Tuesday, July 31, 2012

Regulatory Influence on Safety Culture

In September, 2011 the Nuclear Energy Agency (NEA) and the International Atomic Energy (IAEA) held a workshop for regulators and industry on oversight of licensee management.  “The principal aim of the workshop was to share experience and learning about the methods and approaches used by regulators to maintain oversight of, and influence, nuclear licensee leadership and management for safety, including safety culture.”*

Representatives from several countries made presentations.  For example, the U.S. presentation by NRC’s Valerie Barnes and INPO’s Ken Koves discussed work to define safety culture (SC) traits and correlate them to INPO principles and ROP findings (we previously reviewed this effort here).  Most other presentations also covered familiar territory. 

However, we were very impressed by Prof. Richard Taylor’s keynote address.  He is from the University of Bristol and has studied organizational and cultural factors in disasters and near-misses in both nuclear and non-nuclear contexts.  His list of common contributors includes issues with leadership, attitudes, environmental factors, competence, risk assessment, oversight, organizational learning and regulation.  He expounded on each factor with examples and additional detail. 

We found his conclusion most encouraging:  “Given the common precursors, we need to deepen our understanding of the complexity and interconnectedness of the socio-political systems at the root of organisational accidents.”  He suggests using system dynamics modeling to study archetypes including “maintaining visible convincing leadership commitment in the presence of commercial pressures.”  This is totally congruent with the approach we have been advocating for examining the effects of competing business and safety pressures on management. 

Unfortunately, this was the intellectual high point of the proceedings.  Topics that we believe are important to assessing and understanding SC got short shrift thereafter.  In particular, goal conflict, CAP and management compensation were not mentioned by any of the other presenters.

Decision-making was mentioned by a few presenters but there was no substantive discussion of this topic (the U.K. presenter had a motherhood statement that “Decisions at all levels that affect safety should be rational, objective, transparent and prudent”; the Barnes/Kove presentation appeared to focus on operational decision making).  A bright spot was in the meeting summary where better insight into licensees’ decision making process was mentioned as desirable and necessary by regulators.  And one suggestion for future research was “decision making in the face of competing goals.”  Perhaps there is hope after all.

(If this post seems familiar, last Dec 5 we reported on a Feb 2011 IAEA conference for regulators and industry that covered some of the same ground.  Seven months later the bureaucrats had inched the football a bit down the field.)

*  Proceedings of an NEA/IAEA Workshop, Chester, U.K. 26-28 Sept 2011, “Oversight and Influencing of Licensee Leadership and Management for Safety, Including Safety Culture – Regulatory Approaches and Methods,” NEA/CSNI/R(2012)13 (June 2012).

Friday, July 27, 2012

Modeling Safety Culture (Part 4): Simulation Results 2

As we introduced in our prior post on this subject (Results 1), we are presenting some safety culture simulation results based on a highly simplified model.  In that post we illustrated how management might react to business pressure caused by a reduction in authorized budget dollars.  The actions of management result in shifting of resources from safety to business and lead to changes in the state of safety culture.

In this post we continue with the same model and some other interesting scenarios.  In each of the following charts three outputs are plotted: safety culture in red, management action level in blue and business pressure in dark green.  The situation is an organization with a somewhat lower initial safety culture and confronted with a somewhat smaller budget reduction than the example in Results 1. 

Figure 1
Figure 1 shows an overly reactive management. The blue line shows management’s actions in response to the changes in business pressure (green) associated with the budget change.  Note that management’s actions are reactive, shifting priorities immediately and directly in response. The behavior leads to a cyclic outcome where management actions temporarily alleviate business pressure, but when actions are relaxed, pressure rises again, followed by another cycle of management response.  This could be a situation where management is not addressing the source of the problem, shifting priorities back and forth between business and safety.  Also of interest is that the magnitude of the cycle is actually increasing with time indicating that the system is essentially unstable and unsustainable.  Safety culture (red) declines throughout the time frame.

