Assessing Safety Culture Using Cultural Attributes

Two weeks ago we posted on NUREG-2165, a document that formalizes a “common language” for describing nuclear safety culture (SC).  The NUREG contains a set of SC traits, attributes that define each trait and examples that would evidence each attribute.  We expressed concern about how traits and attributes could and would be applied in practice to assess SC.

Well, we didn’t have to wait very long.  This post reviews a recent International Nuclear Safety Journal article* that describes the SC oversight process developed by the Romanian nuclear regulatory agency (CNCAN).  The CNCAN process uses the International Atomic Energy Agency (IAEA) SC definition and attributes and illustrates how attributes can be used to evaluate SC.  Note that CNCAN is not attempting to directly regulate SC but they are taking comprehensive steps to evaluate and influence the licensee’s SC.

CNCAN started with the 37 IAEA attributes and decided that 20 were accessible via the normal review and inspection activities.  Some of the 20 could be assessed using licensee and related documentation, others through interviews with licensee and contractor personnel, and others by direct observation of relevant activities. 

CNCAN recognizes there are limitations to using this process, e.g., findings that reflect a reviewer’s subjective opinion, the quality of match (relevance) between an attribute and a specific technical or functional area, the quality of the information gathered and used, and over-reliance on one specific finding.  Time is also an issue.  “[A] large number of review and inspection activities are required, over a relatively long period of time, to gather sufficient data in order to make a judgement on the safety culture of an organisation as a whole.” (p. 4)

However, they are optimistic about longer-term effectiveness.  “. . . evidence of certain attributes not being met for several functional areas and processes would provide a clear indication of a problem that would warrant increased regulatory surveillance.”  In addition, “[t]he implementation of the [oversight process] proved that all the routine regulatory reviews and inspections reveal aspects that are of certain relevance to safety culture.  Interaction with plant staff during the various inspection activities and meetings, as well as the daily observation by the resident inspectors, provide all the necessary elements for having an overall picture of the safety culture of the licensee.” (ibid., emphasis added)

Our Perspective

We reviewed a draft of the CNCAN SC oversight process on March 23, 2012.  We found the treatment of issues we consider important to be generally good.  For example, in the area of decision making, goal conflict is explicitly addressed, from production vs. safety to differing personal opinions.  Corrective action (CA) gets appropriate attention, including CA prioritization based on safety significance and verification that fixes are implemented and effective.  Backlogs in many areas, including maintenance and corrective actions, are addressed.  In general, the treatment is more thorough than the examples included in the NUREG.

However, the treatment of management incentives is weak.  We favor a detailed evaluation of the senior managers’ compensation scheme focusing on how much of their compensation is tied to achieving safety (vs. production or other) goals.

So, do we feel better about the qualms we expressed over the NUREG, viz., that it is a step on the road to the bureaucratization of SC evaluation, a rigid checklist approach that ultimately creates an incomplete and possibly inaccurate picture of a plant’s SC?  Not really.  Our concerns are described below.

Over-simplification

For starters, CNCAN decided to focus on 20 attributes because they believed it was possible to gather relevant information on them.  What about the other 17?  Are they unrelated to SC simply because it might be hard to access them?

A second simplification is limiting the information search to artifacts: documents, interviews and observations.  One does not have to hold some esoteric belief, e.g., that SC is an emergent organizational property that results from the functioning of a socio-technical system, to see that focusing on the artifacts may be similar to the shadows in Plato’s cave.  Early on, the article refers to this problem by quoting from a 1999 NEA report: “the regulator can evaluate the outward operational manifestations of safety culture as well as the quality of work processes, and not the safety culture itself.” (p. 2)

Limited applicability

Romania has a single nuclear plant and what is, at heart, a one-size-fits-all approach is much more practical when “all” equals one.  This type of approach might even work in, say, France, where there are multiple plants but a single operator.  On the other hand, the U.S. currently has 32 operators reporting to 81 owners.**  Developing SC assessment techniques that are comprehensive, consistent and perceived as fair by such a large group is not a simple task.  The U.S. approach will continue to subsume SC evaluation under the ROP, which arguably ties SC evaluation to “objective” safety-related performance but unfortunately leads to de facto regulation of SC, less transparency and incomprehensible results in specific cases.***

(It could be worse.  For an example, just look at DOE where the recent “guidance” on conducting SC self-assessments led to unreliable self-assessment results that can’t be compared with each other.  For more on DOE, see our March 31, 2014 post or click on the DOE label at the bottom of this post.)

Bottom line

Ultimately the article can be summarized as follows: It’s hard, maybe impossible to directly evaluate SC but here’s what we (CNCAN) are doing and we think it works.  We say a CNCAN-style approach may be helpful but one should remain alert to important SC factors that may be overlooked.


*  M. Tronea, “Trends and Challenges in Regulatory Assessment of Nuclear Safety Culture,” International Nuclear Safety Journal, vol. 3 no. 1 (2014), pp. 1-5.  Retrieved April 14, 2014.  Dr. Tronea works for the Romanian nuclear authority (CNCAN) and is the founder/moderator of the LinkedIn Nuclear Safety group.

**  NEI website, retrieved April 15, 2014.

***  For an example, see our Jan. 30, 2013 post on Palisades. 

GM’s CEO Revealing Revelation

GM CEO Mary Barra

As most of our readers are aware General Motors has been much in the news of late regarding a safety issue associated with the ignition switches in the Chevy Cobalt.  At the beginning of April the new CEO of GM, Mary Barra, testified at Congressional hearings investigating the issue.  A principal focus of the hearings was the extent to which GM executives were aware of the ignition switch issues which were identified some ten years ago but did not result in recalls until this February.  Barra has initiated a comprehensive internal investigation of the issues to determine why it took so many years for a safety defect to be announced.

