IAEA International Atomic Energy Agency

Lessons Learned about

Safety Culture

in relation to the

National Nuclear Safety Infrastructure

Monica Haage – m.haage@iaea.org

Operational Safety Section

IAEA

Self Reflecting Questions

• What does Safety Culture mean to you:

• as a regulator?

• as a part of a national nuclear programme?

• as part of the global safety regime?

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IAEA Safety Standards

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IAEA Safety Standard - Characteristics and

Attributes for Strong Safety Culture

(GS-G-3.1)

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Safety is a clearly recognized value Attributes

• High priority to safety: shown in documentation, communications and decision- making

• Safety is a primary consideration in the allocation of resources

• The strategic business importance of safety is reflected in business plan

• Individuals are convinced that safety and production go ‘hand in hand’

• A proactive and long-term approach to safety issues is shown in decision-making

• Safety conscious behavior is socially accepted and supported (both formally and informally)

GS-G-3.1

IAEA

Accountability for safety is clear Attributes

• Appropriate relationship with the regulatory body exists, which ensures

that the accountability for safety remains with the licensee

• Roles and responsibilities are clearly defined and understood

• There is a high level of compliance with regulations and procedures

• Management delegates responsibilities with appropriate authority to

enable accountabilities

• Ownership for safety is evident at all organizational levels and by all

individuals

GS-G-3.1

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Safety is learning driven Attributes

• A questioning attitude prevails at all organizational levels

• An open reporting of deviations and errors is encouraged

• Internal and external assessments, including self-assessments are used

• Organizational and operating experience (both internal and external to

the facility) is used

• Learning is enabled through the ability to recognize and diagnose

deviations, formulate and implement solutions and monitor the effects of

corrective actions

• Safety performance indicators are tracked, trended, evaluated and

acted upon

• There is a systematic development of staff competencies

GS-G-3.1

IAEA

Safety is integrated into all activities

Attributes

• Trust permeates the organization

• Consideration for all types of safety, including industrial and environmental safety and security, is evident

• Quality of documentation and procedures is good

• Quality of processes, from planning to implementation and review, is good

• Individuals have the necessary knowledge and understanding of the work processes

• Factors affecting work motivation and job satisfaction are considered

• Good working conditions exist with regards to time pressures, work load and stress

• Cross-functional and interdisciplinary cooperation and teamwork are present

• Housekeeping and material condition reflect commitment to excellence

GS-G-3.1

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Leadership for safety is clear Attributes

• Senior management is clearly committed to safety

• Commitment to safety is evident at all management levels

• Visible leadership showing involvement of management in safety related

activities

• Leadership skills are systematically developed

• Management assures that there is sufficient and competent staff

• Management seeks the active involvement of staff in improving safety

• Safety implications are considered in the change management process

• Management shows a continuous effort to strive for openness and good

communications throughout the organization

• Management has the ability to resolve conflicts as necessary

• Relationships between management and staff are built on trust

GS-G-3.1

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Learn from

experience

Basis:

- IAEA Safety

Standards

- Global safety regime

(Review services,

meetings, etc.)

Regulatory oversight

strategy

Look

ahead

Outcomes:

- Develop regulations

- Enforce regulations

The Role of the Regulator in the

Nuclear National Infrastructure

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Regulatory Principles

In 2002, an IAEA Consultancy Meeting identified four

regulatory principles:

“Responsibility” Principle

• Responsibility for safety must always be with the

operating organization

“Don’t make it worse” Principle

• Regulators should be conscious that they do not take

actions that can have a negative impact on the safety

culture of the operating organization

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Regulatory Principles (Cont’d)

“Foster organizational learning” Principle

• Regulatory activities and questions should foster

self-reflection and learning within the licensee’s

organization

“Regulatory balance” Principle

• Balance three regulatory roles: expert role, authority

role, and public role

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The Role of the Regulator in the

Nuclear National Infrastructure

13

Expert

role

Authority

role

Public

role

• Dialogue and cooperation

- national and international

• Self-criticism

• Reflectivity

Competence

• Independence

• Mediated control

• Perception

Effectiveness

• Reporting

• Informing

• Openness

Credibility

Uncertainty Communication

Accountability

Reiman, T. & Norros, L. (2002).

Regulatory Culture: Balancing the

Different Demands of Regulatory

Practice in the Nuclear Industry.

