practicing Nuclear Safety Management”, March 2008.

**  M. Schrage, "How the Navy SEALS Train for Leadership Excellence," Harvard Business Review (May 28, 2015).

***  Michael Schrage, a research fellow at MIT Sloan School’s Center for Digital Business, is the author of the book Serious Play among others.  Serious Play refers to experiments with models, prototypes, and simulations.

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

IAEA Building

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

Shared Space, Haage

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

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

Leadership for Safety, Carroll and Haage

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

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

Management for Safety, Haage

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

Concept of Culture, Deetz

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

Culture for Safety, Meier

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

Systemic Approach to Safety, Haage

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

Being Systemic, Deetz

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

Cultural Work in Practice, Cardell

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

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

Our Perspective

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

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

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

  

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

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

Deficient Safety Culture at Metro-North Railroad

A new Federal Railroad Administration (FRA) report* excoriates the safety performance of the Metro-North Commuter Railroad which serves New York, Connecticut and New Jersey.  The report highlights problems in the Metro-North safety culture (SC), calling it “poor”, “deficient” and “weak”.  Metro-North’s fundamental problem, which we have seen elsewhere, is putting production ahead of safety.  The report’s conclusion concisely describes the problem: “The findings of Operation Deep Dive demonstrate that Metro-North has emphasized on-time performance to the detriment of safe operations and adequate maintenance of its infrastructure. This led to a deficient safety culture that has manifested itself in increased risk and reduced safety on Metro-North.” (p. 4)

The proposed fixes are likewise familiar: “. . . senior leadership must prioritize safety above all else, and communicate and implement that priority throughout Metro-North. . . . submit to FRA a plan to improve the Safety Department’s mission and effectiveness. . . . [and] submit to FRA a plan to improve the training program. (p. 4)**

Our Perspective 

This report is typical.  It’s not bad, but it’s incomplete and a bit misguided.

The directive for senior management to establish safety as the highest priority and implement that priority is good but incomplete.  There is no discussion of how safety is or should be appropriately considered in decision-making throughout the agency, from its day-to-day operations to strategic considerations.  More importantly, Metro-North’s recognition, reward and compensation practices (keys to shaping behavior at all organizational levels) are not even mentioned.

The Safety Department discussion is also incomplete and may lead to incorrect inferences.  The report says “Currently, no single department or office, including the Safety Department, proactively advocates for safety, and there is no effort to look for, identify, or take ownership of safety issues across the operating departments. An effective Safety Department working in close communication and collaboration with both management and employees is critical to building and maintaining a good safety culture on any railroad.” (p. 13)  A competent Safety Department is certainly necessary to create a hub for safety-related problems but is not sufficient.  In a strong SC, the “effort to look for, identify, or take ownership of safety issues” is everyone’s responsibility.  In addition, the authors don’t appear to appreciate that SC is part of a loop—the deficiencies described in the report certainly influence SC, but SC provides the context for the decision-making that currently prioritizes on-time performance over safety.

Metro-North training is fragmented across many departments and the associated records system is problematic.  The proposed fix focuses on better organization of the training effort.  There is no mention of the need for training content to include any mention of safety or SC.

Not included in the report (but likely related to it) is that Metro-North’s president retired last January.  His replacement says Metro-North is implementing “aggressive actions to affirm that safety is the most important factor in railroad operations.”***

We have often griped about SC assessments where the recommended corrective actions are limited to more training, closer oversight and selective punishment.  How did the FRA do?   


*  Federal Railroad Administration, “Operation Deep Dive Metro-North Commuter Railroad Safety Assessment” (Mar. 2014).  Retrieved Mar. 14, 2014.  The FRA is an agency in the U.S. Department of Transportation.

**  The report also includes a laundry list of negative findings and required/recommended corrective actions in several specific areas.

