1 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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Safety Culture – A Case for Change

George K. MortensenSenior Program Manager Industry & External RelationsInstitute 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 • INPO’s 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 organization’s values, behaviors – modeled by its leaders and internalized by its members – that serve to make nuclear safety an overriding priority.

Typical industry definition – “It’s what your people do (or don’t 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 .... Skills

Structure

Style

Shared Values

Supervision

Staff

Safety Strategy

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Principles for a Strong Safety Culture - INPO

The 8 Principles:1. Everyone is personally responsible

for nuclear safety.

2. Leaders demonstrate commitment to nuclear safety.

3. Trust permeates the organization.

4. Decision-making reflects safety first.

5. Nuclear technology is recognized as special and unique.

6. A questioning attitude is cultivated.

7. Organizational learning is embraced.

8. Nuclear safety undergoes constant examination.

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Various Approaches – Same Focus

NRC Subcomponent INPO Attribute IAEA Attribute

Safety conscious work environment policies

People are treated with respect Management shows a continuous effort to strive for openness and good communication.

Willingness to raise concerns Employees are expected and encouraged to offer innovative ideas to help solve problems

An open reporting of deviations and errors is encouraged

Questioning attitude exists Personnel do not proceed in the face of uncertainty

A questioning attitude prevails at all organizational levels

Operating Experience is used Individuals are well informed of underlying lessons learned from significant industry and station events.

Internal and external operating experience is used

Continuous learning environment exists The organization avoids complacency and cultivates a continuous learning environment

There is a systematic development of staff competencies

Change is managed effectively The effects of impending changes are anticipated and managed such that trust in the organization is maintained

Safety implications are considered in the change management process

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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 Three Mile Island – The initiating event for INPO event for INPO

Three Mile Island – The initiating Three Mile Island – The initiating event for INPO event for INPO

Set and police its own standards of excellenceStrive for dramatic change in attitude toward safety

(safety culture)

Operator continuing training & plant simulators

Agency-accredited training institutions

Systematic gathering & analysis of operating experience

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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

Source: Dr. Edgar Schein 13

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

Plant Complications Modeled

Normal CDF/Event Mean CDF

Time without power

Fermi-2 Gas turbine failed to start – recovered in 3 hours

5.0E-6 / 2E-4 6 hr. 19 min.

FitzPatrick

None 2.44E-6 / 9E-5 2 hr. 49 min.

Ginna PORV’s opened once; MDAFW failed to start

3.96E-5 / 2E-4 0 hr. 49 min.

Indian Point 2

None 2.6E-5 / 1E-4 1 hr. 37 min.

Indian Point 3

None 1.35E-5 / 7E-5 1 hr. 37 min.

Nine Mile Pt. 1

None 1.3E-5 / 3E-5 0 hr. 56 min.

Nine Mile Pt. 2

None 4.8E-5 / 5E-4 6 hr. 24 min.

Perry RCIC manually isolated at 3 hrs, LPCS and RHR B affected by keep fill system problem

7.4E-6 / 5E-4 1 hr. 27 min.

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INPO’s Continuing Focus

on Safety Culture

Training andTraining andAccreditationAccreditation

Events Analysis andEvents Analysis andInformation ExchangeInformation Exchange AssistanceAssistance

EvaluationsEvaluations

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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 (PO&C) -- (OR.1)

• No Stand-alone Safety Culture PO&C• 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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• 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

Tools for Evaluating Safety Culture

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Safety Culture “Touch Points” during Plant Evaluations1. Pre-visit at site

– Discuss evaluation methodology with SVP

2. 2nd Week Phone Call at INPO– Discuss observation facts and conclusion

3. 2nd Week Analysis Meeting at site– Analyze SC using Evaluation tools

4. “OR” assessment meeting at INPO– Discuss SC findings and results

5. Pre-Exit Meeting– Discuss SC findings and results

6. CEO Exit– Discuss health of safety culture

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Organizational learning is embraced.

SAFETY CULTURE

Decision-making reflects safety first.

Nuclear safety is everyone’s

responsibility.

Nuclear is recognized as different.

Leaders demonstrate commitment to safety.

Trust permeates the organization.

Nuclear safety undergoes constant

examination.

A ‘what if’ approach is cultivated.

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.

Safety Culture “Bubble Chart”

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Principles and Selected Attributes Delta Neutral Positive PM 1. Nuclear safety is everyone’s responsibility Relative Ranking The line of authority and responsibility for nuclear safety is defined.

+

Healthy accountability is exercised at all levels of the organization for shortfalls in meeting standards.

+

The system of rewards and sanctions is aligned with safety policies.

+

2. Leaders demonstrate commitment to safety The nuclear safety message is communicated frequently and consistently, occasionally as a stand-alone theme.

+

Managers and supervisors practice visible leadership in the field by placing “eyes on the problem,” coaching, mentoring, and reinforcing standards.

0

Leaders recognize that aggressive production goals can appear to send mixed signals on the importance of nuclear safety. Managers are sensitive to detect and avoid these misunderstandings.

-

3. Trust permeates the organization A variety of methods are available by which personnel can raise nuclear safety concerns without fear of retribution.

+

Impacts of significant changes are anticipated and managed.

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4. Decision making reflects safety first Plant personnel apply a rigorous approach to problem solving. Conservative actions are taken when understanding is incomplete.

0

Managers regularly communicate to the workforce important decisions and their bases.

-

Decision making practices reflect the ability to distinguish between “allowable” choices and prudent choices.

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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




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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




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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




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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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Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).

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How close were we to the corner?

Documents

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