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When things go wrong…

Why is the regulator blamed?

- Fukushima

- Deepwater Horizon

People in the nation trust the regulator to ensuring

protection of people and the environment (from

harmful effects of ionizing radiation)

Learn from experience

Basis: - IAEA Safety

Standards - Global safety

regime (Review services, meetings, etc.)

Regulatory oversight strategy

Look ahead

Outcomes: - Develop regulations - Enforce regulations

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“The weakest link”

The technical factors are advanced and robust

• The safety principles are well developed

• The safety review services and assessments are effective

• The safety processes are advanced and well developed

All these are well structured and provides high level of safety

But, the root causes to accidents are not be found solely in the technology – they are

rooted in the human and organizational constraints e. g.

• How the technology is maintained

• How the safety principles and safety standards are implemented

• How the safety review services are assessments are utilized

The experience as well as the safety science shows that 90% or more is due to the

human and organizational factors and their interaction with the technology

IAEA International Atomic Energy Agency

A Nuclear Safety Action Plan activity

International Experts Meeting (IEM5) on

Human and Organizational Factors in Nuclear Safety in the

Light of the Accident at the Fukushima Daiichi NPP

Vienna, 21 – 24 May 2013

IAEA

• An International Experts Meeting on Human and Organizational

Factors in Nuclear Safety in the Light of the Accident at the

Fukushima Daiichi Nuclear Power Plant (IEM5) was arranged on

21-24 May 2013

• Part of a series of meetings arranged by the IAEA in response to

the Fukushima Accident

• 160 participants from 40 Member States

• Brought together leading experts from areas such as research,

industry, regulatory control and safety assessment and made it

possible for experts to share the lessons learned from the

accident and identify relevant best practices

Lessons learned from The Fukushima Accident: IEM5

無断複製・転載禁止 東京電力株式会社 無断複製・転載禁止 東京電力株式会社 18

Lessons of TEPCO’s Fukushima Accident

from Human and Organizational Aspects

and Challenge for Nuclear Reform

May 21, 2013

@IAEA IEM5

Akira Kawano

Tokyo Electric Power Company

Some of TEPCO’s conclusion in IEM5 The IAEA International Expert Meeting on Human and Organizational Factors

TEPCO: “The cause of the accident should not be treated merely as a natural disaster due to an enormous tsunami being something difficult to anticipate.

We believe it is necessary to seriously acknowledge the result that TEPCO failed to avoid an accident which might have been avoided if ample preparations had been made in advance with thorough use of human intellect.”

TEPCO concluded the following in the IAEA International Expert Meeting5:

• Believed that severe accident was unlikely

• Did not pay attention to low probability high consequence risks

• Missed out the opportunities to learn from others and improve

• Preparation for severe accident management was somewhat deficient

Nuclear Safety

Human and Organizational Factors

Lessons from Fukushima

Kenzo Oshima （NRA Commissioner）

International Experts Meeting

IAEA

May, 2013

Was the accident preventable?

Yes, if…

- “Safety first” policy had been strictly

enforced; risks had been squarely faced;

- Severe accident measures (defense-in-

depth) were in place (esp. natural hazards);

- International safety standards and good

practices had been followed;

- Delays in reinforcements had been

avoided…..

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• The discrete human and organizational factors are important,

but not enough – their interactions with the technology needs

also to be taken into account (HTO/Systemic Approach)

• HTO/Systemic Approach to Safety on organizational level

(encompass the human and organizational interdependencies

with the technology within the organization)

• HTO/Systemic Approach to Safety on national level

(encompass how different organizations/groups influence each

other, e. g. governments, regulatory bodies, licensees, public,

TSOs)

IEM5: Lessons learned 1 – HTO/Systemic Approach

IAEA

H,T,O Complemented with Systemic View HTO

“Human and organizational factors are often considered as discrete variables in

that they are commonly viewed as separate and identifiable issues in the cause of

an event. Examples include lack of training, incorrect procedures, poor decision

making and ineffective communication.

While these factors may very well play a separate and significant role in an

operational failure, it is often a combination of several human, organizational and

technological factors that leads to events and accidents.”

“The complexity of nuclear power plant operating organizations has been

increasing, with higher standards of safety, downward pressure on resources,

increased regulatory requirements, and the accumulation of information and

operating experience. Consequently, to ensure that safety is maintained in this

complex environment, a complementary approach to safety is needed,

taking into account the combination and interaction of all factors in the

operation of a nuclear power plant.”

