TECHNICAL REPORT COMPARISON OF RULES-MAKING AND PRACTICES CONCERNING SAFETY CULTURE OVERSIGHT

ETSON/ 2020-001 November 2020

CONTENTS

1 SCOPE 3 2 INTRODUCTION 4 2.1 Why safety culture is important? 5 2.2 Recent challenges 7 3 HOW TO OBSERVE SAFETY CULTURE? 8 3.1 What to observe? 8 3.2 How to capture safety culture? 9 4 HOW TO ANALYSE SAFETY CULTURE? 13 4.1 Theoretical approaches for analyzing safety culture 13 4.2 Practical approaches for analyzing safety culture 14 5 SAFETY CULTURE ADDED VALUE FOR RBs AND TSOs 26 6 BIBLIOGRAPHY 28 7 ANNEXES 32

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SCOPE 1

This technical report addresses different ways The technical report is structured as follows: to consider safety culture oversight. Recent The chapter 2 reminds some fundamental developments in that domain provided more concepts; insight for understanding the impact of safety The chapter 3 addresses the question of the culture on safety. Some challenges still remain observation of safety culture; in defining and capturing safety culture but The chapter 4 presents practical examples decisive progresses have been made in the of method developed and implemented last years. In contrast, analysing or assessing within some ETSON members. safety culture still requests the attention of practitioners, academics, regulators and TSOs.

The primary goal is then to provide some guidance regarding the way to perform a field oversight in the domain of safety culture. This means that this report will address the needed theoretical elements to understand the concept of safety culture but above all to tackle methodological issues for capturing and assessing safety culture. In that regard, this technical report relies on practical experience considering safety culture oversight within some ETSON members. Obviously, safety culture oversight is also a domain under the responsibility of nuclear authorities. Therefore, this technical report addresses methods explicitly developed and used by TSOs. In other words the technical report does not intend to cover all practices within ETSON members’ countries but to focus on available methods within some ETSON members.

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INTRODUCTION

Traced back to the Chernobyl Accident Nuclear safety culture is characterized by two analysis (INSAG-1), the concept of safety aspects. It is both structural (organisational culture is regarded as a central phenomenon structure, processes roles and responsibilities, influencing behaviours and values within high- management and steering, documentation and risk organisations. Culture has a strong and communication, nuclear safety policy deep impact on individuals’ standard of statement…) and attitudinal (perceptions, behaviours, professional groups’ practices and social norms, way of thinking and patterns of organisational performance. Exerting a behaviours). In other words, nuclear safety considerable influence on people, safety culture is a combination of values, standards, culture is then considered as a major element morals, and norms of acceptable behaviour. of an effective safety management system These elements are the building blocks of a (Grote and Kunzler, 2000). mind-set giving the utmost importance to safety beyond legislative and regulatory Safety culture has therefore generated a great requirements. In this line of thought, nuclear attention in recent years. Since 1986, the safety culture has to be embedded in the concept of nuclear safety culture has been perceptions and actions of all the individuals at expanded and imposed by regulatory bodies every level in an organisation. on the organisations and the management of Therefore, from a safety perspective, culture nuclear facilities as an essential tool for the could be defined as the deeply rooted and improvement of nuclear safety performance. A shared interpretations, assumptions and beliefs growing interest in the concept has been guiding behaviours towards risks: critical to witnessed in the nuclear field but also in high- success or failure in high-risk organisations, risk activities as, among other, air traffic control safety culture could thus be a cause of (Ek et al., 2007; Gordon et al., 2007), blindness (because a culture could limit or maintenance (Farrington-Darby et al., 2005; narrow your perceptions) but, in the same McDonald et al., 2000), offshore drilling token, in the case of a “healthy” safety culture, (Naevestad, 2008; Haukelid, 2008), enables people to be sensitive to early warning construction (Choudhry, 2007; Gherardi et al., signals. 1998) or shipping (Havold, 2010). As Leadership provided by management in that mentioned, the attractiveness of culture for matter is crucial. Leaders can create or at least safety matters is obviously linked to the support a culture that promotes e.g. open assumed relation between safety culture and communication, questioning attitude or safety operations (Morrow et al., 2014). participation. They play therefore a pivotal role in shaping workplace safety (Clarke, 2013), in particular through trust, recognition or

4 / 37 ETSON/20120-001 November 2020  feedback. According to the seminal work of 2.1 Reason (1997: 196), leadership is a central piece integrating a reporting culture, a just Why is safety culture culture, a flexible culture and a learning culture important? in order to build a safety culture. Nevertheless safety culture is not a topic framed by detailed regulations or generic tools. The introduction of the safety culture concept Much interpretation may be required to was an important contribution to risk understand the nature, roots and impacts of management, like the “total quality” concept cultural factors on safety: in other words, safety was in the 80s as a managerial tool for on-going culture oversight cannot be reduced to improvement. checking and evaluating licensee’s compliance In particular, the safety culture concept with relevant rules, regulations or managerial emphasises the fact that risk management is expectations. built at all levels of the organisation, whereas Nuclear safety culture assessment focuses previously the focus was on the operators, heavily on the perceptions, views and especially from the point of view of human behaviours of nuclear safety issues from error. The IAEA INSAG-4 thus presents people at all levels of the organisation. The requirements directed to those in charge of the main purpose is to gain a better understanding risk management policy (regulatory authorities, of how these affect day-to-day work and nuclear operator management structures, etc.), managerial practices. Hence, in order to to those in charge of risk management and to access to all these data, nuclear safety culture the staff in charge of safety-relevant tasks. assessment requires a methodology that The concept also emphasises the more provides relevant information about staff informal aspects of the organisation, in addition perceptions and behaviours regarding the to the technological and procedural aspects cultural and organisational dimensions that that had dominated until then. The values, demonstrate awareness about nuclear safety. habits, business standards, and local contexts, However, capturing nuclear safety culture is not etc., now appear as elements to be considered an easy task. Safety culture is a complex when studying the risk management evolving phenomenon that covers all aspects construction methods within an organisation. of external and internal relationships at the level Safety culture as a concept therefore opens up of individuals and within groups, communities if not unlocks our way of considering safety (Le and organisations. In addition, safety culture Coze, 2019). assessments have to be performed over a long Moreover, the safety culture concept, in its period of time. According to the experience various developments, had the merit of gained in social sciences (sociology, promoting a “systemic approach” to risk psychology, anthropology) the methods to be management issues. Similarly, the safety adopted for cultural assessment should be culture concept introduced the idea that it is based on an ethnographic observation of “field possible to influence the culture of a group, work”. making it evolve by acting on the characteristics This technical report will therefore consider the of the organisation. The role played by the way to capture and assess safety culture explanation of the strategic objectives assigned dimensions. to a group and the associated values and criteria, as well as the feedback and the discussion of the implementation of work practices have also been emphasised. Finally, the safety culture concept has served the “human factors” approach more broadly, both among operators (Lagrange, 2011) and within safety authorities. The concept has been used to position the organisational and human factors, giving them legitimacy at a time when organisational and human factors were still emerging in the field of risk management. The

ETSON/2020-001 November 2020 5 / 37  IAEA, through the various INSAG documents and safety standards that refer to them, has helped to give it the status of a standard in the world of high risk industries1.

1 The concept was first introduced in the IAEA INSAG- identification of safety culture development stages 1 (1986) and further expanded in INSAG-3 (1988) and (SRS-11, 1998). In addition, the GS-R-3 (2006) and the INSAG-4 (1991). Following these IAEA publications, GS-G-3.1 (2006) standards draw out the five main several other documents have been published in order characteristics describing safety culture. According to to enhance safety culture through key issues to be the GSR Part 2 (2016), safety culture assessment is observed (INSAG-15, 2002), surveys or self- now a requirement. We can also note the WANO and assessment methods to be implemented (TECDOC- INPO position (INPO 12-012, rev.1, 2013) concerning 1321, 2002; TECDOC-1329, 2002) or the the safety culture key dimensions. 6 / 37 ETSON/2020-001 November 2020 

objective? Can the safety objective be the same 2.2 for all of the staff, whether they are in charge of Recent challenges maintenance, independent control, or management? How can staff adherence to this

