More BP

We have posted numerous times on the travails of BP following the Deepwater Horizon disaster and the contribution of safety culture to these performance results.  BP is back in the news since the trial date for a variety of suits and countersuits is coming up shortly.  We thought we would take the opportunity for a quick update.

The good news is the absence of any more significant events at BP facilities.  In its presentation to investors on 4Q11 and 2012 Strategy, BP highlighted its 10 point moving forward plan, including at the top of the list, “relentless focus on safety and managing risk”.* 

It is impossible for us to assess how substantive and effective this focus has been or will be, but we’ve now heard from BP’s Board member Frank Bowman.  Bowman is head of the Board’s Safety, Ethics and Environment Assurance Committee.  He served on the panel that investigated BP’s US refineries after the Texas City explosion in 2005 and then became a member of BP’s US advisory council; and in November 2010, he joined the main board as a non-executive director.  Basically Bowman’s mission is to help transfer his U.S. nuclear navy safety philosophy to BP’s energy business.

Bowman reports that he has been impressed by the way the safety and operational risk and upstream organizations have taken decisions to suspend operations when necessary. “We’ve recently walked away from several jobs where our standards were not being met by our partners or a contractor. That sends a message heard around the world, and we should continue to do that.”**

Looking for more specifics in the 4Q11 investor presentation, we came across the following “safety performance record”. (BP 4Q11, p. 12)

The charts plot “loss of containment” issues (these are basically releases of hydrocarbons) and personnel injury frequency.  The presentation notes that “Aside from the exceptional activities of the Deepwater Horizon response, steady progress has been made over the last decade.”  Perhaps but we are skeptical that these data are useful for measuring progress in the area of safety culture and management.  For one they both show positive trends over a time period where BP had two major disasters - the Texas City oil refinery fire in 2005 and Deepwater Horizon in 2010.  At a minimum these charts confirm that the tracked parameters do nothing to proactively predict safety health.  As Mr. Bowman notes, “Culture is set by the collective behaviour of an organisation’s leaders… The collective behaviour of BP’s leaders must consistently endorse safety as central to our very being.” (BP Magazine, p. 10)

On the subject of management behavior, the investigations and analyses of Deepwater Horizon consistently noted the contribution of business pressures and competing priorities that lead to poor decisions.  In our September 30, 2010 blog post we included a quote from the then-new BP CEO:

“Mr. Dudley said he also plans a review of how BP creates incentives for business performance, to find out how it can encourage staff to improve safety and risk management.”

The 4Q11 presentation and Mr. Bowman’s interview are noticeably silent on this subject.  The best we could come up with was the following rather cryptic statement in the 4Q11: “We’ve also evolved our approach to performance management and reward, requiring employees to set personal priorities for safety and risk management, focus more on the long term and working as one team.” (BP 4Q11, p. 15)  We’re not sure how “personal priorities” relate to the compensation incentives which were the real focus of the concerns expressed in the accident investigations.

Looking a bit further we uncovered the following in a statement by the chairwoman of BP’s Board Remuneration Committee: “For 2011 the overall policy for executive directors [compensation] will remain largely unchanged…”***  If you guessed that incentives would be based only on meeting business results, you would be right.

In closing we leave with one other comment from Mr. Bowman, one that we think has great salience in the instant situation of BP and for other high risk industries including nuclear generation: “In any business dealing with an unforgiving environment, complacency is your worst enemy. You have to be very careful about what conclusion to draw from the absence of an accident.” (BP Magazine, p. 9) [emphasis added]

*  BP 4Q11 & 2012 Strategy presentation, p. 8.

**  BP Magazine, Issue 4 2011, p. 9.

***  Letter from the chairman of the remuneration committee (Mar. 2, 2011).

Is Safety Culture An Inherently Stable System?

The short answer:  No.

