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This presentation will provide some general background

information about the field of safety culture, including what it is

about and why it is important.

This presentation also contains some of the history that led to

the development of the Safety Culture Policy Statement that

was finalized in June 2011,  followed by the key elements of the

policy statement.  [Optional: provide State’s position on the

Policy Statement].

Optional:

This presentation will also include several case study examples

from other industries and recent well known events, that have

pointed to weaknesses in safety culture as root or contributing

causes, and one where a strong safety culture contributed to a

positive outcome.  
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The term “safety culture” appears to have been first used after the Chernobyl

nuclear plant disaster in 1986.  The investigation report by the International

Atomic Energy Agency (IAEA) pinpointed “deficient safety culture" as one of

the contributing factors (see page 23 of report at http://www‐

pub.iaea.org/MTCD/publications/PDF/Pub913e_web.pdf).  From then on, the

concept of safety culture has been used more and more in safety research,

particularly in high‐risk industries such as nuclear, petrochemical, and public

mass transportation (railway, aviation), recognizing the importance of the

human element in accident and risk prevention.

Safety culture is generally considered to be a specific aspect of organizational

culture ‐‐ the organization’s shared beliefs, values, and attitudes that

contribute to ensuring safe operations.

Organizational culture is often described as “the way we do things around

here.”

Optional:  [State name] defines safety culture as “...” (if applicable).

The U.S. Nuclear Regulatory Commission’s (NRC) formal definition will be
discussed later in the presentation.

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In each organization, there are competing goals that occur at

every level of the organization.  There may be conflicting

demands from a cost and schedule standpoint, versus safety and

quality.

The organization, and its members, may face these competing

goals on a daily basis.  These decisions may occur at all levels of

the organization, not just at the top.  Each worker may

encounter his/her version of these conflicts and need to make

decisions at the local level to resolve them.  

The organization’s culture (both the intended as well as the

unintended aspects) plays a role in guiding an individual’s

decision.   The person has to weigh what he/she views the

organization is prioritizing as important (safety?  production?).

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Sometimes there is confusion regarding the difference between

occupational safety and safety culture.  

Point of clarification:

•The goal of occupational safety and health programs is to foster a safe

and healthy work environment ‐ work conditions that are free of known

dangers.

•As applied to the nuclear industry, the goal of safety culture is to

encourage values and behaviors that support the safe and secure use of

nuclear materials.
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Sources of evidence that show safety culture affects

safety performance:

• Case studies and root cause analyses of accidents and

events.

• Intervention studies where safety performance

improved after the culture was changed.

• Survey research that demonstrated that changes in

culture were leading indicators of safety performance.
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Research found support for the connection between safety culture and performance across many industries.  

Several well known events have pointed to weaknesses in elements related to safety culture as contributors.  

Here are a few examples.

Chernobyl (1986) – International Atomic Energy Agency (IAEA) report, INSAG‐7, stated, “The accident can be

said to have flowed from deficient safety culture, not only at the Chernobyl plant, but throughout the Soviet

design, operating and regulatory organizations for nuclear power that existed at the time” (http://www‐

pub.iaea.org/MTCD/publications/PDF/Pub913e_web.pdf, page 23).

Challenger (1986) – Report of the Presidential Commission on the Space Shuttle Challenger Accident stated,

“...there was a serious flaw in the decision making process leading up to the launch...both NASA and contractor

management first failed to recognize [the faulty design of its joint] as a problem, then failed to fix it and finally

treated it as an acceptable flight risk”  (http://science.ksc.nasa.gov/shuttle/missions/51‐l/docs/rogers‐

commission/table‐of‐contents.html, chapter 5).  

Columbia (2003) – The accident investigation board found a “broken safety culture” at NASA.  Board concluded

the accident was “...rooted in the Space Shuttle Program’s history and culture” (http://anon.nasa‐

global.speedera.net/anon.nasa‐global/CAIB/CAIB_lowres_full.pdf, page 184).

Deepwater Horizon (2010) – US Coast Guard’s investigation stated, “Deepwater Horizon and its owner,

Transocean, have had serious safety management system failures and a poor safety culture”

(http://www.uscg.mil/hq/cg5/cg545/dw/exhib/DWH%20ROI%20‐%20USCG%20‐%20April%2022,%202011.pdf,

page 111).

Optional – additional slide and talking points that goes into more detail about the safety culture issues involved

with Columbia can be found in the supplemental information section.
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The importance of a positive safety culture has been demonstrated by a number of significant,

high‐visibility events involving nuclear materials over the last 20 years.  Weaknesses in safety

culture were identified as root causes or contributing causes in many of these events.