general objective be designed, when at the The concept is also contested. Some authors same time INSAG-4 stresses the need for a suggested that safety culture presents the risk of possible “systematic questioning” of the rules? avoiding technical issues or downplaying the Shouldn’t divergent objectives be, on the importance of technology design (Rollenhagen, contrary, allowed to intersect and compete to 2010). Likewise it is pointed out that safety foster debate and cause a clarification of the culture discards deeper organizational analyses values and criteria for each, including those taking into account interactions between culture, concerning safety? technology and structure (Naevestad, 2009), This vagueness also concerns the concept of power relations (Antonsen, 2009; Silbey, 2009) “safety”. The INSAG-4 frequently uses this or actual meanings behind observable concept, without ever defining its meaning behaviors (Guldenmund, 2010). Moreover, a (safety appears as a given “data item”) and universal vision of safety culture could have a without ever indicating that this concept is negative impact when implemented in a precisely and continuously at the core of staff particular national culture without adaptation activities. (Chikudade, 2009). Some elements of the IAEA definition suggest In addition this term is also often used in a that safety culture can be decreed “from above” negative form (e.g. a lack of safety culture), and embodied in managerial messages. This particularly in incident reports made by nuclear approach may conflict with the way in which the operators, thereby indicating a lack, a void that effective safety culture is expressed daily in the remains difficult to fully define. These critical organization: it refers to the world of practice. It is views on safety culture lead some authors to in practice that culture is forged and transformed promote the abandonment of the concept (way of working, way of speaking, managerial (Hopkins, 2016) and, in particular, for regulatory attitudes, sharing of good practices...). It also bodies (Grote and Weichbrodt, 2013). refers to history: it is with time and the many The criticism relates also to the vagueness of the experiences in common that collective culture is safety culture concept. This vagueness forged. concerns the concept of culture itself. Indeed, the As a result there is often a gap between the INSAG-4 states that “Safety culture is that decreed (or expected) culture by the assembly of characteristics and attitudes in management and the cultures created by the organizations and individuals which establishes practices and carried by the members of the that, as an overriding priority, nuclear plant safety organization. There are even phenomena of issues receive the attention warranted by their rejection when the culture promoted by the significance”. Therefore INSAG-4 associates company does not correspond to the real safety culture with a number of attitudes and practices of operators (for example, the culture of expected behaviours that actors should develop solidarity and mutual aid is often harmed by to ensure the safe management of the facilities. individual assessment practices). However, the way in which they can be linked

and combined to form a culture is not defined.

We find, for example, the expectation of

adherence of individuals to the common “safety

objective”, which raises more questions than it

answers: What does it mean to have a common

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HOW TO OBSERVE

3 SAFETY

CULTURE?

Assessors aware of their cultural biases, 3.1 “blind spots”, and interests and take steps to What to observe? avoid them as far as possible (e.g. by cross- checking and discussing her/his information and insights with those of other assessors); Culture is considered within this document as an An inductive approach. Proceed in a emerging entity, i.e. a social construction of systematic way by using as many sources beliefs, norms and practices through interaction of information as possible and by trying to and communication over time. The method to be collect information by which an assessor adopted for its study is therefore based on can confirm, rectify or falsify her/his insights ethnographic “field work” observations. In other which should always be considered as open words, observing safety culture is about to change and revision; gathering facts, behaviours, points of view Multiple methods for gathering qualitative regarding these facts and behaviours ethnographic data (through observations (interpretations), representations, discussions, and interviews rather than with etc., striving to reveal the meaning and value questionnaires); systems underlying the activity of the actors and Collecting as many pieces of information as the group cohesion. The data gathering possible about (1) the communications and methods as well as the assessor’s use of the behaviours of people (addressed to other 2 methods are related to this perspective . members of the culture or to the assessor), Addressing cultural issues in this perspective is (2) equipment and documents, (3) the characterized by: relationships between the people, An open-minded, self-critical, systematic, behaviors, artefacts etc. under investigation exhaustive, respectful, and learning-driven and the other members etc. of the culture investigation of as many features of a safety (e.g. how does the maintenance culture as possible; department under investigation interact with

2 Regarding the overall prerequisites of the about the methods of investigation with their investigation, it must be considered that the assessor respective strengths and limits. Most of these points approaches a culture to be investigated (1) with his are self-explaining, but a comment on the interactive own, specific cultural background, (2) by interacting nature of observation is require: in fieldwork, the with specific members of the culture in the context of assessor will be present and himself be observed by specific situations to get relevant information, and (3) members of the culture wondering what she/he is doing with the goal of understanding (i.e. making sense) and interested in and why. This is particularly true, if what she/he observes (4) by use of her/his prior the assessors present themselves as “pure observers” knowledge about the culture to be investigated and (vs participants). ETSON/2020-001 November 2020 8 / 37  and value the members and (or) work of arbitration, etc. All these observables will help us other departments), and (4) cultural aspects to learn about the culture. which need further investigations. Therefore the purpose of assessing nuclear safety culture is to understand how nuclear safety manifests itself in everyday discussions, 3.2 decisions and actions. Hence, nuclear safety How to capture safety culture assessment allows organisations to understand their practical treatment of nuclear culture? safety, and to identify areas and actions for improvement. Based on this ethnographic method, Antonsen (2009) formalised several characteristics concerning this inductive way of working. They 3.2.1 METHODS are summarized here: Each method has its limits (IAEA, 2016). Preferably conducting the study in a “natural Assessors should therefore use (as far as working environment”: in other words, the possible) different methods to compensate the observation of the activity “in situ” and respective shortcomings or drawbacks of the interviews on the field are preferable to individual methods. The application of interviews in researcher’s office, questionnaires is tempting, because they disconnected from the action; support the quick collection of many data, simple Giving full attention to the interpretation, the frequency counts, and rapid statistical analyses. meanings by the persons concerned by a In the light of such advantages, the user of work activity; questionnaire must be aware of drawbacks like Using induction: make sense of the the tendency to avoid extreme answers behaviors and beliefs studied. This means (especially, if the source of such answers is easy that understanding comes from reading and to identify and the respondents might be afraid of interpreting the data related to the analytical negative consequences of answers that frameworks or models, cross analyzed management does not want to hear). against the views of individuals, following an In addition, the subsample of personnel iterative approach. The analyst contrasts his completing the questionnaire might not be view and his interpretation with those of the representative (e.g. dissatisfied people may be actors; less likely than satisfied people to fill in the Cross-referencing the data sources or questionnaire or provide valid information). “triangulating data”: in order to limit the risk of Without additional information, the assessor has arbitrariness and to increase the reliability, no means of clarifying how her/his respondents the analyst must use several methods to did understand the questions in the cross-check data and must also vary the questionnaire and (or) which particular, culture- gathering situations in order to gain access specific meaning terms (jargon) used by to the differences and patterns. The various respondents in their answers do have (as data sources can include the following: compared with an in-depth interview and the interviews, observations, documentary possibilities to ask interviewees for further collection of all kinds, and gathering traces information, more details, explanations etc.). of activity; In contrast face-to-face interviews can be Taking into account the context, the situation conducted with top-management and senior in which the observed phenomena occur managers in order to understand the nuclear (“in situ” action): an activity is always safety policy, how it is steered, managed and connected to a specific context. organised. Aiming to capture cultural aspects of nuclear safety, interviews can also be conducted To these generic principles, we can also add with members of the Nuclear Safety department according to D. Vaughan (2001) that insofar as in order to gain a deeper understanding of how culture is not visible, it is necessary to focus on nuclear safety is experienced, and of their the “events” that will lead to discussions, conflicts practices and ways to improve nuclear safety. of interpretation, decision making modes,

ETSON/2020-001 November 2020 9 / 37  Collective meetings (Focus Groups) can also be teamwork, decision making, supervision, used. This method does not pursue the search peer check; for consensus. It allows the collection of Organizational level: e.g. definition of perceptions, attitudes, beliefs, and the areas of responsibilities, definition and control of resistance. It is adapted to the evaluation of the resources, qualification and training, review safety culture because its objective is not to functions, management commitment, prove (explanatory hypothesis), but to procedures, safety policies, resources. understand the why. Indeed, focus groups are a way of getting people In addition, according to Schein’s model to interact with each other and thus to obtain (1985), this implies also that safety culture opinions on collective issues. This dynamic observations must take into account visible cannot be captured in a face-to-face interview. “artefacts” (system or material elements and Focusing on collective issues (and not on behaviours), tacit “espoused values” (guiding individual responses), those work groups rely on principles as goals, beliefs, norms) and deep- free speech and discussion on day-to-day work seated “basic assumptions” (basis on which focused on nuclear safety related topics, people act upon). Using the iceberg metaphor practices and ways to improve nuclear safety. (Figure 1), we can easily understand that The participants are invited to express culture shows visible and invisible sides. themselves freely about their work and nuclear First, “Artefacts” are material representations safety, about what is going on and what is not in as safety guidance pocket books, charters, terms of nuclear safety in their work, about their workspace and other manifestations that perception of what is important or not (shared include behaviours, rituals, dress code or the prioritization for nuclear safety in daily work, manner in which people interact. sharing of experiences including interfaces). Second, “Espoused values” are defined as For each of these steps, the methodology is values adopted and supported by an based on two fundamental ethical principles: organisation through general statements – respect of the anonymity of each participant, and such as “Safety first” or concerning teamwork, confidentiality of all data collected. decision-making or reporting practices. Third, according to the Schein model, the 3.2.2 CAPTURING VISIBLE AND deepest layer of culture is the underlying INVISIBLE ELEMENTS assumptions, i.e. the taken-for-granted, unquestioned and often unconscious beliefs As already mentioned, the INSAG-4 states that that influence perceptions and behaviours. “Safety culture is that assembly of These shared assumptions are implicitly characteristics and attitudes in organizations understood within an organisation, often and individuals which establishes that, as an unquestioned and deeply grounded on overriding priority, nuclear plant safety issues practices that resulted from a learning process. receive the attention warranted by their Bearing this in mind, the tacit and invisible significance” (1986). dimensions cannot be observed directly and As a main strength, this definition highlights an are complex to address. Since cultural aspects important feature of safety culture, i.e. its two are “submerged” most of the time, safety fundamental sides: safety culture is both culture is mainly observed through artefacts structural (organisational structure, roles and and espoused values. Nevertheless, out of the responsibilities, documentation, policy statement…) and attitudinal (perceptions, social norms, way of thinking, and patterns of behaviour). Therefore, this means that safety culture observations must take into account different types of activities at different levels:

Individual level: e.g. questioning attitude, individual awareness, accountability, reporting, rigorous and prudent approach; Group level: e.g. communication,

10 / 37 ETSON/2020-001 November 2020  safety culture observations, clues about deepest layers can be drawn out.

