Trip Report: IAEA Consultants Meeting On Safety Culture. · 2012. 12. 1. · The IAEA Safety Series document No. 75-INSAG-4, "Safety Culture" presents a systematic cataloguing of

UNITED STATES

NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. ~~~~.

January 18, 1996

MEMORANDUM FOR: Frank J. Congel, Director Incident Response Division, AEOD

FROM: Stuart D. Rubin, Chief ~. \,.'j") I. Diagnostic Evaluation and ()~~l ~

Incident Investigation Branch Incident Response Division, AEOD

SUBJECT: TRIP REPORT: IAEA CONSULTANTS MEETING ON SAFETY CULTURE

Summary

From December 4-8, 1995, I participated in an International Atomic Energy Agency (IAEA) consultants meeting in Vienna, Austria, on the subject of nuclear power plant safety culture. The primary purpose of the meeting was to prepare a draft report which documents examples of good (and ineffective)practices in nuclear power plant safety culture. The meeting participants were: G. Gibson, Nuclear Electric, UK; J.N. Diaz Francisco, IAEA; M. Dusic, IAEA; and myself. The draft report (Attachment 1) was prepared in support of an upcoming IAEA meeting entitled: "Advisory Group Meeting to Compile Good Practices in the Field of Safety Culture," scheduled for October 7-11, 1996. Mr. Gibson and I were the principle authors of the draft report. Suggested uses of the draft report, including followup activities, were also compiledfor consideration in connection with IAr.A'. d~~isory group planning and meeting activities.

Discussion

The December 1995 IAEA consultants meeting on safety culture was organized for the stated purpose of preparing a draft IAEA report which formally documented a range of illustrative examples of good practices in nuclear power plantsafety culture. Examples were based on practices which had been observed at operating nuclear power plants. The decision was made during the organizingphase of the meeting to also include ineffective safety culture practices.Including ineffective (i.e., "poor") safety culture practices would reinforce the positive practices by describing its negative effects on performance and enhance receptiveness of the document among readers from facilities not having strong nuclear safety cultures. Examples (without attribution) of good and ineffective practices were based on observations documented in publicly available diagnostic evaluation team reports and practices and observations of the Nuclear Electric representative.

The IAEA Safety Series document No. 75-INSAG-4, "Safety Culture" presents a systematic cataloguing of good safety culture practices and describes each practice in general terms. Thus, the draft report supplements INSAG-4 with a companion document containing an illustrative example for the areas of goodpractice cited in INSAG-4. Good practice examples were those that were

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" .. Attachment

DRAFT

Examples of

Safety Culture Practices

CONTENTS

1. INTRODUCTION

2. EXAMPLES OF SAFETY CLILTURE PRACTICES

2.1. APPROACH OF GOVERNMENT AND REGULATORY ORGANIZATIONS 2.1.1. Government 2.1.2. Regulatory organizations

2.2. REQUIREMENTS AT POLICY LEVEL IN UTILITY 2.2.1. Statements of safety policy 2.2.2. Management structures 2.2.3. Resources 2.2.4. Self-regulation 2.2.5. Commitment

2.3. REQUIREMENTS ON MANAGERS IN OPERATING ORGANIZATION 2.3.1. Definition of responsibilities 2.3.2. Definitions and control of work practices 2.3.3. Qt.. ... :ifications and training 2.3.4. Rewards and sanctions 2.3.5. Audit, review and comparison 2.3.6. Commitment

2.4. RESPONSE OF INDIVIDUALS 2.4.1. Questioning attitude 2.4.2. Rigorous and prudent approach 2.4.3. Communication

..... EFFECTING SAFETY CULTURE IMPROVEMENT

Appendix A: Safety Cultures Observed by IAEA Missions

Appendix B: Safety Attitudes (Management and Organization Findings) Observed from Diagnostic Evaluations of Poorer Performing Plants

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1. INTRODUCTION

The International Atomic Energy Agency (IAEA) safety series document 75- . INSAG·4 defines safety culture as follows:

Safety culture is the 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.

The principle purpose of INSAG-4 is to document the universal features and attributes of a good safety culture in all types of activities and for organizations and for individuals at all levels involved in the safe production of nuclear power. The levels include: national governments; regulatory bodies; utility and plant operating organizations. INSAG-4 necessarily characterizes the features and attributes of good safety culture in general terms.

Operating nuclear power plant safety performance evaluations conducted worldwide, (e.g., IAEA missions, national regulatory inspections, utility audits and plant self-assessments), have observed and documented many good (and ineffective) safety culture practices as an underlying cause of good (and deficient) safety performance. Many (,; the safety culture observations have been documented tv a varying level of detail in the formal evaluation reports prepared by the involved evaluation groups. These documented evaluations collectively provide a very extensive data base of safety performa.f'lce problems and weaknesses and related safety culture observations. It is the purpose of this report to compile selected examples of specific good safety culture practices observed and documented by these evaluations and to thereby supplement INSAG-4 with specific examples of good safety culture practices. The compilation may be used as a reference for illUstrating the concepts and principles of a good safety culture and training organizations and individuals in nuclear power plant safety culture. The compiled information may also De of value for organizations responsible for nuclear power pIal It safety by providing a reference bais for comparison against their own safety culture and to thereby allow for identifying further opportunities for improvement.

