Sunday, March 29, 2015

Nuclear Safety Assessment Principles in the United Kingdom

A reader sent us a copy of “Safety Assessment Principles for Nuclear Facilities” (SAPs) published by the United Kingdom’s Office for Nuclear Regulation (ONR).*  For documents like this, we usually jump right to the treatment of safety culture (SC).  However, in this case we were impressed with the document’s accessibility, organization and integrated (or holistic) approach so we want to provide a more general review.

ONR uses the SAPs during technical assessments of nuclear licensees’ safety submissions.  The total documentation package developed by a licensee to demonstrate high standards of nuclear safety is called the “safety case.”

Accessibility

The language is clear and intended for newbies as well as those already inside the nuclear tent.  For example, “The SAPs contain principles and guidance.  The principles form the underlying basis for regulatory judgements made by inspectors, and the guidance associated with the principles provides either further explanation of a principle, or their interpretation in actual applications and the measures against which judgements can be made.” (p. 11) 

Also furthering ease of use, the document is not strewn with acronyms.  As a consequence, one doesn’t have to sit with glossary in hand just to read the text.

Organization

ONR presents eight fundamental principles including responsibility for safety, limitation of risks to individuals and emergency planning.  We’ll focus on another fundamental principle, Leadership and Management (L&M) because (a) L&M activities create the context and momentum for a positive SC and (b) it illustrates holistic thinking.

L&M is comprised of four subordinate (but still high-level) inter-related principles: leadership, capable organization, decision making and learning.  “Because of their inter-connected nature there is some overlap between the principles. They should therefore be considered as a whole and an integrated approach will be necessary for their delivery.” (p. 18)

Drilling down further, the guidance for leadership includes many familiar attributes.  We want to acknowledge attributes we have been emphasizing on Safetymatters or reflect new thoughts.  Specifically, leaders must recognize and resolve conflict between safety and other goals, ensure that the reward systems promote the identification and management of risk, encourage safe behavior and discourage unsafe behavior or complacency; and establish a common purpose and collective social responsibility for safety. (p.19) 

Decision making (another Safetymatters hot button issue) receives a good treatment.  Topics covered include explicit recognition of goal conflict; appreciating the potential for error, uncertainty and the unexpected; and the essential functions of active challenges and a questioning attitude.

We do have one bone to pick under L&M: we would like to see words to the effect that safety performance and SC should be significant components of the senior management reward system.

Useful Points

Helpful nuggets pop up throughout the text.  A few examples follow.

“The process of analysing safety requires creativity, where people can envisage the variety of routes by which radiological risks can arise from the technology. . . . Safety is achieved when the people and physical systems together reliably control the radiological hazards inherent in the technology. Therefore the organizational systems (ie interactions between people) are just as important as the physical systems, . . . “ (pp. 25-26)

“[D]esigners and/or dutyholders may wish to put forward safety cases that differ from [SAP] expectations.   As in the past, ONR inspectors should consider such submissions on their individual merits. . . . ONR will need to be assured that such cases demonstrate equivalence to the outcomes associated with the use of the principles here,. . .” (p. 14)  The unstated principle here is equifinality; in more colorful words, there is more than one way to skin a cat.

There are echoes of other lessons we’ve been preaching on Safetymatters.  For example “The principle of continuous improvement is central to achieving sustained high standards of nuclear safety. . . . Seeking and applying lessons learned from events, new knowledge and experience, both nationally and internationally, must be a fundamental feature of the safety culture of the nuclear industry.” (p. 13)

And, in a nod to Nicholas Taleb, if a “hazard is particularly high, or knowledge of the risk is very uncertain, ONR may choose to concentrate primarily on the hazard.” (p. 8)

Our Perspective

Most of the content of the SAPs will be familiar to Safetymatters readers.  We suggest you skim the first 23 pages of the document covering introductory material and Leadership & Management.  SAPs is an excellent example of a regulator actually trying to provide useful information and guidance to current and would-be licensees and is far better than the simple-minded laundry lists promulgated by IAEA.


*  Office for Nuclear Regulation, “Safety Assessment Principles for Nuclear Facilities” Rev. 0 (2014).  We are grateful to Bill Mullins for forwarding this document to us.