In a general sense this sounds all too familiar as the standard response to a significant safety issue.  Launch an independent investigation to gather the facts and figure out what happened, who knew what, who decided what and why.  The current estimate is that it will take almost two months for this process to be completed.  Also familiar is that accountability inevitably starts (and often ends) at the engineering and low level management levels.  To wit, GM has already announced that two engineers involved in the ignition switch issues have been suspended.

But somewhat buried in Barra’s Congressional testimony is an unusually revealing comment.  According to the Wall Street Journal, Barra said “senior executives in the past were intentionally not involved in details of recalls so as to not influence them.”*  Intentionally not involved in decisions regarding recalls - recalls which can involve safety defects and product liability issues and have significant public and financial liabilities.  Why would you not want the corporation's executives to be involved?  And if one is to believe the rest of Barra’s testimony, it appears executives were not even aware of these issues.

Well, what if executives were involved in these critical decisions - what influence could they have that GM would be afraid of?  Certainly if executive involvement would assure that technical assessments of potential safety defects were rigorous and conservative - that would not be undue influence.  So that leaves the other possibility - that involvement of executives could inhibit or constrain technical assessments from assuring an appropriate priority for safety.  This would be tantamount to the chilling effect popularized in the nuclear industry.  If management involvement creates an implicit pressure to minimize safety findings, there goes the safety conscious work environment and safety.

If keeping executives out of the decision process is believed to yield “better” decisions, it says some pretty bad things about either their competence or ethics.  Having executives involved should at least ensure that they are aware and knowledgeable of potential product safety issues and in a position to proactively assure that decisions and actions are appropriate.   What might be the most likely explanation is that executives don’t want the responsibility and accountability for these types of decisions.  They might prefer to remain protected at the safety policy level but leave the messy reality of comporting those dictates with real world business considerations to lower levels of the organization.  Inevitably accountability rolls downhill to somebody in the engineering or lower management ranks. 

One thing that is certain.  Whatever the substance and process of GM’s decision, it is not transparent, probably not well documented, and now requires a major forensic effort to reconstitute what happened and why.  This is not unusual and it is the standard course in other industries including nuclear generation.  Wouldn’t we be better off if decisions were routinely subject to the rigor of contemporaneous recording including how complex and uncertain safety issues are decided in the context of other business priorities, and by whom?


*  J.B. White and J. Bennett, "Some at GM Brass Told of Cobalt Woe," Wall Street Journal online (Apr. 11, 2014)

NRC Issues Safety Culture Common Language NUREG

The NRC has issued NUREG-2165* which formalizes the safety culture (SC) common language that has been under development since the NRC SC Policy Statement (SCPS) was issued.  On topics important to us the NUREG repeats word-for-word the text of a document** prepared after a common language workshop held January 29-30, 2013.  Both documents contain a set of SC traits, attributes that define each trait and examples that would evidence each attribute.  Because the language is the same, our opinion on the treatment of our important topics remains the same, as described in detail in our Feb. 28, 2013 post.  Specifically, the treatment of

Decision making, including the treatment of goal conflicts, is Good;

Corrective action, part of problem identification and resolution, is Satisfactory;

Management Incentives is Unsatisfactory because the associated attributes focuses on workers, not managers, and any senior management incentive program is not mentioned; and

Work Backlogs are mentioned in a couple of specific areas so the overall grade is Minimally Acceptable.

But we have one overarching concern that transcends our opinion of common language specifics.

Our Perspective

Our biggest issue with the traits, attributes and examples approach is our fear it will lead to the complete bureaucratization of SC evaluation, either consciously or unconsciously.  The examples in particular can morph into soft requirements on a physical or mental checklist.  Such an approach leads to numerous questions.  How many of the 10 traits does a healthy or positive SC exhibit?***  How many of the 40 attributes?  Are the traits equally important?  How about the attributes?  Could the weighting factors vary across plant sites?  How many examples must be observed before an attribute is judged acceptably present?

We understand the value of effective communications among regulators, licensee personnel and other stakeholders.  But we worry about possible unintended consequences as people attempt to apply the guidance in NUREG-2165, especially in the NRC’s Reactor Oversight Process (ROP).****


*  NRC NUREG-2165, “Safety Culture Common Language” (Mar. 2014).  ADAMS ML14083A200.

**  Nuclear Safety Culture Common Language 4th Public Workshop January 29-31, 2013.  ADAMS ML13031A343.

***  The NUREG-2165 text describes a “healthy” SC while the SCPS (published as NUREG/BR-0500, Rev. 1, ADAMS ML12355A122) refers to a “positive” SC.  The correct answer to “how many traits?” may be “more than ten” because the authors note “There may also be traits not included in the SCPS that are important in a healthy safety culture.” (p. 2)

****  The common language “initiative is within the Commission-directed framework for enhancing the ROP treatment of cross-cutting areas to more fully address safety culture.” (p. 3)  This may require a little linguistic jujitsu since the SCPS says “traits were not developed for inspection purposes.”

Our Gaze Returns to DOE and its Safety Culture

The Department of Energy (DOE) recently submitted a report* to the Defense Nuclear Facilities Safety Board (DNFSB) covering DOE’s evaluation of Safety Conscious Work Environment (SCWE) self-assessments at various DOE facilities.  This evaluation was included in the DOE’s Implementation Plan** (IP) developed in response to the DNFSB report, Safety Culture at the Waste Treatment and Immobilization Plant.*** (WTP, or the Vit Plant).  This post provides some background on how WTP safety culture (SC) problems led to a wider assessment of SC in DOE facilities and then reviews the current report.

