An Educational Resource

About The NRC’s 

Safety Culture Policy Statement

NRC Licensees, Applicants and Vendors

The Commission expects that individuals and organizations establish and 

maintain a positive safety culture. This includes all licensees, certificate 

holders, permit holders, authorization holders, holders of quality 

assurance program approvals, vendors and suppliers of safety-related 

components, and applicants for a license, certificate, permit, authorization, 

or quality assurance program approval, subject to NRC authority.

Agreement States and Their Licensees

The Organization of Agreement States supports the use of this 

educational resource by its members and licensees. The Commission 

encourages the Agreement States, Agreement State licensees and other 

organizations interested in nuclear safety to support the development 

and maintenance of a positive safety culture.

SAFETY CULTURE

SAFETY CULTURE EDUCATIONAL RESOURCE I

U. S. NUCLEAR REGULATORY COMMISSION

MISSION

The mission of the NRC is to license and regulate 

the Nation’s civilian use of byproduct, source, and 

special nuclear materials to protect public health 

and safety, promote the common defense and 

security, and protect the environment.

SAFETY CULTURE EDUCATIONAL RESOURCE III

TABLE OF CONTENTS

Introduction 1 

Safety Culture Policy Statement 3

Overview 3

Definition and Traits 4

Safety Culture Trait Talk 5

Overview 5

Leadership Safety Values and Actions 6

Work Processes 10

Questioning Attitude 14

Problem Identification and Resolution 18

Environment for Raising Concerns 22

Effective Safety Communication 26

Respectful Work Environment 30

Continuous Learning 34

Personal Accountability 38

Safety Culture Case Study 42

Overview 42

June 2009 Collision of Two Washington Metropolitan Area Transit Authority 

Metrorail Trains near Fort Totten Station, Washington, DC. 43

Safety Culture Journey 46

Overview 46

Washington Metropolitan Area Transit Authority 47

Sources of Information 51

Appendix 52

Safety Culture Policy Statement Federal Register notice 52

SAFETY CULTURE EDUCATIONAL RESOURCE 1

INTRODUCTION

The U.S. Nuclear Regulatory Commission (NRC) 

published the Safety Culture Policy Statement 

(SCPS) in 2011, and developed numerous 

educational tools to facilitate understanding of 

the importance of a positive safety culture. The 

SCPS and the education tools—including the 

nine Safety Culture Trait Talks, Safety Culture 

Case Studies, and a Safety Culture Journey—

can be found on the Web site at http://www.

nrc.gov/about-nrc/safety-culture.html.

This educational resource provides an extra 

level of understanding of the SCPS and the 

nine safety culture traits by focusing on the 

educational tools collectively rather than 

individually. To facilitate this comprehensive 

understanding of the SCPS and traits, this 

document includes a brief overview of the 

SCPS, with the Federal Register notice (FRN) 

of the Final Safety Culture Policy Statement 

attached in the appendix. It also includes 

reformatted Safety Culture Trait Talks, which 

describe each safety culture trait, including 

why each trait is important, examples of 

attitudes and behaviors that apply to each 

trait, and an illustrative scenario showing how 

each trait could play a role in organizational 

events. Finally, the authors reformatted and 

included one Safety Culture Case Study and 

one Safety Culture Journey to further illustrate 

the importance of a positive safety culture. 

The Case Study discusses an accident that 

resulted, in part, from the absence of positive 

safety culture traits. The Journey illustrates this 

same organization’s response to the accident 

depicted in the case study and demonstrates 

the efforts it made to improve its safety culture. 

To help reflection and dialogue, each Trait Talk, 

Case Study, and Journey includes a series of 

questions, with space provided to take notes 

and record answers. 

The NRC encourages all applicants for and 

holders of licenses and certificate holders, 

the Agreement States and their licensees, and 

vendors and suppliers to establish and maintain 

a positive safety culture. This educational 

resource applies to all of these communities 

as the lessons learned from one organization’s 

accident, and the actions taken in response to 

the accident, can always be considered and 

applied to another. Finally, each of the nine 

safety culture traits and their behaviors and 

attitudes are applicable to a wide range of 

organizations as well. 

The NRC will continue to provide information 

about the importance of a positive safety 

culture. If you have a question or would like 

to make a suggestion, please contact the NRC, 

Office of Enforcement, Safety Culture Team, at 

external_safety_culture.resource@nrc.gov. 

SAFETY CULTURE EDUCATIONAL RESOURCE 3

OVERVIEW

Background: The 1986 nuclear accident at 

the Chernobyl nuclear power plant in Ukraine 

revealed the impact that weaknesses in safety 

culture can have on safety. Since then, the 

influence of safety culture has been further 

demonstrated by a number of significant 

events in the United States and internationally. 

Assessments of these events revealed that the 

absences of the traits of a positive safety culture 

was an underlying cause or increased the 

severity of the event.

The NRC addressed aspects of safety culture in 

two previously issued policy statements. The 

“Policy Statement on the Conduct of Nuclear 

Power Plant Operations,” (published in 1989) 

states the NRC’s expectations that licensed 

operators and managers of nuclear power 

plants conduct themselves professionally to 

ensure safety. In 1996, the NRC published 

“Freedom of Employees in the Nuclear 

Industry to Raise Safety Concerns without 

Fear of Retaliation,” a policy statement that 

applies to the regulated activities of all NRC 

licensees and their contractors. It provides 

the expectation that licensees and employers 

subject to NRC authority establish and maintain 

work environments where employees feel 

free to raise safety concerns without fear of 

retaliation (referred to as a safety conscious 

work environment). A safety conscious work 

environment is included in the SCPS as one of 

the traits: Environment for Raising Concerns.

Safety Culture Policy Statement: In 2011, 

the NRC published the SCPS (76 FR 34773; 

June 14, 2011) (see Appendix) which sets 

forth the expectation that individuals and 

organizations performing regulated activities 

establish and maintain a positive safety culture 

commensurate with the safety and security 

significance of their activities and the nature and 

complexity of their organizations and functions. 

This policy statement applies to all licensees, 

certificate holders, permit holders, authorization 

holders, holders of quality assurance program 

approvals, vendors and suppliers of safetyrelated components, and applicants for a 

license, certificate, permit, authorization, or 

quality assurance program approval subject 

to NRC authority. In addition, the Commission 

encourages the Agreement States (States that 

assume regulatory authority over their own use 

of certain nuclear materials), their licensees, and 

other organizations interested in nuclear safety 

to support the development and maintenance of 

a positive safety culture within their regulated 

communities. 

Because safety and security are the primary 

pillars of the NRC’s regulatory mission, 

consideration of both is an underlying 

principle of the Safety Culture Policy Statement. 

Organizations should ensure that personnel in 

the safety and security sectors appreciate the 

importance of each, emphasizing the need for 

integration and balance to achieve both safety 

and security in their activities. 

Industry experience has shown the value 

of establishing and maintaining a positive 

safety culture. It is important to remember 

that individuals and organizations performing 

regulated activities bear the primary 

responsibility for safety and security. The 

Safety Culture Policy Statement is not a 

regulation; therefore, it is the regulated entities’ 

responsibility to consider how to apply this 

policy statement to its regulated activities. 
4 U.S. NUCLEAR REGULATORY COMMISSION

Leadership Safety Values

and Actions

Problem Identification 

and Resolution Personal Accountability

Leaders demonstrate a 

commitment to safety in 

their decisions and behaviors.

Issues potentially impacting 

safety are promptly identified, 

fully evaluated, and promptly 

addressed and corrected 

commensurate with 

their significance.

All individuals take personal

responsibility for safety.

Work Processes Continuous Learning Environment for 

Raising Concerns

The process of planning and 

controlling work activities is 

implemented so that safety 

is maintained. 

Opportunities to learn about ways 

to ensure safety are sought out and 

implemented.

A safety conscious work environment 

is maintained where personnel feel 

free to raise safety concerns without 

fear of retaliation, intimidation, 

harassment or discrimination.

Effective Safety 

Communications Respectful Work Environment Questioning Attitude

Communications maintain 

a focus on safety.

Trust and respect permeate 

the organization.

Individuals avoid complacency 

and continually challenge existing 

conditions and activities in order 

to identify discrepancies that 

might result in error or 

inappropriate action.

DEFINITION AND TRAITS

There are many definitions of safety culture. 

Most of these definitions focus on the idea 

that in a positive safety culture individuals and 

organizations emphasize safety over competing 

goals, such as production or costs, ensuring a 

safety-first focus. 

The NRC’s SCPS defines nuclear safety 

culture as the core values and behaviors 

resulting from a collective commitment by 

leaders and individuals to emphasize safety 

over competing goals to ensure protection of 

people and the environment. 

Experience has shown that certain personal and 

organizational traits are present in a positive 

safety culture. A trait, in this case, is a pattern of 

thinking, feeling, and behaving that emphasizes 

safety, particularly in goal conflict situations, 

e.g., production vs. safety, schedule vs. safety, 

and cost of the effort vs. safety. It is the 

Commission’s expectation that all organizations 

and individuals overseeing or performing 

regulated activities involving nuclear materials 

should take the necessary steps to promote a 

positive safety culture by fostering these traits. 

The following traits were included in the NRC’s 

SCPS, although additional traits may also be 

important in a positive safety culture.
SAFETY CULTURE EDUCATIONAL RESOURCE 5

The Safety Culture Trait Talks were developed 

to offer a better understanding of the nine 

safety culture traits found in the SCPS and 

how they apply to you—whether you are an 

NRC employee interacting with an external 

stakeholder, an NRC licensee, a vendor or 

contractor employee, an organization interested 

in the safe and secure use of nuclear materials, 

or others involved in nuclear safety regulation. 

The NRC identified nine traits of a positive 

safety culture in the SCPS, although the agency 

recognizes that additional traits may also 

be important. In addition, please note that 

the traits were not developed to be used for 

inspection purposes. 

The nine individual Trait Talks are available 

on the Web site, as noted in the Introduction. 

However, for purposes of this document, 

they have been reformatted and included in 

the following pages. Each Trait Talk contains 

information on why the trait is important and 

what it looks like. In addition, each Trait Talk 

includes a fictional scenario based on a different 

licensee or community:

TRAIT LICENSEE OR COMMUNITY SCENARIO

Leadership Safety Values and Actions Radiography

Work Processes Power Reactors

Questioning Attitude Medical/Brachytherapy

Problem Identification and Resolution Power Reactors

Environment for Raising Concerns Research Reactors

Effective Safety Communication Fuel Cycles

Respectful Work Environment Gauges

Continuous Learning Construction

Personal Accountability Vendors

It is important to remember that a scenario that 

depicts a certain community or organization 

can be applicable to any organization. 

The important piece to understand is how 

the presence or absence of safety culture 

traits can mitigate the consequences of, or 

contribute to, an event or accident. Reflection 

on these scenarios should focus on how the 

safety culture traits are visible in your own 

organization and what traits might be weak or 

missing. For example, don’t assume that “this 

can’t happen here” because your organization 

doesn’t have the same work processes. 

Rather, consider how your organization’s 

work processes could potentially allow an event 

or accident to occur because of a lack of focus 

on safety culture.

Note: In the following pages, the superscripts refer to the 

Sources of Information on page 51.

TRAIT TALK OVERVIEW
6 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Leadership Safety 

Values And Actions? 

The NRC’s SCPS defines Leadership Safety Values and 

Actions as when leaders demonstrate a commitment 

to safety in their decisions and behaviors.

Why Is This Trait Important?

Leaders perform essential functions in organizations. 

The quality and actions of leadership have 

widespread consequences for an organization’s 

safety culture and its performance. Leaders have 

significant power to affect an organization’s safety 

culture through the priorities they establish, the 

behaviors and values they model, the reward 

systems they administer, the trust they create, 

and the context and expectations they establish 

for interpersonal relationships, communication, 

and accountability. Leaders also exert significant 

influence on change initiatives. They have the 

power and responsibility to set strategy and 

direction, align people and resources, motivate 

and inspire people, and ensure that problems are 

identified and solved in a timely manner. A lack of 

commitment or clear communication about what is 

important to the organization can create a conflict 

for employees who must then decide between 

competing messages. This leads employees to their 

own interpretations, thereby potentially negatively 

affecting the organization’s safety culture. It is clear 

that behavior matters and leadership behaviors that 

support a positive safety culture are critical.

Leaders at all levels play an important role in 

establishing the organization’s environment and 

safety culture. This is evident in the manner in 

which competing goals that occur at every level 

of the organization are managed. There may be 

conflicting demands from a cost and schedule 

perspective versus safety and quality. The 

organization’s 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 employee may encounter his or her version 

of these conflicts and will be faced with making 

decisions as he or she engages in activities to 

resolve them. The organization’s safety culture plays 

a significant role in guiding employees’ decisions; 

in other words, what they view as the organization’s 

priorities. Is the organization’s priority safety or 

production? This is one of the important junctions 

where leadership at the top of the organization is 

critical in setting the standards and establishing 

overarching safety priorities that all employees 

understand take precedence over all competing 

demands.1

What Does This Trait Look Like? 

Resources: Leaders ensure that personnel, 

equipment, procedures, and other resources are 

available and adequate to support safety. 

Leaders ensure that staffing levels are sufficient 

and personnel are qualified for the work they 

are performing. Leaders ensure that facilities are 

maintained and tools, equipment, procedures, and 

other resources are readily available to support 

work performance. Finally, leaders ensure that 

sufficient corporate resources are allocated for 

maintenance, equipment, and personnel to ensure 

safe and reliable operation. 

Field Presence: Leaders are commonly seen in 

working areas of the organization observing, 

coaching, and reinforcing standards and 

expectations. Deviations from standards and 

expectations are corrected promptly. 

Leaders ensure sufficient oversight of work 

activities. They practice visible leadership in 

the field by coaching, mentoring, reinforcing 

standards, and reinforcing positive 

decisionmaking practices and behaviors. Leaders 

discuss their observations in detail with the group 

they observed and provide useful feedback about 

how to improve individual performance. They 

model safe behaviors and high standards of 

accountability as a way to encourage others. 