Wednesday, March 18, 2015

Safety Culture at the 2015 NRC Regulatory Information Conference

NRC Public Meeting
The Nuclear Regulatory Commission (NRC) held its annual Regulatory Information Conference (RIC) on March 10-12, 2015.  As usual, safety culture (SC) played a minor supporting role: it was the topic of one technical session out of 37 total.  The SC session focused on assessing and/or measuring SC.  It featured a range of presentations—from NRC, Duke Energy, DOE and a SC consultant—which are summarized below.*

NRC

This presentation consisted of one (sic) slide recounting the NRC’s SC outreach program during the past year including the Trait Talk brochures, SC case studies and meetings with other nuclear regulatory bodies.

Duke Energy

The presenter provided a list of internal (CAP, Employee Concerns Program )and external (INPO, NRC) information, and management activities (Nuclear SC Monitoring Panel, Site Leadership team, Corporate Nuclear SC Monitoring Panel, Fleet Nuclear SC Monitoring Panel, Executive Nuclear Safety Council) that are used to assess equipment, processes and people across the Duke fleet.  There was no information on how these activities are integrated to describe plant or fleet SC, or if any SC issues have been identified or corrective actions taken; the slides were basically a laundry list.

Department of Energy (DOE)

The speaker was from DOE’s Office of Environment, Health, Safety and Security.  He reviewed the safety mission and goals related to DOE’s Integrated Safety Management program, DOE’s SC focus areas (leadership, employee/worker engagement and organizational learning) and SC-related activities (extent of condition reviews, self‐assessments, sustainment plans, independent assessments and the SC Improvement Panel.) 

The presentation covered the challenges in relating SC to safety management performance (mostly industrial safety metrics) and in implementing cultural changes.  Factors that make SC improvement difficult include production vs. safety goal conflict, fiscal pressures, leadership changes and internal inertia (resistance to change).

This presentation covered the basics of SC, as customized for DOE, but had no supporting details or any mention of the SC issues that have arisen at various DOE facilities, e.g., Hanford, Pantex and the Waste Isolation Pilot Plant.  We have posted many times on DOE SC; please click on the DOE label to retrieve these posts.

SC Consultant

The presenter was Sonja Haber.  She reviewed the fundamentals of the linkage between culture, behavior and ultimate performance, and the Schein three-level model of culture.

She also covered the major considerations for conducting SC assessments including having a diversity of expertise in assessing culture, using multiple methods of data collection, understanding how cultural complexity impacts performance and considering the interaction of human, organizational and technological factors.

Our Perspective

This was thin gruel compared to the 2014 RIC SC session (which we reviewed April 25, 2014).  Based on the slides, there was not much “there” there at this session.  The speaker who offered the most was Dr. Haber, not a surprise given that she has been involved in SC evaluations at various DOE facilities and testified at a Defense Nuclear Facilities Safety Board hearing on SC (which we reviewed June 9, 2014).

If a webcast of the SC technical session becomes available, we will review it to see if any useful additional information was presented or arose during the discussion.


*  The SC technical session presentations are available on the NRC website.

Friday, March 6, 2015

More Safety Culture “Trait Talk” from the NRC

Typical NRC Trait Talk brochure
The NRC introduced a series of educational brochures, the Safety Culture Trait Talk, at the March 2014 Regulatory Information Conference.  Each brochure covers one of the nine safety culture (SC) traits in the NRC SC Policy Statement (SCPS), describing why the trait is important and providing examples of related attributes and an illustrative scenario.

At that time, only one Trait Talk was available, viz., Leadership Safety Values and Actions.  We thought the content was pretty good.  The “Why is this trait important?” portion was derived from an extensive review of SC-related social science literature, which we liked a lot and posted about Feb. 10, 2013.  The “What does this trait look like?” section (aka attributes) comes from the SC Common Language initiative, which we have reviewed multiple times, most recently on April 6, 2014.  The illustrative scenario is new content developed for each brochure.

During 2014 and early 2015, NRC published additional Trait Talk brochures and now has one for each trait in the SCPS.*  We reviewed them all and still believe they provide a useful introduction and overview for each trait.  Following is our take on each trait’s essence (based on the brochure contents), and each brochure’s strengths and weaknesses.  