As a challenge, the closer we can consider as a lack of “compliance with regulations, rules submerged layers of safety culture the deeper and procedures” is obviously significant but, we can explore safety culture. adopting a safety culture point of view, it is more important to understand why people did not follow the rule: are we facing a bad behaviour, a lack of knowledge of the rules or rather a bad 3.2.3 OBSERVATIONS ARE rule? RATHER DESCRIPTIVE THAN We have then to go further. A question could NORMATIVE arise as to know why operators did not comply: does it mean that we are facing an The meaning of a safety culture artefacts and understanding problem (lack of training, espoused value does not appear knowledge of work process) or a procedure spontaneously. To some extent the positive or fitness problem (adaptation of the procedure to negative sides of an observation are not a specific task)? Relating to the group level we interpretable at first sight. can raise issues concerning the legitimized Standards and guidelines in the field develop level of compliance within a group (department, different lists of key attributes indicating what a team, plant). In terms of management, the good safety culture is. Many statements such questions could be oriented towards the as questioning attitude trust between commitment of management, the leadership management and operators or cross-functional style or the supervision practices. teamwork are attributes commonly considered Adopting a “why approach”, safety culture as characteristics of a strong safety culture. observations are therefore not black or white. Conversely, warning signs of a weak safety As an illustration, the following example shows culture could be identified such as a lack of that the positive or negative sides have to be systematic approach, insufficient reporting evaluated carefully. practices or resource mismatch. “A manager of the Operation department goes The normative view of safety culture gives a into the field after work hours in order to check useful framework defining what safety culture all work in progress. Some gaps are observed should be. However, a good or a bad safety and reported by the manager to the team.” culture is not so clear-cut at the workplace. For In the first instance, this fact reflects the instance, a statement such commitment of this manager and the

ETSON/2020-001 November 2020 11 / 37  continuous improvement capacity of the system but at the same time this observation raises the issue of the effective field presence of the management during the period when daily work is carried out. An observation is an entry point for questioning practices, in this case, regarding the leadership style, the work overload of managers, the capacity to ensure face to face communication. Thus, safety culture observations provide valuable data, but mostly make sense when they are considered in the context of other safety culture elements. Observations should be provided by detailed and repeated questions about why something happened in a given situation and (or) why something is designed or used as it is for the given situation (observations should therefore be “thick descriptions” in the sense of C. Geertz): They should not be treated as isolated, “stand-alone” facts, but as a system of interrelated statements about cultural aspects.

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HOW TO ANALYSE

SAFETY

CULTURE?

4.1 of safety culture shaping. Theoretical Within this top-down approach, safety culture can be then managed and engineered3. A approaches for common approach to assess safety culture analyzing safety using this approach is to apply survey methods such as questionnaires (Smith-Crowe et al., culture 2003) and to identify the general attributes of a strong or good safety culture. Self-completion Two different approaches, respectively called questionnaires are useful tools to capture “functionalist” and “interpretive” (Glendon and perceptions about safety (safety climate) and to Stanton, 2000; Richter and Koch, 2004; explore differences between groups or Naevestad, 2009), are two useful perspectives organisational levels (IAEA, 2016). These helping to understand how to analyse cultural instruments are also appropriate in order to data. provide a baseline for further comparison over From a functionalist perspective, culture is time. However, results obtained through something the organisation has. Safety culture quantitative methods could be limited to an is then a set of behaviours, attributes, organisation’s safety climate snapshot processes or policies assuring that safety is an (Guldenmund, 2007), i.e. to explicit measures overriding priority. Considered as an ideal to influenced by a set of factors such as which organisations should aspire, (a good) organisational circumstances or socially safety culture is established when a set of desirable response strategies (Marquardt et al., features are implemented. On the one hand, 2012). this ideal should be adapted to serve the Conversely, from an interpretive perspective, organisation. On the other hand, it implies that culture is something the organisation is. Safety the management plays a major role as initiators culture is considered as a social construct, as a

3 We could find here the approaches defined as (2013), a connection has to be made with the so-call “analytical” (i.e. based on the statistical treatment of “normative” and “pragmatist” approaches. These quantitative data) and “pragmatic” (i.e. with a authors identified a similar third category called managerial purpose) by Guldenmund (2010). respectively the “academic” and the According to the view developed by Edwards et al. “anthropological” approaches. ETSON/2020-001 November 2020 13 / 37  shared pattern of meanings constructed within can be combined to form a coherent framework social groupings: safety culture then defines of safety culture oversight, analysis, and beliefs – what is safe or dangerous (Vaughan, assessment. 1996) – motivates and legitimizes behaviourc through a shared repertoire of positively and negatively-loaded meanings (Reiman and 4.2.1 EXPLORING CULTURAL 4 Oedewald, 2004) or enables collective identity ASPECTS OF SAFETY (Gherardi et al., 1998). In contrast with the previous perspective, culture is a bottom-up Taking into account cultural aspects of safety phenomenon emerging through interactions may give access to phenomena that are difficult within groups grounded in a specific context of to deal with. On this basis, four analysis levels technology (Rochlin, 1999). are proposed, which provide a breakdown of Interpretive studies on safety culture focus on the overall “culture” topic: organisational thick descriptions of work activities, actors’ cultures, professional cultures, social cultures meanings and occupational culture (Atak and and relations, and national cultures. Kingma, 2011; Antonsen, 2009; Naevestad, 2008; Farrington-Darby et al., 2005; Brooks, Influence of national culture 2005). However, except for some scholars (Perin, 2005; Bourrier, 1996), there have been A number of studies seek to identify managerial few attempts to adopt this kind of ethnographic modes, or types of social relations, which are approach in the nuclear field. As a main pitfall, specific to certain countries and could be observations could lead to an associated with national cultures. P. D'Iribarne overgeneralisation from a small number of (1989, 2005) in particular emphasises the findings or to remain focused on the area of impact of national culture on corporate culture expertise of the observer. from a comparative study between 3 countries In other words, data gathering methods strive (France, USA and the Netherlands). For him, it to reveal the meaning and value systems is a matter of traditions that are rooted in the underlying the activity of actors and the group texture of our social relations throughout cohesion. This way of analysing is opposed to collective life (inside and outside of the traditional hypothetical-deductive approach organisations). that builds hypotheses and then in an orderly Although there is necessarily a reciprocal way gathers items of information that will influence between the traditions of a country enable a response to these. Here, the analyst and the modes of organisation of companies, it is rather in the position of being surprised by is however difficult to characterise this link. The what emerges; he listens, watches and then work by Bourrier (1999 and 2005) calls for puts in order the information and interpretations caution with regard to a cultural interpretation gathered to make sense of them. that would neglect the influence of the role of local organisations. As part of the safety assessments performed by the IRSN, the identification of the traits of 4.2 national culture and the study of their influence on the organisation of operators presents the Practical approaches pitfall of stumbling into the obvious or into clichés about national or regional behaviour, for analyzing safety and may not allow ways for improvement to be culture identified. However, it is necessary to identify the cyclical

