Systemic Approach to Safety in the IAEA Safety Standards

Transcription

1 Systemic Approach to Safety in the Safety Standards Monica Haage International Expert on Safety Culture and Systemic Approach to Safety (The interaction between Human, Technical & Organizational Factors) International Atomic Energy Agency

2 Safety is more than the technology

3 Safety Paradigm The technical factors are advanced and robust The safety principles are well developed The safety review services and assessments are effective The safety processes are advanced and well developed All these are well structured and provides high level of safety But, the underlying factors to accidents are not be found solely in the technology they are systemic weaknesses related to the human and organizational constraints These are typically related to: How the technology is maintained How the safety principles and safety standards are implemented How the safety review services are assessments are utilized How the improvement activities are implemented By the humans and the organization(s)

4 International Atomic Energy Agency

5 Systemic Weaknesses Human, organizational & cultural weaknesses are consistently identified as cross-cutting contributors to significant events: Insufficient understanding of the complexity of reality by leaders ( good news cultures, failure to encourage constructive challenge, compartmentalization) Insufficient connection and integration across consultant/ contractor/vendor network Insufficient understanding of nuclear/process safety issues in decision-making and actions Normalisation of abnormal conditions or deviations Failure to learn from previous events and experiences Complacency Inability to invite the full intelligence of the organizational members into improvement processes Inadequate systemic approach to safety in oversight and supervision

6 2.6. HUMAN AND ORGANIZATIONAL FACTORS Observations and Lessons (2) Observation: While the stakeholders involved in the accident at the Fukushima Daiichi NPP were aware of the possibility of the single safety issues related to the accident in advance, they were not able to anticipate, prevent or successfully mitigate the outcome of the complex and dynamic combination of these issues within the sociotechnical system. Lesson Learned: To proactively deal with the complexity of nuclear operations, the results of research on complex sociotechnical systems for safety need to be taken into account by all stakeholders involved. A systemic approach to safety needs to be taken in event and accident analysis, considering all stakeholders and their interactions over time.

7 Systemic Approach to Safety - The interaction between Human, Technical and Organisational factors (HTO) International Atomic Energy Agency

8 Examples of Human, Organizational and Organizational Factors (OF): Vision and objectives Strategies Integrated Management System Continuous improvements Priorities Knowledge management Communication Contracting Culture etc Technical Factors Technical Factors (TF): Existing technology Sciences Design PSA/DSA I/C Technical Specifications Quality of material Equipment etc Human Factors (HF): Human capabilities Human constraints Work environment Motivation Individuals understanding Emotions etc

9 Systemic Approach to Safety Same concept different labels Systemic safety Systems view Holistic safety System safety Socio-technical system MTO/ITO/HOT This concept is not new it was born out of TMI

10 Systemic Approach to Safety Stressing the dimension of: Interactions Dynamics On-going Complexity

11 Examples of Organizational Factors Organizational Factors (OF): Vision and objectives Strategies Business Models Integrated Management System Continuous improvements Decision making process Knowledge management Priorities Communication Contracting Work environment Culture etc

12 Examples of Technical Factors Technical Factors (TF): Design Existing technology Hard ware/soft ware PSA/DSA Technical Specifications I/C Quality of material Equipment etc

13 Examples of Human Factors Human Factors (HF): Human capabilities Human constraints Perceived work environment Motivation Individuals understanding Emotions etc

14 Safety Standards

15 Safety Principle SF-1 The Interaction between individuals, technology and the organization An important factor in a management system is the recognition of the entire range of interactions of individuals at all levels with technology and with organizations. To prevent human and organizational failures, human factors have to be taken into account and good performance and good practices have to be supported.

16 Safety Standard GS-G-3.5 The Interaction between individuals, technology and the organization All safety barriers are designed, constructed, strengthened, breached or eroded by the action or inaction of individuals. Human factors in the organization are critical for safe operation and they should not be separated from technical aspects. Ultimately, safety results from the interaction of individuals with technology and with the organization The concept of safety culture embraces this integration of individuals and technical aspects.

17 Safety Standard - Characteristics and Attributes for Strong Safety Culture Safety Culture is that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, protection and safety issues receives the attention warranted by their significance Safety Glossary (GS-G-3.1)

18 Safety Standard GS-G-3.5 The Interaction between individuals, technology and the organization In a strong safety culture, there should be a knowledge and understanding of human behaviour mechanisms and established human factor principles should be applied to ensure the outcomes for safety of individuals technology organization interactions. This could be achieved by including experts on human factors in all relevant activities and teams.

