Safety Culture A Case for Change

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Safety Culture A Case for Change

• George K. Mortensen
• Senior Program Manager Industry External
  Relations
• Institute of Nuclear Power Operations (INPO)

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Quotes

• If you want to make enemies, try to change
  something.
• Woodrow Wilson
• If we don't change direction soon, we'll end up
  where we're going.
• Professor Irwin Corey
• The future has a way of arriving unannounced.
• George Will

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Culture - Where are you headed?
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Topics

• Safety culture according to INPO
• Learning from the past
• INPOs continuing focus on safety culture
• Safety culture lessons learned
• Looking ahead to the future

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Safety Culture - According to INPO

• Safety Culture
• An organizations values, behaviors modeled by
  its leaders and internalized by its members
  that serve to make nuclear safety an overriding
  priority.
• Typical industry definition Its what your
  people do (or dont do) on night shift when you
  are not around.
• Culture is for the group what character and
  personality are for the individual
• It starts at the top

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IAEA Definition of Safety Culture

• That assembly of characteristics and attitudes
  in organizations and individuals which
  establishes that, as an overriding priority,
  (nuclear) plant safety issues receive the
  attention warranted by their significance.
• Source International Atomic Energy Agency
  (IAEA). 1991. Safety Culture, Safety Series, No.
  75-INSAG-4. Vienna International Atomic Energy
  Agency.

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European Understanding the 7 S of Safety
Culture ....
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Principles for a Strong Safety Culture - INPO

• The 8 Principles
• Everyone is personally responsible for nuclear
  safety.
• Leaders demonstrate commitment to nuclear safety.
• Trust permeates the organization.
• Decision-making reflects safety first.
• Nuclear technology is recognized as special and
  unique.
• A questioning attitude is cultivated.
• Organizational learning is embraced.
• Nuclear safety undergoes constant examination.

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Various Approaches Same Focus
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Learning From the Past -- Events With Significant
Safety Culture Impact

• RMS Titanic (1912)
• TMI Case Study (1979)
• Bhopal Event (1982)
• Salem Marsh Grass Event (1984)
• Challenger Case Study (1986)
• Chernobyl Case Study (1986)
• USS Greeneville Case Study (2001)
• Davis-Besse Case Study (2002)
• Columbia Case Study (2003)
• Various Ethics Case Studies

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Three Mile Island The initiating event for INPO
Systematic gathering analysis of operating
experience
Operator continuing training plant simulators
Agency-accredited training institutions
Set and police its own standards of
excellence Strive for dramatic change in attitude
toward safety (safety culture)
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THEMES from Extended Plant Shutdowns...

• Overconfidence
• Isolationism
• Managing Relationships
• Operations and Engineering
• Production Priorities
• Managing Change
• Plant Events
• Nuclear Leaders
• Self-Critical

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Top 10 Reasons Nuclear WorkersDon't Comply with
Safety Culture Expectations

• 10. Ignorance -- I did not know this was a
  hazard."
• 9. Lack of skill -- "I did not know what to do
  about it."
• 8. Mistrust of authority -- "They lied to us
  before about safety, so how do I know they're
  telling the truth now?"
• 7. Personal experiences -- Risk taking Nothing
  bad ever happened to me before by doing it this
  way, so why worry now?"
• 6. Lack of incentives -- "What's in it for me?
  Why should I follow this much harder procedure?"
• 5. Mixed incentives -- "My boss tells me to
  report unsafe conditions but still expects me to
  get the job done on time and with less help.
• 4. Unclear disciplinary processes -- "Nothing
  bad will happen to me if I ignore the hazard or
  do things my own way."
• 3. Group norms -- "If I point out the hazard, my
  buddies will think I'm ratting on them or if I
  insist on following some procedure, they'll think
  I'm a wimp risk taking."
• 2. Macho self-image -- "I can do this job in
  spite of the hazards, thrill of risk taking, I
  can be a hero, and others will respect me for
  it."
• 1. Personality factors -- "I know better - who
  needs to work that hard? Who cares - it's not my
  problem."

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RISK Taking- A Significant Influence on Safety
Culture

• Chemicals in the brain determine whether a person
  is a risk-taker or risk avoider or somewhere
  in-between
• Risk Decisions May have their roots in the
  Fight or Flight nature of man
• The Human is the only animal that knowingly takes
  Risks for pleasure
• The adrenaline surge after a successful risk is a
  large PIC Positive, Immediate, Certain effect
• Reinforced risk taking can cause non conservative
  decision making

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Risks Can Be Evaluated Ahead of Time

• Northeast Blackout (August 14, 2003)
• No major equipment failures, thus no major
  surprises

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INPOs Continuing Focus on Safety Culture
Evaluations
Events Analysis and Information Exchange
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Safety Culture Can Be Observed

• We like to observe attitudes, behaviors
  conditions

• We also prepare our evaluators with performance
  information

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Safety Culture and Plant Evaluations