LEADERSHIP SAFETY VALUES AND ACTIONS
SAFETY CULTURE EDUCATIONAL RESOURCE 7

Incentives, Sanctions, and Rewards: Leaders ensure 

incentives, sanctions, and rewards are aligned 

with safety policies and reinforce behaviors and 

outcomes that reflect safety as the overriding 

priority. 

Leaders ensure disciplinary actions are 

appropriate, consistent, and support safety and a 

safety conscious work environment. They reward 

individuals who identify and raise issues affecting 

safety and praise behaviors that reflect a positive 

safety culture. Leaders foster an environment that 

promotes accountability and hold individuals 

accountable for their actions. Leaders consider 

potential chilling effects when taking disciplinary 

actions and other personnel actions, and they take 

compensatory actions when appropriate. 

Strategic Commitment to Safety: Leaders ensure 

priorities are aligned to reflect safety as the 

overriding priority. 

Leaders develop and implement cost and schedule 

goals in a manner that reinforces the importance 

of safety. Information from independent oversight 

organizations is used to help establish priorities 

that align with safety. Leaders establish strategic 

and business plans that reflect safety as the 

overriding priority and ensure that corporate 

priorities also align with safety priorities. 

Change Management: Leaders use a systematic 

process for evaluating and implementing change so 

that safety remains the overriding priority. 

Leaders use a systematic process for planning, 

coordinating, and evaluating the safety impacts 

and potential negative effects on the willingness 

of individuals to raise safety concerns, when 

making major changes. This includes decisions 

concerning changes to organizational structure 

and functions, leadership, policies, programs, 

procedures, and resources. Leaders ensure safety 

is maintained when planning, communicating, 

and implementing change and ensure that 

significant unintended consequences are avoided. 

Leaders ensure that individuals understand 

the importance of, and their role in, the change 

management process. 

Roles, Responsibilities, and Authorities: Leaders 

clearly define roles, responsibilities, and authorities 

to ensure safety. 

Leaders ensure roles, responsibilities, and 

authorities of executives, senior managers, 

and corporate managers are clearly defined, 

understood, and documented. They appropriately 

delegate responsibility and authority to promote 

ownership and accountability. Leaders ensure 

that recommendations from review boards and 

independent oversight organizations do not 

override senior leaders’ ultimate responsibility for 

decisions affecting safety. 

Constant Examination: Leaders ensure that safety 

is constantly scrutinized through a variety of 

monitoring techniques, including assessments of 

safety culture. 

Leaders ensure that board members and members 

of independent oversight organizations meet 

with different levels of management and staff 

to develop an understanding of the status of the 

organization’s safety culture. They use a variety 

of monitoring tools—including employee surveys, 

self- and independent assessments, external safety 

review board member feedback, and employee 

concern investigations—to regularly monitor 

safety culture. Leaders support and participate in 

candid assessments of workplace attitudes and 

safety culture and act on issues that affect trust 

in management and detract from a healthy safety 

culture. 

Leader Behaviors: Leaders exhibit behaviors that set 

the standard for safety. 

Leaders “walk the talk,” modeling correct 

behaviors, especially when resolving apparent 

conflicts between safety and production. They act 

promptly when a safety issue is raised to ensure 

it is understood and appropriately addressed. 

Leaders maintain high standards of personal 

conduct that promote all aspects of a positive 

safety culture, and actively seek out the opinions 

and concerns of workers at all levels. Leaders 

encourage personnel to challenge unsafe behavior 

and unsafe conditions, and motivate others to 

practice positive safety culture behaviors.2
8 U.S. NUCLEAR REGULATORY COMMISSION

WHAT IS A SCENARIO IN WHICH THIS TRAIT 

COULD PLAY A ROLE? 

Senior management at a nuclear power plant 

developed a new incentive program after noticing 

substantial schedule delays during outages at the 

plant. The incentive program included bonuses for 

meeting schedule goals during outages. During an 

outage, a supervisor signed off on work without 

completing an independent verification, which 

was not required but recommended by procedure. 

The supervisor made this decision because there 

were no qualified workers available at the time 

and waiting for the next shift of workers would 

have caused a schedule slip, affecting the potential 

outage bonus. The supervisor defended the decision 

to management by stating that a peer check was 

completed, and considered sufficient to verify the 

work performed. 

Over time, peer checks were substituted for a number 

of independent verifications during outages because 

it saved time, helped the team stay on-schedule, 

and resulted in larger bonuses at the end of the 

outage. After several years of this practice, a short 

in a breaker that was replaced during an outage 

inadvertently caused a loss of power to an entire 

train of equipment, which then caused a reactor trip. 

One of the primary cooling pumps on the active train 

was out of service at the time of the loss of power. 

It had been scheduled for repair during the outage 

but was rescheduled because waiting for the parts to 

repair the pump would have extended the outage. As 

a result, the plant had to rely on emergency systems 

to cool the reactor core because both of the primary 

cooling pumps were unavailable. 

The root cause analysis of the event found that an 

independent verification of the breaker replacement 

was not completed because common practice had 

been to accept a peer check as adequate verification 

of the work performed. Management’s focus on 

meeting schedule goals, and acceptance of peer 

checks in place of recommended independent 

verifications, contributed to a reactor trip that 

challenged the plant’s safety systems.3

Thinking about this scenario, consider the following questions: 

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 9

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

questions: 

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
10 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Work Processes?

The NRC’s SCPS defines Work Processes as when the 

process of planning and controlling work activities 

is implemented so that safety is maintained.

Why Is This Trait Important?

The process of designing and controlling work 

to ensure safety is an important part of an 

organization, and how effectively an organization 

manages and implements their work processes is 

a reflection of their safety culture. For example, 

effective work processes in a positive safety culture 

will have a well-designed workflow that includes 

the assignment of responsibilities to leaders, work 

groups, and individuals. Work activities will be 

prioritized, coordinated across workgroups, and 

communicated effectively. Policies and procedures 

will incorporate the appropriate risk insights 

and be effectively planned, executed, verified, 

and documented. The rigorous development, 

management and adherence to work processes 

helps ensure the safe use of nuclear materials and 

reflects a positive safety culture.

Many organizations operating high-risk technologies 

(such as in industries using nuclear materials) 

employ collaborative decisionmaking, develop 

detailed procedures, and require verification of steps 

during procedure implementation under normal 

operations. The development and implementation 

of emergency operating procedures is equally 

as rigorous. Other high reliability organizations, 

however, may base activities around individual 

expertise and professionalism, autonomy, and rapid 

team-based response, particularly during off-normal 

conditions. Both perspectives can be important for 

the design and implementation of work processes. 

For example, organizations may require strict 

adherence to normal and emergency operating 

procedures. However, flexibility may be necessary 

when responding to off-normal conditions.

The need for procedural compliance during normal 

or emergency operations and the allowance for 

flexibility and individual autonomy during periods 

of offnormal conditions pose a dilemma for many 

organizations. One of the biggest management 

challenges may be how to realize the benefits of 

both approaches given that these two perspectives 

on controlling work processes can create internal 

inconsistencies.1

What Does This Trait Look Like?

Work Management: The organization implements a 

process of planning, controlling, and executing work 

activities such that nuclear safety is the overriding 

priority. The work process includes the identification 

and management of risk commensurate to the work.

Work is effectively planned and executed by 

incorporating risk insights, job-site conditions, 

and the need for coordination with different 

groups or job activities. The work process 

appropriately prioritizes work and incorporates 

contingency plans, compensatory actions, and 

abort criteria as needed. Leaders consider the 

impact of changes to the work scope and the need 

to keep personnel apprised of the work status. 

The work process ensures individuals are aware 

of the nuclear safety risks associated with work 

in the field, and other parallel station activities. 

Insights from probabilistic risk assessments are 

considered in daily work activities and change 

processes. Work activities are coordinated to 

address conflicting or changing priorities across 

the whole spectrum of activities contributing to 

nuclear safety. The work process limits temporary 

modifications.

Design Margins: The organization operates and 

maintains equipment within design margins. Margins 

are carefully guarded and changed only through a 

systematic and rigorous process. Special attention 

is placed on maintaining fission product barriers, 

defense-in-depth, and safety-related equipment.

The work process supports nuclear safety and the 

maintenance of design margins by minimizing 

long-standing equipment issues, preventive 

WORK PROCESSES
SAFETY CULTURE EDUCATIONAL RESOURCE 11

maintenance deferrals, and maintenance and 

engineering backlogs. The work process ensures 

focus on maintaining fission product barriers, 

defense-in-depth, and safety-related equipment. 

Design and operating margins are carefully 

guarded and changed only with great thought and 

care. Safety-related equipment is operated and 

maintained well within design requirements.

Documentation: The organization creates and 

maintains complete, accurate, and up-to-date 

documentation.

Activities are governed by comprehensive, highquality programs, processes, and procedures. 

Design documentation, procedures, and work 

packages are complete, thorough, accurate, 

and current. Components are labeled clearly, 

consistently, and accurately. The backlog of 

document changes is understood, prioritized, and 

actively managed to ensure quality.

Procedure Adherence: Individuals follow processes, 

procedures, and work instructions.

Individuals follow procedures. Individuals 

understand and use human error reduction 

techniques. Individuals review procedures 

and instructions prior to work to validate that 

they are appropriate for the scope of work and 

that required changes are completed prior 

to implementation. Individuals manipulate 

equipment only when appropriately authorized 

and directed by approved procedures or work 

instructions. Individuals ensure that the status of 

work activities is properly documented.2

What Is A Scenario In Which This Trait Could 

Play A Role?

Two radiographers were performing nondestructive 

testing operations of pipe welds at a temporary job 

site using a 2.4 TBq (65 Ci) iridium -192 radioactive 

source in a radiography camera. In between shots, 

the first radiographer briefly entered the restricted 

area without conducting a radiation survey. 

Upon exiting the restricted area, he noticed that 

a piece of equipment had fallen onto the guide 

tube, putting a crimp in the tube. After the next 

shot, without conducting a radiation survey, both 

radiographers entered the restricted area to set 

up for the next operation thinking that the source 

had been properly retracted into the shielded 

position. However, the crimp in the guide tube 

from the fallen equipment prevented the source 

from retracting back to the shielded position. The 

second radiographer’s ratemeter sounded an alarm 

indicating that radiation exposures greater than the 

preset amount were being exceeded, while the first 

radiographer’s ratemeter did not alarm. Because 

the first radiographer’s ratemeter did not alarm, 

they both assumed that the second radiographer’s 

ratemeter was not functioning properly. They 

continued operations and did not notify the 

radiation safety officer of the incident. The radiation 

safety officer became aware of the incident when he 

identified an overexposure of both workers from the 

personnel dosimetry reports that he received a few 

weeks later. 

There is a high potential dose hazard associated 

with industrial radiographic operations. The process 

of planning and controlling work activities so that 

safety is maintained (work processes) was lacking in 

this scenario. Although the regulations require it, the 

radiographers did not conduct a radiation survey 

to ensure that the source was properly retracted 

into the shielded position in the camera. The 

radiographers failed to investigate the discrepancy 

between the two ratemeters. Also, the radiographers 

did not properly follow procedures for notification 

of the radiation safety officer of the incident or the 

potential overexposure because they believed that 

the ratemeter that sounded was faulty.3
12 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Photo courtesy of Davidmack via Wikipedia
SAFETY CULTURE EDUCATIONAL RESOURCE 13

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

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
14 U.S. NUCLEAR REGULATORY COMMISSION

What is the Definition of Questioning 

Attitude? 

The NRC’s SCPS defines Questioning Attitude 

as when individuals avoid complacency and 

continuously challenge existing conditions and 

activities in order to identify discrepancies that 

might result in error or inappropriate action.

Why Is This Trait Important?

The NRC has identified complacency as a key 

contributor to many incidents involving nuclear 

materials, such as the Davis-Besse nuclear power 

plant reactor vessel head degradation event and 

the Pennsylvania cancer treatment center event in 

which a patient died of radiation exposure. Avoiding 

complacency is essential to ensuring nuclear safety 

and can be achieved by instilling a questioning 

attitude in every employee. From the operator at a 

nuclear power plant challenging an assumption, to 

the medical physicist in a cancer treatment center 

questioning an unexpected change in treatment 

parameters, having a questioning attitude is vital 

for the safe use of nuclear materials and a positive 

safety culture.

It is each individual’s responsibility to continuously 

assess his or her duties, procedures, and job 

site to identify inconsistencies or abnormalities. 

Challenging assumptions, stopping work in the 

face of uncertainty, and proactively anticipating 

what may go wrong during a prejob brief reflect a 

questioning attitude and a positive safety culture. 

Employees should routinely and actively ask the 

following questions as they perform their jobs: Am I 

doing the right thing? How could we do this better? 

Are we using the right assumptions? Are we putting 

our people, plant, or patients at risk? What new 

practices could we implement that would minimize 

complacency and encourage a questioning attitude? 

Recognizing that external and internal conditions 

change over time, leaders must also continuously 

assess the organization or operation in its entirety, 

look beyond the individual task, and ask questions 

to ensure they understand what is currently 

happening and what might go wrong. As leaders 

ask questions and encourage others to do the same, 

the importance of having a questioning attitude will 

be reinforced throughout the organization. Leaders 

should consistently reward employees for asking 

questions and routinely discuss actual situations 

where a questioning attitude helped achieve a 

positive outcome.

A positive safety culture requires the collective 

commitment by both leaders and employees 

to emphasize safety over competing goals. A 

questioning attitude supports that commitment.1

What does this trait look like?

Nuclear is Recognized as Special and Unique: 

Individuals understand that complex technologies 

can fail in unpredictable ways. 

The organization ensures that activities that 

could affect nuclear materials are conducted 

with particular care, caution, and oversight. 

Individuals recognize the special characteristics 

and unique hazards of nuclear technology, 

including radioactive byproducts, and the 

importance of features designed to maintain 

nuclear safety. Executives and senior managers 

ask probing questions to understand the 

implications and consequences of anomalies, and 

challenge managers to ensure degraded conditions 

are fully understood and appropriately resolved, 

especially those involving equipment important to 

nuclear safety. 

