Overview
of JANSI
Annual Conference
2022
JANSI
AnnualConference
2022 の概要◆Time & Date: March 23, 2022 (Wed), 14:00-17:00◆Venue: Tokyo International Forum Hall D7◆Format: Hybrid (also delivered via WebEx)◆Number of participants: Approx. 600 people

Keynote speechOpening
Remarks

Panel discussion

Chairman,Japan Nuclear Safety Institute (JANSI)
William Edward Webster Jr.

As Chairman of JANSI, I am honored to welcome you to theAnnual Conference 2022. The Annual Conference is a time when the
nuclear industry comes together and reaffirms our collective
commitment earnestly to pursue the highest standards of nuclear
safety. This Annual Conference is held every March with the aim ofreaffirming the seriousness of the accident at Fukushima Daiichi
Nuclear Power Plant and renewing the vow never to forget thelessons learned from the accident. While listening to the valuablelectures of the presenters today, we would like to take the lessons
learned from the accident to our hearts again.
Before moving on to the program of this conference, I would like to give a brief
update of the situation at JANSI. Since spring 2020, JANSI's business activities andother social activities have been greatly affected by COVID-19 pandemic. After a brief
stoppage, however, we have continued with the evaluation and support activities
related to nuclear safety while taking appropriate measures to prevent the spread of
COVID-19 infection. This was accomplished through the innovative ideas of the JANSI
staff and our counterparts in the industry. In the future, we will continue to make
improvements and carry out JANSI’s mission of evaluation and support activities evenunder adverse circumstances.
The JANSI 10-Year Strategy, approved by the Board of Directors in 2019, continues toprovide firm direction for all JANSI activities. The Strategy summarizes the positioning
and future direction of each JANSI activity to realize the ideal that we have put together
with the utilities. We regularly check the progress of the Strategy, and we are making
good progress as measured against our milestones.
Based on the environmental changes in the industry and the progress of activities, we

1will continue strongly to lead the nuclear industry towards enhancement of selfregulation and with activities such as carrying out effective and efficient peer reviews
including measures for WANO equivalency, continuing to monitor information on power
plant performance between peer reviews, and providing support for the restart of units
that have been in long-duration shutdowns and the initial operation of the JNFL
reprocessing facility.
JANSI‘s progress as a self-regulatory organization is a journey and we are well on ourway. With the support and active involvement of all of you, we are determined to boldly
take on challenges and to make efforts by steadily accumulating wisdom and innovativeideas across the industry. We are confident that the voluntary safety improvement on
which we work together will create a synergistic effect with national regulations andlead to the further improvement of nuclear safety for the utilities.
Under the slogan "Excellence Starts at Home," each and every employee of JANSI
continues to strive for self-improvement including improving technical capabilities, andwe will do our utmost to further improve the effectiveness of self-regulatory activities inclose cooperation with our members. I would like to ask for your continued support andcooperation in JANSI's business activities.

Guest
SpeechChairman,
Nuclear Regulation Authority
Toyoshi Fuketa

The Japan Nuclear Safety Institute (JANSI) and the Nuclear
Regulation Authority are both entities that independently keep aclose eye on the safety of nuclear facilities. As today’s conference
will focus on organizational culture that contributes to safety, I
would like to talk about several aspects related to organizational
culture.
First, let me introduce what we appealed vigorously within theorganization immediately after the Nuclear Regulation Authority
was established. That is to “identify yourself”. We asked to first
identify your name, not your job title, when you give a comment
during a meeting. Your expertise is not attached to job titles suchas section managers. Authority and responsibility may come with the job title but notexpertise. By expressing scientific and technical opinions with your name, it specifies
that expertise exists within the organization. The regulatory authority before the TEPCO
Fukushima Daiichi Nuclear Power Station Accident often took a process that could beseen as an evasion of responsibility by saying that the decision was made by an
external party with expertise, even though the substantive decision was made within
the public office. Since the location of authority is clear, we believe it is necessary to
clarify the name during the discussion process to make it clear that the decision will bemade by the person who have authority and responsibility for it.
Another thing I have been repeatedly asking within the organization since becoming
the Chairman is to “speak up”. We insist that you are obligated to speak up if you havea question about your position. Not speaking up just because your colleague ormanager has a different opinion is the same as an abdication of responsibility. The
Nuclear Regulation Authority is aiming to become a workplace where everyone must
speak up when needed.

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Looking at safety in particular, what kind of psychology or mindset makes it difficult to
speak up? One example is the mindset that having room for improvement means thestatus quo is inadequate. When something requiring improvement is pointed out toimprove safety, it is regarded that the status quo is inadequate and claimed that thefacility should be stopped until the improvement is completed. Such kind of claim canalso lead to pressure to make people talk about the simplest and worst safety myththat all nuclear facilities are equally safe enough and have no room for improvement.
Both excessive claims of safety and excessive claims of danger are dangerous elementsthat could revive the safety myth.
Another example is that the stance of the regulating side makes it difficult for the
regulated side to speak up. When an operator proposes a good improvement measure,I think it is dangerous if the stance of the regulatory authority is to immediately
incorporate the measure into the standards and make it a requirement. Any new
improvement measure proposed is made a requirement by the regulatory authority andforced on all operators; this undermines the willingness of operators to speak up.
On the other hand, we are careful not to let the stance of the regulated side silence
the voice of the regulating side. It is not necessarily limited to the regulated side, but
often times when we make a decision, we make an extreme assumption and we takean approach that is ok if it is ok under such assumption. This is equivalent to ceasing tothink when we make an extremely conservative assumption, which silences voices that
seek the most probable value through understanding of the phenomenon. There may
be unavoidable cases when we determine the requirement level and equipment
specifications amid large uncertainties, but making an extreme assumption could
seriously undermine the value of the assessment in the case of an impact assessment.
The quality and quantity of gained information and the way it is trusted are different
between giving leeway to take into account various uncertainties upon making efforts
to seek the most reliable assessment result, and insisting that making an extreme
assumption is ok because its result fits within the aimed range. Assessments withextreme assumptions signify ceasing to think about safety, which will never lead totrust.
Reviews and discussions on safety culture, nuclear security culture, organizational
culture and other cultures should not take up themes with the expectation that they are
unlikely to lead to concrete actions. If there are parties that do not desire new actions
and parties that desire to maintain the status quo, the contours of the discussion areblurred with a large amount of incomprehensible or ambiguous information coming in,creating an impression that conclusions that lead to action are not immediately
obtained. It is true that discussions around culture are extremely important, and, at thesame time, difficult to derive a conclusion, but it is desirable to be moderately aware ofconnecting to actions while in the stage of discussion.
JANSI and the Nuclear Regulation Authority are independent of each other andrespectively seek to fulfill important missions. They do not depend on each other but
communication between the two organizations will continue to be important.