Figure 2
Figure 2 shows the identical conditions but where management implements a more restrained approach, delaying its response to changes in business.  The overall system response is still cyclic, but now the magnitude of the cycles is decreasing and converging on a stable outcome.

Figure 3
Figure 3 is for the same conditions, but the management response is restrained further.  Management takes more time to assess the situation and respond to business pressure conditions.  This approach starts to filter out the cyclic type of response seen in the first two examples and will eventually result in a lower business gap.

Perhaps the most important takeaway from these three simulations is that the total changes in safety culture are not significantly different.  A certain price is being paid for shifting priorities away from safety, however the ability to reduce and maintain lower business pressure is much better with the last management strategy.

Figure 4
The last example in this set is shown in Figure 4.  This is a situation where business pressure is gradually ramped up due to a series of small step reductions in budget levels.  Within the simulation we have also set a limit on extent of management actions.  Initially management takes no action to shift priorities - business pressure is within a value that safety culture can resist.  Consequently safety culture remains stable.  After the third “bump” in business pressure, the threshold resistance of safety culture is broken and management starts to modestly shift priorities.  Even though business pressure continues to ramp up, management response is capped and does not “chase” closing the business gap.  As a result safety culture suffers only a modest reduction before stabilizing.  This scenario may be more typical of an organization with a fairly strong safety culture - under sufficient pressure it will make modest tradeoffs in priorities but will resist a significant compromise in safety.

Friday, July 20, 2012

Cognitive Dissonance at Palisades

“Cognitive dissonance” is the tension that arises from holding two conflicting thoughts in one’s mind at the same time.  Here’s a candidate example, a single brief document that presents two different perspectives on safety culture issues at Palisades.

On June 26, 2012, the NRC requested information on Palisades’ safety culture issues, including the results of a 2012 safety culture assessment conducted by an outside firm, Conger & Elsea, Inc (CEI).  In reply, on July 9, 2012 Entergy submitted a cover letter and the executive summary of the CEI assessment.*  The cover letter says “Areas for Improvement (AFls) identified by CEI over1apped many of the issues already identified by station and corporate leadership in the Performance Recovery Plan. Because station and corporate management were implementing the Performance Recovery Plan in April 2012, many of the actions needed to address the nuclear safety culture assessment were already under way.”

Further, “Gaps identified between the station Performance Recovery Plan and the safety culture assessment are being addressed in a Safety Culture Action Plan. . . . [which is] a living document and a foundation for actively engaging station workers to identify, create and complete other actions deemed to be necessary to improve the nuclear safety culture at PNP.”

Seems like management has matters in hand.  But let’s look at some of the issues identified in the CEI assessment.

“. . . important decision making processes are governed by corporate procedures. . . .  However, several events have occurred in recent Palisades history in which deviation from those processes contributed to the occurrence or severity of an event.”

“. . . there is a lack of confidence and trust by the majority of employees (both staff and management) at the Plant in all levels of management to be open, to make the right decisions, and to really mean what they say. This is indicated by perceptions [of] the repeated emphasis of production over safety exhibited through decisions around resources.” [emphasis added]

“There is a lack in the belief that Palisades Management really wants problems or concerns reported or that the issues will be addressed. The way that CAP is currently being implemented is not perceived as a value added process for the Plant.”

The assessment also identifies issues related to Safety Conscious Work Environment and accountability throughout the organization.

So management is implying things are under control but the assessment identified serious issues.  As our Bob Cudlin has been explaining in his series of posts on decision making, pressures associated with goal conflict permeate an entire organization and the problems that arise cannot be fixed overnight.  In addition, there’s no reason for a plant to have an ineffective CAP but if the CAP isn’t working, that’s not going to be quickly fixed either.

*  Letter, A.J. Vitale to NRC, “Reply to Request for Information” (July 9,2012) ADAMS ML12193A111.

