Nordisk kernesikkerhedsforskning Norrænar kjarnöryggisrannsóknir Pohjoismainen ydinturvallisuustutkimus Nordisk kjernesikkerhetsforskning Nordisk kärnsäkerhetsforskning Nordic nuclear safety research NKS-131 ISBN 87-7893-193-2 Nordic perspectives on safety manage- ment in high reliability organizations: Theory and applications Ola Svenson et al. (Eds.) Stockholm University, Sweden April 2006 Abstract The chapters in this volume are written on a stand-alone basis meaning that the chapters can be read in any order. The first 4 chapters focus on theory and method in general with some applied examples illustrating the methods and theories. Chapters 5 and 6 are about safety management in the aviation industry with some additional information about incident reporting in the aviation industry and the health care sector. Chapters 7 through 9 cover safety management with applied examples from the nuclear power industry and with considerable validity for safety management in any industry. Chapters 10 through 12 cover generic safety issues with examples from the oil industry and chapter 13 presents issues related to organizations with different internal organizational structures. Although the many of the chapters use a specific industry to illustrate safety management, the messages in all the chapters are of importance for safety management in any high reliability industry or risky activity. The interested reader is also referred to, e.g., a document by an international NEA group (SEGHOF), who is about to publish a state of the art report on Systematic Approaches to Safety Management (cf., CSNI/NEA/SEGHOF, home page: www.nea.fr) Key words Safety management NKS-131 ISBN 87-7893-193-2 Electronic report, April 2006 The report can be obtained from NKS Secretariat NKS-775 P.O. Box 49 DK - 4000 Roskilde, Denmark Phone +45 4677 4045 Fax +45 4677 4046 www.nks.org e-mail [email protected] NNOORRDDIICC PPEERRSSPPEECCTITIVVEESS OONN SSAAFFEETYTY MMAANNAAGGEEMMEENNTT IINN HHIIGGHH RREELLIIAABBIILLIITYTY OORRGGAANNIIZZAATITIOONNSS Theoryy aanndd aapplpplicaattionnss EEditeddited byby OOlala SSvvensenson,on, IIlklkkkaa SSalo,alo, PPiaia OOedewedewald,ald, TeemuTeemu ReimanReiman andand AnnAnn BrBrittitt SSkkjerjervvee Nordic perspectives on safety management in high reliability organizations: Theory and applications Edited by Ola Svenson, Ilkka Salo, Ann Britt Skjerve, Teemu Reiman and Pia Oedewald Copyright 2006 by the authors of each individual chapter. Svenson et al. (Eds.) Nordic perspectives on safety management in high reliability organizations: Theory and applications. Stockholm: Stockholm University, Department of Psychology S - 106 91 Stockholm Sweden AUTHORS Pernilla Allwin Stockholm University, Stockholm, Sweden Sven Ove Hansson Royal Institute of Technology, Stockholm, Sweden Jari Kettunen VTT Technical Research Centre of Finland, Espoo, Finland Øyvind Lauridsen Institute for Energy Technology, Halden, Norway. Lars Lindblom Royal Institute of Technology, Stockholm, Sweden Svein Nilsen Institute for Energy Technology, Halden, Norway Pia Oedewald VTT Industrial Systems, Finland Teemu Reiman VTT Industrial Systems, Finland Carl Rollenhagen Mälardalens University, Västerås and SwedPower, Stockholm, Sweden Helena Rådbo Karlstad University, Karlstad, Sweden Ilkka Salo Lund University, Lund and Stockholm University, Stockholm, Sweden Per-Olof Sandén Swedish Nuclear Power Inspectorate (SKI), Stockholm, Sweden Ann Britt Skjerve Institute for Energy Technology, Halden, Norway Inge Svedung Karlstad University, Karlstad, Sweden Ola Svenson Stockholm University, Stockholm, Sweden Ingemar Torbiörn Stockholm University, Stockholm, Sweden Björn Wahlström VTT Technical Research Centre of Finland, Espoo, Finland CONTENT Preface i Chapter 1 A Frame of Reference for Studies of Safety Management Ola Svenson 1 Chapter 2 Efficient Inspections Lars Lindblom and Sven Ove Hansson 9 Chapter 3 Feedback for Pro-activity: Who Should LearnWhat from Events, When and How Inge Svedung and Helena Rådbo 21 Chapter 4 On Safety Indicators From a Regulator Perspective: Some Methodological Aspects Per-Olof Sandén 35 Chapter 5 Safety Management in Luftfartsinspektionen – Swedish Civil Aviation Safety Authority Pernilla Allwin 45 Chapter 6 On Event Reporting in the Swedish Health Care and Civil Aviation Systems Ola Svenson 67 Chapter 7 Safety Management of Nuclear Power Plants - Values and Balance of Attention Carl Rollenhagen 75 Chapter 8 Analysis of Challenges to Nuclear Power Plant Safety Management: Finland, Sweden, and the European Context Jari Kettunen, Teemu Reiman and Björn Wahlström 95 Chapter 9 Organizational Culture and Social Construction of Safety in Industrial Organizations Teemu Reiman and Pia Oedewald 115 Chapter 10 Norwegian Petroleum Operations and