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GuestSpeechChairman,Federation of Electric Power Companies
Kazuhiro Ikebe

As we see in the news every day, Russia’s aggression against
Ukraine continues. I hope the entire world can make diplomaticefforts to strive for a peaceful resolution. There were militaryattacks on related facilities of the Zaporizhzhia Nuclear Power Plant
in the southeastern part of Ukraine. Such an attack could have asevere impact on the surrounding region and exposes the public todanger and anxiety. It should be severely condemned. I hope thissituation gets resolved as soon as possible.
Today I would like to talk about our efforts as nuclear operatorsand expectations for JANSI. Under a strong commitment to neverlet an accident like the Fukushima Daiichi Nuclear Power Station
Accident occur again, we, nuclear power operators, have been autonomously andcontinuously improving safety beyond what is required in new regulatory requirements
in recognition of the unique characteristics of and risks associated with nuclear power
generation. We are also making further efforts to improve safety of nuclear power
stations through collaboration with JANSI and other external organizations. The nuclear
industry as a whole will continue to look for our weaknesses and challenges and makecontinuous improvements.
Last February, an incident related to nuclear security occurred at TEPCO Holdings. We
took it very seriously that such an incident should not happen, and measures to address
the incident promptly began among all operators. Specifically, mutual reviews are
conducted among operators involved in physical protection work as an effort to learn
from external parties and incorporate such learning into improvements, and safety
culture fostering activities not limited to physical protection are continuously being
improved. JANSI has assessed the effectiveness of the self-assessment process forsafety culture at each operator in the efforts for continuous improvement of safety
culture fostering activities. Based on this result, each operator is currently promoting
autonomous improvement of safety culture fostering activities involving management. I
would like to ask JANSI to continue to support these efforts.
As interest toward climate change is globally increasing, Japan’s energy supplydemand structure is experiencing various changes in circumstances, such as increased
frequency and severity of natural disasters, growing risks that threaten stable energy
supply, and emergence of issues associated with the progress of electricity deregulation
including risk of fossil fuel price rising and necessity of securing supply capacity. We
need to overcome these issues. The 6th Strategic Energy Plan reaffirms the importanceof realizing S+3E at the same time as the basic perspective of energy policies. In orderto further promote S+3E which is the basis of energy policies in Japan, we nuclear
operators need to regain trust from the siting region and the public and steadily
advance restart and stable operation of nuclear power stations, by continuing to strive
to autonomously improve safety and continuously reducing risks.
Today, we will be discussing the theme of improvement of resilience of nuclear safety
as a new perspective in operating nuclear power stations. Resilience means being
flexible, having recuperative powers and being responsive. I believe it is extremely
important for the improvement of safety of nuclear power stations to continue making
efforts with a flexible mindset instead of sticking to conventional ways. I hope to gain
many insights through the keynote speech and panel discussions.

4Lastly, JANSI has provided tremendous support including various recommendations
through peer reviews, collection and analysis of operating experience information as
well as development of various guidelines including CAP (Corrective Action Program)
etc. I would like to ask for your continued cooperation in leading us nuclear operators
to pursue the world’s highest level of excellence and aim for untiring excellence.

Guest
SpeechChairman of WANO (World Association of
Nuclear Operators)
Tom Mitchell

I would like to talk about how WANO is dealing with the situation in
Ukraine and supporting our member operators. WANO is taking a
steady but responsible approach and carefully watching over thesituation of the Ukrainian member operators. There are two WANO
member operators in Ukraine. NNEGC "Energoatom" is a Category 1
member and operates 15 Units. Specialized State Enterprise (SSE)
Chernobyl is a Category 3 member and is responsible for thedecommissioning and waste management at Chernobyl facilities.
Our goal is to support our member operators in all forms that are
realistic. On the website for the general public and website formembers, WANO has issued a message requesting there be nointerference of any kind with the Ukrainian member operators’ ability to safely performtheir work. This message is entirely aligned with WANO’s mission and focus on nuclear
safety in operation. WANO’s performance objectives and criteria (PO&C) provide highstandards to guide nuclear plant operators worldwide on safe nuclear facility operation.
WANO is concerned about external factors in Ukraine that may challenge these highstandards of operation. For example, personnel not readily being rested could
jeopardize fitness for duty, and there may be difficulties in providing necessary supplies
and spare goods to power stations. There is also the risk of inadequate supply ofelectricity for stations due to loss of offsite power.
In such situation, WANO supports the seven principles for nuclear safety of IAEA. If
these principles are properly observed, problems that threaten safe operation can beprevented. We welcome IAEA and Director General Grossi demonstrating theirleadership in the global diplomatic efforts for this problem. WANO made a publicstatement to directly support the activities of IAEA. However, we will stick to our nonpolitical position which is the key to the success of our mission.
WANO responded quickly in terms of communication. We established the Crisis
Information Centre to directly provide updated information on the safety status of
power stations and other nuclear facilities in Ukraine to the CEOs and CNOs of all
members on a regular basis. Along with regular statements published on IAEA’s
website, such updated information is considered as an extremely reliable information
source based on facts on safety at Ukrainian nuclear power stations.

5WANO was established at the peak of the Cold War, 33 years ago. We pay great
respect to the vision and courage of our founders. We would like to ask for yourpatience and commitment toward WANO’s founding principle of operators supporting
each other to achieve excellence. Since its establishment, WANO has closely cooperated
with members around the world including Japan. We enhanced our internal process in
response to the Fukushima Accident, and in recent times, we have taken measuresagainst the COVID-19 pandemic. WANO became a stronger and more cohesive
organization by having members come together to face these challenges.
And now, we are facing a similar or greater challenge in Ukraine. I hope thatmembers around the world will unite to help us address this new challenge as anindustry. I appreciate your support and commitment toward WANO’s mission. For the
next several weeks and several months, we will be facing various difficulties, but I
believe in WANO’s safety mission. Let us work together to continue fulfilling our safety
mission in a cooperative, calm and professional manner, and we shall establish a strong
structure so that we can continue to support all our members anywhere in the world.

KeynoteSpeechProfessor Emeritus,
Linköping University, Ecole des Mines deParis, University of Southern Denmark
Erik Hollnagel“Healthy, Safe & Effective Organizations: A Systemic Approach”
What is a more effective, safer organization? I would like to talkabout an approach that is different from a traditional approach.
What exactly is safety? For example, the World Health Organization(WHO) defines, “Health is a state of complete physical, mental andsocial well-being and not merely the absence of disease or infirmity.”
It is a definition that focuses not only on the absence of disease but
also on the presence of health, in other words “being” healthy. On
the other hand, various industries including nuclear power focus onsafety, but its definition is “prevention of accident or mitigation of
impact of accident.”
Safety has two meanings. The conventional definition says it is the state of “nounacceptable risks”. However, when you think in the same way as WHO, it can also be
defined as “being able to function as required under various conditions”. These aredefined as Safety-I and Safety-II. From this perspective, organizational integrity is theability to develop a common vision, work together to achieve it, and upgrade theorganization in parallel.

