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Usually ships in 1 business days | | | Technical, psychological and social aspects of industrial safety come under the rigorous scrutiny of scientists and engineers from a vast array of different backgrounds. For many years, as an immediate result of direct international governmental and popular concern, the nuclear power industry has led the safety world. Safety Culture in Nuclear Power Operations presents a cross-disciplinary look at the latest human factors developments in this industry, with wider applications for the entire industrial sector. The book discusses all aspects of safety issues including conceptual bases, societal dynamics and trends, and managing workplace issues and personnel. | | | |
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Nuclear Power Safety: Culture Is The Key Apr 15, 2007
"Safety Culture in Nuclear Power Operations" is an important volume for any professional interested in safety in any tightly-coupled technological domain. The term "safety culture" came to the forefront after the Chernobyl accident: today no analysis of safety, especially in a High Reliability Organization (HRO) would be possible without a consideration of the underlying safety, corporate, and regulatory cultures. Nuclear Power Plants (NPP) are perfect examples of HROs in that they are high-hazard, low-risk institutions (p. 5; see also the definitions of HROs on p. 40,) and conform well to the example definitions of safety culture throughout the book (see Schein's model on p. 7, and the excellent definition on p. 10 in particular; note also the corresponding definition of "safety system" on p.11.)
The subsection titled "The Changeableness of Safety Culture" (p. 12) explores the important topics of system complexity as the cause of accidents, and the role of management in the prevention of accidents through appropriate orientation, action, funding, etc. (p.13.) The role of time in accident chains is explored as well: most accidents occur over a very long period of time (p.20,) although the chain may only be visible retrospectively. This is a key point in my opinion, and argues very strongly for managerial involvement in, and promotion of, safety programs. Managerial importance is demonstrated in the case of the turnaround of the Palo Verde, Arizona station (p.98;) the relationship of profit versus safety culture is well defined on p. 101. The role of knowledgeable safety consultants is demonstrated in the discussion of Billie Garde and Little Harbor Consultants in the shutdown and restart of the Millstone plant (p.216.) An excellent basic guideline titled "Modeling of Organizational Factors Influencing Safety Performance" (pp. 191-192) delineates the interrelationship between accidents and organizational factors concisely. These sections should be mandatory reading for any manager in a safety-critical industry.
Most NPPs have traditionally operated in a regulation-based culture, but problematically, this type of rule-based orientation only prevents previous accidents from being repeated as it is not forward-thinking (pp.25-27). People working in NPPs are bright, competent, motivated, and professional: management must grasp that there is an important role for people to play in NPP operation within a framework of good operating practices (p. 27.) The key to this is good professional education, and understanding of potential consequences of actions, thus allowing for balanced decision making. This is not only my opinion, but is explored in depth (p.30) with knowledge-based decision making seen as being key in ambiguous and intransparent situations. Humans are best at interpretation of information in "context dependent" scenarios (p.81) and excel at "organizational recombination" (p.43) when necessary. This ability to recombine quickly into task-oriented working groups in a crisis is a marker of a positive safety culture, and is commonly seen in other HROs as well (commercial aviation, aircraft carriers, etc.) An excellent example of incident analysis with a focus on decision making in ambiguity begins on p. 159. The incident involves a confusing reactor trip related to steam safety valve functionality, gland sealing steam recovery, and feedwater control deficiencies. The incident is reviewed in great detail, and is an excellent example of the type of incident that can be analyzed and then used for training as an error-forcing context in a scenario-based simulation.
I view training as key to successful crisis management in any industry, and further view simulation and scenario-based training as most beneficial for decision making in ambiguous situations. One method of training design discussed deals with implementing "error-forcing contexts" (p.84) in scenarios. These are unusual combinations of events designed to maximize cognitive and team decision-making skills and are most useful when designed with reference to previous real-world incidents. Airlines do this in simulator training, and NPPs are learning the benefits of this approach with fewer operator errors as a result. At the time of the Three Mile Island accident there were eight NPP simulators in the US; today there are over 80. Not only has appropriate analysis been given to "symptoms versus events" in NPP operator training, but a key measure of operational excellence, the number of unplanned reactor trips, has fallen dramatically since this training has been implemented (p. 105.) Chapter 14 contains an excellent analysis of organizational learning beginning on p.244.
Safety lapses still occur in all industries, even in HROs. One important element of many failings is the role of miscommunication in incidents. This element is discussed throughout the book (please especially note pp. 153 and 175.) I was pleased this got so much attention: almost all accidents involve communication problems in one form or another.
Chapter 18 "Sharing Knowledge on Human Error Prevention" by Tetsuya Tsukada and Fumio Kotani, is a brilliant piece of work. The themes of the chapter discuss data sharing and correlation, human factors research, and training. The authors note (p. 301) that "it is important that workers have sufficient knowledge of 'the most suitable error prevention methods for different situations,'" which argues not only for excellent professional training, but also for data and incident sharing between operators, a situation where nuclear power leads aviation. This chapter underscores the importance of humans in the decision making loop, especially in situations of great ambiguity.
While the book as a whole is a notable and praiseworthy work in the field, there are several detractors. Chapter 10, by Björn Wahlstöm, while generally good, has some translation errors that make it rather difficult to read in a few places, notably on p.200 during discussion of the "synthesized variances plane." Likewise, the final chapter, "A Sign System for Safety" is sub par and sometimes borders on incomprehensible. It proposes a set of signage conventions for NPPs some of which are both convoluted and counterintuitive, although in defense of the chapter, there are some excellent points made, especially on the subject of color coding.
I recommend this book highly to any safety professional.
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