Regulatory Activities from a System Safety Perspective Ilkka Salo 131 Chapter 11 Factors Affecting Employees’ Willingness to Use Mindful Safety Practices at Norwegian Petroleum Installations Ann Britt Skjerve and Øyvind Lauridsen 151 Chapter 12 Challenges to Safety Management when Incorporating Integrated Operations Solutions in the Oil Industry Svein Nilsen 171 Chapter 13 Elements of uncertainty and risk in intercultural contact Ingemar Torbiörn 183 i Preface This volume has its origin in a series of seminars sponsored by Nordic Nuclear Safety Research (NKS). The book is the result of support form many other different funding sources including the Swedish Nuclear Power Inspectorate (SKI), but also from support from the authors themselves, who devoted so much of their time writing chapters, and the editors who reviewed the chapters. The volume is published as an open- access document, and the copyright of each chapter is owned exclusively by the authors of the chapter. The volume is distributed for free (except for eventual mailing costs) from the editors as long as the printed version will be available. There will also be a CD version of the volume. Stockholm, Lund, Helsinki and Halden October 2005 The Editors ii iii Introduction The chapters in this volume are written on a stand-alone basis meaning that the chapters can be read in any order. The first 4 chapters focus on theory and method in general with some applied examples illustrating the methods and theories. Chapters 5 and 6 are about safety management in the aviation industry with some additional information about incident reporting in the aviation industry and the health care sector. Chapters 7 through 9 cover safety management with applied examples from the nuclear power industry and with considerable validity for safety management in any industry. Chapters 10 through 12 cover generic safety issues with examples from the oil industry. Although the many of the chapters use a specific industry to illustrate safety management, the messages in all the chapters are of importance for safety management in any high reliability industry or risky activity. The interested reader is also referred to, e.g., a document by an international NEA group (SEGHOF), who is about to publish a state of the art report on Systematic Approaches to Safety Management (cf., CSNI/NEA/SEGHOF, home page: www.nea.fr) In Chapter 1 Svenson proposes a theoretical framework for studies of safety management. The framework is generic and does not go into great detail. The starting point is the interaction of living and non-living systems in high hazard industries. The chapter stresses the dynamic systemic character of management and safety management in those industries and other high-risk activities. The chapter covers many different forms of feedback and system adjustment processes in the organizational context. One important form of feedback is provided by safety inspections. In Chapter 2 Lindblom and Hansson analyze safety inspections of workplace organizations starting from a simple theoretic model. They discuss criteria for inspections and explain difficulties in designing and interpreting results from studies of the efficiency of inspections. The chapter also contains information about some empirical studies of efficiency of inspections. Chapter 3 by Svedung and Rådbo also treats the issue of feedback in organizations. In particular they stress the important role of learning from events at different levels as a function of feedback. In Chapter 4 Sandén discusses what measures that can be used as indicators of the safety of a management process in an industrial organization, such as the nuclear power industry. He points out that only recently the focus was shifted from technical and operator safety analyses to organizational issues and proceeds to present and discuss safety indicators in more detail. Allwin gives an account of safety management in the Swedish Civil Aviation Safety Authority in Chapter 5. She illustrates how a system perspective is used, how threats are identified and how information is fed back into the system. In Chapter 6 Svenson continues on the theme of aviation by providing some information about event reporting in the Swedish aviation industry. The chapter also includes information about event reporting in the Swedish health care system including some advantages and shortcomings of different kinds of reporting systems and their legal frameworks. iv In Chapter 7 Rollenhagen gives a theoretical perspective on safety management in nuclear power plants and stresses the issue of the managers' attention to different subsystems of a plant and its organization. He uses a model with different focus areas among which attention resources of the management have to be properly