ML19190A155

Safety Culture Policy Statement Educational Resource, Rev 2, 2019

ML19190A155
Person / Time
Issue date:	07/09/2019
From:	Catherine Thompson NRC/OE
To:
Thompson C
References
Safety Culture Policy Statement
Download: ML19190A155 (68)

Text

SAFETY CULTURE An Educational Resource about the NRCs Safety Culture Policy Statement

U. S. NUCLEAR REGULATORY COMMISSION MISSION The NRC licenses and regulates the Nations civilian use of radioactive materials to provide reasonable assurance of adequate protection of public health and safety and to promote the common defense and security and to protect the environment.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E I

NRC Licensees, Applicants and Vendors The Commission expects that individuals and organizations establish and maintain a positive safety culture. This includes all licensees, certificate holders, permit holders, authorization holders, holders of quality assurance program approvals, vendors and suppliers of safety-related components, and applicants for a license, certificate, permit, authorization, or quality assurance program approval, subject to NRC authority.

Agreement States and Their Licensees The Organization of Agreement States supports the use of this educational resource by its members and licensees. The Commission encourages the Agreement States, Agreement State licensees and other organizations interested in nuclear safety to support the development and maintenance of a positive safety culture.

TABLE OF CONTENTS Introduction 1 Safety Culture Policy Statement 3 Overview 3 Definition and Traits 4 Safety Culture Trait Talk 5 Overview 5 Leadership Safety Values and Actions 6 Work Processes 10 Questioning Attitude 14 Problem Identification and Resolution 18 Environment for Raising Concerns 22 Effective Safety Communication 26 Respectful Work Environment 30 Continuous Learning 34 Personal Accountability 38 Safety Culture Case Study 42 Overview 42 June 2009 Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains near Fort Totten Station, Washington, DC. 43 Safety Culture Journey 46 Overview 46 Washington Metropolitan Area Transit Authority 47 Sources of Information 51 Appendix 52 Safety Culture Policy Statement Federal Register notice 52 S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E III

INTRODUCTION The U.S. Nuclear Regulatory Commission (NRC) The NRC encourages all applicants for and published the Safety Culture Policy Statement holders of licenses and certificate holders, (SCPS) in 2011, and developed numerous the Agreement States and their licensees, and educational tools to facilitate understanding of vendors and suppliers to establish and maintain the importance of a positive safety culture. The a positive safety culture. This educational SCPS and the education toolsincluding the resource applies to all of these communities nine Safety Culture Trait Talks, Safety Culture as the lessons learned from one organizations Case Studies, and a Safety Culture Journey accident, and the actions taken in response to can be found on the Web site at http://www. the accident, can always be considered and nrc.gov/about-nrc/safety-culture.html. applied to another. Finally, each of the nine safety culture traits and their behaviors and This educational resource provides an extra attitudes are applicable to a wide range of level of understanding of the SCPS and the organizations as well.

nine safety culture traits by focusing on the educational tools collectively rather than The NRC will continue to provide information individually. To facilitate this comprehensive about the importance of a positive safety understanding of the SCPS and traits, this culture. If you have a question or would like document includes a brief overview of the to make a suggestion, please contact the NRC, SCPS, with the Federal Register notice (FRN) Office of Enforcement, Safety Culture Team, at of the Final Safety Culture Policy Statement external_safety_culture.resource@nrc.gov.

attached in the appendix. It also includes reformatted Safety Culture Trait Talks, which describe each safety culture trait, including why each trait is important, examples of attitudes and behaviors that apply to each trait, and an illustrative scenario showing how each trait could play a role in organizational events. Finally, the authors reformatted and included one Safety Culture Case Study and one Safety Culture Journey to further illustrate the importance of a positive safety culture.

The Case Study discusses an accident that resulted, in part, from the absence of positive safety culture traits. The Journey illustrates this same organizations response to the accident depicted in the case study and demonstrates the efforts it made to improve its safety culture.

To help reflection and dialogue, each Trait Talk, Case Study, and Journey includes a series of questions, with space provided to take notes and record answers.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 1

OVERVIEW

Background:

The 1986 nuclear accident at commensurate with the safety and security the Chernobyl nuclear power plant in Ukraine significance of their activities and the nature and revealed the impact that weaknesses in safety complexity of their organizations and functions.

culture can have on safety. Since then, the This policy statement applies to all licensees, influence of safety culture has been further certificate holders, permit holders, authorization demonstrated by a number of significant holders, holders of quality assurance program events in the United States and internationally.

approvals, vendors and suppliers of safety-Assessments of these events revealed that the related components, and applicants for a absences of the traits of a positive safety culture license, certificate, permit, authorization, or was an underlying cause or increased the quality assurance program approval subject severity of the event.

to NRC authority. In addition, the Commission The NRC addressed aspects of safety culture in encourages the Agreement States (States that two previously issued policy statements. The assume regulatory authority over their own use Policy Statement on the Conduct of Nuclear of certain nuclear materials), their licensees, and Power Plant Operations, (published in 1989) other organizations interested in nuclear safety states the NRCs expectations that licensed to support the development and maintenance of operators and managers of nuclear power a positive safety culture within their regulated plants conduct themselves professionally to communities.

ensure safety. In 1996, the NRC published Because safety and security are the primary Freedom of Employees in the Nuclear pillars of the NRCs regulatory mission, Industry to Raise Safety Concerns without consideration of both is an underlying Fear of Retaliation, a policy statement that principle of the Safety Culture Policy Statement.

applies to the regulated activities of all NRC Organizations should ensure that personnel in licensees and their contractors. It provides the safety and security sectors appreciate the the expectation that licensees and employers importance of each, emphasizing the need for subject to NRC authority establish and maintain integration and balance to achieve both safety work environments where employees feel and security in their activities.

free to raise safety concerns without fear of retaliation (referred to as a safety conscious Industry experience has shown the value work environment). A safety conscious work of establishing and maintaining a positive environment is included in the SCPS as one of safety culture. It is important to remember the traits: Environment for Raising Concerns. that individuals and organizations performing regulated activities bear the primary Safety Culture Policy Statement: In 2011, responsibility for safety and security. The the NRC published the SCPS (76 FR 34773; Safety Culture Policy Statement is not a June 14, 2011) (see Appendix) which sets regulation; therefore, it is the regulated entities forth the expectation that individuals and responsibility to consider how to apply this organizations performing regulated activities policy statement to its regulated activities.

establish and maintain a positive safety culture S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 3

DEFINITION AND TRAITS There are many definitions of safety culture. Experience has shown that certain personal and Most of these definitions focus on the idea organizational traits are present in a positive that in a positive safety culture individuals and safety culture. A trait, in this case, is a pattern of organizations emphasize safety over competing thinking, feeling, and behaving that emphasizes goals, such as production or costs, ensuring a safety, particularly in goal conflict situations, safety-first focus. e.g., production vs. safety, schedule vs. safety, and cost of the effort vs. safety. It is the The NRCs SCPS defines nuclear safety Commissions expectation that all organizations culture as the core values and behaviors and individuals overseeing or performing resulting from a collective commitment by regulated activities involving nuclear materials leaders and individuals to emphasize safety should take the necessary steps to promote a over competing goals to ensure protection of positive safety culture by fostering these traits.

people and the environment.

The following traits were included in the NRCs SCPS, although additional traits may also be important in a positive safety culture.

Leadership Safety Values Problem Identification Personal Accountability and Actions and Resolution Issues potentially impacting safety are promptly identified, Leaders demonstrate a fully evaluated, and promptly All individuals take personal commitment to safety in addressed and corrected responsibility for safety.

their decisions and behaviors.

commensurate with their significance.

Environment for Work Processes Continuous Learning Raising Concerns A safety conscious work environment The process of planning and Opportunities to learn about ways is maintained where personnel feel controlling work activities is to ensure safety are sought out and free to raise safety concerns without implemented so that safety implemented. fear of retaliation, intimidation, is maintained.

harassment or discrimination.

Effective Safety Respectful Work Environment Questioning Attitude Communications Individuals avoid complacency and continually challenge existing Communications maintain Trust and respect permeate conditions and activities in order a focus on safety. the organization. to identify discrepancies that might result in error or inappropriate action.

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TRAIT TALK OVERVIEW The Safety Culture Trait Talks were developed be important. In addition, please note that to offer a better understanding of the nine the traits were not developed to be used for safety culture traits found in the SCPS and inspection purposes.

how they apply to youwhether you are an The nine individual Trait Talks are available NRC employee interacting with an external on the Web site, as noted in the Introduction.

stakeholder, an NRC licensee, a vendor or However, for purposes of this document, contractor employee, an organization interested they have been reformatted and included in in the safe and secure use of nuclear materials, the following pages. Each Trait Talk contains or others involved in nuclear safety regulation.

information on why the trait is important and The NRC identified nine traits of a positive what it looks like. In addition, each Trait Talk safety culture in the SCPS, although the agency includes a fictional scenario based different recognizes that additional traits may also licensees.

TRAIT LICENSEE OR COMMUNITY SCENARIO Leadership Safety Values and Actions Power Reactors Work Processes Radiography Questioning Attitude Medical/Brachytherapy Problem Identification and Resolution Power Reactors Environment for Raising Concerns Research Reactors Effective Safety Communication Fuel Cycles Respectful Work Environment Gauges Continuous Learning Construction Personal Accountability Vendors It is important to remember that a scenario that missing. For example, dont assume that this depicts a certain community or organization cant happen here because your organization can be applicable to any organization. doesnt have the same work processes.

The important piece to understand is how Rather, consider how your organizations the presence or absence of safety culture work processes could potentially allow an event traits can mitigate the consequences of, or or accident to occur because of a lack of focus contribute to, an event or accident. Reflection on safety culture.

on these scenarios should focus on how the Note: In the following pages, the superscripts refer to the safety culture traits are visible in your own Sources of Information on page 51.

organization and what traits might be weak or S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 5

LEADERSHIP SAFETY VALUES AND ACTIONS What Is The Definition Of Leadership Safety decisions as he or she engages in activities to Values And Actions? resolve them. The organizations safety culture plays a significant role in guiding employees decisions; The NRCs SCPS defines Leadership Safety Values and in other words, what they view as the organizations Actions as when leaders demonstrate a commitment priorities. Is the organizations priority safety or to safety in their decisions and behaviors. production? This is one of the important junctions where leadership at the top of the organization is critical in setting the standards and establishing Why Is This Trait Important? overarching safety priorities that all employees understand take precedence over all competing Leaders perform essential functions in organizations.

demands.1 The quality and actions of leadership have widespread consequences for an organizations safety culture and its performance. Leaders have What Does This Trait Look Like?

significant power to affect an organizations safety culture through the priorities they establish, the Resources: Leaders ensure that personnel, behaviors and values they model, the reward equipment, procedures, and other resources are systems they administer, the trust they create, available and adequate to support safety.

and the context and expectations they establish for interpersonal relationships, communication, Leaders ensure that staffing levels are sufficient and accountability. Leaders also exert significant and personnel are qualified for the work they influence on change initiatives. They have the are performing. Leaders ensure that facilities are power and responsibility to set strategy and maintained and tools, equipment, procedures, and direction, align people and resources, motivate other resources are readily available to support and inspire people, and ensure that problems are work performance. Finally, leaders ensure that identified and solved in a timely manner. A lack of sufficient corporate resources are allocated for commitment or clear communication about what is maintenance, equipment, and personnel to ensure important to the organization can create a conflict safe and reliable operation.

for employees who must then decide between Field Presence: Leaders are commonly seen in competing messages. This leads employees to their working areas of the organization observing, own interpretations, thereby potentially negatively coaching, and reinforcing standards and affecting the organizations safety culture. It is clear expectations. Deviations from standards and that behavior matters and leadership behaviors that expectations are corrected promptly.

support a positive safety culture are critical.

Leaders ensure sufficient oversight of work Leaders at all levels play an important role in activities. They practice visible leadership in establishing the organizations environment and the field by coaching, mentoring, reinforcing safety culture. This is evident in the manner in standards, and reinforcing positive decision which competing goals that occur at every level making practices and behaviors. Leaders discuss of the organization are managed. There may be their observations in detail with the group they conflicting demands from a cost and schedule observed and provide useful feedback about how perspective versus safety and quality. The to improve individual performance. They model organizations members may face these competing safe behaviors and high standards of goals on a daily basis. These decisions may occur accountability as a way to encourage others.

at all levels of the organization, not just at the top.

Each employee may encounter his or her version of these conflicts and will be faced with making 6 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Incentives, Sanctions, and Rewards: Leaders ensure Roles, Responsibilities, and Authorities: Leaders incentives, sanctions, and rewards are aligned clearly define roles, responsibilities, and authorities with safety policies and reinforce behaviors and to ensure safety.

outcomes that reflect safety as the overriding Leaders ensure roles, responsibilities, and priority.

authorities of executives, senior managers, Leaders ensure disciplinary actions are and corporate managers are clearly defined, appropriate, consistent, and support safety and a understood, and documented. They appropriately safety conscious work environment. They reward delegate responsibility and authority to promote individuals who identify and raise issues affecting ownership and accountability. Leaders ensure safety and praise behaviors that reflect a positive that recommendations from review boards and safety culture. Leaders foster an environment that independent oversight organizations do not promotes accountability and hold individuals override senior leaders ultimate responsibility for accountable for their actions. Leaders consider decisions affecting safety.

potential chilling effects when taking disciplinary Constant Examination: Leaders ensure that safety actions and other personnel actions, and they take compensatory actions when appropriate. is constantly scrutinized through a variety of monitoring techniques, including assessments of Strategic Commitment to Safety: Leaders ensure safety culture.

priorities are aligned to reflect safety as the Leaders ensure that board members and members overriding priority.

of independent oversight organizations meet Leaders develop and implement cost and schedule with different levels of management and staff goals in a manner that reinforces the importance to develop an understanding of the status of the of safety. Information from independent oversight organizations safety culture. They use a variety organizations is used to help establish priorities of monitoring toolsincluding employee surveys, that align with safety. Leaders establish strategic self- and independent assessments, external safety and business plans that reflect safety as the review board member feedback, and employee overriding priority and ensure that corporate concern investigationsto regularly monitor priorities also align with safety priorities. safety culture. Leaders support and participate in candid assessments of workplace attitudes and Change Management: Leaders use a systematic safety culture and act on issues that affect trust process for evaluating and implementing change so in management and detract from a healthy safety that safety remains the overriding priority. culture.

