3/2003 Rev 1 IV.3.2 – slide 1 of 111 Session IV.3.2 IAEA Post Graduate Educational Course...

3/2003 Rev 13/2003 Rev 1 IV.3.2 – slide IV.3.2 – slide 11 of 111 of 111

Session IV.3.2Session IV.3.2

IAEA Post Graduate Educational CourseIAEA Post Graduate Educational CourseRadiation Protection and Safe Use of Radiation SourcesRadiation Protection and Safe Use of Radiation Sources

Part IV Principles of Radiation Protection and theInternational Framework

Module 3 The Development ofSafety Culture

Session 2 Indicators and Examples


We will discuss the indicators for the We will discuss the indicators for the existence of a Safety Cultureexistence of a Safety Culture

We will also present some examples of We will also present some examples of acceptable Safety Cultureacceptable Safety Culture

OverviewOverview


Safety culture is that assembly Safety culture is that assembly of characteristics and attitudes of characteristics and attitudes in organizations and in organizations and individuals which establishes individuals which establishes that, as an overriding priority, that, as an overriding priority, nuclear plant safety issues nuclear plant safety issues receive the attention warranted receive the attention warranted by their significance.by their significance.

Safety CultureSafety Culture


Safety Culture IndicatorsSafety Culture Indicators

There are four groups for which Safety There are four groups for which Safety Culture indicators are provided:Culture indicators are provided:

Government Organizations (Regulator)Government Organizations (Regulator) Operating Organization (Licensee)Operating Organization (Licensee) Research OrganizationsResearch Organizations Design OrganizationsDesign Organizations


Government andGovernment andIt’s OrganizationsIt’s Organizations

Government Commitment to SafetyGovernment Commitment to Safety

Is the body of legislation satisfactory?Is the body of legislation satisfactory?

Are there any undue impediments to the necessary Are there any undue impediments to the necessary amendment of regulations?amendment of regulations?

Do legislation and government policy statements Do legislation and government policy statements emphasize safety as a prerequisite for the use of emphasize safety as a prerequisite for the use of nuclear power?nuclear power?




Have budgets for regulatory agencies kept pace with Have budgets for regulatory agencies kept pace with inflation, with the growth of the industry and with inflation, with the growth of the industry and with other increased demands? Is funding sufficient to other increased demands? Is funding sufficient to allow the hiring of staff of adequate competence?allow the hiring of staff of adequate competence?

Does the government provide adequate funding for Does the government provide adequate funding for necessary safety research? Are the research results necessary safety research? Are the research results made available to other countries?made available to other countries?

How free is the exchange of safety information with How free is the exchange of safety information with other countries?other countries?




How free is the exchange of safety information with How free is the exchange of safety information with other countries?other countries?

Does the country support the IAEA Incident Does the country support the IAEA Incident Reporting System, the Operational Safety Review Reporting System, the Operational Safety Review Teams (OSART) and Assessment of Safety Teams (OSART) and Assessment of Safety Significant Events Teams (ASSET) programmes of Significant Events Teams (ASSET) programmes of the IAEA and other relevant international activities?the IAEA and other relevant international activities?

Are there any instances of undue interference in Are there any instances of undue interference in technical matters with safety relevance?technical matters with safety relevance?



Performance of Regulatory AgenciesPerformance of Regulatory Agencies

Are regulatory safety objectives annunciated clearly, Are regulatory safety objectives annunciated clearly, meaningfully and so that they are neither too general meaningfully and so that they are neither too general nor too prescriptive? Do they permit a proper nor too prescriptive? Do they permit a proper balance between innovation and reliance on proven balance between innovation and reliance on proven techniques?techniques?

Are comments on regulatory requirements sought Are comments on regulatory requirements sought from competent bodies? Have such comments been from competent bodies? Have such comments been taken into account frequently enough to encourage taken into account frequently enough to encourage future comments?future comments?




Is there a predictable and logical process for dealing Is there a predictable and logical process for dealing with issues that require a consideration of both with issues that require a consideration of both safety and economic factors?safety and economic factors?

What is the record of project delays or loss of What is the record of project delays or loss of production due to lack of clarity of regulatory production due to lack of clarity of regulatory requirements or lack of timely regulatory decisions?requirements or lack of timely regulatory decisions?

Are regulatory practices generally consistent with Are regulatory practices generally consistent with the objectives of the IAEA’s Nuclear Safety the objectives of the IAEA’s Nuclear Safety Standards (NUSS) programme?Standards (NUSS) programme?




Is there an education and training programme for Is there an education and training programme for regulatory staff?regulatory staff?

Does the regulatory agency participate actively in Does the regulatory agency participate actively in relevant international activities?relevant international activities?

Are reports on important safety problems published Are reports on important safety problems published routinely by the regulatory agency?routinely by the regulatory agency?




Does the regulatory agency periodically publish a Does the regulatory agency periodically publish a summary review of the safety performances of summary review of the safety performances of plants?plants?

What is the nature of the relation with licensees? Is What is the nature of the relation with licensees? Is there an appropriate balance between formality and there an appropriate balance between formality and a direct professional relationship?a direct professional relationship?




Is there mutual respect between the regulatory staff Is there mutual respect between the regulatory staff and the operating organization based on a common and the operating organization based on a common level of competence? What proportion of regulatory level of competence? What proportion of regulatory technical experts have practical operating or design technical experts have practical operating or design experience?experience?

Is there regular joint discussion of the licensees’ Is there regular joint discussion of the licensees’ experience and problems and the impact of experience and problems and the impact of regulatory activities on these?regulatory activities on these?




To what extent does the regulatory agency rely on To what extent does the regulatory agency rely on the internal safety processes of the operating the internal safety processes of the operating organization?organization?

What is the nature and extent of the regulators’ What is the nature and extent of the regulators’ presence at the plant?presence at the plant?


Operating OrganizationOperating Organization

Corporate Level Safety PolicyCorporate Level Safety Policy

Has a safety policy statement been issued? Is it Has a safety policy statement been issued? Is it clear? Does the policy express the overriding clear? Does the policy express the overriding demand for nuclear safety?demand for nuclear safety?

Is it brought to staff attention from time to time?Is it brought to staff attention from time to time?