The examples which have been selected for inclusion in this document are those which are considered worthy of special mention. The examples selected for utility or operating plant organizations are either uncommonly observed at operating nuclear facilities or are considered to be representative of practices which are fundamentally important but have not as yet been consistently observed at all operating plants. The applicability and value of the good practices will be dependant on the specific organization and the cour,try concerned. Therefore, a specific good practice example may not be directly transferable to different cultures, unlike the underlying features and attributes, which are universally applicable. Additionally, examples of ineffective safety culture are also provided. The practices identified are those considered to have a negative impact of safety performance and thereby

... ...

illustrate the importance of the positive safety culture attribute. This document is intended to be an initial very limited compilation of the extensive safety culture data base. It is believed that many additional supplemental and revised examples should be incorporated as good safety culture practices are identified and documented in plant performance evaluation reports. Additional or alternative examples should be considered for inclusion as safety culture norms and safety performance standards evolve with time.

The document is organized and structured to be generally consistent with the terminology and sequence of safety culture attributes presented in INSAG·4. Section 3. summarizes some experiences and approaches used by organizations to change their safety culture. Finally, Appendix A contains summary examples of safety culture characteristics observed by IAEA Missions and Appendix B provides examples of safety attitudes observed by diagnostic evaluations of poorer performing plants.

,

2. EXAMPLES OF SAFETY CULTURE PRACTICES

2.1 APPROACH OF GOVERNMENT AND ITS REGULATORY ORGANIZATIONS

2.1.1. Government

INSAG·4 Safety Culture Attribute:

The practical approach that governments adopt towards safety in general .and nuclear safety in particular has a major effect on all organizations influencing nuclear safety.

< No examples are provided. >

2.1.2. Regulatory Organizations


The Regulators have considerable discretionary authority in matters of nuclear safety this is conferred by legislation and the more detailed instruments under which they operate.

Good Practice 1:

The Regulator recognized that a positive safety culture could not be regulated or mandated. Neither did the regulatory body considered safety culture directly in evaluating nuclear power plant performance. However, to the extent that safety performance deficiencies were identified by inspections, the Regulator's inspection program required its inspectors to determine the underlying safety culture (Le., management and organizational) causes. In such cases inspectors were expected to document the contributing safety culture causes in the inspection report underlying the performance problem or weakness. Inspc.;:.~:on program guidance documents codified this diagnostic aspect of inspections. Required training for inspectors included both root cause analysis techniques and principles and practices of management and organization in order to effectively carry out this guidance. Inspectors were also given special assignments to participate in the regulator's special plant safety performance evaluation teams in order to obtain first-hand practical experience in the safety culture evaluation techniques and to learn about contributing safety culture causes for performance problems.

These Regulatory initiatives have helped to focus greater utility and plant management attention on the safety culture issues underlying safety performance deficiencies and have problems and issues and have improved the Regulator's ability to identify underlying safety culture weaknesses.

Good Practice 2

The Regulator's senior management established, published and distributed

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an internal guidance document entitled "Principles of Good Regulation" for the regulatory staff. The principles provided the acceptable attributes associated with all activities and decisions associated with the organization's regulatory mission. The principles underscored the ethics with which regulatory actions and activities should be conducted. The principles stated that all regulatory actions and decisions shall be of: a high degree of ethical standards, openness to the public, efficient use of agency resources and timeliness, coherency and logic, and based on best available knowledge. The principles were established with the input and support of the regulatory staff. The IJrrnciples were prominently pc!:~ed within the regulatory agency's work areas and were periodically utilized to the conduct agency self-assessments. The regulatory agency also developed and issued a code of organizational values to guide its internal organizational work activities.

The documentation of formal statements of the principles of good regulation and organizational values codified th:l cultural \talues existing 'JI.'!thin the agency and supported its continuation into the future. The statements served to make even more clear the principles and values of the organization and thereby further strengthened these aspects. The statements also provided a reference "yardstick" with which to assess whether staff regulatory actions and internal organizational activities measured up to the principles and values.

INSAG-4 Safety Culture Attribute:

Controversial topics are dealt with in an open fashion. An open approach is adopted to setting safety objectives so that those whom they regulate have an opportunity to comment on the intent.

Good Practice 1:

The Regulator intended to establish and publish a regulatory policy statement on the safety goals for the their domestic nuclear power plants. The Regulatory agency recognized that the establishment of a numerical safety goal would be controversial and would have the potential for affecting changes in the design, operation, etc. for the plants that were already operating. The proposed safety goals were published for public comment and disseminated to the affected entities and interest groups. The final safety goals were eventually established with the participation and input of the nuclear power plant industry, the public and special interest groups. The established numerical safety goals were quantified on a probabalistic risk basis. The safety goals included the probability of occurrence of a core damage event and the probability of occurrence of an event with off site consequence.