Leaders use a systematic process for planning, Leader Behaviors: Leaders exhibit behaviors that set coordinating, and evaluating the safety impacts the standard for safety.

and potential negative effects on the willingness of individuals to raise safety concerns, when Leaders walk the talk, modeling correct making major changes. This includes decisions behaviors, especially when resolving apparent concerning changes to organizational structure conflicts between safety and production. They act and functions, leadership, policies, programs, promptly when a safety issue is raised to ensure procedures, and resources. Leaders ensure safety it is understood and appropriately addressed.

is maintained when planning, communicating, Leaders maintain high standards of personal and implementing change and ensure that conduct that promote all aspects of a positive significant unintended consequences are avoided. safety culture, and actively seek out the opinions Leaders ensure that individuals understand and concerns of workers at all levels. Leaders the importance of, and their role in, the change encourage personnel to challenge unsafe behavior management process. and unsafe conditions, and motivate others to practice positive safety culture behaviors.2 S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 7

WHAT IS A SCENARIO IN WHICH THIS TRAIT and resulted in larger bonuses at the end of the COULD PLAY A ROLE? outage. After several years of this practice, a short in a breaker that was replaced during an outage Senior management at a nuclear power plant inadvertently caused a loss of power to an entire developed a new incentive program after noticing train of equipment, which then caused a reactor trip.

substantial schedule delays during outages at the One of the primary cooling pumps on the active train plant. The incentive program included bonuses for was out of service at the time of the loss of power.

meeting schedule goals during outages. During an It had been scheduled for repair during the outage outage, a supervisor signed off on work without but was rescheduled because waiting for the parts to completing an independent verification, which repair the pump would have extended the outage. As was not required but recommended by procedure. a result, the plant had to rely on emergency systems The supervisor made this decision because there to cool the reactor core because both of the primary were no qualified workers available at the time cooling pumps were unavailable.

and waiting for the next shift of workers would have caused a schedule slip, affecting the potential The root cause analysis of the event found that an outage bonus. The supervisor defended the decision independent verification of the breaker replacement to management by stating that a peer check was was not completed because common practice had completed, and considered sufficient to verify the been to accept a peer check as adequate verification work performed. of the work performed. Managements focus on meeting schedule goals, and acceptance of peer Over time, peer checks were substituted for a number checks in place of recommended independent of independent verifications during outages because verifications, contributed to a reactor trip that it saved time, helped the team stay on-schedule, challenged the plants safety systems.3 Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Leadership Safety Values and Actions?

2. What kinds of leadership behaviors would have reinforced safety as the overriding priority?

3. How could management have handled this situation differently?

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Now that you have read this Trait Talk on Leadership Safety Values and Actions, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 9

WORK PROCESSES What Is The Definition Of Work Processes? flexibility and individual autonomy during periods of off normal conditions pose a dilemma for many The NRCs SCPS defines Work Processes as when the organizations. One of the biggest management process of planning and controlling work activities challenges may be how to realize the benefits of is implemented so that safety is maintained. both approaches given that these two perspectives on controlling work processes can create internal inconsistencies.1 Why Is This Trait Important?

The process of designing and controlling work to ensure safety is an important part of an What Does This Trait Look Like?

organization, and how effectively an organization Work Management: The organization implements a manages and implements their work processes is process of planning, controlling, and executing work a reflection of their safety culture. For example, activities such that nuclear safety is the overriding effective work processes in a positive safety culture priority. The work process includes the identification will have a well-designed workflow that includes and management of risk commensurate to the work.

the assignment of responsibilities to leaders, work groups, and individuals. Work activities will be Work is effectively planned and executed by prioritized, coordinated across workgroups, and incorporating risk insights, job-site conditions, communicated effectively. Policies and procedures and the need for coordination with different will incorporate the appropriate risk insights groups or job activities. The work process and be effectively planned, executed, verified, appropriately prioritizes work and incorporates and documented. The rigorous development, contingency plans, compensatory actions, and management and adherence to work processes abort criteria as needed. Leaders consider the helps ensure the safe use of nuclear materials and impact of changes to the work scope and the need reflects a positive safety culture. to keep personnel apprised of the work status.

The work process ensures individuals are aware Many organizations operating high-risk technologies of the nuclear safety risks associated with work (such as in industries using nuclear materials) in the field, and other parallel station activities.

employ collaborative decision making, develop Insights from probabilistic risk assessments are detailed procedures, and require verification of steps considered in daily work activities and change during procedure implementation under normal processes. Work activities are coordinated to operations. The development and implementation address conflicting or changing priorities across of emergency operating procedures is equally the whole spectrum of activities contributing to as rigorous. Other high reliability organizations, nuclear safety. The work process limits temporary however, may base activities around individual modifications.

expertise and professionalism, autonomy, and rapid team-based response, particularly during off-normal Design Margins: The organization operates and conditions. Both perspectives can be important for maintains equipment within design margins. Margins the design and implementation of work processes. are carefully guarded and changed only through a For example, organizations may require strict systematic and rigorous process. Special attention adherence to normal and emergency operating is placed on maintaining fission product barriers, procedures. However, flexibility may be necessary defense-in-depth, and safety-related equipment.

when responding to off-normal conditions.

The work process supports nuclear safety and the The need for procedural compliance during normal maintenance of design margins by minimizing or emergency operations and the allowance for long-standing equipment issues, preventive 10 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

maintenance deferrals, and maintenance and shot, without conducting a radiation survey, both engineering backlogs. The work process ensures radiographers entered the restricted area to set focus on maintaining fission product barriers, up for the next operation thinking that the source defense-in-depth, and safety-related equipment. had been properly retracted into the shielded Design and operating margins are carefully position. However, the crimp in the guide tube guarded and changed only with great thought and from the fallen equipment prevented the source care. Safety-related equipment is operated and from retracting back to the shielded position. The maintained well within design requirements. second radiographers ratemeter sounded an alarm indicating that radiation exposures greater than the Documentation: The organization creates and preset amount were being exceeded, while the first maintains complete, accurate, and up-to-date radiographers ratemeter did not alarm. Because documentation. the first radiographers ratemeter did not alarm, Activities are governed by comprehensive, high- they both assumed that the second radiographers quality programs, processes, and procedures. ratemeter was not functioning properly. They Design documentation, procedures, and work continued operations and did not notify the packages are complete, thorough, accurate, radiation safety officer of the incident. The radiation and current. Components are labeled clearly, safety officer became aware of the incident when he consistently, and accurately. The backlog of identified an overexposure of both workers from the document changes is understood, prioritized, and personnel dosimetry reports that he received a few actively managed to ensure quality. weeks later.

Procedure Adherence: Individuals follow processes, There is a high potential dose hazard associated procedures, and work instructions. with industrial radiographic operations. The process of planning and controlling work activities so that Individuals follow procedures. Individuals safety is maintained (work processes) was lacking in understand and use human error reduction this scenario. Although the regulations require it, the techniques. Individuals review procedures radiographers did not conduct a radiation survey and instructions prior to work to validate that to ensure that the source was properly retracted they are appropriate for the scope of work and into the shielded position in the camera. The that required changes are completed prior radiographers failed to investigate the discrepancy to implementation. Individuals manipulate between the two ratemeters. Also, the radiographers equipment only when appropriately authorized did not properly follow procedures for notification and directed by approved procedures or work of the radiation safety officer of the incident or the instructions. Individuals ensure that the status of potential overexposure because they believed that work activities is properly documented.2 the ratemeter that sounded was faulty.3 What Is A Scenario In Which This Trait Could Play A Role?

Two radiographers were performing nondestructive testing operations of pipe welds at a temporary job site using a 2.4 TBq (65 Ci) iridium -192 radioactive source in a radiography camera. In between shots, the first radiographer briefly entered the restricted area without conducting a radiation survey.

Upon exiting the restricted area, he noticed that a piece of equipment had fallen onto the guide tube, putting a crimp in the tube. After the next S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 11

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Work Processes?

2. What kinds of actions and behaviors would have reinforced safety as the overriding priority?

3. How could management have handled this situation differently?

Photo courtesy of Davidmack via Wikipedia 12 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Work Processes, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 13

QUESTIONING ATTITUDE What is the Definition of Questioning happening and what might go wrong. As leaders Attitude? ask questions and encourage others to do the same, the importance of having a questioning attitude will The NRCs SCPS defines Questioning Attitude be reinforced throughout the organization. Leaders as when individuals avoid complacency and should consistently reward employees for asking continuously challenge existing conditions and questions and routinely discuss actual situations activities in order to identify discrepancies that where a questioning attitude helped achieve a might result in error or inappropriate action. positive outcome.

A positive safety culture requires the collective Why Is This Trait Important? commitment by both leaders and employees to emphasize safety over competing goals. A The NRC has identified complacency as a key questioning attitude supports that commitment.1 contributor to many incidents involving nuclear materials, such as the Davis-Besse nuclear power plant reactor vessel head degradation event and What does this trait look like?

the Pennsylvania cancer treatment center event in which a patient died of radiation exposure. Avoiding Nuclear is Recognized as Special and Unique:

complacency is essential to ensuring nuclear safety Individuals understand that complex technologies and can be achieved by instilling a questioning can fail in unpredictable ways.

attitude in every employee. From the operator at a The organization ensures that activities that nuclear power plant challenging an assumption, to could affect nuclear materials are conducted the medical physicist in a cancer treatment center with particular care, caution, and oversight.

questioning an unexpected change in treatment Individuals recognize the special characteristics parameters, having a questioning attitude is vital and unique hazards of nuclear technology, for the safe use of nuclear materials and a positive including radioactive byproducts, and the safety culture. importance of features designed to maintain It is each individuals responsibility to continuously nuclear safety. Executives and senior managers assess his or her duties, procedures, and job ask probing questions to understand the site to identify inconsistencies or abnormalities. implications and consequences of anomalies, and Challenging assumptions, stopping work in the challenge managers to ensure degraded conditions face of uncertainty, and proactively anticipating are fully understood and appropriately resolved, what may go wrong during a prejob brief reflect a especially those involving equipment important to questioning attitude and a positive safety culture. nuclear safety.

Employees should routinely and actively ask the Challenge the Unknown: Individuals stop when following questions as they perform their jobs: Am I faced with uncertain conditions. Risks are evaluated doing the right thing? How could we do this better? and managed before proceeding.

Are we using the right assumptions? Are we putting our people, plant, or patients at risk? What new Leaders reinforce expectations that individuals practices could we implement that would minimize take the time to do the job right the first time, complacency and encourage a questioning attitude? seek guidance when unsure, and stop if an unexpected condition or equipment response is Recognizing that external and internal conditions encountered. Individuals maintain a questioning change over time, leaders must also continuously attitude during pre-job briefings and job-site assess the organization or operation in its entirety, reviews to identify and resolve unexpected look beyond the individual task, and ask questions conditions. Individuals challenge unanticipated to ensure they understand what is currently test results rather than rationalizing them.

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For example, abnormal indications are not What Is A Scenario In Which This Trait Could automatically attributed to indication problems Play A Role?

but are thoroughly investigated before activities are allowed to continue. Individuals stop work A hospital was conducting a cancer treatment with activities when confronted with an unexpected a high-dose rate brachytherapy remote afterloading condition, communicate with supervisors, and system using an iridium-192 source. Just prior to resolve the condition prior to continuing work the cancer treatment, the hospital had replaced the activities. When appropriate, individuals consult source and upgraded the software. When entering system and equipment experts. If a procedure or the data into the treatment system, the medical work document is unclear or cannot be performed physicist was unable to electronically transfer the as written, individuals stop work until the issue patients treatment plan from the planning system is resolved. to the treatment system due to an error message.

After several failed attempts by staff, the medical Challenge Assumptions: Individuals challenge physicist entered the treatment plan manually into assumptions and offer opposing views when they the treatment systems control console, rather than think something is not correct. question why he was seeing the error message.