“Stable” means that an organization’s safety culture effectiveness remains at about the same level* over time.  However, if a safety culture effectiveness meter existed and we attached it to an organization, we would see that, over time, the effectiveness level rises and falls, possibly even dropping to an unacceptable level.  Level changes occur because of shocks to the system and internal system dynamics.

Shocks

Sudden changes or challenges to safety culture stability can originate from external (exogenous) or internal (endogenous) sources.

Exogenous shocks include significant changes in regulatory requirements, such as occurred after TMI or the Browns Ferry fire, or “it’s not supposed to happen” events that do, in fact, occur, such as a large earthquake in Virginia or a devastating tsunami in Japan that give operators pause, even before any regulatory response.

Organizations have to react to such external events and their reaction is aimed at increasing plant safety.  However, while the organization’s focus is on its response to the external event, it may take its eye off the ball with respect to its pre-existing and ongoing responsibilities.  It is conceivable that the reaction to significant external events may distract the organization and actually lower overall safety culture effectiveness.

Endogenous shocks include the near-misses that occur at an organization’s own plant.  While it is unfortunate that such events occur, it is probably good for safety culture, at least for awhile.  Who hasn’t paid greater attention to their driving after almost crashing into another vehicle?

The insertion of new management, e.g., after a plant has experienced a series of performance or regulatory problems, is another type of internal shock.  This can also raise the level of safety culture—IF the new management exercises competent leadership and makes progress on solving the real problems. 

Internal Dynamics    

Absent any other influence, safety culture will not remain at a given level because of an irreducible tendency to decay.  Decay occurs because of rising complacency, over-confidence, goal conflicts, shifting priorities and management incentives.  Cultural corrosion, in the form of normalization of deviance, is always pressing against the door, waiting for the slightest crack to appear.  We have previously discussed these challenges here.

An organization may assert that its safety culture is a stability-seeking system, one that detects problems, corrects them and returns to the desired level.  However, performance with respect to the goal may not be knowable with accuracy because of measurement issues.  There is no safety culture effectiveness meter, surveys only provide snapshots of instant safety climate and even a lengthy interview-based investigation may not lead to repeatable results, i.e, a different team of evaluators might (or might not) reach different conclusions.  That’s why creeping decay is difficult to perceive. 

Conclusion

Many different forces can affect an organization’s safety culture effectiveness, some pushing it higher while others lower it.  Measurement problems make it difficult to know what the level is and the trend, if any.  The takeaway is there is no reason to assume that safety culture is a stable system whose effectiveness can be maintained at or above an acceptable level.


*  “Level” is a term borrowed from system dynamics, and refers to the quantity of a variable in a model.  We recognize that safety culture is an organizational property, not something stored in a tank, but we are using “level” to communicate the notion that safety culture effectiveness is something that can improve (go up) or degrade (go down).

VIT Plant Glop (Part 2)

(Ed. note: We're pleased to present an interesting take on the Vit Plant from Bill Mullins as a guest contributor.  We welcome contributions from others who would like to contribute leading edge thinking on nuclear safety culture.)

Bob Cudlin’s Jan. 24 post concludes, "Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting might be the better emphasis."

From where I sit, in this simple piece of seemingly practical advice hides much of the iceberg the WTP Titanic keeps circling around to repeatedly encounter amidst the fog of Nuclear Safety Culture (NSC) and such.

The key word is "expectations” – this is because for DOE the definition of Quality is “performance that meets or exceeds requirements and expectations.” Importantly the DOE Quality standard embraces a “continuous improvement” criterion. This definition of Quality and its attendant context are considerably more expansive than the one found at 10 CFR 50 Appendix B – and there is a very necessary reason for that.

At the Program level all the DOE Mission portfolios are of the Discover and Develop type. DOE programs and projects are chartered to go where none has gone before (i.e. nor generally can afford the capital risks to go such places first).

Not every project in DOE is of comparable difficulty, but many (e.g., the Environmental Management Program) of the sub-portfolios (e.g., Hanford Cleanup) take decades of trial and error practice to create reliable Acquisition Strategies.