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When viewing a nuclear power station as one organization, it is divided into individual
departments, sections and units, which are respectively responsible for different areas.
This is referred to as stove-piped (silo), where safety, quality, human resources,
maintenance, operation, engineering and outage planning, for example, are fragmented
with their own specialists and budgets.
Exchange and coordination between departments are limited unless they are officiallyrequired. This comes from the thousands of years of our history of how we constructed
our society. In activities related to safety and quality, our long history has seen safety
becoming an issue first, then addressed, followed by the quality becoming an issue andthen addressed. This resulted in a stove-piped situation where different sections wereseparately responsible.
On the other hand, when you want to increase the productivity of the organization,
ensure safety and achieve all integrity, reliability, quality and sustainability, we must
look at the big picture by combining all features, rather than looking at each of them
individually. This is because each feature is interdependent and interrelated.
For example, should safety management, quality management and productivity
management be regarded as different systems? We need to view them as a single
system to manage a single organization as a whole. We need to understand this toresolve issues.
Humans tend to simplify a problem. However, solutions to complex problems will
always be complex. If we present a simple solution even though the problem iscomplex, such as presenting safety culture as a solution to a complex problem, it islikely that such solution will not work out. Simplifying to explain is simply an illusion
and keeps things from moving forward.
The traditional Blunt and Sharp End Model explains what determines the performanceof people and organizations and why people behave in such a way. The Sharp End isalso known as the coal phase, which refers to coal miners or people who cause or are
directly affected by failures and breakdowns in the field. According to many research
results on organizational accidents, factors of unsafe behavior include factors that are
remote (spread out) from the field, such as workplace environment, organizational
management, and traditions and culture unique to the industry. There are also cases oftime lag, where a current problem could be the result of decisions that were made longago. For example, regulation is done at the blunt end which is remote from the field,
but its impact is felt at the sharp end (field).
Let us think about safety culture using this model. INPO defines safety cultures as “Anorganization’s values and behaviors—modeled by its leaders and internalized by its
members—that serve to make nuclear safety the overriding priority.” This is anextremely simple definition that covers everything and seems to seek a simple solution
to a complex problem. However, safety culture by itself will not solve the problem. In
fact, it can worsen the problem by obscuring what is actually happening.

7One way to describe safety culture is the idea of a safety journey. In other words, it is
the idea that there are stages in safety culture. It starts with Basic (no safety culture),
and travels through the steps Reactive (responding to a problem after it occurs),
Compliant (complying with regulations), Proactive (taking the initiative) and Resilient.
Necessary elements to promote and enhance safety culture, such as shared values,
involvement of management, continuous learning, accountability and sustained support,
are often seen as individual ideas. However, if we want to improve safety culture, weshould ask ourselves three questions. The first is to know your current position. Where
are you currently and how well is it going? The second is to know your goal. Where do
you want to head? When you think about nuclear safety culture, you would certainly
want to aim for resilience. The third is means. How will you reach your goal from yourcurrent position and what kind of changes will occur? In this mindset, it is clear thatsafety culture is not a practical solution. It is easy to say that we should move fromcomplying with regulations to proactively acting on our own, but it is difficult to know
how to get there including the speed to do so.
Therefore, we may get a better understanding if we change our perspective fromsafety culture to organizational culture. Edgar Schein identifies three elements inorganizational culture. The first element is things that are created by people and areeasily visible within an organization or by external individuals. The second element isbasic assumption, or unconscious behavior that is taken for granted and underlies ourculture. The third element is advocated value, which refers to values expressed by theorganization, rules of behavior, and organizational goals. Schein says safety culture lies
where these three elements overlap. Each element is not simple, and the part where
those elements overlap (safety culture) is also not simple.
Next, I would like to talk about WANO’s 10 Traits. WANO defines the traits as,“personal and organizational traits that are present in a positive safety culture.
Conversely, shortfalls in these traits and attributes are a significant contributor to plant
events.” There is complexity in safety culture and more in its background. These are
the 10 Traits.
WANO says, “Utility managers are encouraged to make in-depth comparisons
between these traits and their day-to-day policies and practices, and to use any
differences as a basis for improvements.” This is where we need to clarify the current
position, goals and means, which were mentioned earlier. Additionally, the 10 Traits are
divided into three large categories: individual commitment to safety, management
commitment to safety, and management systems. We need to consider how thesethree categories affect each other, how the 10 Traits relate to each other, and howchanging one Trait will affect the others.

8In the end, we need think about what performance is. In the traditional approach on
safety, focus is placed on performance in the field. It means that performance is anaction by someone when given a task. On the other hand, in the systemic performance
approach, performance in the field is also observed but the perspective is different. We
observe what enables performance and what is necessary to let people do what theyneed to do or want to do, rather than what determines performance. In other words, asystemic perspective is used, not a human perspective. For example, operators in themain control room do not work alone. This means to look at it from the perspective ofwhat the organization as a system must be able to do, and what individuals andexecutives must be able to do.
In the systemic performance approach, instead of looking at only the field (micro), we
think about what would increase the likelihood of getting the job done properly at all
micro, mezzo and macro levels of the organization. We call this the systemic potential.
The concept of resilience engineering was introduced in 2004 and emphasizes notresilience itself but resilient performance. Resilient performance is that the organization
can function as required even when faced with an unexpected situation. To do so, fourthings are needed as potentials. Namely, the ability to be flexibly respond to a situation,ability to externally and internally monitor what is happening, the ability to learn fromboth successes and failures, and the ability to anticipate long-term changes in demand
and resources, as well as the effects of actions.
Taking the example of how Ukraine is defending themselves and how the Russian
military is attacking, there is a big difference in their coping capabilities. Ukraine is more
flexible in their response, while the Russian military has no oversight of what ishappening in the field as their attacks are based on a plan that was formulated longago. It is the same for the ability to learn and ability to anticipate. The entire world isanticipating what would happen, monitoring what is happening and trying to respond to
this situation. The world is also trying to learn from what is happening right now. It isan extremely tragic and unfortunate situation, but we can think about the four
potentials (responding, monitoring, learning, anticipating) from this case.
First we need to respond. If we cannot respond, we would leave both discussions andopportunities open, which will cause gradual loss of control. We also need to monitor,
because if we cannot monitor, everything that is happening will become unexpected.
The situation in Ukraine and the pandemic are no different. And we also need to learn.
If we do not learn, we will end up taking the same action all the time, which is not
good.
Resilience engineering advocates the need for the potentials to respond, monitor,
learn and anticipate at all levels of the organization. It is not enough that only theoperators should be able to do this. Middle managers, executives, the regulatory
authority and the government must also have these potentials at their respective
organizational levels. And each must respond, monitor, learn and anticipate.