Sunday, July 15, 2012

Modeling Safety Culture (Part 3): Simulation Results 1

As promised in our June 29, 2012 post, we are taking the next step to incorporate our mental models of safety culture and decision making in a simple simulation program.  The performance dynamic we described viewed safety culture as a “level”, and the level of safety culture determines its ability to resist pressure associated with competing business priorities. If business performance is not meeting goals, pressure on management is created which can be offset by sufficiently strong safety culture. However if business pressure exceeds the threshold for a given safety culture level, management decision making can be affected, resulting in a shift of resources from safety to business needs. This may relieve some business pressure but create a safety gap that can degrade safety culture, making it potentially even more vulnerable to business pressure.

It is worth expanding on the concept of safety culture as a “level” or in systems dynamics terms, a “stock” - an analogy might be the level of liquid in a reservoir which may increase or decrease due to flows into and out of the reservoir.  This representation causes safety culture to respond less quickly to changes in system conditions than other factors.  For example, an abrupt cut in an organization’s budget and its pressure on management to respond may occur quite rapidly - however its impact on organizational safety culture will play out more gradually.  Thus “...stocks accumulate change.  They are kind of a memory, storing the results of past actions...stocks cannot be adjusted instantaneously no matter how great the organizational pressures…This vital inertial characteristic of stock and flow networks distinguishes them from simple causal links.”* 

Let’s see this in action in the following highly simplified model.  The model considers just two competing priorities: safety and business.  When performance in these categories differs from goals, pressure is created on management and may result in actions to ameliorate the pressure.  In this model management action is limited to shifting resources from one priority to the other.  Safety culture, per our June 29, 2012 post, is an organization’s ability to resist and then respond to competing priorities.  At time zero, a reduction in authorized budget is imposed resulting in a gap (current spending versus authorized spending) and creating business pressure on management to respond.

Figure 1
Figure 1 shows the response of management.  Actions are initiated very quickly and start to reduce safety resources to relieve budget pressure.  The plot tracks the initial response, a plateauing to allow effectiveness to be gauged, followed by escalation of action to further reduce the budget gap.

Figure 2
Figure 2 overlays the effect of the management actions on the budget gap and the business
pressure associated with the gap.  Immediately following the budget reduction, business pressure rapidly increases and quickly reaches a level sufficient to cause management to start to shift priorities.  The first set of management actions brings some pressure relief, the second set of actions further reduces pressure.  As expected there is some time lag in the response of business pressure to the actions of management.

Figure 3
In Figure 3, the impact of these changes in business pressure and management actions are
accumulated in the safety culture.  Note first the gradual changes that occur in culture versus the faster and sharper changes in management actions and business pressure.  As management takes action there is a loss of safety priority and safety culture slowly degrades. When further escalation of management action occurs it is at a point where culture is already lower, making the organization more susceptible to compromising safety priorities.  Safety culture declines further. This type of response is indicative of a feedback loop which is an important dynamic feature of the system.  Business pressure causes management actions, those actions degrade safety culture, degraded culture reduces resistance to further actions.

We invite comments and questions from our readers.

*  John Morecroft, Strategic Modelling and Business Dynamics (John Wiley & Sons, 2007) pp. 59-61.

Tuesday, July 3, 2012

NRC Non-Regulation of Safety Culture: Second Quarter Update

NRC SC poster, ADAMS ML120810464.
On March 17th we published a post on NRC safety culture (SC) related activities with individual licensees since the SC policy statement was issued in June, 2011.  This post is an update, highlighting selected NRC actions from mid-March through June. 

Our earlier post mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking SC related activities.  It looks like none of those plants has resolved its SC issues. 

For Browns Ferry we reported that the NRC was reviewing the plant’s 2011 SC surveys.  Turns out that was just the tip of the iceberg.  A recent PI&R inspection report indicates that the plant’s SC problems have existed for years and are deep-rooted.  Over time, Browns Ferry has reported SC issues including production and schedule taking priority over safety (2008), “struggling” with SC issues (2010) and a decline in SC (2011).  All of this occurred in spite of multiple licensee interventions and corrective actions.  The NRC’s current view is “Despite efforts to address SC issues at the site, the inspectors concluded that the lack of full confidence in the CAP has contributed to a decline in the SC since the last PI&R inspection.”*  We don’t expect this one to go away anytime soon.

