WANO Publicizes Projects That Promote Safety But Short-Changes Nuclear Safety Culture

NOT WANO's world headquarters

The World Association of Nuclear Operators (WANO) recently announced* the completion and delivery of 12 post-Fukushima projects intended to enhance safety in the world’s commercial nuclear power plants.  It appears the projects were accomplished by a combination of WANO and member personnel.  An addendum to the press release describes how WANO has revised its own practices to more effectively deliver its services in the 12 project areas to members.  The projects address emergency preparedness, emergency support plan, severe accident management, early event notification, onsite fuel storage, design safety fundamentals, peer review frequency and equivalency, corporate peer reviews, WANO assessment, transparency and visibility, and WANO internal assessment. 

Our Perspective

We usually don’t waste time with WANO because it has never developed or promoted any insight into the systemic interactions of the management and cultural variables that create ongoing nuclear organizational performance.  And the results they are touting are based on their familiar, inadequate worldview, viz. promoting more development for leaders and more detail to functional areas.

That said, we recognize that incremental improvements in the project areas might add some modest value and hopefully do not hurt performance.  (Performance may be “hurt” when personnel punctiliously and mindlessly follow policies, rules and procedures without considering if they are actually appropriate for the situation at hand.)

Most of WANO’s claims for improving its own services are typical chest-thumping but a few items perpetuate long-standing industry shortcomings, especially excessive secrecy.  For example, under design safety fundamentals WANO peer reviews assess whether safety-related design features are appropriately managed but “WANO does not make design-change recommendations or evaluate the design of the plant itself.”  WANO assessments of utility/plant performance are confidential to the subject CEOs.  And WANO’s concept of improving transparency means “effectively sharing information and best practices within the membership.”  Looks like WANO’s prime directive is to shield the dues-paying members from any hard questions or external criticism.

Our biggest gripe is WANO’s treatment, or lack thereof, of nuclear safety culture (NSC).  In the press release, culture is mentioned once: Mid-to-senior level “managers at nuclear power plants play a vital part in delivering excellence and a strong nuclear safety culture, due to their positional influence throughout the organisation.”  That’s true, but culture is much more pervasive, systemic and important than that.

We find it surreal that WANO has been busy organizing worldwide resources to polish the bowling ball** and then claim they have made the industry safer post-Fukushima.  Linking their putative progress to Fukushima ignores a fundamental truth: while weaknesses in various functional areas were causal factors that made a bad situation worse, the root cause of the Fukushima disaster was the deep-seated, value-driven unwillingness of people who knew to speak truth to power about the tsunami design inadequacies.  It was culture that killed the plant.


*  WANO press release, “WANO calls on industry to build on progress after post-Fukushima improvements” (June 26, 2018).  Retrieved July 5, 2018.

**  “polish a bowling ball” - A phrase we use to describe activities that make an existing construct shinier but have no impact on its fundamental nature or effectiveness.

WANO and NEA to Cooperate on Nuclear Safety Culture

World Nuclear News Oct. 4, 2017

According to an item* in World Nuclear News, the World Association of Nuclear Operators (WANO) and the Organisation for Economic Co-operation and Development’s Nuclear Energy Agency (NEA) signed a memorandum of understanding to cooperate on "the further development of approaches, practices and methods in order to proactively strengthen global nuclear safety."

One objective is to “enhance the common understanding of nuclear safety culture challenges . . .”  In addition, the parties have identified safety culture (SC) as a "fundamental subject of common interest" and plan to launch a series of "country-specific discussions to explore the influence of national culture on the safety culture".

Our Perspective

As usual, the press release touts all the benefits that are going to flow from the new relationship.  We predict the flow will be at best a trickle based on what we’ve seen from the principals over the years.  Following is our take on the two entities.

WANO is an association of the world's nuclear power operators.  Their objective is to exchange safety knowledge and operating experience among its members.  We have mentioned WANO in several Safetymatters posts, including Jan. 23, 2015, Jan. 7, 2015, Jan. 21, 2014 and May 1, 2010.  Their public contributions are generally shallow and insipid.  WANO may be effective at facilitating information sharing but it has no real authority over operators.  It is, however, an overhead cost for the economically uncompetitive commercial nuclear industry. 

NEA is an intergovernmental agency that facilitates cooperation among countries with nuclear technology infrastructures.  In our March 3, 2016 post we characterized NEA as an “empty suit” that produces cheerleading and blather.  We stand by that assessment.  In Safetymatters’ history, we have come across only one example of NEA adding value—when they published a document that encouraged regulators to take a systems view of SC.  See our Feb. 10, 2016 post for details.

