The Davis Besse Hole

Most people will read the title of this post and think of the corrosive hole in the Davis Besse reactor vessel head discovered in 2002.  But the post actually refers to the seven year hole in regulatory space into which the plant and its organization fell as a result of the reactor vessel head incident.  Several items in our safety culture news website box cite the NRC announcement this past week that the plant was returning to normal regulatory status. 

Since 2002 Davis Besse has become synonymous with the issue of safety culture in the nuclear industry.  As with many safety and regulatory issues, there are many fundamentally important reasons to comply with the NRC’s criteria and requirements.  But the potential regulatory consequences of not meeting those criteria also merit some consideration.  Two years shutdown, five years of escalated NRC oversight, civil penalties, prosecutions of individuals . . . . Davis Besse was the TMI of nuclear safety culture.

A LearnSafe Afterthought

The line of thinking in the Wahlström and Rollenhagen paper and the LearnSafe project appears to provide a strong nudge away from thinking of safety culture in terms of a set of beliefs and values.  Or of thinking of safety culture as something apart from the how the multiple, complex decision processes within an organization are occurring.

One could also ask, as did Wahlström and Rollenhagen, if the present interpretations of safety culture are rich enough to serve the need for a requisite variety; i.e. does the concept have the same order of complexity as the plant organization that it is supposed to control? [p.8]

One tool for representing the many factors at work in a given environment is an influence diagram.  As Wahlström and Rollenhagen note, “Influence diagrams are often used as the next step in a model building exercise to track dependencies between issues. It is relatively easy for people to identify up-stream causes and down-stream consequences of some specific issue. It is far more difficult to merge these influences to a comprehensive model of some interesting phenomenon, because there are usually very many influences to be traced. Sometimes the influences form loops, which in practice may render the influence diagram more difficult to use for making predictions of how some issue may influence another. When the influences are linear, models are relatively easy to build and validate, but many systems include influences with threshold and saturation effects.” [p. 4, emphasis added]  Multiple variables, loops, and threshold and saturation effects are all important constructs in the system dynamics world view.

Link to paper.

Schrodinger’s Bat

This post follows on the issue of whether safety culture is a concept unto itself or a state that is defined by many constituent actions.  Some of our own thinking about safety culture in developing the nuclearsafetysim website and tools led us to prefer a focus on safety management as opposed to safety culture.  Safety management includes the key “levers” of organizational performance (e.g., resource allocation, problem idenfication and resolution, building of trust, etc.) and the integrated effect of the manipulation of these levers results in a safety culture “value” in the simulation.  Thus all the dynamics flow from actions and decisions to a safety culture resultant, not the reverse.

Dare I put forth a sports analogy?  In baseball there is a defined “strike zone”.   In theory the umpire uses the strike zone to make calls of balls and strikes.  But the zone is really open to interpretation in the dynamic, three dimensional world of pitching and umpiring.  The reality is that the strike zone becomes the space delineated by the aggregate set of balls and strike calls by an umpire.  It relies on the skill of the umpire, his understanding of the strike zone and his commitment to making accurate calls. The linked article provides some interesting data on the strike zone and the psychology of umpires' decisions.

Link to "Schrodinger’s Bat" July 26, 2007.

Is Safety Culture the Grand Unifying Concept?

I thought I would use this question as an entre back into some of Professor Bernhard Wilpert’s work with what became known as the LearnSafe project.  The LearnSafe website is worth visiting for insights into this issue and a number of others.

Two of the principal contributors to LearnSafe, Björn Wahlström and Carl Rollenhagen, published some of their interpretations of the study results in a 2004 paper, link below.  In the paper they state:

“The data collected in the LearnSafe project provides interesting views on some of the major issues connected to the concept of safety culture. A suggestion generated from the data is that attempts to define and measure safety culture may be counterproductive and a more fruitful approach may be to use the concept to stimulate discussions on how safety is constructed. ” [p. 2]

The contribution of the LearnSafe project comes from the empirical data developed in the surveys and discussions with over 300 nuclear managers.  It was found that the term safety culture was not frequently mentioned as a challenge for managing nuclear plants.  Instead, much more frequently mentioned were factors that are commonly understood to be part of safety culture. Wahlström and Rollenhagen observe, “This would suggest the interpretation is that safety culture is not a concept for itself, but it is instead ingrained in various aspects of the management activities.” [p. 6] 

This observation leads to the question of whether it is useful to put forward safety culture as a top level concept that somehow is responsible for or “produces” safety.  Or would it be better to think of it as an organic process that continuously evolves and develops within an organization.  This perspective would say that safety culture is more the product of the myriad of decisions and interactions that occur within an organization rather than some set of intrinsic values that is the determinant of those decisions.

Link to paper.

FAA Moves Away from Blame and Punishment

The Federal Aviation Administration (FAA) took another step toward a new safety culture by reducing the emphasis on blame in the reporting of operational errors by air traffic controllers.  “We’re moving away from a culture of blame and punishment,” said FAA Administrator Randy Babbitt. “It’s important to note that controllers remain accountable for their actions, but we’re moving toward a new era that focuses on why these events occur and what can be done to prevent them.” 
 
Effective immediately, the names of controllers will not be included in reports sent to FAA headquarters on operational errors…. Removing names on the official report will allow investigators to focus on what happened rather than who was at fault.

Link to FAA press release.

The Complacency Thing Again

Commissioner Klein’s recent address to the ANS once again hits on the complacency issue.  Read his remarks at the link below.


Link to speech.

EdF Faces Conflicting Pressures

As described in the linked article, workers at Electricite de France are raising concerns about conflicting pressures to work faster, achieve higher capacity factors and provide competitive electricity.  EdF has long held a very high reputation for its nuclear operations, in part attributed to the national government’s central ownership and operating responsibilities.  While it remains to be seen the extent of such concerns, it is apparent that central ownership does not provide a shield against many of the same pressures experienced by U.S. plants.  The article also highlights the potential complications of heavy reliance on subcontractors if it leads to the loss of core competencies in the host organization.


Link to article.