Is it consistent with the concept of Safety Culture Is it consistent with the concept of Safety Culture presented in this report?presented in this report?

Are managers and workers familiar with the safety Are managers and workers familiar with the safety policy and can staff cite examples that illustrate its policy and can staff cite examples that illustrate its meaning?meaning?



Safety Practices at Corporate LevelSafety Practices at Corporate Level

Does the corporate board have expertise in nuclear Does the corporate board have expertise in nuclear plant safety?plant safety?

Do formal meetings at this level include agenda Do formal meetings at this level include agenda items on safety?items on safety?

Do operating staff attend to discuss the safety Do operating staff attend to discuss the safety performance of plants?performance of plants?



Safety Practices at Corporate LevelSafety Practices at Corporate Level

Is there an active nuclear safety review committee Is there an active nuclear safety review committee which reports its findings at corporate level?which reports its findings at corporate level?

Is there a senior manager with nuclear safety as a Is there a senior manager with nuclear safety as a prime responsibility? How is he supported and prime responsibility? How is he supported and assisted in his duties? What is his standing assisted in his duties? What is his standing compared with that of the heads of other functions?compared with that of the heads of other functions?

Are the resource requirements for the safety Are the resource requirements for the safety function reviewed periodically at corporate level? function reviewed periodically at corporate level? With what results?With what results?



Definition of ResponsibilityDefinition of Responsibility

Has the assignment of safety responsibilities been Has the assignment of safety responsibilities been clearly annunciated?clearly annunciated?

Has the responsibility of the plant manager for Has the responsibility of the plant manager for nuclear safety been clearly stated and accepted?nuclear safety been clearly stated and accepted?

Are the documents that identify safety Are the documents that identify safety responsibilities kept up to date and reviewed responsibilities kept up to date and reviewed periodically? With what result?periodically? With what result?



TrainingTraining

Does all critical training and retraining culminate in Does all critical training and retraining culminate in formal assessment and approval for duties? What is formal assessment and approval for duties? What is the success/failure record? What is the proportion the success/failure record? What is the proportion of operating staffs time devoted to training and how of operating staffs time devoted to training and how does this compare with the practices of other does this compare with the practices of other nuclear plant operators?nuclear plant operators?

What resources are allocated to training? How does What resources are allocated to training? How does this compare with the allocations of other nuclear this compare with the allocations of other nuclear plant operators?plant operators?



TrainingTraining

Is the quality of training programmes assessed at Is the quality of training programmes assessed at corporate and plant management levels?corporate and plant management levels?

Is there a periodic review of the applicability, Is there a periodic review of the applicability, correctness and results of training courses? Does correctness and results of training courses? Does this review take into account operating experience this review take into account operating experience feedback?feedback?

How frequently are production requirements How frequently are production requirements permitted to interfere with scheduled training?permitted to interfere with scheduled training?



TrainingTraining

Do staff understand the significance of the operating Do staff understand the significance of the operating limits of the plant in their areas of responsibility?limits of the plant in their areas of responsibility?

Are the staff educated in the safety consequences of Are the staff educated in the safety consequences of the malfunction of plant items?the malfunction of plant items?

Are staff trained in the special importance of Are staff trained in the special importance of following procedures? Are they regularly reminded? following procedures? Are they regularly reminded? Are they trained in the safety basis of the Are they trained in the safety basis of the procedures?procedures?



TrainingTraining

Can training staff cite examples of operating errors Can training staff cite examples of operating errors that have resulted in modifications to a training that have resulted in modifications to a training programme?programme?

For control room operators, do retraining sessions For control room operators, do retraining sessions on simulators take into account the difficulties that on simulators take into account the difficulties that staff have experienced and the questions that they staff have experienced and the questions that they have raised?have raised?



TrainingTraining

For maintenance personnel, do training sessions For maintenance personnel, do training sessions make use of mock-ups and video recordings before make use of mock-ups and video recordings before a complex maintenance activity is performed?a complex maintenance activity is performed?

Are training simulator modifications made as soon Are training simulator modifications made as soon as the plant is modified?as the plant is modified?

Do training programmes address Safety Culture?Do training programmes address Safety Culture?



Selection of ManagersSelection of Managers

Do the staff recognize that attitude to safety is Do the staff recognize that attitude to safety is important in the selection and promotion of important in the selection and promotion of managers? How is this recognition fostered?managers? How is this recognition fostered?

Do annual performance appraisals include a specific Do annual performance appraisals include a specific section on attitude to safety?section on attitude to safety?

Can cases be identified in which safety attitude was Can cases be identified in which safety attitude was a significant factor in approving or rejecting a a significant factor in approving or rejecting a promotion to management level?promotion to management level?



Review of Safety PerformanceReview of Safety Performance

Does senior management receive regular reviews of Does senior management receive regular reviews of the safety performance of the plant? Do these the safety performance of the plant? Do these include comparisons with the performance of other include comparisons with the performance of other nuclear plants?nuclear plants?

Are the results of safety reviews acted on in a timely Are the results of safety reviews acted on in a timely way? Is there feedback to managers on the way? Is there feedback to managers on the implementation of lessons learned? Can managers implementation of lessons learned? Can managers identify changes that resulted from reviews?identify changes that resulted from reviews?




Are managers aware of how the safety of their plant Are managers aware of how the safety of their plant compares with that of others in the same company? compares with that of others in the same company? In the country? In the world?In the country? In the world?

Do staff routinely read and understand reports on Do staff routinely read and understand reports on operating experience?operating experience?

Is there a system of safety performance indicators Is there a system of safety performance indicators with a programme for the improvement of with a programme for the improvement of performance?performance?




Are the safety performance indicators understood Are the safety performance indicators understood by staff?by staff?

Are managers aware of the trends of safety Are managers aware of the trends of safety performance indicators and the reasons for the performance indicators and the reasons for the trends?trends?

What arrangements exist for reporting safety related What arrangements exist for reporting safety related events at a plant? Is there a formal means for events at a plant? Is there a formal means for evaluating such events and learning the lessons?evaluating such events and learning the lessons?




Is there a formal mechanism by which the staff who Is there a formal mechanism by which the staff who were involved in a significant event are consulted on were involved in a significant event are consulted on the final contents of a report?the final contents of a report?