Even now the Hanford Cleanup work is pretty well partitioned between 1) things we now do reliably and with a modicum of efficiency (cf. River Corridor Cleanup contract), and 2) that Goop/Gorp unconventional uncertainty. Today the former goes well and the latter goes poorly.

The WTP is a full-blooded Discover and Develop enterprise - the high-level tank waste is vastly more subtle in its physical chemistry than DOE and its prime contractor have been willing to acknowledge to their stakeholders in the Tri-Party Agreement with EPA and WA State. The stakeholders seem reluctant to puncture the veil of schedule illusion as well.

Generally I conclude the River Protection Program (RPP), which governs the WTP development, is not sufficiently aware of its vulnerability to unconventional uncertainty. It is the more unpredictable behavior of the tank waste that should be the center of attention; not unrealistic schedules and life cycle budget estimates into the far future.

It is this (some would say “studied”) blindness that the DNFSB is ultimately getting at via its nuclear safety oversight charter – I’m inclined to doubt that the Board recognizes the blind spot any better than most in DOE leadership. Like the carpenter with only a hammer on his tool belt, the Board’s way of framing issues with progress at the RPP tends to make every unanticipated or unwelcome outcome seem like a “nuclear safety nail.”

At the end of most days this over-dramatization of nuclear safety significance has been a deliberate strategy of the Board since it began its Safety in Design “action-forcing” campaign about four years ago.

In broad reality, the situation of the RPP can be viewed as a matter of inadequate safety consciousness or poorly chosen Acquisition Strategy – the latter perspective has more traction precisely because in encompasses protection concerns without being dragged into the “good vs. bad” attitude debates – which tend to be the heart of NSC conversations - that are presently fogging the air of the Hanford 200 Area.

Later in Bob’s post he observes: “In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.”

This conclusion is not without its supporting evidence: From the time that the Walt Thomasitus pushback on Bechtel Management began, DOE Office of River Protection project management has responded from a position that reeks annoyance and resentment. This has not helped with sorting out the key issues at the WTP, in fact when the Recommendation 2011-1 appeared the knee-jerk defensive response of the Deputy Secretary actually made things worse for a time.

There are now three prominent whistle-blowers feeding the maw of both GAO and the national press.*  Unfortunately, Thomasitus, Alexander, and Busche each raise concerns about whether the plant will work as advertised – not as matters of Acquisition Strategy, but as safety issues. That is unfortunate because it leads to this: “The treatment plant "is not a project that can be stopped and restarted," said Rep. Doc Hastings, R-Wash.”**

Just lately, we have a memorandum from the Secretary and Deputy Secretary that I believe finally puts a suitable Line Management framework around the 2011-1 IP and the WTP issue.  It will take a further post to elaborate the basis for my belief that this particular memorandum “answers the mail” about NSC in the DOE nuclear programs. At that point I can also suggest what I see as the barriers to this missive gaining the policy high ground against the wave of other “over-commitments” throughout the remainder of the 2012-1 IP.

(Mr. Mullins is a Principal at Better Choices Consulting.)

*  P. Eisler, “Problems plague cleanup at Hanford nuclear waste site,” USA Today (Jan. 25, 2012).

**  P. Eisler, “Safety at Wash. nuclear-waste site scrutinized,” USA Today (Jan. 27, 2012).

***  Letter from D.B. Poneman to P.S. Winokur transmitting DOE Memorandum dated Dec. 5, 2011 from S. Chu and D.B. Poneman to Heads of All Departmental Elements re: Nuclear Safety at the Department of Energy (Jan. 24, 2012).