Challenge the Unknown: Individuals stop when 

faced with uncertain conditions. Risks are evaluated 

and managed before proceeding. 

Leaders reinforce expectations that individuals 

take the time to do the job right the first time, 

seek guidance when unsure, and stop if an 

unexpected condition or equipment response is 

encountered. Individuals maintain a questioning 

attitude during pre-job briefings and job-site 

reviews to identify and resolve unexpected 

conditions. Individuals challenge unanticipated 

test results rather than rationalizing them. 

QUESTIONING ATTITUDE
SAFETY CULTURE EDUCATIONAL RESOURCE 15

For example, abnormal indications are not 

automatically attributed to indication problems 

but are thoroughly investigated before activities 

are allowed to continue. Individuals stop work 

activities when confronted with an unexpected 

condition, communicate with supervisors, and 

resolve the condition prior to continuing work 

activities. When appropriate, individuals consult 

system and equipment experts. If a procedure or 

work document is unclear or cannot be performed 

as written, individuals stop work until the issue 

is resolved. 

Challenge Assumptions: Individuals challenge 

assumptions and offer opposing views when they 

think something is not correct. 

Leaders solicit challenges to assumptions when 

evaluating nuclear safety issues. Individuals 

ask questions to fully understand the bases of 

operational and management decisions that 

appear to be contrary to nuclear safety, and 

managers question assumptions, decisions, and 

justifications that do not appear to consider 

impacts to nuclear safety sufficiently. 

Avoid Complacency: Individuals recognize and plan 

for the possibility of mistakes, latent problems, 

and inherent risk, even while expecting successful 

outcomes. 

The organization is aware that latent conditions 

can exist, addresses them as they are discovered, 

and considers the extents of the conditions 

and their causes. Prior to authorizing work, 

individuals verify procedure prerequisites are 

met rather than assuming they are met based 

on general work site conditions. Individuals 

perform a thorough review of the work site and 

the planned activity every time work is performed 

rather than relying on past successes and assumed 

conditions, and they consider potential undesired 

consequences of their actions prior to performing 

work and implement appropriate error reduction 

tools. Leaders ensure specific contingency actions 

are discussed and understood during job planning 

and pre-job briefings.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

A hospital was conducting a cancer treatment with 

a high-dose rate brachytherapy remote afterloading 

system using an iridium-192 source. Just prior to 

the cancer treatment, the hospital had replaced the 

source and upgraded the software. When entering 

the data into the treatment system, the medical 

physicist was unable to electronically transfer the 

patient’s treatment plan from the planning system 

to the treatment system due to an error message. 

After several failed attempts by staff, the medical 

physicist entered the treatment plan manually into 

the treatment systems control console, rather than 

question why he was seeing the error message. 

Due to a bug in the software upgrade, the 

treatment system software created an unexpected 

source step size change in the treatment 

parameters. When the medical physicist entered 

the data manually for the source dwell times, the 

software automatically changed the entered data to 

the default parameters for the source step size. The 

medical physicist faced an unexpected condition 

with the software error, and failed to recognize 

the change in the source step size. The patient 

was then treated with a mispositioned source. The 

medical physicist failed to verify that the treatment 

computer system was correct after data entry and 

prior to treatment. As a result, the patient received 

a radiation dose to tissue outside the treatment 

area and an underdose to the treatment site. In 

addition, the hospital failed to follow its procedure 

of performing an independent review of the 

treatment plan prior to patient treatment.

This scenario illustrates equipment (software) 

errors as the initial precipitating event. Had the 

medical physicist used a questioning attitude, he 

could have identified the equipment failure and the 

hospital could have corrected this failure before 

treating the patient.3
16 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 17

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

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
18 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Problem 

Identification And Resolution? 

The NRC’s SCPS defines Problem Identification and 

Resolution as when issues potentially impacting 

safety are promptly identified, fully evaluated, and 

promptly addressed and corrected commensurate 

with their significance.

Why Is This Trait Important?

Problem identification and resolution is an 

important element of safety culture. Leaders 

are responsible for identifying and diagnosing 

organizational or technical deficiencies, taking 

corrective action, and anticipating emerging issues. 

All members of an organization support problem 

identification and resolution by promptly raising 

and reporting concerns (for example, by working 

through a corrective action program). The extent 

and manner in which organizations identify and 

resolve problems serve as an example how the 

organization prioritizes safety. The ability and 

willingness of workers and managers to identify and 

address problems is also important for continuous 

learning, another trait of a positive safety culture.

An effective problem identification and resolution 

program uses the organization’s corrective action 

program, operating experience, and self-assessment 

results to ensure safe operations. The corrective 

action program should have a transparent process 

for evaluating, prioritizing, and resolving issues. 

Leaders should ensure that they and the rest of the 

organization fully understand safety-related issues. 

Without full understanding, the organization cannot 

appropriately prioritize and resolve these issues so 

that they do not occur again. In addition, an effective 

problem identification and resolution program leads 

to a strong safety conscious work environment. In 

such an environment, the organization removes 

barriers to a free flow of information to ensure that all 

employees feel free to raise safety-related concerns. 

Organizations can approach problem identification 

and resolution with different mindsets. One mindset 

focuses on finding existing problems and correcting 

weaknesses, typically through the organization’s 

corrective action program. However, an organization 

with a positive safety culture also has a problem 

identification and resolution program that 

anticipates issues, reviews operating experience, 

and tracks emerging industry themes and trends. 

Organizational learning is most successful when 

issues are anticipated and addressed before they 

become weaknesses to be corrected.1

What does this trait look like?

Identification: The organization implements a 

corrective action program with a low threshold 

for identifying issues. Individuals identify issues 

completely, accurately, and in a timely manner in 

accordance with the program. 

Individuals recognize deviations from standards 

and understand how to enter issues into the 

corrective action program. They ensure that 

issues, problems, degraded conditions, and near 

misses are promptly reported and documented in 

the corrective action program at a low threshold. 

Individuals describe the issues entered in the 

corrective action program in sufficient detail 

to ensure they can be appropriately prioritized, 

trended, and assigned for resolution. 

Evaluation: The organization thoroughly evaluates 

problems to ensure that resolutions address causes 

and extents of conditions commensurate with their 

safety significance. 

The organization ensures that issues are properly 

classified, prioritized, and evaluated according 

to their safety significance. Extent-of-condition 

and extent-of-cause evaluations are completed in 

a timely manner, commensurate with the safety 

significance of the issue. The organization ensures 

that apparent and root cause investigations 

identifying primary and contributing causal 

factors are completed as required. Issues are 

investigated thoroughly according to their 

safety significance, and root cause analyses are 

rigorously applied to identify and correct the 

fundamental cause of significant issues. The 

underlying organizational and safety culture 

contributors to issues are evaluated thoroughly 

and are given the necessary time and resources 

to be clearly understood. Managers conduct 

PROBLEM IDENTIFICATION AND RESOLUTION
SAFETY CULTURE EDUCATIONAL RESOURCE 19

effectiveness reviews of significant corrective 

actions to ensure that the resolution addressed 

the causes effectively. 

Resolution: The organization takes effective 

corrective actions to address issues in a timely 

manner commensurate with their safety 

significance. 

The organization ensures that corrective actions 

are completed in a timely manner. Deferrals of 

corrective actions are minimized, and when 

required, due dates are extended using an 

established process that appropriately considers 

safety significance. The organization ensures that 

appropriate interim corrective actions are taken 

to mitigate issues while more fundamental causes 

are being assessed. Corrective actions resolve and 

correct the identified issues, including causes and 

extents of conditions, and prevent the recurrence 

of significant conditions adverse to quality. Trends 

in safety performance indicators are acted on to 

resolve problems early. 

Trending: The organization periodically analyzes 

information from the corrective action program 

and other assessments in the aggregate to identify 

programmatic and common cause issues. 

The organization develops indicators that monitor 

both equipment and organizational performance, 

including safety culture. Managers use indicators 

that provide an accurate representation 

of performance and early indications of 

declining trends, and routinely challenge the 

organization’s understanding of declining trends. 

Organizational and departmental trend reviews 

are completed in a timely manner in accordance 

with program expectations.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

A maintenance worker at a nuclear power 

plant found water leaking through the roof of 

the auxiliary building and into the emergency 

shutdown panel during a heavy rainstorm. He 

notified the control room supervisor, cleaned 

up the water, and wrote a condition report. The 

power plant management assigned the condition 

report a priority 4 (the lowest level). After the 

plant identified the degraded condition of the roof, 

management issued a work order to repair the 

roof. However, other layers of management never 

approved the work to proceed. Shortly afterwards, 

the plant started a program to maintain building 

integrity in all weather conditions; however, the 

plant never made plans or took actions to properly 

prioritize, identify and correct the roof leakage.

Two years later, the maintenance worker found 

water pooling around the power supply breakers 

for the feed water pump in the auxiliary building. 

Three months after that, the maintenance worker 

found water dripping onto the high-pressure 

safety injection pump. After both incidents, the 

maintenance worker notified the control room 

supervisor, mopped up the water, covered the 

equipment with a protective material as needed, 

and wrote a condition report. Each time, plant 

management assigned the condition a priority level 

of 4. The worker identified that the source of the 

water was from the roof of the auxiliary building 

and asked his supervisor why the roof was not 

repaired. The supervisor said work orders were 

written each time, but they were never approved or 

scheduled due to other priorities. The supervisor 

was not sure about the status of the program to 

ensure building integrity and had never seen any 

plans or schedules to repair roof leaks. Further, 

when the supervisor asked his manager about 

the ongoing degraded roof issues, the manager 

discovered that there were 43 open work orders 

to repair roof leaks, and none of these orders had 

ever been approved, scheduled, or completed.

Recently, water from a heavy rainstorm again 

leaked through the auxiliary building roof and into 

the switchgear room. This time the water caused an 

electrical ground short near a current transformer, 

which then tripped the reactor coolant pump. This 

led to a reactor trip due to a low reactor coolant 

system flow signal. 

The auxiliary building provides structural support 

and separation to safety- and nonsafety-related 

equipment, and is designed to provide protection 

against external events such as rain, wind, and 

snow. However, the plant’s failure to resolve the 

leakage through its problem identification and 

resolution and corrective action program left 

the safety systems unprotected. The weak safety 

culture and problem identification and resolution 

in this plant directly led to the reactor trip.3
20 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 21

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

questions: 

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
22 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Environment For 

Raising Concerns?

The NRC’s SCPS defines Environment for Raising 

Concerns as maintaining a safety-conscious work 

environment where personnel feel free to raise safety 

concerns without fear of retaliation, intimidation, 

harassment, or discrimination.

Why Is This Trait Important?

Fostering an environment for raising concerns 

is an important attribute of a positive nuclear 

safety culture. Organizations should have a work 

environment where employees are encouraged to 

raise safety concerns and where those concerns 

are reviewed promptly, given the proper priority 

based on their potential safety significance, and 

appropriately resolved, with timely feedback to the 

originator of the concerns and to other employees 

as appropriate. 

Employees should feel free to raise safety concerns 

to their management without fear of harassment, 

intimidation, retaliation, or discrimination. The 

organization is prohibited by law from taking 

adverse retaliatory actions against employees 

because they raised concerns. When allegations of 

discrimination or retaliation arise, the appropriate 

level of management must be involved to review 

the facts, evaluate or reconsider the action, and, 

where warranted, remedy the matter. In addition 

to the hardship caused to the individual employee, 

the perception by fellow workers that raising 

concerns has resulted in retaliation can generate a 

chilling effect that may discourage other workers 

from raising concerns. Any reluctance on the part 

of employees to raise concerns can be detrimental 

to nuclear safety.

The organization should clearly identify the 

processes that employees may use to raise 

concerns, such as discussing issues with their 

supervisor or filing deficiency reports for problem 

identification and resolution. However, it is 

important to recognize that some employees 

may not always be comfortable raising concerns 

through the normal channels, such as with their 

immediate supervisor. From a safety perspective, 

no method of raising potential safety concerns 

should be discouraged. Therefore, the organization 

should focus on achieving and maintaining an 

environment where employees feel free to raise 

their concerns directly to their supervisors, as well 

as ensuring that alternate means of raising and 

addressing concerns are accessible, credible, and 

effective. These alternative approaches may include 

an “open-door” policy that allows the employee 

to bring a concern to a higher-level manager, an 

ombudsman program, or an employee concerns 

program.

An organization that reinforces an environment 

for raising concerns typically has well-developed 

systems for prioritizing problems and directing 

resources, effective communications for openly 

sharing information and analyzing the root causes 

of identified problems, and management that 

promotes employee confidence in raising and 

resolving concerns.1

What Does This Trait Look Like? 

Safety Conscious Work Environment (SCWE) 

Policy: The organization effectively implements 

a policy that supports individuals’ rights and 

responsibilities to raise safety concerns and does 

not tolerate harassment, intimidation, retaliation, or 

discrimination for doing so. 

Individuals feel free to raise nuclear safety 

concerns without fear of retribution, with 

confidence that their concerns will be addressed. 

Executives and senior managers set and reinforce 

expectations for establishing and maintaining a 

safety-conscious work environment. Policies and 

procedures reinforce that individuals have the 

right and responsibility to raise nuclear safety 

concerns and define the responsibilities of leaders 

to create an environment in which individuals feel 

free to raise safety concerns. Leaders are trained 

to take ownership when receiving and responding 

ENVIRONMENT FOR RAISING CONCERNS?
SAFETY CULTURE EDUCATIONAL RESOURCE 23

to concerns, recognizing confidentiality if 

appropriate, and ensuring they are adequately 

addressed in a timely manner. Individuals are 

trained that behaviors or actions that could prevent 

concerns from being raised, including harassment, 

intimidation, retaliation, or discrimination, will 

not be tolerated and are violations of law and 

policy. All claims of retaliation are investigated 

and any necessary corrective actions are taken in 

a timely manner, including actions to mitigate any 

potential chilling effect. 

Alternate Process for Raising Concerns: The 

organization effectively implements a process for 

raising and resolving concerns that is independent 

of line management influence. Safety issues may be 

raised in confidence and are resolved in a timely 

and effective manner. 