Leaders solicit challenges to assumptions when Due to a bug in the software upgrade, the evaluating nuclear safety issues. Individuals treatment system software created an unexpected ask questions to fully understand the bases of source step size change in the treatment operational and management decisions that parameters. When the medical physicist entered appear to be contrary to nuclear safety, and the data manually for the source dwell times, the managers question assumptions, decisions, and software automatically changed the entered data to justifications that do not appear to consider the default parameters for the source step size. The impacts to nuclear safety sufficiently. medical physicist faced an unexpected condition with the software error, and failed to recognize Avoid Complacency: Individuals recognize and plan the change in the source step size. The patient for the possibility of mistakes, latent problems, was then treated with a mispositioned source. The and inherent risk, even while expecting successful medical physicist failed to verify that the treatment outcomes. computer system was correct after data entry and prior to treatment. As a result, the patient received The organization is aware that latent conditions a radiation dose to tissue outside the treatment can exist, addresses them as they are discovered, area and an underdose to the treatment site. In and considers the extents of the conditions addition, the hospital failed to follow its procedure and their causes. Prior to authorizing work, of performing an independent review of the individuals verify procedure prerequisites are treatment plan prior to patient treatment.

met rather than assuming they are met based on general work site conditions. Individuals This scenario illustrates equipment (software) perform a thorough review of the work site and errors as the initial precipitating event. Had the the planned activity every time work is performed medical physicist used a questioning attitude, he rather than relying on past successes and assumed could have identified the equipment failure and the conditions, and they consider potential undesired hospital could have corrected this failure before consequences of their actions prior to performing treating the patient.3 work and implement appropriate error reduction tools. Leaders ensure specific contingency actions are discussed and understood during job planning and pre-job briefings.2 S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 15

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Questioning Attitude?

2. What kinds of actions and behaviors would have reinforced safety as the overriding priority?

3. How could this situation have been prevented?

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Now that you have read this Trait Talk on Questioning Attitude, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 17

PROBLEM IDENTIFICATION AND RESOLUTION What Is The Definition Of Problem with a positive safety culture also has a problem Identification And Resolution? identification and resolution program that anticipates issues, reviews operating experience, The NRCs SCPS defines Problem Identification and and tracks emerging industry themes and trends.

Resolution as when issues potentially impacting Organizational learning is most successful when safety are promptly identified, fully evaluated, and issues are anticipated and addressed before they promptly addressed and corrected commensurate become weaknesses to be corrected.1 with their significance.

What does this trait look like?

Why Is This Trait Important?

Identification: The organization implements a Problem identification and resolution is an corrective action program with a low threshold important element of safety culture. Leaders for identifying issues. Individuals identify issues are responsible for identifying and diagnosing completely, accurately, and in a timely manner in organizational or technical deficiencies, taking accordance with the program.

corrective action, and anticipating emerging issues.

All members of an organization support problem Individuals recognize deviations from standards identification and resolution by promptly raising and understand how to enter issues into the and reporting concerns (for example, by working corrective action program. They ensure that through a corrective action program). The extent issues, problems, degraded conditions, and near and manner in which organizations identify and misses are promptly reported and documented in resolve problems serve as an example of how the the corrective action program at a low threshold.

organization prioritizes safety. The ability and Individuals describe the issues entered in the willingness of workers and managers to identify and corrective action program in sufficient detail address problems is also important for continuous to ensure they can be appropriately prioritized, learning, another trait of a positive safety culture. trended, and assigned for resolution.

An effective problem identification and resolution Evaluation: The organization thoroughly evaluates program uses the organizations corrective action problems to ensure that resolutions address causes program, operating experience, and self-assessment and extents of conditions commensurate with their results to ensure safe operations. The corrective safety significance.

action program should have a transparent process The organization ensures that issues are properly for evaluating, prioritizing, and resolving issues.

classified, prioritized, and evaluated according Leaders should ensure that they and the rest of the to their safety significance. Extent-of-condition organization fully understand safety-related issues.

and extent-of-cause evaluations are completed in Without full understanding, the organization cannot a timely manner, commensurate with the safety appropriately prioritize and resolve these issues so significance of the issue. The organization ensures that they do not occur again. In addition, an effective that apparent and root cause investigations problem identification and resolution program leads identifying primary and contributing causal to a strong safety conscious work environment. In factors are completed as required. Issues are such an environment, the organization removes investigated thoroughly according to their barriers to a free flow of information to ensure that all safety significance, and root cause analyses are employees feel free to raise safety-related concerns. rigorously applied to identify and correct the Organizations can approach problem identification fundamental cause of significant issues. The and resolution with different mindsets. One mindset underlying organizational and safety culture focuses on finding existing problems and correcting contributors to issues are evaluated thoroughly weaknesses, typically through the organizations and are given the necessary time and resources corrective action program. However, an organization to be clearly understood. Managers conduct 18 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

effectiveness reviews of significant corrective management issued a work order to repair the actions to ensure that the resolution addressed roof. However, other layers of management never the causes effectively. approved the work to proceed. Shortly afterwards, the plant started a program to maintain building Resolution: The organization takes effective integrity in all weather conditions; however, the corrective actions to address issues in a timely plant never made plans or took actions to properly manner commensurate with their safety prioritize, identify and correct the roof leakage.

significance.

Two years later, the maintenance worker found The organization ensures that corrective actions water pooling around the power supply breakers are completed in a timely manner. Deferrals of for the feed water pump in the auxiliary building.

corrective actions are minimized, and when Three months after that, the maintenance worker required, due dates are extended using an found water dripping onto the high-pressure established process that appropriately considers safety injection pump. After both incidents, the safety significance. The organization ensures that maintenance worker notified the control room appropriate interim corrective actions are taken supervisor, mopped up the water, covered the to mitigate issues while more fundamental causes equipment with a protective material as needed, are being assessed. Corrective actions resolve and and wrote a condition report. Each time, plant correct the identified issues, including causes and management assigned the condition a priority level extents of conditions, and prevent the recurrence of 4. The worker identified that the source of the of significant conditions adverse to quality. Trends water was from the roof of the auxiliary building in safety performance indicators are acted on to and asked his supervisor why the roof was not resolve problems early. repaired. The supervisor said work orders were Trending: The organization periodically analyzes written each time, but they were never approved or information from the corrective action program scheduled due to other priorities. The supervisor and other assessments in the aggregate to identify was not sure about the status of the program to programmatic and common cause issues. ensure building integrity and had never seen any plans or schedules to repair roof leaks. Further, The organization develops indicators that monitor when the supervisor asked his manager about both equipment and organizational performance, the ongoing degraded roof issues, the manager including safety culture. Managers use indicators discovered that there were 43 open work orders that provide an accurate representation to repair roof leaks, and none of these orders had of performance and early indications of ever been approved, scheduled, or completed.

declining trends, and routinely challenge the organizations understanding of declining trends. Recently, water from a heavy rainstorm again Organizational and departmental trend reviews leaked through the auxiliary building roof and into are completed in a timely manner in accordance the switchgear room. This time the water caused an with program expectations.2 electrical ground short near a current transformer, which then tripped the reactor coolant pump. This led to a reactor trip due to a low reactor coolant What Is A Scenario In Which This Trait Could system flow signal.

Play A Role?

The auxiliary building provides structural support A maintenance worker at a nuclear power and separation to safety- and nonsafety-related plant found water leaking through the roof of equipment, and is designed to provide protection the auxiliary building and into the emergency against external events such as rain, wind, and shutdown panel during a heavy rainstorm. He snow. However, the plants failure to resolve the notified the control room supervisor, cleaned leakage through its problem identification and up the water, and wrote a condition report. The resolution and corrective action program left power plant management assigned the condition the safety systems unprotected. The weak safety report a priority 4 (the lowest level). After the culture and problem identification and resolution plant identified the degraded condition of the roof, in this plant directly led to the reactor trip.3 S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 19

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Problem Identification & Resolution?

2. What kinds of actions and behaviors would have reinforced safety as the overriding priority?

3. How could this situation been handled differently?

20 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Problem Resolution & Identification, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 21

ENVIRONMENT FOR RAISING CONCERNS?

What Is The Definition Of Environment For may not always be comfortable raising concerns Raising Concerns? through the normal channels, such as with their immediate supervisor. From a safety perspective, The NRCs SCPS defines Environment for Raising no method of raising potential safety concerns Concerns as maintaining a safety-conscious work should be discouraged. Therefore, the organization environment where personnel feel free to raise safety should focus on achieving and maintaining an concerns without fear of retaliation, intimidation, environment where employees feel free to raise harassment, or discrimination. their concerns directly to their supervisors, as well as ensuring that alternate means of raising and addressing concerns are accessible, credible, and Why Is This Trait Important? effective. These alternative approaches may include an open-door policy that allows the employee Fostering an environment for raising concerns to bring a concern to a higher-level manager, an is an important attribute of a positive nuclear ombudsman program, or an employee concerns safety culture. Organizations should have a work program.

environment where employees are encouraged to raise safety concerns and where those concerns An organization that reinforces an environment are reviewed promptly, given the proper priority for raising concerns typically has well-developed based on their potential safety significance, and systems for prioritizing problems and directing appropriately resolved, with timely feedback to the resources, effective communications for openly originator of the concerns and to other employees sharing information and analyzing the root causes as appropriate. of identified problems, and management that promotes employee confidence in raising and Employees should feel free to raise safety concerns resolving concerns.1 to their management without fear of harassment, intimidation, retaliation, or discrimination. The organization is prohibited by law from taking What Does This Trait Look Like?

adverse retaliatory actions against employees because they raised concerns. When allegations of Safety Conscious Work Environment (SCWE) discrimination or retaliation arise, the appropriate Policy: The organization effectively implements level of management must be involved to review a policy that supports individuals rights and the facts, evaluate or reconsider the action, and, responsibilities to raise safety concerns and does where warranted, remedy the matter. In addition not tolerate harassment, intimidation, retaliation, or to the hardship caused to the individual employee, discrimination for doing so.

the perception by fellow workers that raising concerns has resulted in retaliation can generate a Individuals feel free to raise nuclear safety chilling effect that may discourage other workers concerns without fear of retribution, with from raising concerns. Any reluctance on the part confidence that their concerns will be addressed.

of employees to raise concerns can be detrimental Executives and senior managers set and reinforce to nuclear safety. expectations for establishing and maintaining a safety-conscious work environment. Policies and The organization should clearly identify the procedures reinforce that individuals have the processes that employees may use to raise right and responsibility to raise nuclear safety concerns, such as discussing issues with their concerns and define the responsibilities of leaders supervisor or filing deficiency reports for problem to create an environment in which individuals feel identification and resolution. However, it is free to raise safety concerns. Leaders are trained important to recognize that some employees to take ownership when receiving and responding 22 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

to concerns, recognizing confidentiality if This allowed the source to emit radiation through appropriate, and ensuring concerns are adequately the unshielded section of the pool wall and create addressed in a timely manner. Individuals are an unplanned high radiation area. The procedures trained that behaviors or actions that could prevent for moving the source did not clearly require cross-concerns from being raised, including harassment, checking with maintenance activities.

intimidation, retaliation, or discrimination, will not be tolerated and are violations of law and During the investigation of this incident, the policy. All claims of retaliation are investigated research scientist told the investigator that he and any necessary corrective actions are taken in previously raised concerns to his supervisor about a timely manner, including actions to mitigate any the adequacy of procedures for moving the source potential chilling effect. and ensuring that the source was appropriately shielded. Further, he noted that he had told the Alternate Process for Raising Concerns: The supervisor on numerous occasions that many of the organization effectively implements a process for procedures dealing with the safety of laboratory raising and resolving concerns that is independent activities may be insufficient. After this incident, he of line management influence. Safety issues may be told the supervisor that he was going to notify the raised in confidence and are resolved in a timely facility administration about his concerns and the and effective manner. supervisors lack of response. The supervisor told the scientist that because of significant budget cuts Executives establish, support, and promote the in research programs, and subsequent reduction use of alternative processes for raising concerns in staff, he did not have the resources to review and ensure corrective actions are taken. Leaders and revise all of the procedures and he did not understand their role in supporting alternate want to draw any more attention to the program.

processes for raising concerns. Processes for In addition, the supervisor said that if the scientist raising concerns or resolving differing professional raised this concern with the administration, his opinions that are alternatives to the corrective future employment would be discussed. A few action program and operate outside the influence days later, the scientist discussed his concerns of the management chain are communicated and with the administration officials, and two weeks accessible to individuals. Alternative processes later, the scientist was laid off due to budget are independent, include an option to raise cuts. The remaining research staff was aware of concerns confidentially, and ensure these concerns the circumstances surrounding their colleagues are appropriately resolved in a timely manner. termination. The supervisor told staff members that Individuals receive feedback in a timely manner. any concerns they have should never be taken up Individuals have confidence that issues raised will the chain of command.

be appropriately resolved. Individuals assigned to respond to concerns have the appropriate Continuing budget cuts and their colleagues competencies.2 termination have resulted in the remaining research staff members being concerned about their jobs, the future of the research programs, and their What Is A Scenario In Which This Trait Could safety while working at the research facility. Staff Play A Role? members have expressed reluctance to raise any concerns to their supervisor or the administration, A research scientist in the nuclear physics program and they continue to be worried about the at a research laboratory moved a high activity adequacy of procedures and policies. This chilling radioactive source to temporary storage area of effect prevents the staff from feeling free to raise the irradiation pool. He was not aware that, three nuclear safety concerns without fear of retaliation, days prior to moving the source, maintenance and weakens the facilitys safety culture.3 workers had removed a small section of the concrete shielding from the irradiation pool wall.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 23

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Environment for Raising Concerns?

2. What kinds of actions and behaviors would have reinforced safety as the overriding priority?

3. How could this situation been handled differently?

Experimental gamma irradiation source similar to the source referenced in the Trait Talk example.