Fort Calhoun management had said that SC deficiencies had contributed to problems in their CAP.  During the quarter, they presented actions planned or taken to remediate their SC deficiencies.  On June 11th, the NRC issued a Confirmatory Action Letter with a lengthy list of actions to be completed prior to plant restart.  One item is “OPPD will conduct a third-party safety culture assessment . . . and implement actions to address the results . . . .”**  It looks like Fort Calhoun is making acceptable progress on the SC front and we’d be surprised if SC ends up being an item that prevents restart.  Last April we provided some additional information on Fort Calhoun here.

In Palisades’ case, the NRC is asking for an extensive set of information on the actions being taken to improve SC at the site.  The last item on the long list requests the latest SC assessment for Entergy’s corporate office.  (This is not simply a fishing expedition.  Entergy is in trouble at other nuclear sites for problems that also appear related to SC deficiencies.)  After the information is provided and reviewed, the NRC “believe[s] that a public meeting on the safety culture assessment and your subsequent actions would be beneficial to ensure a full understanding by the NRC, your staff, and the public.”***  Back in January, we provided our perspective on Palisades here and here.

New NRC SC activity occurred at Susquehanna as part of a supplemental inspection related to a White finding and a White performance indicator.  The NRC conducted an “assessment of whether any safety culture component caused or significantly contributed to the white finding and PI.”  The assessment was triggered by PPL’s report that SC issues may have contributed to the plant’s performance problems.  The NRC inspectors reviewed documents and interviewed focus groups, individual managers and groups involved in plant assessments.  They concluded “components of safety culture identified by PPL did not contribute to the White PI or finding, and that the recently implemented corrective actions appear to being well received by the work force.”****  We report this item because it illustrates the NRC’s willingness and ability to conduct its own SC assessments where the agency believes they are warranted.

Our March post concluded: “It’s pretty clear the NRC is turning the screw on licensee safety culture effectiveness, even if it’s not officially “regulating” safety culture.”  That still appears to be the case.

*  V.M. McCree (NRC) to J.W. Shea (TVA), Browns Ferry Nuclear Plant - NRC Problem Identification and Resolution Inspection Report 05000259/2012007, 05000260/2012007 and 05000296/2012007 and Exercise of Enforcement Discretion (May 28, 2012) ADAMS ML12150A219.

**  E.E. Collins (NRC) to D.J. Bannister (OPPD), Confirmatory Action Letter – Fort Calhoun Station (June 11, 2012)  ADAMS ML12163A287.

***  G.L. Shear (NRC) to A. Vitale (Entergy), Request for Information on SC Issues at Palisades Nuclear Plant (June 26, 2012) ADAMS ML12179A155.

**** D.J. Roberts (NRC) to T.S. Rausch (PPL Susquehanna), Susquehanna Steam Electric Station – Assessment Follow-Up Letter and Interim NRC 95002 Supplemental Inspection Report 05000387/2012008 (May 7, 2012) ADAMS ML12125A374.

Friday, June 29, 2012

Modeling Safety Culture (Part 2): Safety Culture as Pressure Boundary

No, this is not an attempt to incorporate safety culture into the ASME code.  As introduced in Part 1 we want to offer a relatively simple construct for safety culture - hoping to provide a useful starting point for a model of safety culture and a bridge between safety culture as amorphous values and beliefs, and safety culture that helps achieve desired balances in outcomes.

We propose that safety culture be considered “the willingness and ability of an organization to resist undue pressure on safety from competing business priorities”.  Clearly this is a 30,000 foot view of safety culture and does not try to address the myriad ways in which it materializes within the organization. This is intentional since there are so many possible moving parts at the individual level making it too easy to lose sight of the macro forces. 

