1 The nuclear option: human factors in safety Sue Cox Professor of Safety and Risk Management Dean Lancaster University Management School Blackett Memorial.

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The nuclear option: human factors in safety

Sue CoxProfessor of Safety and Risk Management

Dean Lancaster University Management School

Blackett Memorial Lecture 14th March 2006

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Key questions

• Nuclear Power: a problem or the solution?

• Can Safety Science help answer this question?

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Source: http://www.cogema.com

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Current nuclear capacity (UK)NDA Sites British Energy Sites

Source: http://www.nda.gov.uk Source: http://www.british-energy.co.uk

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‘First Movers’

Berkeley, UK

Calder Hall, UK

Source: http://www.google.image.com

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FAQ - New reactors

• Why is nuclear back on the agenda? Due to alarm over climate change and the security of gas supplies. All but one of the existing nuclear stations will close by 2023 and ministers are anxious to ‘keep the lights on’.

• So what’s stopping them? Fears over cost and issues of nuclear waste disposal.

• What about safety? The nuclear sector says the new reactor designs are much safer.

• How much would we pay for them? Fixed electricity prices, or so-called nuclear tax, is one option for the future.

• What happens next? Separate strands of research are due to come together in time for a decision which is due summer 2006.

Source: The Guardian, 07.03.2006

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TVO Olkiluoto 3, Finland

As on 19th January 2006

Source: http://www.tvo.fi/474.htm

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The Safety Imperative

‘Defence in depth’ includes consideration of the following:

• Preventing incidents and accidents by considering the potential for equipment failure, human error and external factors (for example seismic event, airplane crash, adverse weather conditions, etc) during the design phase - implementing effective systems and procedures

• Monitoring facilities during operation to detect and correct deviations

• Designing and implementing measures to limit consequences of any accidents that may occur despite the precautions taken.

Source: IAEA (1996) Defence-in-Depth in Nuclear Safety. A report by the International Nuclear Safety Advisory Group, INSAG-10, Vienna.

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Nuclear Accidents

Chernobyl, 1986

Three Mile Island, 1979

Source: http://www.google.image.com

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Defence in Depth

Three Mile Island Chernobyl

Safety Function Faults

Loss of control of cooling function

Loss of control of cooling function

Loss of control of reactivity function

Loss of control of containment function

Barrier Failures

First barrier failure Instantaneous and simultaneous loss of first and second barriers

Design fault with third barrier (i.e. not designed to remain leak-tight in the event of an accident)

Second barrier failure (later restored)

Satisfactory behaviour of third barrier

Accident Consequences

Limited gaseous release - no consequences for the population

Unacceptable release detectable in a number of European countries

Contamination of a wide area

Loss of Life

Human factors have been implicated in the aetiology of many nuclear (and non nuclear) accidents

Source: IAEA (2003) Major Accident Summary. http://www.iaea.org/index.html

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Human Factors

• Human factors is a multidisciplinary activity concerned with peoples’ characteristics and capabilities in relation to the design of jobs, products, workplaces and equipment (Cox & Cox, 1996).

• Hollnagel (1993) quotes figures which show a rise in human error rates from 25% of accident causation in the 1960s to 90% in the 1990s. He highlights the enhanced reliability of technology in part explanation.

• Whatever the causation, the message is clear: managing the safety, reliability and efficiency of systems requires an understanding of human factors.

• However, human factors, as traditionally conceived, is too narrow an approach to ‘people’ related issues in nuclear safety.

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Organisation

Social Environment

Job

People-related Issues: Broader View

Person

Wider Environments

The Person as an Information

Processor

Developed from: Cox and Cox (1996) Safety, Systems and People. Oxford: Butterworth-Heinemann

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LearnSafe http://www.vtt.fi/virtual/learnsafe/

Management of Change

• What are the perceived emerging challenges in the management of nuclear power plants?

• How do senior managers cope with emerging challenges in the management of nuclear power plants?

• What improvements could be made in respect to coping with emerging challenges in the management of nuclear power plants?

Organisational Learning

• What kind of features and attributes characterise learning organisations?

• What are the most common barriers to organisational learning and how can they be removed?

• How are various national and company cultures influencing organisational learning?

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Methodology: MetaFuzz

• 800 statements on ‘emerging challenges’ were collected from 300 managers in 10 power plants in 5 countries using a Metaplan method

• Data subject to a 3 stage procedure derived from fuzzy set analysis:

– Common classification model: 5 dimensions (derived from Competing Values Framework: Cameron and Quinn, 1999) treated as fuzzy sets

– Classification of statements on ‘emerging challenges’ in terms of these sets: 0-100 strength of membership

– Hierarchical cluster analysis: clustering coefficient showed a large increase from 9 to 10 clusters. K Means Method1 used to create 9 clusters. Named on challenges close to centre of cluster.

• Cross tabs by cluster, country and management level (Chi-square)

1Tou JT and Gonzales RC. (1974). Pattern Recognition Principles. Reading, MA: Addison -Wesley. (pp. 94-97).