NRC recognized that organizational factors have the potential to contribute to accidents well

before the term “safety culture” was introduced.  NRC’s investigation of the Three Mile Island

(TMI) accident in 1979, for example, identified management problems, not hardware problems,

as one of the principal deficiencies in commercial reactor safety.

There are links between safety culture and safety performance.

Examples by NRC licensees include loss of control of sealed sources, prostate radioactive seed

therapy performed without evaluating seed placement, and years of undetected boric acid

corrosion in the reactor pressure vessel head at the Davis‐Besse Nuclear Power Station (2002).  

The Davis Besse event led to the NRC to enhance their reactor inspection and oversight program

to better address safety culture.

Optional:  provide applicable State examples.

Because weaknesses in safety culture or a deteriorating safety culture appear to increase the

likelihood of performance problems and the consequences of those problems, both the NRC

and [State name] consider safety culture in our oversight activities.
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Expanding on the work that was done in the reactor area, in February 2008, the

Commission directed NRC staff to expand the policy on safety culture to address the

unique aspects of security and ensure that the policy was applicable to all licensees

and certificate holders. The Commission also directed the staff to increase attention

to safety culture in the materials area.

Over the course of the three‐year development period until the time that it was

finalized in June 2011, the NRC staff held a series of public meetings and workshops

with stakeholders to inform the development of the policy statement and gather a

broad spectrum of views on safety culture terminology and the traits that comprise

the safety culture concept.  The Organization of Agreement States actively

participated throughout the development process.

The Safety Culture Policy Statement recognizes the diversity of the regulated

entities.  It applies to all regulated entities including reactors, the many and diverse

materials users, fuel facilities, spent fuel shipping and storage cask vendors ‐‐ essentially all licensees and certificate holders.

The policy statement addresses what is important in a positive safety culture, but

does not address how licensees should implement the policy statement’s

expectations of safety culture in their organization.

Throughout this initiative,  the overriding direction from the Commission has been

to educate and inform the regulated community about the importance of

developing and maintaining a positive safety culture.   The NRC staff and Agreement

State partners have done that by developing educational tools and by continuing to
speak at various stakeholder forums and industry conferences.

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The next few slides will provide the key elements of the policy statement.

A policy statement is a tool used to communicate with licensees and other 

stakeholders about matters that are important to the NRC.

Policy statements are not regulations or requirements.

The safety culture policy statement is an expectation; it does not contain 

requirements that must be implemented.

So, in this regard

•Licensees have the primary responsibility for safety culture at their facilities.

•Licensees are to do what they deem appropriate for the scope of their program.

•Safety culture must be tailored to the organization.

•It is up to the organization to determine how to apply the policy statement.
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The policy statement defines “safety culture” as provided

in this slide.

“Nuclear” was added to “safety culture” because some

stakeholders felt that it was important to capture the idea

that nuclear is different.  Definition reflects input and

alignment among diverse range of participants during

development process.  

It’s interesting to note that the definition is only 32

words.  The goal was to make it simple and a definition

that everyone can understand.
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The Policy Statement describes how certain personal and

organizational traits are present in a positive safety culture.

A trait is a pattern of thinking, feeling, and behaving that

emphasizes safety.  This is particularly the case in situations

where organizational goals are actually, or perceived to be, in

conflict, such as:

•Production vs. safety – “adding these safety controls will impact

our production quotas;” •Schedule vs. safety – “we can’t afford the time to do it right; we’ll miss our deadline;” and •Cost of the effort vs. safety – “the safety controls cost too

much.”

A positive safety culture is often described as having a “safety‐ first focus.”  Characteristics of a positive safety culture include:   valuing safety over other competing goals, such as production;

conservative decision‐making; maintaining a questioning attitude; and problem identification and resolution.  

You can think of safety culture as what “someone is doing when

no one is looking.”
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The policy statement contains nine traits that are important 

to a positive safety culture.

They are in no particular order, other than placing 

“Leadership Values” first, as it is important for leadership to 

value safety in order for it to be effective.

There may be traits not included in the Policy Statement, 

that are also important to a specific organization in 

maintaining a positive safety culture.
Encourage audience to think about safety culture in the context

of their own organizations.  

•What does safety culture mean to them?

•What does it look like in their organization (e.g., policies,

procedures, attitudes, behaviors, etc.)?

•How is safety being communicated and demonstrated as a

priority (or is it)?    

Conditions that could potentially signal a weak safety culture

include:

• A management team that stresses productivity over safety.

• A maintenance department that allows backlogs to add up.

• Supervisors who do not provide adequate oversight of safety‐

significant actions.

• Employees who proceed even when uncertain and do not

raise concerns.

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Safety culture is not limited to the nuclear industry.  It is being discussed in an increasing number of sectors.