Is there a full time safety review group which reports Is there a full time safety review group which reports directly to the plant manager?directly to the plant manager?

Does the organization have effective safety Does the organization have effective safety information links with operators of similar plants?information links with operators of similar plants?




Does the organization contribute effectively to Does the organization contribute effectively to international safety reporting systems?international safety reporting systems?

What are the trends for the number of outstanding What are the trends for the number of outstanding deficiencies, temporary modifications or operating deficiencies, temporary modifications or operating manuals in need of revision?manuals in need of revision?



Highlighting SafetyHighlighting Safety

Does the plant manager hold periodic meetings with Does the plant manager hold periodic meetings with his senior staff that are devoted solely to safety?his senior staff that are devoted solely to safety?

Are there opportunities for non-management staff to Are there opportunities for non-management staff to participate in meetings devoted to safety?participate in meetings devoted to safety?

Do these meetings cover safety significant items at Do these meetings cover safety significant items at that plant? At other plants in the company? At that plant? At other plants in the company? At other plants in the country? At other plants in the other plants in the country? At other plants in the world?world?



Highlighting SafetyHighlighting Safety

Has consideration been given to requesting an Has consideration been given to requesting an OSART mission or similar external review?OSART mission or similar external review?

Is there a process by which more junior staff can Is there a process by which more junior staff can report safety related concerns directly to the plant report safety related concerns directly to the plant manager? Is the process well known?manager? Is the process well known?

Is there a system for reporting individuals’ errors? Is there a system for reporting individuals’ errors? How is it made known to staff?How is it made known to staff?

Do systems of reward include factors relating to Do systems of reward include factors relating to safety performance?safety performance?



WorkloadWorkload

Is there a clear policy on limits to overtime worked? Is there a clear policy on limits to overtime worked? To which staff does it apply?To which staff does it apply?

How is overtime controlled, monitored and reported How is overtime controlled, monitored and reported to the plant manager and higher management?to the plant manager and higher management?

What fraction of the time of the senior person on What fraction of the time of the senior person on shift is spent on administrative duties?shift is spent on administrative duties?



Relations Between Plant Management and RegulatorsRelations Between Plant Management and Regulators

Is the relation frank, open and yet adequately Is the relation frank, open and yet adequately formal?formal?

What is the nature of arrangements for access of What is the nature of arrangements for access of regulators to documentation? To facilities? To regulators to documentation? To facilities? To operating staff?operating staff?

Are required reports to the regulatory agency made Are required reports to the regulatory agency made in a timely fashion?in a timely fashion?



Relations Between Plant Management and RegulatorsRelations Between Plant Management and Regulators

At what levels are the plant contacts for the At what levels are the plant contacts for the regulatory inspectors?regulatory inspectors?

Does the plant manager meet routinely with Does the plant manager meet routinely with regulatory staff?regulatory staff?



Attitudes of ManagersAttitudes of Managers

When there is apparent conflict between safety and When there is apparent conflict between safety and cost or between safety and operation, do managers cost or between safety and operation, do managers discuss with staff members how it is resolved?discuss with staff members how it is resolved?

Are the schedules and content of work for annual Are the schedules and content of work for annual shutdowns examined by an internal safety review shutdowns examined by an internal safety review process?process?

When safety considerations introduce a delay in the When safety considerations introduce a delay in the startup of a plant, do managers use the occasion to startup of a plant, do managers use the occasion to illustrate that safety comes first?illustrate that safety comes first?




During periods of heavy work-load, do managers During periods of heavy work-load, do managers ensure that staff are reminded that unnecessary ensure that staff are reminded that unnecessary haste and shortcuts are inappropriate?haste and shortcuts are inappropriate?

Do managers explain their commitment to Safety Do managers explain their commitment to Safety Culture to their staff? Do they regularly disseminate Culture to their staff? Do they regularly disseminate relevant information such as objectives, relevant information such as objectives, expenditure, accomplishments and shortcomings? expenditure, accomplishments and shortcomings? What practical steps are taken to assist management What practical steps are taken to assist management commitment, such as establishing professional commitment, such as establishing professional Codes of Conduct?Codes of Conduct?




How often have directives from management been How often have directives from management been aimed at the improvement of safety?aimed at the improvement of safety?

Do managers disseminate to their staff the lessons Do managers disseminate to their staff the lessons learned from experience at their own and similar learned from experience at their own and similar plants? Is this a training topic?plants? Is this a training topic?




Is there a system for bringing safety related Is there a system for bringing safety related concerns or potential improvements to the attention concerns or potential improvements to the attention of higher management? Is its use encouraged by of higher management? Is its use encouraged by managers? Do managers respond satisfactorily? managers? Do managers respond satisfactorily? Are individuals who transmit such concerns Are individuals who transmit such concerns rewarded and given public recognition?rewarded and given public recognition?

What is the attitude of managers to safety reviews What is the attitude of managers to safety reviews and audits affecting their activities? Do they and audits affecting their activities? Do they discuss with their staff the results and the means by discuss with their staff the results and the means by which deficiencies may be corrected?which deficiencies may be corrected?




What is the attitude of managers to the application What is the attitude of managers to the application of quality assurance measures to their activities?of quality assurance measures to their activities?

Does management regularly review the performance Does management regularly review the performance of personnel, with assessment of their attitude to of personnel, with assessment of their attitude to safety?safety?

Do managers give public recognition to staff Do managers give public recognition to staff members who take actions beneficial to safety?members who take actions beneficial to safety?




What is the response of management to safety What is the response of management to safety infringements and violations of safety related infringements and violations of safety related technical specifications?technical specifications?

What systems exist to apprise managers of safety What systems exist to apprise managers of safety accomplishments or shortcomings? How effective accomplishments or shortcomings? How effective are they?are they?

Are managers alert to the need to identify Are managers alert to the need to identify weaknesses in their staff, to specify training weaknesses in their staff, to specify training requirements or to provide other support?requirements or to provide other support?




Do managers participate in staff training courses at Do managers participate in staff training courses at which safety policies and procedures are explained? which safety policies and procedures are explained? Do they present any of the training material? Do Do they present any of the training material? Do they follow the training of their staff and are they they follow the training of their staff and are they aware of their training status and levels of ability? aware of their training status and levels of ability? Do they encourage good staff members to spend Do they encourage good staff members to spend time as instructors? Do managers themselves time as instructors? Do managers themselves undergo retraining in safety matters?undergo retraining in safety matters?