Leadership Safety Values and Actions

This trait focuses on the responsibilities of leaders to set the tone for SC through their own visible actions.  There is a good discussion of how employees at all levels can face goal conflicts, e.g., safety vs. production.  The focus of the reward system is on the staff; unfortunately, there is no mention of management’s financial incentives.  Although leaders’ decisions set the priority for safety, there is no mention of the decision making process, arguably management’s most fundamental and important function.**

Work Processes

This trait focuses on controlling work.  It emphasizes limiting temporary modifications, minimizing backlogs and adhering to procedures, which is all good.  It also says “organizations may require strict adherence to normal and emergency operating procedures.   However, flexibility may be necessary when responding to off-normal conditions.”  This may give the purists heartburn but it reflects reality and is a major observation of the Fukushima disaster.

Questioning Attitude

This trait is about avoiding complacency, watching for abnormalities while going about one’s duties and stopping work if unexpected conditions or results are encountered.  The key is ensuring safety has its appropriate priority at all times, which is not easy if a plant is under significant financial or political pressure.

Problem Identification and Resolution

This trait is about identifying and permanently resolving current problems, and anticipating potential future challenges and dealing with them before they manifest.  In our view, this is one of the two most important areas (the other being decision making) where everyone sees what a plant’s real priorities are.  This Trait Talk covers the topic well.

Environment for Raising Concerns

The trait is about establishing and maintaining a safety conscious work environment (SCWE).  The Trait Talk lays out the theory but the truth is whistle-blowers in many industries, including nuclear, become pariahs.

Effective Safety Communication

This trait is about transparency (although the term does not appear in the brochure.)  All business communication should be clear, complete, understandable and respectful.  The Trait Talk’s discussion on the importance of first-level supervisors being a primary source of information for their employees is very good.

Respectful Work Environment

The title says it all about this trait which overlaps with others, including questioning attitude, SCWE and transparent communications.  The Trait Talk has a good discussion of trust, at both the individual and organizational level.  One aspect we would add to the trust “equation” is the perception of self-interest vs. concern for others.

Continuous Learning

This trait is about identifying, obtaining, sharing, applying and retaining new knowledge that can lead to improved individual or organizational performance.  This trait overlaps with others, including questioning attitude and a respectful work environment.

Personal Accountability

This trait is mostly about everyone’s willingness to accept responsibility for safety but it also encompasses assigned individuals’ obligation for specific safety responsibilities.  For the latter case, the brochure’s statement that “Personal accountability is not finger pointing, blame, or punishment” is simply not true. 

Our Perspective 


The brochures provide a useful introduction and overview for each trait in the SCPS.  The content is generally good, with some weak spots and missing items.  These are, after all, four-page brochures and roughly 45 percent of the content is the same in every brochure.


*  All the Trait Talk brochures can be downloaded from the SC education materials page on the NRC website.

**  Interestingly, Decision Making is included as a tenth trait in NRC NUREG-2165, “Safety Culture Common Language” (Mar. 2014).  ADAMS ML14083A200.

Friday, February 20, 2015

NRC Office of Investigations 2014 Annual Report: From Cases to Culture

The Nuclear Regulatory Commission (NRC) Office of Investigations (OI) recently released its FY2014 annual report.*  The OI investigates alleged wrongdoing by entities regulated by the NRC; OI’s focus is on willful and deliberate actions that violate NRC regulations and/or criminal statutes.

The OI report showed a definite downward trend in the number of new cases being opened, overall a 41% drop between FY2010 and FY2014.  Only one of the four categories of cases increased over that time frame, viz., material false statements, which held fairly steady through FY2013 but popped in FY2014 to 67% over FY2010.  We find this disappointing because false statements can often be linked to cultural attributes that prioritize getting a job done over compliance with regulations.

The report includes a chapter on “Significant Investigations.”  There were eight such investigations, four involving nuclear power plants.  We have previously reported on two of these cases, the Indian Point chemistry manager who falsified test results (see our May 12, 2014 post) and the Palisades security manager who assigned a supervisor to an armed responder role for which he was not currently qualified (see our July 24, 2014 post).  The other two, summarized below, occurred at River Bend and Salem.