Examples of Human, Organizational and Technical Factors (HTO)

Organizational Factors (OF): • Vision and objectives • Strategies • Integrated Management System • Continuous improvements • Priorities • Knowledge management • Communication • Contracting • Work environment • Culture • etc

Technical Factors (TF): • Existing technology • Technical parameters • Design • PSA/DSA • I&C • Technical Specifications • Quality of material • Equipment • etc

Human Factors (HF): • Human capabilities • Human constraints • Perceived work environment • Motivation • Individuals understanding • Emotions • etc

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Fundamental Safety Principles SF-1

The Interaction between human, technology and the organization - HTO

3.14. “An important factor in a management system is the recognition of the entire range of interactions of individuals at all levels with technology and with organizations. To prevent human and organizational failures, human factors have to be taken into account and good performance and good practices have to be supported.”

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Systemic Approach to Safety

• A systemic approach to safety addresses the complexity

of the nuclear system as a whole.

• It looks at how the dynamic interactions between and

within the human, technical and organizational (HTO)

factors in an organization impact safety.

• A systemic approach to safety takes into account the HTO

interactions within the organization as well as the HTO

interactions between organizations.

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• The regulatory bodies safety culture influence on the licensees

safety culture

• The regulatory bodies relationships with governments,

regulatory bodies, licensees, TSOs, media, public etc needs to

be based on integrity and mutual respect for the different roles

in the national nuclear infrastructure

• The need for safety culture assessments and continuous

improvement activities within the regulatory body

• Safety culture regulations and oversight

IEM5: Lessons learned 2 – Safety Culture

IAEA

Corresponding IAEA Safety Standard:

GSR Part 1 – Requirement 1

Requirement 1: National policy and strategy for safety

In the national policy and strategy, account shall be taken of the

following:

(g) The promotion of leadership and management for safety,

including safety culture.

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Corresponding IAEA Safety Standard:

GSR Part 1 – Requirement 19

Requirement 19: The management system of the regulatory

body

(…)

4.15. The management system of the regulatory body has three

purposes:

(3) The third purpose is to foster and support a safety culture in

the regulatory body through the development and reinforcement of

leadership, as well as good attitudes and behaviour in relation to

safety on the part of individuals and teams.

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The need of social and behavioural science expertise in the

regulatory bodies for conduct of:

• Establishment of regulations and guidance

• Integrated oversight - inspections

• Periodic assessments/reviews in human and organizational

factors as well as safety culture (SC)

IEM5: Lessons learned 3 –

Human and Organization Factor (HOF) Expertise

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Recognition of diversity of expertise

One expert or one type of expertise cannot cover the whole

spectra of HOF-SC

Need different kinds of human and organizational expertise

working together with the technical experts in an integrated

manner, e.g.: • Human factor (HF)

• Organizational Factors (OF)

• Human Performance (HU)

• Human Factor Engineering (HFE)

• Human Reliability Assessment (HRA)

• Safety Culture (SC)

• Etc

IAEA

Corresponding IAEA Safety Standard:

GSR Part 1 – Requirement 11

Requirement 11: Competence for safety

The government shall make provision for building and

maintaining the competence of all parties having

responsibilities in relation to the safety of facilities and

activities.

2.34. As an essential element of the national policy and strategy for safety, the necessary

professional training for maintaining the competence of a sufficient number of suitably qualified

and experienced staff shall be made available.

2.35. The building of competence shall be required for all parties with responsibilities for the

safety of facilities and activities, including authorized parties, the regulatory body and

organizations providing services or expert advice on matters relating to safety. Competence

shall be built, in the context of the regulatory framework for safety, by such means as:

—Technical training;

—Learning through academic institutions and other learning centres;

—Research and development work.

IAEA

Safety Standard GS-G-3.5

The Interaction between individuals, technology and the organization

• 2.34. “In a strong safety culture, there should be a knowledge and

understanding of human behaviour mechanisms and established

human factor principles should be applied to ensure the outcomes for

safety of individuals–technology–organization interactions. This could

be achieved by including experts on human factors in all relevant

activities and teams.”

