JANSI Annual Conference 2022
Responses/Opinions Given to Comments and/or Questions
May 11th, 2022

JANSI’s replies, views and other comments are posted below to comments and/or questions
received in chats during the conference or from the post-conference survey.

Category

Comment/Question

Response/Opinion from JANSI (or Presenter)

Keynote Speech “Healthy, Safe & Effective Organizations : A Systemic Approach”
Question

Question for Dr. Hollnagel
Is the process from “reactive”
to “resilient” linear? I personallyfeel there are occasional, yetmajor, gaps along the way thatcall for phase transitions. What
are your thoughts? I think aparticularly significant qualitative gap exists from the“compliant” phase and beyond.
Do you have any importantpractical points as to going past
the gap and advancing further?

Thank you for your question. We received thefollowing reply from Dr. Hollnagel.
The difference between a “reactive” (Safety-I) and“resilient” (Safety-II) approach is mainly a change or
extension of perspective. Being reactive means thatthe emphasis is on avoiding that something goes
wrong. The rationale for that goes back to Heinrich(1931) who wrote that “the cure of a given
troublesome condition depends primarily uponknowledge of its cause and the elimination, or at least
the mitigation, of that cause”. Being resilient meansthat the emphasis is on how to ensure that the system
can perform as required. This means that attention
must be paid to all operations, and not just those thathave failed.
In my view, the problem is therefore not so muchgaps or obstacles in a (linear) progression from one
state to another (from “reactive” to “resilient”), butrather that it can be difficult, for a person or an
organisation, to change how to look at things and how
to deal with them. It requires taking a step away fromcertainty and routine into something that seems
uncertain and where the comfort that lies in doing
things “as usual” cannot be guaranteed. There is anunderstandable reluctance and resistance to do so.
One solution is to avoid a big jump or change andinstead do it in smaller steps. For instance byconsidering carefully what compliance actually means,
and whether there really is a balance between theadvantages and disadvantages.

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Comment/Question

Question

Question for Dr. Hollnagel
I do agree on the need toevaluate systemic potential fromfour different perspectives thatlead to specific action, butshouldn’t we also look at relationships within an organizationthat can allow for them to coexist? That, I believe, is the cruxof an organizational culture thatmakes it possible to adapt wellto complex issues. Can you
share your thoughts?

Question

Question for Dr. Hollnagel
Your definition on performance was interesting. At INPO
and WANO we have said that
performance = behaviors +results. We use this often in
helping frame our opinion for an
overall assessment or grade ofperformance. In light of yourpresentation we might conclude
it is overly simple and therefore
not that useful. What thoughts
do you have on this alternate
definition of performance?
Thank you.

Response/Opinion from JANSI (or Presenter)Thank you for your question. We received thefollowing reply from Dr. Hollnagel.
It is absolutely necessary to look at the potentials
together. It is also necessary to look at the various
concerns and objectives (safety, productivity,
reliability, etc.) together rather than one-by-one.
Unfortunately nearly all models are expressed in termsof separate parts or elements (the sharp-end, bluntend; the levels of safety culture; Edgar Schein’s modelof organisational culture; WANO’s 10 traits) and wetherefore tend to pay more attention to the parts thanto how they relate to or depend on each other. The
methods that go together with these models usuallyalso fail to pay sufficient attention to the relations, but
focus on the parts in more or less splendid isolation.
In order to look at the relationships, systems should
be described in terms of their functions rather thantheir structures (physical or organisational). There are
fortunately good ways of doing that, ranging fromForrester’s system dynamic models to the Functional
Resonance Analysis Method.
Thank you for your question. We received thefollowing reply from Dr. Hollnagel.
In the sciences, for instance psychology, it has neverbeen easy to agree on the difference between
performance and behaviour. In relation to nuclear
safety, behaviour describes what humans do (asindividuals, and often relative to social norms)
whereas performance describes how the system,
humans plus technology plus organisation, functions
and how well it is able to achieve the intended goals.
Behaviour is what people do when faced with a task,
while performance is what a system should be able to
do to remain in control.
In the operation of an NPP it is necessary to pay
attention to the process, to how things are done, in
addition to paying attention to the results. (The latter
leads to a reactive approach.) But understanding andmanaging the performance of a system, of an NPP,
cannot be accomplished by looking only at the parts,
e.g., human behaviour. In line with the issues raisedin question above in this page, it is necessary to beable to understand system performance in its many
details and to manage these together. Resilient
performance has been defined as the ability of anorganisation to function as required under expected
and unexpected conditions alike. This requires achange in perspective (cf., question in page 1) andusing an alternative definition of performance may
contribute to achieve that.

