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Safety Culture A Case for Change

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Title: Safety Culture A Case for Change


1
Safety Culture A Case for Change
  • George K. Mortensen
  • Senior Program Manager Industry External
    Relations
  • Institute of Nuclear Power Operations (INPO)

2
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

3
Culture - Where are you headed?
4
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

5
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

6
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.

7
European Understanding the 7 S of Safety
Culture ....
8
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.

9
Various Approaches Same Focus
10
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

11
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)
12
THEMES from Extended Plant Shutdowns...
  • Overconfidence
  • Isolationism
  • Managing Relationships
  • Operations and Engineering
  • Production Priorities
  • Managing Change
  • Plant Events
  • Nuclear Leaders
  • Self-Critical

13
Top 10 Reasons Nuclear Workers Don'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."

14
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

15
Risks Can Be Evaluated Ahead of Time
  • Northeast Blackout (August 14, 2003)
  • No major equipment failures, thus no major
    surprises

16
INPOs Continuing Focus on Safety Culture
Evaluations
Events Analysis and Information Exchange
17
Safety Culture Can Be Observed
  • We like to observe attitudes, behaviors
    conditions
  • We also prepare our evaluators with performance
    information

18
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

19
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

20
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

21
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.
22
Safety Culture Relative Ranking
23
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.

24
INPO Programs
INPO Programs
Evaluations
Evaluations
Events Analysis and Information Exchange
Events Analysis and Information Exchange
25
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

26
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.

27
INPO Programs
Evaluations
Events Analysis and Information Exchange
28
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

29
INPO Programs
Evaluations
Events Analysis and Information Exchange
30
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

31
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

32
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?

33
Davis-Besse Lessons Learned
34
How close were we to the corner?
Source James Reason. Managing the Risks of
Organizational Accidents, 1997 (in press).
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