The open manner in which the safety goals were established served the public interest for protecting public health and safety as well as the interests of the power industry for ensuring that no unnecessary financial burdens would be imposed. The process had the effect of strengthening the support of all parties for meeting the final safety goals.

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2.2. REQUIREMENTS AT POLICY lEVEL IN UTILITY

2.2.1 Statements of safety policy


An organization pursuing activities with a bearing on nuclear plant safety makes its responsibilities well known and understood in its safety policy stat:ment. This statement is provided as guidance to staff and to declare the organization's objectives and the public commitment of corporate management to nuclear plant safety.

Good Practice:

One utility prepared, documented and distributed to all managers, staff and contractors a clear and concise statement on their health and safety policy. The policy document was written to include statements which clearly defined who within the organization responsible for safeN.

Assigning safety responsibilities within the policy document resulted in a high degree of awareness and understanding among the responsible individuals.

2.2.2. Management structures


Implementation of the utilities safety policies requires that accountability in safety matters is clear. In addition, large organizations with significant impact on nuclear plant safety provide independent internal management units with responsibility for the surveillance of nuclear safety activities.

Good Practice 1

One utility has improved the management structures at its operating power plant by reducing the numbers of organizational layers to clarify safety accountabilities. A four level structure was introduced with the span of control for each line manager limited to less than 12 people. The levels comprised the following.

Working level (eg plant operators) involved with specific operational tasks.

Team leaders and supporting specialists involved with providing a service to the working level. The team leaders are responsible for work planning and

.coordinating the training for their staff, whilst supporting specialists (eg health physic) provide specific technical advice.

Section or function heads involved with managing a process or system. They are responsible for developing operational standards and ensuring that

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their part of overall business plan for the unit is achieved.

Unit Management involved with developing the longer term strategic plan for the unit and managing the interface with the utility and regulatory body.

The change in management structure was found to improve communication on site because there was less organizational layers acting as barriers to communication. It also improved team work between different functions because of the wider organizatlul,al grouping.

The example shows the benefits of having a management structure with clear reporting lines and few and simple interfaces.

Good Practice 2:

The organization of one utility has a unit which acts as an internal health and safety "regulator" for the utility's chief executive officer. (The internal unit is not responsible for safety which rests with site management.) The unit has permanent inspectors assigned to each operating unit. The inspectors serve as the "eyes and ears" of the regulator, particularly in observing the safety culture at each unit. Inspectors also assist site manager in understanding their legal responsibilities related to safety. Inspectors are chosen based on their broad operational safety experience. The onsite inspectors are able tl'\ j-jC!ntify safety culture issues better than inspectors based offsite. Offsite inspectors were responsible for assessing plant safety experience, proposed significant plant modifications and performance trending, (e.g. reactor trips).

This example shows the benefits of scrutinizing the attitudes and practices of staff in monitoring the level of safety culture.

2.2.3, Resources


Adequate resources are devoted to safety.

Good Practice 1

A task group was set up at one site to provide resources for safety culture improvement initiatives. Members consist of volunteers drawn from other organizational units at the site and are typically assigned to the group for 6 months. The group is charged with identifying areas for improvement based on their own experience, station audits and safety review findings. Those areas not adequately addressed by the site's work planning process are selected for followup. Initiatives have included development of a safety awareness training and improved labelling of safety-related labelling.

The task group provides the staff an opportunity to initiate and participate

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directly in safety improvement initiatives and to exchange ideas and knowledge with other personnel at the station. The experience also supcorts enhanced organizational teamwork after members return to their line responsibilities.

2.2.4. Self-regulation

INSAG4 Safety Culture Attribute:

As a matter of policy, all or!lanizatlOns arrange for regular review af those of their practices that contribute to nuclear plant safety.

Good Practice 1

Operating event reviews at one site included a rating for safety culture significance. A three element taxonomy was used for the rating based upon INSAG-4. The elements consisted of: A) People (Le., the competence and awareness 'of staff regarding hazards and their control); B) Process ·(i.e,. the capability of the management system to provide for risk assessment, procedures, systems for training, and audit and monitoring arrangements and; C) Culturf~ (Le., the commitment to safety, the adoption of a rigorous and prudent approaC'''' and the organizational priority to safety including the provision of adequate resources).

This example shows the benefit of organizational monitoring of its safety culture as part of its self-assessment process.

2.2.5 Commitment


On a personal hasis, managers at the most senio, :evel demonstrate their commitment by their attention to regular review of the processes that bear on nuclear safety, by taking direct interest in the more significant questions ofnuclear safety or product quality as they arise and by frequent citation of the importance of safety and quality in communication to staff.