and contextual variables that can permeate the In order to highlight the diversity of global culture of the organisations of operators, methodological approaches for analysing and explain the strategic choices involving the safety culture, this chapter will describe three actors: different approaches respectively developed Environment, institutional and regulatory and applied within IRSN, GRS and Bel V. The policy: type of risk governance, regulatory three approaches seem to be quite different, changes and prescriptive force of the latter, but the concluding chapter will show that they 14 / 37 ETSON/2020-001 November 2020  etc.; identifying the tools as such, as well as the Economic environment that may influence discussions and the underlying value the strategic choices: restructuring; systems (Boussard, 2008). Discussions Social construction of risks: place of risks in give meaning to the tool; the company, consideration for the nuclear Among the devices, the following can be industry, etc. (coupled with the mobilization distinguished: processes aimed at of civil society actors); optimization, rationalization (operating National/regional traditions in social procedures, quality processes, etc.); relationships (employer-employee relations) managerial arrangements aimed at and hierarchical relationships (management regulating social relations, commitment and design); motivation of actors (performance contracts, HR systems in general); measuring devices Organisational cultures and the reporting of results (charts, etc.); procurement processes; The following issues may be retained to fuel the Rapport with the rules: latitude to change the study of organisational culture: rules, degree of involvement of the actors in the process of creating rules; Historical elements: the circumstances of Event management arrangements: the creation of the organization, founders, decision making process, arbitration criteria milestones, stages of its development (with and methods, etc. (Vaughan, 1996). regard to the activities, technologies, structures, scope of the organization, It is not a question, of course, of exploring all of strategies, etc.). All of this contributes to these aspects, but rather of identifying those structuring myths that often persist long after that are relevant to the context and the the founding and evolution of the problems to be dealt with. organization; Activity: the core business, specific and Professional cultures and identities at distinctive know-how, and technologies. work Values: generic values of the organization (distinguishing “declared values” - or The consideration of cultural aspects can “espoused values according to Schein - enrich risk management system assessments, those in the texts, institutional discourses in particular: and “operating” values, those that are found in the management systems, decision The professionalization process: these can making methods, procedures in general - be addressed through the consideration of recruitment, budget, etc.); safety-related the organizational provisions implemented values (what is considered “good” risk (training, tutoring, retraining, etc.) and in management / “bad” risk management, terms of the technical skills acquired. etc.); However, this process goes beyond just Signs and Symbols: behaviour codes, these aspects if we take into account the fact space planning, captions, etc.; that professionalization also enables the Structure type (entrepreneurial, sharing of professional knowledge specific professional, bureaucratic, mechanistic, to a given community, thereby fostering a innovative, missionary, or politicized common “culture” for this community and organisation), work division arrangements contributing to its cohesion. This secondary (versatility/specialization, etc.) and type of socialization is particularly important coordination (internal/external contracts); insofar as it helps to understand how work Management style: e.g. standards are built, transmitted and made authoritarian/directive style, sustainable. Professional “culture” paternalistic/benevolent style, consultative constitutes here a method for integrating style, or participative style); young entrants, as well as building skills, Management tools and processes: Inter-group cooperation: this can be distinguishing management tools (action addressed from the perspective of the oriented) and assessment tools (reporting); different places and coordination support

ETSON/2020-001 November 2020 15 / 37  tools considered purely on a “functional” overtime pay, participation in projects, level for performing the tasks. However, the autonomy, room to manoeuvre, etc.); quality of cooperation also depends on the Work well done criteria and the quality of work, way in which these sites and tools take into which may in particular emerge from events to account the pivotal role of the social group be managed, uncertainties and dilemmas, recognized as being of the same occupation sparking debates that enable the or same profession, as well as shared implementation of these criteria to be observed. values (e.g., operation, maintenance, At this time, different professional practices logistics, dismantling, etc.). The group may also emerge within a same occupational imposes standards, rules, ways of doing family. things, and values of its own, and thus plays a role of leadership and control over its The consideration of the cultural aspects that members that will affect cooperation. contribute to the cohesion of professional groups is especially important when work is Based on the work of F. Osty (2003), the increasingly performed by actors associated following aspects to study the professional and with various organisations, e.g. working in occupational cultures may be retained: project mode in relation to sustainable entities, The social groups belonged to a formal resorting to subcontracting. professional line (referring to the officially used nomenclature), as well as a reference Cultures and social relations group (the one that makes sense to the actor). The study may involve various levels: The work in sociology of organisations the company; the plant or site, and the conducted in the nuclear field are scarce. M. related features (values, operating modes, Bourrier appears to be a key author from this atmosphere, etc.); the professional line point of view. She provides a strategic (operation, maintenance, etc.); the approach to reliability: “Reliability should be occupation (electromechanic, valve analysed as the product of choice, decisions repairman, etc.); etc. The goal is not to carry and successive, parallel and concurrent out an exhaustive exploration, but rather to regulations, congruent or conflicting as identify and prioritize the 2 or 3 reference appropriate”, and thus proposes to analyse groups to which an individual, or a high-risk organisations “from the point of view of community refers, on which it relies to the the actors, of their strategies and of how they extent that it is both an identity resource and negotiate their participation in a very also a knowledge resource and a milestone demanding organisation”. She is particularly for work standards; interested in strategic games, games that take Professional socialization modes provided place around the “prescription”, the rules and by the company (training, career paths, the procedures, and deduces “reliability plans” etc.), peers (tutoring practices, buddy from them (specific organisational system, rotating implications), hierarchy configurations). Indeed, these are particularly (training sessions, tutored simulations); determined by an individual’s social place Collective life and exchange spaces for trust within the organisation; places that are different and cooperation, and ways to regulate for different plants. Comparing the operation of potential tensions or conflicts: collective life four nuclear power plants (2 in France and 2 in (rituals, meals, etc.), solidarity/cohesion the US) during the 90s, she identifies various within a professional group (degree of “regimes”. cohesion, support modes, hierarchical role For example, in Bugey, circumventing rules in collective life in general, informal leaders), would be relatively common and can be for exchanges (meetings, informal explained by the fact that technicians would not exchange times, time spent on them, etc.) participate either in the development or in the method for managing tensions and conflicts changes to the rules and, similarly, would not (arbitration modes); forward information up the command chain Skill recognition mechanisms, and more with a view to improving them. This would be generally (salary, classification, accompanied by a specific socialisation, compensation, bonuses, various benefits, belonging to a particular community that

16 / 37 ETSON/2020-001 November 2020  defines “how far one can go too far”. This modes of operation within a collective, model, which would promote “DIY”, is effective especially if these provisions affect the from a certain point of view, but by increasing managerial functions (profile, legitimacy) and the gap between what is prescribed and what the modalities of collaboration and is real it risks stretching limits of acceptability management. and would promote opacity, encouraging The approach proposed by M. Bourrier thus partitioning and “turfs”. appears particularly fruitful for understanding Another example of a reliability scheme, is that what is at stake in social balances, which may of Diablo Canyon in the USA: a form of constitute barriers or, on the contrary, levers in bureaucracy (division of tasks, long hierarchy the cooperation and co-construction of risk line, excess of procedures, etc.) that management. nevertheless “would work”. The unexpected Such factors can also be captured by the would be limited, through planning, to the distinction between formal and informal support that technicians would benefit from, to organization: The “formal organization” is the a lack of appreciation of initiative, etc. In other officially issued body of procedures, words, M. Bourrier demolishes the idea of “too instructions, prescriptions orders etc. which much” or “not enough” procedures, and people are required to observe. The term of supports the idea that reliability is built upon the “informal organization” is used in a narrow and quality of the social relationships and in a broad sense: Some scholars define the interactions that develop in relation to these informal organization as the behaviours which rules and procedures. However, the latter is are useful and necessary in order to maintain determined by the relative positions of the and develop the organisation (Lang, 2004). various social groups, the opportunities to Specifically, it is a case of finding the fine exchange and negotiate where applicable, the balances that develop between social groups absence of sterile power games that would within work organisations, beyond the formal lead to hiding information or to not cooperate, aspects. In methodological terms, it may be etc. useful to build upon the work carried out in She thus makes the connection between the classical sociology of organisations (Bernoux, way personnel or subgroups of personnel 2014) which gather data on the following actually behave in the organization (“social aspects: reading of the organisation”) and reliability with Formal elements relating to the ways of which personnel follow formal rules and exercising power and to the division of work: procedures: this reliability depends on social hierarchical strata, classification and factors and interpersonal interactions. This recognition system, horizontal division of “social reading” can be in line or at variance with work, social data (age, gender, seniority, how members of the organization or of etc.); organizational units within the organization are Symbolic aspects related to the roles and formally expected to work, cooperate, and places within the organisation. It is communicate. Thus, for example, beyond the particularly a case of identifying: the prestige traditional division between “operation” and associated with a particular function, how to “maintenance”, there may be rivalries between participate in the development/modification maintenance teams related to their different of rules and procedures, autonomy, histories. decision latitude and control of areas of Similarly, the manner of exercising the uncertainty. These aspects can be supervising function can be different for understood from the analysis of work different plants, depending on whether it is meetings; for example, the decision-making embodied by a technical expert who draws his modes (who decides what and by what legitimacy from his knowledge of the field, or by process - see in particular the issue of a “manager” who has a distinctive way of developing and changing rules), the leading the collectives. She also shows how autonomy margins associated with a organisational reforms jostle alliances between particular function, respecting the rules, etc.; social groups, transforming social regulation Elements related to the interactions methods. Indeed, new organizational between actors and groups of actors: arrangements may have impacts on the analysis of actor games, alliances,