24 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Environment for Raising Concerns, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 25

EFFECTIVE SAFETY COMMUNICATION What Is The Definition Of Effective Safety upward communication include fear of retaliation, Communication? concerns that the communication will be filtered as it goes up the chain of command, perceptions The NRCs SCPS defines Effective Safety that management is resistant to critical feedback, Communication as communications that maintain and fear of creating interpersonal conflict. These a focus on safety. communication barriers, if unaddressed, can have a negative impact on information exchange, organizational learning, and ultimately safe Why Is This Trait Important? performance. To facilitate effective upward communication, it is important for managers Effective Safety Communication is vital to to create an environment that is supportive, maintaining a safety culture. When employees encouraging, and accepting of both positive and regularly communicate with each other in an open, negative feedback, so employees always feel free respectful manner, they are also more willing to to speak up.1 give and receive feedback. Effective communication also supports teamwork and coordination between groups. What Does This Trait Look Like?

Employees learn about, and become part Work Process Communications: Individuals of, an organizations safety culture through incorporate safety communications in work communication. Lack of clear communication activities.

from management can result in situations where managers say one thing but do another. Employees Communications within work groups are timely, then spend time and energy trying to interpret the frequent, and accurate. Work groups and conflicting messages. In such situations, employees supervisors communicate with other work groups will generally interpret a managers behavior as and supervisors during the performance of their the more valid indicator of the organizations work activities. Individuals communicate with values and priorities. Persistent mismatches each other such that everyone has the information between formal and informal communications necessary to accomplish work activities safely and can lead employees to disregard or develop a effectively. Communications during shift turnovers cynical view of formal communications. This can and pre-job briefings provide information lead to ineffective formal communications from necessary to support nuclear safety. Work groups management and a weakened safety culture. integrate nuclear safety messages into daily activities and meetings.

Top-down communication is most effective when senior managers communicate directly with Bases for Decisions: Leaders ensure that the bases immediate supervisors and immediate supervisors for operational and organizational decisions are communicate with their staff. Ensuring that communicated in a timely manner.

supervisors are informed about organizational issues, and then allowing them to communicate Leaders promptly communicate expected outcomes, these issues to their staff, helps create and potential problems, planned contingencies, and reinforce the supervisors authority. Research shows abort criteria for important decisions. Leaders that when employees perceive their supervisor as share information on a wide range of issues having authority, employees have greater trust in with individuals and periodically verify their their supervisor, greater desire to communicate understanding of the information. Leaders take with their supervisor, and are more likely to steps to avoid unintended or conflicting messages believe the information coming from their that may be conveyed by decisions. Leaders supervisor. encourage individuals to ask questions if they do not understand the basis of a management Upward communication from workers to managers, decision. Executives and senior managers and information exchange among workers, is communicate the reasons for resource allocation essential for organizational learning and safe decisions, organizational changes, and other operations. An employees perceptions about decisions affecting the organization as a whole, support for safety can strongly influence his or her including the safety implications of those decisions.

willingness to speak up. Some common barriers to 26 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Free Flow of Information: Individuals communicate operator noticed a slight decrease in the solution openly and candidly, both up, down, and across level inside the extraction column of the uranium the organization and with oversight, audit, and recovery process. The operator was not properly regulatory organizations. trained for recognizing the possible scenarios and the required actions for seeing such level Leaders encourage the free flow of information. fluctuation in the panel. The operator sent an Individuals share information openly and employee for a visual check of the extraction candidly. Leaders respond to individuals in system equipment. That employee found a small an open, honest, and non-defensive manner. amount of liquid on the floor near the extraction Individuals provide complete, accurate, and column level control valve and assumed it was forthright information to oversight, audit, and a leaking valve stem near the control valve. The regulatory organizations. Leaders actively solicit employee communicated to the control room feedback, listen to concerns, and communicate that everything was okay. During the next shift, a openly with all individuals. Leaders candidly second operator continued to see a level deviation communicate the results of monitoring and in the monitor of the extraction column process assessments throughout the organization and with area and notified his supervisor. The supervisor independent oversight organizations. immediately inspected the system components and identified a leak in the extraction column Expectations: Leaders frequently communicate and piping which resulted in a spill of high-enriched reinforce the expectation that nuclear safety is the uranium solution with the potential of causing an organizations overriding priority.

inadvertent criticality accident.

Executives and senior managers communicate A criticality accident is an uncontrolled, sustained, expectations regarding nuclear safety so that nuclear chain reaction that occurs in an unsafe individuals understand that safety is the highest geometry containing fissile material. The sudden priority. Executives and senior managers release of heat, neutrons, and gamma radiation implement a strategy of frequent communication associated with an inadvertent criticality accident using a variety of tools to reinforce that nuclear may be lethal to nearby personnel. Criticality safety safety is the overriding priority. Executives and and the prevention of accidental criticality depend senior managers reinforce the importance of on a number of factors which are not production nuclear safety by clearly communicating its parameters: material enrichment, geometry, relationship to strategic issues, including budget, reflection, moderation, and other conditions. After workforce planning, equipment reliability, and communicating with the responsible individuals, business plans. Leaders communicate desired the spill was handled in accordance with plant safety behaviors to individuals, providing procedures and no inadvertent criticality occurred.

examples of how behaviors positively or negatively affect nuclear safety. Leaders routinely verify that The lack of communications in this scenario communications on the importance of nuclear resulted in an increased potential for a criticality safety have been heard and understood. Leaders accident. The risk of an inadvertent criticality ensure supplemental personnel understand accident could have been significantly lower had expected behaviors and actions necessary to the operator in the first shift communicated the maintain nuclear safety.2 need for additional training and communicated the level fluctuation he identified to the supervisor.

The risk of a potential occupational exposure What Is A Scenario In Which This Trait Could could also have been significantly lower had the Play A Role? employee who first inspected the system notified Fuel fabrication facilities monitor many of the the operator and supervisors about the small spill processes of plant operations that use special so it could have been immediately addressed.

nuclear material from the control room. This Communications that maintain a focus on safety are monitoring allows qualified operators to identify essential for the safe handling of special nuclear process deviations or system problems when material and for the protection of the workers, the processes are not working as intended or there public and the environment.3 are equipment malfunctions. During one shift, an S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 27

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Effective Safety Communication?

2. What kinds of communications would have reinforced safety as the overriding priority?

3. How could this situation been handled differently?

28 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Effective Safety Communication, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 29

RESPECTFUL WORK ENVIRONMENT What Is The Definition Of Respectful Work Open communication, fairness, and management Environment? accountability are the most frequently identified mechanisms that build trust and respect in an The NRCs SCPS defines Respectful Work organization. Leaders earn trust and respect when Environment as when trust and respect permeates employees can see that they are fair, deal directly with the organization. problems and issues, and encourage and value all ideas and opinions. A strong safety culture requires mutually respectful, trusting relationships between and within Why Is This Trait Important? workgroups and between all levels in the organization.1 Trust and respect are among the most frequently discussed concepts in studies of organizational and What Does This Trait Look Like?

safety culture. Trust and respect are fundamental to positive interpersonal relationships and central Respect is Evident: Everyone is treated with dignity components of effective working relationships. and respect.

The nature and level of trust and respect between workers and their managers and supervisors affect The organization regards individuals and their all aspects of their relationship and influence their professional capabilities and experiences as its attitudes and behaviors. Studies of organizations most valuable asset. Individuals at all levels of the have found that trust in management is positively organization, within and between workgroups, related to employee job performance, organizational treat each other with dignity and respect. They citizenship behavior, and engagement in safety do not demonstrate or tolerate bullying or behaviors. Distrust of management tends to lower humiliating behaviors. Leaders monitor for levels of engagement and reduce feelings of behaviors that can have a negative impact on the personal responsibility for safety. work environment and address them promptly.

They ensure policies and expectations are enforced At an individual level, trust involves the willingness fairly and consistently for individuals at all levels of one person to depend on another person, with of the organization. Individuals treat decision-a relative sense of security. The perception that makers with respect, even when they disagree an individual is competent, has integrity, and is with a decision. Leaders ensure facilities are predictable increases the likelihood that he is trusted conducive to a productive work environment and and respected. Trust and respect affect the persuasive housekeeping is maintained.

power of an individual. Efforts to influence others are more likely to succeed when those attempting Opinions are Valued: Individuals are encouraged to influence are trusted and respected. In addition, to voice concerns, provide suggestions, and raise successful work groups, teamwork, and collaboration questions. Differing opinions are respected.

require respect for others opinions and differing The organization encourages individuals to views. When differences are respected, they can offer ideas, concerns, suggestions, differing be a source of motivation and innovation for an opinions, and questions to help identify and solve organization; lack of respect can destroy trust and problems. Leaders are receptive to ideas, concerns, weaken safety culture.

suggestions, differing opinions, and questions.

At an organizational level, trust and respect instill The organization promotes robust discussions, confidence that the organization is just and fair, recognizing that differing opinions are a natural which promotes open communication and accurate result of differences in expertise and experience.

reporting, enhances organizational learning, and Individuals value the insights and perspectives promotes the development of shared perceptions provided by quality assurance, the employee and norms. In studies of safety culture, higher concerns program, and independent oversight levels of trust and respect are associated with organization personnel.

positive safety attitudes, reduced risky behavior, and increased personal responsibility for safety.

30 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

High Level of Trust: Trust is fostered among Several weeks later, one of the licensees gauges individuals and work groups throughout the was stolen from the cab of a pickup truck parked organization. overnight at a hotel. The new employee, now an authorized gauge user, stated that he placed the Leaders promote collaboration among work gauge case inside the extended cab of the pickup groups. Leaders respond to questions and concerns truck, as previously instructed, and locked the in an open and honest manner. Leaders, sensitive vehicles doors using the key fob as he walked to the negative impact of a lack of information, inside the hotel. The side window of the pickup share important information in an open, honest, truck had been left in a partially raised position.

and timely manner such that trust is maintained. Since there were no signs of forced entry, it was They ensure that status and important work concluded that the theft was a crime of opportunity milestones are communicated throughout the and that the thief may have simply unlocked the organization. Leaders acknowledge positive door by reaching inside the vehicle through the performance and address negative performance window. Once the thief was inside the vehicle, the promptly and directly with the individual involved. unsecured gauge case did not delay or deter the Confidentiality is maintained as appropriate. thiefs removal of the gauge. The new employee Leaders welcome performance feedback from notified management of the theft and informed throughout the organization and modify their them that he had raised a concern involving the behavior when appropriate. failure to secure the gauge case to the authorized Conflict Resolution: Fair and objective methods are gauge user who had provided his on-the-job used to resolve conflicts. training. Because the on-the-job trainer discounted the new employees recommendation to secure The organization implements processes to ensure the gauge case to the inside of the pickup truck, fair and objective resolution of conflicts and the new employee explained that he did not feel differing views. Leaders ensure conflicts are it would be appropriate to go around the trainer resolved in a balanced, equitable, and consistent to raise the concern directly to the radiation safety manner, even when outside of defined processes. officer or management.

Individuals have confidence that conflicts will be resolved respectfully and professionally.2 As a result of this incident, the licensee conducted an analysis and determined that the root cause of the violation was the licensees failure to fully What Is A Scenario In Which This Trait Could understand how to implement the requirement Play A Role? of securing the gauge. The licensees practice was focused on the visibility of the gauge case An authorized gauge user was conducting on-the- as opposed to properly securing the gauge case.

job training for a new employee on the licensees A contributing cause of the incident was the practice of placing the portable density gauge licensees employee leaving the passenger side inside the extended cab of a pickup truck when window in a partially open position. The new staying overnight at a hotel, as is often required employee again stated he did not feel that it when working at temporary job sites. During would be respectful to the trainer if he continued this on-the-job instruction, the new employee to question the practice since the trainer was stated that simply placing the gauge case inside senior to him, and he did not feel he could trust the extended cab of a pickup truck would only the radiation safety officer or management not to provide one barrier, the locked vehicle door. The provide negative feedback to the trainer.3 new employee suggested the gauge case also be secured to the inside of the pickup truck. Since the authorized gauge user conducting the on-the-job training had many years of experience, he discounted the new employees comment as inconsequential.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 31

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Respectful Work Environment?

2. What kinds of communications would have reinforced safety as the overriding priority?

3. How could this situation been handled differently, and what might have been the outcome?

32 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Respectful Work Environment, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 33

CONTINUOUS LEARNING What Is The Definition Of Continuous that lessons learned are shared throughout an Learning? organization. They evaluate their own programs and policies for opportunities for improvement, The NRCs SCPS defines Continuous Learning as benchmark other organizations, and understand opportunities to learn about ways to ensure safety the importance of training. Organizations focusing are sought out and implemented. on continuous learning ensure that opportunities to improve safety are identified and shared, and by doing so, build a strong safety culture.1 Why Is This Trait Important?