Executives establish, support, and promote the 

use of alternative processes for raising concerns 

and ensure corrective actions are taken. Leaders 

understand their role in supporting alternate 

processes for raising concerns. Processes for 

raising concerns or resolving differing professional 

opinions that are alternatives to the corrective 

action program and operate outside the influence 

of the management chain are communicated and 

accessible to individuals. Alternative processes 

are independent, include an option to raise 

concerns confidentially, and ensure these concerns 

are appropriately resolved in a timely manner. 

Individuals receive feedback in a timely manner. 

Individuals have confidence that issues raised will 

be appropriately resolved. Individuals assigned 

to respond to concerns have the appropriate 

competencies.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

A research scientist in the nuclear physics program 

at a research laboratory moved a high activity 

radioactive source to temporary storage area of 

the irradiation pool. He was not aware that, three 

days prior to moving the source, maintenance 

workers had removed a small section of the 

concrete shielding from the irradiation pool wall. 

This allowed the source to emit radiation through 

the unshielded section of the pool wall and create 

an unplanned high radiation area. The procedures 

for moving the source did not clearly require crosschecking with maintenance activities.

During the investigation of this incident, the 

research scientist told the investigator that he 

previously raised concerns to his supervisor about 

the adequacy of procedures for moving the source 

and ensuring that the source was appropriately 

shielded. Further, he noted that he had told the 

supervisor on numerous occasions that many of the 

procedures dealing with the safety of laboratory 

activities may be insufficient. After this incident, he 

told the supervisor that he was going to notify the 

facility administration about his concerns and the 

supervisor’s lack of response. The supervisor told 

the scientist that because of significant budget cuts 

in research programs, and subsequent reduction 

in staff, he did not have the resources to review 

and revise all of the procedures and he did not 

want to draw any more attention to the program. 

In addition, the supervisor said that if the scientist 

raised this concern with the administration, his 

“future employment” would be discussed. A few 

days later, the scientist discussed his concerns 

with the administration officials, and two weeks 

later, the scientist was laid off due to budget 

cuts. The remaining research staff was aware of 

the circumstances surrounding their colleague’s 

termination. The supervisor told staff members that 

any concerns they have should never be “taken up 

the chain of command.”

Continuing budget cuts and their colleague’s 

termination have resulted in the remaining research 

staff members being concerned about their jobs, 

the future of the research programs, and their 

safety while working at the research facility. Staff 

members have expressed reluctance to raise any 

concerns to their supervisor or the administration, 

and they continue to be worried about the 

adequacy of procedures and policies. This chilling 

effect prevents the staff from feeling free to raise 

nuclear safety concerns without fear of retaliation, 

and weakens the facility’s safety culture.3
24 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Experimental gamma irradiation source similar to the source referenced in the Trait Talk example.
SAFETY CULTURE EDUCATIONAL RESOURCE 25

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

questions: 

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
26 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Effective Safety 

Communication? 

The NRC’s SCPS defines Effective Safety 

Communication as communications that maintain 

a focus on safety.

Why Is This Trait Important?

Effective safety communication is vital to 

maintaining a safety culture. When employees 

regularly communicate with each other in an open, 

respectful manner, they are also more willing to 

give and receive feedback. Effective communication 

also supports teamwork and coordination between 

groups. 

Employees learn about, and become part 

of, an organization’s safety culture through 

communication. Lack of clear communication 

from management can result in situations where 

managers say one thing but do another. Employees 

then spend time and energy trying to interpret the 

conflicting messages. In such situations, employees 

will generally interpret a manager’s behavior as 

the more valid indicator of the organization’s 

values and priorities. Persistent mismatches 

between formal and informal communications 

can lead employees to disregard or develop a 

cynical view of formal communications. This can 

lead to ineffective formal communications from 

management and a weakened safety culture. 

Top-down communication is most effective when 

senior managers communicate directly with 

immediate supervisors and immediate supervisors 

communicate with their staff. Ensuring that 

supervisors are informed about organizational 

issues, and then allowing them to communicate 

these issues to their staff, helps create and 

reinforce the supervisor’s power. Research shows 

that when employees perceive their supervisor as 

having power, employees have greater trust in their 

supervisor, greater desire to communicate with 

their supervisor, and are more likely to believe the 

information coming from their supervisor. 

Upward communication from workers to managers, 

and information exchange among workers, is 

essential for organizational learning and safe 

operations. An employee’s perceptions about 

support for safety can strongly influence his or her 

willingness to speak up. Some common barriers to 

upward communication include fear of retaliation, 

concerns that the communication will be filtered 

as it goes up the chain of command, perceptions 

that management is resistant to critical feedback, 

and fear of creating interpersonal conflict. These 

communication barriers, if unaddressed, can 

have a negative impact on information exchange, 

organizational learning, and ultimately safe 

performance. To facilitate effective upward 

communication, it is important for managers 

to create an environment that is supportive, 

encouraging, and accepting of both positive and 

negative feedback, so employees always feel free 

to speak up.1

What Does This Trait Look Like? 

Work Process Communications: Individuals 

incorporate safety communications in work 

activities. 

Communications within work groups are timely, 

frequent, and accurate. Work groups and 

supervisors communicate with other work groups 

and supervisors during the performance of their 

work activities. Individuals communicate with 

each other such that everyone has the information 

necessary to accomplish work activities safely and 

effectively. Communications during shift turnovers 

and pre-job briefings provide information 

necessary to support nuclear safety. Work groups 

integrate nuclear safety messages into daily 

activities and meetings. 

Bases for Decisions: Leaders ensure that the bases 

for operational and organizational decisions are 

communicated in a timely manner. 

Leaders promptly communicate expected outcomes, 

potential problems, planned contingencies, and 

abort criteria for important decisions. Leaders 

share information on a wide range of issues 

with individuals and periodically verify their 

understanding of the information. Leaders take 

steps to avoid unintended or conflicting messages 

that may be conveyed by decisions. Leaders 

encourage individuals to ask questions if they 

do not understand the basis of a management 

decision. Executives and senior managers 

communicate the reasons for resource allocation 

decisions, organizational changes, and other 

decisions affecting the organization as a whole, 

including the safety implications of those decisions. 

EFFECTIVE SAFETY COMMUNICATION
SAFETY CULTURE EDUCATIONAL RESOURCE 27

Free Flow of Information: The organization takes 

effective corrective actions to address issues in 

a timely manner commensurate with their safety 

significance. 

The organization ensures that corrective actions 

are completed in a timely manner. Deferrals of 

corrective actions are minimized, and when 

required, due dates are extended using an 

established process that appropriately considers 

safety significance. The organization ensures that 

appropriate interim corrective actions are taken 

to mitigate issues while more fundamental causes 

are being assessed. Corrective actions resolve and 

correct the identified issues, including causes and 

extents of conditions, and prevent the recurrence 

of significant conditions adverse to quality. Trends 

in safety performance indicators are acted on to 

resolve problems early. 

Expectations: Leaders frequently communicate and 

reinforce the expectation that nuclear safety is the 

organization’s overriding priority. 

Executives and senior managers communicate 

expectations regarding nuclear safety so that 

individuals understand that safety is the highest 

priority. Executives and senior managers 

implement a strategy of frequent communication 

using a variety of tools to reinforce that nuclear 

safety is the overriding priority. Executives and 

senior managers reinforce the importance of 

nuclear safety by clearly communicating its 

relationship to strategic issues, including budget, 

workforce planning, equipment reliability, and 

business plans. Leaders communicate desired 

safety behaviors to individuals, providing 

examples of how behaviors positively or negatively 

affect nuclear safety. Leaders routinely verify that 

communications on the importance of nuclear 

safety have been heard and understood. Leaders 

ensure supplemental personnel understand 

expected behaviors and actions necessary to 

maintain nuclear safety.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

Fuel fabrication facilities monitor many of the 

processes of plant operations that use special 

nuclear material from the control room. This 

monitoring allows qualified operators to identify 

process deviations or system problems when 

processes are not working as intended or there 

are equipment malfunctions. During one shift, an 

operator noticed a slight decrease in the solution 

level inside the extraction column of the uranium 

recovery process. The operator was not properly 

trained for recognizing the possible scenarios 

and the required actions for seeing such level 

fluctuation in the panel. The operator sent an 

employee for a visual check of the extraction 

system equipment. That employee found a small 

amount of liquid on the floor near the extraction 

column level control valve and assumed it was 

a leaking valve stem near the control valve. The 

employee communicated to the control room 

that everything was okay. During the next shift, a 

second operator continued to see a level deviation 

in the monitor of the extraction column process 

area and notified his supervisor. The supervisor 

immediately inspected the system components 

and identified a leak in the extraction column 

piping which resulted in a spill of high-enriched 

uranium solution with the potential of causing an 

inadvertent criticality accident. 

A criticality accident is an uncontrolled, sustained, 

nuclear chain reaction that occurs in an unsafe 

geometry containing fissile material. The sudden 

release of heat, neutrons, and gamma radiation 

associated with an inadvertent criticality accident 

may be lethal to nearby personnel. Criticality safety 

and the prevention of accidental criticality depend 

on a number of factors which are not production 

parameters: material enrichment, geometry, 

reflection, moderation, and other conditions. After 

communicating with the responsible individuals, 

the spill was handled in accordance with plant 

procedures and no inadvertent criticality occurred. 

The lack of communications in this scenario 

resulted in an increased potential for a criticality 

accident. The risk of an inadvertent criticality 

accident could have been significantly lower had 

the operator in the first shift communicated the 

need for additional training and communicated the 

level fluctuation he identified to the supervisor. 

The risk of a potential occupational exposure 

could also have been significantly lower had the 

employee who first inspected the system notified 

the operator and supervisors about the small spill 

so it could have been immediately addressed. 

Communications that maintain a focus on safety are 

essential for the safe handling of special nuclear 

material and for the protection of the workers, the 

public and the environment.3
28 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 29

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

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
30 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Respectful Work 

Environment? 

The NRC’s SCPS defines Respectful Work 

Environment as when trust and respect permeates 

the organization.

Why Is This Trait Important?

Trust and respect are among the most frequently 

discussed concepts in studies of organizational and 

safety culture. Trust and respect are fundamental 

to positive interpersonal relationships and central 

components of effective working relationships. 

The nature and level of trust and respect between 

workers and their managers and supervisors affect 

all aspects of their relationship and influence their 

attitudes and behaviors. Studies of organizations 

have found that trust in management is positively 

related to employee job performance, organizational 

citizenship behavior, and engagement in safety 

behaviors. Distrust of management tends to lower 

levels of engagement and reduce feelings of 

personal responsibility for safety.

At an individual level, trust involves the willingness 

of one person to depend on another person, with 

a relative sense of security. The perception that 

an individual is competent, has integrity, and is 

predictable increases the likelihood that he is trusted 

and respected. Trust and respect affect the persuasive 

power of an individual. Efforts to influence others 

are more likely to succeed when those attempting 

to influence are trusted and respected. In addition, 

successful work groups, teamwork, and collaboration 

require respect for others’ opinions and differing 

views. When differences are respected, they can 

be a source of motivation and innovation for an 

organization; lack of respect can destroy trust and 

weaken safety culture. 

At an organizational level, trust and respect instill 

confidence that the organization is just and fair, 

which promotes open communication and accurate 

reporting, enhances organizational learning, and 

promotes the development of shared perceptions 

and norms. In studies of safety culture, higher 

levels of trust and respect are associated with 

positive safety attitudes, reduced risky behavior, 

and increased personal responsibility for safety. 

Open communication, fairness, and management 

accountability are the most frequently identified 

mechanisms that build trust and respect in an 

organization. Leaders earn trust and respect when 

employees can see that they are fair, deal directly with 

problems and issues, and encourage and value all ideas 

and opinions. A strong safety culture requires mutually 

respectful, trusting relationships between and within 

workgroups and between all levels in the organization.1

What Does This Trait Look Like? 

Respect is Evident: Everyone is treated with dignity 

and respect. 

The organization regards individuals and their 

professional capabilities and experiences as its 

most valuable asset. Individuals at all levels of the 

organization, within and between workgroups, 

treat each other with dignity and respect. They 

do not demonstrate or tolerate bullying or 

humiliating behaviors. Leaders monitor for 

behaviors that can have a negative impact on the 

work environment and address them promptly. 

They ensure policies and expectations are enforced 

fairly and consistently for individuals at all levels 

of the organization. Individuals treat decisionmakers with respect, even when they disagree 

with a decision. Leaders ensure facilities are 

conducive to a productive work environment and 

housekeeping is maintained. 

Opinions are Valued: Leaders ensure that the bases 

for operational and organizational decisions are 

communicated in a timely manner. 

Individuals are encouraged to voice concerns, 

provide suggestions, and raise questions. Differing 

opinions are respected. The organization 

encourages individuals to offer ideas, concerns, 

suggestions, differing opinions, and questions 

to help identify and solve problems. Leaders are 

receptive to ideas, concerns, suggestions, differing 

opinions, and questions. The organization 

promotes robust discussions, recognizing 

that differing opinions are a natural result 

of differences in expertise and experience. 

Individuals value the insights and perspectives 

provided by quality assurance, the employee 

concerns program, and independent oversight 

organization personnel. 

RESPECTFUL WORK ENVIRONMENT
SAFETY CULTURE EDUCATIONAL RESOURCE 31

High Level of Trust: Trust is fostered among 

individuals and work groups throughout the 

organization. Leaders promote collaboration among 

work groups. 

Leaders respond to questions and concerns in 

an open and honest manner. Leaders, sensitive 

to the negative impact of a lack of information, 

share important information in an open, honest, 

and timely manner such that trust is maintained. 

They ensure that status and important work 

milestones are communicated throughout the 

organization. Leaders acknowledge positive 

performance and address negative performance 

promptly and directly with the individual involved. 

Confidentiality is maintained as appropriate. 

Leaders welcome performance feedback from 

throughout the organization and modify their 

behavior when appropriate. 

Conflict Resolution: Fair and objective methods are 

used to resolve conflicts. 