In the River Bend case, a security officer deliberately falsified training records by taking a plant access authorization test for her son, a contractor employed by a plant supplier.  Similar to the Palisades case, Entergy elected alternative dispute resolution (ADR) and ended up with multiple corrective actions including revising its security procedures, establishing new controls for security-related information (SRI), evaluating SRI storage, developing a document highlighting the special responsibilities of nuclear security personnel, establishing decorum protocols for certain security posts, preparing and delivering a lessons learned presentation, conducting an independent third party safety culture (SC) assessment of the River Bend security organization [emphasis added], and delivering refresher training on 10 CFR 50.5 and 50.9.  Most of these requirements are to be implemented fleet-wide, i.e., at all Entergy nuclear plants, not just River Bend.**

The Salem case involved a senior reactor operator who used an illegal substance then performed duties while under its influence.  The NRC issued a Level III Notice of Violation (NOV) to the operator.  The operator’s NRC license was terminated at PSE&G’s request.***  PSE&G was not cited in this case.

Our Perspective

You probably noticed that three of the “significant” cases involved Entergy plants.  Entergy is no stranger to issues with a possible cultural component including the following:****

In 2013, Arkansas Nuclear One received a NOV after an employee deliberately falsified documents regarding the performance of Emergency Preparedness drills and communication surveillances.

In 2012, Fitzpatrick received a Confirmatory Order (Order) after the NRC discovered violations, the majority of which were willful, related to adherence to site radiation protection procedures.

During 2006-08, Indian Point received two Orders and three NOVs for its failure to install backup power for the plant’s emergency notification system.

In 2012, Palisades received an Order after an operator left the control room without permission and without performing a turnover to another operator.  Entergy went to ADR and ended up with multiple corrective actions, some fleet-wide.  We have posted many times about the long-running SC saga at Palisades—click on the Palisades label to pull up the posts. 

In 2005, Pilgrim received a NOV after an on-duty supervisor was observed sleeping in the control room.  In 2013, Pilgrim received a NOV for submitting false medical documentation on operators.

In 2012, River Bend received a NOV for operators in the control room accessing the internet in violation of an Entergy procedure. 

These cases involve behavior that was (at least in hindsight) obviously wrong.  It’s not a stretch to suggest that a weak SC may have been a contributing factor.  So has Entergy received the message?  You be the judge.

“Think of how stupid the average person is, and realize half of them are stupider than that.” ― George Carlin (1937–2008)


*  NRC Office of Investigations, “2014 OI Annual Report,” NUREG-1830, Vol. 11 (Feb. 2015).  ADAMS ML15034A064.

**  M.L. Dapas (NRC) to E.W. Olson (River Bend), “Confirmatory Order, Notice of Violation, and Civil Penalty – NRC Special Inspection Report 05000458/2014407 and NRC Investigation Report 4-2012-022- River Bend Station” (Dec. 3, 2014).  ADAMS ML14339A167.

***  W.M. Dean (NRC) to G. Meekins (an individual), “Notice of Violation (Investigation Report No. 1-2014-013)” (July 9, 2014).  ADAMS ML14190A471.

****  All Entergy-related NRC enforcement actions were obtained from the NRC website.

Friday, February 13, 2015

Congressional Panel Slices and Dices Culture in Report on DOE/NNSA

A U.S. congressional panel recently released a report* detailing its recommendations for improving the performance of the National Nuclear Security Administration (NNSA).  NNSA is an agency within the Department of Energy responsible for maintaining the U.S. nuclear weapons stockpile, reducing danger from weapons of mass destruction, providing the Navy with nuclear propulsion, and responding to nuclear and radiological emergencies.**

The panel’s report has a host of recommendations and action items for making NNSA more effective, including changing the agency’s management culture to be more mission performance oriented.  The report’s key points would fit on one page but of course they aren’t presented that way; this is a 188 page government report with a 16 page executive summary.

What caught our eye was how many different types of culture were mentioned in the report.  While the report’s focus was putatively on management culture, the authors also referred to DOE, civilian, enterprise, risk management, risk aversion, safety, entitlement, non-inclusion, governance, corporate, compliance, security, professional, organizational, reliability and generic “culture.”  I am not making this up.

With so many types of culture, one might think there must have been a significant effort to define culture.  Well, no.  I saw only one definition of culture: “A common definition of management culture is, “This is how things are done here.”” (p. 39)  Could they have done better?  You be the judge.

Lots of insight into culture?  Not really.  I saw one systemic observation about culture: “In a healthy organization, management practices and culture are mutually reinforcing in creating productive behaviors: management practices shape the culture; the culture shapes behaviors and reinforces the management practices.” (ibid.)  We’ll award E for Effort here because this can be true although not always.