Do managers review regularly the assignment of Do managers review regularly the assignment of their staffs duties? Are the relevant documents up their staffs duties? Are the relevant documents up to date?to date?

Do managers attend regularly at the work-place to Do managers attend regularly at the work-place to review safety related activities?review safety related activities?

Do managers give attention to the physical working Do managers give attention to the physical working environment of their staff?environment of their staff?



Attitudes of IndividualsAttitudes of Individuals

Are staff aware of the management commitment to Are staff aware of the management commitment to Safety Culture?Safety Culture?

Can personnel state ways in which safety might be Can personnel state ways in which safety might be prejudiced by their own erroneous actions? And by prejudiced by their own erroneous actions? And by those of others working in related areas?those of others working in related areas?

Can staff clearly enunciate their own Can staff clearly enunciate their own responsibilities? Can they cite the documents that responsibilities? Can they cite the documents that define them?define them?




Can operating and maintenance personnel list any Can operating and maintenance personnel list any recent violations of operating limits of the plant, recent violations of operating limits of the plant, describe the way they happened and state what has describe the way they happened and state what has been done to prevent repetition?been done to prevent repetition?

Are laid down procedures followed strictly even Are laid down procedures followed strictly even when quicker methods are available?when quicker methods are available?

How attentive are staff to the completeness and How attentive are staff to the completeness and accuracy of records, log-books and other accuracy of records, log-books and other documentation?documentation?




What steps would staff take if they observed actions What steps would staff take if they observed actions that might reduce safety margins?that might reduce safety margins?

What attitude do individuals take towards their own What attitude do individuals take towards their own mistakes that might prejudice safety?mistakes that might prejudice safety?

What would an operator or a member of the What would an operator or a member of the maintenance staff do if in following a written maintenance staff do if in following a written procedure he came upon a step that he thought was procedure he came upon a step that he thought was a mistake?a mistake?




What would an instructor do if he came upon a step What would an instructor do if he came upon a step in a procedure that he thought was a mistake?in a procedure that he thought was a mistake?

Do staff use the mechanisms for reporting on safety Do staff use the mechanisms for reporting on safety shortcomings and suggesting improvements? Is the shortcomings and suggesting improvements? Is the mechanism used to report individuals* errors? Is it mechanism used to report individuals* errors? Is it used even when no detrimental effect is apparent?used even when no detrimental effect is apparent?

Do staff respond satisfactorily to the investigation of Do staff respond satisfactorily to the investigation of safety problems, assisting effectively in seeking the safety problems, assisting effectively in seeking the causes and implementing improvements?causes and implementing improvements?




Do co-workers look favourably on those who exhibit Do co-workers look favourably on those who exhibit a good safety attitude by actions such as attention a good safety attitude by actions such as attention to housekeeping, completeness of entries in log-to housekeeping, completeness of entries in log-books and adherence to procedures?books and adherence to procedures?

Do control room staff show a watchful and alert Do control room staff show a watchful and alert attitude at all times?attitude at all times?

Are staff aware of the system of rewards and Are staff aware of the system of rewards and sanctions relating to safety matters?sanctions relating to safety matters?




Do staff make maximum use of training Do staff make maximum use of training opportunities? Do they adopt a responsible opportunities? Do they adopt a responsible approach, complete necessary preparatory work and approach, complete necessary preparatory work and participate actively in discussions?participate actively in discussions?

Do staff stop and think when facing an unforeseen Do staff stop and think when facing an unforeseen situation? In such cases are their actions ‘safety situation? In such cases are their actions ‘safety inspired’?inspired’?




What is the attitude of staff to safety reviews and What is the attitude of staff to safety reviews and audits affecting their area of work? How responsive audits affecting their area of work? How responsive are they to improvements sought as a result?are they to improvements sought as a result?

Do staff participate in peer reviews of safety Do staff participate in peer reviews of safety activities aimed at reducing human errors?activities aimed at reducing human errors?

Do staff communicate their experience effectively to Do staff communicate their experience effectively to other individuals and groups? What examples are other individuals and groups? What examples are there?there?



Local PracticesLocal Practices

Has the plant manager instituted any safety related Has the plant manager instituted any safety related initiatives that go beyond requirements set at the initiatives that go beyond requirements set at the corporate level?corporate level?

What mechanism is available to staff to report errors What mechanism is available to staff to report errors even when they were immediately corrected or had even when they were immediately corrected or had no detectable effect? Do staff make occasional use no detectable effect? Do staff make occasional use of the mechanism provided?of the mechanism provided?



Local PracticesLocal Practices

Are records on the performance or maintenance of Are records on the performance or maintenance of components and systems easily retrievable? components and systems easily retrievable? Complete? Understandable? Accurate? Up to date?Complete? Understandable? Accurate? Up to date?

What is the general state of the plant in terms of What is the general state of the plant in terms of general appearance and tidiness, steam and oil general appearance and tidiness, steam and oil leaks, the tidiness of log-books and records?leaks, the tidiness of log-books and records?

What are the arrangements for supervising, What are the arrangements for supervising, reviewing and signing off maintenance work carried reviewing and signing off maintenance work carried out by supporting organizations?out by supporting organizations?



Field Supervision by ManagementField Supervision by Management

What is the working style of the senior supervisors What is the working style of the senior supervisors on shift? Do they seek information? Are they well on shift? Do they seek information? Are they well informed? Do they visit routinely the areas where informed? Do they visit routinely the areas where safety related work is being done? Are they safety related work is being done? Are they interested in the problems or solely the schedules?interested in the problems or solely the schedules?

Do middle managers often make first hand Do middle managers often make first hand inspections of the conduct of safety related work for inspections of the conduct of safety related work for which they are responsible?which they are responsible?



Field Supervision by ManagementField Supervision by Management

Does the plant manager from time to time inspect Does the plant manager from time to time inspect the conduct of safety related work?the conduct of safety related work?

Do senior managers visit the plant regularly? Do Do senior managers visit the plant regularly? Do they give attention to safety matters?they give attention to safety matters?