ETSON/2020-001 November 2020 17 / 37  cooperation, and the conflicts that are In MESKA, the safety culture in a licensee forged. This strategic reading of the company is conceived to be composed of organisation and the actors helps to safety subcultures whose number and understand both the levers and the potential differences may vary to a greater or lesser bottlenecks, for example, in the extent. Different sites, organizational units, implementation of a reorganization, since management hierarchy levels, and other any change indeed modifies the grey areas groups of members of a licensee company controlled by the actors, resulting in a may develop their specific subcultures with change in the power balances. respect to safety. A safety subculture may be shared by people who are not members of the These different levels of analysis support the licensee company: for example, there may be break-down of the global topic “safety culture” mixed teams of plant and contractor personnel which appears to be too complex to be who have been developing common values, addressed directly. These different levels are norms, mentalities, and patterns of behaviour intended to complement each other and to during their co-operations. In general, there will enable a comprehensive understanding of the be many interactions between safety cultural aspects of an organization and their subcultures at the licensee company and the potential impact on safety. socio-economic, political, and cultural environment of the company. There may be an overarching, company-wide safety culture which is common to each safety subculture 4.2.2 FOCUSING ON (like a common backbone or core), but such an LEADERSHIP INFLUENCE ON overarching company-wide safety culture need SAFETY CULTURE not exist. And if it exists, it may not be a strong one in the sense of the IAEA definition. The MESKA4 intends to support the qualitative methodology of MESKA is fit to capture such 5 evaluation of the safety culture at licensee diversities of safety subcultures . companies. MESKA is also used in order to MESKA uses primarily information which collect the information required for these results from oversight activities by safety assessments and to trigger the appropriate authorities. Principal information sources are: responses of safety authorities. The steps of observations and conversations during plant gathering and processing of information, visits, inspections, meetings e.g. with top evaluation, and response to evaluation- management, and other occasions of outcomes shall be continuously iterated during interpersonal information exchange with the the entire life-cycle of a licensee company. personnel of the licensee company, including MESKA was developed for use by safety contractors; documents to be submitted to authorities but it can also be applied by safety authorities; event reports, and any other licensees for self-assessments or peer reviews, information safety authorities can request from by technical support organizations, and by or about the licensee. other institutions, which are working on safety MESKA thus does NOT require information culture analyses and assessments. The collected with specific instruments such as following description focuses on the use by safety culture questionnaires or investigation safety authorities. The term “inspector” will be methods whose application necessitates a used to designate members of the safety scientific background and training in authority in charge of oversight activities. anthropology, psychology, sociology etc. The IAEA definition, characteristics, and Nevertheless, it is possible to use information attributes of safety culture were used as a from such sources, if this information is conceptual framework for MESKA available to the safety authorities. This means development.

4MESKA is an acronym for the German title developed on behalf of the German Federal Safety “Methode für die Erfassung der Sicherheitskultur Authorities. durch Aufsichtsbehörden“. A neat English 5 In the following the term of safety culture will be used translation would be “Method for the Evaluation of for the sake of simplicity. But the reader shall keep in Safety Culture by Safety Authorities“. MESKA was mind that “safety culture” essentially refers to a system of safety subcultures. 18 / 37 ETSON/2020-001 November 2020  that the safety authorities can easily include As an important point, note that the actions and safety culture in their oversight activities. measures in Annex 2 table are observable. As MESKA is focused on leadership for safety shown by ample empirical evidence from culture i.e. the actions and measures taken by scholarly research, they promote subordinates’ leaders to foster safety culture. This focus on high performance by providing best possible leaders’ actions and measures requires a conditions of task performance and by comment on what is meant by “leader” and strengthening the psychological factors “leadership for safety culture”, why this focus underlying high performance such as was adopted, and to which extent this focus knowledge, motivation, values, feeling and causes gaps or biases in safety culture wellbeing, work satisfaction, etc. Annex 2 table oversight. The term “leader” is used for all thus presents leaders’ action and measures members of a licensee company from top which are both observable and have managers down to front-line managers and empirically well-established positive effects on personnel to whom a leadership function is psyche and performance of personnel. assigned only for a specific task and a In MESKA development, it was also checked specified, normally short period of time6. and verified, that the leadership activity areas, MESKA is then applicable and shall be applied actions and measures cover the observable (or to leaders on all levels. It therefore supports the “tangible”) attributes of a strong safety culture gathering and analysis of information about listed in Appendix I of IAEA GS-G-3.5. It was cooperation and information flow between therefore concluded that leaders’ actions and levels of the company hierarchy. In MESKA, measures will promote personnel’s safety- leadership for safety culture is defined broadly relevant attitudes and performance. Since and covers several areas. Based on scholarly these observable generic actions and research, a breakdown of the leadership task measures and their effects on unobservable into five areas of activity was performed in psychological factors like attitudes, values, MESKA development. These areas7 are the motivation, knowledge etc. cover the safety following: culture attributes as defined by IAEA, MESKA Create conditions of work; does not neglect important aspects of safety Direct subordinates’ work activities; culture. Although MESKA is focused on Work on mistakes, improvements, leadership for safety culture, it thus supports the preventive measures; analysis and assessment of the safety culture Recognize and sanction; in a licensee company. Cultivate fair interpersonal relationships. Users of MESKA are thus directed to collect and analyse information about actions and MESKA also defines which actions and measures of those members of a licensee measures leaders should perform in each company who have the power, the resources, activity area to properly fulfil their leadership and a specific responsibility for safety culture task. Annex 2 table presents these actions and promotion. This has the advantage of focusing measures of an ideal, efficient leader. By use of not only on what safety culture “is” but, in scholarly literature and expert judgement it was addition, on how and to which extent it is concluded that the leadership areas as well as (loosely speaking) “produced” by people in the required actions and measures provide a charge of leadership and management in the generic and exhaustive description of the licensee company. leadership task and of what efficient leaders MESKA supports two oversight approaches shall do. All actions and measures are which are called en passant- and en bloc- considered equally important, i.e. there is no approach. ranking or differential weighting of the individual The en passant-approach was developed to actions and measures. use as many as possible oversight activities by safety authorities - in particular plant visits - as a

6 This broad use is due to the German language in managers and leaders. Rather, “manager” is which “leader” can be used as a quite general term, subsumed to “leader”. which covers “manager”. In other languages, leader 7 Task-area descriptions are presented in a table in and manager may have more distinct, less overlapping appendix. meanings. The reader should therefore keep in mind that MESKA does not draw a neat distinction between ETSON/2020-001 November 2020 19 / 37  source of information which could provide defined scope, time-frames, and resources. insights into how safety culture is fostered by The scope of an en bloc-investigation may licensee personnel in charge of leadership vary: the safety authority may conduct a tasks. The philosophy of this approach is the company-wide investigation of leadership for following one: Even if the primary goal of safety culture or it may limit the study to e.g. oversight activities is not the collection of organizational units of the company like the information about “leadership for safety culture” maintenance department8. (but e.g. a technical inspection), it may provide In both approaches, inspectors in charge of relevant information as a by-product. An information collection shall: inspector may observe that a team leader does Collect as many pieces of information as not act as a role model for the subordinates possible; because that leader does not wear a helmet Observe not only leaders and (or) limit their even though wearing a helmet is mandatory in conversations to leaders, but (as far as that situation or for the specific task. The possible) also try to get information from inspectors may, for example, make such subordinates, superiors, colleagues, and observations on the way to the place where other members of the licensee company as they will perform the task for which they visit the well as the contractors on the leader and plant. use this information to cross-check the The idea of MESKA is to get and use these information from observations and (or) many pieces of safety culturally relevant conversations with leaders; information by increasing inspectors’ Collect information about the human and awareness for such details and supporting their organizational factors which are relevant to reporting of such information to the safety task performance by leaders and personnel; authorities. If many or, ideally, all inspectors Keep asking question to better understand participate in this approach, safety authorities what is observed and (or) learned from will be provided with a constant flow of many members of the licensee company; pieces of information about leadership for Collect information which helps cross-check safety culture from all parts of a licensee other pieces of information; company which are subject to oversight Collect information not only about activities. weaknesses but also about strengths of The en passant-approach must be applied in leadership for safety culture; such a way that the licensee is practically Avoid self-censorship and do not throw unable to anticipate the specific actions and away any piece of information because it measures of leadership for safety culture an seems to be irrelevant, etc. inspector or inspector team will look at on occasion of his/her/their oversight activity. This Note that the en passant-approach is not only counteracts licensee’s impression that a means of information collection. It could be inspectors are only interested in specific considered as an integral part of safety culture aspects of leadership for safety culture. This oversight, if collection and processing of impression may lead in turn to licensee’s information, as well as feedback to the licensee concentration on the promotion of these are performed extensively, continuously, and aspects and (or) preparations which may bias with minimal delays, and if these activities the information to be collected by inspectors. trigger licensees’ prompt and, at best, proactive The en bloc-approach supports the gathering promotion of safety culture without of information about leadership for safety compromising licensees’ full responsibility for culture in the context of an investigation which safety culture and its enhancement. is dedicated to this leadership. It is called en Since in both approaches the information bloc, because it is practically organized as a obtained consists of a considerable number of study of leadership for safety culture with possibly heterogeneous individual pieces, a