Good Practice 1

The numerical targets for the plant safety and performance measures were incrementally raised on an annual basis at one plant to promote continuing safety and performance improvement. Managers whose responsibilities were significantly tied to measures were assigned the responsibility for tracking, trending, documenting and reporting on their assigned measures at monthly status meetings. The meetings were widely attended by site and utility managers. The senior nuclear executive and chief executive officer also attended and actively participated in each of the meetings. Both executives used the meetings to emphasize the importance of achieving the established goals and in particular the achievement of the safety goals as the highest priority.

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The presence of the most senior level managers at the monthly status meetings visibly demonstrated the importance placed on achieving the established safety goals. Their presence and communications had the effect of further reinforcing the plant organizational attitude of "safety first" while vigorously addressing the need for overall plant performance improvement.

2.3. REQUIREMENTS ON MANAGERS IN OPERATING ORGANIZATION

2.3.1. Definition of responsibilities


Discharge of individual responsibility is facilitated by unique and clear lines of authority.

Ineffective Practice 1

An event investigation at one plant uncovered that a radiological survey data collection sheet required four separate signatures; the radiation technician who collected the data, th'" radiation technician's supervisor, the health physics engineer and the health physics engineer's supervisor. It was also found that none of the signatories clearly understood their review responsibilities connected with signing the data sheet. Once the radiatil'n technician had entered an abnormally high radiation level, each signer believed someone else was responsible to followup. Accordingly no one followed up on the abnormal radiation condition.

This example shows the importance of clearly defining and assigning individual responsibilities to prevent oversight and omissions in the conduct of safety related activities.

2.3.2. Definitions and control of working practices


Managers ensure that work on matters related to nuclear safety is carried out in a rigorous manner.

Ineffective Practice 1:

The Operations Manager at' one plant told the reactor operator to raise power more rapidly than had been done in the past. In response to the request the reactor operator directed a plant equipment operator to not perform a number of the pre·startup valve alignment checks. As it turned out one of the valves which would have been normally verified was in the incorrect position for the startup. This was the result of the valve not being returned to normal position following the completion of an earlier maintenance test. The valve misalignment resulted in an essential plant system being effectively c.ut-of-service. The out-of-service system caused the reactor to trip during the power increase.

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This example shows the importance of managers ensuring that all required tasks are carried out in a rigorous manner regardless of circumstances.

2.3.3. Qualifications and training


Managers ensure that their staff are fully competent for their duties.

Good Practice 1

The Operations Manager at one plant observed and evaluated each crew's weekly simulator exercise. The manager critiqued each exercise and communicated how he expected crews to respond to particular facets of the event (e.g., when to enter the Site Emergency Plan). The manager also used the exercise observations to reinforce and/or clarify his standards and expectations on crew member performance.

The Operations Manager's observations of the weekly simulator exercises provided direct first-hand know1qdge of each crew member's competence to carry out assigned duties in response to an event. The manager's presence and involvement also ensured that deviations from expected performance were promptly recognized and corrected.

Good Practice 2

The plant equipment operators and maintenance workers at one utility attended a nuclear safety awareness course to supplement their technical training. The one-day course provided both an improved understanding of the station, plant ~"d safety-related systems design and the potential adverse imr:;3cts of operational and maintenance activities. The course also clarified the regulatory and procedural requirements associated with staff activities and reinforced the understanding of their importance in assuring plant safety.

The example illustrates managers' responsibilities to ensure that individuals broadly understanding the potential for their activities degrading plant safety. Such training promoted a more questioning attitude while performing assigned work.

Good Practice 3

The managers and supervisors at one utility attended a management course on safety culture to supplement their management skills training. The two-day course provided the line managers with the awareness and skills necessary to better understand and manage safety culture improvement initiatives. The course provided fundamentals management techniques in implementing safety culture improvements and identified the priority actions (e.g., leadership and communications related to safety).

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The example supports the importance of manager experience or training in improving safety culture.


Almost half of the 50 control room operators at one plant either had not attended or not completed refresher training in the prior 12 months as required by the national safety regulations. Station management also had not complied with its internal requirements that individuals who missed training must complete a makeup class within 12 weeks or be removed from shift duties. Affected individuals included shift supervisors, assistant shift supervisors and reactor operators.

The example shows that where management attitudes hold training to be of lower importance, required safety knowledge and skills will diminish over time and staff may no longer be fully competent for their assigned duties.

2.3.4 Rewards and sanctions


Ultimately, satisfactory practice deoends on the behavior of individuals, as influenced by motivation and attitudes, both personal and group. Managers encourage and praise and seek to provide tangible reward for particularly commendable attitudes in safety matters.

Good Practice 1

The staff of one plant frequently did not report minor eve•• ~s for fear of being blamed. The staff was also unclear about which of several reporting system should be used to report such events. A "blame-free" reporting policy was introduced with the support of staff unions to overcome the staffs' hesitation to report such incidents. The policy stated that individuals would not be blamed or suffer financial loss for any unintentional mistake. Individuals would only be considered blameworthy for wilful acts. In addition, a single form was introduced to report any event or near-miss. The form was used to initiate more detailed followup investigations as required. Reporting of minor events increased significantly under the new system.