Background

The DNFSB report on the WTP was issued June 9, 2011; it said the WTP SC was “flawed.”  Issues included discouraging technical dissent, goal conflicts between schedule/budget and safety, and intimidation of personnel.  We posted on the DNFSB report June 15, 2011.  The report’s recommendations included this one: that the Secretary of Energy “conduct an Extent of Condition Review to determine whether these safety culture weaknesses are limited to the WTP Project, . . .” (DNFSB, p. 6) 

After some back-and-forth between DOE and DNFSB, DOE published their IP in December 2011.  We reviewed the IP on Jan. 24, 2012.  Although the IP contained multiple action items, our overall impression was “that DOE believes there is no fundamental safety culture issue. . . . While endlessly citing all the initiatives previously taken or underway, never does the DOE reflect on why these initiatives have not been effective to date.”  So we were not exactly optimistic but DOE did say it would “conduct an Extent of Condition Review to find out whether similar safety culture weaknesses exist at other sites in addition to the WTP and whether there are barriers to strong safety culture at Headquarters and the Department as a whole (e.g., policies or implementation issues). The review will focus on the Safety Conscious Work Environment (SCWE) at each site examined.” (IP, p. 17)  In other words, SC was reduced to SCWE from the get-go.****

Part of the DOE review was to assess SCWE at a group of selected DOE facilities.  DOE submitted SC assessments covering five facilities to DNFSB on Dec. 12, 2012.  We reviewed the package in our post Jan. 25, 2013 and observed “The DOE submittal contained no meta-analysis of the five assessments, and no comparison to Vit Plant concerns.  As far as [we] can tell, the individual assessments made no attempt to focus on whether or not Vit Plant concerns existed at the reviewed facilities.”  We called the submittal “foot dragging” by DOE.

Report on SCWE Self-Assessments

A related DOE commitment was to perform SCWE self-assessments at numerous DOE facilities and then evaluate the results to determine if SCWE issues similar to WTP’s existed elsewhere.  It is important to understand that this latest report is really only the starting point for evaluating the self-assessments because it focuses on the processes used during the self-assessments and not the results obtained. 

The evaluation of the self-assessments was a large undertaking.  The evaluation team visited 22 DOE and contractor organizations and performed document reviews for 9 additional organizations, including the DOE Office of River Protection and Bechtel National, major players in the WTP drama. 

Problems abounded.  Self-assessment guidance was prepared but not distributed to all sites in a timely manner and there was no associated training.  Each self-assessment team had a “subject matter expert” but the qualifications for that role were not specified.  Data collection methods were not consistently applied and data analyses were of variable quality.  As a consequence, the self-assessment approaches used varied widely and the results obtained had variable reliability.

The self-assessment reports exhibited varying quality.  Some were satisfactory but “In many of the self-assessment reports, the overall conclusions did not accurately reflect the information in the data and analysis sections. In some cases, negative results were presented with a statement rationalizing or minimizing the issue, rather than indicating a need to find out more about the issue and resolve it.  In other cases, although data and/or analysis reflected potential problems, those problems were not mentioned in the conclusions or executive summaries, which senior management is most likely to read.” (p. 7)

The evaluation team summarized as follows: “The overall approach ultimately used to self-assess SCWE across the complex did not provide for consistent application of assessment methodologies and was not designed to ensure validity and credibility. . . . The wide variation in the quality of methodologies and analysis of results significantly reduces the confidence in the conclusions of many of the self-assessments.  Consequently, caution should be used in drawing firm conclusions about the state of SCWE or safety culture across the entire DOE complex based on a compilation of results from all the site self-assessments.” (p. iii)

“The Independent Oversight team concluded that DOE needs to take additional actions to ensure that future self-assessments provide a valid and accurate assessment of the status of the safety culture at DOE sites and organizations, . . .” (p. 8)  This is followed by a series of totally predictable recommendations for process improvements: “enhance guidance and communications,” increase management “involvement in, support for, and monitoring of site self-assessments,” and “DOE sites . . . should increase their capabilities to perform self-assessments . . .” (pp. 9-10)

Our Perspective

The steps taken to date do not inspire confidence in the DOE’s interest in determining if and what SCWE (much less more general SC) issues exist in the DOE complex.  For the facilities that were directly evaluated, we have some clues to the existence similar problems.  For the facilities that conducted self-assessments, so far we have—almost nothing.

There is one big step remaining: DOE also said it would “develop a consolidated report from the results of the self-assessments and HSS independent reviews.” (IP, p. 20)  We await that report with bated breath.

For our U.S. readers: This is your tax dollars at work. 


*  DOE Office of Enforcement and Oversight, “Independent Oversight Evaluation of Line Self-Assessments of Safety Conscious Work Environment” (Feb. 2014).

**  U.S. Dept. of Energy, “Implementation Plan for Defense Nuclear Facilities Safety Board Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant”  (Dec. 2011).

***  Defense Nuclear Facilities Safety Board, Recommendation 2011-1 to the Secretary of Energy "Safety Culture at the Waste Treatment and Immobilization Plant" (Jun 9, 2011).

****  DOE rationalized reducing the scope of investigation from SC to SCWE by saying “The safety culture issues identified at WTP are primarily SCWE issues. . .” (p. 17)  We posted a lecturette about SC being much more than SCWE here.

NRC "National Report" to IAEA

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

6.3.11 Public Participation 

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

8.1.6.2 Human Resources

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

10.4 Safety Culture

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

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

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

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

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

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

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

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

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

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

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

10.4.2 The NRC Safety Culture 

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

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

Institute of Nuclear Power Operations (INPO) 

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

6. Priority to Safety (Safety Culture)

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

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

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

Conclusion

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

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

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

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


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

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

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

Safety Culture at Tohoku Electric vs. Tokyo Electric Power Co. (TEPCO)

Fukushima No. 1 (Daiichi)

An op-ed* in the Japan Times asserts that the root cause of the Fukushima No. 1 (Daiichi) plant’s failures following the March 11, 2011 earthquake and tsunami was TEPCO’s weak corporate safety culture (SC).  This post summarizes the op-ed then provides some background information and our perspective.