8 It is in principle also possible to include several of time (e.g. several days or weeks). MESKA licensee companies in the investigation. MESKA is recommends that such studies are performed with the sufficiently flexible to support varying scopes of the en support of experts in human, organizational, and bloc-investigation. As compared with the (ideally safety cultural factors to properly guide such in-depth continuous, never-ending) en passant-approach, en- investigations. bloc investigations will be performed in a short period 20 / 37 ETSON/2020-001 November 2020  synthesis must be produced by which the to specific leadership actions or measures and pieces will be coherently put together. Guiding leadership actions and measures which do not questions of this synthesis are the following: reveal or a need of increased promotion. Users Are the individual pieces of information correct must not evaluate the safety culture of a or do they contain errors (e.g. an inspector may licensee as a strong one, because the number commit an error regarding the correct of leadership actions and measures which designation of a component)? Do correct were evaluated according to category (C) is pieces of information reveal a systematic, to a higher than the number of the leadership larger or lesser extent wide-spread activities with a category-(A) or category-(B) phenomenon or trend or are they “outliers” (i.e. evaluation. The underlying reason is the nothing that is valid for other people, situations, following one: if the licensee tolerates equipment etc.)? How wide-spread are the degradation in a specific area of leadership for phenomena, which are no outliers, do these safety culture, personnel and leaders may feel phenomena reveal something which free or even encouraged to neglect adequate characterizes the entire company or only safety promotion of safety culture not only in this, but subcultures within the company (i.e. reluctance in more and more other areas. of members of one organizational unit to After an evaluation, safety authorities may communicate with other units)? either continue the collection and processing of The synthesis shall address causes, information without providing feedback to the consequences, and interactions between licensee to get more evidence or they may leadership actions and measures. Safety provide feedback, evaluate licensee’s authorities thus can react quickly, if these response and explanations to the feedback, pieces of information provide enough evidence and trigger necessary planning and on degradations in the areas of safety, safety implementation of corrective measures by the culture, and related leadership activities. Even licensee. Due to the licensee’s responsibility for a single piece of information can be sufficient to safety and safety culture, safety authorities will trigger safety authorities’ responses. only indicate the need for corrective measures. In both approaches, evaluations are based on It is entirely up to the licensee to define and the same criterion. Each leadership action and apply appropriate measures. measure must be evaluated individually. Inspectors can evaluate observed leadership actions and measures with three categories: 4.2.3 ASSESSING SAFETY “Leadership action or measure in question CULTURE OBSERVATIONS requires promotion because of unacceptable discrepancies from the leadership action or The model proposed in this chapter is based on measure that should be practiced”; a “Safety Culture Observations” (SCO) process “Leadership action or measure in question applied for several years within Bel V. This requires more promotion because without model is fed by field observations – as additional promotion unacceptable described in 2.2. – provided by inspectors or discrepancy from leadership that should be safety analysts during any contact with a practiced have to be expected”; licensee (inspections, meetings, phone “No such discrepancies were found, leadership calls…). These observations are recorded action or measure in question has to be within an observation sheet (e.g., excel) aimed promoted with at least the same effort which at describing factual and contextual issues. has been invested until now”. These observations are thereafter linked to safety culture attributes based on IAEA These categories can be visualized by the red, standards9. yellow and green light of a traffic light. Operationally speaking, the applied Each leadership action or measure evaluated observation sheet template gives a as (A) or (B) must be considered as an issue homogenous framework to introduce which requires improvement by the licensee. It information about the facility, the type of is not possible to balance deficits with respect intervention during which the observation has

9 A similar approach is used in the Romanian approach. ETSON/2020-001 November 2020 21 / 37  been made (inspection, meeting, etc.), the topic roles. These gaps are therefore valuable (matter of inspection/discussion) and the date findings to be further investigated during future of observation. More fundamentally, a safety inspections. culture observation also implies the description According to the assessment model of the context, the identification of safety culture developed, safety culture observations are attributes, and an argumentation developing analysed through a four-dimension model the reasons why the observed fact is linked to structured by two axis (see Figure 2). First, safety culture. As an important feature, safety culture observations could concern observations can be positive or negative. “organisational processes” (processes, In other words, safety culture observations are procedures and documentation, the interfaces fully integrated into the inspectors’ daily between departments, etc.) or “behavioural” practices. Actually, performing an observation issues (way of doing, norms, attitude, etc.). This is an opportunity to capture and record Human axis is therefore in line with the two sides of and Organisational Factors (HOF) issues safety culture as defined by the INSAG-4. which are not always addressed within an Second, safety culture observations could inspection report. As an illustration, the concern “managerial” issues (what is said and following example shows that an observation done by managers) or “workplace practices” can raise issues related to human (what is done in the field). performance. More precisely, according to this Then, at the intersection of these two axes, we example, the SCO identifies what is called a found four dimensions - Management system, “confirmation bias”, i.e., the tendency to search Leadership, Human Performance and for information in a way that confirms one’s pre- Learning - that reflect the different “building existing beliefs or hypotheses. blocks” of safety culture: “During an inspection within the main control Management system: within this dimension room, an alarm occurs. The Main Control we can find safety culture elements such as Room operator directly clears the alarm without safety policies, work process, procedures, checking the alarm card. The operator explains and interfaces. The main issue here is to to the inspector that the alarm was related to assess the level of integration of safety maintenance works on a system. within the management system and related Nevertheless, the operator is unable to documentation; describe the technical links between the Leadership: within this dimension we can maintenance intervention and the alarm. After find safety culture elements such as a short investigation the inspector found that commitment, decision making, and the link between the maintenance intervention supervision. The main issue here is to and the alarm was not relevant”. assess the level of managers’ involvement Performing an observation is also an regarding operations management; opportunity to gain more insights into a Human performance: within this dimension situation. As an illustration, the following we can find safety culture elements such as example shows that an observation helps to a questioning attitude, compliance, team make assumptions about “the way people do skills, and situation awareness. The main things around here”. issue here is to assess the consistency “Requested checklists related to the use of hot between field practices and human cells are not systematically completed. That performance principles as well as the remark has already been made several times adaptation capabilities of field operators; to operators by the nuclear authority”. Learning: within this dimension we can find Obviously, a single observation is not enough safety culture elements such as reporting or to provide an overall cultural picture, but in that assessment practices, knowledge transfer, last case, we can observe some shortcomings continuous improvement. The main issue regarding procedure adherence and use, and here is to assess the learning capabilities of the capacity of the organisation to take into the organisation. account comments from the authority. In During the assessment step, the four addition, this observation also gives an indirect dimensions are used to gather observations insight in the way the management line or the showing similarities (clustering step). For health physics department fulfil their respective instance, safety culture observations related to

22 / 37 ETSON/2020-001 November 2020  the managers’ commitment are taken together a three-year basis an in-depth safety culture in order to understand how deep commitment assessment report is performed in order to

is demonstrated.