• Safety Culture Principals are included in our
  Performance Objectives Criteria (POC) --
  (OR.1)
• No Stand-alone Safety Culture POC
• Techniques developed to help teams evaluate
  safety culture
• Safety Culture Touch Points Established to Push
  Discussions
• Many more high activity period observations being
  made Refueling Outages, Reactor Startups, or
  Shutdowns
• Analysis Review includes Safety Culture look

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Tools for Evaluating Safety Culture

• Safety culture bubble chart
• Safety culture relative ranking
• Safety culture summary observation
• Corrective action database
• Root cause reports
• Event reports
• Oversight reports
• Significant Operating Experience Report (SOER)
  02-4, Revision 1 Davis-Besse Event

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Safety Culture Touch Points during Plant
Evaluations

• Pre-visit at site
• Discuss evaluation methodology with SVP
• 2nd Week Phone Call at INPO
• Discuss observation facts and conclusion
• 2nd Week Analysis Meeting at site
• Analyze SC using Evaluation tools
• OR assessment meeting at INPO
• Discuss SC findings and results
• Pre-Exit Meeting
• Discuss SC findings and results
• CEO Exit
• Discuss health of safety culture

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Safety Culture Bubble Chart
SAMPLE TEXT Weak self-assessments, root cause
determinations, trending processes.
SAMPLE TEXT Leaders demonstrate commitment and
are open to input, but they are not sufficiently
involved.
Leaders demonstrate commitment to safety.
Organizational learning is embraced.
Nuclear safety is everyones responsibility.
SAFETY CULTURE
A what if approach is cultivated.
Decision-making reflects safety first.
Nuclear safety undergoes constant examination.
Nuclear is recognized as different.
Trust permeates the organization.
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Safety Culture Relative Ranking
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Evaluation Results

• 34 plant evaluations and domestic peer reviews
  were conducted in 2005
• Nine AFIs were written that refer to shortfalls
  with the safety culture principles. These AFIs
  cited deficiencies with 15 principles.
• Recent OR.1 AFI Example
• A systematic, rigorous approach has not been used
  for important decisions, this has resulted in
  automatic shutdowns and isolations, distractions
  to the workforce and increased dose, and
  challenged automatic safety features. Also,
  oversight of these decisions by the station
  leadership team is lacking.

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INPO Programs
INPO Programs
Evaluations
Evaluations
Events Analysis and Information Exchange
Events Analysis and Information Exchange
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Events Analysis and Safety Culture

• Screeners add SC (Safety Culture) code to
  potential events
• Follow-up with station for additional detail on
  these events
• Trend reports
• Earlier identification of declining performance
• Performance Indicators
• NRC Reactor Oversight Process
• Analysis Review Board

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INPO Significant Operating Experience Report
(SOER) 02-04

• Recommendations
• Cover the Davis-Besse case study, or a similar
  case study, with all managers and supervisors.
  Continue on a periodic basis and for new managers
  and supervisors.
• Conduct a self-assessment to determine to what
  degree your organization has a healthy respect
  for nuclear safety and that nuclear safety is not
  compromised by production priorities. The
  self-assessment should emphasize the leadership
  skills and approaches necessary to achieve and
  maintain the proper focus on nuclear safety.
• Identify and document abnormal plant conditions
  or indications at your station that cannot be
  readily explained. Pay particular attention to
  long-term unexplained conditions.
• Recommendations can be evaluated every plant
  evaluation.

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INPO Programs
Evaluations
Events Analysis and Information Exchange
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Training and Safety Culture

• Train the way you work
• Safety culture elements embedded in training
• HPI training reinforces safety culture
• Management owns training
• Periodic comprehensive training accreditation
  board review (Safety culture is in evidence)
• Emphasis during our seminars and courses

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INPO Programs
Evaluations
Events Analysis and Information Exchange
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Assistance Activities

• Assistance visits look at safety culture
• Comments provided at assistance debrief
• Senior representatives assigned for assistance
  interactions
• Four key activities
• Operator turnover
• Oncoming shift crew briefing
• Plan of the day meeting (Leadership meeting)
• Condition report screening

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INPO Lessons Learned

• Significant events typically drive major safety
  culture changes
• Safety culture principles are effective
• Strong safety culture yields strong performance
• Senior management must buy into and reinforce
  safety culture principles (i.e., it starts at the
  top)
• Tendency to become complacent is difficult to
  overcome

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Looking Ahead to the Future

• Principles for a Strong Nuclear Safety Culture
  are not expected to change
• Gain experience with new evaluation Performance
  Objectives Criteria
• OR.1 FOUNDATION FOR NUCLEAR SAFETY
• OR.2 LEADERSHIP AND MANAGEMENT
• OR.3 HUMAN PERFORMANCE
• OR.4 MANAGEMENT AND LEADERSHIP DEVELOPMENT
• OR.5 INDEPENDENT MONITORING AND ASSESSMENT
• Continue to embed Safety Culture elements deeply
  into the 4 INPO Cornerstone programs
• Work with the NRC on the integration of Safety
  Culture into the Reactor Oversight Process
• Further Integration of Safety Culture and Human
  Performance?

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Davis-Besse Lessons Learned
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How close were we to the corner?
Source James Reason. Managing the Risks of
Organizational Accidents, 1997 (in press).