9Let us think about assessment of performance potentials. Each potential must be
examined from a more specific perspective. Let us use anticipating as an example,
which is the most difficult to do. It is thinking about what explicit or implicit models of
the future look like, how far the organization is envisioning, and how much risk theorganization is willing to take. We can grasp our current position by asking specificquestions about each potential, such as whether we respond to a crisis after it occurs orwhether we do it normally.
Systemic Potentials Management (SPM) explains the potential to respond, monitor,
learn and anticipate, in detail, and raises detailed questions about each potential.
Specific questions can be identified for a specific organization based on these detailed
questions. The questions raised here are only general, so they need to be changed toquestions that are more specific to the organization. And they must be more diagnostic
and more formative. The answers to these questions can be used as a basis for making
decisions about how to respond and what to do. When we think about a question, wemust be able to do something with the answer. If we are not going to take action fromthat answer, it is meaningless to ask the question in the first place.
Answering these questions will represent the current situation. For example, questions
about the potential to respond include a list of events to see what kind of events can beaddressed, as well as important items such as whether there is a rule about when tostop addressing an event, whether they were verified and whether they can beaddressed for a long period. Other questions include how quickly an event can beaddressed, how many measures are prepared, what the threshold for addressing theevent is, what the appropriateness of the action is and what the background is. These
questions will receive detailed answers, which are plotted in the radar chart. By asking
the same questions after a while and creating another radar chart, it lets you see where
your current position is and how it has changed from the previous chart. It also lets you
determine if the change is headed in the desirable direction. It means you can use theradar chart as a basis to grasp your current position and determine how you shouldchange.
It can also show the goal you want to reach. After showing what the current situationis, managers and executives can indicate how far they want to go and how far theywant to stretch the organization about the same item.
People may dislike complex answers, but we need to acknowledge that we need toprepare complex solutions for complex problems. I have seen actual examples at manyorganizations for many years. We can do something about organizational performanceand build a safe organization. However, to achieve this, it is not enough with theconventional view that “safe equals accident-free”.
I introduced the concept of resilience engineering, which is the ability to perform therequired actions in any situation. “The Systemic Potentials Management” report is about
air traffic control and not nuclear power, and is available at the SKYbrary website(https://skybrary.aero/sites/default/files/bookshelf/32380.pdf). Please take a lookwhen you have a chance.

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PanelDiscussion
Theme:“Enhancement of Resilience in Nuclear Safety- New Perspective for Plant Operation -”Chairperson:
Kyoko Oba: Deputy Chief Engineer, Japan Atomic Energy Agency (JAEA)
Associate Professor, Nagaoka University of Technology
Panelists:
Erik Hollnagel: Professor Emeritus, Linköping University, Ecole des Mines deParis, University of Southern Denmark
Jacques Regaldo: Senior Vice President, EDF
Former Chairman of WANO (World Association of Nuclear Operators)
Kazue Nakajima: Executive Director, Japan Organization of Occupational
Health and Safety
Visiting Professor, Osaka University Faculty of Medicine
Keisuke Nagai: Director and President, Shikoku Electric Power Company
Hiromi Yamazaki: President & CEO, Japan Nuclear Safety Institute (JANSI)

Chairperson:
Deputy Chief Engineer,
Japan Atomic Energy Agency (JAEA)
Associate Professor,
Nagaoka University of Technology
Kyoko Oba
The theme of this panel discussion is “Enhancement of Resilience in Nuclear Safety New Perspective for Plant Operation -”. Resilience engineering has been discussed since2004, mainly by Dr. Hollnagel who just gave the keynote speech, and was published in2006. It was introduced to Japan, thanks to the efforts of Emeritus Professor Masaharu
Kitamura of Tohoku University and Professor Akinori Komatsubara of Waseda University.
The viewpoints and importance of this concept have been shared due to the Fukushima
Daiichi Nuclear Power Station Accident that was caused by the Great East Japan
Earthquake in 2011. However, I think it is a common perception that there is still a long
way to go in terms of whether it has reached the point of implementation based on thisconcept and understanding of importance. Today, I hope we can give participants
something to take home by asking for your opinions from the perspective of resilienceengineering toward achieving a higher level of nuclear safety while facing the current
situation.

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Short Speech:
Senior Vice President, EDF
Former Chairman of WANO (World
Association of Nuclear Operators)
Jacques Regaldo
Today, I would like to explain defense-in-depth of organizationaland safety culture at EDF. Since the Three Mile Island Accident in
1979, EDF has adopted various programs, and has considered nontechnical aspects or human factors in doing so. One of these is theestablishment of an independent safety department. This has taken root asorganizational culture for several decades and enables efficient monitoring of safety
culture to this day. Additionally, experts on human factors are stationed at power
stations, who analyze human factors and safety culture.
From around 2019, we decided to systematically implement further activities at eachpower station. This is because safety culture may be one answer but is too simple tobecome the answer to a complex problem, as Dr. Hollnagel has also said. Therefore,
we developed a multi-year safety roadmap four years ago, and adopted the action ofdiagnosing safety of each power station on-site every year and discussing it with Head
Office.
In creating the roadmap, we take into account internal and external input. For internal
input, a safety awareness survey is normally conducted every two years in oddnumbered years. This is based on WANO’S 10 Traits. The survey is subject to all station
staff, sometimes including permanent contractor personnel, and can grasp both positive
and negative trends at the power station. In even-numbered years, self-assessment isconducted for managers at the power station. This focuses on three categories:
leadership, development and involvement with staff, and management and sustained
improvement. The received feedback identifies the strengths and weaknesses of thepower station. We create a roadmap with such input, and each action indicated in theroadmap is put into practice after decision-making. Additionally, the safety diagnosis is
implemented every year. The power station and Head Office hold discussions at theexecutive level based on this diagnosis. They discuss the results of internal assessments
and internal reviews and also discuss how they can be utilized in the roadmap.
Opinions from external parties are also utilized. For example, data form experts onhuman science, as well as other external sources, are taken in. There is also an internalorganization that conducts an audit known as nuclear inspection. Each power station
undergoes an internal comprehensive safety evaluation and WANO peer review every
four years, and their differences are also discussed. In this way, EDF is working toincrease resilience in safety culture as an organization, while also making use ofopinions of external parties including WANO.