No one should expect this new arrangement to lead to any breakthroughs in SC theory or insights into SC practice.  It will lead to meetings, conferences, workshops and boondoggles.  One hopes it doesn’t indirectly raise the industry’s costs or, more importantly, distract WANO from its core mission of sharing safety information and operating experience across the international nuclear industry. 


*  “WANO, NEA enhance cooperation in nuclear safety,” World Nuclear News (Oct. 4, 2017).

Defense in Depth and Safety Culture from an IAEA Conference

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

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

SC in WANO

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

SC in Indonesia

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

The Experimental Fuel Element Installation (EFEI)

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

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

Kartini Research Reactor

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

Our Perspective

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

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

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

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

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

Human Performance at a Nuclear Power Plant

2015 is off to a slow start in the safety culture (SC) space but we recently saw two mid-2014 articles worth a few words: “Putting People in the Mix” Parts I and II by Ken Ellis, both originally published in Nuclear Engineering International.*  The basic premise is that an incident investigation finding of human error is only “the tip of the iceberg” in understanding human performance issues.

Part I

Part I describes how people add a probabilistic aspect to nuclear plant performance.  Ellis begins by reviewing the nuclear industry’s defense-in-depth: physical barriers, safety systems and contingency plans.  If an incident occurs, then linear root cause analysis starts with the outcome and works back to identify what happened.  Lessons learned are used to update the defense-in-depth system.

But people don’t always behave according to the laws of physics.  People “can circumvent both equipment and process, either unwittingly or wittingly” because of their personal history, perceptions, stress and other factors.  Adding people makes a complicated system (a nuclear plant) a complex one.  One consequence is that a complete and accurate reconstruction of the events preceding an incident may not be possible.  Incident analysis should include investigating the dynamic context in which any relevant human behavior occurred. 

Part II

Part II describes risk management.  It begins with a list of factors that can increase risks at nuclear plants, including lack of leadership, time pressures, complacency and normalization of deviance.  The organization’s primary goal in risk space “is to narrow the band of what constitutes acceptable risk.” The strategy should be to control human behavior by making the boundaries of the work space “explicit and known, and giving workers opportunities to develop coping skills at boundaries.”

Ellis on goes to list  practices that can help improve safety including communication protocols, conservative decision-making and a questioning attitude.  He concludes with some suggestions for managing human performance risk including explicit discussion of complexity and risk boundaries, seeking divergent opinions and understanding how workers interpret messages from corporate. 

Our Perspective 

There is really nothing wrong with these articles.  Ellis covers the ground fairly well in 2400 words intended for a general nuclear industry audience.  But there is nothing new here.  More importantly, this is a brisk treatment of some important concepts about human behavior, the nature of human and system errors, competing mental models of nuclear operations, and desirable management attributes.  The author’s lack of references means a curious reader is left to his own devices.  One really needs direction to key sources, e.g., Dekker, Hollnagel, Reason, Taleb, Vaughan, Woods and the HRO people to gain a meaningful understanding of such concepts.  If you’ve been following Safetymatters for awhile, you know we’ve covered these folks and their ideas at length.

*  K. Ellis, “Putting People in the Mix: Part I,” Nuclear Engineering International (July 18, 2014) and “Putting People in the Mix:Part II,” Nuclear Engineering International (July 21, 2014).  Mr. Ellis is the Managing Director of the World Association of Nuclear Operators (WANO).  Thanks to Dr. W.R. Corcoran for publicizing Part I in the LinkedIn Nuclear Safety Culture group.

Lessons Learned from “Lessons Learned”: The Evolution of Nuclear Power Safety after Accidents and Near-Accidents by Blandford and May

This publication appeared on a nuclear safety online discussion board.*  It is a high-level review of significant commercial nuclear industry incidents and the subsequent development and implementation of related lessons learned.  This post summarizes and evaluates the document then focuses on its treatment of nuclear safety culture (SC). 

The authors cover Three Mile Island (1979), Chernobyl (1986), Le Blayais [France] plant flooding (1999), Davis-Besse (2002), U.S. Northeast Blackout (2003) and Fukushima-Daiichi (2011).  There is a summary of each incident followed by the major lessons learned, usually gleaned from official reports on the incident. 

Some lessons learned led to significant changes in the nuclear industry, other lessons learned were incompletely implemented or simply ignored.  In the first category, the creation of INPO (Institute of Nuclear Power Operations) after TMI was a major change.**  On the other hand, lessons learned from Chernobyl were incompletely implemented, e.g., WANO (World Association of Nuclear Operators, a putative “global INPO”) was created but it has no real authority over operators.  Fukushima lessons learned have focused on design, communication, accident response and regulatory deficiencies; implementation of any changes remains a work in progress.