The following diagram conceptualizes the boundary between safety priorities (i.e., safety culture) and other organizational priorities (business pressure).  The plotted line is essentially a threshold where the pressure for maintaining safety priorities (created by culture) may start to yield to increasing amounts of pressure to address other business priorities.  In the region to the left of the plot line, safety and business priorities exist in an equilibrium.  To the right of the line business pressure exceeds that of the safety culture and can lead to compromises.  Note that this construct supports the view that strong safety performance is consistent with strong overall performance.  Strong overall performance, in areas such as production, cost and schedule, ensure that business pressures are relatively low and in equilibrium with reasonably strong safety culture.  (A larger figure with additional explanatory notes is available here.)

The arc of the plot line suggests that the safety/business threshold increases (requires greater business pressure) as safety culture becomes stronger.  It also illustrates that safety priorities may be maintained even at lower safety culture strengths when there is little competing business pressure.  This aspect seems particularly consistent with determinations at certain plants that safety culture is “adequate” but still requires strengthening.  It also provides an appealing explanation for how complacency can over time erode a relatively strong safety culture . If overall performance is good, resulting in minimal business pressures, the culture might not be “challenged” or noticed even as culture becomes degraded.

Another perspective on safety culture as pressure boundary is what happens when business pressure elevates to a point where the threshold is crossed.  One reason that organizations with strong culture may be able to resist more pressure is a greater ability to manage business challenges that arise and/or a willingness to adjust business goals before they become overwhelming.  And even at the threshold such organizations may be better able to identify compensatory actions that have only minimal and short term safety impacts.  For organizations with weaker safety culture, the threshold may lead to more immediate and direct tradeoffs of safety priorities.  In addition, the feedback effects of safety compromises (e.g., larger backlogs of unresolved problems) can compound business performance deficiencies and further increase business pressure.  One possible insight from the pressure model is that in some cases, perceived safety culture issues may be more a situation of reasonably strong safety culture being over matched by excessive business pressures.  The solution may be more about relieving business pressures than exclusively trying to reinforce culture.

In Part 3 we hope to further develop this approach through some simple simulations that illustrate the interaction of managing resources and balancing pressures.  In the meantime we would like to hear reactions from readers to this concept.

Tuesday, June 26, 2012

Modeling Safety Culture (Part 1)

Our June 12th post on the nature of decision making raised concerns about current perceptions of safety culture and the lack of a crisp mental model.  We contended that decisions were the critical manifestation of safety culture and should be understood as an ongoing process to achieve superior performance across all key organizational assets.  A recent post on LinkedIn by our friend Bill Mullins provided a real world example of this process from his days as a Rad Protection Manager.

“As a former Plant Radiation Protection Manager with lots of outage experience, my risk-balancing challenge arose across an evolving portfolio of work…We had to make allocations of finite human capital - radiation protection technicians, supervisors, and radiological engineers - day in a day out, in a way that matched the tempo of the ‘work proceeding safely.’"*

What would a model of safety culture look like?  In terms of a model that describes how safety culture is operationalized, there is not much to cite.  NEI has weighed in with a “safety culture process” diagram which may or may not be a model but includes elements such as CAP that one might expect to see in a model.  A fundamental consideration of any model is how to represent safety culture; does safety culture “determine” actions taken by an organization (a causal relationship), or just provide a context within which actions are taken, or is it really a product, or integration, of the actions taken?   

There is a very interesting overview of these issues in an article by M. D. Cooper titled, appropriately, “Toward a Model of Safety Culture.”  One intriguing assertion by the author is safety culture must be able to be managed and manipulated, contrary to many, including Schein, who take a different view (that it is inherent in the social system). (p. 116)  In another departure from Schein Cooper finds fault with a “linear” view of safety culture where attitudes directly result in behaviors. (p. 122)  Ultimately Cooper suggests an approach where reciprocal relationships between personal and situational aspects yield what we view as culture.  (This article is also worth a read for the observations about the limits of safety culture surveys and whether the goal of initiatives taken in response to surveys is improving safety culture—or improving safety culture survey results.)