12Executive Director,
Japan Organization of Occupational Healthand Safety
Visiting Professor,
Osaka University Faculty of Medicine
Kazue Nakajima
I am going to talk about how psychological safety and teaming are necessary for an
organization to demonstrate resilient performance. Today, resilience is a topic ofinterest in healthcare in Japan, particularly in safety and quality management as well asteam or organization management.
How a complex system is controlled varies among workplaces. For example, in theautomobile production line, the company builds the work environment with a top-down
approach to pursue work efficiency, where people demonstrate standardized
performance. On the other hand, health care settings have constant changes and many
constraints, characterized by unpredictability and uncertainty. People demonstratebottom-up, autonomous, goal-oriented and flexible performance through agility andteamwork. Many workplaces are located somewhere between these two ends. More
important is that any business is a complex adaptive system that functions in thechanging environment under constraints.
There are two approaches to understanding how a complex system functions. An
analytical approach attempts to understand the parts of a complex system (biologicalsystem, for example) by reducing it to its components. A synthetic approach attempts
to understand and reconstruct what characteristics of the whole system arise frominteractions among its components. In safety management, an analytical approach wasconventionally used, where a failure that occurred in a system such as a team and anorganization was explained by the performance of its components, specifically byadding up poor performances of individuals or machines (Safety-I). In contrast, a
synthetic approach based on resilience engineering theory unravels the mechanism ofresilient performance by a team or organization by focusing on interactions between
individuals or systems to make things go well (Safety-II).
Resilience refers to the characteristics of a system that can successfully adapt to andcontinue to function in a disturbed and constrained environment. It can be calledsustainable adaptability. In a resilient system, flexibility, autonomy, efficiency, andextensibility are observed. In a resilient organization, teaming is often demonstrated.
Teaming means that people who do not usually work together gather acrossdepartmental and professional boundaries to collaborate and improvise teamwork
according to the situation, unlike teams that train together with the same members likea sports team. Psychological safety and someone who bridges boundaries, known as aboundary spanner, are essential to make this happen.
Let me give you an example of teaming in a hospital setting. A patient suspected ofaortic dissection and urgently admitted to cardiovascular surgery developed severe
anaphylactic shock during a contrast-enhanced CT scan. Even worse, the patient went
into difficulty securing the airway necessary for lifesaving measures and was finally
saved and treated. A few days after the medical intervention, aortic dissection was
suspected again. Another contrast-enhanced CT scan could cause the same criticalsituation. There was a high possibility that he could not be saved in that case. On theother hand, when the scan was not provided, an appropriate treatment plan could not
be developed to save his life.

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The attending cardiovascular surgeon consulted the patient safety doctor, who wasfamiliar with the hospital resources and specialized in emergency medicine. He
proposed to perform the CT scan in the emergency department, not in the CT room of
the radiology department for planned CT scanning, with support from a radiologist andnurses of the emergency department and an anesthesiologist and a pharmacist in theoperating room. However, everyone hesitated. Then, he asked the radiologist, thenurses, the OR pharmacist, and the anesthesiologist what they were concerned about
and how they were truly feeling, and acted to mitigate these concerns. This process
fostered to form psychological safety, leading to teaming. They were confident thatthey just had to perform their tasks as usual within their scope of responsibility, which
resulted in achieving the goal safely.
Psychological safety does not mean a comfortable and friendly atmosphere. It is aworkplace environment where each staff member can speak up without hesitation tovoice concerns or different opinions, ask for help and openly discuss failures. It is kindof a catalyst for a chemical reaction known as teaming. Psychological safety is an
essential requirement for teaming because it promotes collective learning. To take risks
and challenge a goal in unpredictable and uncertain high-stake situations, everyone
should share their opinions and wisdom, find robust solutions, and make corrections
while doing. These interacting processes bring about effective team performance.
The role of a leader is vital in shaping psychological safety. In particular, work shouldbe framed as "a place for team learning." Work is not routine operations in a fixedmanner. The leader also needs to encourage team members to speak up by asking
various questions to avoid staying quiet. In this clinical case, the patient safety doctor
connected various departments and experts in the hospital as a boundary spanner andresolved actual concerns and questions of the people involved, thereby generating
psychological safety.
Fostering interactions between people and departments are needed to demonstrate
resilient performance and the integrated strength of a team or an organization, whileconventional staff education focuses on improving individual performance andcompetency.
In FY2020, being so busy and stressful during the COVID-19 pandemic, theDepartment of Nursing at Osaka University Hospital conducted training incorporating
resilience engineering theory in nursing management. The purpose was to change themindset of nurse managers. The goal was to understand how people achieve their work
under changes and constraints to enhance the resilient performance of a team, rather
than identifying the poor performance of individuals in failures and improving
compliance. Based on the cases brought by each nurse manager, group discussions
were held focusing on how their work was achieved, paying attention to disturbancesand constraints in their work environment, looking at the system broadly, and having
interests in interactions between the people or the departments. Then they sharedfindings in their discussions and exchanged their opinions. The post-training
questionnaire found many positive words in the free comment, such as ties of people
and relationships between departments, change in the mindset of safety, pride for theorganization, joys in work, etc. That may indicate that the purpose of the training wasachieved.
In summary, the formation of psychological safety and boundary-spanning leadershipcan enable the team and organizational learning, leading to demonstrating team andorganizational resilience.

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Director and President,
Shikoku Electric Power Company

Keisuke Nagai
I would like to introduce our initiatives to enhance organizational
resilience at Ikata Power Station. Currently at Ikata Power Station,
Units 1 and 2 are in decommissioning and Unit 3 is in operation.
Ikata Unit 3 restarted its operation in August 2016 after achieving
conformity with the New Regulatory Requirements. It is now in its
3rd cycle after restart. In October 2021, use of specific major accident response
facilities began, which completed the series of development of hardware and software
for the New Regulatory Requirements. This means we have shifted from the phase ofachieving conformity with the New Regulatory Requirements to the phase of enhancing
organizational resilience upon brushing up past developments. Today, I would like tointroduce three initiatives deeply related to “Anticipating” capability which is one of thefour basic skills of resilience.
The first initiative is the utilization of enterprise asset management (EAM). In order to
optimize overall equipment maintenance work such as daily maintenance and outage,
Ikata Power Station introduced EAM for all of its group companies in FY2008 ahead ofother companies. This allowed various information related to work management andother station operations to be shared in a timely manner with everyone involved anddrastically improved the transparency and reliability of work. Activities to widely collectproblems that may affect the quality, analyze causes and take corrective actions (CAP)
are developed using EAM, and any employee or group company employee is able toinput findings from the field into the system. In the daily screening meeting, input
information is determined whether it will affect nuclear safety (CAQ), and activities are
implemented accordingly. Highly transparent work execution and information sharing
through utilization of this system are the basis of organizational resilience at Ikata
Power Station.
The second initiative is the establishment of the Process Control Section. This is anorganization whose purpose is to review work plans developed by the section in charge
from an independent standpoint and check its validity. Rather than simply doublechecking work procedures, the Section conducts reviews focusing on risk-critical workfrom a risk management perspective that examines what kind of action should be taken
if an accidental failure during work or other unexpected situations occur, and proposes
improvements as necessary. This contributes to improving and enhancing anticipating
capabilities.
The third initiative is top leadership. Since assuming the position of President, I try tovisit Ikata Power Station and other field offices for opportunities to directly talk with our
employees. We exchange opinions in small groups to share safety awareness throughtwo-way communication where I listen to the honest feelings of the employees and I
share my thoughts. Knowing the situation of the organization in real time increases
anticipation capabilities, which is also necessary for demonstrating top leadership.
There are two points for enhancing anticipating capability. The first is being able toappropriately collect many findings and information, and the second is being anorganization that can flexibly make decisions focusing on nuclear safety at all levels.
Even if the decision comes up empty, I think the culture which values the action isimportant. I would like to brush up these activities and continue to enhanceorganizational resilience.

