NRC Safety Culture Initiatives

The link below is to a September 29, 2009 speech by Chairman Jaczko of the Nuclear Regulatory Commission, outlining the NRC’s current initiative regarding safety culture and safety conscious work environment.  There is no big news in the speech, mostly it is notable for the continuing focus on safety culture issues at the highest level of the agency.

Perhaps of some significance is that almost all of Jaczko’s comments regard initiatives by the NRC on safety culture.  Not surprising in one sense in that it would be a logical focus for the NRC Chairman.  However I thought that the absence of industry-wide actions, perhaps covering all plants, could be perceived as a weakness.  Jaczko mentions that “We have seen an increasing number of licensees conducting periodic safety culture self-assessments…”, but that may only tend to highlight that each nuclear plant is going its own way.  True?  If so, will that encourage the NRC to define additional regulatory policies to bring greater uniformity?

Link to speech.

Social Licking?

The linked file contains a book review with some interesting social science that could be of great relevance to building and sustaining safety cultures.  But I couldn’t resist the best quote of the review, commenting about some of the unusual findings in recent studies of social networks.  To wit,

“In fact, the model that best predicted the network structure of U.S. senators was that of social licking among cows.”

Back on topic, the book is Connected by Nicholas Christakis and James Fowler, addressing the surprising power of social networks and how they shape our lives.  The authors may be best known for a study published several years ago about how obesity could be contagious.  It is based on observations of networked relationships – friends and friends of friends – that can lead to individuals modeling their behaviors based on those to whom they are connected.

“What is the mechanism whereby your friend’s friend’s obesity is likely to make you fatter? Partly, it’s a kind of peer pressure, or norming, effect, in which certain behaviors, or the social acceptance of certain behaviors,
get transmitted across a network of acquaintances.”  Sounds an awful lot like how we think of safety culture being spread across an organization.  For those of you who have been reading this blog, you may recall that we are fans of Diane Vaughan’s book The Challenger Launch Decision, where a mechanism she identifies as “normalization of deviance” is used to explain the gradual acceptance of performance results that are outside normal acceptance criteria.  An organization's standards decay and no one even notices.

The book review goes on to note, “Mathematical models of flocks of birds, or colonies of ants, or schools of fish reveal that while there is no central controlling director telling the birds to fly one direction or another, a collective intelligence somehow emerges, so that all the birds fly in the same direction at the same time.  Christakis and Fowler argue that through network science we are discovering the same principle at work in humans — as individuals, we are part of a superorganism, a hivelike network that shapes our decisions.”  I guess the key is to ensure that the hive takes the workers in the right direction.

Question:  Does the above observation that “there is no central controlling director” telling the right direction have implications for nuclear safety management?  Is leadership the key or development of a collective intelligence?
 
Link to review.
 

“Culture isn’t just one aspect of the game. It is the game.”

The quote is from Lou Gerstner, retired Chairman of IBM, and appears in an interesting presentation by the management team at Wolf Creek Nuclear Operating Company.  In it they put forth their perspectives on addressing culture change within their organization.  There are many good points in the presentation and several I would like to specifically highlight.

First, the issue of trust is addressed on several slides.  For example, on the Engaged Employees slide (p. 24) it is noted that training in building trust had been initiated and would be ongoing.  A later slide, Effective Leadership Team (p. 31), notes that there was increased trust at the station.  In our thinking about safety management, and specifically in our simulation modeling, we include trust as a key variable and driver of safety culture.  Trust is a subjective ingredient but its importance is real.  We think there are at least two mechanisms for building trust within an organization.  One is through the type of initiatives described in the slides – direct attention and training in creating trust within the management team and staff.  A second mechanism that perhaps does not receive as much recognition is the indirect impact of decisions and actions taken by the organization and the extent to which they model desired safety values.  This second mechanism is very powerful as it reflects reality.  If reality comports with the espoused values, it reinforces the values and builds trust.  If reality is contra to the values, it will undermine any amount of training or pronouncements about trust.

The second point to be highlighted is addressed on the Culture slide in the Epilogue section (p.35).  There it is noted that as an industry we are good at defining the desired behaviors, but we are not good at defining how to achieve a culture where most people practice those behaviors.  We think there is a lot of truth in this and the “how” aspect of building and maintaining a robust safety culture is something that merits more attention.  “Practicing” those behaviors is the subject of our white paper, “Practicing Nuclear Safety Management.”

Link to presentation.

Air France

A recent Wall Street Journal article indicates that Air France is taking an unusual step in asking its partner airline, Delta, to help assess its safety practices.  The Air France CEO stated, “Safety is a dynamic thing, the risk is to say, ‘We’ve done our work, so let’s stop.’”  This action emanates from the June crash of an Air France flight en route from Brazil to Paris.

On the one hand it is unbelievably sad to see that an accident becomes the straw that initiates action to delve more deeply into safety issues.  But we find optimism in that the CEO recognizes the dynamic nature of safety.  We wholeheartedly agree.

Link to article.

Quote of the Day

I came across the following in a discussion forum related to Davis Besse issues.

“So it appears that man is capable of controlling the climate, but not the atom.  God is laughing.”

While not exactly on point for SafetyMatters, it was irresistible.

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.