IAEA

The importance of:

• The discrete human and organizational factors (HOF)

• The systemic approach to safety- the interactions between

human, technical and organizational factors (HTO) on both

organizational level and national level

• Safety culture continuous improvement within the regulatory

body and mindfulness how the regulatory body safety culture

influence other stakeholders within the national nuclear

infrastructure

• The need to involve social and behavioural science expertise

to comprehend and apply a systemic approach to safety as

well as in the continuous improvement work in safety culture

IEM5: Summary Lessons learned 1-3

IAEA

Safety Standard GS-G-3.5

The Interaction between individuals, technology and the organization

• 2.32.”All safety barriers are designed, constructed, strengthened,

breached or eroded by the action or inaction of individuals. Human

factors in the organization are critical for safe operation and they should

not be separated from technical aspects. Ultimately, safety results

from the interaction of individuals with technology and with the

organization.”

• 2.33. ”The concept of safety culture embraces this integration of

individuals and technical aspects.

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Safety Culture vs HTO Systemic Approach

Strong safety culture HTO – embraces the

systemic interactions

HTO – embraces the

systemic interactions Strong safety culture

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Self reinforcing dynamics

Strong safety culture HTO – embraces the

systemic interactions

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The bigger picture

Systemic View on the National Nuclear Infrastructure

Licensee

Regulatory Body

Universities

Suppliers

Governmental Ministries

Technical Support Organizations

Standards Organizations Lobby Groups

International Bodies

Media

Professional Associations

Work Unions

Waste Management Organizations

Vendors

Energy Markets

Competing Energy Providers

Interest Groups

Legal Bodies

IAEA

Regulatory Role: Systemic

40

Expert

role

Authority

role

Public

role

• Dialogue and cooperation

• Self-criticism

• Reflectivity

Competence

• Independence

• Mediated control

• Perception

Effectiveness

• Reporting

• Informing

• Openness

Credibility

Subjectivity vs. objectivity

Uncertainty Communication

Accountability

Use of power

vs. equality

Social vs.

technical

issues

Systemic

role

Reiman, T. & Norros, L. (2002).

Regulatory Culture: Balancing the

Different Demands of Regulatory

Practice in the Nuclear Industry.

IAEA

Regulatory Bodies Proactive Measures

•To enhance the approaches to safety culture to go beyond

enforcement and oversight of compliance

•To be mindful of the interactions created within the nuclear

infrastructure

•To be a role model for what is enforced when it comes to

safety culture

• To be ahead the licensee in understanding and enactment of

safety culture and systemic approach to safety

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To deal with the HTO-SC proactively…

…need different kinds of expertise (covering technical, human

and organizational factors) working as a team in an

integrated manner to develop and conduct:

• regulations

• oversight strategies

• oversight-inspections

• periodic assessments

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Prerequisite to success

On a human, organizational and cultural level it comes down

to how we work together within the national and global

safety regime to achieve safety as the paramount priority to

protect people and environment. It is the level of

collaboration and how we are interacting that will qualify

and determine the success. In short, how able we are to

effectively:

• Communicate

• Share information, experiences, knowledge

• Learn

• Implement

• Assess and review

…Thank you for your attention

IAEA

GSR Part 1 – The global safety regime

3.1. “International cooperation in relation to safety, including the safety

of nuclear installations, radiation safety, the safety of radioactive waste

management and safety in the transport of radioactive material, has

contributed to the development of a global safety regime. The

organizations and persons involved in the utilization of nuclear energy and

radiation sources for peaceful purposes are interdependent in that the

performance of one may have implications for all, and a serious

nuclear accident would be of major significance around the world.

Recognition of this mutual dependence has led to a number of

international arrangements that are intended to enhance safety in all

States.”

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GSR Part 1 – The global safety regime

Requirement 14: International obligations and arrangements for international

cooperation

The government shall fulfil its respective international obligations, participate in the

relevant international arrangements, including international peer reviews, and

promote international cooperation to enhance safety globally.

3.2.The features of the global safety regime include:

(a) International conventions that establish common obligations and mechanisms for ensuring

protection and safety;

(b) Codes of conduct that promote the adoption of good practices in the relevant facilities

and activities;

(c) Internationally agreed IAEA safety standards that promote the development and

application of internationally harmonized safety requirements, guides and practices;

(d) International peer reviews of the regulatory control and safety of facilities and activities,

and mutual learning by participating States;

(e) Multilateral and bilateral cooperation that enhances safety by means of harmonized

approaches as well as increased quality and effectiveness of safety reviews and

inspections.