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President & CEO,Japan Nuclear Safety Institute (JANSI)
Hiromi Yamazaki
Based on the lessons learned from the Fukushima Daiichi Nuclear
Power Station Accident, industries in Japan and JANSI have worked
to establish a culture of organizational management andcontinuous improvement that not only satisfy national regulations
but also learn from domestic and international knowledge andmake continuous improvements upon identifying problems on its own.
After listening to Dr. Hollnagel’s keynote speech, I thought about again how we canmake the most of our past efforts to establish self-regulation and autonomously
improve safety.
In addition to Safety-I, which analyzes the causes of infrequent accidents and events
to prevent their recurrence, Safety-II or resilience, which focuses on what is going wellfor the majority, that is, the ability to notice fluctuations in daily performance andmaintain functions through the management structure and appropriate human
response, gave us a new perspective.
Improvement initiatives at nuclear power stations and JANSI’s support activities are
considered to have already taken in the perspective of Safety-II and resilience, butmore consciously focusing on what is working well and the importance of resilientorganizations may give us more hints for safety improvement. We may also realize thatwhat is working well on the surface just happened to work and find ourselves in
unexpected pitfalls. It is also important to have the perspective to focus on and improve
performance and the four core skills.
We organized the initiatives in nuclear power station operations and JANSI’s activities
that support them into the four core skills. In the future, we would like to focus on what
is working better than ever in each activity, and focus on perspectives that ensuresindividuals, management and the organization effectively function as a system as awhole in each activity. We shall start out with further improvement of the effectivenessof our activities by adding new perspectives to existing activities, rather than starting a
new project.
What we need to be careful here is that the mentioned activities do not just fit into
one of the four core skills. For example, CAP (Corrective Action Program” is an activity
to report and share events that are even slightly out of the ordinary at a low threshold,
nip problems in the bud, prevent equipment failure and human errors, and identify andaddress trends of deterioration of performance by analyzing the vast number ofregistered events. This is an activity involving not only the skill of learning but all skillsof monitoring, anticipating and responding. If we add new perspectives here, we canlearn something new about near-miss cases registered in CAP by regarding them as
successful cases that did not lead to an accident based on not only its cause but also
why it was just a near miss.
Improvement of resilience requires an organization to both effectively function as asystem and appropriately maintain safety culture as its base. In particular, it isimportant to view people as a factor for working well by appropriately responding underchanging operating and environmental conditions, and not just as risk factors thatcause human errors. I believe it is important to have an environment where each
person can feel as the main character and an open atmosphere where everyone cancommunicate without division.

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Discussion:○Chairperson Oba The four panelists introduced theirexperiences and initiatives in their organizations in line withthe keyword “resilience”. First, we would like to ask Dr.
Hollnagel for his comments, and then proceed to discuss. In
the second half, I would like us to think about improvementof resilience in nuclear safety and new perspectives of plant
operations, using the keyword of psychological safety which
was pointed out by an independent review committee forthe incident on nuclear material protection occurred at
TEPCO Holdings last year.
Then, Dr. Hollnagel, were the initiatives of each organization in line with “approach ofsystematic performance” which you address? Can you evaluate each initiative byspecifically pointing out what was good and what needs to be improved, while linking
them to current position, objectives and means which you raised as challenges ofcreating and managing safety culture?
○Dr. Hollnagel Extremely interesting initiatives were introduced. Everyone clearly
understood that they need to change their perspectives. While the traditional approach
was to focus on weaknesses and risks and reduce or eliminate them, Safety-II focuses
on strengths and seeks what can be done better. I think the initiatives introduced byeveryone are conducive to this. Focus on strengths and strengthen what is working wellto make it even better. Doing that systematically and systemically is what resilienceengineering advocates. Its potentials are responding, monitoring, anticipating andlearning. However, this does not mean that we should just introduce this as one
package. It is not a simple solution but a change in our approach to establish a newperspective.
The importance of anticipating was pointed out by several people, but the future is
uncertain and no one can anticipate what the future will turn out to be. The wordroadmap was also mentioned several times. It is meant to be a map that shows theway forward, but this is too simple in some aspects. For example, when you draw apath for safety and production or long-term maintenance and servicing, there is no mapthat shows the future. That is because situations constantly change. A roadmap isbased on the assumption that the situation will not change.
Anticipating is of course necessary, and developing plans for the future are also
necessary. However, the road to the future is not on land but on sea. We must assume
that we do not know what the sea conditions will be like. There are no signposts. We
always have to know where we are, know the sea conditions, and think about how we
can move forward.
○Chairperson Oba The road to the future is on sea. This is quite intense and very
different from our perception, but it made me realize that we must think as such andprepare for it. I would like us to enhance our performance and potential to be able totake better actions in any situation from here on, so I would like to cut into some of thebarriers and problems to do so. Mr. Nagai, what did you think of what Dr. Hollnagel
said?

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○President Nagai
We have taken on conventional
approaches, such as awareness surveys, oversight, andtrend analysis of CAP, and we can evaluate thequalitative improvements made by them, but we have
had difficulty connecting them to quantitative results andit has been a problem that we are unable to makeconcrete improvements. In particular, there is achallenge of how to evaluate the actual effect of top
leadership initiative. After listening to Dr. Hollnagel, I
thought SPM would be an effective tool. I would liketo ask for your suggestions on how we can apply this to nuclear power.
○Dr. Hollnagel SPM is a systematic method. Since it is not commercially available tobe used as is, it must be adapted to individual conditions and organizations. The
important thing is to do things systematically. Therefore, management documents mustshow that a systematic approach is properly taken. It would likely be a guideline, and it
needs to be tailored to your organization and in the context of nuclear power when you
use it.

○Chairperson Oba I know that JANSI is making various efforts, but I would like to
ask you if there are any areas that you feel are lacking in order to increase resilience innuclear power sector in Japan or if there are any areas that you have noticed that need
to be strengthened, through this conference.

○President & CEO Yamazaki The Japanese industry is working to ensure that
autonomous continuous safety improvement activities take root, based on the reflectionof the Fukushima Daiichi Nuclear Power Station Accident, and the mindset of not only
management but also the field is changing considerably. By adding the perspectives ofresilience and Safety-II to these activities, I hope for the activities to further contributeto the improvement of safety
However, the concept of Safety-II and resilience in normal times itself is new to the
nuclear industry, especially in the field at power stations, so it is premature to apply it
to any new project or package. I believe that the ideas of resilience and Safety-II are
already part of our daily activities, so we should start by being aware of them andthinking about them from a different perspective. On top of that, it would be good if ourdaily improvement activities could change into initiatives that improve core skills.
It is a wonderful idea to learn more from what is working well. However, we are notusually aware of what is working well, so we must consider how to find and identify it.
For example, we regard near-miss cases not as something negative but as successful
cases, think about factors that prevented further deterioration in the analysis of thecauses of accidents, and JANSI has a bird’s-eye-view of performance of each power
station in Japan. Thus, I think it is important to start with details, such as taking up
what went well and not just what went wrong, by introducing activities that are better
than others and reflecting daily work in the field at power stations.