The organization implements processes to ensure 

fair and objective resolution of conflicts and 

differing views. Leaders ensure conflicts are 

resolved in a balanced, equitable, and consistent 

manner, even when outside of defined processes. 

Individuals have confidence that conflicts will be 

resolved respectfully and professionally.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

An authorized gauge user was conducting on-thejob training for a new employee on the licensee’s 

practice of placing the portable density gauge 

inside the extended cab of a pickup truck when 

staying overnight at a hotel, as is often required 

when working at temporary job sites. During 

this on-the-job instruction, the new employee 

stated that simply placing the gauge case inside 

the extended cab of a pickup truck would only 

provide one barrier, the locked vehicle door. The 

new employee suggested the gauge case also be 

secured to the inside of the pickup truck. Since 

the authorized gauge user conducting the onthe-job training had many years of experience, 

he discounted the new employee’s comment as 

inconsequential. 

Several weeks later, one of the licensee’s gauges 

was stolen from the cab of a pickup truck parked 

overnight at a hotel. The new employee, now an 

authorized gauge user, stated that he placed the 

gauge case inside the extended cab of the pickup 

truck, as previously instructed, and locked the 

vehicle’s doors using the key fob as he walked 

inside the hotel. The side window of the pickup 

truck had been left in a partially raised position. 

Since there were no signs of forced entry, it was 

concluded that the theft was a crime of opportunity 

and that the thief may have simply unlocked the 

door by reaching inside the vehicle through the 

window. Once the thief was inside the vehicle, the 

unsecured gauge case did not delay or deter the 

thief’s removal of the gauge. The new employee 

notified management of the theft and informed 

them that he had raised a concern involving the 

failure to secure the gauge case to the authorized 

gauge user who had provided his on-the-job 

training. Because the on-the-job trainer discounted 

the new employee’s recommendation to secure 

the gauge case to the inside of the pickup truck, 

the new employee explained that he did not feel 

it would be appropriate to go around the trainer 

to raise the concern directly to the radiation safety 

officer or management.

As a result of this incident, the licensee conducted 

an analysis and determined that the root cause 

of the violation was the licensee’s failure to fully 

understand how to implement the requirement 

of securing the gauge. The licensee’s practice 

was focused on the visibility of the gauge case 

as opposed to properly securing the gauge case. 

A contributing cause of the incident was the 

licensee’s employee leaving the passenger side 

window in a partially open position. The new 

employee again stated he did not feel that it 

would be respectful to the trainer if he continued 

to question the practice since the trainer was 

senior to him, and he did not feel he could trust 

the radiation safety officer or management not to 

provide negative feedback to the trainer.3
32 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 33

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

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
34 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Continuous 

Learning? 

The NRC’s SCPS defines Continuous Learning as 

opportunities to learn about ways to ensure safety 

are sought out and implemented.

Why Is This Trait Important?

Continuous learning contributes substantially 

to a positive safety culture. Continuous learning 

organizations are characterized by an enhanced 

ability and willingness of individuals to apply 

their individual learning in the workplace and 

to share and transfer it to their team members 

and coworkers. At the individual and team level, 

continuous learning includes obtaining knowledge, 

determining how that knowledge applies to the 

work of the individual and the team, as well as 

sharing that knowledge and ensuring that it is 

retained in the organization. To capture and sustain 

the benefits from individual and team learning, 

learning organizations develop leadership that 

prioritizes and motivates the desired learning 

and behaviors that are effective in ensuring that 

knowledge is shared and retained within an 

organization.

Organizations committed to continuous learning 

reflect an organizational perspective that specifically 

addresses learning requirements at the individual, 

group, and organizational levels. Leadership at all 

of these levels must focus on learning, teaching, 

and changing an organization into a learning 

organization. Continuous learning requires that 

leaders and managers trust and respect their 

workers. An environment that supports continuous 

learning is one that encourages an employee to ask 

questions, demonstrates appreciation for raising 

differing views, allows time for understanding, and 

encourages communication and collaboration. 

Learning organizations are committed to learning 

from their mistakes and those of others, and they 

take appropriate action to address lessons learned. 

They evaluate operating experiences and ensure 

that lessons learned are shared throughout an 

organization. They evaluate their own programs 

and policies for opportunities for improvement, 

benchmark other organizations, and understand 

the importance of training. Organizations focusing 

on continuous learning ensure that opportunities 

to improve safety are identified and shared, and by 

doing so, build a strong safety culture.1

What Does This Trait Look Like? 

Operating Experience: The organization 

systematically and effectively collects, evaluates, and 

implements relevant internal and external operating 

experience in a timely manner. 

A process is in place to ensure a thorough review 

of operating experience provided by internal 

and external sources. Operating experience is 

implemented and institutionalized effectively 

through changes to processes, procedures, 

equipment, and training programs. Operating 

experience is used to understand equipment, 

operational, and industry challenges and to adopt 

new ideas to improve performance. Operating 

experience is used to support daily work functions, 

with emphasis on the possibility that “it could 

happen here.” Operating experience is shared in a 

timely manner. 

Self-Assessment: The organization routinely 

conducts self-critical and objective assessments of 

its programs and practices. 

Independent and self- assessments, including 

nuclear safety culture assessments, are thorough 

and effective and are used as a basis for 

improvements. The organization values the 

insights and perspectives assessments provide. 

Self-assessments are performed on a variety of 

topics, including the self-assessment process itself. 

They are performed at a regular frequency and 

provide objective, comprehensive, and self-critical 

information that drive corrective actions. Targeted 

self-assessments are performed when a more 

thorough understanding of an issue is required. 

A balanced approach of self-assessments and 

CONTINUOUS LEARNING
SAFETY CULTURE EDUCATIONAL RESOURCE 35

independent oversight is used and periodically 

adjusted based on changing needs. Self-assessment 

teams include individual contributors and leaders 

from within the organization and from external 

organizations when appropriate. 

Benchmarking: The organization learns from other 

organizations to continuously improve knowledge, 

skills, and safety performance. 

The organization uses benchmarking as an 

avenue for acquiring innovative ideas to improve 

nuclear safety. The organization participates 

in benchmarking activities with other nuclear 

and nonnuclear facilities. The organization 

seeks out best practices by using benchmarking 

to understand how others perform the same 

functions. Benchmarking is used to compare 

standards to the industry and to make adjustments 

to improve performance. Individual contributors 

are actively involved in benchmarking. 

Training: The organization provides training 

and ensures knowledge transfer to maintain a 

knowledgeable, technically competent workforce 

and instill nuclear safety values. 

The organization fosters an environment in which 

individuals value and seek continuous learning 

opportunities. Individuals, including supplemental 

workers, are adequately trained to ensure 

technical competency and an understanding of 

standards and work requirements. Individuals 

master fundamentals to establish a solid 

foundation for sound decisions and behaviors. 

The organization develops and effectively 

implements knowledge transfer and knowledge 

retention strategies. Knowledge transfer and 

knowledge retention strategies are applied to 

capture the knowledge and skill of experienced 

individuals to advance the knowledge and skill 

of less experienced individuals. Leadership and 

management skills are systematically developed. 

Training is developed and continuously improved 

using input and feedback from individual 

contributors and subject-matter experts. Executives 

obtain the training necessary to understand basic 

operations and the relationships between major 

functions and organizations.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

Before a concrete pour at a nuclear power plant 

under construction, an engineer discovered that 

steel reinforcing bars were not spliced correctly 

in some locations. Work was halted and the rebar 

was reworked before the concrete pour. However, 

since the rebar was only spliced incorrectly in a 

“few” locations, the engineer gave verbal feedback 

to the concrete crew foreman on shift at the time 

of the discovery, but did not initiate a corrective 

action program condition report. The foreman of 

the concrete crew then had a brief discussion with 

his crew about the acceptable method of rebar 

splicing for the project. However, because the 

foreman believed that the issue was “skill of the 

craft,” no further training was necessary. He did 

not generate a corrective action report, request that 

work procedures be revised to specify the correct 

rebar splicing instructions, or provide feedback to 

the qualification training program. He intended to 

inform the concrete crew foreman of the other shift, 

but forgot during the hectic shift turnover.

Two months later, during another concrete pour, 

quality assurance inspectors discovered that several 

rebar splices were incorrect. However, this time the 

concrete pour had already begun. The pour was 

stopped and the condition was assessed. Extensive 

re-work was required to correct the rebar splices 

and remove the poured concrete sections. This 

work could not be performed expeditiously, and the 

entire concrete batch was lost. 

Upon review of the issue, the licensee discovered 

that problems with rebar splicing were not 

uncommon in the construction industry, and there 

were similar occurrences at nuclear construction 

projects both in the United States and at foreign 

sites. Also, concrete subcontractors often work 

on construction projects in different areas of 

construction, and they frequently work at sites with 

different requirements—sometimes during the same 

week. Continuous learning, through the use of 

benchmarking and lessons learned programs, may 

have prevented this incident.3
36 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 37

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

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
38 U.S. NUCLEAR REGULATORY COMMISSION

What Is The Definition Of Personal 

Accountability? 

The NRC’s SCPS defines Personal Accountability as 

all individuals take personal responsibility for safety.

Why Is This Trait Important?

Personal accountability reflects the belief that 

leaders and employees are responsible and have 

ownership for their performance and the roles they 

play in nuclear safety. Personal accountability is not 

finger pointing, blame, or punishment.

In organizations with positive safety cultures, 

individuals have a strong sense of accountability for 

the safe operation of the facility, their own safety, 

and for the safety of their coworkers and the public. 

Leaders can develop personal accountability within 

their organization by empowering employees. They 

must give employees the skills and training needed 

to communicate, explain, and do their jobs well. 

They must set performance objectives with specific 

behaviors and outcomes and evaluate performance 

and give timely feedback.

Furthermore, leaders should encourage 

accountability through rewards rather than 

discourage through punishment. When leaders 

model, acknowledge, and reward positive 

accountability behaviors, employees are more 

likely to be motivated to invest in safe operations 

personally. 

Everyone must take personal ownership for his 

or her actions and decisions for accountability to 

become a fundamental part of an organization’s 

safety culture. Reinforcement can come from 

supervisors and managers, but also from coworkers, 

the public, and an individual’s own personal 

values and standards. Accountability can motivate 

mindfulness, attention to detail, and self-assessment, 

and can result in fewer accidents and incidents. 

An ongoing challenge in fostering personal 

accountability is to identify who is responsible for 

the factors that affect safety within an organization 

and how to make appropriate accountability 

assignments. For example, responsibility can be 

assigned to ensure that training is completed, 

procedures are updated, and decisions are 

made. Accountability systems in an organization 

involve identifying who is held accountable for 

which actions and by whom. Alignment in these 

accountability systems within an organization can 

create effective communications, teamwork, strong 

safety performance, and motivated employees and 

can lead to a positive safety culture.1

What Does This Trait Look Like? 

Standards: Individuals understand the importance 

of adherence to nuclear standards. All levels of the 

organization exercise accountability for shortfalls in 

meeting standards. 

Individuals encourage each other to adhere to 

high standards. They demonstrate a proper focus 

on nuclear safety and reinforce this focus through 

peer coaching and discussions. Individuals hold 

themselves personally accountable for modeling 

nuclear safety behaviors and individuals across 

the organization apply nuclear safety standards 

consistently. Individuals actively solicit and are 

open to feedback and they help supplemental 

personnel understand and practice expected 

behaviors and actions. 

Job Ownership: Individuals understand and 

demonstrate personal responsibility for the 

behaviors and work practices that support nuclear 

safety. 

Individuals understand their personal 

responsibility to foster a professional environment, 

encourage teamwork, and identify challenges to 

nuclear safety. They understand their personal 

responsibility to raise nuclear safety issues, 

PERSONAL ACCOUNTABILITY
SAFETY CULTURE EDUCATIONAL RESOURCE 39

including those identified by others. Individuals 

take ownership for the preparation and execution 

of assigned work activities. They actively 

participate in pre-job briefings, understanding 

their responsibility to raise nuclear safety concerns 

before work begins. Individuals ensure that they 

are trained and qualified to perform assigned 

work and understand the objective of the work 

activity, their role in the activity, and their 

personal responsibility for safely accomplishing the 

overall objective. 

Teamwork: Individuals and work groups 

communicate and coordinate their activities within 

and across organizational boundaries to ensure 

nuclear safety is maintained. 

Individuals demonstrate a strong sense of 

collaboration and cooperation in connection with 

projects and operational activities. They work as 

a team to provide peer-checks, verify certifications 

and training, ensure detailed safety practices, 

actively peer coach new personnel, and share 

tools and publications. Individuals strive to meet 

commitments. 

Conflict Resolution: Fair and objective methods are 

used to resolve conflicts. 

The organization implements processes to ensure 

fair and objective resolution of conflicts and 

differing views. Leaders ensure conflicts are 

resolved in a balanced, equitable, and consistent 

manner, even when outside of defined processes. 

Individuals have confidence that conflicts will be 

resolved respectfully and professionally.2

What Is A Scenario In Which This Trait Could 

Play A Role? 

A welder at a vendor facility inadvertently dropped 

a spool of weld wire into a puddle while carrying it 

to the controlled storage area at the end of his shift. 

When weld wire is exposed to water, the flux inside 

absorbs moisture. Once the welding wire is wetted 

or absorbs an excessive amount of moisture, no 

process can “dry out” the welding wire. Dropping 

a spool of weld wire in a puddle would make it 

unacceptable for use in welding safety-related 

components. Wetted weld wire can potentially result 

in welding defects such as porosity. Wetted weld 

wire also can contribute to hydrogen cracking, 

which might not be detected unless the inspection 

of the welds is conducted at least 48 hours after the 

weld is completed.

However, the quality inspector responsible for 

checking in the wire believed that the spool would 

dry out, and attached a handwritten note “DO 

NOT USE SPOOL” to prevent issuance while it 

was still wet. The quality inspector accepting the 

wetted wire did not enter the issue into either the 

nonconformance or corrective action programs, as 

required. Within a few days, the wire developed 

spots of surface rust. Numerous quality inspectors, 

including the lead inspector, who had access to the 

controlled storage area and responsibility to issue 

and receive the wire on a daily basis, observed 

the spool of wire with the handwritten note. Many 

knew that it had been wetted or that it had visible 

rust spots. No personnel took the appropriate action 

to write a nonconformance or corrective action 

report. Because the issue was not documented in 

the corrective action system, the spool was not 

segregated from the spools ready for issue, the 

cause of the rust had not been determined, and an 

investigation had not been performed to determine 

whether any nonconforming wire had actually been 

used in a safety-related welding application.