The fields of safety culture and organizational culture are evolving, and we continue to learn more, both from

positive and negative outcomes.  There has been growing interest from all types of industries and organizations

and an increase in sharing across specialties.

In conclusion, safety culture is a continuous journey.  It is a living, evolving concept. It is not an end goal that can

be checked off, or something static. It is always changing, and a positive safety culture is implemented differently

by different organizations.

Encourage audience to view the details through their “safety culture lens” and consider how elements of safety

culture applied or played a role, as they read more about the events discussed in this presentation and others

that may be happening in the news in the upcoming months.  

Encourage audience to move forward together with collective efforts to enhance safety culture.  Share insights

on how to establish and maintain a positive safety culture and to work with each other, their safety managers,

and other organizations in educating and engaging on safety culture.  In this way, we will facilitate a “safety first”

focus and our shared commitment to safety.

End with the following quote from NRC Chairman Macfarlane, in a speech she made on Sept 17, 2012, related to

the Fukushima accident and safety culture:  “there are many lessons that we must all take away from the

accident at Fukushima, but some of the most valuable extend beyond the technical aspects and are embedded in

human and organizational behaviors. Among these is safety culture. I commend the courage of our Japanese

colleagues in demonstrating critical self‐reflection and transparency so that all nations can benefit from their

experiences. By continuing to discuss the organizational learning engaged in by the operators to enhance safety

culture principles, we will all benefit from the insights gained and be able to apply them to our own operations”  

(http://pbadupws.nrc.gov/docs/ML1226/ML12261A373.pdf).  

Optional:  add in any State specific quotes or additional thoughts.

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The tools NRC has developed to facilitate safety culture

outreach are listed on this slide.  

Except for the pop‐ups, they are also available on the

website.
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Edgar Schein, a former professor at the Massachusetts Institute of Technology,

was the first to put the concept of “organizational culture” on the map in the

1980’s.

Here is a quote from him that describes the concept of organizational culture.

Highlight a couple of important points from this statement.  “A pattern of

shared assumptions...that has worked well enough to be considered

valid...and taught to new members as the correct way...”  This is a very

important point.  Some have described organizational culture as the “residue of

success.”  What has worked in the past is passed on to an organization’s new

members.  

Culture includes our values (what’s really important to the organization) and

the norms (how we do things around here).

It’s important to note that organizational culture can be a combination of the

intended (i.e., what the organization formally has in place and states its values

and beliefs are) as well as the unintended (i.e., how things are really done).  

Most of the time those can be in agreement, but other times they may not.  

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Reference:  Schein, Organizational Culture & Leadership, 1992.

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What is the importance of subcultures?  In large organizations, culture

may not be uniform across all groups.  Different organizational units may

develop their own cultures, which sometimes could be different than the

culture of the larger organization.

Some of the factors that could cause these differences are variations in

type of work/profession, geography, demographics, etc.  

Sometimes subcultures can be a more powerful influence than the

overall organizational culture.  Consider a large, international

organization.  In some cases, the local culture could have more influence

on a unit in the organization, than the overall organizational culture.

It’s also possible that the culture at the local level may conflict or be

inconsistent with the organization’s broader culture.

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NASA’s space shuttle Columbia broke apart on February 1, 2003 as it returned to Earth from a 16‐day mission.  All 7

astronauts were killed. NASA created the Columbia Accident Investigation Board to investigate the accident.  The

Board presented its view that, in additional to technical failures, NASA’s organizational culture contributed just as

much to the accident.  

The report states that “organizational culture is a powerful force that can persist through reorganizations and the

change of key personnel. It can be a positive or a negative force.”

In the report, safety culture refers to an organization’s characteristics and attitudes – promoted by its leaders and

internalized by its members – that serve to make safety the top priority.

The board found that there was a “broken safety culture” at NASA.

•There was a pattern of ineffective communication, leaving risks improperly defined, problems unreported, and

concerns unexpressed.  The Board believed that deficiencies in communication were a foundation for the Columbia

accident. The system for reporting safety problems was too cumbersome and time‐consuming.  There was an absence

of authority in two key program areas responsible for integrating information across all programs and elements in the

Shuttle program.

•The Board witnessed a consistent lack of concern about the debris strike on Columbia. NASA managers told the

Board “there was no safety‐of‐flight issue” and “we couldn’t have done anything about it anyway.”

•NASA had a culture that had gradually begun to accept escalating risk, and a safety program that was largely silent

and ineffective.  

Regarding organizational causes, the Board concluded the accident was “...rooted in the Space Shuttle Program’s

history and culture.”  Cultural traits and organizational practices detrimental to safety were allowed to develop,

including: reliance on past successes as a substitute for sound engineering practices; organizational barriers that

prevented effective communication of critical safety information and stifled professional differences of opinion; lack

of integrated management across program elements; and the evolution of an informal chain of command and

decision‐making processes that operated outside the organization’s rules.