Continuous Learning contributes substantially What Does This Trait Look Like?

to a positive safety culture. Continuous Learning organizations are characterized by an enhanced Operating Experience: The organization ability and willingness of individuals to apply systematically and effectively collects, evaluates, and their individual learning in the workplace and implements relevant internal and external operating to share and transfer it to their team members experience in a timely manner.

and coworkers. At the individual and team level, Continuous Learning includes obtaining knowledge, A process is in place to ensure a thorough review determining how that knowledge applies to the of operating experience provided by internal work of the individual and the team, as well as and external sources. Operating experience is sharing that knowledge and ensuring that it is implemented and institutionalized effectively retained in the organization. To capture and sustain through changes to processes, procedures, the benefits from individual and team learning, equipment, and training programs. Operating learning organizations develop leadership that experience is used to understand equipment, prioritizes and motivates the desired learning operational, and industry challenges and to adopt and behaviors that are effective in ensuring that new ideas to improve performance. Operating knowledge is shared and retained within an experience is used to support daily work functions, organization. with emphasis on the possibility that it could happen here. Operating experience is shared in a Organizations committed to continuous learning timely manner.

reflect an organizational perspective that specifically addresses learning requirements at the individual, Self-Assessment: The organization routinely group, and organizational levels. Leadership at all conducts self-critical and objective assessments of of these levels must focus on learning, teaching, its programs and practices.

and changing an organization into a learning Independent and self- assessments, including organization. Continuous Learning requires that nuclear safety culture assessments, are thorough leaders and managers trust and respect their and effective and are used as a basis for workers. An environment that supports continuous improvements. The organization values the learning is one that encourages an employee to ask insights and perspectives assessments provide.

questions, demonstrates appreciation for raising Self-assessments are performed on a variety of differing views, allows time for understanding, and topics, including the self-assessment process itself.

encourages communication and collaboration. They are performed at a regular frequency and Learning organizations are committed to learning provide objective, comprehensive, and self-critical from their mistakes and those of others, and they information that drive corrective actions. Targeted take appropriate action to address lessons learned. self-assessments are performed when a more They evaluate operating experiences and ensure thorough understanding of an issue is required.

A balanced approach of self-assessments and 34 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

independent oversight is used and periodically What Is A Scenario In Which This Trait Could adjusted based on changing needs. Self-assessment Play A Role?

teams include individual contributors and leaders from within the organization and from external Before a concrete pour at a nuclear power plant organizations when appropriate. under construction, an engineer discovered that steel reinforcing bars were not spliced correctly Benchmarking: The organization learns from other in some locations. Work was halted and the rebar organizations to continuously improve knowledge, was reworked before the concrete pour. However, skills, and safety performance. since the rebar was only spliced incorrectly in a The organization uses benchmarking as an few locations, the engineer gave verbal feedback avenue for acquiring innovative ideas to improve to the concrete crew foreman on shift at the time nuclear safety. The organization participates of the discovery, but did not initiate a corrective in benchmarking activities with other nuclear action program condition report. The foreman of and nonnuclear facilities. The organization the concrete crew then had a brief discussion with seeks out best practices by using benchmarking his crew about the acceptable method of rebar to understand how others perform the same splicing for the project. However, because the functions. Benchmarking is used to compare foreman believed that the issue was skill of the standards to the industry and to make adjustments craft, no further training was necessary. He did to improve performance. Individual contributors not generate a corrective action report, request that are actively involved in benchmarking. work procedures be revised to specify the correct rebar splicing instructions, or provide feedback to Training: The organization provides training the qualification training program. He intended to and ensures knowledge transfer to maintain a inform the concrete crew foreman of the other shift, knowledgeable, technically competent workforce but forgot during the hectic shift turnover.

and instill nuclear safety values.

Two months later, during another concrete pour, The organization fosters an environment in which quality assurance inspectors discovered that several individuals value and seek continuous learning rebar splices were incorrect. However, this time the opportunities. Individuals, including supplemental concrete pour had already begun. The pour was workers, are adequately trained to ensure stopped and the condition was assessed. Extensive technical competency and an understanding of re-work was required to correct the rebar splices standards and work requirements. Individuals and remove the poured concrete sections. This master fundamentals to establish a solid work could not be performed expeditiously, and the foundation for sound decisions and behaviors. entire concrete batch was lost.

The organization develops and effectively implements knowledge transfer and knowledge Upon review of the issue, the licensee discovered retention strategies. Knowledge transfer and that problems with rebar splicing were not knowledge retention strategies are applied to uncommon in the construction industry, and there capture the knowledge and skill of experienced were similar occurrences at nuclear construction individuals to advance the knowledge and skill projects both in the United States and at foreign of less experienced individuals. Leadership and sites. Also, concrete subcontractors often work management skills are systematically developed. on construction projects in different areas of Training is developed and continuously improved construction, and they frequently work at sites with using input and feedback from individual different requirementssometimes during the same contributors and subject-matter experts. Executives week. Continuous Learning, through the use of obtain the training necessary to understand basic benchmarking and lessons learned programs, may operations and the relationships between major have prevented this incident.3 functions and organizations.2 S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 35

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Continuous Learning?

2. What kinds of communications would have reinforced safety as the overriding priority?

3. How could this situation been handled differently?

36 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Continuous Learning, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 37

PERSONAL ACCOUNTABILITY What Is The Definition Of Personal An ongoing challenge in fostering Personal Accountability? Accountability is to identify who is responsible for the factors that affect safety within an organization The NRCs SCPS defines Personal Accountability as and how to make appropriate accountability all individuals take personal responsibility for safety. assignments. For example, responsibility can be assigned to ensure that training is completed, Why Is This Trait Important? procedures are updated, and decisions are made. Accountability systems in an organization Personal Accountability reflects the belief that involve identifying who is held accountable for leaders and employees are responsible and have which actions and by whom. Alignment in these ownership for their performance and the roles they accountability systems within an organization can play in nuclear safety. Personal Accountability is not create effective communications, teamwork, strong finger pointing, blame, or punishment. safety performance, and motivated employees and can lead to a positive safety culture.1 In organizations with positive safety cultures, individuals have a strong sense of accountability for the safe operation of the facility, their own safety, What Does This Trait Look Like?

and for the safety of their coworkers and the public.

Leaders can develop Personal Accountability within Standards: Individuals understand the importance their organization by empowering employees. They of adherence to nuclear standards. All levels of the must give employees the skills and training needed organization exercise accountability for shortfalls in to communicate, explain, and do their jobs well. meeting standards.

They must set performance objectives with specific Individuals encourage each other to adhere to behaviors and outcomes and evaluate performance high standards. They demonstrate a proper focus and give timely feedback. on nuclear safety and reinforce this focus through Furthermore, leaders should encourage peer coaching and discussions. Individuals hold accountability through rewards rather than themselves personally accountable for modeling discourage through punishment. When leaders nuclear safety behaviors and individuals across model, acknowledge, and reward positive the organization apply nuclear safety standards accountability behaviors, employees are more consistently. Individuals actively solicit and are likely to be motivated to invest in safe operations open to feedback and they help supplemental personally. personnel understand and practice expected behaviors and actions.

Everyone must take personal ownership for his or her actions and decisions for accountability to Job Ownership: Individuals understand and become a fundamental part of an organizations demonstrate personal responsibility for the safety culture. Reinforcement can come from behaviors and work practices that support nuclear supervisors and managers, but also from coworkers, safety.

the public, and an individuals own personal Individuals understand their personal values and standards. Accountability can motivate responsibility to foster a professional environment, mindfulness, attention to detail, and self-assessment, encourage teamwork, and identify challenges to and can result in fewer accidents and incidents. nuclear safety. They understand their personal responsibility to raise nuclear safety issues, 38 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

including those identified by others. Individuals However, the quality inspector responsible for take ownership for the preparation and execution checking in the wire believed that the spool would of assigned work activities. They actively dry out, and attached a handwritten note DO participate in pre-job briefings, understanding NOT USE SPOOL to prevent issuance while it their responsibility to raise nuclear safety concerns was still wet. The quality inspector accepting the before work begins. Individuals ensure that they wetted wire did not enter the issue into either the are trained and qualified to perform assigned nonconformance or corrective action programs, as work and understand the objective of the work required. Within a few days, the wire developed activity, their role in the activity, and their spots of surface rust. Numerous quality inspectors, personal responsibility for safely accomplishing the including the lead inspector, who had access to the overall objective. controlled storage area and responsibility to issue and receive the wire on a daily basis, observed Teamwork: Individuals and work groups the spool of wire with the handwritten note. Many communicate and coordinate their activities within knew that it had been wetted or that it had visible and across organizational boundaries to ensure rust spots. No personnel took the appropriate action nuclear safety is maintained.

to write a nonconformance or corrective action Individuals demonstrate a strong sense of report. Because the issue was not documented in collaboration and cooperation in connection with the corrective action system, the spool was not projects and operational activities. They work as segregated from the spools ready for issue, the a team to provide peer-checks, verify certifications cause of the rust had not been determined, and an and training, ensure detailed safety practices, investigation had not been performed to determine actively peer coach new personnel, and share whether any nonconforming wire had actually been tools and publications. Individuals strive to meet used in a safety-related welding application.

commitments.2 The vendor did not document or investigate the issue until a U.S. Nuclear Regulatory Commission What Is A Scenario In Which This Trait Could inspector discovered the spool of weld wire Play A Role? during a walkdown. The wire was intended for use on nuclear safety-related welds for modular A welder at a vendor facility inadvertently dropped subassemblies for a domestic plant. Ultimately, the a spool of weld wire into a puddle while carrying it vendor determined that the spool of wire had not to the controlled storage area at the end of his shift. been used for production work after it was wetted, When weld wire is exposed to water, the flux inside even though it was on the shelf and could have absorbs moisture. Once the welding wire is wetted potentially been used. This incident may have been or absorbs an excessive amount of moisture, no prevented if the vendor personnel had exhibited process can dry out the welding wire. Dropping Personal Accountability for their behaviors and a spool of weld wire in a puddle would make it work practices.3 unacceptable for use in welding safety-related components. Wetted weld wire can potentially result in welding defects such as porosity. Wetted weld wire also can contribute to hydrogen cracking, which might not be detected unless the inspection of the welds is conducted at least 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> after the weld is completed.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 39

Thinking about this scenario, consider the following questions:

1. How does this scenario apply to the safety culture trait of Personal Accountability?

2. What kinds of communications would have reinforced safety as the overriding priority?

3. How could this situation been handled differently, what might have been the outcome?

40 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Now that you have read this Trait Talk on Personal Accountability, consider the following questions:

1. How does this trait apply to my organization?

2. Are there other attributes and examples that better fit my organization?

3. What impact does this trait have on the safety culture in my organization?

4. How does this increase my understanding of the safety culture in my organization?

5. How could I improve the performance of this trait in my organization?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 41

SAFETY CULTURE CASE STUDY Overview June 2009 Collision of Two The NRC developed the Case Studies to provide Washington Metropolitan Area real-life events where review of the circumstances Transit Authority Metrorail surrounding the events and the results of the Trains near Fort Totten Station, investigations found clear examples of the role Washington, DC that safety culture played in contributing to, or lessening, the loss of life and damage associated with the event. These Case Studies represent a breadth of industries, including energy, medical, and What Happened?

transportation, and can be found on the Web site at On Monday, June 22, 2009, at about 4:58 p.m.

http://www.nrc.gov/about-nrc/safety-culture.html. Eastern Daylight Time (EDT), WMATA Metrorail train 112 struck the rear of stopped Metrorail train The Case Studies aid in understanding the 214. The powerful impact caused the rear car of importance of developing and maintaining a positive train 214 to telescope into the lead car of train 112, safety culture. They highlight the significance of resulting in a loss of occupant survival space in the safety culture in the analysis and identification lead car of about 63 feet (about 84 percent of its of root causes of an event and enhance safety by total length). Nine people aboard train 112, raising awareness of safety culture and by applying including the train operator, were killed.

lessons learned.

Emergency response agencies reported transporting The Case Study included here, June 2009 Collision 52 people to local hospitals.1 of Two Washington Metropolitan Area Transit Authority (WMATA) Metrorail Trains near Fort Totten Station, Washington, DC, includes a Probable Cause description of the event that occurred, probable * A failure of track circuit modules caused the cause, lessons learned, automatic train control system to lose detection of and an analysis of the event in terms of the safety one train (train 214) allowing a second train (train culture traits. This Case Study was chosen because it 112) to strike it from the rear.2 complements the subsequent Safety Culture Journey

• WMATA failed to institutionalize and employ on the same event and organization. Readers can across the system an enhanced track circuit gain a more in-depth understanding of safety culture verification test procedure that was developed by considering this Case Study and Journey following a near collision in Rosslyn, VA, in 2005.

together.

If this test procedure had been institutionalized It is important to remember that a Case Study and used systemwide, it would have identified the depicting a certain community or organization can faulty track circuit before the accident.1 be applicable to any organization. When reviewing

• O  ther major contributing factors were WMATAs the Case Study, consider how an event in your own lack of a safety culture and WMATAs failure organization could occur if you are experiencing to replace or retrofit 1000-series railcars, which similar weak, or absent, safety culture traits.

were shown in a 2004 accident to exhibit poor crashworthiness.1 42 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

SCPS Traits Evidence of Weak Safety Culture Traits1 Leadership Safety Values and Actions At a monthly board meeting on June 25, 2009, WMATA provided a safety culture presentation to its Board of Directors. The presentation focused on WMATAs commitment to correct recognized hazards, such as parking lot injuries and improper door operations. It did not address safety or train operations or audit findings and corrective action plans. The National Transportation Safety Board (NTSB) was concerned that senior management may have placed too much emphasis on investigating these types of hazards to the exclusion of passenger safety during transit.

Problem Identification and Resolution In 2006, the NTSB recommended that WMTA accelerate the retirement of the 1000-series cars or retrofit them with crashworthiness collision protection comparable to the 6000-series cars. In 2007, that recommendation was classified ClosedUnacceptable Action based on WMATAs response that it was not feasible to retrofit the 1000-series cars and that they would remain in service until replacement with the 7000-series cars in 2014, as originally planned. This issue was identified and evaluated but not addressed or corrected commensurate with the potential risk. The NTSB report recommends replacing all 1000-series railcars as soon as possible with cars that have crashworthiness collision protection at least comparable to the 6000-series railcars.