The vendor did not document or investigate the 

issue until a U.S. Nuclear Regulatory Commission 

inspector discovered the spool of weld wire 

during a walkdown. The wire was intended for 

use on nuclear safety-related welds for modular 

subassemblies for a domestic plant. Ultimately, the 

vendor determined that the spool of wire had not 

been used for production work after it was wetted, 

even though it was on the shelf and could have 

potentially been used. This incident may have been 

prevented if the vendor personnel had exhibited 

personal accountability for their behaviors and 

work practices.3
40 U.S. NUCLEAR REGULATORY COMMISSION

Thinking about this scenario, consider the following questions: 

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. How could management have handled this situation differently? 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 41

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

1. How does this trait apply to my organization? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
42 U.S. NUCLEAR REGULATORY COMMISSION

Overview

The NRC developed the Case Studies to provide 

real-life events where review of the circumstances 

surrounding the events and the results of the 

investigations found clear examples of the role 

that safety culture played in contributing to, or 

lessening, the loss of life and damage associated 

with the event. These Case Studies represent a 

breadth of industries, including energy, medical, and 

transportation, and can be found on the Web site at

http://www.nrc.gov/about-nrc/safety-culture.html. 

The Case Studies aid in understanding the 

importance of developing and maintaining a positive 

safety culture. They highlight the significance of 

safety culture in the analysis and identification 

of root causes of an event and enhance safety by 

raising awareness of safety culture and by applying 

lessons learned. 

The Case Study included here, “June 2009 Collision 

of Two Washington Metropolitan Area Transit 

Authority Metrorail Trains near Fort Totten Station, 

Washington, DC,” includes a description of the event 

that occurred, probable cause, lessons learned, 

and an analysis of the event in terms of the safety 

culture traits. This Case Study was chosen because it 

complements the subsequent Safety Culture Journey 

on the same event and organization. Readers can 

gain a more in-depth understanding of safety culture 

by considering this Case Study and Journey together.

It is important to remember that a Case Study that 

depicts a certain community or organization can 

be applicable to any organization. When reviewing 

the Case Study, consider how an event in your own 

organization could occur if you are experiencing 

similar weak, or absent, safety culture traits. 

June 2009 Collision of Two 

Washington Metropolitan Area 

Transit Authority Metrorail 

Trains near Fort Totten Station, 

Washington, DC

What Happened?

On Monday, June 22, 2009, at about 4:58 p.m. 

eastern daylight time, WMATA Metrorail train 112 

struck the rear of stopped Metrorail train 214. The 

powerful impact caused the rear car of train 214 to 

telescope into the lead car of train 112, resulting in 

a loss of occupant survival space in the lead car of 

about 63 feet (about 84 percent of its total length). 

Nine people aboard train 112, including the train 

operator, were killed. Emergency response agencies 

reported transporting 52 people to local hospitals.1

Probable Cause

• “A failure of track circuit modules caused the 

automatic train control system to lose detection of 

one train (train 214) allowing a second train (train 

112) to strike it from the rear.”2

• WMATA failed to institutionalize and employ 

across the system an enhanced track circuit 

verification test procedure that was developed 

following a near collision in Rosslyn, VA, in 2005. 

If this test procedure had been institutionalized 

and used systemwide, it would have identified the 

faulty track circuit before the accident.1

• Other major contributing factors were “WMATA’s 

lack of a safety culture” and WMATA’s failure 

to replace or retrofit 1000-series railcars, which 

were shown in a 2004 accident to exhibit poor 

crashworthiness.1

SAFETY CULTURE CASE STUDY
SAFETY CULTURE EDUCATIONAL RESOURCE 43

SCPS Traits Evidence of Weak Safety Culture Traits1

Leadership Safety Values and Actions At a monthly board meeting on June 25, 2009, WMATA provided a safety culture presentation to 

its Board of Directors. The presentation focused on WMATA’s commitment to correct recognized 

hazards, such as parking lot injuries and improper door operations. It did not address safety or train 

operations or audit findings and corrective action plans. The NTSB was concerned that senior 

management may have placed too much emphasis on investigating these types of hazards to the 

exclusion of passenger safety during transit. 

Problem Identification and Resolution “In 2006, the NTSB recommended that WMTA accelerate the retirement of the 1000-series cars 

or retrofit them with crashworthiness collision protection comparable to the 6000-series cars. In 

2007, that recommendation was classified ‘Closed—Unacceptable Action’ based on WMATA’s 

response that it was not feasible to retrofit the 1000-series cars and that they would remain in 

service until replacement with the 7000-series cars in 2014,” as originally planned. This issue was 

identified and evaluated but not addressed or corrected commensurate with the potential risk. The 

NTSB report recommends replacing all 1000-series railcars as soon as possible with cars that have 

crashworthiness collision protection at least comparable to the 6000-series railcars.

Personal Accountability The June 25, 2009, WMATA safety presentation defined a preventable accident as “an accident 

that occurred because the employee failed to do everything reasonably expected of a trained 

professional to avoid involvement in an accident.” (NTSB/RAR-10/02) Based on this definition, NTSB 

concluded that “WMATA placed much of the blame for causing and much of the responsibility for 

preventing accidents on frontline employees. Placing blame on frontline employees is not likely to 

improve the safety of the system as a whole.”

Work Processes As the result of a 2005 audit, the Federal Transit Administration issued nine deficiency findings 

and one recommendation to comply with the Code of Federal Regulations. After 2 years, the audit 

findings were still open and WMATA did not have a process to identify and address system safety 

deficiencies.

Continuous Learning The 2005 near collision in Rosslyn, VA, afforded a prime opportunity to learn about ways to ensure 

safety. WMATA developed an enhanced track circuit verification test to identify track circuits 

with the potential to lose train detection; however, the test was never institutionalized and circuit 

monitoring tools fell into disuse, indicating that WMATA either did not recognize the severity of the 

risk posed or did not communicate that hazard to all departments of the agency. The results of the 

hazard assessment and procedures for addressing the identified risk should have been integrated 

into the training and guidance materials for all affected personnel. 

Environment for Raising Concerns NTSB found examples of a deficient reporting culture within WMATA resulting from fear of 

retaliation. As a result of these findings, NTSB recommended that WMATA develop and implement a 

nonpunitive safety reporting program to collect and review reports from staff at all levels throughout 

the organization and share the results of these reviews with all divisions of WMATA.

Effective Safety Communication In response to the 2005 event in Rosslyn, VA, WMATA developed and issued technical bulletins 

requiring the use of an enhanced circuit verification test procedure; however, none of the WMATA 

technicians interviewed as part of the investigation was familiar with the enhanced procedure. 

NTSB concluded that WMATA failed to recognize that the near collision in Rosslyn represented an 

unacceptable hazard and did not ensure that the communication reached all affected divisions in the 

organization for resolution.

Respectful Work Environment WMATA required all trains to be operated in automatic mode during the morning and evening rush 

periods. The operator of train 214 had been reprimanded previously for operating his train in manual 

mode; however, on the day of the accident, he changed from automatic to manual mode because he 

did not want to rely on the automated system to properly position the train along the platform. His 

actions are indicative of the distrust between WMATA management and its employees. “Disciplinary 

practices perceived as unfair can motivate individuals to hide safety-related information or adopt 

behaviors to avoid blame.” 

Questioning Attitude The NTSB report states that managers had an apparent tendency to tolerate failures and 

malfunctions in the automatic train control system. This may explain why WMATA officials had 

designated track circuit alarms in the Metrorail Operations Control Center as requiring no specific 

response and why neither technicians nor maintenance officials placed a high priority on addressing 

a loss of train detection. NTSB concluded that this complacency likely influenced the inadequate 

response to malfunctions. 
44 U.S. NUCLEAR REGULATORY COMMISSION

What Can Organizations Learn From 

This Accident?

This accident reinforces the need for, and 

importance of, promoting a positive safety culture 

by routinely evaluating NRC safety culture activities 

and initiatives and making enhancements and 

adjustments to ensure that your organization 

remains proactive and appropriately focused in this 

important area. Key lessons from this case study 

include the following:

• Leaders and individuals should be committed to 

the core values and behaviors that emphasize 

safety over competing goals to ensure protection 

of people and the environment.

• Problems that have been identified as potential 

safety threats, but that have not been fully 

evaluated and addressed, should be escalated until 

resolved.

• Personnel should be encouraged to raise concerns 

without fear of retaliation.

• Processes and procedures should be standardized, 

implemented, maintained, and communicated.

• Personnel, equipment, tools, procedures, and 

other resources needed to ensure safety and 

security should be available.
SAFETY CULTURE EDUCATIONAL RESOURCE 45

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

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

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_________________________________________________________________________________________________________

2. What impact did safety culture have on the event’s outcome, including whether it could have helped to 

prevent the event all together? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. What can I learn from this case? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

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46 U.S. NUCLEAR REGULATORY COMMISSION

Overview

How did the organization assess its safety culture 

and identify weaknesses? What corrective actions 

and new initiatives did it take? How can it sustain 

a positive safety culture? The NRC was asked these 

questions many times after stakeholders, vendors, 

and others involved in safety regulation reviewed 

the Safety Culture Case Studies. In response to these 

questions, the NRC developed the Safety Culture 

Journey—a case study of an organization’s efforts to 

improve its safety culture.

Safety culture is a dynamic process that can change 

with new leadership, situations, and organizational 

conditions. Building and sustaining a positive 

safety culture that can withstand organizational 

challenges requires time, vigilance, and initiative. 

An organization’s response to accidents or events 

typically includes assessment of its safety culture, 

identification of weaknesses, and implementation 

of corrective actions and new initiatives. An 

organization must continue to be diligent, plan 

for the future, and put goals in place to keep the 

focus on safety. The journey it takes reflects its 

commitment to safety as its highest priority.

The Safety Culture Journey offers a brief synopsis 

of an event and highlights how the organization 

assessed its safety culture and identified weaknesses, 

and what corrective actions and new initiatives the 

organization took. Many of these initiatives reflect 

the traits of a positive safety culture as described in 

the SCPS, and this analysis is also included. Finally, 

the Journey discusses the strategies the organization 

put in place to sustain a positive safety culture. 

The Safety Culture Journey included here is “The 

Washington Metropolitan Area Transit Authority” 

because it is the followup to the previous case study 

included in this education resource on the same 

subject. These two studies, read together, provide an 

in-depth look at an event, as well as the followup 

actions taken to improve the organization’s safety 

culture. Please note that the Safety Culture Journey 

summarizes actions taken during a discrete period 

of time, in this case between 2009 and 2013. Events, 

initiatives, or actions occurring after this time period 

may continue to challenge the organization’s safety 

culture, which reflects the continuous journey that is 

safety culture. 

After reading this Safety Culture Journey, reflect 

on how the safety culture traits are visible in your 

own organization and what actions you might take 

to move forward on your safety culture journey. 

The lessons learned by the organization depicted 

in this Safety Culture Journey and the actions taken 

in response to the accident may work in your 

organization as well, although they may need to be 

modified to fit. Remember that assessments, strategic 

plans, or educational initiatives are universal action 

items that are not specific to any one organization. 

The Washington Metropolitan Area 

Transit Authority

On Monday, June 22, 2009, the Washington 

Metropolitan Area Transit Authority (WMATA) 

Metrorail train 112 struck the rear of stopped 

Metrorail train 214 at the Fort Totten station. Nine 

people aboard train 112 were killed and 52 people 

were injured. One major contributing factor to this 

accident was “WMATA’s lack of a safety culture.”1,2 

Since the accident, WMATA has conducted safety 

culture assessments, implemented new initiatives 

and prioritized safety culture in its strategic plan. 

The journey demonstrates how an organization’s 

weak safety culture can contribute to a serious 

accident, how safety culture can be assessed and 

improved, and how a positive safety culture can be 

fostered and sustained through strategic planning 

and leadership commitment to safety as the highest 

priority.

SAFETY CULTURE JOURNEY
SAFETY CULTURE EDUCATIONAL RESOURCE 47

How did the organization assess their safety 

culture and identify weaknesses?

Since the Metro accident in 2009, there has been 

an investigation, audit, reports and surveys. These 

assessments provided WMATA with the information 

needed to decide what actions to take. Although 

the following list of reports is not comprehensive, it 

demonstrates WMATA’s continuous focus on safety 

culture.3

• On March 4, 2010, the Federal Transit 

Administration (FTA) issued its audit of the TriState Oversight Committee (TOC) and WMATA. 

The report highlighted key deficiencies in the 

safety and oversight programs at WMATA and TOC 

in the aftermath of the Ft. Totten collision, and 

recommended that WMATA fundamentally change 

its organization and culture.3

• The National Transportation Safety Board (NTSB) 

investigated the accident and released its report 

on July 27, 2010. This report included the 11 

findings and 10 recommendations from the 

FTA’s 2010 audit, and it provided evidence of an 

ineffective safety culture within the organization. 

NTSB issued a total of 34 recommendations in 

connection with this accident.1

• During 2010, the WMATA Office of the Inspector 

General (OIG) performed a control self 

-assessment (CSA) of employee safety. The CSA 

results indicated that employees did not believe 

WMATA provided them with a safe working 

environment because of unmitigated hazards, 

inadequate training and ineffective internal and 

external communication.3

• During July 2010, over 9,000 WMATA employees 

completed a safety culture survey and the 

organization reported the results in October 2010. 