This example shows the importance of identifying and changing employee attitudes which hinder safety improvement.

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2.3.5. Audit, review and comparison


Managerial responsibilities include the implementation of a range of monitoring practices which go beyond the implementation of quality assurance measures and include, for example, regular reviews of training programs, staff appointment procedures, working practices, document control and quality assurance systems.

Good Practice 1

A safety culture questionnaire was used at one plant to better understand and gauge the perceptions, attitudes and beliefs of site staff. The questionnaire was used to supplement other monitorir.g techniques 3uch as audits to identify safety culture issues. Development and use of the questionnaire involved a focus group to identify topics and issues, an initial questionnaire trial test, followed by final questionnaire response by the full organization and finally independent analysis of the completed questionnaires.

Many weaknesses in safety attitude were identified using the safety culture questionnaire allowing management to develop an action plan to address the deficiencies


Managers make arrangements to. benefit from all sources of relevant experience, research, technical developments operational data and events of safety significance all of which are carefully evaluated ir "heir own contexts.

Good Practicellneffective Practice 1

The corporate engineering organization for one plant conducted a very comprehensive technical assessment to identify plant equipment problems which could potentially affect safe plant operation. The assessment included design, maintenance, testing and operations aspects. The assessment identified over 50 potential vulnerabilities which were comprehensively documented in a detailed formal report. The report was forwarded to the plant manager for review and followup. An external audit of the station conducted about nine months after the report was issued found that station management had initiated no followup actions to resolve the issues identified in the report. Detailed followup reviews were thereupon promptly initiated by the onsite technical organizations. The followup reviews determined that certain. safety equipment would not be capable of performing their intended functions in all required situations, necessitating immediate corrective actions.

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The comprehensive and well-implemented vulnerability study conducted by the engineering organization indicated a strong positive attitude by engineering management in ensuring plant safety. However, plant management's untimely response to the issues identified in the·study indicated weaknesses in their safety attitudes and responsibilities toward potentially significant safety information.

2.3.6. Commitment


It is the task of managers to ensure that their staff respond to and benefit from this established framework of practices and by attitude and example, to ensure that their staff are continuously motivated towards high levels of personal performance of their duties.

Good Practice 1

A section manager or shift supervisor in the Operations Department at one plant periodically accompanied and observed the performance of equipment operators while making their rounds. During the rounds managers provided equipment operators guidance and feedback on specific surveillance activities and communicated their high standards for performing the duties assigned to the operators. The program paired a manager or supervisor with an operator about once every six weeks. Several months after the program was implemented the equipment deficiency reporting by the operators and "housekeeping" cleanliness in plant equipment areas had improved.

The example shows the importance of managers effectively communicating acceptable practices and standards to their staff and the positive impact it has on staff attitude: ::!'1d performance.


The offsite engineering organization conducted a detailed engineering study to determine whether selected safety-related valves in the plant were vulnerable (failure to open) under certain design conditions. The analysis was conducted in response to an operational experience feedback document received from an outside safety organization. The feedback document was based on valve experiences and corrective actions at several nuclear plants. The engineering study concluded that a similar vulnerability for safety-related valve failures existed at both units of their nuclear station. The engineering organization forwarded their study report to site management imd recommended that corrective actions be promptly implemented on selected safety-related valves. The site manager disapproved the recommended modification. Disapproval was substantially based on the fact that no valve failures or degradations of the sort experienced at the plants outside the utility had ever been reported by either unit at the station. However, about three years later during an outage, one valve in a 10;' pres. 're safety system was discovered to have failed (closed) and another valve in the alternate safety system train was

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discovered to have become severely degraded due to the phenomena cited in the feedback document. All potentially affected valves in th6 ~:-I;Jtdown unit were modified prior to plant startup and the potentially affected valves in the operating unit were modified during its next outage.

The example shows the importance of management commitment to safety and the importance of ensure that their staffs vigorously respond to established framework of practices such as the process for evaluation and response to outside operational experience.

2.4. RESPONSE OF INDIVIDUALS

2.4.1. Questioning attitude

The response of all those who strive for excellence in matters affecting nuclear safety is characterized by a questioning attitude.

Ineffective Practices 1

The following situations were observed at different plants:

Although prohibited by procedure, two safety system pumps were operating while its associated heat exchanger was tagge;l out-of-service. The condition was not recognized for over three hours despite control room indications.

Control room annunciators/alarms were not always investigated and thoroughly questioned as to their cause.

A main feedwater pump and turbine were spun without lubricating oil. A feed water pump bearing high temperature alarm was not questioned or investigated.

A shutdown cooling monitor alarm was not thoroughly questioned by control room operators and was a factor in primary coolant system shutdown cooling return line temperature dropping well-below the minimum allowable value.

On a walkdown during a regulatory agency inspection, one of the bolts that fastens the operator to body of one of the main steam isolation valves was found to be missing.

The observations above show the importance of individuals having a questioning attitude.

