lec22

Operational Reactor Safety

22.091 /22.903

Professor Andrew C. Kadak Professor of the Practice

Safety Culture Lecture 22

Topics to be Covered

• Important Safety and Performance Factors

• Definition of Safety Culture

• Examples – good – b ad

• Recent examples

• How do you get it ?

• How do you keep it ?

• What is important?

• Role of regulator ?

Key Success Safety and Performance Factors ?

• Safety Culture

• Basic Design of Plant – Fault tolerant

• Training – O perations, Engineering, Mgt.

• Quality Assurance – Self Assessment

• Organizational Factors – Sustain Safety

• Regulations – M otivate Safety (Risk Informed Regulations)

Culture

• “The totality of socially transmitted behavior patterns, arts, beliefs, institutions and all other products of human work and thought characteristics of a community or population.”

Dictionary

Application in a Nuclear Plant

- S afety Culture

• Need to create a “community” t hat has socially transmitted behaviors, beliefs and work ethics that focus on safety.

• Management must create this community by transmitting behavior patterns that support the safety mission with clarity and without confusion. (production vs safety)

Safety Culture

• Vital ingredient of successful nuclear operations

• Essential to protect plant investment

Safety Culture Metrics ? Ideas ?

• If you have it, you know it

• If you don’t have it, everyone knows it !

Attributes of A Good Safety Culture

• Trust People to:

– Operate conservatively

– M ake the right technical decisions

– Perform preventive maintenance

– M ake design and operational improvements not because someone ordered you to do it, but because it was the right thing to do.

Basic Attributes 1

• 1. A prevailing state of mind...

– A lways looking for ways to improve safety

– C onstantly aware of what can go wrong

– Strong feelin g of personal accountability

– Sense of pride and ownership in the plant

1. Thomas Murley (form er NRR Director)

• 2. Disciplined and crisp approach to operations

– C onfident and highly trained staff that is not

complacent

– Good team work

– C risp communications (clear)

• 3. Insistence on sound technical basis for actions.

– P rocedures, design basis and technical documentation is up-to-date.

– P lant design basis well understood by all

– P lant operated within the design basis

• 4. Rigorous Self- Assessment

– O rganization should be open to problem finding and facing

– Management should be capable of dealing with bad and good news

– P roblems should be dealt with immediately and not put off

Example: Plant A

• Staff rigorously follows procedures

• Little overtime

• Unplanned shutdowns rare

• Plant shutdown to fix safety problems even though tech specs permit operations

• Professional decorum exist in control room

• Plant clean

• Low maintenance backlog

Example Plant B

• Procedures are viewed as guidelines

• Many management and staff vacancies exist

• Frequent scrams

• Equipment allowed to run until it breaks

• High maintenance backlog

• Plant runs routinely under LCO

• Equipment out of service for a long time

• Plant has many high radiation areas.

Recent Examples of Failures of Safety Culture

• Davis Besse

– U nwillingness to find out what was going on

– Focus on Production - not safety

– M anagement set wrong tone

– C omplacency - t hought they were good

– O versight groups internal to utility, INPO, NRC failed to question

– P lant staff didn’t push concerns

Davis Besse Pictures

April 17, 1998 February 2002

• Millstone Nuclear Power Station

– T hought they were good

– M anagement focus on reducing costs

– S ignificant staff re ductions without a plan

– M any slogans but actions not consistent

– E mployee concerns raised but dismissed

– No trust in management

– Employees thought is was just a “job”

Cost of Regulatory Non-compliance

• Millstone $1.5 Billion

• Davis Besse >$400 Million

• Nuclear industry Billions

• Loss of public support and confidence

Nuclear Plants are Businesses

• Policies and directions established by the Board of Directors and implemented by CEO.

• Chief Nuclear Officer is the field person

• Pressures of competition and cost are real

• Budgets need to be maintained - i nvestments

• Plants need to operate well

• If not, they will be shut down

• Public support is needed

How do you get a good safety culture ?

• Developed over time

• Cannot be regulated, mandated or delegated (Can we ?)

• Awareness of the importance of each and every job

• Awareness of dependency on other to do the right thing

• Keen understanding that you are personally responsible for the people who work at the plant and the public

Role of Top Management

• Set tone and example

• Know what is going on

• Do not delegate safety

• Attention to detail

• Staff must believe in and respect top management

• Hire people who have good work ethic

• Commitment to safety that goes beyond slogans and posters and meetings .

How to Keep a Safety Culture ?

• Avoid complacency - h ard to do..

• Safety culture is fragile - d elegate balance of people, problems and pressures

– Requires strong internal communications

• Foster identification and resolution of problems - no shooting messenger !

• Maintenance of trust in the organization and its value system

• Motivate people to do the right thing

Maintenance of Safety Culture

• People are an important “safety system”

• Organizational behavior issues are as important as plant components in assuring safety

• Managers and supervisors must be trained in dealing with people and open communications.

• People should understand the importance of their job in the overall success of the plant.

Summary

• Nuclear plants are complex man-machines.

• NRC regulations do not ensure safety – t hey establish requirements which if met will help.

• The utility determines whethe r the plant is safe or not.

• The management of the utility is part of the plant’s safety system as are all the employees.

• Safety culture as set by senior management will determine the plant’s economic and safety success.

What is Safety Culture?

Not an Easy Question !

"We really don't understand what an adequate safety culture is and how to measure it "

NRC ACRS Chairman Dr. George Apostolakis : (Plain Dealer Dec 2002)

Homework Assignment

• Safety culture is an important aspect of safe nuclear plant support and operations. At pres ent it is not “regulated” by the Nuclear Regulatory Commission a nd only indirectly assessed by INPO.

Question:

• If you were a regulator, what regulation would you suggest with associated metrics to regulate safety culture? Please specifically identify the metric and how it will be measured consider ing all the f actors associa t ed with safety culture. Justify your answer.

• Read Sorensen article on “Safety Culture: A Survey of the State of the Art” – posted.

• Due on Tuesday May 13, 2008 - 2 pages

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22.091 Nuclear Reactor Safety

Spring 200 8

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