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

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

Culture - Where are you headed? Facilitator Note: Ask attendees for comments on the “Culture” that performed this action.

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

Safety Culture - According to INPO 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

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. Facilitator Note: Items to consider when looking at Safety Culture (from the IFPO “how-to” on evaluating Safety Culture) Errors and problems are reported by employees in a “no blame” environment, where the stated goal is to understand and learn from what happened. Examine the station’s event history for events that may indicate a weakness in safety culture, and review the utility-identified root causes, including information that would indicate other apparent causes. Analyze about three recent events for shortfalls in safety culture. Request and review the results of any employee surveys that may contain questions related to safety culture. Review station power history and low level events for indications of reactivity management weaknesses and excessively fast power recoveries after scrams or forced shutdowns. Look at station performance indicators and goals and objectives for indicators that production may be receiving excessive emphasis when compared to reactor safety. Review any corporate and station statements of safety policy and objectives (e.g., vital importance of reactor safety, safety objectives override production objectives). These policies should contain a commitment to excellence in activities important to reactor safety, making it clear that reactor safety has the overriding priority over production and schedule demands. Line organizations use experts to validate degree of achievement of expected behaviors. Benchmarking at other organizations is encouraged to improve performance. Workers exhibit questioning behaviors and will stop activities when unexpected conditions or results are obtained. Decisions affecting reactor safety are made after thorough preparation and discussion. Probabilistic safety analyses are consulted to support decisions regarding safety of options affecting plant operation. Decisions are reviewed when initial conditions change. Operability determinations are approached with a mindset toward verifying operability; not proving the equipment is not operable. Control room operators are alert, watchful, and questioning at all times regarding reactor safety. Proper operation and availability of equipment used to monitor reactor parameters is frequently verified, and deficiencies are promptly reported and corrected. Short-term performance is measured and analyzed for use in improving long-term performance. Rewards and recognition are given to support departments as well as generation departments. Selection guidelines for personnel assignments include an evaluation of safety behaviors of candidates, where appropriate to the position. Safety systems and equipment are maintained to high performance and reliability levels, and workarounds are vigorously eliminated. Training for station staff includes design safety features, importance of reactor safety, use of operating experience, use of pre-evolution training, and consequences when safety is not held paramount. Senior management has a strong role in establishing the safety culture, participates in safety discussions and decisions, and is involved with nuclear safety topics in utility Board meetings and safety review groups. Team members should discuss observed behaviors and observation results with counterparts so there is agreement on the facts. Behaviors from past events also should be discussed, with focus on agreement of the facts. Again, team members need to understand what is driving or what is behind the behaviors, looking for a pattern of behaviors that indicate they are culturally driven. Followup discussions with the plant staff who were observed and interviews are needed to fully understand the driving force of any observable behavior. It is expected that concerns will be characterized by facts early in the evaluation and that the concern is in the safety culture performance objective would occur later in the evaluation.

European Understanding the 7 “S” of Safety Culture .... Style Skills Staff Supervision Structure Shared Values Safety Strategy

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.

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

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

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)

THEMES from Extended Plant Shutdowns... Overconfidence Isolationism Managing Relationships Operations and Engineering Production Priorities Managing Change Plant Events Nuclear Leaders Self-Critical Facilitator Note: 4 highlighted attributes focus most on safety culture

Source: Dr. Edgar Schein 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." Source: Dr. Edgar Schein

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 Display on screen prior to starting presentation.

Risks Can Be Evaluated Ahead of Time 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 2.6E-5 / 1E-4 1 hr. 37 min. Indian Point 3 1.35E-5 / 7E-5 Nine Mile Pt. 1 1.3E-5 / 3E-5 0 hr. 56 min. Nine Mile Pt. 2 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. Northeast Blackout (August 14, 2003) No major equipment failures, thus no major surprises

Training and Accreditation INPO’s Continuing Focus on Safety Culture Evaluations Training and Accreditation Assistance Events Analysis and Information Exchange

Safety Culture Can Be Observed We like to observe attitudes, behaviors & conditions We also prepare our evaluators with performance information

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

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

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 CEO Exit Discuss health of safety culture

Safety Culture “Bubble Chart” SAMPLE TEXT: Leaders demonstrate commitment and are open to input, but they are not sufficiently involved. SAMPLE TEXT: Weak self-assessments, root cause determinations, trending processes. Leaders demonstrate commitment to safety. Organizational learning is embraced. Nuclear safety is everyone’s 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.

Safety Culture “Relative Ranking”

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.

Training and Accreditation Training and Accreditation INPO Programs INPO Programs Evaluations Evaluations Training and Accreditation Training and Accreditation Assistance Assistance Events Analysis and Information Exchange Events Analysis and Information Exchange

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

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.

Training and Accreditation INPO Programs Evaluations Training and Accreditation Assistance Events Analysis and Information Exchange

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

Training and Accreditation INPO Programs Evaluations Training and Accreditation Assistance Events Analysis and Information Exchange

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

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

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?

Davis-Besse Lessons Learned The physical degradation is the most obvious consequence of what happened. However, more importantly are the consequences that organizations suffer when the physical plant is allowed to deteriorate to this degree. How many poor decisions had to be made to get to this point? How many times were unpopular views discounted? How many deficiencies were improperly prioritized? How many times did managers and supervisors lay eyes-on problems in the plant? What was done about it?

How close were we to the corner? tn Bankruptcy Prevention Production Accident new plant state plant event Source: James Reason. Managing the Risks of Organizational Accidents, 1997 (in press).