So it’s culture this and culture that but it’s left as an exercise for the reader to determine what exactly culture is and how the various sub-cultures contribute to an understanding of the larger picture.

Our Perspective

Every member of the panel has an opinion of what organizational culture is.  However, without a precise definition and a representation of how culture relates to other organizational factors (including hard ones like practices and soft ones like leadership and trust) there is no shared mental model.  And without that, there is no clear appreciation of how their proposed interventions might leverage (or antagonize) the existing culture or even work at all.  This lack of effort on culture is especially disappointing given that one member of the panel was the NRC Chairman back when that agency was agonizing endlessly over the proper definition of safety culture.

But let’s look at the larger reality here.  Most people (myself included) will never take the time to wade through a report like this and that’s probably the way the serious stakeholders (DOD, DOE and their contractors) want it; they are willing to play along with Congress rearranging the lounge car chairs as long as the money train keeps running.


*  Congressional Advisory Panel on the Governance of the Nuclear Security Enterprise, “A New Foundation for the Nuclear Enterprise” (Dec. 2014).  Thanks to Bill Mullins for recommending this report. 

**  National Nuclear Security Administration website.

Friday, February 6, 2015

Corrosion in the Culture of the DNFSB?



We have posted many times on the Defense Nuclear Facilities Safety Board’s (DNFSB) efforts to get the Department of Defense (DOE) to confront and resolve its safety culture (SC) issues.  Now it appears the DNFSB has management and cultural issues of its own.  In a stinging report* by an outside consultant, DNFSB board members are said to have a “divisive and dysfunctional relationship” and the organizational culture is called “toxic.” (p. iii)  This post highlights the cultural aspects of selected issues and the proposed fixes.

Major issues that can affect culture are the board itself, the negative tone of oral and written communications, and the performance recognition system.

DNFSB is a small agency (100+ people) and most work in the same office.  There is no place to hide from the effects of troubles at the top.  The Board’s basic problem is that the members don’t have a shared mental model of the DNFSB’s mission and strategies.  And, because the members are political appointees representing both major parties, creating some kind of unity is a major challenge.  The report contains many recommendations related to improving board functioning but the reality is it’s mainly a political issue.  Board dysfunctionality is a cultural issue because hydra-headed leadership distracts, confuses and ultimately demoralizes the agency staff.  Most alarming to us, to the extent investigations are driven by board members’ interests rather than by science and safety considerations (a perception reported by some staff), the board’s shortcomings can impinge on the agency’s SC. 

Communications problems start at the board level and permeate the agency. Negative communications, e.g., condescending language and personal attacks, lead to a culture of disrespect.  The recommendations for communications include “Immediately ensure a professional tone in all communications, both among board members and throughout the Agency.  Consider use of an internal communication code of conduct.” (p. 3-2)  In our view, business communications should focus on the issues, be respectful and exhibit a modicum of integrity.

Performance recognition recommendations include “Assess staff sentiment with regard to priorities for nonmonetary incentives, and develop offerings accordingly.” (p. 3-5)  Nonmonetary recognition was mentioned by an employee committee tasked with identifying underlying causes for DNFSB’s declining scores on the periodic federal employee viewpoint survey.  We’re not sure why monetary recognition is off the table, perhaps because of perceived budget problems.  Our feeling is if some type of above-and-beyond behavior is worth recognizing, then an organization should be willing to pay something for it.

There are also a couple of more straightforward management issues: frequent disruptive organizational changes, and the lack of management and leadership competence.  If not addressed, such issues can certainly weaken culture but they are not as important as the ones described previously.

Change management recommendations include “Develop a change management organizational competency . . .  [and] a change management plan, . . .” (p. 3-3)  As an aside, the NRC Inspector General (IG) provides IG services to the DNFSB; an October 2014 IG report** identified change management as a serious challenge facing the agency.

Increasing competence corrective actions include “Institute tailored management and supervisory training for technical staff management and supervisors. . . .” (p. 3-3)  This is not controversial; it simply needs to be accomplished.

Our Perspective 

If the report accurately describes DNFSB’s reality, it looks like a bit of a mess.  The board’s chairman recently retired so the President has an opportunity to nominate someone who is willing and able to clean it up.  Absent competent leadership from the top, the report’s recommendations may make a dent in the problems but will not be a cure-all.