2.4.2. Rigorous and prudent approach

< No examples are provided. >

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·.

2.4.3. Communication


lt1dividua/~recognize that a communicative approach is essential to safety. This involves: obtaining useful information from others; transmitting information to others; reporting on and documenting results of work; suggesting new safety initiatives.

Good Practice 1

A series of awareness raising workshops for team leaders, section heads and station management were initiated at a station seeking to improve its safety culture. The purpose of the workshops was to achieve a site-wide consensus on the significant safety culture issues and to identify ideas for improvement. The identified issues included misunderstanding of safety priorities and suspicions that specific individuals were being assigned blame for events. -rhe workshops broadened acknowledgement of the need to address the identified problems and strengthened the ownership for subsequently proposed improvement initiatives.

The example shows the importance of manager's listening and involving staff in improvement initiatives as the success of the initiatives is dependent on both itf acceptance by the individuals affec·~d ~nd its techr.ical quality.

Good Practice 2

The senior nuclear executive selected about five individuals each month with whom to have lunch in order to enhance vertical communications within the organization. The individuals were given the opportunity to raise questions and as well as issues and concerns. The senior executive used the meetings to directly unde: stand lower level concerns without the filtering effect of middle managers, to feedback answers and to clarify management standards and expectations for individual and organizational performance. The monthly meetings helped to identify employee concerns and issues which negatively impacted organizational safety performance and prompted the initiation of corrective actions.

The example shows the importance of a communicative approach and obtaining useful information from others so that actions may be initiated where appropriate to improve safety

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3. EFFECTING SAFETY CULTURE IMPROVEMENT

The process of managing safety culture improvement comprises the following .... steps:

Need for change. Management and staff need to be made aware of the need to improve.

Want to change. Once a need for change is identified there needs to be a commitment to change among all staff and managers.

Know what to change. The need to identify the critical issues requiring change, those which will bring most benefit in a given period of time.

Know how to change. Identify the activities required to bring about the change.

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A number of techniques are available for improving safety culture. All of the techniques are considered impo..tant to some extent. The table below ranks the techniques in terms of their relative effective strength in changing the safety culture of individuals, groups and organizations based on prior research, experience and studies'.

Table. Techniques Organizations Use to Change Their Culture

Level of Importance

Most Important

Very Important

Moderate Importance

Some Importance

Technique

Senior management visibly and vigorously demonstrates their commitment and support for safety culture values.

Staff is provided training to convey and develop skills related to safety culture values.

Safety culture value statements are developed. Safety culture values are communicated to staff. Management practices are consistent with desired safety culture values.

Rewards, incentives, and promotions are offered to encourage individual practices compatible with Safety culture values.

Organizational gatherings are used to convey and support the safety culture values.

The organizational structure is made compatible with safety culture values2

•

Systems, procedures, and processes which are compatible with the safety culture values are established 2

•

The responsibilities of employees who do not supportb desired safety culture values are replaced or changed2

•

Anecdotes and stories are used to convey safety culture values.

Employees who demonstrate exemplary safety culture are made company heroes.

Employees who possess or are willing to accept safety culture values are recruited 2

•

"ORGANIZATIONAL CULTURE Techniques Companies Use to Perpetuate or Change Beliefs and Values," GAO/NSIAD-91-105, February 1992

2 Views of the importance of this technique vary significantly among company 'officials.

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Slogans and signs are used to symbolize safety culture values.

A manager or group primarily responsible for safety culture change efforts is established2

•

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Pilot change. If the change is going to impact the whole site, there may be benefit in piloting the change in initially a single work area or work team. This ensures enough management attention and resources can be devoted to make the change a success. Once part is successful, it can be used as an example to others. .

Reinforce change. Once the change has been introduced, it is essential that the process is reinforced to ensure the change process is followed through and successfully implemented.

In one utility, each stat!on as part of preparing their overall business plan, produces a safety enhancement plant identifying those aspects of the business plan related to improvements in safety culture. Having the safety enhancement plant an integral part of overall business plan allows the normal business planning processes to be used such as determining activities against business plan objectives, allocating resources and monitoring progress. In drawing the safety initiatives out, it provides a visible demonstration of the stations commitment to safety improvement. In addition, it allows the various safety initiatives to be integrated and prioritized. Improving safety culture is often not easy because it required sustained effort and commitment over a long period of time. There are also no panaceas as there are many barrie~s to ~uccess that have to be overcome. These barriers can normally only be addressed through a number of initiatives combined.

The example shows that the management of safety culture improvement has to be managed as any other station business objective as safety needs to be an integral part of managing the business is not a bolt on extra. However, there needs to be a mechanism of separately identifying safety culture improvements which often require long term initiatives, which may link to other business objectives eg those related to human resources, production -and maintenance. The safety enhancement plan in the example embraces these two diverse requirements.

I,

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Acknowledgement

The authors would like to acknowledge those nuclear power organizations worldwide who have provided the examples for use in this document.