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○Chairperson Oba To focus on the things that went right, which is one of theactivities after the Fukushima Daiichi Nuclear Power Station Accident, is extremely
important in properly assessing what we have now and knowing our current position as
Dr. Hollnagel pointed out.
On the other hand, there is a significant gap between normal times and emergencies
in nuclear power. It is extremely difficult to judge under which circumstances andsituations resilience should be demonstrated. Dr. Nakajima, I think that even in the
medical field, it may be quite difficult in some areas to actually change people’s
behavior even if the conditions are right or we know that this is necessary. What do you
think about this?

○Dr. Nakajima The initiatives at Osaka University
Hospital that I told are not an intervention led bysomeone in a top-down way. The head nurses were
doing their best every day, but they tended to focus on
the incidents and issues and introduced many rules tosolve them. They have been wondering whether this is
the right thing to do. In such a situation, Dr. Hollnagel
visited our hospital in 2013 to give a lecture, which led
us to think that resilience might fit nursing
management and inspire them to learn more about it
and implement it even though it is difficult. The headnurses at Osaka University Hospital generally scored high in psychological safetymeasurements but felt a little uneasy in nursing management. Head nurses thought
they should know correct answers to issues raised from everyday clinical work,
providing them to the staff. In fact, there is no absolute solution, and anyone, even aleader, cannot make a proper decision alone because things are often uncertain andunpredictable in the medical field. Instead of working by the book, people in the teamshould learn together through their work, feeling their growth. The learning program in
the Nursing Department is an autonomous movement by those who are attracted byresilient performance, and we are in the middle of learning, growing and evolving.

○Chairperson Oba Dr. Nakajima mentioned earlier that psychological safety is never
simply comfortable. In addition to psychological safety, boundary spanners, people who
bridge boundaries, are catalysts for a chemical reaction called teaming, which results inincreased resilience. In Mr. Regaldo’s experience, was there a power station that wasaware of psychological safety? If so, I would like you to share with us from when that
was and what kind of effect it had.

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○Mr. Regaldo Psychological safety is obviously
important, regardless of how you describe it. It has
become recognized within the business community that
it is important that all team members work under trust
and that any questions or concerns need to be reported.
The concept is also covered extensively in WANO's 10
Traits as "Questioning Attitude," "Respectful Work
Environment," and "Environment for Raising Concerns.”
For example, EDF's power stations accept safety
awareness surveys and WANO peer reviews andincorporate the results of these evaluations into ourroadmaps. In this context, it is observed whether deviations and near misses areproperly reported. This is necessary in order to anticipate unfavorable events andimplement preventive measures.
○Chairperson Oba Next, I would like to ask Mr. Nagai. We can report what has
occurred, but at the stage where we have a concern, while we do not know if it will
actually occur, it is difficult to discuss concrete measures to prevent it. In particular,
Japan is originally known to be a society where it is difficult to express one's opinions,but how conscious is Shikoku Electric Power Company of psychological safety?
○President Nagai We often say “an open workplace.” Having an atmosphere where
people can frankly confide any concerns or worries they may have will lead to
improvements and squashing any budding risks. However, it is extremely difficult to put
this into practice.
Ikata Power Station implements very muddy activities. For example, in order to fostera sense of unity and create an environment where people can frankly discuss issues, we
engage in volunteer activities and friendly activities altogether by those who work at thestation including members of subcontracted companies. In addition, in order to resolve
the situation of being difficult to confide problems, the Ikata Forum is regularly held
where executives and the younger generation freely exchange their opinions. When I
also visit the field to talk with young workers, I have station executives leave their seatsso we can have a frank interaction. In any case, since everyone at nuclear power
station works under a very high tension, I think it is very important to create an
atmosphere where people can release this tension and say one’s opinion candidly eachother to prevent failures caused by people.
○Chairperson Oba Dr. Nakajima, from your perspective as someone who engages
in resilience in medical field, what did you think about the initiatives at nuclear power
stations described by Mr. Nagai?
○Dr. Nakajima Exchanging opinions between senior management and front-line
people, which Mr. Nagai showed in his presentation, can be a place for collective
learning and a valuable opportunity to enhance the potential for resilient performance inthe organization. I am very impressed that you have cherished and nurtured what wecannot see. And when solving systemic problems, changing information or material

20flows rather than intervening individual behavior can be workable as system thinking
suggested. Implementing the integrated information monitoring system, a system thatallows everyone to see the information just in time rather than just a few people is an
excellent intervention to change the organization's behavior.
For one more thing, Dr. Hollnagel seems skeptical about implementing predeterminedor static approaches such as programs or packages for safety management. I think thatthe nuclear industry is not a simple system that everything would go right as long as
you do this and that. Things do not proceed in a deterministic manner. Instead, thenuclear industry is a dynamic system, not static, and demonstrates safety because
people in the systems make performance adjustments under various constraints anddisturbances. In that sense, it can be better to adopt approaches in safety
management, considering the dynamic nature of your system.
○Chairperson Oba I would also like to ask Dr. Hollnagel. I understand that medical
or other fields and nuclear power have many differences in their original situation, but I
would like to hear from you if there is anything you would like to see deepened or if you
would like to reiterate this point of view, among what you have heard so far from thenuclear side.
○Dr. Hollnagel Psychological safety can also be
described as anticipation and certainty. What is theprobability of something occurring? For example, if it canbe assumed that a certain thing is bound to happen in a
relationship, then it is a safe relationship. If you can be
sure that nothing unexpected will happen with that person
and that the other person will not react in a way that you
do not know how to react to, then you have psychologicalsafety.
Nuclear safety is certainty. You ensure that problems do
not occur at a plant. The same goes for medical care. The
goal is to ensure that the treatment does not result in a bad situation, that proper carecan be given to the patient, and that the disease is cured. Various activities are carriedout and people work at all levels for this. Whether it be senior management, thepresident, maintenance personnel, or a worker, each of them tries to understand what
is going on and increase certainty by their own actions. This gives them psychologicalsafety and allows them to work with a sense of peace and serenity as individuals. When
you are psychologically unsafe, you are unable to relax, are stressful and unable toconcentrate, and have to be on constant alert. Therefore, how you achieve
psychological safety becomes extremely important.
Also, the concept of safety culture was mentioned many times, but we always missthe concept of time when we talk about safety culture. There is no perspective on how
much time we need to change the culture. To be honest, no one knows that, but theculture will not change unless it takes 10 years, 15 years or 20 years, not half a year,
several months or two years. Therefore, there is still no simple solution. It is because a
simple solution should not take so much time.