Research OrganizationsResearch Organizations

Research Input to Safety AnalysesResearch Input to Safety Analyses

Do researchers ensure that they understand how the Do researchers ensure that they understand how the results of their work will be used in safety analyses? results of their work will be used in safety analyses? Are they familiar with how their data are used in Are they familiar with how their data are used in interpolating or extrapolating for ranges of interpolating or extrapolating for ranges of parameters different from those in their parameters different from those in their experiments?experiments?

Do researchers identify the shortcomings and Do researchers identify the shortcomings and limitations of their results?limitations of their results?




Do they keep abreast of safety analyses to permit Do they keep abreast of safety analyses to permit them to identify any misuse of their work? Do they them to identify any misuse of their work? Do they report any potential misuse or misinterpretation?report any potential misuse or misinterpretation?

On any particular topic, is it clear which group or On any particular topic, is it clear which group or individual is responsible for monitoring new material individual is responsible for monitoring new material or international data? What personal contacts have or international data? What personal contacts have been developed to keep abreast of new data?been developed to keep abreast of new data?




Is there a mechanism for reporting new information Is there a mechanism for reporting new information that may invalidate previous safety analyses? What that may invalidate previous safety analyses? What is the appeal route if the first level of notification is is the appeal route if the first level of notification is ineffective? How often are these mechanisms used?ineffective? How often are these mechanisms used?

Is there a mechanism for ensuring that the relevant Is there a mechanism for ensuring that the relevant research to solve design and operational safety research to solve design and operational safety problems is pursued and carried out in a timely problems is pursued and carried out in a timely fashion?fashion?




How promptly are the results of research fed into the How promptly are the results of research fed into the design and regulatory process?design and regulatory process?

Is there a policy for regular publication of research Is there a policy for regular publication of research results in journals that insist on refereeing by results in journals that insist on refereeing by peers?peers?


Design OrganizationsDesign Organizations

Codes for Safety Aspects of DesignCodes for Safety Aspects of Design

What processes exist for verification and validation What processes exist for verification and validation of computer modelling codes? Do these involve the of computer modelling codes? Do these involve the relevant researchers?relevant researchers?

Are the safety design codes verified and validated Are the safety design codes verified and validated for the specific circumstances?for the specific circumstances?

Are the limitations of codes taken into account Are the limitations of codes taken into account explicitly in the design review process?explicitly in the design review process?



Codes for Safety Aspects of DesignCodes for Safety Aspects of Design

In which international standard problem exercises In which international standard problem exercises have analysts participated to test national computer have analysts participated to test national computer modelling codes? What efforts have been made on modelling codes? What efforts have been made on a bilateral or multilateral basis to compare work with a bilateral or multilateral basis to compare work with that of experts in another country?that of experts in another country?

What is the formal mechanism for reporting the What is the formal mechanism for reporting the matter if it is considered that the previously reported matter if it is considered that the previously reported outputs of a computer model may be invalid? Has outputs of a computer model may be invalid? Has there been a need to use this mechanism?there been a need to use this mechanism?



Design Review ProcessDesign Review Process

In which areas has outside expertise been used to In which areas has outside expertise been used to supplement in-house capability? How was the supplement in-house capability? How was the competence of the outside experts established?competence of the outside experts established?

Where are the functions and responsibilities of Where are the functions and responsibilities of design review teams described?design review teams described?

Has the design review process been audited by Has the design review process been audited by internal Quality Assurance auditors? By the internal Quality Assurance auditors? By the regulatory agency? By a peer group of national or regulatory agency? By a peer group of national or international members?international members?


Safety Culture PracticesSafety Culture Practices

Safety Reports Series No. 1 Safety Reports Series No. 1 provides many observed and provides many observed and documented examples of good documented examples of good (and some ineffective) safety (and some ineffective) safety culture practices relating to good culture practices relating to good (and poor) safety performance.(and poor) safety performance.

Although the examples are Although the examples are related to activities at Nuclear related to activities at Nuclear Power Plants, the concepts are Power Plants, the concepts are applicable to all activities applicable to all activities involving radioactive materials.involving radioactive materials.



This report provides only a selection of safety This report provides only a selection of safety culture practices - not necessarily “best” practicesculture practices - not necessarily “best” practices

It provides a basis for comparison against existing It provides a basis for comparison against existing safety culture practices and identifying opportunities safety culture practices and identifying opportunities for improvementfor improvement

Safety culture attributes are quoted from INSAG-4Safety culture attributes are quoted from INSAG-4

Also included are some experiences and approaches Also included are some experiences and approaches used by organizations to change their safety cultureused by organizations to change their safety culture



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

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

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

What to change.What to change. There is a need to identify the critical There is a need to identify the critical issues requiring change; those which will bring most issues requiring change; those which will bring most benefit in a given period of time.benefit in a given period of time.




How to change.How to change. Those activities required to bring Those activities required to bring about the change need to be identified.about the change need to be identified.

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




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


Approach Of Government and Approach Of Government and Its Regulatory OrganizationsIts Regulatory Organizations

GovernmentGovernment

In any important activity, the manner in which people act In any important activity, the manner in which people act is conditioned by requirements set at a high level. The is conditioned by requirements set at a high level. The highest level affecting nuclear plant safety is the highest level affecting nuclear plant safety is the legislative level, at which the national basis for safety legislative level, at which the national basis for safety culture is set.culture is set.



Good Practice:Good Practice:

Legislative body creates independent agency to regulate Legislative body creates independent agency to regulate the safety of nuclear power installations. Agency the safety of nuclear power installations. Agency charged with ensuring adequate protection of public charged with ensuring adequate protection of public health and safety and protection of the environment. health and safety and protection of the environment. Given broad discretion in licensing and setting Given broad discretion in licensing and setting standards. Regulatory processes are independent of standards. Regulatory processes are independent of outside influence. Agency conducts safety research as outside influence. Agency conducts safety research as needed. Adequate funding provided to the agency.needed. Adequate funding provided to the agency.