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Appendix A

Safety Cultures Observed by IAEA Missions

<TO BE PROVIDED BY IAE" ~

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Appendix B

Safety Attitudes (Management and Organization Findings) Observed from Diagnostic Evaluations of Poorer Performing Pi~~ts3

ATrITUDES TOWARD QUALITY

low Standards for Performance Are Accepted

ATIITUDES TOWARD CORRECTIVE ACTIONS

Personnel Do Not Exhibit a Questioning Attitude Problem Identification Is Not Encouraged or Rewarded Superficial Root Cause Investigations are Accepted lessons of Own Experience Is Not Aiways learned or Acted On Weak Efforts Are Made to Learn Lessons from Other Plants

An-'TUDES TOWARD FACILITY AND EQUIPMENT

Degraded Equipment Is Expected and Tolerated Operators Are Expected to Work Around Equipment Problems Equipment Evaluations Try to "Prove" Operability Poor Housekeeping Is Acceptable

An-ITUDES TOWARD PROCESS CONTROLS

Operators Tolerate Procedure Deficiencies Operators Are Expected to Work Around Procedure Deficiencies Configuration Control Problems Are Expected

ATIITUDES TOWARD RISK

PRA Provides a Basis for Not Taking Actions

ATTITUDES TOWARD ORGANIZATIONAL PERFORMANCE

A Reactive Problem Solving Environment Is Expected and Evident Quality Assurance Is Not Seen as a Contributor to Performance Improvement

A Technically Weak and Reactive Engineering Staff Is Accepted The Licensing Staff Often Takes the Lead in Interpreting the Design Basis A Weak Sense of Individual Accountability or Ownership Is Evident A Weak Sense of Organizational Teamwork Exists Poor Communications Within or Between Departments Is Evident

3 "Safety Attitudes Identified During Diagnostic Evaluations" presented at the International Topical Meeting on Safety Culture April 24-28, 1995 Vienna, Austria

history,' ; ~. • ""il':'; .~\ ,r

t1 '" l

,,,":

;/:-. ~

• 1982 - beginning of the OSART progra~e

......... ~

fI 1992 - Safety Culture 'included' in the review process '

• " • '''0

Asia JI' ..... _ -------.:.:..:. --"- ~ ~_

...-~. ~~'

• respect towards superiors~;, ,1><- ...... .

,- .. ,"

• staff supportive of their superiors • work closely as a team .

~. easy to emphasize employee's responsibility

lack of questioning attitude los'e critical input to adequate

policies

Asia ,(contd.) ~- .

~" ~~... ~

'i:"

....,.".l"

• NPP with· hi reliability

• growth in electricity • dependent on

nuclear energy

complacency towards unanticipated situations

risk for-Safety Culture as a priority

Example ::~Jssue(Asia 1) ···.tV'" ,"'~ ..." ..,. ,.'

/' ----- ---~

• policy'wit~ yery generic statements on S.C. • objective~ neither provide guidance to the

staff nor declare the commitment to nuclear safety ". ~.

the state·ment should be imprOVed and communicated to all staff

it sh.ould be cle~r the corporate commitment:·to nuclear safety and indicate measurable expectations of individuals

.

Example III good practice (Asia 2)

• all employees receive 1 year initial .~ ...training

"

• 4/12 months (if university graduate) or 1O/12\rrronths (if high school graduate) on shift i,

this enhances the knowledge in areas relatedito plant familiarization and safe plant 6peration

Exal1lpl.~.;,,· good practice (Asia 3) ~,..'-~, -It,~, T"I"'i~4:; "

;/' .. _ ':'.~' t ,', ."

• object'ives,determined by corporate motivate safety dp~ration of the plant: • to improve the performance of a rninimun of two syst~,rt1s per y~ar

- to hcivb an excess of SROs and ROs "",:,

• to minimize findings by the rR authority, and to minimize the time to solve them • minimize anavailability of safety related equipment • minimize plant staff absence from training programmes

E. Europe and Former Soviet Union",' .

. ~-:

'. ~. ... ~---.

~~:;K

I management style - authoritarian ,"

lack of questioning attitude , ,~nd self-assessment approach

operatlonal decisions in very higll level of hierarchy

I compartmentalized, structure ~ _ lack of knowledge and

curiosity of other areas

. . ..

E. Europe and Former Soviet Unio.n ~(contd~l

~.>,> ","" ,1~' ... _ ...... ...0..-:.- ...... _;':c..

.."... t' ' .

• shortag~ intelectricity/ Ii/ '~l"7a ~ ,iii •

.... ' ..

\ ;

continue with plants which have recognized ,safety deficiencies

Example ... issue (EE 1) .ol'\ .~

• root cause analysis not responding to the cumulative affect of a large number of transients:

,

- in 1~~~~ 22 ~~j~~~ns or load

- in 1995,5 scrams were experienced up until September - regulatory authority noted weaknesses in the safety systems and the conditions of safety barriers in 1992 (annual report comments)

(contd. 2/3)

Exal11pl,e,· issue (EE 1) ..