The findings identified numerous weaknesses 

in safety culture. Among them: Employees were 

concerned about retaliation from peers; reported 

safety concerns were not consistently addressed 

across Metro; and when safety issues were 

appropriately addressed, employees felt Metro did 

not close the loop with employees.5

• In February 2011, WMATA issued a safety progress 

report to its Board of Directors that included the 

following goal: “Many recommendations, one 

central theme-Metro must instill a strong, unified 

and pervasive safety culture and thereby improve 

the safety of our employees, customers and 

communities we serve.”6

• From September through October 2012, WMATA 

administered an Employee Engagement Survey 

to measure the progress in creating a safety 

culture and identify WMATA strengths and 

opportunities for improvement. The results 

indicated that WMATA has made significant 

progress in strengthening its safety culture. The 

most important finding was that employees were 

reporting significant progress in implementing 

Metro’s safety culture:

• The scores of the survey indicated that employees: 

• know how to report safety issues or concerns 

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

can provide ideas and suggestions for improving 

safety

• assert that their direct supervisor regularly 

provides safety communication 

• report that their co-workers take safety policies 

and procedures seriously

• believe effective action would be taken if a safety 

violation was reported

• assert they are comfortable in reporting safety 

violations and concerns7

What Corrective Actions and New Initiatives 

Did They Take?

In response to the 2009 accident and subsequent 

investigation, audits and surveys, WMATA 

implemented changes to its organization and 

developed new programs and policies.3,4 These 

initiatives reflect the traits of a positive safety culture 

as described in the NRC’s Safety Culture Policy 

Statement (SCPS). Although some initiatives could 

reflect several SCPS traits, only the most relevant 

trait associated with each key initiative is listed. 

In addition, because one trait may best represent 

several initiatives, all nine SCPS traits may not be 

represented in the following chart.
48 U.S. NUCLEAR REGULATORY COMMISSION

SCPS Traits Initiatives

Leadership Safety Values and Actions Metro’s Board took the lead in building a safety - first culture by establishing the Safety 

and Security Committee that provides public information on WMATA’s safety program 

activities and initiatives, safety performance, as well as the results of investigations into 

accidents and incidents.

Leadership Safety Values and Actions WMATA’s Chief Safety Officer is a direct report to the General Manager and Chief 

Executive Officer (GM/CEO) and is an active and involved member of the Executive 

Leadership Team. Since 2010, the Safety Department has doubled in size and increased it 

authority and technical capacity. The Safety Department’s annual budget has more than 

tripled since 2010 to $17.4 million.

Work Processes WMATA updated its Metrorail Safety Rules and Procedures Handbook (MSRPH), and 

developed a new Roadway Worker Protection (RWP) program. Both initiatives represent a 

positive change in the way WMATA conducts its operations and maintenance.

Problem Identification and Resolution WMATA re-established and strengthened its safety committee structure to ensure that 

safety concerns are identified at the field level, evaluated and resolved at the managerial 

level, and that conflicts and differenced of opinion are decided at the executive level.

Environment for raising Concerns WMATA initiated a safety hotline that includes an anonymous, Web-based reporting 

application that runs 24/7.

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

Questioning Attitude WMATA gave employees the right to challenge their safety on the job through a “Good 

Faith Challenge” process.

Personal Accountability WMATA created the “Champions of Safety” program to recognize employees who 

maintain safe work practices.

Effective Safety Communication All WMATA executive management communications with employees have been reviewed 

to ensure that safety is included and prioritized, and is the first agenda item for most 

executive meetings and briefings.

Leadership Safety Values and Actions WMATA’s GM/CEO conducts one-on-one monthly meetings with members of the Executive 

Leadership Team to reduce communication silos and promote proactive ownership of 

safety issues.

Continuous Learning WMATA’s Executive Safety Committee has been re-established and reviews WMATA’s 

safety performance to discuss the results of investigations into accidents, incidents and 

unusual occurrences.
SAFETY CULTURE EDUCATIONAL RESOURCE 49

How can WMATA Sustain a Positive Safety 

Culture?

In 2013, WMATA issued their 2013-2025 strategic 

plan, which states the following: “Continuous 

attention to improving safety culture has resulted 

in employees who are now highly engaged, have 

clarity about their mission, and have the authority 

and information to do their jobs well. Finally, the 

strategic plan clearly articulates that everyone must 

do their part in creating and sustaining a culture of 

safety and security, and affirms that safety is the first 

priority.” Goal 1 of this plan, “Build and Maintain 

a Premier Safety Culture and System,” reflects their 

focus on safety culture and includes the following:4

• Keep safety Metro’s first priority: Metro will 

continue its efforts to return to and keep the 

system equipment and infrastructure in good 

condition. Metro will use data-driven and sciencebased methods to allocate resources, use system 

safety practices and principles and environmental 

design to enhance safety, and seek to meet or 

exceed national safety and security standards 

for transit.

• Create a shared climate of safety: Metro will work 

with employees, riders, jurisdictional partners, 

and the general public to make sure that everyone 

does their part in creating and sustaining a culture 

of safety and security in stations, vehicles, support 

facilities, and access points. Metro will enhance its 

communications feedback loops to bring critical 

safety information to empowered agents quickly to 

prevent accidents before they happen.

• Expect the unexpected: Metro will continue 

to support the region’s emergency transit 

management and security readiness protocols and 

seek to make transit emergency protocols widely—

and easily—understood. Metro will maintain 

regional evacuation capability and prepare for 

any event that requires wide-scale response. On 

a smaller scale, Metro will continue to improve 

incident response timing, planning, preparation, 

and investigation.
50 U.S. NUCLEAR REGULATORY COMMISSION

Now that you have read through this Safety Culture Journey, consider how the actions, initiatives and 

lessons learned could apply to your organization and ask yourself the following questions: 

1. Has my organization been on a similar journey? 

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_________________________________________________________________________________________________________

2. What did my organization do differently? 

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_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. What can I learn from this organization’s experience? 

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
SAFETY CULTURE EDUCATIONAL RESOURCE 51

Sources of Information

Sources of Information for Safety Culture Trait Talk: 

1. “Why is this trait important?” was derived, in part, 

from a literature review (Agencywide Documents 

Access and Management System (ADAMS) 

Accession No. ML13023A054) prepared by Pacific 

Northwest National Laboratories for the NRC 

Office of Nuclear Regulatory Research. 

2. “What does this trait look like?” was derived 

from the Safety Culture Common Language 

effort (ADAMS Accession No. ML13031A343), 

under the direction of the Office of Nuclear 

Reactor Regulation. Panelists from the NRC, 

nuclear power industry, and the public created 

attributes of a positive nuclear safety culture, and 

examples of each attribute that a nuclear power 

organization should demonstrate in maintaining a 

positive safety culture. Although these attributes 

and examples were created specifically for the 

reactor community, they may also be applicable 

to various other communities and organizations. 

For purposes of Trait Talk, the examples were 

partially rewritten to increase applicability to 

reactor as well as non-reactor communities. 

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

was developed specifically for Safety Culture Trait 

Talk for educational purposes only. The scenario 

is fictional and any resemblance to actual events, 

people, or organizations is purely coincidental.

Sources of Information for Safety Culture Case Study:

The information included in these case studies 

was taken from official investigative reports and 

other documents, assessments and reports that 

were publicly available when the specific case 

study was developed The NRC has not conducted 

a formal analysis of the events discussed herein 

for, or in conjunction with, NTSB, WMATA, or any 

other organization. The NRC compiled the factual 

information presented from publicly available sources.

1. NTSB Number RAR-10/02

2. NTSB News-SB-10-29

Sources of Information for the Safety Culture 

Journey:

The information included in the Safety Culture 

Journey was taken from assessments, documents 

and reports that were publicly available when the 

specific Safety Culture Journey was developed. The 

NRC has not conducted a formal analysis of the 

events discussed herein for, or in conjunction with, 

NTSB, WMATA, or any other organization. The NRC 

compiled the factual information presented from 

publicly available sources: 

1. Railroad Accident Report, NTSB Number 

RAR-10/02

2. Safety Culture Communicator case study 1: 

June 2009 Collision of Two Washington 

Metropolitan Area Transit Authority Metrorail 

Trains Near Fort Totten Station, Washington, DC

3. Rail Transit Safety Program: Safety and 

Maintenance Audit of the Washington 

Metropolitan Area transit Authority (WMATA) 

Final Audit Report November 28, 2012, Federal 

Transit Administration, Office of Safety and 

Security.

4. MOMENTUM The Next Generation of Metro 

Strategic Plan 2013–2025

5. Safety Culture Survey Report, October 28, 2010

6. Safety Progress Report, WMATA, Safety and 

Security Committee, February 24, 2011

7. Board Action/Information Summary: Employee 

Engagement Survey, Washington Metropolitan 

Area Transit Authority, December 6, 2012
52 U.S. NUCLEAR REGULATORY COMMISSION

Safety Culture Policy 

Statement 

76 FR 34773; June 14, 2011

Nuclear Regulatory 

Commission 

[NRC–2010–0282] 

Final Safety Culture Policy 

Statement 

AGENCY: Nuclear Regulatory 

Commission. 

ACTION: Issuance of final safety 

culture policy statement. 

SUMMARY: The U.S. Nuclear 

Regulatory Commission (NRC or 

the Commission) is issuing this 

Statement of Policy to set forth 

its expectation that individuals 

and organizations performing or 

overseeing regulated activities 

establish and maintain a positive 

safety culture commensurate 

with the safety and security 

significance of their activities 

and the nature and complexity of 

their organizations and functions. 

The Commission defines Nuclear 

Safety Culture as the core values 

and behaviors resulting from a 

collective commitment by leaders 

and individuals to emphasize 

safety over competing goals to 

ensure protection of people and 

the environment. This policy 

statement applies to all licensees, 

certificate holders, permit holders, 

authorization holders, holders 

of quality assurance program 

approvals, vendors and suppliers 

of safety-related components, and 

applicants for a license, certificate, 

permit, authorization, or quality 

assurance program approval, 

subject to NRC authority. 

DATES: This policy statement 

becomes effective upon 

publication in the Federal Register. 

ADDRESSES: You can access 

publicly available documents 

related to this document using the 

following methods: 

• NRC’s Public Document Room 

(PDR): The public may examine 

and have copied, for a fee, 

publicly available documents 

at the NRC’s PDR, Room O1– 

F21, One White Flint North, 

11555 Rockville Pike, Rockville, 

Maryland 20852. 

• NRC’s Agencywide Documents 

Access and Management System 

(ADAMS): Publicly available 

documents created or received at 

the NRC are available online in 

the NRC Library at http://www.

nrc.gov/reading-rm/adams.html.

From this page, the public can 

gain entry into ADAMS, which 

provides text and image files of 

the NRC’s public documents. If 

you do not have access to ADAMS 

or if there are problems in 

accessing the documents located 

in ADAMS, contact the NRC’s PDR 

reference staff at 1–800–397–4209, 

301–415–4737, or by e-mail to 

pdr.resource@nrc.gov.

• Federal rulemaking Web site: 

Public comments and supporting 

materials related to this document 

can be found at http://www.

regulations.gov by searching 

on Docket ID NRC–2010– 0282. 

Address questions about NRC 

dockets to Carol Gallagher, 

telephone: 301–492–3668; e-mail: 

Carol.Gallagher@nrc.gov.

FOR FURTHER INFORMATION 

CONTACT: Roy P. Zimmerman, 

Director, Office of Enforcement, 

U.S. Nuclear Regulatory 

Commission, Washington, DC 

20555–0001; telephone: 

301–415–2741; e-mail: 

Roy.Zimmerman@nrc.gov. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A. Previous Policy Statements and 

Events Involving Safety Culture

The NRC has long recognized 

the importance of a safetyfirst focus in nuclear work 

environments for public health 

and safety. The Commission’s 

emphasis on a safety-first focus 

is reflected in two previously 

published NRC policy statements. 

The 1989, ‘‘Policy Statement on 

the Conduct of Nuclear Power 

Plant Operations’’ (54 FR 3424; 

January 24, 1989), applies to all 

individuals engaged in activities 

that affect the safety of nuclear 

power plants, and provides the 

Commission’s expectations of 

utility management and licensed 

operators with respect to the 

conduct of operations. The 

1996, ‘‘Freedom of Employees 

in the Nuclear Industry to Raise 

Safety Concerns Without Fear of 

Retaliation’’ (61 FR 24336; May 

14, 1996), applies to the regulated 

activities of all NRC licensees 

and their contractors and 

subcontractors, and provides the 

Commission’s expectations that 

licensees and other employers 

subject to NRC authority establish 

and maintain safety-conscious 

work environments in which 

employees feel free to raise 

APPENDIX
SAFETY CULTURE EDUCATIONAL RESOURCE 53

safety concerns, both to their 

management and to the NRC, 

without fear of retaliation. This 

Safety Culture Statement of Policy, 

in conjunction with the previous 

policy statements, is intended to 

emphasize the importance the 

NRC places on the development 

and maintenance of a positive 

safety culture for all regulated 

activities. 

The accident at the Chernobyl 

nuclear power plant in 1986, 

brought attention to the 

importance of safety culture and 

the impact that weaknesses in 

safety culture can have on safety 

performance. Since then, the 

importance of a positive safety 

culture has been demonstrated 

by a number of significant, highvisibility events worldwide. In the 

United States, incidents involving 

the civilian uses of radioactive 

materials have not been confined 

to a particular type of licensee 

or certificate holder, as they have 

occurred at nuclear power plants 

and fuel cycle facilities and during 

medical and industrial activities 

involving regulated materials. 

Assessments of these incidents 

revealed that weaknesses in the 

regulated entities’ safety cultures 

were an underlying cause of the 

incidents or increased the severity 

of the incidents. The causes of 

these incidents included, for 

example, inadequate management 

oversight of process changes, 

perceived production pressures, 

lack of a questioning attitude, and 

poor communications. One such 

incident indicated the need for 

additional NRC efforts to evaluate 

whether the agency should 

increase its attention to reactor 

licensees’ safety cultures. This 

resulted in important changes 

to the NRC’s Reactor Oversight 

Process (ROP). Commission 

paper SECY–06–0122, dated May 

24, 2006, (ADAMS Accession 

No. ML061320282) describes the 

NRC’s safety culture activities at 

that time and the outcomes of 

those activities. 