The authors echo some concerns we have raised elsewhere on this blog.  For example, they note “the likelihood of a rare external event at some site at some time over the lifetime of a reactor is relatively high.” (p. 16)  And “the industry should look at a much higher probability of problems than is implied in the “once in a thousand years” viewpoint.” (p. 26)  Such cautions are consistent with Taleb's and Dédale's warnings that we have discussed here and here.

The authors also say “Lessons can also be learned from successes.” (p. 3)  We agree.  That's why our recommendation that managers conduct periodic in-depth analyses of plant decisions includes decisions that had good outcomes, in addition to those with poor outcomes.

Arguably the most interesting item in the report is a table that shows deaths attributable to different types of electricity generation.  Death rates range from 161 (per TWh) for coal to 0.04 for nuclear.  Data comes from multiple sources and we made no effort to verify the analysis.***

On Safety Culture

The authors say “. . . a culture of safety must be adopted by all operating entities. For this to occur, the tangible benefits of a safety culture must become clear to operators.” (p. 2, repeated on p. 25)  And “The nuclear power industry has from the start been aware of the need for a strong and continued emphasis on the safety culture, . . .” (p. 24)  That's it for the direct mention of SC.

Such treatment is inexcusably short shrift for SC.  There were obvious, major SC issues at many of the plants the authors discuss.  At Chernobyl, the culture permitted, among other things, testing that violated the station's own safety procedures.  At Davis-Besse, the culture prioritized production over safety—a fact the authors note without acknowledging its SC significance.  The combination of TEPCO's management culture which simply ignored inconvenient facts and their regulator's “see no evil” culture helped turn a significant plant event at Fukushima into an abject disaster.

Our Perspective

It's not clear who the intended audience is for this document.  It was written by two professors under the aegis of the American Academy of Arts and Sciences, an organization that, among other things, “provides authoritative and nonpartisan policy advice to decision-makers in government, academia, and the private sector.”****  While it is a nice little history paper, I can't see it moving the dial in any public policy discussion.  The scholarship in this article is minimal; it presents scant analysis and no new insights.  Its international public policy suggestions are shallow and do not adequately recognize disparate, even oppositional, national interests.  Perhaps you could give it to non-nuclear folks who express interest in the unfavorable events that have occurred in the nuclear industry. 


*  E.D. Blandford and M.M. May, “Lessons Learned from “Lessons Learned”: The Evolution of Nuclear Power Safety after Accidents and Near-Accidents” (Cambridge, MA: American Academy of Arts and Sciences, 2012).  Thanks to Madalina Tronea for publicizing this article on the LinkedIn Nuclear Safety group discussion board.  Dr. Tronea is the group's founder/moderator.

**  This publication is a valentine for INPO and, to a lesser extent, the U.S. nuclear navy.  INPO is hailed as “extraordinarily effective” (p. 12) and “a well-balanced combination of transparency and privacy; . . .” (p. 25)

***  It is the only content that demonstrates original analysis by the authors.

****  American Academy of Arts and Sciences website (retrieved Jan. 20, 2014).

Why is Nuclear Different?

We saw a very interesting observation in a recent World Nuclear News item describing updates to World Association of Nuclear Operators’ structure. The WANO managing director said “Any CEO must ensure their own facilities are safe but also ensure every other facility is safe. [emphasis added] It's part of their commitment to investors to do everything they can to ensure absolute safety and the one CEO that doesn't believe in this concept will risk the investment of every other.” As WNN succinctly put it, “These company heads are hostages of one another when it comes to nuclear safety.”

I think it's true that nuclear operators are joined at the wallet, but why? In most industries, a problem at one competitor creates opportunities for others. Why is the nuclear industry so tightly coupled and at constant risk of contagion? Is it the mystery and associated fears, suspicion and, in some cases, local visibility that attends nuclear?

Coal mining and oil exploration exist in sharp contrast to nuclear. "Everyone knows" coal mining is dirty and dangerous but bad things only happen, with no wide-ranging effects, to unfortunate folks in remote locations. Oil exploration is somewhat more visible: people will be upset for awhile over the recent blow-out in the Gulf of Mexico, offshore drilling will be put on a temporary hold, but things will eventually settle down. In the meantime, critics will use BP as a punching bag (again) but there will be no negative spillover to, say, Chevron.