Personal Accountability The June 25, 2009, WMATA safety presentation defined a preventable accident as an accident that occurred because the employee failed to do everything reasonably expected of a trained professional to avoid involvement in an accident. (NTSB/RAR-10/02) Based on this definition, NTSB concluded that WMATA placed much of the blame for causing and much of the responsibility for preventing accidents on frontline employees. Placing blame on frontline employees is not likely to improve the safety of the system as a whole.

Work Processes As the result of a 2005 audit, the Federal Transit Administration issued nine deficiency findings and one recommendation to comply with the Code of Federal Regulations. After 2 years, the audit findings were still open and WMATA did not have a process to identify and address system safety deficiencies.

Continuous Learning The 2005 near collision in Rosslyn, VA, afforded a prime opportunity to learn about ways to ensure safety. WMATA developed an enhanced track circuit verification test to identify track circuits with the potential to lose train detection; however, the test was never institutionalized and circuit monitoring tools fell into disuse, indicating that WMATA either did not recognize the severity of the risk posed or did not communicate that hazard to all departments of the agency. The results of the hazard assessment and procedures for addressing the identified risk should have been integrated into the training and guidance materials for all affected personnel.

Environment for Raising Concerns NTSB found examples of a deficient reporting culture within WMATA resulting from fear of retaliation. As a result of these findings, NTSB recommended that WMATA develop and implement a nonpunitive safety reporting program to collect and review reports from staff at all levels throughout the organization and share the results of these reviews with all divisions of WMATA.

Effective Safety Communication In response to the 2005 event in Rosslyn, VA, WMATA developed and issued technical bulletins requiring the use of an enhanced circuit verification test procedure; however, none of the WMATA technicians interviewed as part of the investigation was familiar with the enhanced procedure.

NTSB concluded that WMATA failed to recognize that the near collision in Rosslyn represented an unacceptable hazard and did not ensure that the communication reached all affected divisions in the organization for resolution.

Respectful Work Environment WMATA required all trains to be operated in automatic mode during the morning and evening rush periods. The operator of train 214 had been reprimanded previously for operating his train in manual mode; however, on the day of the accident, he changed from automatic to manual mode because he did not want to rely on the automated system to properly position the train along the platform. His actions are indicative of the distrust between WMATA management and its employees. Disciplinary practices perceived as unfair can motivate individuals to hide safety-related information or adopt behaviors to avoid blame.

Questioning Attitude The NTSB report states that managers had an apparent tendency to tolerate failures and malfunctions in the automatic train control system. This may explain why WMATA officials had designated track circuit alarms in the Metrorail Operations Control Center as requiring no specific response and why neither technicians nor maintenance officials placed a high priority on addressing a loss of train detection. NTSB concluded that this complacency likely influenced the inadequate response to malfunctions.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 43

What Can Organizations Learn From *P

 roblems that have been identified as potential This Accident? safety threats, but that have not been fully evaluated and addressed, should be escalated until This accident reinforces the need for, and resolved.

importance of, promoting a positive safety culture by routinely evaluating NRC safety culture activities *P

 ersonnel should be encouraged to raise concerns and initiatives and making enhancements and without fear of retaliation.

adjustments to ensure that your organization

• P

 rocesses and procedures should be standardized, remains proactive and appropriately focused in this implemented, maintained, and communicated.

important area. Key lessons from this case study include the following: *P

 ersonnel, equipment, tools, procedures, and other resources needed to ensure safety and

• Leaders and individuals should be committed to security should be available.

the core values and behaviors that emphasize safety over competing goals to ensure protection of people and the environment.

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Now that you have read through this Safety Culture Case Study, consider the following questions:

1. What could have been done differently to prevent this event?

2. What impact did safety culture have on the events outcome, including whether it could have helped to prevent the event all together?

3. What can I learn from this case?

4. How does this increase my understanding of safety culture?

5. How do the lessons learned from this case study apply to my organization or community?

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 45

SAFETY CULTURE JOURNEY Overview summarizes actions taken during a discrete period of time, in this case between 2009 and 2013. Events, How did the organization assess its safety culture initiatives, or actions occurring after this time period and identify weaknesses? What corrective actions may continue to challenge the organizations safety and new initiatives did it take? How can it sustain culture, which reflects the continuous journey that is a positive safety culture? The NRC was asked these safety culture.

questions many times after stakeholders, vendors, and others involved in safety regulation reviewed After reading this Safety Culture Journey, reflect the Safety Culture Case Studies. In response to these on how the safety culture traits are visible in your questions, the NRC developed the Safety Culture own organization and what actions you might take Journeya case study of an organizations efforts to to move forward on your safety culture journey.

improve its safety culture. The lessons learned by the organization depicted in this Safety Culture Journey and the actions taken Safety culture is a dynamic process that can change in response to the accident may work in your with new leadership, situations, and organizational organization as well, although they may need to be conditions. Building and sustaining a positive modified to fit. Remember that assessments, strategic safety culture that can withstand organizational plans, or educational initiatives are universal action challenges requires time, vigilance, and initiative. items that are not specific to any one organization.

An organizations response to accidents or events typically includes assessment of its safety culture, identification of weaknesses, and implementation The Washington Metropolitan Area of corrective actions and new initiatives. An Transit Authority organization must continue to be diligent, plan for the future, and put goals in place to keep the On Monday, June 22, 2009, the Washington focus on safety. The journey it takes reflects its Metropolitan Area Transit Authority (WMATA) commitment to safety as its highest priority. Metrorail train 112 struck the rear of stopped Metrorail train 214 at the Fort Totten station. Nine The Safety Culture Journey offers a brief synopsis people aboard train 112 were killed and 52 people of an event and highlights how the organization were injured. One major contributing factor to this assessed its safety culture and identified weaknesses, accident was WMATAs lack of a safety culture.1,2 and what corrective actions and new initiatives the Since the accident, WMATA has conducted safety organization took. Many of these initiatives reflect culture assessments, implemented new initiatives the traits of a positive safety culture as described in and prioritized safety culture in its strategic plan.

the SCPS, and this analysis is also included. Finally, The journey demonstrates how an organizations the Journey discusses the strategies the organization weak safety culture can contribute to a serious put in place to sustain a positive safety culture. accident, how safety culture can be assessed and The Safety Culture Journey included here is The improved, and how a positive safety culture can be Washington Metropolitan Area Transit Authority fostered and sustained through strategic planning because it is the followup to the previous case study and leadership commitment to safety as the highest included in this education resource on the same priority.

subject. These two studies, read together, provide an in-depth look at an event, as well as the followup actions taken to improve the organizations safety culture. Please note that the Safety Culture Journey 46 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

How did the organization assess their safety central theme-Metro must instill a strong, unified culture and identify weaknesses? and pervasive safety culture and thereby improve the safety of our employees, customers and Since the Metro accident in 2009, there has been communities we serve.6 an investigation, audit, reports and surveys. These assessments provided WMATA with the information *F  rom September through October 2012, WMATA needed to decide what actions to take. Although administered an Employee Engagement Survey the following list of reports is not comprehensive, it to measure the progress in creating a safety demonstrates WMATAs continuous focus on safety culture and identify WMATA strengths and culture.3 opportunities for improvement. The results indicated that WMATA has made significant

• On March 4, 2010, the Federal Transit progress in strengthening its safety culture. The Administration (FTA) issued its audit of the Tri- most important finding was that employees were State Oversight Committee (TOC) and WMATA. reporting significant progress in implementing The report highlighted key deficiencies in the Metros safety culture:

safety and oversight programs at WMATA and TOC in the aftermath of the Ft. Totten collision, and

• The scores of the survey indicated that employees:

recommended that WMATA fundamentally change

• know how to report safety issues or concerns its organization and culture.3

• feel they have the training to do the job safely and

• The National Transportation Safety Board (NTSB) can provide ideas and suggestions for improving investigated the accident and released its report safety on July 27, 2010. This report included the 11 findings and 10 recommendations from the

• a ssert that their direct supervisor regularly FTAs 2010 audit, and it provided evidence of an provides safety communication ineffective safety culture within the organization.

NTSB issued a total of 34 recommendations in

• r eport that their co-workers take safety policies connection with this accident.1 and procedures seriously

• During 2010, the WMATA Office of the Inspector *b  elieve effective action would be taken if a safety General (OIG) performed a control self violation was reported

-assessment (CSA) of employee safety. The CSA

• a ssert they are comfortable in reporting safety results indicated that employees did not believe violations and concerns7 WMATA provided them with a safe working environment because of unmitigated hazards, inadequate training and ineffective internal and What Corrective Actions and New Initiatives external communication.3 Did They Take?

• During July 2010, over 9,000 WMATA employees In response to the 2009 accident and subsequent completed a safety culture survey and the investigation, audits and surveys, WMATA organization reported the results in October 2010.

implemented changes to its organization and The findings identified numerous weaknesses developed new programs and policies.3,4 These in safety culture. Among them: Employees were initiatives reflect the traits of a positive safety culture concerned about retaliation from peers; reported as described in the NRCs Safety Culture Policy safety concerns were not consistently addressed Statement (SCPS). Although some initiatives could across Metro; and when safety issues were reflect several SCPS traits, only the most relevant appropriately addressed, employees felt Metro did trait associated with each key initiative is listed.

not close the loop with employees.5 In addition, because one trait may best represent

• In February 2011, WMATA issued a safety progress several initiatives, all nine SCPS traits may not be report to its Board of Directors that included the represented in the following chart.

following goal: Many recommendations, one S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 47

SCPS Traits Initiatives Leadership Safety Values and Actions Metros Board took the lead in building a safety - first culture by establishing the Safety and Security Committee that provides public information on WMATAs safety program activities and initiatives, safety performance, as well as the results of investigations into accidents and incidents.

Leadership Safety Values and Actions WMATAs Chief Safety Officer is a direct report to the General Manager and Chief Executive Officer (GM/CEO) and is an active and involved member of the Executive Leadership Team. Since 2010, the Safety Department has doubled in size and increased it authority and technical capacity. The Safety Departments annual budget has more than tripled since 2010 to $17.4 million.

Work Processes WMATA updated its Metrorail Safety Rules and Procedures Handbook (MSRPH), and developed a new Roadway Worker Protection (RWP) program. Both initiatives represent a positive change in the way WMATA conducts its operations and maintenance.

Problem Identification and Resolution WMATA re-established and strengthened its safety committee structure to ensure that safety concerns are identified at the field level, evaluated and resolved at the managerial level, and that conflicts and differenced of opinion are decided at the executive level.

Environment for raising Concerns WMATA initiated a safety hotline that includes an anonymous, Web-based reporting application that runs 24/7.

Environment for Raising Concerns WMATA strengthened its whistleblower policy, making it non-punitive.

Questioning Attitude WMATA gave employees the right to challenge their safety on the job through a Good Faith Challenge process.

Personal Accountability WMATA created the Champions of Safety program to recognize employees who maintain safe work practices.

Effective Safety Communication All WMATA executive management communications with employees have been reviewed to ensure that safety is included and prioritized, and is the first agenda item for most executive meetings and briefings.

Leadership Safety Values and Actions WMATAs GM/CEO conducts one-on-one monthly meetings with members of the Executive Leadership Team to reduce communication silos and promote proactive ownership of safety issues.

Continuous Learning WMATAs Executive Safety Committee has been re-established and reviews WMATAs safety performance to discuss the results of investigations into accidents, incidents and unusual occurrences.

48 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

How can WMATA Sustain a Positive Safety Culture?

In 2013, WMATA issued their 2013-2025 strategic * Create a shared climate of safety: Metro will work plan, which states the following: Continuous with employees, riders, jurisdictional partners, attention to improving safety culture has resulted and the general public to make sure that everyone in employees who are now highly engaged, have does their part in creating and sustaining a culture clarity about their mission, and have the authority of safety and security in stations, vehicles, support and information to do their jobs well. Finally, the facilities, and access points. Metro will enhance its strategic plan clearly articulates that everyone must communications feedback loops to bring critical do their part in creating and sustaining a culture of safety information to empowered agents quickly to safety and security, and affirms that safety is the first prevent accidents before they happen.

priority. Goal 1 of this plan, Build and Maintain a Premier Safety Culture and System, reflects their * Expect the unexpected: Metro will continue focus on safety culture and includes the following:4 to support the regions emergency transit management and security readiness protocols and

• Keep safety Metros first priority: Metro will seek to make transit emergency protocols widely continue its efforts to return to and keep the and easilyunderstood. Metro will maintain system equipment and infrastructure in good regional evacuation capability and prepare for condition. Metro will use data-driven and science- any event that requires wide-scale response. On based methods to allocate resources, use system a smaller scale, Metro will continue to improve safety practices and principles and environmental incident response timing, planning, preparation, design to enhance safety, and seek to meet or and investigation.

exceed national safety and security standards for transit.