Vit Plant Glop

Hanford WTP

DOE’s Waste Treatment Plant at Hanford, the “Vit Plant”, is being built to process a complex mixture of radioactive waste products from 1950s nuclear weapons production.  The wastes, currently in liquid form and stored in tanks at the site, was labeled “gorp” by William Mullins in one of his posts on the LinkedIn Nuclear Safety thread.*  Actually we think the better reference is to “glop”.  Glop is defined at merriam-webster.com as “a thick semiliquid substance (as food) that is usually unattractive in appearance”.  Readers should disregard the reference to food.  We would like to call attention to another source of “glop” accumulating at the Vit Plant.  It is the various reports by DOE and Hanford regarding safety culture at the site, most recently in response to the Defense Nuclear Facilities Safety Board’s (DNFSB, Board) findings in June 2011.  These forms of glop correspond more closely to the secondary definition in m-w, that is, “tasteless or worthless material”.

The specific reports are the DOE’s Implementation Plan (IP)** for the DFNSB’s review of safety culture at the WTP and the DOE's Office of Health, Safety and Security (HSS) current assessment of safety culture at the site.  Neither is very satisfying but we’ll focus on the IP in this post.

What may be most interesting in the DOE IP package are the reference documents including the DNFSB review and subsequent exchanges of letters between the Secretary of Energy and the DNFSB Chairman.  It takes several exchanges for the DNFSB to wrestle DOE into accepting the findings of the Board.  Recall in the Board’s original report it concluded:

“Taken as a whole, the investigative record convinces the Board that the safety culture at WTP is in need of prompt, major improvement and that corrective actions will only be successful and enduring if championed by the Secretary of Energy.” (IP, p. 33)***

In DOE’s initial (June 30, 2011) response they stated:

“Even while DOE fully embraces the objectives of the Board’s specific recommendations, it is important to note that DOE does not agree with all of the findings included in the Board’s report.”  (IP, p. 42)****

It goes on to state that “specifically” DOE does not agree with the conclusions regarding the overall quality of the safety culture.  Not surprisingly this brought the following response in the DNFSB’s August 12, 2011 letter, “...the disparity between the [DOE’s] stated acceptance and disagreement with the findings makes it difficult for the Board to assess the response….”  (IP, p. 46)*****  Note that in the body of the IP (p. 4) DOE does not acknowledge this difference of opinion either in the summary of its June 30 response or the Board’s August 12 rejoinder. 

We note that neither the DNFSB report nor the DOE IP is currently included among the references on Bechtel's Vit Plant website.  One can only wonder what the take away is for Vit Plant personnel — isn’t there a direct analogy between how DOE reacts to issues raised by the DNFSB and how Vit Plant management respond to issues raised at the plant?  Here’s an idea: provide a link to the safetymatters blog on the Vit Plant website.  Plant personnel will be able to access the IP, the DNFSB report and all of our informative materials and analysis.

In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.  Their cause analysis focuses on inadequate expectation setting, more knowledge and awareness and (closer to the mark) the conflicting goals emerging in the construction phase (IP, pp. 5-8).  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.  What is DOE’s answer?  More assessments and surveys, more training, more “guidance”, more expectations, etc.

We do find Actions 1-5 and 1-6 interesting (IP, p. 16).  These will revise the BNI contract to achieve “balanced priorities”.  This is important and a good thing.  We have blogged about the prevalence of large financial incentives for nuclear executives in the commercial nuclear industry and assessments of most, if not all, other significant safety events (BP gulf disaster, BP refinery fire, Upper Big Branch coal mine explosion, etc.) highlight the presence of goal conflicts.  How one balances priorities is another thing and a challenge.  We have blogged extensively on this subject - search on “incentives” to identify all relevant posts.  In particular we have noted that where safety goals are included in incentives they tend to be based on industrial safety which is not very helpful to the issues at hand.  Our favorite quote comes from our April 7, 2011 post re the gulf oil rig disaster and is taken from Transocean’s annual report:

“...notwithstanding the tragic loss of life in the Gulf of Mexico, we [Transocean] achieved an exemplary statistical safety record as measured by our total recordable incident rate (‘‘TRIR’’) and total potential severity rate (‘‘TPSR’’).”

Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting, might be the better emphasis.  Then monitoring and independently assessing how specific technical and safety issues are reviewed and decided.  Training, expectations setting, reinforcement, policies, etc. are useful in “setting the table” but the test of whether the organization is embracing and implementing a strong safety culture can only be found in its actions.  Note that the Board’s June 2011 report focused on two specific examples of deficient decision processes and outcomes.  (One, the determination of the appropriate deposition velocity for analysis of the transport of radioactivity, the other the conservatism of a criticality analysis.)

There are two aspects of decisions: the process and the result.  The process includes the ability to freely raise safety concerns, the prioritization and time required to evaluate such issues, and the treatment of individuals who raise such concerns.  The result is the strength of the decision reached; i.e., do the decisions reinforce a strong safety culture?  We have posted and provided examples on the blog website of decision assessment using some methods for quantitative scoring.

*  The link to the thread is here.  Search for "gorp" to see Mr. Mullins' comment.

**  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).

***  IP Att. 1, DNFSB Recommendation 2011-1, “Safety Culture at the Waste Treatment and Immobilization Plant” (June 9, 2011).

****  IP Att. 2, Letter from S. Chu to P.S. Winokur responding to DNFSB Recommendation 2011-1 (June 30, 2011) p. 4.

*****  IP Att. 4, Letter from P.S. Winokur  to S. Chu responding to Secretary Chu’s June 30, 2011 letter (Aug. 12, 2011) p. 1.

Will Safety Culture Kill Palisades?

To tell the truth, I have no idea.  But the plant has an interesting history and reviewing it may give us some hints with respect to the current situation.

If Palisades were a person, we would think it existed in almost laboratory-like conditions for developing a distinct cultural strain.  It’s elderly, a little “different” and a singleton, with a stillborn sibling and a parent who never really loved it.

Palisades is the 9th oldest of U.S. units that are still operating and was/is Combustion Engineering’s first commercial reactor.  C-E reactors were not as popular as GE or Westinghouse; about 13 percent of the current U.S. fleet uses C-E reactors.  The other old units were owned by companies that developed additional nuclear plants but that didn’t happen for Palisades.  It was supposed to have a big brother, Midland, but the project collapsed, primarily because of construction problems, in 1984 when Midland was about 85% complete, almost bankrupting the owner, Consumers Power (which morphed into CMS Energy and then Consumers Energy.) 

Consumers was looking for someone else to operate or take over the plant as far back as the early 1990s.  Eventually, in 2001, they hired the Nuclear Management Company to operate the plant.  That relationship continued until the plant was sold to Entergy in April 2007.

New managers were able to increase performance in terms of capacity factor (CF).  Under Consumers management, 1996-2000 average CF was 85.2%; under NMC, 2002-2006 CF was 90.0 %; and under Entergy, 2007-2010 CF was 93.0%.  In addition, each of those averages was higher than the average CF of the entire U.S. nuclear fleet for the same period.  (I deliberately omitted 2001; it was a terrible year, with a normal refueling outage followed by a six-month maintenance outage to replace control rod drive assemblies.)

More important from the standpoint of trying to infer something about the safety culture, Palisades kept its nose clean with respect to the NRC.  There were three Severity Level III violations during the Consumers era, and one SL-III and one White violation in 2001.  It looks like three different management regimes were able to maintain an effective safety culture but there has been a recent lapse with three White violations since 2009 and preliminary White and Yellow findings in process.

Conclusion

What does this tell us, if anything?  Has Entergy been squeezing the plant too hard?  Did the CF success under Entergy lead to complacency?  Are there any long-standing material condition problems to sap morale and depress safety culture?  Have there been regular, in-depth independent assessments of organizational issues?  I have no insight into this situation although in our Jan. 12 post, I said it looked like the process of normalization of deviance had occurred.  But there is one thing that should jolt the staff into paying attention to detail, at least for awhile: Some Entergy MBA is carefully watching the numbers.  If the NRC shuts down Palisades, it won’t be long before Entergy folds up its tent and walks away.  No generation means no revenue.  And I can’t believe the PSC or ratepayers in economically depressed Michigan have much interest in bailing out a carpetbagger owner.