Regulatory OrganizationsRegulatory Organizations

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




Inspectors expected to document the safety culture Inspectors expected to document the safety culture causes contributing to identified performance problems causes contributing to identified performance problems or weaknesses. Training for inspectors included root or weaknesses. Training for inspectors included root cause analysis techniques and principles and practices cause analysis techniques and principles and practices of management and organization. Inspectors of management and organization. Inspectors participated in safety performance evaluation teams to participated in safety performance evaluation teams to obtain practical experience and to learn about obtain practical experience and to learn about contributing safety culture causes for safety contributing safety culture causes for safety performance problemsperformance problems




A regulatory body has a weighty influence on the safety A regulatory body has a weighty influence on the safety of nuclear plants within its purview and an effective of nuclear plants within its purview and an effective Safety Culture pervades its own organization and its Safety Culture pervades its own organization and its staff The basis is again set down in a safety policy staff The basis is again set down in a safety policy statement. This makes a commitment to implement statement. This makes a commitment to implement legislation and to act to promote plant safety and the legislation and to act to promote plant safety and the protection of individuals and the public, and to protect protection of individuals and the public, and to protect the environment.the environment.




Agency senior management distributed guidance Agency senior management distributed guidance document entitled Principles of Good Regulation document entitled Principles of Good Regulation established with the input of the regulatory staff:established with the input of the regulatory staff:

all regulatory actions and decisions shall be of the all regulatory actions and decisions shall be of the highest ethical standardshighest ethical standards

be open to the publicbe open to the public use agency resources efficientlyuse agency resources efficiently be timely, coherent and logicalbe timely, coherent and logical be based on the best available knowledgebe based on the best available knowledge




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




Regulatory body intended to establish a policy Regulatory body intended to establish a policy statement on the safety goals for its domestic nuclear statement on the safety goals for its domestic nuclear power plants. Establishment of a numerical safety goal power plants. Establishment of a numerical safety goal would be controversial and might require changes in would be controversial and might require changes in the design and operation of plants already operating. the design and operation of plants already operating. Proposed safety goals were published for public Proposed safety goals were published for public comment. Safety goals were established with the comment. Safety goals were established with the participation and input of the nuclear power plant participation and input of the nuclear power plant industry, the public and special interest groups. industry, the public and special interest groups.




Regulators recognize that the primary responsibility for Regulators recognize that the primary responsibility for safety rests with the operating organization and not the safety rests with the operating organization and not the regulator. To this purpose, they ensure that regulatory regulator. To this purpose, they ensure that regulatory requirements are clear but not so prescriptive as to set requirements are clear but not so prescriptive as to set undue constraints.undue constraints.




Regulatory body initiated industry and public Regulatory body initiated industry and public discussion on the risk from nuclear plants and the discussion on the risk from nuclear plants and the introduction of a less prescriptive licensing approach. introduction of a less prescriptive licensing approach. Led to the publication of risk document which clarified Led to the publication of risk document which clarified the regulatory position. The resulting less prescriptive the regulatory position. The resulting less prescriptive licensing requirements allowed utilities to propose a licensing requirements allowed utilities to propose a utility specific safety approach, which conforms to the utility specific safety approach, which conforms to the less prescriptive requirements and must be approved less prescriptive requirements and must be approved by the regulator. Led to greater flexibility in meeting by the regulator. Led to greater flexibility in meeting safety requirements and greater ownership of safety requirements and greater ownership of approved safety approaches by the utilities.approved safety approaches by the utilities.


Requirements atRequirements atPolicy Level in the UtilityPolicy Level in the Utility

Statements of Safety PolicyStatements of Safety Policy

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



A utility distributed to all managers, staff and A utility distributed to all managers, staff and contractors a clear and concise statement on its health contractors a clear and concise statement on its health and safety policy. The policy document clearly defined and safety policy. The policy document clearly defined individual roles and responsibilities for ensuring individual roles and responsibilities for ensuring safety. The utility avoided issuing too many additional safety. The utility avoided issuing too many additional policies, which could have weakened the clarity and policies, which could have weakened the clarity and importance of its health and safety policy.importance of its health and safety policy.




Management StructuresManagement Structures

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



The utility reduced organizational layers to clarify The utility reduced organizational layers to clarify safety accountabilities. The key levels were:safety accountabilities. The key levels were:

Working level (e.g. plant operators) involved with Working level (e.g. plant operators) involved with specific operational tasksspecific operational tasks

Team leaders responsible for work planning and Team leaders responsible for work planning and coordinating training and supporting specialists coordinating training and supporting specialists (e.g. physician) providing specific technical advice(e.g. physician) providing specific technical advice

Section or function heads managing a process or Section or function heads managing a process or system. Responsible for operational standards.system. Responsible for operational standards.

Unit management developing the longer term Unit management developing the longer term strategic plan for the unitstrategic plan for the unit




ResourcesResources

Adequate resources are devoted to safety.Adequate resources are devoted to safety.



Following a careful review, a significant increase in the Following a careful review, a significant increase in the training needed was identified. Additional staff training needed was identified. Additional staff resources identified as necessary for the operations resources identified as necessary for the operations department to conduct normal tasks while allowing department to conduct normal tasks while allowing time for training. Determined that other departments time for training. Determined that other departments could reallocate staff members to operations could reallocate staff members to operations department without loss of effectiveness.department without loss of effectiveness.




Self-regulationSelf-regulation

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



Senior executives developed a range of quantitative Senior executives developed a range of quantitative performance indicators relating to safety culture. performance indicators relating to safety culture. Routinely evaluated at safety review meeting. Routinely evaluated at safety review meeting. Indicators reflect various attributes of a good safety Indicators reflect various attributes of a good safety culture and include features such as the number of culture and include features such as the number of plant management tours, the amount of safety training plant management tours, the amount of safety training and the number of outstanding maintenance defects. and the number of outstanding maintenance defects. These indicators provide senior executives with an These indicators provide senior executives with an assessment of the consistency between the actual assessment of the consistency between the actual safety practices and the desired safety culture.safety practices and the desired safety culture.




CommitmentCommitment

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



Corporate manager frequently attended the plant Corporate manager frequently attended the plant manager’s daily planning meeting with his department manager’s daily planning meeting with his department heads and principal supervisors. Site director used heads and principal supervisors. Site director used opportunity to communicate the importance of opportunity to communicate the importance of ensuring high quality in the resolution of safety related ensuring high quality in the resolution of safety related problems being discussed. He reminded those present problems being discussed. He reminded those present that plant operating schedules would be modified if that plant operating schedules would be modified if needed to ensure that quality and safety performance needed to ensure that quality and safety performance standards were not compromised.standards were not compromised.