Report link:  http://anon.nasa‐global.speedera.net/anon.nasa‐global/CAIB/CAIB_lowres_full.pdf
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In April, 2010, a series of explosions occurred inside the Upper Big Branch

mine in southern West Virginia.  Twenty‐nine coal miners lost their lives in the

“largest coal mine disaster in the U.S. in 40 years.”

The company has a documented pre‐existing history of poor safety

performance. They failed to report accident data accurately ‐‐ they had twice

as many accidents as the operator reported.

The case study lists many violations of regulatory safety standards.  The

flagrant safety violations contributed to a coal dust explosion, but the

employer was found directly responsible for the blast.

The regulatory authority was also found to be at fault for failing to take action

even after the employer was found to have multiple safety violations at the

Upper Big Branch mine in 2009.

This case study provides examples of weaknesses in each of nine Safety

Culture Policy Statement traits.  A repeated theme was the fear of retaliation

by the employees and a culture of intimidation by management.

Announced in December: Record $210 million settlement.  Cited:  “Culture of

fear and intimidation” and the employer promoting a workplace culture that

“valued production over safety.”
Case study link:  

http://pbadupws.nrc.gov/docs/ML1206/ML12069A003.pdf.

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These two items (safety and corporate performance) are

not mutually exclusive and can and must successfully

coexist.  Linkages between safety culture and

performance were discussed earlier in the presentation.  

A strong safety culture demands a safety first focus

approach to business.
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In June, 2009, during the evening rush hour, a Metrorail train struck the rear of a stopped Metrorail train. The

powerful impact caused the rear car of the stopped train to telescope into the lead car of the moving train,

resulting in a loss of occupant survival space in the lead car of about 63 feet (about 84 % of its total length). Nine

people aboard the moving train, including the train operator, were killed. Emergency response agencies

transported 52 people to local hospitals.

Three of the safety culture traits in this event included:

(1) Problem Identification and Resolution:  In 2006, the National Transportation Safety Board (NTSB)

recommended that WMATA accelerate the retirement of all 1000‐series railcars, and replace them as soon as

possible with cars that have crash worthiness collision protection at least comparable to the 6000‐series railcars.  

This issue was identified and evaluated but not addressed or corrected commensurate with the potential risk.

(2) Environment for raising concerns: The NTSB found examples of a deficient reporting culture within WMATA

resulting from fear of retaliation.

(3) Continuous  learning and effective safety communication:  WMATA developed an enhanced track circuit

verification test to identify track circuits with the potential to lose train detection; however, the test was never

institutionalized and circuit monitoring tools fell into disuse, indicating that WMATA did not communicate that

hazard to all departments of the agency. WMATA developed and issued technical bulletins requiring the use of

an enhanced circuit verification test procedure; however, none of the WMATA technicians interviewed as part of

the investigation was familiar with the enhanced procedure.

This accident reinforces the need for, and importance of, promoting a positive safety culture.  

Case study link:  http://pbadupws.nrc.gov/docs/ML1115/ML11159A220.pdf.
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On January 15, 2009, US Airways Flight 1549 departed LaGuardia Airport and less than 2 minutes

after takeoff, the captain told the control tower there was an emergency. There were bird strikes in

both engines. With both engines dead, the captain started the auxiliary power unit and took control

of the aircraft. Initially, he informed the control tower of his intent to return to LaGuardia;

however, he was unable to return to the runway and informed the controller that he had no other

alternative but to land on the Hudson River.  The plane started quickly losing altitude and the

captain glided the aircraft, tail first, into the Hudson River. Although the airplane was substantially

damaged, all 155 passengers and crew evacuated safely.

Safety culture traits in this event included:

Leadership Safety Values and Actions:  Even after the successful landing on the Hudson River, the

captain’s commitment to the safety of others was evident. Before leaving the cabin, he walked up

and down the aisle twice to make sure everyone was out. Once he was out of the cabin, he

instructed the rescue boats to take care of the people on the wings first because those in the rafts

were already safe. His commitment to the safety of others before thinking of himself is a reflection

of his strong leadership skills.

Continuous Learning/Training:  In order to ensure safety, US Airways Crew Resource Management

and Threat Error Management training had been integrated into all aspects of the US Airways

mandatory training plan. The captain stated that the training gave them the skills and tools needed

to build a team quickly, open lines of communication, share common goals and work together.

This event provides an example where a positive safety culture contributed to a safe outcome when

an unplanned sequence of events was set in place and put the safety of the passengers and crew in

danger.

Case study link: http://pbadupws.nrc.gov/docs/ML1122/ML11228A218.pdf.