Problems at Palisades—A Case of Normalization of Deviance?

The Palisades nuclear plant is in trouble with the NRC.  On Jan. 11, 2012 the NRC met with Entergy (the plant’s owner and operator) to discuss two preliminary inspection findings, one white and one yellow.  Following is the NRC summary of the more significant event.

 “The preliminary yellow finding of substantial significance to safety is related to an electrical fault caused by personnel at the site. The electrical fault resulted in a reactor trip and the loss of half of the control room indicators, and activation of safety systems not warranted by actual plant conditions. This made the reactor trip more challenging for the operators and increased the risk of a serious event occurring. The NRC conducted a Special Inspection and preliminarily determined the actions and work preparation for the electrical panel work were not done correctly.”*

At the meeting with NRC, an Entergy official said “Over time, a safety culture developed at the plant where workers thought if they had successfully accomplished a task in the past, they could do it again without strictly following procedure [emphasis added]. . . .

Management also accepted that, and would reward workers for getting the job done. This led to the events that caused the September shutdown when workers did not follow the work plan while performing maintenance.”**

In an earlier post, we defined normalization of deviance as “the gradual acceptance of performance results that are outside normal acceptance criteria.”  In the Palisades case, we don’t know anything more than the published reports but it sure looks to us like an erosion of performance standards, an erosion that was effectively encouraged by management.

Additional Background on Palisades

This is not Palisades’ first trip to the woodshed.  Based on a prior event, the NRC had already demoted Palisades from the Reactor Oversight Process (ROP) Licensee Response Column to the Regulatory Response Column, meaning additional NRC inspections and scrutiny.  And they may be headed for the Degraded Cornerstone Column.***  But it’s not all bad news.  At the end of the third quarter 2011, Palisades had a green board on the ROP.****  Regular readers know our opinion with respect to the usefulness of the ROP performance matrices.


*  NRC news release, “NRC to Hold Two Regulatory Conferences on January 11 to Discuss Preliminary White and Preliminary Yellow Findings at Palisades Nuclear Plant,” nrc.gov (Jan. 5, 2012).

**  F. Klug, “Decline in safety culture at Palisades nuclear power plant to be fixed, company tells regulators,” Kalamazoo Gazette on mlive.com (Jan. 11, 2012).

***  B. Devereaux, “Palisades nuclear plant bumped down in status by NRC; Entergy Nuclear to dispute other findings next week,” mlive.com (Jan. 4, 2012).

****  Palisades 3Q/2011 Performance Summary, nrc.gov (retrieved Jan. 12, 2012).

2011 End of Year Summary

We thought we would take this opportunity to do a little rummaging around in the Google analytics and report on some of the statistics for the safetymatters blog.

The first thing that caught our attention was the big increase in page views (see chart below) for the blog this past year.  We are now averaging more than 1000 per month and we appreciate every one of the readers who visits the blog.  We hope that the increased readership reflects that the content is interesting, thought provoking and perhaps even a bit provocative.  We are pretty sure people who are interested in nuclear safety culture cannot find comparable content elsewhere.

The following table lists the top ten blog posts.  The overwhelming favorite has been the "Normalization of Deviation" post from March 10, 2010.  We have consistently commented positively on this concept introduced by Diane Vaughan in her book The Challenger Launch Decision.  Most recently Red Conner noted in his December 8, 2011 post the potential role of normalization of deviation in contributing to complacency.  This may appear to be a bit of a departure from the general concept of complacency as primarily a passive occurrence.  Red notes that the gradual and sometimes hardly perceptive acceptance of lesser standards or non-conforming results may be more insidious than a failure to challenge the status quo.  We would appreciate hearing from readers on their views of “normalization”, whether they believe it is occurring in their organizations (and if so how is it detected?) and what steps might be taken to minimize its effect.