Our own view is more in the direction of Cooper.  We think safety culture can be thought of as a force or pressure within the organization to ensure that actions and decisions reflect safety.  But safety competes with other forces arising from competing business goals, incentives and even personal interests.  The actual actions and decisions turn on the combined balance of these various pressures.***  Over time the integrated effect of the actions manifest the true priority of safety, and thus the safety culture.  

Such a process is not linear, thus to the question of does safety culture determine outcomes or vice versa, the answer is “yes”.  The diagram below illustrates the basic relationships between safety culture, management actions, business performance and safety performance. It is a cyclic and continuously looping process, driven by goals and modulated by results.  The basic idea is that safety culture exists in an equilibrium with safety and business performance much of the time.  However when business performance cannot meet its goals, it creates pressure on management and its ability to continue to give safety the appropriate priority.  (A larger figure with additional explanatory notes is available here.)

*  The link to the thread (including Bill's comment) is here.  This may be difficult for readers who are not LinkedIn members to access.

**  M.D. Cooper, “Toward a Model of Safety Culture,” Safety Science 36 (2000): 111-136.

*** As summarized in an MIT Sloan Management Review article we blogged about on Sept. 1, 2010, “All decisions….are values-based.  That is, a decision necessarily involves an implicit or explicit trade-off of values.”  Safety culture is merely one of the values that is involved in this computation.

Saturday, June 23, 2012

More Markey Malarkey?

As you know, Rep. Edward Markey (D-MA) is no friend of the NRC and has a record of complaining about NRC management practices and errors, retaliation against NRC employees who disagree with their managers, the other Commissioners outvoting outgoing Chairman Jazcko on post-Fukushima proposals,* etc. 

As a consequence, a new NRC-related emission from the Congressman’s office is of little interest to us.  However, his June 4, 2012 letter to Chairman Jazcko** got our attention.  While it recaps and supposedly updates prior complaints about the conduct of NRC managers and retaliation against employees, it also adds a couple of new items: (1) a claim that NRC employees don’t trust the NRC Inspector General (IG) to fairly investigate the issues previously raised and (2) a call for an independent investigation of the NRC’s safety culture (SC). 

I have not yet seen any NRC response to the Markey letter but it’s interesting to speculate how this might this play out.

It would not surprise me if the NRC develops a two-pronged approach: (1) show support for their IG by assigning specific instances of alleged misconduct to the IG office for investigation and (2) create some sort of broader (agency-wide) initiative to reinforce SC policy and traits.  Expect a lot of parsing, posturing and pronouncements, some retraining, and perhaps a reprimanded manager.  It may also present an opportunity for incoming Chairman Macfarlane to articulate her understanding of and expectations for SC. 

Unfortunately, what you won’t see is an in-depth analysis of either the professional decision-making system that allows internal controversies to simmer until they boil over, or the real (as opposed to nominal) management reward system that encourages an agency middle manager to act in such an unprofessional manner (if indeed anyone did).  Who would risk his career by downgrading findings and/or retaliating against subordinates unless there was some considerable agency or personal pressure to do so?  But it’s not unthinkable.  An earlier Markey letter, citing information received from NRC staff, points to an item in the regional plan, “which apparently awards Senior Executive Service bonuses in a manner that scales inversely with the number of enforcement actions that are challenged and overturned by licensees.”***  Is this a smoking gun or just someone blowing smoke?  

*  Jaczko served as a Congressional Science Fellow in Rep. Markey’s office so the Congressman is likely complaining about the other Commissioners picking on his guy.

**  Letter E.J. Markey to G. Jaczko Re: Region IV follow-up (June 4, 2012).

***  Letter E.J. Markey to G. Jaczko Re: Texas Headquarters (May 9, 2012).