Op-Ed Summary 

According to the authors, Tohoku Electric had a stronger SC than TEPCO.  Tohoku had a senior manager who strongly advocated safety, company personnel participated in seminars and panel discussions about earthquake and tsunami disaster prevention, and the company had strict disaster response protocols in which all workers were trained.  Although their Onagawa plant was closer to the March 11, 2011 quake epicenter and experienced a higher tsunami, it managed to shut down safely.

SC-related initiatives like Tohoku’s were not part of TEPCO’s culture.  Fukushima No. 1’s problems date back to its original siting and early construction.  TEPCO removed 25 meters off the 35 meter natural seawall of the plant site and built its reactor buildings at a lower elevation of 10 meters (compared to 14.7m for Onagawa).  Over the plant’s life, as research showed that tsunami levels had been underestimated, TEPCO “resorted to delaying tactics, such as presenting alternative scientific studies and lobbying”** rather than implementing countermeasures.

Background and Our Perspective

The op-ed is a condensed version of the authors’ longer paper***, which was adapted from a research paper for an engineering class, presumably written by Ms. Ryu.  The op-ed is basically a student paper based on public materials.  You should read the longer paper, review the references and judge for yourself if the authors have offered conclusions that go beyond the data they present.

I suggest you pay particular attention to the figure that supposedly compares Tohoku and TEPCO using INPO’s ten healthy nuclear SC traits.  Not surprisingly, TEPCO doesn’t fare very well but note the ratings were based on “the author’s personal interpretations and assumptions” (p. 26)

Also note that the authors do not mention Fukushima No. 2 (Daini), a four-unit TEPCO plant about 15 km south of Fukushima No. 1.  Fukushima No. 2 also experienced damage and significant challenges after being hit by a 9m tsunami but managed to reach shutdown by March 18, 2011.  What could be inferred from that experience?  Same corporate culture but better luck?

Bottom line, by now it’s generally agreed that TEPCO SC was unacceptably weak so the authors plow no new ground in that area.  However, their description of Tohoku Electric’s behavior is illuminating and useful.


*  A. Ryu and N. Meshkati, “Culture of safety can make or break nuclear power plants,” Japan Times (Mar. 14, 2014).  Retrieved Mar. 19, 2014.

**  Quoted in the op-ed but taken from “The official report of the Fukushima Nuclear Accident Independent Investigation Commission [NAIIC] Executive Summary” (The National Diet of Japan, 2012), p. 28.  The NAIIC report has a longer Fukushima root cause explanation than the op-ed, viz, “the root causes were the organizational and regulatory systems that supported faulty rationales for decisions and actions, . . .” (p. 16) and “The underlying issue is the social structure that results in “regulatory capture,” and the organizational, institutional, and legal framework that allows individuals to justify their own actions, hide them when inconvenient, and leave no records in order to avoid responsibility.” (p. 21)  IMHO, if this were boiled down, there wouldn’t be much SC left in the bottom of the pot.

***  A. Ryu and N. Meshkati, “Why You Haven’t Heard About Onagawa Nuclear Power Station after the Earthquake and Tsunami of March 11, 2011” (Rev. Feb. 26, 2014).

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)

Eliminate the Bad Before Attempting the Good

An article* in the McKinsey Quarterly suggests executives work at rooting out destructive behaviors before attempting to institute best practices.  The reason is simple: “research has found that negative interactions with bosses and coworkers [emphasis added] have five times more impact than positive ones.” (p. 81)  In other words, a relatively small amount of bad behavior can keep good behavior, i.e., improvements, from taking root.**  The authors describe methods for removing bad behavior and warning signs that such behavior exists.  This post focuses on their observations that might be useful for nuclear managers and their organizations.

Methods

Nip Bad Behavior in the Bud — Bosses and coworkers should establish zero tolerance for bad behavior but feedback or criticism should be delivered while treating the target employee with respect.  This is not about creating a climate of fear, it’s about seeing and responding to a “broken window” before others are also broken.  We spoke a bit about the broken window theory here.

Put Mundane Improvements Before Inspirational Ones/Seek Adequacy Before Excellence — Start off with one or more meaningful objectives that the organization can achieve in the short term without transforming itself.  Recognize and reward positive behavior, then build on successes to introduce new values and strategies.  Because people are more than twice as likely to complain about bad customer service as to mention good customer service, management intervention should initially aim at getting the service level high enough to staunch complaints, then work on delighting customers.

Use Well-Respected Staff to Squelch Bad Behavior — Identify the real (as opposed to nominal or official) group leaders and opinion shapers, teach them what bad looks like and recruit them to model good behavior.  Sounds like co-opting (a legitimate management tool) to me.

Warning Signs

Fear of Responsibility — This can be exhibited by employees doing nothing rather than doing the right thing, or their ubiquitous silence.  It is related to bystander behavior, which we posted on here.

Feelings of Injustice or Helplessness — Employees who believe they are getting a raw deal from their boss or employer may act out, in a bad way.  Employees who believe they cannot change anything may shirk responsibility.

Feelings of Anonymity — This basically means employees will do what they want because no one is watching.  This could lead to big problems in nuclear plants because they depend heavily on self-management and self-reporting of problems at all organizational levels.  Most of the time things work well but incidents, e.g., falsification of inspection reports or test results, do occur.

Our Perspective

The McKinsey Quarterly is a forum for McKinsey people and academics whose work has some practical application.  This article is not rocket science but sometimes a simple approach can help us appreciate basic lessons.  The key takeaway is that an overconfident new manager can sometimes reach too far, and end up accomplishing very little.  The thoughtful manager might spend some time figuring out what’s wrong (the “bad” behavior) and develop a strategy for eliminating it and not simply pave over it with a “get better” program that ignores underlying, systemic issues.  Better to hit a few singles and get the bad juju out of the locker room before swinging for the fences.


*  H. Rao and R.I. Sutton, “Bad to great: The path to scaling up excellence,” McKinsey Quarterly, no. 1 (Feb. 2014), pp. 81-91.  Retrieved Mar. 13, 2014.