19 Thank you for your attention

20 4. Personal and behavioral competences 4.1 Analytical thinking and problem solving 4.2 Personal effectiveness and Self Management 4.3 Communication 4.4 Team work 4.5 Management and Leadership 4.6 Safety Culture These are all related to human and organizational factors (HOF) and safety culture. There are three levels of competences in these areas 1. Generic level All should have a know-how level. Competence level 1: to know what what HOF and safety culture means in practice and to be able to identify strengths or weakness 2. Expert level Specialized experts which have experience and training in HOF/SC. Competence level 2: to analyze and review safety cases 3. Specialist level Specialist with behavior and social science degree. Competence level 3: to perform complex analyzes to identify underlying dynamics related to HOF/SC

21 Complexity and Systemic Challenges in relation to transition to decommissioning Organizational Factors (OF): Change of vision and objectives Creation of clarity and adaptation to new strategies New licensing process Revision of the Integrated Management System New conventional safety risks Momentum in the continuous improvements activities Revision and clarity of priorities Knowledge management Openness in communication Contractor management Systematic and continuous improvements of safety culture What more? Technical Factors (TF): Preparation for dismantling Segregation of operating and decommissioning System integration Waste management RP-arrangements/provisions New technologies/ equipment's What more? Human Factors (HF): Change in mindset Cooperation and teamwork Learning and reflection Stress and fatigue Motivation Individuals understanding Trust Self-management New work task What more?

22 Tools and Practices for Systemic Approach Systemic Mapping HTO Analysis event and proactive analysis HTO Trainings including Mock-ups Cross-functional workgroups Systemic reviews on the organizational changes HTO review and monitoring Integrated Management Systems Shared Space

23 Questions 1 Basic Assumptions What do you pay attention to and take for granted in your area of expertise? What do you not pay attention to? Where are you blind spots?

24 Boundaries: Accepted & Non-Accepted Protecting People and Environment The Rational Perspective Accepted Safety Standards Nuclear Acts (law) National regulations Integrated Management Systems Procedures Work instructions Strong safety culture Not Accepted Violations of laws, regulations, rules, - work instructions Malicious acts Weak safety culture

25 AN EXAMPLE Powerdynamics N/A Info Available Info Expert Knowledge Info. Hierarchy Formalized Decision Making Decision Making Decision Making Process Procedure Work Order Equipment Preparedness Communication equipment Public opinion Communications External pressure n Sea Water Injection? n? Time n Stress n n Training n Experience All this human and organizational factors are potential sources of error contributing to an undesirable outcome

26 The weakest link The technical factors are advanced and robust The safety principles are well developed The safety review services and assessments are effective The safety processes are advanced and well developed All these are well structured and provides high level of safety The weakest link is the human and organizational factors The root causes to accidents are not be found in the technology they are rooted in the human and organizational constraints The importance of human and organizational factors are not fully realized and addressed in an equivalent level as the technical factors

27 Underlying Systemic Weaknesses to Significant Events: Insufficient understanding of the complexity of reality by leaders ( good news cultures, failure to encourage constructive challenge, compartmentalization) Insufficient connection and integration across consultant/ contractor/vendor network Insufficient understanding of nuclear/process safety issues in decision-making and actions Normalisation of abnormal conditions or deviations Failure to learn from previous events and experiences Complacency Inability to invite the full intelligence of the organizational members into improvement processes Inadequate systemic approach to safety in oversight and supervision

28 Complexity and Systemic Challenges in Organizational Factors (OF): Alignment of vision and objectives Clear and appropriate strategies Current Integrated Management System Continuous improvements Priorities Transfer of knowledge Openness of communication Contractor management Systematic and continuous improvements of safety culture etc relation to Safety Technical Factors (TF): Existing technology Advanced technology Automation Analogue/digital Modifications etc Human Factors (HF): Job readiness Cooperation and teamwork Learning and reflection Stress and fatigue Motivation Individuals understanding Trust Self-management etc

29 The Complex Perspective Examples of external factors which influence the ongoing interactions between HF, OF and TF Societal context (National Factors) Political climate New sciences Interrelationships with external organizations (Governmental bodies, regulatory bodies, non-governmental organizations, corporate organizations, international organizations) Culture Public opinion Generational shift Implementation and reinforcement of Law Regulations Financial climate Peoples understanding Interpretations & perceptions Power dynamics New management trends International Standards

30 The Hindsight bias Ref.Hollnagel

31 Hindsight Bias kkkk Ref.Hollnagel, 1998

32 Thank you for your attention

33 Reactive towards Proactive The concept of HTO can be used as a tool to structure our thinking

34 Principles of HTO Value and seek diversity through Ensure diversified competencies in teams Encourage diversity in thinking and opinions as it minimize simplification in safety decisions Be comfortable with ambiguity Encompass the complexity, the nature of dynamic and non-linear relationships Communicate through dialogue rather than argumentation to avoid polarization

35 The Human and Organizational factors Depends on the quality of interactions Ability to share information, knowledge and the understanding about the reality Level of collaboration Urge to think out of the boundaries to continuously inquiry the boundaries of the unknown

36 Paradigm shift in the basic principles Interim conclusions of the Investigation Committee on the Accident at the Fukushima Nuclear Power Stations of Tokyo Electric Power Company: The Investigation Committee is convinced of the need of a paradigm shift in the basic principles of disaster prevention programs for such a huge system, whose failure may cause enormous damage.