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○Chairperson Oba After hearing what everyone has said, I would like to hear Mr.
Yamazaki's opinions on actual examples of various initiatives and current problems,from the perspective of improving psychological safety of station personnel or safety
culture.
○President & CEO Yamazaki Psychological safety isessential not only for resilience but also for an
organizational culture that contributes to safety.
As Mr. Regaldo said, psychological safety is not a single
item, but a combination of various factors, such as
leadership, communication and work environment, that
ensure psychological safety.
JANSI provides opportunities for just CEOs or CNOs togather and discuss their efforts and concerns about
fostering safety culture. When we had a discussion
among CNOs the other day, there was something thatmade a lot of sense to me. While knee-to-knee
discussions with the person in charge at the power station can be effective in increasing
psychological safety, we should not just listen to it and end it there. Feedback, where
you organize the opinions that come up, communicate your thoughts, and take
immediate action on those that need to be addressed, increases psychological safety.
Conversely, not doing so feeds learned apathy.
Additionally, the system for psychological safety must be designed to reinforce it in
the work done in the field. For example, in the CAP, you are asked to report various
items that you notice. You need to clearly indicate to station workers and contractor
staff that it is the station’s expectation to immediately report it and share it within the
power station if they notice anything out of the ordinary. It is also important that thesystem is designed so that those who give the report are recognized and appreciated,even if it is a failure or human error event as reporting them contribute toimprovement. Feedback is important here as well, and if appropriate action is taken,
such as commending the reporter for an important report and making it visible that thereported content, including its details, is utilized for improvement, it will increase thestaff’s sense of participation and foster psychological safety.
○Chairperson Oba Lastly, I would like to ask Dr. Hollnagel, Mr. Reglado and Dr.
Nakajima to give a word of encouragement to the Japanese nuclear industry in its
pursuit to increase resilience. Followed by Mr. Nagai and Mr. Yamazaki to say a few
words of their determination to pursue enhancement of nuclear safety.
○Dr. Hollnagel I feel that changes are evidently occurring right now. We found thatthe essence of resilience engineering, which is to take a good look at what is going welland well done and move in the direction to further enhance them, rather than justfocusing on failures and what is not going well, is not only recognized but actually used
in a very practical way.

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○Mr. Regaldo Nuclear safety, safety culture and psychological safety, which we
discussed today, are not new concepts, but they have made very significant progress.
For example, after the Three Mile Island Accident, we understood that human errors
can accumulate, and we have tried to address human factors and find answers. Later,
the term "safety culture" emerged and tools were developed to measure it. This isbecause it will lead to improvement if it can be measured. This is a good trend and I
think we are moving in the right direction.
However, we want to reduce uncertainties as much as possible, and progress stillneeds to be made. In my experience, it is a very meaningful and useful discussion to go
in depth and raise objections when there is a discrepancy between a plant's selfassessment and WANO's peer review observations. There is no end point to these
efforts, but I think we have seen a great deal of progress over the past 10 years or
more.
○Dr. Nakajima I learned a lot today. As Dr. Hollnagel pointed out, conventionalsafety management viewed humans as dangerous beings that cause human errors, but
new safety management by systemic approach views humans as sources that produce
resilient performance of the team or organization. This is what we exactly saw in the
response to COVID-19 by us in the medical community.
It was important for everyone's performance to be well synchronized without
dissonance. The first thing that supported this was the morale of the staff in the field.
The second was that various experts in various departments were teamed up acrossboundaries, with psychological safety and a clear goal to save patients’ lives. The thirdis inconsistency. Generally it is thought to be a bad leadership, but implementation of
anticipating, monitoring, responding and learning as mentioned by Dr. Hollnagel today,
had to be done under the inconsistent conditions responding to COVID-19. I believethese three things is an important aspect that is common across varieties of industries
for resilient performance of organization.
○President Nagai Ikata Power Station has completed the series of actions for the
New Regulatory Requirements and has entered a new stage. In order to further
increase safety and security, I realized the importance of strengthening organizational
resilience, lowering psychological barriers and incorporating Safety-II in addition to
Safety-I to address safety in a more relaxed manner. Since it is not easy to do this on
our own, we would like to have JANSI and other third parties come to the site and give
recommendations, so that we can enhance our existing efforts to further address safety
and security.
○President & CEO Yamazaki Resilience and Safety-II, which we discussed today,
are still new concepts for the Japanese nuclear industry. Rather than aiming to
implement them in the field right now, I think we should start out by using today's
discussion as an opportunity to take another look at our work from this new perspective
and focus on what is working well with the four core skills as keywords.

23

Lastly, in the workshop for head nurses presented by Dr. Nakajima, there very
positive comments from the participants saying, “We may be able to find a different
improvement measure under Safety-II,” and “It makes me happy to hear about
examples that are going well.” I felt that the perspective of focusing on what is going
well, rather than only on the failures, provides new insights in the field.
○Chairperson Oba For those of us who are used to thinking of nuclear safety interms of implementing hardware measures, fostering safety culture is a difficult task,
but today I could understand once again that we must not seek simple solutions but
rather work with the assumption that it will take time. We also conduct various
questionnaires and interviews to try to understand the state of safety culture, but fromthe viewpoint of whether we are giving feedback, furthermore, asking specificquestions, requesting specific answers and leading to specific actions based on them,
we need to rethink it. This is new perspective of station operations.
I would like us to focus again on psychological safety and properly evaluate what weare doing now. New good activities might be found when viewed from the perspectiveof Safety-II. I hope we can apply them to our future safety enhancement includingthese points.

Closing
Remarks

President & CEO,Japan Nuclear Safety Institute (JANSI)
Hiromi Yamazaki

In today’s conference, we focused on organizational culture that
contributes to safety, held discussions with domestic andinternational experts and deepened understanding, and envisioned
future activities to improve resilience of nuclear power stations. The
conference was unfortunately held mostly in online style due to therecent COVID-19 circumstances. In such situation, we hadoverseas guests who gave a lecture or participated in thediscussions early in their morning, we had panelists who came tothe venue despite the COVID-19 circumstances, and we had
approximately 600 participants in Japan and from overseas. I
would like to thank everyone for all of this.
Ideas of Safety-II and systemic approach, which were introduced in the keynote
speech and discussions, are very attractive as it gives us a new perspective, but I
believe we in the nuclear industry are still in the process of developing a concrete
theory. I hope today’s keynote speech and panel discussion became an opportunity for
you to gain many new insights to improve nuclear safety and organizational resilience. I
hope they will be utilized in your own way.
JANSI will continue to lead autonomous continuous improvement activities ofoperators and respond to their requests as a self-regulatory organization in theindustry. As the organizer, I would like to express my deepest gratitude to everyone
who participated in this conference.

This document was prepared under the responsibility of Japan Nuclear Safety Institute(JANSI). Honorifics have been omitted.

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