Considering all the observations related to the behaviours of the management line, we can consider deep-rooted cultural issues (Bernard, build up an overall view of leadership. The 2014). same process is then applied for the other Safety culture observations are then assessed dimensions. It is worth mentioning that some through these four key dimensions which allow observations could be used in several for placing the emphasis on specific safety dimensions. culture attributes, and, adopting an overall view, Regarding the assessment side, a “Safety to identify the major cultural traits of a nuclear Culture Coordinator” (SCC) provides a set of installation. As a holistic approach, the main evaluations aimed at identifying early signs of issue is to understand the connections: firstly, safety problems (through a quarterly the connections between observations in order monitoring) and deep-rooted cultural issues to provide relevant clusters at the level of each (through annual and plurennial assessments). dimension; secondly, the connections between clusters in order to draw a cultural picture at the As a result of these evaluations, it could be level of a nuclear installation. decided to analyse a plant’s performance in As an illustration, the following case study could more detail in order to understand the be presented. This case concerns an NPP underlying causes of a problem or to focus characterised by several occurrences of inspections on specific aspects. On a yearly infringement of nuclear regulations related to basis, a detailed safety culture assessment compliance with the Plant Technical report is released (addressing the main safety Specifications (Operational Limits & culture observations) and a synthesis is Conditions). For example, some of the violated presented and discussed with the licensee. On conditions were related to time delay for performing tests or to bring the systems back in ETSON/2020-001 November 2020 23 / 37  full compliance with the plant Technical safety culture observations gathered during a Specifications. Some other events were also three-year period and following the method related to erroneous position of valves. described in previous chapters. As explained, Several of these events triggered reactive these safety culture observations have been inspections by the Regulatory Body. The grouped according to their belonging to the four licensee had been requested to provide dimensions presented. Then “Artefacts” and immediate and short-term actions supporting manifestations as “Espoused values” have compliance and as well as a longer term action been interpreted in order to arrive at a plan aimed at achieving a cultural change. description of shared underlying assumptions. These plans validated by the Regulatory Body The following elements synthesize the main covered a large set of dimensions, including findings of the assessment. HOF issues such as leadership, training Through the lens of the management system, management or ergonomics of procedures. In most of the observations are related to a lack of essence, the actions taken were dedicated to adherence to procedures and to some increasing the operator’s vigilance, the discrepancies related to major work processes. reinforcement of the leaders’ presence on the In addition, a large set of observations shows a field and the improvement of methods poor use of prescribed forms and a lack of rigor addressing HOF in event analysis. In short, this in document management as well. set of measures aimed at reinforcing safety Concerning the leadership dimension, positive culture. The Regulatory Body followed up the observations demonstrate the involvement of implementation phase and performed a set of the upper management in the improvement of dedicated inspections aimed at assessing the safety. Besides, some examples of effectiveness of scheduled actions. Among conservative decision-making or transparency these inspections, two specific safety culture to the regulator reflect the safety commitment of inspections (within two years) were conducted field managers. Nevertheless, a set of based on qualitative interviews techniques in observations raises the question of the order to evaluate the depth of the undertaken effectiveness of the managers’ field presence. changes. Actually, managers were in the field but mainly To some extent, this case shows strong when problems occurred. This implies a similarities with a recent situation that occurred management style that could be considered as within the “Arkansas Nuclear One” (ANO) NPP “management by exception”. in 201410. For instance, in terms of safety As regards the human performance culture, it was identified within ANO that the dimension, a set of observations shows most significant causes for declining weaknesses in rules compliance, in performance were ineffective change questioning attitude and in the quality of work management with respect to resource interventions. Underlying reasons of these reductions, and leadership behaviours. weaknesses are grounded in a lack of Actually, the licensee reduced resources ownership - i.e., regarding processes, across its fleet in 2007 and 2013, but it did not corrective actions, respect of time delay or adequately consider the unique staffing needs peer-check - and in a routinisation process - i.e., for ANO created by having two units with the force of habits and the normalisation of different designs. Additionally, an unexpected long-standing practices. increase in employee attrition between 2012 Regarding the learning dimension, some and 2014 caused a loss in experienced positive observations are related to the personnel, which led to a reduced capacity to licensee’s capacity to investigate technical root accomplish work, and an increased need for causes and to perform deep analysis. training and supervision. In both cases, the However, some reluctance was also observed regulator ensured a follow-up of the licensee to tackle recurrent events, particularly when action plans, conducted a set of inspections they are rooted in organisational or human and performed a safety culture assessment. issues. More significantly, a large set of Coming back to our study case, we performed observations show weaknesses in the a safety culture assessment on the basis of 199 implementation of effective corrective actions,

10 USNRC. ANO-NRC Supplemental Inspection https://www.nrc.gov/docs/ML1616/ML16161B279.pd Report: f (retrieved on 6 September 2019). 24 / 37 ETSON/2020-001 November 2020  questioning the capacity of the licensee to conduct in-depth changes.

It is also important to notice that these findings organisation to ensure continuous emerge recurrently after several assessments, improvement. indicating deep-seated issues. Therefore, In other words, the identified traits demonstrate adopting a holistic view, we can draw out an internal consistency (i.e., strong links cultural traits for each of the four dimensions between dimensions) in order to draw a (see Figure 3). relevant cultural picture. It is also important to Management system: Loss of meaning note that this picture is not only a snapshot but regarding rules; could also be used to “anticipate”, as a far as Leadership: Lack of effective field presence possible, potential evolutions or and leadership by exception; consequences. For instance, these findings Human performance: Lack of ownership could be connected to the work of Snook who and routinization of practices; identified four states in the life of socio-technical Learning: Insufficient capacity for in depth systems that entail a specific safety situation: changes. “Designed organization”: firstly, the global rules are followed; In other words, these four dimensions are not “Engineered organization”: these rules can isolated features, but rather, tightly connected be considered as not necessary because elements of a larger cultural system influencing their usefulness is no longer perceived; the way people think and act within an “Applied organization”: it appears that local installation. Regarding our case study, we can rules take precedence in daily practices; see that the four dimensions are strongly “Failure”: ultimately it is the whole system linked: in a nutshell, the lack of an effective field that becomes vulnerable. presence by managers contributed to a loss of In the same way, the cultural picture identified meaning regarding rules. Slowly, people could lead to adverse effects. If the traits are not considered work activities as routines and did under control, these discrepancies can lead to no longer demonstrate a strong sense of what Snook called a “Practical drift”, a slow and ownership. This also implies some insidious drift causing the uncoupling between weaknesses regarding the capacity of the the written rules and the actual practices in the field.

ETSON/2020-001 November 2020 25 / 37 

SAFETY CULTURE

ADDED VALUE

5 FOR RBs AND

TSO s

Many research projects have been already safety culture oversight is an opportunity to conducted on safety culture within nuclear capture safety issues that are sometimes installations11. Despite this large amount of poorly addressed (e.g. leadership style, studies, few of them focused on regulatory capacity to change, workforce perceptions). As bodies’ / TSOs’ strategy needs. In other words, a result, Human and Organisational Factors little guidance is provided on how regulatory topics could be better integrated within the bodies and TSOs might provide a safety culture technical inspection programme. In other oversight. words, according to the findings of a safety This technical report showed that safety culture culture analysis, a regulatory body / TSO has a assessment contributes to open new avenues better view on strengths and weaknesses of a for regulatory practices. Through cultural nuclear installation. As said, the provided analyses as described within this document, a assessment highlights areas (practices, regulatory body/TSO can obtain valuable competences, equipment, departments) in insights in critical safety issues to be addressed need of attention. by the licensee and, therefore, verify the It is worthwhile mentioning that safety strengths capability of the licensee to provide appropriate and weaknesses are not only related to the actions to tackle these issues. Licensees operation phase but to the whole lifecycle of a obviously retain the prime responsibility for nuclear installation, from design to safety but a regulator or a TSO has an decommissioning. opportunity to promote safety culture The technical report described also a diversity enhancements, identify topics to be improved of approaches: the IRSN approach intends to and monitor the directions taken by a licensee. analyse safety culture through a multi-level Therefore, safety culture assessment findings perspective whereas the GRS approach are no longer intangible, but have rather assesses leadership practices through a set of become tangible safety aspects to be expectations and the Bel V approach aims at managed (Naevestad et al., 2019). identifying an overall cultural picture on the This present document tried also to basis of observations. In order to address demonstrate that the implementation of a safety culture issues, we have therefore at

11 See Lee, 1998; Lee and Harrison, 2000; Wilpert and Mariscal et al., 2012; Garcia-Herrero et al., 2013; Itoigawa, 2001; Harvey, 2002; Findley et al., 2007; Rollenhagen et al., 2013, Schöbel et al., 2017. Mengolini and Debarberis, 2007; Reiman et al., 2012; ETSON/2020-001 November 2020 26 / 37  disposal “normative-oriented” methods (based The three approaches described within this on safety culture attributes to be assessed) and technical report share then the objective to “ethnographic-oriented” approaches (where capture and decipher cultural items according safety culture has to be explored). In that to their deep meanings for individuals, groups sense, the document reflects the diversity of and organisations. perspectives and definitions that characterised From this perspective, the concept of safety the field of safety culture. culture is considered useful for safety. Nevertheless, as a commonality between However, the “political dimension” and the approaches, the analysis of safety culture “technical dimension” of the concept should be outcomes implies to adopt a global (i.e. holistic) highlighted. In its political dimension, safety point of view: facts or statements drawn out culture is mainly an element of language aiming during specific interactions with licensees at communicating the importance of safety. In (meetings, inspections, assessments, walk- its technical dimension, the concept is mainly down, informal contacts…) are part of a an “object” to be addressed through statistical broader system of humans, technology, and and engineering methods. In both cases, safety organization. The three approaches culture analyses should go beyond these unanimously advocate the methodological simplifications in order to avoid a strictly principle, that observations should trigger an in- managerial and superficial sense of the depth evaluation which addresses as far as concept. possible: (1) the reasons underlying behaviours in a work situation; (2) the human, organizational, social, and technological factors, which influence this situation from a cultural point of view; (3) the relationships (“cultural picture”) between these behaviours and these factors; (4) the consequences for safety.