Requirements on ManagersRequirements on Managersin Operating Organizationsin Operating Organizations

Definition of ResponsibilitiesDefinition of Responsibilities

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



To ensure responsibilities are clearly understood, To ensure responsibilities are clearly understood, specific roles and responsibilities of each manager and specific roles and responsibilities of each manager and technical advisor are clearly defined during discussion technical advisor are clearly defined during discussion between the supervisor and subordinate. Resources between the supervisor and subordinate. Resources assigned to each department are defined, together with assigned to each department are defined, together with interrelationships between departments and interrelationships between departments and individuals. Information is circulated to all staff. Roles individuals. Information is circulated to all staff. Roles and responsibilities are formally documented and and responsibilities are formally documented and signed by all individuals involved.signed by all individuals involved.



Ineffective Practice:Ineffective Practice:

A radiological survey data collection sheet required A radiological survey data collection sheet required four separate signatures: the radiation technician who four separate signatures: the radiation technician who collected the data, the radiation technician’s collected the data, the radiation technician’s supervisor, the health physics engineer and the health supervisor, the health physics engineer and the health physics engineer’s supervisor. None of the signatories physics engineer’s supervisor. None of the signatories understood their review responsibilities connected understood their review responsibilities connected with signing the data sheet. The radiation technician with signing the data sheet. The radiation technician once entered an abnormally high radiation level and once entered an abnormally high radiation level and each signatory believed someone else was responsible each signatory believed someone else was responsible for follow-up. No one followed up on the abnormal for follow-up. No one followed up on the abnormal radiation condition.radiation condition.




Definitions and Control of Work PracticesDefinitions and Control of Work Practices

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



A booklet was prepared before an outage and sent to A booklet was prepared before an outage and sent to potential contractors, giving very precise information potential contractors, giving very precise information relating to the outage, industrial safety, fire safety, relating to the outage, industrial safety, fire safety, responsibilities of different sections, work order responsibilities of different sections, work order procedure, tagging regulations, the outage plan, the procedure, tagging regulations, the outage plan, the contact person’s location and telephone numbers and contact person’s location and telephone numbers and logistical information.logistical information.




An operations manager requested the reactor operator An operations manager requested the reactor operator to raise power more rapidly than had been done in the to raise power more rapidly than had been done in the past. The reactor operator directed a plant equipment past. The reactor operator directed a plant equipment operator to ignore a number of pre-startup valve operator to ignore a number of pre-startup valve alignment checks. One of the valves was not in the alignment checks. One of the valves was not in the correct position for startup. The valve misalignment correct position for startup. The valve misalignment resulted in an essential plant system being effectively resulted in an essential plant system being effectively out of service. The out-of-service system caused the out of service. The out-of-service system caused the reactor to trip during the power increase.reactor to trip during the power increase.




Qualifications and TrainingQualifications and Training

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



Managers and supervisors attended a management Managers and supervisors attended a management course on safety culture to supplement their course on safety culture to supplement their management skills training. The two day course helped management skills training. The two day course helped them to better understand and manage safety culture them to better understand and manage safety culture improvement initiatives. The course provided improvement initiatives. The course provided fundamental management techniques in implementing fundamental management techniques in implementing safety culture improvements and identified the priority safety culture improvements and identified the priority actions (e.g. leadership and communications related to actions (e.g. leadership and communications related to safety).safety).




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




Rewards and SanctionsRewards and Sanctions

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



The following are examples of rewards and sanctions The following are examples of rewards and sanctions that were considered good or ineffective safety that were considered good or ineffective safety culture practices in their respective local culture:culture practices in their respective local culture:

Each month an employee was selected as STAR Each month an employee was selected as STAR player of the month and each year one of them was player of the month and each year one of them was selected for the reward of STAR player of the year. selected for the reward of STAR player of the year. Each reward was announced in the utility*s monthly Each reward was announced in the utility*s monthly journal.journal.

A plant manager gave each plant shift supervisor a A plant manager gave each plant shift supervisor a small sum of money to award to members of their small sum of money to award to members of their staff who exhibited high safety standards during the staff who exhibited high safety standards during the shift.shift.



Examples of rewards and sanctions (cont):Examples of rewards and sanctions (cont): A plant manager sent a personal letter to individuals A plant manager sent a personal letter to individuals

who exhibited a high level of safety performance. who exhibited a high level of safety performance. The letter was sent to the individual’s home and was The letter was sent to the individual’s home and was more widely publicized at the discretion of the more widely publicized at the discretion of the individual.individual.

A site director established an “employee of the A site director established an “employee of the month” policy to recognize employees who have month” policy to recognize employees who have exhibited an exceptional safety approach during the exhibited an exceptional safety approach during the previous month. The employee who was selected previous month. The employee who was selected each month was recognized in the plant newsletter each month was recognized in the plant newsletter and was given a choice parking space with a sign and was given a choice parking space with a sign which read “employee of the month”.which read “employee of the month”.



Audit, Review and ComparisonAudit, Review and Comparison

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



A safety culture questionnaire was used to better A safety culture questionnaire was used to better understand the perceptions, attitudes and beliefs of understand the perceptions, attitudes and beliefs of site staff. The questionnaire was developed using a site staff. The questionnaire was developed using a focus group and distributed throughout the focus group and distributed throughout the organization. The completed questionnaires were organization. The completed questionnaires were assessed by independent off-site personnel. The assessed by independent off-site personnel. The questionnaire was used to supplement other questionnaire was used to supplement other monitoring techniques such as audits to identify safety monitoring techniques such as audits to identify safety culture issues.culture issues.




Audit, Review and ComparisonAudit, Review and Comparison

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


Good but Ineffective Practice:Good but Ineffective Practice:

Corporate engineering conducted comprehensive Corporate engineering conducted comprehensive technical assessment to identify plant equipment technical assessment to identify plant equipment problems which could potentially affect safe operation. problems which could potentially affect safe operation. Over 50 potential vulnerabilities were documented in a Over 50 potential vulnerabilities were documented in a detailed technical report and forwarded to the plant detailed technical report and forwarded to the plant manager. An external audit nine months later found manager. An external audit nine months later found that station management had initiated no follow-up that station management had initiated no follow-up actions to resolve the issues. Detailed follow-up actions to resolve the issues. Detailed follow-up reviews were immediately initiated which determined reviews were immediately initiated which determined that certain safety equipment would not be capable of that certain safety equipment would not be capable of performing its intended function in all required performing its intended function in all required situations, necessitating immediate corrective actions.situations, necessitating immediate corrective actions.




