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IAEA International Atomic Energy Agency
Lessons Learned about
Safety Culture
in relation to the
National Nuclear Safety Infrastructure
Monica Haage – [email protected]
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
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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
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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
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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
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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
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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
IAEA
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.”
IAEA
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.