S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 49

Now that you have read through this Safety Culture Journey, consider how the actions, initiatives and lessons learned could apply to your organization and ask yourself the following questions:

1. Has my organization been on a similar journey?

2. What did my organization do differently?

3. What can I learn from this organizations experience?

4. How does this information increase my understanding of safety culture?

5. How could I improve safety culture in my organization?

50 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

Sources of Information Sources of Information for Safety Culture Trait Talk: Sources of Information for the Safety Culture Journey:

1. Why is this trait important? was derived, in part, from a literature review (Agencywide Documents The information included in the Safety Culture Access and Management System (ADAMS) Journey was taken from assessments, documents Accession No. ML13023A054) prepared by Pacific and reports that were publicly available when the Northwest National Laboratories for the NRC specific Safety Culture Journey was developed. The Office of Nuclear Regulatory Research. NRC has not conducted a formal analysis of the events discussed herein for, or in conjunction with,

2. What does this trait look like? was derived NTSB, WMATA, or any other organization. The NRC from the Safety Culture Common Language compiled the factual information presented from effort (ADAMS Accession No. ML13031A343), publicly available sources:

under the direction of the Office of Nuclear Reactor Regulation. Panelists from the NRC, 1. Railroad Accident Report, NTSB Number nuclear power industry, and the public created RAR-10/02 attributes of a positive nuclear safety culture, and

2. Safety Culture Communicator case study 1:

examples of each attribute that a nuclear power June 2009 Collision of Two Washington organization should demonstrate in maintaining a Metropolitan Area Transit Authority Metrorail positive safety culture. Although these attributes Trains Near Fort Totten Station, Washington, DC and examples were created specifically for the reactor community, they may also be applicable 3. Rail Transit Safety Program: Safety and to various other communities and organizations. Maintenance Audit of the Washington For purposes of Trait Talk, the examples were Metropolitan Area transit Authority (WMATA) partially rewritten to increase applicability to Final Audit Report November 28, 2012, Federal reactor as well as non-reactor communities. Transit Administration, Office of Safety and Security.

3. What is a scenario in which this trait played a role?

was developed specifically for Safety Culture Trait 4. MOMENTUM The Next Generation of Metro Talk for educational purposes only. The scenario Strategic Plan 2013-2025 is fictional and any resemblance to actual events, people, or organizations is purely coincidental. 5. Safety Culture Survey Report, October 28, 2010 Sources of Information for Safety Culture Case Study: 6. Safety Progress Report, WMATA, Safety and Security Committee, February 24, 2011 The information included in these case studies was taken from official investigative reports and 7. Board Action/Information Summary: Employee other documents, assessments and reports that Engagement Survey, Washington Metropolitan were publicly available when the specific case Area Transit Authority, December 6, 2012 study was developed The NRC has not conducted a formal analysis of the events discussed herein for, or in conjunction with, NTSB, WMATA, or any other organization. The NRC compiled the factual information presented from publicly available sources.

1. NTSB Number RAR-10/02

2. NTSB News-SB-10-29 S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 51

APPENDIX Safety Culture Policy DATES: This policy statement FOR FURTHER INFORMATION Statement becomes effective upon CONTACT: Roy P. Zimmerman, publication in the Federal Register. Director, Office of Enforcement, 76 FR 34773; June 14, 2011 U.S. Nuclear Regulatory Nuclear Regulatory ADDRESSES: You can access Commission, Washington, DC Commission publicly available documents 20555-0001; telephone:

related to this document using the 301-415-2741; e-mail:

[NRC-2010-0282] following methods: Roy.Zimmerman@nrc.gov.

Final Safety Culture Policy

• NRCs Public Document Room Statement (PDR): The public may examine SUPPLEMENTARY INFORMATION:

and have copied, for a fee, AGENCY: Nuclear Regulatory publicly available documents I. Background Commission. at the NRCs PDR, Room O1- A. Previous Policy Statements and F21, One White Flint North, Events Involving Safety Culture ACTION: Issuance of final safety 11555 Rockville Pike, Rockville, The NRC has long recognized culture policy statement. Maryland 20852. the importance of a safety-

• NRCs Agencywide Documents first focus in nuclear work

SUMMARY

The U.S. Nuclear environments for public health Regulatory Commission (NRC or Access and Management System (ADAMS): Publicly available and safety. The Commissions the Commission) is issuing this emphasis on a safety-first focus Statement of Policy to set forth documents created or received at the NRC are available online in is reflected in two previously its expectation that individuals published NRC policy statements.

and organizations performing or the NRC Library at http://www.

nrc.gov/reading-rm/adams.html. The 1989, Policy Statement on overseeing regulated activities the Conduct of Nuclear Power establish and maintain a positive From this page, the public can gain entry into ADAMS, which Plant Operations (54 FR 3424; safety culture commensurate January 24, 1989), applies to all with the safety and security provides text and image files of the NRCs public documents. If individuals engaged in activities significance of their activities that affect the safety of nuclear and the nature and complexity of you do not have access to ADAMS or if there are problems in power plants, and provides the their organizations and functions. Commissions expectations of The Commission defines Nuclear accessing the documents located in ADAMS, contact the NRCs PDR utility management and licensed Safety Culture as the core values operators with respect to the and behaviors resulting from a reference staff at 1-800-397-4209, 301-415-4737, or by e-mail to conduct of operations. The collective commitment by leaders 1996, Freedom of Employees and individuals to emphasize pdr.resource@nrc.gov.

• Federal rulemaking Web site: in the Nuclear Industry to Raise safety over competing goals to Safety Concerns Without Fear of ensure protection of people and Public comments and supporting materials related to this document Retaliation (61 FR 24336; May the environment. This policy 14, 1996), applies to the regulated statement applies to all licensees, can be found at http://www.

regulations.gov by searching activities of all NRC licensees certificate holders, permit holders, and their contractors and authorization holders, holders on Docket ID NRC-2010- 0282.

Address questions about NRC subcontractors, and provides the of quality assurance program Commissions expectations that approvals, vendors and suppliers dockets to Carol Gallagher, telephone: 301-492-3668; e-mail: licensees and other employers of safety-related components, and subject to NRC authority establish applicants for a license, certificate, Carol.Gallagher@nrc.gov.

and maintain safety-conscious permit, authorization, or quality work environments in which assurance program approval, employees feel free to raise subject to NRC authority.

52 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

safety concerns, both to their to the NRCs Reactor Oversight the staff to answer several management and to the NRC, Process (ROP). Commission additional questions, including:

without fear of retaliation. This paper SECY-06-0122, dated May (1) Whether safety culture as Safety Culture Statement of Policy, 24, 2006, (ADAMS Accession applied to reactors needed to in conjunction with the previous No. ML061320282) describes the be strengthened; (2) how to policy statements, is intended to NRCs safety culture activities at increase attention to safety culture emphasize the importance the that time and the outcomes of in the materials area; (3) how NRC places on the development those activities. stakeholder involvement can most and maintenance of a positive Following the terrorist attacks effectively be used to address safety culture for all regulated of September 11, 2001, the safety culture for all NRC and activities. Commission issued orders Agreement State licensees and The accident at the Chernobyl enhancing security at facilities certificate holders, including any nuclear power plant in 1986, whose operations, if attacked, unique aspects of security; and brought attention to the could have an impact on public (4) whether publishing the NRCs importance of safety culture and health and safety. During the early expectations for safety culture the impact that weaknesses in years of implementation of these and for security culture would be safety culture can have on safety security enhancements, several best accomplished in one safety/

performance. Since then, the violations of the Commissions security culture statement or in importance of a positive safety security requirements were two separate statements while culture has been demonstrated identified in which the licensees still considering the safety and by a number of significant, high- failure to cultivate a positive security interfaces.

visibility events worldwide. In the safety culture impacted the In response to Commission United States, incidents involving effectiveness of the licensees direction, the NRC staff reviewed the civilian uses of radioactive security program. The most visible domestic and international materials have not been confined of these involved security officers safety-culture-related documents to a particular type of licensee sleeping in a ready room while and considered NRC lessons or certificate holder, as they have on shift at a nuclear power plant. learned. Additionally, the staff occurred at nuclear power plants Most of the weaknesses involved sought insights and feedback and fuel cycle facilities and during inadequate management oversight from external stakeholders. This medical and industrial activities of security, lack of a questioning was accomplished by providing involving regulated materials. attitude within the security information in a variety of forums, Assessments of these incidents organization, complacency, such as stakeholder organization revealed that weaknesses in the barriers to raising concerns about meetings, newsletters, and regulated entities safety cultures security issues, and inadequate teleconferences, and by were an underlying cause of the training of security personnel. publishing questions developed incidents or increased the severity B. Commission Direction to address Commission direction of the incidents. The causes of In February 2008, the in the February 9, 2009, Federal these incidents included, for Commission issued Staff Register notice (FRN) (74 FR 6433) example, inadequate management Requirements Memorandum entitled Safety Culture Policy oversight of process changes, (SRM), SRM-COMGBJ Statement Development: Public perceived production pressures, 0001 (ADAMS Accession No. Meeting and Request for Public lack of a questioning attitude, and ML080560476), directing Comments (ADAMS Accession poor communications. One such the NRC staff to expand the No. ML090260709).

incident indicated the need for Commissions policy on safety In February 2009, the NRC additional NRC efforts to evaluate culture to address the unique held a public workshop on whether the agency should aspects of security and to ensure the Development of a Policy increase its attention to reactor the resulting policy is applicable Statement on Safety Culture and licensees safety cultures. This to all licensees and certificate Security Culture in which a broad resulted in important changes holders. The Commission directed range of stakeholders participated, S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 53

including representatives from accordance with the existing the workshop was for panelists the Agreement States (Meeting ROP self-assessment process; representing a broad range of Summary: ADAMS Accession (2) described actions taken and stakeholders to reach alignment, No. ML090930572). The staff planned for increasing attention using common terminology, on developed draft characteristics to safety culture in the materials a definition of safety culture (subsequently referred to as area; and (3) described actions and a high-level set of traits traits) of a positive safety taken and planned for most that describe areas important culture and presented them effectively obtaining stakeholder to a positive safety culture. The at the workshop. Mindful of involvement to address safety workshop panelists represented the increased attention to the culture, including any unique a wide range of stakeholders important role of security, the aspects of security, for all NRC regulated by the NRC and/ or staff also sought input from the and Agreement State licensees and the Agreement States, including workshop participants on whether certificate holders. medical, industrial, and fuel cycle there should be a single safety In SRM-SECY-09-0075 (ADAMS materials users, and nuclear culture policy statement or two Accession No. ML092920099), the power reactor licensees, as well policy statements addressing Commission directed the staff to: as the Nuclear Energy Institute, safety and security independently (1) Publish the draft safety culture the Institute of Nuclear Power while considering the interface policy statement for no fewer than Operations (INPO), and members of both. Before providing 90 days; (2) continue to engage of the public. The workshop its recommendations to the a broad range of stakeholders, panelists reached alignment with Commission, the staff developed including the Agreement States input from the other meeting a draft definition of safety culture and other organizations with attendees on a definition of safety in which it modified a definition an interest in nuclear safety, to culture and a high-level set of from the International Atomic ensure the final policy statement traits describing areas important Energy Agencys advisory group, presented to the Commission to a positive safety culture.

the International Nuclear Safety reflects a broad spectrum of Following the February 2010, Group, to make it applicable to views and provides the necessary workshop, the NRC staff evaluated all NRC-regulated activities and to foundation for safety culture the public comments that were address security. applicable to the entire nuclear submitted in response to the Based on its review and industry; (3) make the necessary November 6, 2009, FRN (74 FR stakeholder feedback, in adjustments to encompass security 57525). Additionally, the staff SECY-09-0075, Safety Culture within the statement; (4) seek participated on panels and made Policy Statement, dated opportunities to comport NRC presentations at various industry May 16, 2009 (ADAMS Accession terminology, where possible, with forums in order to provide No. ML091130068), the NRC staff that of existing standards and information to stakeholders about provided a single draft safety references maintained by those the development of the safety culture policy statement for that the NRC regulates; and (5) culture policy statement and/

Commission approval. The draft consider incorporating suppliers or to obtain additional input policy statement acknowledged and vendors of safety-related and to ascertain whether the the importance of safety and components in the safety culture definition and traits developed at security, and the interface of both, policy statement. the workshop accurately reflect within an overarching culture of C. Development of the Final Policy a broad range of stakeholders safety. Additionally, in response Statement views. These outreach activities to the Commissions questions, On February 2-4, 2010, the included, for example, the staff: (1) Concluded that NRC held a second safety culture participation in a Special Joint the NRCs oversight of safety workshop to provide a venue for Session on Safety Culture at the culture as applied to reactors has interested parties to comment Health Physics Society Annual been strengthened, is effective, on the draft safety culture policy Meeting, and presentations on the and continues to be refined in statement. The additional goal of development of the safety culture 54 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

policy statement at the Annual published the revised draft safety meeting in September 2010, in Fuel Cycle Information Exchange, culture policy statement (ADAMS the Las Vegas Hearing Facility, the Conference of Radiation Accession No. ML102500563) Las Vegas, Nevada, which Control Program Directors on September 17, 2010 (75 was simultaneously broadcast Annual National Conference on FR 57081), for a 30-day public in the Commission Hearing Radiation Control, the Institute of comment period. Because Room, Rockville, Maryland, Nuclear Materials Managements public comments reflected some and over the internet via Web Annual Meeting, the Second NRC misunderstanding regarding the streaming in order to allow Workshop on Vendor Oversight Commissions use of a policy remote participation. The goals for New Reactors, and the statement rather than a regulation of the September 2010, FRN Organization of Agreement States or rule, the September 2010, FRN and meeting were to provide Annual Meeting. In response to provided clarification, pointing additional opportunities for Commission direction in SRM- out that the Commission may stakeholders to comment on the SECY- 09-00075, the staff focused use a policy statement to address revised draft policy statement, attention on attending meetings matters relating to activities that including the definition and involving the Organization of are within NRC jurisdiction and traits developed at the February Agreement States and other are of particular interest and 2010, workshop, and to discuss materials licensees. importance to the Commission. the information gathered from In July 2010, the NRC held a Policy statements help to guide the outreach activities that had public teleconference with the the activities of the NRC staff and occurred since the February panelists who participated in can express the Commissions 2010, workshop. Additionally, the February 2010, workshop to expectations of others; however, a representative from INPO discuss the status of outreach they are not regulations or rules presented information on the activities associated with the and are not accorded the status validation study INPO conducted development of the policy of a regulation or rule within the as part of INPOs efforts to help statement. At the July 2010, meaning of the Administrative establish a technical basis for meeting, the panelists reiterated Procedure Act. The Agreement the identification and definition their support for the definition States, which are responsible of areas important to safety and traits developed at the for overseeing their materials culture. A member of the Office of February 2010, workshop as a licensees, cannot be required Nuclear Regulatory Research also result of their outreach with their to implement the elements of presented findings related to the industry colleagues. This position a policy statement because oversight of the INPO study.

aligns with the comments the such statements, unlike NRC II. Public Comments staff received during the various regulations, are not a matter of The November 2009, FRN outreach activities. In September compatibility. Additionally, policy and the September 2010, FRN 2010, the staff held an additional statements cannot be considered generated 76 comments from teleconference to provide binding upon, or enforceable affected stakeholders and information on the initial results against, NRC or Agreement State members of the public. The staffs of a validation study conducted licensees and certificate holders.

evaluation concluded that many by INPO, which was conducted, This Statement of Policy has of the comments were statements in part, to see whether and to been developed to engage of agreement on the information what extent the factors that came individuals and organizations included in the draft and revised out of INPOs safety culture performing regulated activities safety culture policy statements survey support the February involving nuclear materials and did not require further action.