We wish them well.  If the DNFSB’s focus wanes, it bodes ill for efforts to spur DOE to increase its management competence and strengthen its SC.


*  J. O'Hara and P.M. Darmory, “Assessment of the Defense Nuclear Facilities Safety Board Workforce and Culture,” Report DNF40T1 (Dec. 2014).  Thanks to Bill Mullins for recommending this report.

**H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.

Thursday, January 29, 2015

Safety Culture at Chevron’s Richmond, CA Refinery



The U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report* on the August 2012 fire at the Chevron refinery in Richmond, CA caused by a leaking pipe.  In the discussion around the CSB’s interim incident report (see our April 16, 2013 post) the agency’s chairman said Chevron’s safety culture (SC) appeared to be a factor in the incident.  This post focuses on the final report findings related to the refinery’s SC.

During their investigation, the CSB learned that some personnel were uncomfortable working around the leaking pipe because of potential exposure to the flammable fluid.  “Some individuals even recommended that the Crude Unit be shut down, but they left the final decision to the management personnel present.  No one formally invoked their Stop Work Authority.  In addition, Chevron safety culture surveys indicate that between 2008 and 2010, personnel had become less willing to use their Stop Work Authority. . . . there are a number of reasons why such a program may fail related to the ‘human factors’ issue of decision-making; these reasons include belief that the Stop Work decision should be made by someone else higher in the organizational hierarchy, reluctance to speak up and delay work progress, and fear of reprisal for stopping the job.” (pp. 12-13) 

The report also mentioned decision making that favored continued production over safety. (p. 13)  In the report’s details, the CSB described the refinery organization’s decisions to keep operating under questionable safety conditions as “normalization of deviance,” a term popularized by Diane Vaughn and familiar to Safetymatters readers. (p. 105) 

The report included a detailed comparison of the refinery’s 2008 and 2010 SC surveys.  In addition to the decrease in employees’ willingness to use their Stop Work Authority, surveyed operators and mechanics reported an increased belief that using such authority could get them into trouble (p. 108) and that equipment was not properly cared for. (p. 109) 

Our Perspective

We like the CSB.  They’re straight shooters and don’t mince words.  While we are not big fans of SC surveys, the CSB’s analysis of Chevron’s SC surveys appears to show a deteriorating SC between 2008 and 2010. 

Chevron says they agree with some CSB findings however Chevron believes “the CSB has presented an inaccurate depiction of the Richmond Refinery’s current process safety culture.”  Chevron says “In a third-party survey commissioned by Contra Costa County, when asked whether they feel free to use Stop Work Authority during any work activity, 93 percent of Chevron refinery workers responded favorably.  The overall results for the process safety survey exceeded the survey taker’s benchmark for North American refineries.”**  Who owns the truth here?  The CSB?  Chevron?  Both?    

In 2013, the city of Richmond adopted an Industrial Safety Ordinance (RISO) that requires Chevron to conduct SC assessments, preserve records and develop corrective actions.  The CSB recommendations including beefing up the RISO to evaluate the quality of Chevron’s action items and their actual impact on SC. (p. 116)

Chevron continues to receive blowback from the incident.  The refinery is the largest employer and taxpayer in Richmond.  It’s not a company town but Chevron has historically had a lot of political sway in the city.  That’s changed, at least for now.  In the recent city council election, none of the candidates backed by Chevron was elected.***

As an aside, the CSB report referenced a 2010 study**** that found a sample of oil and gas workers directly intervened in only about 2 out of 5 of the unsafe acts they observed on the job.  How diligent are you and your colleagues about calling out safety problems?


*  CSB, “Final Investigation Report Chevron Richmond Refinery Pipe Rupture and Fire,” Report No. 2012-03-I-CA (Jan. 2015).

**  M. Aldax, “Survey finds Richmond Refinery safety culture strong,” Richmond Standard (Jan. 29, 2015).  Retrieved Jan. 29, 2015.  The Richmond Standard is a website published by Chevron Richmond.

***  C. Jones, “Chevron’s $3 million backfires in Richmond election,” SFGate (Nov. 5, 2014).  Retrieved Jan. 29, 2015.

****  R.D. Ragain, P. Ragain, Mike Allen and Michael Allen, “Study: Employees intervene in only 2 of 5 observed unsafe acts,” Drilling Contractor (Jan./Feb. 2011).  Retrieved Jan. 29, 2015.