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Comment/Question

Question

Question for Dr. Hollnagel
I understand that technicalresilience supported by margin,
tolerance and buffering capability and embedded in the plantsystems and components would
be the basis of human andorganizational resilience that ismainly discussed today. How doyou think about mutual chemistry between technical resilienceand human & organizational
resilience, and how can we
optimize this chemistry withwhat specific actions?

Comment

I felt the messages are clear andpersuasive based on his experiences.

Comment

I became painfully aware it isinsightful that the word that acomplex problem will not be
simplified even if it is disguised
as a simple one.

Comment

Although the presentation was
highly suggestive, I felt it wasdifficult to understand how I
should take actions concretely.

Response/Opinion from JANSI (or Presenter)Thank you for your question. We received thefollowing reply from Dr. Hollnagel.
Since resilient performance means the ability tofunction as required under expected and unexpectedconditions alike, it is not really necessary to think ofresilience as a quality or as something that a system(or a part of it) has. Resilience is rather somethingthat a system does, i.e., that it characterises a certain
type of performance. The materials of technicalsystems can be physically resilient, although this is oflimited interest today. Technical systems can also tosome extent be functionally resilient because they
may be able to adjust there functioning to theconditions. (This is something that may become more
important in the future if and when artificial
intelligence migrates into technical systems.)
It is better to focus on the resilient performance of
the whole (socio-technical) system, than on theresilient performance of the parts (plant systems andcomponents, humans, the organisation) and to try tounderstand how the system functions as a whole. The
suggestion of the four systemic potentials (respond,monitor, learn, anticipate) is a way to do that. Eachpotential will require the combined efforts of humans,
technology and organisation but unified rather thanfragmented. The four potentials must also be
considered together rather than individually, as
discussed in relation to question listed above in page2.
Thank you for your comment. So that the conference
meets everyone’s expectations, we will strive toenrich content through appropriate planning andsmooth administration.

Thank you for your comment. We will take thecomments voiced into consideration in planning andadministering future conferences as we strive tofurther enhance and improve conference content.

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Category

Comment/Question

Response/Opinion from JANSI (or Presenter)

Panel Discussion“Enhancement of Resilience in Nuclear Safety
Question

Question for Mr. Regaldo
How does EDF integrate ASN's(the French nuclear safety
regulator's) assessment of NPP
performance in the areas of
nuclear safety and safety culture
into its Roadmap on slide 4?

Question

Question for Dr. NakajimaYour presentation gave me
good insight into the importanceof boundary spanners. To
efficiently perform in a nuclear
power station, where tasks
range from operations andmaintenance to radiation control, boundary spanners canserve significant roles. How can
we develop such leadership?
Can you give us some suggestions with an example in healthcare settings?

- New Perspective for Plant Operation -”Thank you for your question. We received thefollowing reply from Mr. Regaldo.
The French Nuclear Safety Regulator (the ASN),
usually doesn’t carry out systematic and periodical
safety culture assessment. Most of its inspections arefocused on specific topics or are following significant
nuclear safety events. When a thematic inspection isdedicated to nuclear safety or interventions reliability
management, of course, we take into account thelessons learned and recommendations. These external
inputs were not figuring in the drawing of slide 4,
because this slide was figuring a simplified process andbecause these inspections feedback are notsystematic.
Thank you for your question. We received thefollowing reply from Dr. Nakajima.
I think it is necessary to communicate this term itself
and its concept and significance using various
opportunities (training, meetings, etc.). For example,
a single patient safety manager (generally the headnurse) is usually assigned at a Japanese hospital.
When examining measures for incidents reported byvarious professionals at the hospital, you get stuck if
you think you have to find a solution all by yourself.
On the other hand, if you know people that may comeup with a solution, call out to them, and gather theirknowledge, you can find countermeasures or inspiration.
“What I am doing is boundary spanning (bridging
people or departments to achieve a goal and solve anissue, and promoting coordination and team learning
across boundaries).” “It is a trait of good leadershipand an important role for demonstrating organizational resilience.” By being aware of these, a patient
safety manager can work with confidence, which
results in flexible and autonomous performance fromthe bottom-up as an organization.
Rather than developing boundary spanners, there
are many of them already in the organization, butpeople who can fulfill that role are different dependingon the issue or case. I think it is necessary to give aname to such kind of leadership (to be a hub for crossboundary working and human networking) andpromote and approve such behavior.