**  Even Machiavelli recognized the disproportionate impact of negative interactions.  “For injuries should be done all together so that being less tasted they will give less offence.  Benefits should be granted little by little so that they may be better enjoyed.”  The Prince, ch. VIII.

Declining Safety Culture at the Waste Isolation Pilot Plant?

DOE WIPP

Here’s another nuclear-related facility you may or may not know about: The Department of Energy’s (DOE) Waste Isolation Pilot Plant (WIPP) located near Carlsbad, NM.  WIPP’s mission is to safely dispose of defense-related transuranic radioactive waste.  “Transuranic” refers to man-made elements that are heavier than uranium; in DOE’s waste the most prominent of these elements is plutonium but waste also includes others, e.g., americium.*

Recently there have been two incidents at WIPP.  On Feb. 5, 2014 a truck hauling salt underground caught fire.  There was no radiation exposure associated with this incident.  But on Feb. 14, 2014 a radiation alert activated in the area where newly arrived waste was being stored.  Preliminary tests showed thirteen workers suffered some radiation exposure.

It will come as no surprise to folks associated with nuclear power plants that WIPP opponents have amped up after these incidents.  For our purposes, the most interesting quote comes from Don Hancock of the Southwest Research and Information Center: “I’d say the push for expansion is part of the declining safety culture that has resulted in the fire and the radiation release.”  Not surprisingly, WIPP management disputes that view.**

Our Perspective

So, are these incidents an early signal of a nascent safety culture (SC) problem?  After all, SC issues are hardly unknown at DOE facilities.  Or is the SC claim simply the musing of an opportunistic anti?  Who knows.  At this point, there is insufficient information available to say anything about WIPP’s SC.  However, we’ll keep an eye on this situation.  A bellwether event would be if the Defense Nuclear Facilities Safety Board decides to get involved.


*  See the WIPP and Environmental Protection Agency (EPA) websites for project information.  If the WIPP site is judged suitable, the underground storage area is expected to expand to 100 acres.

The EPA and the New Mexico Environmental Department have regulatory authority over WIPP.  The NRC has regulatory authority over the containers used to ship waste.  See National Research Council, “Improving the Characterization Program for Contact-Handled Transuranic Waste Bound for the Waste Isolation Pilot Plant” (Washington, DC: The National Academies Press, 2004), p. 27.

**  J. Clausing, “Nuclear dump leak raises questions about cleanup,” Las Vegas Review-Journal (Mar. 1, 2014).  Retrieved Mar. 3, 2014.

Left Brain, Right Stuff: How Leaders Make Winning Decisions by Phil Rosenzweig

In this new book* Rosenzweig extends the work of Kahneman and other scholars to consider real-world decisions.  He examines how the content and context of such decisions is significantly different from controlled experiments in a decision lab.  Note that Rosenzweig’s advice is generally aimed at senior executives, who typically have greater latitude in making decisions and greater responsibility for achieving results than lower-level professionals, but all managers can benefit from his insights.  This review summarizes the book and explores its lessons for nuclear operations and safety culture. 

Real-World Decisions

Decision situations in the real world can be more “complex, consequential and laden with uncertainty” than those described in laboratory experiments. (p. 6)  A combination of rigorous analysis (left brain) and ambition (the right stuff—high confidence and a willingness to take significant risks) is necessary to achieve success. (pp. 16-18)  The executive needs to identify the important characteristics of the decision he is facing.  Specifically,

Can the outcome following the decision be influenced or controlled?

Some real-world decisions cannot be controlled, e.g., the price of Apple stock after you buy 100 shares.  In those situations the traditional advice to decision makers, viz., be rational, detached, analyze the evidence and watch out for biases, is appropriate. (p. 32)

But for many decisions, the executive (or his team) can influence outcomes through high (but not excessive) confidence, positive illusions, calculated risks and direct action.  The knowledgeable executive understands that individuals perceived as good executives exhibit a bias for action and “The essence of management is to exercise control and influence events.” (p. 39)  Therefore, “As a rule of thumb, it's better to err on the side of thinking we can get things done rather than assuming we cannot.  The upside is greater and the downside less.” (p. 43)

Think about your senior managers.  Do they under or over-estimate their ability to influence future performance through their decisions?

Is the performance based on the decision(s) absolute or relative?

Absolute performance is described using some system of measurement, e.g., how many free throws you make in ten attempts or your batting average over a season.  It is not related to what anyone else does. 

But in competition performance is relative to rivals.  Ten percent growth may not be sufficient if a rival grows fifty percent.**  In addition, payoffs for performance may be highly skewed: in the Olympics, there are three medals and the others get nothing; in many industries, the top two or three companies make money, the others struggle to survive; in the most extreme case, it's winner take all and the everyone else gets nothing.  It is essential to take risks to succeed in highly skewed competitive situations.

Absolute and relative performance may be connected.  In some cases, “a small improvement in absolute performance can make an outsize difference in relative performance, . . .” (p. 66)  For example, if a well-performing nuclear plant can pick up a couple percentage points of annual capacity factor (CF), it can make a visible move up the CF rankings thus securing bragging rights (and possibly bonuses) for its senior managers.

For a larger example, remember when the electricity markets deregulated and many utilities rushed to buy or build merchant plants?  Note how many have crawled back under the blanket of regulation where they only have to demonstrate prudence (a type of absolute performance) to collect their guaranteed returns, and not compete with other sellers.  In addition, there is very little skew in the regulated performance curve; even mediocre plants earn enough to carry on their business.  Lack of direct competition also encourages sharing information, e.g., operating experience in the nuclear industry.  If competition is intense, sharing information is irresponsible and possibly dangerous to one's competitive position. (p. 61)

Do your senior managers compare their performance to some absolute scale, to other members of your fleet (if you're in one), to similar plants, to all plants, or the company's management compensation plan?