Friday, January 23, 2015

Defense in Depth and Safety Culture from an IAEA Conference


A 2013 IAEA conference focused on the concept of Defense in Depth (DID) and its implementation at nuclear facilities.  It was a large-scale event with almost 50 presentations and papers.  The published proceedings* run over 350 pages.  This post focuses on the treatment of safety culture (SC) by the authors and presenters.  The proceedings started off well: SC was explicitly mentioned as a cross-cutting issue in the implementation of DID. (p. 1)  In addition, the conference itself was predicated on Fukushima lessons learned which, as everyone now knows, included SC shortcomings in both licensee and government organizations.

But on the whole the treatment of SC was something of a disappointment.  The presentations from Argentina, Pakistan and Vietnam mentioned SC in passing.  The presentation from Egypt discussed the regulator’s role in SC oversight at length. (pp. 302-304)  Only the following three presentations gave SC a featured role.

SC in WANO

The World Association of Nuclear Operators (WANO) presenter said this about SC: “Safety supposes that no operator feels isolated, or refuses openness and permanent self-questioning; it requests as well for WANO to ensure that cultural and sometimes political barriers do not hinder safety culture . . . . In WANO, we believe that management system and practices are at the centre of safety culture, and a full involvement of top management (CEOs) of our members is absolutely requested.”**

SC in Indonesia

Two papers discussed SC at different nuclear facilities in Indonesia.  Desirable SC characteristics at both facilities were based on INSAG-4.

The Experimental Fuel Element Installation (EFEI)

The abstract of this paper*** highlighted SC’s role at this facility.  “The application of safety culture in a nuclear facility is one way of DID implementation.  Safety culture aims at the performance of safe works, the prevention of deviation, and the accomplishment of quality operation.  It is in accordance with the first level of DID concept which is the prevention of abnormal operation and failures that is done through conservative design and high quality in construction and operation. . . The objective of safety culture implementation in the EFEI is to encourage workers to have a stronger sense of responsibility on safety and to contribute actively for its development”  The paper presented a laundry list of strategies used to strengthen SC including briefings, workshops, training, senior management visits, integration of safety into work processes, self-assessments, open reporting on safety incidents, open and timely reporting to the regulator, evaluation of safety performance indicators and an annual SC questionnaire.

The authors displayed a bit of realism when they said “Leaders cannot completely control safety culture, but they may influence it.” (p. 179)  They also said their questionnaire results indicated that EFEI SC is at Stage 2 (from IAEA-TECDOC-1329) where “Safety becomes an organizational goal.”  They want SC to evolve to Stage 3 where the organization believes “Safety can always be improved.” (pp. 187-188)

Kartini Research Reactor

This paper**** reported the findings of a SC self-assessment.  The method consisted of questionnaire responses reviewed by experts.  The assessment identified several good current practices in maintaining the safety status of Kartini reactor.  As supporting evidence, the authors noted the number of inspection/audit findings from the regulator went down while reactor utilization and operating hours increased over the past several years.  One opportunity for improvement was the need for more frequent dialogues between employees and managers.

Our Perspective

There is not much SC substance here.  The recitations on SC repeated familiar stuff you’ve seen in lots of places.  In other words, zero new information or insight.  The single page WANO presentation indicates their lowest common denominator audience is even lower than IAEA’s.  Perhaps there were technical issues discussed at the conference that are of interest to you.  Otherwise, don’t invest your coffee break in going through this lengthy document.


*  IAEA, International Conference on TopicalIssues in Nuclear Installation Safety: Defence in Depth — Advances andChallenges for Nuclear Installation Safety, Oct. 21-24, 2013 ConferenceProceedings, IAEA-TECDOC-CD-1749 (Vienna, 2014).  We are grateful to Madalina Tronea for publicizing this material.  Dr. Tronea is the founder and moderator of the LinkedIn Nuclear Safety Culture forum.

**  J. Regaldo, “WANO Actions to Reinforce the Operators’ Safety Culture Worldwide,” p. 147.

***  H. Hardiyanti, B. Herutomo and G. K. Suryaman, “Safety Culture as a Pillar of Defense-in-Depth Implementation at the Experimental Fuel Element Installation, Batan, Indonesia,” pp. 173-188.

****  S. Syarip, “Safety Management and Safety Culture Self Assessment of Kartini Research Reactor,” pp. 321-326.