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Comment/Question

Question

Question for Dr. Nakajima
On page 17 of Dr. Nakajima’s
slides, it says, “learn fromsuccess to improve resilience.”
Please share with us how you
focus on successful cases. Is
there any threshold that defines
success, or is it randomly
sampled?

Response/Opinion from JANSI (or Presenter)Thank you for your question. We received thefollowing reply from Dr. Nakajima.
That is a good point. In Professor Hollnagel's
resilience engineering theory, it is important how you
express this word which is expressed as "everyday(clinical) work" or "things that go right." In Japanese,"success" means successful cases or gives an image ofa specific event, but here, it means "a vast number ofdaily operations" that is not an adverse event orincident. He said that it is difficult to be expressed in
one word.
Furthermore, the Swiss cheese model, which is anaccident model that has been used in conventionalsafety management, is a linear model (for example, it
is explained that an accident occurred due to an
additive result of an error by A, lack of confirmation by
B and failure of equipment C), but resilienceengineering theory is based on a non-linear model
where success and failure are equivalent. In otherwords, we believe that things go well thanks topeople's performances adjustment, but when thisadjustment (=variability) of performance, which isessential and inevitable for such work, causes nonlinear functional resonance, it becomes an accident.
Therefore, although it says "learning from success,"
precisely speaking, "how everyday work is performed"
is a subject to be learnt. However, from an outcome
viewpoint, adverse events are a few, and theremaining cases are significant in number. That is why
it is expressed as "learn from success."
Now what to focus on when practicing this approach.
I will share an example from our hospital. Responding
to an incident of pharmacists dispensing oral
medications to a hospitalized patient, Safety-II,proactive safety management was introduced. We
focused on the "process of administering oral
medications to inpatients," which is a frequent daily
operation, instead of Safety-I which implements"identifying causes of human errors and improving
compliance for prevention." Systems involved in thisprocess were broadly looked at, specifically,
understanding how pharmacists and nurses adjust
their performance in an environment with constraints(limited number of pharmacists and time available fordispensing) in the process of physician prescription
order → pharmacist dispensing → drug transportation
to inpatient wards → ward nurse distributing drugs to
inpatients. Then we identified systemic problems
arising from their interactions and implemented
fundamental solutions instead of patchy measures for
symptomatic problems.
The short answer to the question, "what is focusedon" is that we focus on highly frequent daily
operations. Its purpose is to understand people's
performance adjustment and their interactions forachieving their goals and proactively manage thesystem so that things go well (achieving the intended
goals under perturbations and constraints).

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Category

Comment/Question

Question

Question for Mr. Nagai of
Shikoku Electric Power
Company

Comment
Comment

Comment

Comment

Comment

Ikata Nuclear Power Station’s
establishment of its Process
Control Section was interesting.
I would also like to know what
your evaluation is as to sections
in charge of work becoming
dependent on such crosssectional groups and negatively
impacting organizational culture.
I could get the new perspective
to share with my teammembers.
I felt that the departure fromcurrent nuclear situation wherecompliance is extremely emphasized is the goal for us tohead from now.
I was impressed by the speech
on medical field. In order tocreate a more open workplace,
I took a hint to improve
effectively.
Facilitation of the chairperson
was natural, so I could receive
panelists’ messages comfortably.
Presentation on psychologicalsafety and teaming was so
informative.

Response/Opinion from JANSI (or Presenter)Thank you for your question. We received thefollowing reply from Shikoku Electric Power Company.
The sections in charge of work shall gain approvalof the manager upon improving and confirming thework procedure such as incorporating items from theprevious work or other work into the work procedure.
Thus, we do not think they are dependent on theProcess Control Section.
If the review of the Process Control Section finds
insufficiently reviewed work procedures, the Process
Control Section will alert the sections in charge ofwork to take appropriate actions.
Thank you for your comment. So that the conference
meets everyone’s expectations, we will strive toenrich content through appropriate planning andsmooth administration.

OthersComment

Comment

Comment

It was said that the materials
can be downloaded from thelinked one, but I couldn’t
because the security system of
my company was severe.
I viewed online via webex, but I
took time to find out the reasonof trouble of sound.

Thank you for your comment. We will consider
clarification of inquiry contact and more than one
method to download materials or view online, and we
strive to further improve continuously.

I hope web conference continuously after the corona pandemic
is over.

Thank you for your comment. We will take thecomments voiced into consideration in planning andadministering future conference.

Thank you for your valuable comments and questions. We will use these for future reference as
we continue in our efforts to further improve conference content.
We have consolidated some similar comments and questions and omitted others relating toadministrative matters etc. Thank you very much for your understanding.
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