Will the decision result in rapid feedback and be repeated or is it a one-off or will it take a long time to see results? 

Repetitive decisions, e.g., putting at golf, can benefit from deliberate practice, where performance feedback is used to adjust future decisions (action, feedback, adjustment, action).  This is related to the extensive training in the nuclear industry and the familiar do, check and adjust cycle ingrained in all nuclear workers.

However, most strategic decisions are unique or have consequences that will only manifest in the long-term.  In such cases, one has to make the most sound decision possible then take the best shot. 

Executives Make Decisions in a Social Setting

Senior managers depend on others to implement decisions and achieve results.  Leadership (exaggerated confidence, emphasizing certain data and beliefs over others, consistency, fairness and trust is indispensable to inspire subordinates and shape culture.  Quoting Jack Welch, “As a leader, your job is to steer and inspire.” (p. 146)  “Effective leadership . . . means being sincere to a higher purpose and may call for something less than complete transparency.” (p. 158)

How about your senior managers?  Do they tell the whole truth when they are trying to motivate the organization to achieve performance goals?  If not, how does that impact trust over the long term?  
    
The Role of Confidence and Overconfidence

There is a good discussion of the overuse of the term “overconfidence,” which has multiple meanings but whose meaning in a specific application is often undefined.  For example, overconfidence can refer to being too certain that our judgment is correct, believing we can perform better than warranted by the facts (absolute performance) or believing we can outperform others (relative performance). 

Rosenzweig conducted some internet research on overconfidence.  The most common use in the business press was to explain, after the fact, why something had gone wrong. (p. 85)  “When we charge people with overconfidence, we suggest that they contributed to their own demise.” (p. 87)  This sounds similar to the search for the “bad apple” after an incident occurs at a nuclear plant.

But confidence is required to achieve high performance.  “What's the best level of confidence?  An amount that inspires us to do our best, but not so much that we become complacent, or take success for granted, or otherwise neglect what it takes to achieve high performance.” (p. 95)

Other Useful Nuggets

There is a good extension of the discussion (introduced in Kahneman) of base rates and conditional probabilities including the full calculations from two of the conditional probability examples in Kahneman's Thinking, Fast and Slow (reviewed here).

The discussion on decision models notes that such models can be useful for overcoming common biases, analyzing large amounts of data and predicting elements of the future beyond our influence.  However, if we have direct influence, “Our task isn't to predict what will happen, but to make it happen.” (p. 189)

Other chapters cover decision making in a major corporate acquisition (focusing on bidding strategy) and in start-up businesses (focusing on a series of start-up decisions)

Our Perspective

Rosenzweig acknowledges that he is standing on the shoulders of Kahneman and others students of decision making.  But “An awareness of common errors and cognitive biases is only a start.” (p. 248)  The executive must consider the additional decision dimensions discussed above to properly frame his decision; in other words, he has to decide what he's deciding.

The direct applicability to nuclear safety culture may seem slight but we believe executives' values and beliefs, as expressed in the decisions they make over time, provide a powerful force on the shape and evolution of culture.  In other words, we choose to emphasize the transactional nature of leadership.  In contrast, Rosenzweig emphasizes its transformational nature: “At its core, however, leadership is not a series of discrete decisions, but calls for working through other people over long stretches of time.” (p. 164)  Effective leaders are good at both.

Of course, decision making and influence on culture is not the exclusive province of senior managers.  Think about your organization's middle managers—the department heads, program and project managers, and process owners.  How do they gauge their performance?  How open are they to new ideas and approaches?  How much confidence do they exhibit with respect to their own capabilities and the capabilities of those they influence? 

Bottom line, this is a useful book.  It's very readable, with many clear and engaging examples,  and has the scent of academic rigor and insight; I would not be surprised if it achieves commercial success.


*  P. Rosenzweig, Left Brain, Right Stuff: How Leaders Make Winning Decisions (New York: Public Affairs, 2014).

**  Referring to Lewis Carroll's Through the Looking Glass, this situation is sometimes called “Red Queen competition [which] means that a company can run faster but fall further behind at the same time.” (p. 57)

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).

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.

Thinking, Fast and Slow by Daniel Kahneman

Kahneman is a Nobel Prize winner in economics.  His focus is on personal decision making, especially the biases and heuristics used by the unconscious mind as it forms intuitive opinions.  Biases lead to regular (systematic) errors in decision making.  Kahneman and Amos Tversky developed prospect theory, a model of choice, that helps explain why real people make decisions that are different from those of the rational man of economics.

Kahneman is a psychologist so his work focuses on the individual; many of his observations are not immediately linkable to safety culture (a group characteristic).  But even in a nominal group setting, individuals are often very important.  Think about the lawyers, inspectors, consultants and corporate types who show up after a plant incident.  What kind of biases do they bring to the table when they are evaluating your organization's performance leading up to the incident?

The book* has five parts, described below.  Kahneman reports on his own research and then adds the work of many other scholars.  Many of the experiments appear quite simple but provide insights into unconscious and conscious decision making.  There is a lot of content so this is a high level summary, punctuated by explicative or simply humorous quotes.

Part 1 describes two methods we use to make decisions: System 1 and System 2.  System 1 is impulsive, intuitive, fast and often unconscious; System 2 is more analytic, cautious, slow and controlled. (p. 48)  We often defer to System 1 because of its ease of use; we simply don't have the time, energy or desire to pore over every decision facing us.  Lack of desire is another term for lazy.