.t' _ .....

• (conta~ ~(3)} . ~,'. '. ~

- n'o, regulatory authority comments in 1994/5(f - management initially indicated this situatio'r1~~t6 be acceptable because production targets were not impacted

'~

this indicated reduced defense in-depth (contd. 3/3)

Example·· issue (EE 1) I[ ~

. ,~; ('

• (~~ntd. 3J3l . - programme to reduce number of

trans,itSnts ,,\pre~ent root cause analysis

programme should be continued and the root causes of all-safety significant plant transients andiincidentswhich have occurred over the last three years should be reviewed

- grou·p of causes, trends, etc..

.

cExample issue (EE 2)"

'i 10'·" ~!

• p~,ant pe,rso'nnel attitude: - low level equipment defects not reported - indu.strial safety inadequate - poor radiation protection practices - procedures not used - uncontrolled operator aids - poor equipment status control

(contd. 2/4)

Examples-issue (EE 2) ,..' ,.

~" '

• (contd.;2/4) • Plant management attitude:

- do not t~ke immediate corrective actions if observing unsatisf2ctory behavior - systematically bypassing plant rules - defensive when discussing weaknesses in plant staff performance -the target is to meet regulations

l

(contd. 3/4)

.

ExamplE!.· issue (EE 2)

• (contd. 3:/4)/ • plant poli"cies:

- noALARA - no s'et<'of goals and indicators to reinforce safety culture - disciplinary policy directed to personal punishment

(contd.4/4)

.

Exam.~.le - issue (EE 2)

.. (c.ontd. 414)", • management shoUfatake necessary measurem~ntstowards improving nuclear!safety beyond r. requirements: - standards beyond r. requirements, including goals, objectives, and indicators. Trending and communication - non-punitive policy - training ptogramme, including

•supervisors

.

w. Europe and N.America ~.:. Log

it .. _ "'""

• SafetYCLilture increasingly receiving management attention

• Self-assessment development

but...

• lower working levels need to enhance the effectiveness of S.C. application to everyday jobs

w. Eur:ope and N. America (contd.)

'n., • in some countries, high level staff edudation

complacency, poor self-assessment

difficulties .with detecting deterioration of performance

Example· good practice (NA 1) ....... ,,",

• written maintenance philosophy found in: procedures, boards, notice walls in the control room passage, meeting rooms and man~agement offices

• it is based on the SC. concept and set goals for the maintenance staff to strive for high profesisional standards

"

• the corresponding performance data are publish in the plant performance report

.

Exampl.e· ...90od practice (WE 1) . "

r .... __ ...i:

• sCifety cu~tute oriented reporting system is implemented in the plant. It is named Deficiency in Safety Culture.

• e'ncourages personnel at all levels to report conditions adverse to safety

• the management supports the actions needed to improve safety culture

•

Exa~ple .. good practice (WE 2) "

, • S.C..,\dissem'in'a:tion: . letter mailed to each staff member by site director · safety and quality team weekly bulletin · recruitment uses specialized screening technique · Quality Assurance Manual incorporated nuclear safety doctrine · nuclear safety goals in management contracts at a

. levels . every staff member attended a one day workshop on safety quality (contd.2/2)

.. ...

•

. Example .. good practice (WE 2) , .. ', .,

'" - ~

,i.' :1 ~

• (c~ntd. 212) . a safety culture questionnaire

completed:by all employees, followed by correcti'ons and discussions with immedlate management

.. ...

•

Example • issue (WE 3) • indicators of a need for foster a more

questioning,. self~critical approach to plant activities: ~./

- only one safety review committee, meets less freque·nt and re,,-iews safety performance in less depth than the industry norm -loose materials and unsecured equipment in the reactor co'htainment .

C building that could interfere with safety system performance under accident

(contd. 2/4)

>. ~ .

Example .. issue (WE 3)

• (contd. 2/4) : safety related design changes have not been adequately reviewed and approved - high th-reshold for Clnalysing plant events 'fo·r root causes - safety culture goals provide little guidance on how the improvement should be achieved

(contd. 3/4)

- -

• .. • >

Exartlple- issue (WE 3) ,.- ;t" ., ,!-~

• (contd. 314) ... . 1n'summary, high level of confidence

. .

within the ;plant of continued strong performance of the plant staff is weakening defenses against unexpected deterioration in nuclear safety

plant management should developa more questioning, self-critical approach to safety performance at all levels (contd.4/4)

II

" •.�

.

Example • issue (WE 3)

• (contd. 4/4) - extensive use of self-assessment - lowering thresholds for event analysis - extensive training and discussion on manageme·nt's expectations for self-assessment ' - more thorough safety reviews of plant activities by the nuclear safety review committee

Documents

Trip Report: IAEA Consultants Meeting On Safety Culture. · 2012. 12. 1. · The IAEA Safety Series document No. 75-INSAG-4, "Safety Culture" presents a systematic cataloguing of