A common denominator among a number of the popular posts is safety culture assessment, whether in the form of surveys, performance indicators, or other means to gauge the current state of an organization.  Our sense is there is a widespread appetite for approaches to measuring safety culture in some meaningful way; such interest perhaps also indicates that current methods, heavily dependent on surveys, are not meeting needs.  What is even more clear in our research is the lack of initiative by the industry and regulators to promote or fund research into this critical area.   

A final observation:  The Google stats on frequency of page views indicate two of the top three pages were the “Score Decision” pages for the two decision examples we put forward.  They each had a 100 or more views.  Unfortunately only a small percentage of the page views translated into scoring inputs for the decisions.  We’re not sure why the lack of inputs since they are anonymous and purely a matter of the reader’s judgment.  Having a larger data set from which to evaluate the decision scoring process would be very useful and we would encourage anyone who did visit but not score to reconsider.  And of course, anyone who hasn’t yet visited these examples, please do and see how you rate these actual decisions from operating nuclear plants.

From SCWE to Safety Culture—Time for the Soapbox

Is a satisfactory Safety Conscious Work Environment (SCWE) the same as an effective safety culture (SC)?  Absolutely not.  However, some of the reports and commentary we’ve seen on troubled facilities appear to mash the terms together.  I can’t prove it, but I suspect facilities that rely heavily on lawyers to rationalize their operations are encouraged to try to pass off SCWE as SC.  In any case, following is a review of the basic components of SC:

Safety Conscious Work Environment

An acceptable SCWE* is one where employees are encouraged and feel free to raise safety-related issues without fear of retaliation by their employer.  Note that it does not necessarily address individual employees’ knowledge of or interest in such issues.

Problem Identification and Resolution (PI&R)

PI&R is usually manifested in a facility’s corrective action program (CAP).  An acceptable CAP has a robust, transparent process for evaluating, prioritizing and resolving specific issues.  The prioritization step includes an appropriate weight for an issue’s safety-related elements.  CAP backlogs are managed to levels that employees and regulators associate with timely resolution of issues.

However, the CAP often only deals with identified issues.  Effective organizations must also anticipate problems and develop plans for addressing them.  Again, safety must have an appropriate priority.

Organizational Decision Making

The best way to evaluate an organization’s culture, including safety culture, is through an in-depth analysis of a representative sample of key decisions.  How did the decision-making process handle competing goals, set priorities, treat devil’s advocates who raised concerns about possible unfavorable outcomes, and assign resources?  Were the most qualified people involved in the decisions, regardless of their position or rank?  Note that this evaluation should not be limited to situations where the decisions led to unfavorable consequences; after all, most decisions lead to acceptable outcomes.  The question here is “How were safety concerns handled in the decision making process, independent of the outcome?”

Management Behavior

What is management’s role in all this?  Facility and corporate managers must “walk the talk” as role models demonstrating the importance of safety in all aspects of organizational life.  They must provide personal leadership that reinforces safety.  They must establish a recognition and reward system that reinforces safety.  Most importantly, they must establish and maintain the explicit and implicit weighting factors that go into all decisions.  All of these actions reinforce the desired underlying assumptions with respect to safety throughout the organization. 

Conclusion

Establishing a sound safety culture is not rocket science but it does require focus and understanding (a “mental model”) of how things work.  SCWE, PI&R, Decision Making and Management Behavior are all necessary components of safety culture.  Not to put too fine a point on it, but safety culture is a lot more than quoting a survey result that says “workers feel free to ask safety-related questions.”


*  SCWE questions have also been raised on the LinkedIn Nuclear Safety and Nuclear Safety Culture discussion forums.  Some of the commentary is simple bloviating but there are enough nuggets of fact or insight to make these forums worth following.