System 1 often operates below consciousness, utilizing associative memory to link a current stimulus to ideas or concepts stored in memory. (p. 51)  System 1's impressions become beliefs when accepted by System 2 and a mental model of the world takes shape.  System 1 forms impressions of familiarity and rapid, precise intuitions then passes them on to System 2 to accept/reject. (pp. 58-62)

System 2 activities take effort and require attention, which is a finite resource.  If we exceed the attention budget or become distracted then System 2 will fail to obtain correct answers.  System 2 is also responsible for self-control of thoughts and behaviors, another drain on mental resources. (pp. 41-42)

Biases include a readiness to infer causality, even where none exists; a willingness to believe and confirm in the absence of solid evidence; succumbing to the halo effect where we project a coherent whole based on an initial impression; and problems caused by WYSIATI** including basing conclusions on limited evidence, overconfidence, framing effects where decisions differ depending on how information and questions are presented and base-rate neglect where we ignore widely-known data about a decision situation. (pp. 76-88)

Heuristics include substituting easier questions for the more difficult ones that have been asked, letting current mood affect answers on general happiness and allowing emotions to trump facts. (pp. 97-103) 

Part 2 explores decision heuristics in greater detail, with research and examples of how we think associatively, metaphorically and causally.  A major topic throughout this section is the errors people tend to make when handling questions that have a statistical dimension.  Such errors occur because statistics requires us to think of many things at once, which System 1 is not designed to do, and a lazy or busy System 2, which could handle this analysis, is prone to accept System 1's proposed answer.  Other errors occur because:

We make incorrect inferences from small samples and are prone to ascribe causality to chance events.  “We are far too willing the reject the belief that much of what we in life is random.” (p. 117)  We are prone to attach “a causal interpretation to the inevitable fluctuations of a random process.” (p. 176)  “There is more luck in the outcomes of small samples.” (p. 194)

We fall for the anchoring effect, where we see a particular value for an unknown quantity (e.g., the asking price for a used car) before we develop our own value.  Even random anchors, which provide no relevant information, can influence decision making.

People search for relevant information when asked questions.  Information availability and ease of retrieval is a System 1 heuristic but only System 2 can judge the quality and relevance of retrieved content.  People are more strongly affected by ease of retrieval and go with their intuition when they are, for example, mentally busy or in a good mood. (p. 135)  However, “intuitive predictions tend to be overconfident and overly extreme.” (p. 192)

Unless we know the subject matter well, and have some statistical training, we have difficulty dealing with situations that require statistical reasoning.  One research finding “illustrates a basic limitation in the ability of our mind to deal with small risks: we either ignore them altogether or give them far too much weight—nothing in between.” (p. 143)  “There is one thing you can do when you have doubts about the quality of the evidence: let your judgments of probability stay close to the base rate.” (p. 153)  “. . . whenever the correlation between two scores is imperfect, there will be regression to the mean. . . . [a process that] has an explanation but does not have a cause.” (pp. 181-82)

Finally, and the PC folks may not appreciate this, but “neglecting valid stereotypes inevitably results in suboptimal judgments.” (p. 169)

Part 3 focuses on specific shortcomings of our thought processes: overconfidence, fed by the illusory certainty of hindsight, in what we think we know, and underappreciation of the role of chance in events.

“Subjective confidence in a judgment is not a reasoned evaluation of the probability that this judgment is correct.  Confidence is a feeling.” (p. 212)  Hindsight bias “leads observers to assess the quality of a decision not by whether the process was sound but by whether its outcome was good or bad. . . . a clear outcome bias.” (p. 203)  “. . . the optimistic bias may well be the most significant of the cognitive biases.” (p. 255)  “The optimistic style involves taking credit for success but little blame for failure.” (p. 263)

“The sense-making machinery of System 1 makes us see the world as more tidy, predictable, and coherent than it really is.” (p. 204)  “. . . reality emerges from the interactions of many different agents and force, including blind luck, often producing large and unpredictable results.” (p. 220)  “An unbiased appreciation of uncertainty is a cornerstone of rationality—but it is not what people and organizations want. . . . Acting on pretended knowledge is often the preferred solution.” (p. 263)

And the best quote in the book: “Professional controversies bring out the worst in academics.” (p. 234)

Part 4 contrasts the rational people of economics with the more complex people of psychology, in other words, the Econs vs. the Humans.  Kahneman shows how prospect theory opened a door between the two disciplines and contributed to the start of the field of behavioral economics.

Economists adopted expected utility theory to prescribe how decisions should be made and describe how Econs make choices.  In contrast, prospect theory has three cognitive features: evaluation of choices is relative to a reference point, outcomes above that point are gains, below that point are losses; diminishing sensitivity to changes; and loss aversion, where losses loom larger than gains. (p. 282)  In practice, loss aversion leads to risk-averse choices when both gains and losses are possible, and diminishing sensitivity leads to risk taking when sure losses are compared to a possible larger loss.  “Decision makers tend to prefer the sure thing over the gamble (they are risk averse) when the outcomes are good.  They tend to reject the sure thing and accept the gamble (they are risk seeking) when both outcomes are negative.” (p. 368)

“The fundamental ideas of prospect theory are that reference points exist, and that losses loom larger than corresponding gains.” (p. 297)  “A reference point is sometimes the status quo, but it can also be a goal in the future; not achieving the goal is a loss, exceeding the goal is a gain.” (p. 303)  Loss aversion is a powerful conservative force.” (p. 305)

When people do consider vary rare events, e.g., a nuclear accident, they will almost certainly overweight the probability in their decision making.  “ . . . people are almost completely insensitive to variations of risk among small probabilities.” (p. 316)  “. . . low-probability events are much more heavily weighted when described in terms of relative frequencies (how many) than when stated is more abstract terms of . . . “probability” (how likely).” (p. 329)  Framing of questions evoke emotions, e.g., “losses evokes stronger negative feelings than costs.” (p. 364)  But “[r]eframing is effortful and System 2 is normally lazy.” (p. 367)  As an exercise, think about how anti-nuclear activists and NEI would frame the same question about the probability and consequences of a major nuclear accident. 