CommitmentCommitment

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



A site director sent a memorandum to his staff to A site director sent a memorandum to his staff to communicate his commitment to plant safety and communicate his commitment to plant safety and emphasize his expectations on safety matters having a emphasize his expectations on safety matters having a direct bearing on each employee. This letter was direct bearing on each employee. This letter was attached to the safety handbook and distributed to attached to the safety handbook and distributed to each department.each department.




Based on experiences at other plants, an off-site Based on experiences at other plants, an off-site organization conducted a study to determine if organization conducted a study to determine if selected safety related valves were vulnerable under selected safety related valves were vulnerable under certain conditions. Conclusion was that a similar certain conditions. Conclusion was that a similar vulnerability existed at this plant. The report was sent vulnerability existed at this plant. The report was sent to site management recommending corrective action. to site management recommending corrective action. The site manager rejected the recommendations since The site manager rejected the recommendations since no valve failures of the sort described had ever been no valve failures of the sort described had ever been reported. Three years later during an outage, one reported. Three years later during an outage, one safety related valve was found to have failed and safety related valve was found to have failed and another severely degraded. All potentially affected another severely degraded. All potentially affected valves were modified.valves were modified.



Response of IndividualsResponse of Individuals

Questioning AttitudeQuestioning Attitude

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



As a safety policy management directed that the As a safety policy management directed that the control room annunciator panel would be maintained in control room annunciator panel would be maintained in as near a “black board” (lights out) condition as as near a “black board” (lights out) condition as possible during operation. Degraded or failed possible during operation. Degraded or failed equipment involving control room annunciator panel equipment involving control room annunciator panel lights was promptly repaired to enable the annunciator lights was promptly repaired to enable the annunciator panel to be returned to a near black board condition as panel to be returned to a near black board condition as quickly as possible. Also, all safety related equipment quickly as possible. Also, all safety related equipment areas were maintained in a visually ‘clean* appearance areas were maintained in a visually ‘clean* appearance through maintenance of equipment and floors, walls through maintenance of equipment and floors, walls and ceiling surfaces painted to a “like new” condition.and ceiling surfaces painted to a “like new” condition.




For 3 hours despite indications, two safety system For 3 hours despite indications, two safety system pumps were operating while their associated heat pumps were operating while their associated heat exchanger was tagged out-of-serviceexchanger was tagged out-of-service

Control room annunciators/alarms not investigated Control room annunciators/alarms not investigated and thoroughly questioned as to their causeand thoroughly questioned as to their cause

Main feedwater pump and turbine were spun without Main feedwater pump and turbine were spun without lubricating oil. High temperature alarm not lubricating oil. High temperature alarm not questioned or investigatedquestioned or investigated

Shutdown cooling alarm not questioned by control Shutdown cooling alarm not questioned by control room operators allowing the temperature to drop room operators allowing the temperature to drop well below minimum valuewell below minimum value

During a regulatory agency inspection a bolt on a During a regulatory agency inspection a bolt on a main steam isolation valve was found to be missingmain steam isolation valve was found to be missing



Rigorous and Prudent ApproachRigorous and Prudent Approach

The response of all those who strive for excellence in The response of all those who strive for excellence in matters affecting nuclear safety is characterized by a matters affecting nuclear safety is characterized by a rigorous and prudent approach.rigorous and prudent approach.




To improve the rigour with which maintenance To improve the rigour with which maintenance activities were evaluated from a safety standpoint a activities were evaluated from a safety standpoint a risk assessment methodology was developed. All risk assessment methodology was developed. All activities planned on a function or system (in priority activities planned on a function or system (in priority safety related) are now evaluated by a multidisciplinary safety related) are now evaluated by a multidisciplinary team, focusing on the risk of human error (e.g. team, focusing on the risk of human error (e.g. common cause failures). Changes in maintenance common cause failures). Changes in maintenance plans are subject to risk analysis and cannot be plans are subject to risk analysis and cannot be implemented without the authorization of the team implemented without the authorization of the team leader.leader.



CommunicationCommunication

Individuals recognize that a communicative approach is Individuals recognize that a communicative approach is essential to safety. This involves: obtaining useful essential to safety. This involves: obtaining useful information from others; transmitting information to information from others; transmitting information to others; reporting on and documenting results of work, others; reporting on and documenting results of work, both routine and unusual; suggesting new safety both routine and unusual; suggesting new safety initiatives.initiatives.




Each month a senior nuclear executive selected Each month a senior nuclear executive selected several plant workers with whom to have lunch in order several plant workers with whom to have lunch in order to enhance vertical communications within the to enhance vertical communications within the organization. The individuals were given the organization. The individuals were given the opportunity to raise questions as well as issues and opportunity to raise questions as well as issues and concerns. The senior executive used the meeting to concerns. The senior executive used the meeting to gauge lower level concerns without middle managers gauge lower level concerns without middle managers filtering the message and to clarify management filtering the message and to clarify management standards and expectations. The monthly meetings standards and expectations. The monthly meetings helped to identify employee concerns and issues which helped to identify employee concerns and issues which negatively impacted organizational safety performance negatively impacted organizational safety performance and helped to prompt corrective actions.and helped to prompt corrective actions.



Where to Get More InformationWhere to Get More Information

IAEA Safety Series Report No 75-INSAG-4, Safety IAEA Safety Series Report No 75-INSAG-4, Safety Culture, 1991Culture, 1991

IAEA Safety Series Report No 1, Examples of Safety IAEA Safety Series Report No 1, Examples of Safety Culture Practices, 1997Culture Practices, 1997

3/2003 Rev 1 IV.3.2 – slide 1 of 111 Session IV.3.2 IAEA Post Graduate Educational Course...

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Transcript of 3/2003 Rev 1 IV.3.2 – slide 1 of 111 Session IV.3.2 IAEA Post Graduate Educational Course...