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Key safety challenges for nuclear industry

CHALLENGE CLUSTERS FIN GER SP SWE UK ALL

1. Economic pressures0 16 11 12 4 8.6

2. HR management21 18 19 29 26 22.6

3. Nuclear know-how5 11 8 11 4 7.8

4. Rules and regulation 2 5 8 6 7 5.6

5. Focus and priorities16 8 3 11 16 10.8

6. Ageing, modernisation18 13 3 9 12 11.0

7. Public confidence and trust11 5 21 11 1 9.8

8. Climate and culture21 16 24 8 27 19.2

9. Miscellaneous5 8 3 3 4 4.6

TOTAL99 100 100 100 101 -

Source: http://www.vtt.fi/virtual/learnsafe/

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Culture and People Management

• LearnSafe data show very clearly that ‘human resource management’ (22.6%) and ‘climate and culture’ (19.2%) are perceived by the industry to be the two most important challenges for nuclear safety going forward.

• Other challenges range in perceived importance from 4.6% to 11.0% (‘ageing and modernisation).

• LearnSafe also collected case study data on how managers were coping with these challenges through: safety culture change programmes, leadership training and staff development. .

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Interaction of Culture and Behavioural Safety

• There are two quite distinct approaches to promoting safety in high reliability industries: the top down organisational change approach and the bottom up individually focused approach

• Today these are more enlightened and may manifest in:– Culture change (top down)– Behavioural safety programmes (bottom up)

• Neither can fulfil its potential without the other and the key, going forward, is an integrative approach where individually focused behavioural safety programmes are supported and framed by strong leadership through organisational culture change.

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Safety Culture

• A plethora of definitions exist that are relevant to the nuclear industry (for example: ACSNI and IAEA) and, associated with these, a wide array of measurement systems and tools

• Some definitons (and studies) make a distinction between safety climate and safety culture: not always helpful in practice as most differences are based on methodological (research) considerations

• There is an obvious value of explicative models in the development and application of measurement systems and tools and in the interpretation of the data collected using them (for example, Cheyne, Cox, Oliver and Tomas, 1998)

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Modelling Safety Culture

• ACSNI definition as a starting point:

‘Safety culture is the product of individual and group values, perceptions, competencies and patterns of behaviour that determine the commitment to and the style and proficiency of an organisation’s health and safety management’ (HSC, 1993; p 23)

• Research model derived from this definition. Study based on about 1,000 workers within a multinational manufacturing company. Questionnaire data subject to structural equation modelling (LISREL).

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An Empirical Model of Safety Culture

Safety standards and

goals

Safety management

Physical work environment

Communication

Personal involvement

Individual responsibility

Workplace hazards

Safety activities

.796**

.197*

.720**

.867**

-.232**

.284**

.505**

.450**

.317**

.102*

-.266**

.384**

Source: Cheyne, A., Cox, S., Oliver, A. and Tomas, J. (1998) Work and Stress, 12, 255-271

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Behavioural Safety Process

Review existing safety

data

Coaching and mentoring

Feedback on an individual group

and site wide level

Make periodic observations of

routine work tasks

Modifications to environment, equipment or procedures

Developed from: Cox, S., Jones, B., and Rycraft, H (2004) Safety Science, 42, 825-839

Organisational learning

Management problem

solving cycle

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Evaluation

• Difficult challenge to evaluate outcomes because of ceiling effect: safety measures are, by-and-large, in place and nuclear safety performance is good both in terms of releases and accidents: not able to experiment by withdrawing measures

• Some evidence (next slide for example) that additional new measures, such as those described here, have effect

• Emphasis therefore has to be on process based evaluation and compliance and involvement in new strategy

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NuSAC Reporting

• The 7th Annual Report, produced by NuSAC in January 2006 reviews the safety performance of the nuclear industry to date considering a wide range of safety related measures.

• It concludes that “ the substantial improvements (in safety) repoirted over the last decade for the Civil Licensees have been broadly maintained … At the Defence Sites, performance on dose management continues to show good results with no employee or contractor experiencing a dose in excess of 5 mSv. .. “

• All measures of safety risk show low levels on all measures, for example:– Licensee employee RIDDOR injuries: 0 – 0.69 / 100,000 hours

(2004-05)– Unplanned trips: 1.30 / 7000 hours critical

Source: Open document NuSAC (2006) P3

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Process Measurement

• A variety of different measurement procedures and tools have been developed to describe and evaluate the processes involved in managing nuclear safety, for example:

– SCART (BNG)– LearnSafe– Lancaster group’s work

(next slide)

• Some have been developed specifically for the nuclear industry, some for the high reliability sector and some for general industrial use.

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Impact of Safety Initiatives: Process

• Data collected by Lancaster group from 3 UK nuclear power plants: interviews with key stakeholders followed by questionnaire-based survey of 150 staff

• Focus: successful application of behavioural safety programmes (BSP)

• Key issues was: sustainability

• Key factor: Trust ~ BSP would fail and not be sustained if:

– Trust between key stakeholders is not evident

– BSP was used as a managerial tool to ‘spy’ on staff

– BSP was used as a ‘weapon’ against staff

– There was a lack of consistency between the BSP and the organisation’s ‘just’ culture

Source: Cox, S., Jones, B., and Rycraft, H (2004) Safety Science, 42, 825-839

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Source: http://www.nuclearsites.co.uk/

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Thank You