2010, workshop traits. The factors and share the Commissions A few of the commenters raised support the traits developed at the expectations regarding the issues that the staff considered workshop. development and maintenance of during the development of the Based on its review and a positive safety culture.

policy statement, but ultimately stakeholder feedback, the staff The NRC held a public concluded that the issues were S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 55

either not applicable to the policy Additionally, the Commission Statement of Policy under the statement, for example, that by should acknowledge the efforts trait, Questioning Attitude.

virtue of its all encompassing already underway as the regulated Questioning Attitude is applicability, the policy must be community addresses the described in the final Statement taken as a strategic utterance; Statement of Policy. of Policy as a culture in which or either misunderstood or 5. How does the NRC plan to individuals avoid complacency disregarded the concept of enforce adherence to the policy and continuously challenge a policy statement in this statement? existing conditions and activities application, for example, that 6. Comments on the draft in order to identify discrepancies a policy statement is largely policy statement were generally that might result in error or inadequate for purposes of supportive of including vendors inappropriate action.

establishing broad-reaching and suppliers of safety-related This policy statement is being performance standards. The components in the Statement of issued after careful consideration remaining comments informed Policy, but reflected concern about of the staffs evaluation of the the NRC staffs development of jurisdictional issues, as well as public comments received on the the final policy statement. These the impact that including vendors November 2009, and September were grouped into the following and suppliers in the Statement of 2010, FRNs; the public meetings themes: Policy might have on licensees held in February 2009, and

1. The NRC should adopt ability to work with these entities. February, July, and September the definition and traits 7. During its evaluation of the 2010; the views expressed developed during the February public comments on the draft by stakeholders during the 2010, workshop. This theme safety culture policy statement, Commission briefing in March encompassed additional the staff felt that a trait addressing 2010; and the informal dialogue comments indicating that complacency should be added with the various stakeholders retaining the term security in the to the February 2010, workshop during the staffs additional definition and traits of a positive traits. Several months later, the outreach efforts from the February safety culture may be confusing results of an INPO study indicated 2010, workshop until the second to many licensees, particularly that the trait Questioning public comment period ended on materials licensees. Attitude had strong support October 18, 2010.

2. The traits from the February with operating nuclear plant The following paragraphs 2010, workshop should be personnel. This trait resonated provide the specific information included in the Statement of with the staff as an approach that was used in the development Policy in order to provide for addressing complacency for of the final policy statement, additional clarity as to its intent. all regulated activities. At the including the changes that were

3. More guidance is needed September 2010, public meeting, made to the November 2009, FRN:

on the NRCs expectations as to as part of a larger presentation 1. The Statement of Policy how the policy statement will be providing the results of the INPO adopts the February 2010, implemented. This encompassed validation study, the staff added workshop definition and traits the additional theme that a question about whether to of a positive safety culture. The stakeholders would like to be include this trait. Additionally, the term security is not included actively involved in the process of September 2010, FRN specifically in either the definition or the developing this guidance and that asked whether complacency traits. The Commission agrees the continued use of workshops should be addressed in the that an overarching safety culture with the various licensees would Statement of Policy. Although addresses both safety and security be helpful. the responses to this question and does not need to single

4. A discussion should be varied, the staff concluded it out security in the definition.

included in the policy statement should be considered in a positive However, to ensure that security that addresses the diversity safety culture and included the is appropriately encompassed of the regulated community. concept of complacency in the within the Statement of Policy, 56 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

a preamble to the traits has Policy or that they agree with involved in medical uses of been added and the robust the original decision to include radioactive materials; research discussion of security, including the traits in their own section of and test reactors; large-scale fuel the importance of considering the the policy statement. However, fabrication facilities; as well as interface of safety and security several commenters indicated operating nuclear power plants that was included in the draft that adding the traits to the and the construction of new Statement of Policy, has been Statement of Policy itself would facilities where operations will retained in the Statement of help to clarify the Commissions involve radioactive materials Policy. expectations. Because the traits in with the potential to affect

2. The Commission agrees question were developed by the public health and safety and that including the traits in the stakeholders at the February 2010, the common defense and Statement of Policy will serve to workshop to provide a high-level security) and recognizes that clarify the intent of the policy. The description of the areas important implementation will be more draft policy statement published to a positive safety culture, the complex in some settings than in the November 2009, FRN did level of detail that was included others. The NRC program not include the characteristics in the draft characteristics is not offices responsible for licensing (now described as traits) in present in the traits. Thus, even and oversight of the affected the actual Statement of Policy. with inclusion of the traits, the entities intend to work with The staff developed the draft Statement of Policy remains brief their constituents, who bear the characteristics based on a variety and concise; in addition, this primary responsibility for safely of sources, including the 13 safety approach provides high-level handling and securing regulated culture components used in the detail that was not in the draft materials, to address the next ROP. The characteristics included Statement of Policy. Including steps and specific implementation significantly more detail than the the traits in the Statement of issues. Nevertheless, before traits included in the Statement Policy rather than as part of the implementation issues are of Policy. The staffs basis for the policy statement visually supports addressed, the regulated original decision to include the their standing as part of the community can begin assessing characteristics in another section Commissions expectation that their activities to identify areas of the draft policy statement but these are areas that members of for enhancement. For example, not in the actual draft Statement the regulated community should industry representatives of Policy was three-fold: first, consider as they develop a could begin to identify tacit it would keep the Statement of positive safety culture. Finally, as organizational and personal goals Policy brief and concise; second, the Statement of Policy points out, that, at times, may compete with it would maintain the Statement the list of traits was not developed a safety-first focus and develop of Policy at a high level; and for inspection purposes nor does strategies for adjusting those third, it would not invalidate the it represent an all-inclusive list goals. Some monetary incentive characteristics standing as part of areas important to a positive or other rewards programs of the draft policy statement to safety culture. could work against making a place them in another section 3. Implementation is not directly safe decision. Current training of the draft policy statement. addressed in this policy statement, programs may not address safety The November 6, 2009, FRN which sets forth the overarching culture and its traits or how those that contained the draft policy principles of a positive safety traits apply to dayto- day work statement specifically requested culture. This discussion is not activities. Identification of both comments on whether the included because the Commission strengths and weaknesses related characteristics should be included is aware of the diversity of its to safety culture in the regulated in the Statement of Policy. Some regulated community (which community will be helpful in commenters indicated that they includes, for example, industrial understanding implementation would prefer not to include the radiography services; hospitals, strategies.

traits in the actual Statement of clinics and individual practitioners S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 57

4. The final Statement of maintain a positive safety culture primary responsibility for safety Policy includes a statement that in their organizations for the same and security. The performance the Commission recognizes reasons that other NRC regulated of individuals and organizations the diversity of the various entities should do so. can be monitored and trended organizations that are included in 7. The final Statement of Policy and, therefore, may be used the Statement of Policy and the adds the trait Questioning to determine compliance with fact that some organizations have Attitude to the traits developed requirements and commitments already spent significant time and at the February 2010, workshop and may serve as an indicator resources in the development as an appropriate vehicle for of possible problem areas in of programs and policies to addressing complacency. an organizations safety culture.

support a positive safety culture. The NRC will not monitor or III. Statement of Policy The Commission will take these trend values. These will be the The purpose of this Statement efforts into consideration as the organizations responsibility as of Policy is to set forth the regulated community addresses part of its safety culture program.

Commissions expectation that the Statement of Policy. Organizations should ensure individuals and organizations

5. Because there seemed that personnel in the safety establish and maintain a positive to be some questions about and security sectors have an safety culture commensurate the Commissions use of a appreciation for the importance with the safety and security policy statement rather than a of each, emphasizing the need significance of their activities regulation, the staff provided for integration and balance to and the nature and complexity of a brief discussion of the achieve both safety and security in their organizations and functions.

differences in the September their activities. Safety and security This includes all licensees, 17, 2010, FRN, pointing out that activities are closely intertwined.

certificate holders, permit holders, policy statements, while not While many safety and security authorization holders, holders enforceable, guide the activities activities complement each other, of quality assurance program of the NRC staff and express there may be instances in which approvals, vendors and suppliers the Commissions expectations. safety and security interests create of safety-related components, and The Commission reiterates the competing goals. It is important applicants for a license, certificate, conclusion of the discussion that consideration of these permit, authorization, or quality provided in the September 2010, activities be integrated so as not assurance program approval, FRN that while the option to to diminish or adversely affect subject to NRC authority. The consider rulemaking exists, the either; thus, mechanisms should Commission encourages the Commission believes at this time, be established to identify and Agreement States, Agreement that developing a policy statement resolve these differences. A safety State licensees and other is a more effective way to engage culture that accomplishes this organizations interested in nuclear stakeholders. would include all nuclear safety safety to support the development

6. Vendors and suppliers of and security issues associated and maintenance of a positive safetyrelated components have with NRC regulated activities.

safety culture, as articulated in been included in this Statement Experience has shown this Statement of Policy.

of Policy. A few stakeholders that certain personal and Nuclear Safety Culture is have raised concerns about organizational traits are present in defined as the core values and how implementation would a positive safety culture. A trait, in behaviors resulting from a be carried out, particularly this case, is a pattern of thinking, collective commitment by leaders in cases where vendors and feeling, and behaving that and individuals to emphasize suppliers are located outside of emphasizes safety, particularly safety over competing goals to NRC jurisdiction. However, the in goal conflict situations, e.g.,

ensure protection of people and Commission believes that vendors production, schedule, and the the environment. Individuals and suppliers of safety-related cost of the effort versus safety. It and organizations performing components should develop and should be noted that although the regulated activities bear the 58 U.S . NU CLE A R R E GULATO RY CO MMISS IO N

term security is not expressly (9) Questioning Attitude included in the following traits, Individuals avoid complacency safety and security are the and continuously challenge primary pillars of the NRCs existing conditions and activities regulatory mission. Consequently, in order to identify discrepancies consideration of both safety and that might result in error or security issues, commensurate inappropriate action.

with their significance, is an There may be traits not included underlying principle of this in this Statement of Policy that are Statement of Policy. also important in a positive safety The following are traits of a culture. It should be noted that positive safety culture: these traits were not developed to (1) Leadership Safety Values and be used for inspection purposes.

ActionsLeaders demonstrate It is the Commissions a commitment to safety in their expectation that all individuals decisions and behaviors; and organizations, performing (2) Problem Identification and or overseeing regulated activities ResolutionIssues potentially involving nuclear materials, impacting safety are promptly should take the necessary steps to identified, fully evaluated, and promote a positive safety culture promptly addressed and corrected by fostering these traits as they commensurate with their apply to their organizational significance; environments. The Commission (3) Personal Accountability recognizes the diversity of these All individuals take personal organizations and acknowledges responsibility for safety; that some organizations have (4) Work ProcessesThe process already spent significant time and of planning and controlling work resources in the development activities is implemented so that of a positive safety culture. The safety is maintained; Commission will take this into (5) Continuous Learning consideration as the regulated Opportunities to learn about ways community addresses the to ensure safety are sought out Statement of Policy.

and implemented; Dated at Rockville, Maryland, (6) Environment for Raising this 8th day of June 2011.

ConcernsA safety conscious For the Nuclear Regulatory work environment is maintained Commission.

where personnel feel free to Annette L. Vietti-Cook, Secretary of the Commission.

raise safety concerns without

[FR Doc. 2011-14656 Filed 6-13-11; fear of retaliation, intimidation, 8:45 am]

harassment, or discrimination; BILLING CODE 7590-01-P (7) Effective Safety Communication Communications maintain a focus on safety; (8) Respectful Work Environment Trust and respect permeate the organization; and S AFE T Y CULT U RE E DU C AT IO NA L RE SO U RC E 59