ETSON/2020-001 November 2020 27 / 37 

BIBLIOGRAPHY 6

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30 / 37 ETSON/2020-001 November 2020  NAEVESTAD, T-O, K. “Professional Subcultures in HESJEVOLL, I.S., Nuclear Power Plants”. Safety RANESTAD, K., ANTONSEN, Science, 2013, 59, 78-85. S. “Strategies Regulatory SCHEIN, E.H. Organizational Authorities Can Use to Influence Culture and Leadership: A Safety Culture in Organizations: Dynamic View. Jossey Bass: Lessons based on Experiences San Francisco, CA, USA, 1985. from Three Sectors”. Safety SCHOBEL, M. LOSTERMANN, Science, 2019, 118, 409-423. A., LASALLE, R., BECK, J., NAEVESTAD, T-O. “Safety MANZEY, D. “Digging Deeper! Understandings among Crane Insights from Multi-method Operators and Process Assessment of Safety Culture in Operators on a Norwegian Nuclear Power Plant based on Offshore Platform”. Safety Schein’s Culture Model”. Safety Science, 2008, 46, 520-534. Science, 2017, 95, 38-49. OSTY F. Le désir de métier. SMITH-CROWE, K., BURKE, Engagement, identité et M.J., LANDIS, R.S. reconnaissance au travail. “Organizational Climate as a Rennes : Presses Universitaires Moderator of Safety Knowledge- de Rennes, 2003. Safety Performance PERIN, C. Shouldering Risks. Relationship”. Journal of The Culture of Control in the Organisational Behavior, 2003, Nuclear Power Industry. 24, 861-876. Princeton University Press: SNOOK, S.A. Friendly Fire: The Princeton, NJ, USA, Oxford, UK, Accidental Shootdown of US 2005. Black Hawks over Northern Iraq. REASON, J. Managing the Princeton University Press: Risks of Organizational Princeton, NJ, USA, 2000. Accidents. Ashgate, Aldershot, Van NUNEN, K., LI, J., 1997. RENIERS, G., PONNET, K. REIMAN, T., PIETIKAINEN, E., “Bibliometric Analysis of Safety OEDEWALD, P. GOTCHEVA, Culture Research”. Safety N. “System Modelling with the Science, 2018, 108, 248-258. DISC Framework: Evidence VAUGHAN, D. The Challenger from Safety-critical Domains”. Launch Decision. Risky Work, 2012, 41, 3018-3025. Technologies, Culture and REIMAN, T., OEDEWALD, P. Deviance at NASA. Chicago “Measuring Maintenance University Press: Chicago, IL, Culture and Maintenance Core USA, 1996. Task with CULTURE- WEICK, K.E. “Organizational questionnaire - A Case Study in Culture as a Source of High the Power Industry”. Safety Reliability”. California Science, 2004, 42, 859-889. Management Review, 1987, 29, RICHTER, A., KOCH, C. 2, 112-127. “Integration, Differentiation and WILPERT, B. ITOIGAWA, N. Ambiguity in Safety Cultures”. Safety Culture in Nuclear Power Safety Science, 2004, 42, 703- Operations. Taylor and Francis: 722. London, UK; New York, NY, ROCHLIN, G.I. “Safe Operation USA, 2001. as a Social Construct”. Ergonomics, 1999, 42, 1549- 1560. ROLLENHAGEN, C., WESTERLUND, J., NASWALL,

ETSON/2020-001 November 2020 31 / 37 

. 7 ANNEXES

32 / 37 ETSON/2020-001 November 2020 

ACTIONS AND

ANNEX 1 MEASURES ON ANNEX 1

THE PART OF THE

EXECUTIVES PER

AREA OF ACTIVITY

Area of activity Keyword Target actions and measures of leaders

Leaders on all levels of the company hierarchy should in their respective areas of # responsibility ... Create conditions 1 Priority of Clearly explain the policies and objectives of the company and plant, the operating of work safety regulations and their importance for reliable, safety-oriented actions.

2 Performance Create the best possible conditions of reliable, safety-oriented actions regarding man, shaping organization and technology (including no time pressure, good work equipment). factors

3 Personnel Objectively assess competence, actions and performance of subordinates and provide development suitable development opportunities.

Direct 4 Clear Make clear decisions, give precise instructions, and provide accurate information, subordinates’ specifications especially in regard to safety and reliability. work activities 5 Role model Be a role model for subordinates by taking only reliable, safety-oriented actions. 6 Facilitate Encourage and support subordinates, to ask questions and to raise concerns about work, asking safety and reliability without delay, reserve or self-censorship. questions 7 Reactions to Answer questions and resolve concerns of subordinates regarding work, safety, and questions reliability appropriately, validly, and before subordinates start the tasks in question. 8 Supervision Effectively monitor reliable and safety-oriented actions of subordinates at the workplace, provide support and perform, if necessary, corrective actions.

Area of activity Keyword Target actions and measures of leaders

# Leaders... should ...

Work on 9 Subordinates’ Encourage and support subordinates to pay attention to actions, near-misses and mistakes, mindfulness circumstances that adversely affect safety and reliability, and where necessary: to intervene improvements, to correct, and to report their findings completely, promptly and clearly. preventive 10 Leaders’ own Assume responsibility for their own actions, own errors, and consequences of these measures errors actions/errors. 11 Error handling Objectively investigate errors and needs for improvement, accurately identify causes of errors/issues in need of improvement, and take suitable measures in due time.

12 Suggestions Encourage and support subordinates to fully and openly express their ideas on how safety for and reliability can be improved. improvement 13 Continuously Use in due time findings from comments/responses/statements of subordinates learning (questions, concerns, reports, proposals, etc.), operational experiences, own observations, organization and other sources for the improvement of safety and reliability. Recognize and 14 Recognition Recognize the performance of subordinates in due time, in reasonable proportion to the sanction actual performance, and in such a way that safety and reliability are strengthened. 15 Sanctioning Sanction in due time and adequately actions that are to be sanctioned for sound reasons.

Cultivate fair 16 Work climate Promote a work climate with and between subordinates that supports reliable, safety-

interpersonal oriented actions. relationships 17 Trustworthiness Implement their announcements and keep their promises, explain in time if realization turns out to be impossible.

34 / 37 ETSON/2020-001 November 2020 

BREAKDOWN OF

ANNEX 2 THE LEADERSHIP

TASK INTO AREA

OF ACTIVITY

Area of activity Explanation

Create conditions of work Conditions of work are the provisions of the company policy and of the plant policy, the objectives of the company and of the plant as well as the human, organizational and technical factors under which the subordinates must act. Company leadership, plant management and managers must create these provisions and conditions and ensure their implementation. Direct subordinates’ work Leaders direct, depending on their position in the company hierarchy, the activities of a more or activities less large number of individuals who they instruct, control and assess.

Work on mistakes, The safe operation of a plant also requires support for reliable performance of safety-oriented improvements, preventive tasks in the best way possible. For this it is necessary to properly examine mistakes, to develop measures and implement preventive measures, and to make other improvements. The responsibility of leaders for safe operation includes the responsibility for these steps to further increase safety.

Recognize and sanction Recognition and sanctioning are essential activities on the part of the leaders to promote desired actions or to counter unwanted behavior. “Sanction” is to be understood as the justified, impartial infliction of adequate, clearly predefined negative consequences on a person for verifiably inacceptable, work-related behavior by responsible people (“punishment”), not as an approval of an action. The necessary condition of a sanction is that the acting individual did not follow an instruction or did not comply with a standard. To avoid arbitrariness and injustice, the instructions and standards as well as the consequences of their non-compliance must be specified in advance.

ETSON/2020-001 November 2020 35 / 37  Also, the investigation of the deviation from the instructions or standards must clearly show, that the acting individual could have obeyed them (compliance was not prevented by external circumstances such as lack of time or other unsuitable working conditions). Sanctioning belongs to the legal sphere: if necessary, the operating company must contact the competent authorities. Part of the sanctioning must be an instruction on how to act in compliance with the instructions and standards. For the operating company the challenges in sanctioning consist, on the one hand, of preventing the actions that occurred and which are punishable by sanctions, without branding the sanctioned individuals and reducing their willingness to act in accordance with standards and instructions. The company, on the other hand, must also consider the possible consequences of not sanctioning, and thereby sending a strong signal that laxness regarding compliance with standards and instructions does not necessarily lead to negative consequences in the case of non-compliance. Recognition and sanctioning are closely linked: Both the lack of recognition and the lack of sanctions signal to the subordinates that their commitment to safety does not really matter and that violations of safety requirements do not have any consequences. For recognition in a broader sense, it is also necessary to create the best possible support for the actions subordinates have to perform. This includes remuneration, job security and development opportunities. In this way, the leaders show that they respect the subordinates as human beings with their capabilities and limits.

Cultivate fair interpersonal Leadership is also an interpersonal relationship, the quality of which can have a significant impact relationships on safety and reliability. Condescending behavior, for example, can lessen the willingness of subordinates to ask questions, the clarification of which is important for the correct performance of a task. Another negative example is unjustified blaming, which compromises an objective analysis of errors and the development of appropriate countermeasures. Positive examples are the respect leaders demonstrate for the subordinates and the latter’s decent treatment.

36 / 37 ETSON/2020-001 November 2020 

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