There are some things an organization can do to improve its decision making.  It can use local centers of over optimism (Sales dept.) and loss aversion (Finance dept.) to offset each other.  In addition, an organization's decision making practices can require the use an outside view (i.e., a look at the probabilities of similar events in the larger world) and a formal risk policy to mitigate against known decision biases. (p. 340)

Part 5 covers two different selves that exist in every human, the experiencing self and the remembering self.  The former lives through an experience and the latter creates a memory of it (for possible later recovery) using specific heuristics.  Our tendency to remember events as a sample or summary of actual experience is a factor that biases current and future decisions.  We end up favoring (fearing) a short period of intense joy (pain) over a long period of moderate happiness (pain). (p. 409) 

Our memory has evolved to represent past events in terms of peak pain/pleasure during the events and our feelings when the event is over.  Event duration does not impact our ultimate memory of an event.  For example, we choose future vacations based on our final evaluations of past vacations even if many of our experiences during the past vacations were poor. (p. 389)

In a possibly more significant area, the life satisfaction score you assign to yourself is based on a small sample of highly available ideas or memories. (p. 400)  Ponder that the next time you take or review responses from a safety culture survey.

Our Perspective

This is an important book.  Although not explicitly stated, the great explanatory themes of cause (mechanical), choice (intentional) and chance (statistical) run through it.  It is filled with nuggets that apply to the individual (psychological) and also the aggregate if the group shares similar beliefs.  Many System 1 characteristics, if unchecked and shared by a group, have cultural implications.*** 

We have discussed Kahneman's work before on this blog, e.g., his view that an organization is a factory for producing decisions and his suggestion to use a “premortem” as a partial antidote for overconfidence.  (A premortem is an exercise the group undertakes before committing to an important decision: Imagine being a year into the future, the decision's outcome is a disaster.  What happened?)  For more on these points, see our Nov. 4, 2011 post.

We have also discussed some of the topics he raises, e.g., the hindsight bias.  Hindsight is 20/20 and it supposedly shows what decision makers could (and should) have known and done instead of their actual decisions that led to an unfavorable outcome, incident, accident or worse.  We now know that when the past was the present, things may not have been so clear-cut.

Kahneman's observation that the ability to control attention predicts on-the-job performance (p. 37) is certainly consistent with our reports on the characteristics of high reliability organizations (HROs). 

“The premise of this book is that it is easier to recognize other people's mistakes than our own.” (p. 28)  Having observers at important, stressful decision making meetings is useful; they are less cognitively involved than the main actors and more likely to see any problems in the answers being proposed.

Critics' major knock on Kahneman's research is that it doesn't reflect real world conditions.  His model is “overly concerned with failures and driven by artificial experiments than by the study of real people doing things that matter.” (p. 235)  He takes this on by collaborating with a critic in an investigation of intuitive decision making, specifically seeking to answer: “When can you trust a self-confident professional who claims to have an intuition?” (p. 239)  The answer is when the expert acquired skill in a predictable environment, and had sufficient practice with immediate, high-quality feedback.  For example, anesthesiologists are in a good position to develop predictive expertise; on the other hand, psychotherapists are not, primarily because a lot of time and external events can pass between their prognosis for a patient and ultimate results.  However, “System 1 takes over in emergencies . . .” (p. 35)  Because people tend to do what they've been trained to do in emergencies, training leading to (correct) responses is vital.

Another problem is that most of Kahneman's research uses university students, both undergraduate and graduate, as subjects.  It's fair to say professionals have more training and life experience, and have probably made some hasty decisions they later regretted and (maybe) learned from.  On the other hand, we often see people who make sub-optimal, or just plain bad decisions even though they should know better.

There are lessons here for managers and other would-be culture shapers.  System 1's search for answers is mostly constrained to information consistent with existing beliefs (p. 103) which is an entry point for  culture.  We have seen how group members can have their internal biases influenced by the dominant culture.  But to the extent System 1 dominates employees' decision making, decision quality may suffer.

Not all appeals can be made to the rational man in System 2 even though a customary, if tacit, assumption of managers is they and their employees are rational and always operating consciously, thus new experiences will lead to expected new values and beliefs, new decisions and improved safety culture.  But it may not be this straightforward.  System 1 may intervene and managers should be alert to evidence of System 1 type thinking and adjust their interventions accordingly.  Kahneman suggests encouraging “a culture in which people look out for one another as they approach minefields.” (p. 418) 

We should note Systems 1 and 2 are constructs and “do not really exist in the brain or anywhere else.” (p. 415)  System 1 is not Dr. Morbius' Id monster.****  System 1 can be trained to behave differently, but it is always ready to provide convenient answers for a lazy System 2.

The book is long, with small print, but the chapters are short so it's easy to invest 15-20 min. at a time.  One has to be on constant alert for useful nuggets that can pop up anywhere—which I guess promotes reader mindfulness.  It is better than Blink, which simply overwhelmed this reader with a cloudburst of data showing the informational value of thin slices and unintentionally over-promoted the value of intuition. (see pp. 235-36)  And it is much deeper than The Power of Habit, which we reviewed last February.

(Common sense is nothing more than a deposit of prejudices laid down by the mind before you reach eighteen.  Attributed to Albert Einstein)

*  D. Kahneman, Thinking, Fast and Slow (New York: Farrar, Straus and Giroux, 2011).

**  WYSIATI – What You See Is All There Is.  Information that is not retrieved from memory, or otherwise ignored, may as well not exist. (pp. 85-88)  WYSIATI means we base decisions on the limited information that we are able or willing to retrieve before a decision is due.  

***  A few of these characteristics are mentioned in this report, e.g., impressions morphing into beliefs, a bias to believe and confirm, and WYSIATI errors.  Others include links of cognitive ease to illusions of truth and reduced vigilance (complacency), and narrow framing where decision problems are isolated from one another. (p. 105)

****  Dr. Edward Morbius is a character in the 1956 sci-fi movie Forbidden Planet.