# Presentation: 825751

## Safety Culture(& ISM)					

- Safety Culture(& ISM)**	****	****	****	****	**

**Peter S. Winokur**
***Thanks to Matt Moury, Doug Minnema, and Dan Burnfield***
**Defense Nuclear Facilities Safety Board**
**November 28, 2007**

## Outline

- DNFSB ISM focus
- Safety Culture
- Top 10 ... ways to knowyou have a safety culture!
- Challenge ahead

## Recent DNFSB ISM Focus

- Integrating Safety in Design
- Properly address safety-related design requirements and issues early in the design process.
- DOE Standard 1189, *Integration of Safety into the Design Process. *
- Nuclear Safety Research (Rec 2004-1)
- DOE should establish, fund, and execute an integrated corporate nuclear safety research program that cuts across program lines.
- Efforts to date have not produced a viable program.
- Board continues press DOE to institute program.

## Integrated Safety Management

**Functions**

**Principles**

**HPI**

**VPP**

**Integrated Safety Management**

**Committed**
**Leadership**

**Empowered**
**Workers**

**Shared Desire**
**For Excellence**

**Safety Culture**

**Figure adopted from: Jim Collins, **_**Good to Great**_**; HarperCollins Publishers, NY; 2001.**

**Buildup**

**Breakthrough**

**Leadership**

**Oversight**

**HEDGEHOG CONCEPT: Safety is on the critical path to mission.**

##            Safety Culture

**Safety culture** is an organization’s values and  behaviors – modeled by its leaders and internalized by its members – that serve to make nuclear safety an overriding priority.*
- - Dating back to SEN-35-91, it’s DOE Policy.
- -  It’s perishable.
- *INPO, *Principles for a Strong Nuclear Safety Culture*, November 2004.

## No. 1: Leadership (the talk)

- The safety message from upper management is loud and clear and they are its leading advocate.
-     - “Safety is a core value of DOE.” (S-2)
-     -  _*But not*_* : *“We are too risk averse”; “Getting the job
-        done”; “Mission first”; “Managing the ‘contract’ and
-        not the ‘contractor’ – the ‘what’ but not the ‘how.’”
- Leaders realize that production goals, if not properly communicated, can send mixed signals on the importance of nuclear safety.

##   No. 2: Balanced priorities

- Safety is the overriding priority.
- ISM priorities are “balanced” if weighted in favor of safety as the first priority.
- 	- “No job is more important that your health, your safety,
-         and the protection of our environment.”
- 	-  The end result of good safety practices is productivity;
-         compromise safety ... compromise mission.
- 	   *HEDGEHOG CONCEPT:* Safety is on the critical path to mission.
- Cleaning up legacy waste promotes public safety; missions of national importance.
- Line managers must resolve the natural conflict between what they want to do (mission), and what they need to do (safety).

##      No. 3: The walk

- There is management *commitment*, *support, and* *resources *for safety programs.
- Senior and line managers are involved in operations and fully accountable for safety and performance of operations.
- Continuing and effective management presence on the floor means technical understanding and awareness of the work and the hazards.
- The importance of identifying, evaluating, and fixing weaknesses, failures, and accident causal factors is emphasized loudly and often.

##      No. 4: Empowerment

- A clear understanding by workers that line management is responsible for creating the safest work environment, but ultimately safety is _the worker’s_ responsibility.
- Ownership that empowers workers to raise safety concerns and offer continuous improvement suggestions.
- “Safety Culture” may be driven by management, but it is measured by the behaviors, attitudes, and values of workers.

##    No. 5: Responsibility

- Workers accept responsibility for their own personal safety and the safety of their coworkers.
- Employees help each other, and there’s peer pressure to work safely.
- Workers are capable of discovering the potential hazards, risks, and problems associated with their work, and the controls to protect them, i.e., ISM.
- Respect for radioactive materials, criticality, and other hazards associated with nuclear activities.

##       No. 6: Trust 

- Employees are encouraged, and even rewarded, to step back or stop work if safety practices are questioned.
- Workers can identify problems without fear of retaliation and with confidence the problems will be properly addressed and/or fixed in a timely manner.
- Opposing views are encouraged and considered.
- A questioning attitude is cultivated.
- There is an openness to criticism and recommendations for improvement.

##    No. 7: Lessons learned

- Emphasis on feedback and improvement, including a robust lessons learned program that works.
- Corrective actions get at root causes and are effective and long lasting.
- We can learn much more from our failures than from our successes.
-      - In evaluating a failure, we can usually identify its source.
- 	- It’s much more difficult to learn from success; the margin
-        of success is difficult to quantify especially for low
-  	  probability, high-consequence events.
- 	- *“Past performance is no [guarantee] of future returns.”*
- 	-  STAMP OUT COMPLACENCY!!!

##   No. 8: Checks & balances

- Internal and external oversight is a must.
- Safety organizations have clear responsibilities and authorities that are independent of the line.
- Safety organizations are not dependent on line organizations for funding and have organizational influence.
- Mutual respect (esp. at design labs) and effective communication between line managers and independent oversight.
- Any adversarial relationships that exist between line managers and assessors should be discouraged by both sides.

##    No. 9: Proactivity

- The organization has a good understanding of leading (and technically-relevant) indicators of potential safety concerns, as opposed to lagging indicators.
- Anomalies, near-misses, off-normal, and random events are recognized and fully investigated.
- The *status quo* is questioned.
- A strong focus on nuclear safety R&D in support of risk-informed decisions.

##    No. 10: Training

- Training and qualification are continuous.
- Organizational knowledge is valued and preserved.
- Managers and supervisors are personally involved in high-quality training that consistently reinforces expected worker behaviors.
- Trainers are adept at instilling nuclear safety values and beliefs that serve as the correct way to *think, act, and feel*  [INPO]. The organization places a high cultural value on safety.
- Training is augmented with sufficient practical exercises to instill competence and confidence.

## CLIMBING THE STEPS TO AN EFFECTIVE SAFETY CULTURE

**TOOLS: VPP, QA, TRAINING, HPI, STANDARDS**

**BALANCED PRIORITIES & RESOURCES**

**COMMITTED LEADERSHIP**

**EMPOWERED WORKERS**

**SHARED DESIRE**
**FOR EXCELLENCE**

**CLIMBING THE STEPS TO AN EFFECTIVE SAFETY CULTURE**

**CHECKS & BALANCES**

##     Final Thoughts & Challenge Ahead

**Can ISM be used to change the safety culture of an organization?  Yes!****	****  **
**Has ISM had a fundamental impact on DOE’s safety culture? Yes!**
**The Challenge Ahead**
**	**-  We can engineer systems and processes to facilitate a more effective
- 	   safety culture.
- 	-  But we cannot engineer the committed leadership, the empowered
- 	   workers, or the shared desire for excellence that will take us the rest
-            of the way to the top – **to a well-established safety culture!**
-            ***That is our next great challenge!***