***  M. Flegenheimer, “Report Finds Punctuality Trumps Safety at Metro-North,” New York Times (Mar. 14, 2014).  Retrieved Mar. 14, 2014)

Safety Culture Training Labs

Not a SC Training Lab

This post highlights a paper* Carlo Rusconi presented at the American Nuclear Society meeting last November.  He proposes the use of “training labs” to develop improved safety culture (SC) through the use of team-building exercises, e.g., role play, and table-top simulations.  Team building increases (a) participants' awareness of group dynamics, e.g., feedback loops, and how a group develops shared beliefs and (b) sensitivity to the viewpoints of others, viewpoints that may differ greatly based on individual experience and expectations.  The simulations pose evolving scenarios that participants must analyze and develop a team approach for addressing.  A key rationale for this type of training is “team interactions, if properly developed and trained, have the capacity to counter-balance individual errors.” (p. 2155)

Rusconi's recognition of goal conflict in organizations, the weakness of traditional methods (e.g., PRA) for anticipating human reactions to emergent issues, the need to recognize different perspectives on the same problem and the value of simulation in training are all familiar themes here at Safetymatters.

Our Perspective

Rusconi's work also reminds us how seldom new approaches for addressing SC concepts, issues, training and management appear in the nuclear industry.  Per Rusconi, “One of the most common causes of incidents and accidents in the industrial sector is the presence of hidden or clear conflicts in the organization. These conflicts can be horizontal, in departments or in working teams, or vertical, between managers and workers.” (p. 2156)  However, we see scant evidence of the willingness of the nuclear industry to acknowledge and address the influence of goal conflicts.

Rusconi focuses on training to help recognize and overcome conflicts.  This is good but one needs to be careful to clearly identify how training would do this and its limitations. For example, if promotion is impacted by raising safety issues or advocating conservative responses, is training going to be an effective remedy?  The truth is there are some conflicts which are implicit (but very real) and hard to mitigate. Such conflicts can arise from corporate goals, resource allocation policies and performance-based executive compensation schemes.  Some of these conflicts originate high in the organization and are not really amenable to training per se.

Both Rusconi's approach and our NuclearSafetySim tool attempt to stimulate discussion of conflicts and develop rules for resolving them.  Creating a measurable framework tied to the actual decisions made by the organization is critical to dealing with conflicts.  Part of this is creating measures for how well decisions embody SC, as done in NuclearSafetySim.

Perhaps this means the only real answer for high risk industries is to have agreement on standards for safety decisions.  This doesn't mean some highly regimented PRA-type approach.  It is more of a peer type process incorporating scales for safety significance, decision quality, etc.  This should be the focus of the site safety review committees and third-party review teams.  And the process should look at samples of all decisions not just those that result in a problem and wind up in the corrective action program (CAP).

Nuclear managers would probably be very reluctant to embrace this much transparency.  A benign view is they are simply too comfortable believing that the "right" people will do the "right" thing.  A less charitable view is their lack of interest in recognizing goal conflicts and other systemic issues is a way to effectively deny such issues exist.

Instead of interest in bigger-picture “Why?” questions we see continued introspective efforts to refine existing methods, e.g., cause analysis.  At its best, cause analysis and any resultant interventions can prevent the same problem from recurring.  At its worst, cause analysis looks for a bad component to redesign or a “bad apple” to blame, train, oversee and/or discipline.

We hate to start the new year wearing our cranky pants but Dr. Rusconi, ourselves and a cadre of other SC analysts are all advocating some of the same things.  Where is any industry support, dialogue, or interaction?  Are these ideas not robust?  Are there better alternatives?  It is difficult to understand the lack of engagement on big-picture questions by the industry and the regulator.


*  C. Rusconi, “Training labs: a way for improving Safety Culture,” Transactions of the American Nuclear Society, Vol. 109, Washington, D.C., Nov. 10–14, 2013, pp. 2155-57.  This paper reflects a continuation of Dr. Rusconi's earlier work which we posted on last June 26, 2013.