Following the terrorist attacks 

of September 11, 2001, the 

Commission issued orders 

enhancing security at facilities 

whose operations, if attacked, 

could have an impact on public 

health and safety. During the early 

years of implementation of these 

security enhancements, several 

violations of the Commission’s 

security requirements were 

identified in which the licensee’s 

failure to cultivate a positive 

safety culture impacted the 

effectiveness of the licensee’s 

security program. The most visible 

of these involved security officers 

sleeping in a ‘‘ready room’’ while 

on shift at a nuclear power plant. 

Most of the weaknesses involved 

inadequate management oversight 

of security, lack of a questioning 

attitude within the security 

organization, complacency, 

barriers to raising concerns about 

security issues, and inadequate 

training of security personnel. 

B. Commission Direction 

In February 2008, the 

Commission issued Staff 

Requirements Memorandum 

(SRM), SRM–COMGBJ– 08–

0001 (ADAMS Accession No. 

ML080560476), directing 

the NRC staff to expand the 

Commission’s policy on safety 

culture to address the unique 

aspects of security and to ensure 

the resulting policy is applicable 

to all licensees and certificate 

holders. The Commission directed 

the staff to answer several 

additional questions, including: 

(1) Whether safety culture as 

applied to reactors needed to 

be strengthened; (2) how to 

increase attention to safety culture 

in the materials area; (3) how 

stakeholder involvement can most 

effectively be used to address 

safety culture for all NRC and 

Agreement State licensees and 

certificate holders, including any 

unique aspects of security; and 

(4) whether publishing the NRC’s 

expectations for safety culture 

and for security culture would be 

best accomplished in one safety/

security culture statement or in 

two separate statements while 

still considering the safety and 

security interfaces. 

In response to Commission 

direction, the NRC staff reviewed 

domestic and international 

safety-culture-related documents 

and considered NRC lessons 

learned. Additionally, the staff 

sought insights and feedback 

from external stakeholders. This 

was accomplished by providing 

information in a variety of forums, 

such as stakeholder organization 

meetings, newsletters, and 

teleconferences, and by 

publishing questions developed 

to address Commission direction 

in the February 9, 2009, Federal 

Register notice (FRN) (74 FR 6433) 

entitled ‘‘Safety Culture Policy 

Statement Development: Public 

Meeting and Request for Public 

Comments’’ (ADAMS Accession 

No. ML090260709). 

In February 2009, the NRC 

held a public workshop on 

the ‘‘Development of a Policy 

Statement on Safety Culture and 

Security Culture’’ in which a broad 

range of stakeholders participated, 
54 U.S. NUCLEAR REGULATORY COMMISSION

including representatives from 

the Agreement States (Meeting 

Summary: ADAMS Accession 

No. ML090930572). The staff 

developed draft characteristics 

(subsequently referred to as 

‘‘traits’’) of a positive safety 

culture and presented them 

at the workshop. Mindful of 

the increased attention to the 

important role of security, the 

staff also sought input from the 

workshop participants on whether 

there should be a single safety 

culture policy statement or two 

policy statements addressing 

safety and security independently 

while considering the interface 

of both. Before providing 

its recommendations to the 

Commission, the staff developed 

a draft definition of safety culture 

in which it modified a definition 

from the International Atomic 

Energy Agency’s advisory group, 

the International Nuclear Safety 

Group, to make it applicable to 

all NRC-regulated activities and to 

address security. 

Based on its review and 

stakeholder feedback, in 

SECY–09–0075, ‘‘Safety Culture 

Policy Statement,’’ dated 

May 16, 2009 (ADAMS Accession 

No. ML091130068), the NRC staff 

provided a single draft safety 

culture policy statement for 

Commission approval. The draft 

policy statement acknowledged 

the importance of safety and 

security, and the interface of both, 

within an overarching culture of 

safety. Additionally, in response 

to the Commission’s questions, 

the staff: (1) Concluded that 

the NRC’s oversight of safety 

culture as applied to reactors has 

been strengthened, is effective, 

and continues to be refined in 

accordance with the existing 

ROP self-assessment process; 

(2) described actions taken and 

planned for increasing attention 

to safety culture in the materials 

area; and (3) described actions 

taken and planned for most 

effectively obtaining stakeholder 

involvement to address safety 

culture, including any unique 

aspects of security, for all NRC 

and Agreement State licensees and 

certificate holders. 

In SRM–SECY–09–0075 (ADAMS 

Accession No. ML092920099), the 

Commission directed the staff to: 

(1) Publish the draft safety culture 

policy statement for no fewer than 

90 days; (2) continue to engage 

a broad range of stakeholders, 

including the Agreement States 

and other organizations with 

an interest in nuclear safety, to 

ensure the final policy statement 

presented to the Commission 

reflects a broad spectrum of 

views and provides the necessary 

foundation for safety culture 

applicable to the entire nuclear 

industry; (3) make the necessary 

adjustments to encompass security 

within the statement; (4) seek 

opportunities to comport NRC 

terminology, where possible, with 

that of existing standards and 

references maintained by those 

that the NRC regulates; and (5) 

consider incorporating suppliers 

and vendors of safety-related 

components in the safety culture 

policy statement. 

C. Development of the Final Policy 

Statement 

On February 2–4, 2010, the 

NRC held a second safety culture 

workshop to provide a venue for 

interested parties to comment 

on the draft safety culture policy 

statement. The additional goal of 

the workshop was for panelists 

representing a broad range of 

stakeholders to reach alignment, 

using common terminology, on 

a definition of safety culture 

and a high-level set of traits 

that describe areas important 

to a positive safety culture. The 

workshop panelists represented 

a wide range of stakeholders 

regulated by the NRC and/ or 

the Agreement States, including 

medical, industrial, and fuel cycle 

materials users, and nuclear 

power reactor licensees, as well 

as the Nuclear Energy Institute, 

the Institute of Nuclear Power 

Operations (INPO), and members 

of the public. The workshop 

panelists reached alignment with 

input from the other meeting 

attendees on a definition of safety 

culture and a high-level set of 

traits describing areas important 

to a positive safety culture. 

Following the February 2010, 

workshop, the NRC staff evaluated 

the public comments that were 

submitted in response to the 

November 6, 2009, FRN (74 FR 

57525). Additionally, the staff 

participated on panels and made 

presentations at various industry 

forums in order to provide 

information to stakeholders about 

the development of the safety 

culture policy statement and/ 

or to obtain additional input 

and to ascertain whether the 

definition and traits developed at 

the workshop accurately reflect 

a broad range of stakeholders’ 

views. These outreach activities 

included, for example, 

participation in a Special Joint 

Session on Safety Culture at the 

Health Physics Society Annual 

Meeting, and presentations on the 

development of the safety culture 
SAFETY CULTURE EDUCATIONAL RESOURCE 55

policy statement at the Annual 

Fuel Cycle Information Exchange, 

the Conference of Radiation 

Control Program Directors’ 

Annual National Conference on 

Radiation Control, the Institute of 

Nuclear Materials Management’s 

Annual Meeting, the Second NRC 

Workshop on Vendor Oversight 

for New Reactors, and the 

Organization of Agreement States 

Annual Meeting. In response to 

Commission direction in SRM–

SECY– 09–00075, the staff focused 

attention on attending meetings 

involving the Organization of 

Agreement States and other 

materials licensees. 

In July 2010, the NRC held a 

public teleconference with the 

panelists who participated in 

the February 2010, workshop to 

discuss the status of outreach 

activities associated with the 

development of the policy 

statement. At the July 2010, 

meeting, the panelists reiterated 

their support for the definition 

and traits developed at the 

February 2010, workshop as a 

result of their outreach with their 

industry colleagues. This position 

aligns with the comments the 

staff received during the various 

outreach activities. In September 

2010, the staff held an additional 

teleconference to provide 

information on the initial results 

of a validation study conducted 

by INPO, which was conducted, 

in part, to see whether and to 

what extent the factors that came 

out of INPO’s safety culture 

survey support the February 

2010, workshop traits. The factors 

support the traits developed at the 

workshop. 

Based on its review and 

stakeholder feedback, the staff 

published the revised draft safety 

culture policy statement (ADAMS 

Accession No. ML102500563) 

on September 17, 2010 (75 

FR 57081), for a 30-day public 

comment period. Because 

public comments reflected some 

misunderstanding regarding the 

Commission’s use of a policy 

statement rather than a regulation 

or rule, the September 2010, FRN 

provided clarification, pointing 

out that the Commission may 

use a policy statement to address 

matters relating to activities that 

are within NRC jurisdiction and 

are of particular interest and 

importance to the Commission. 

Policy statements help to guide 

the activities of the NRC staff and 

can express the Commission’s 

expectations of others; however, 

they are not regulations or rules 

and are not accorded the status 

of a regulation or rule within the 

meaning of the Administrative 

Procedure Act. The Agreement 

States, which are responsible 

for overseeing their materials 

licensees, cannot be required 

to implement the elements of 

a policy statement because 

such statements, unlike NRC 

regulations, are not a matter of 

compatibility. Additionally, policy 

statements cannot be considered 

binding upon, or enforceable 

against, NRC or Agreement State 

licensees and certificate holders. 

This Statement of Policy has 

been developed to engage 

individuals and organizations 

performing regulated activities 

involving nuclear materials 

and share the Commission’s 

expectations regarding the 

development and maintenance of 

a positive safety culture. 

The NRC held a public 

meeting in September 2010, in 

the Las Vegas Hearing Facility, 

Las Vegas, Nevada, which 

was simultaneously broadcast 

in the Commission Hearing 

Room, Rockville, Maryland, 

and over the internet via Web 

streaming in order to allow 

remote participation. The goals 

of the September 2010, FRN 

and meeting were to provide 

additional opportunities for 

stakeholders to comment on the 

revised draft policy statement, 

including the definition and 

traits developed at the February 

2010, workshop, and to discuss 

the information gathered from 

the outreach activities that had 

occurred since the February 

2010, workshop. Additionally, 

a representative from INPO 

presented information on the 

validation study INPO conducted 

as part of INPO’s efforts to help 

establish a technical basis for 

the identification and definition 

of areas important to safety 

culture. A member of the Office of 

Nuclear Regulatory Research also 

presented findings related to the 

oversight of the INPO study. 

II. Public Comments 

The November 2009, FRN 

and the September 2010, FRN 

generated 76 comments from 

affected stakeholders and 

members of the public. The staff’s 

evaluation concluded that many 

of the comments were statements 

of agreement on the information 

included in the draft and revised 

safety culture policy statements 

and did not require further action. 

A few of the commenters raised 

issues that the staff considered 

during the development of the 

policy statement, but ultimately 

concluded that the issues were 
56 U.S. NUCLEAR REGULATORY COMMISSION

either not applicable to the policy 

statement, for example, that ‘‘by 

virtue of its all encompassing 

applicability, the policy must be 

taken as a strategic utterance;’’ 

or either misunderstood or 

disregarded the concept of 

a policy statement in this 

application, for example, that 

a policy statement is ‘‘largely 

inadequate for purposes of 

establishing broad-reaching 

performance standards.’’ The 

remaining comments informed 

the NRC staff’s development of 

the final policy statement. These 

were grouped into the following 

themes: 

1. The NRC should adopt 

the definition and traits 

developed during the February 

2010, workshop. This theme 

encompassed additional 

comments indicating that 

retaining the term ‘‘security’’ in the 

definition and traits of a positive 

safety culture may be confusing 

to many licensees, particularly 

materials licensees. 

2. The traits from the February 

2010, workshop should be 

included in the Statement of 

Policy in order to provide 

additional clarity as to its intent. 

3. More guidance is needed 

on the NRC’s expectations as to 

how the policy statement will be 

implemented. This encompassed 

the additional theme that 

stakeholders would like to be 

actively involved in the process of 

developing this guidance and that 

the continued use of workshops 

with the various licensees would 

be helpful. 

4. A discussion should be 

included in the policy statement 

that addresses the diversity 

of the regulated community. 

Additionally, the Commission 

should acknowledge the efforts 

already underway as the regulated 

community addresses the 

Statement of Policy. 

5. How does the NRC plan to 

‘‘enforce’’ adherence to the policy 

statement? 

6. Comments on the draft 

policy statement were generally 

supportive of including vendors 

and suppliers of safety-related 

components in the Statement of 

Policy, but reflected concern about 

jurisdictional issues, as well as 

the impact that including vendors 

and suppliers in the Statement of 

Policy might have on licensees’ 

ability to work with these entities. 

7. During its evaluation of the 

public comments on the draft 

safety culture policy statement, 

the staff felt that a trait addressing 

complacency should be added 

to the February 2010, workshop 

traits. Several months later, the 

results of an INPO study indicated 

that the trait ‘‘Questioning 

Attitude’’ had strong support 

with operating nuclear plant 

personnel. This trait resonated 

with the staff as an approach 

for addressing complacency for 

all regulated activities. At the 

September 2010, public meeting, 

as part of a larger presentation 

providing the results of the INPO 

validation study, the staff added 

a question about whether to 

include this trait. Additionally, the 

September 2010, FRN specifically 

asked whether complacency 

should be addressed in the 

Statement of Policy. Although 

the responses to this question 

varied, the staff concluded it 

should be considered in a positive 

safety culture and included the 

concept of complacency in the 

Statement of Policy under the 

trait, ‘‘Questioning Attitude.’’ 

‘‘Questioning Attitude’’ is 

described in the final Statement 

of Policy as a culture ‘‘in which 

individuals avoid complacency 

and continuously challenge 

existing conditions and activities 

in order to identify discrepancies 

that might result in error or 

inappropriate action.’’ 

This policy statement is being 

issued after careful consideration 

of the staff’s evaluation of the 

public comments received on the 

November 2009, and September 

2010, FRNs; the public meetings 

held in February 2009, and 

February, July, and September 

2010; the views expressed 

by stakeholders during the 

Commission briefing in March 

2010; and the informal dialogue 

with the various stakeholders 

during the staff’s additional 

outreach efforts from the February 

2010, workshop until the second 

public comment period ended on 

October 18, 2010. 

The following paragraphs 

provide the specific information 

that was used in the development 

of the final policy statement, 

including the changes that were 

made to the November 2009, FRN: 

1. The Statement of Policy 

adopts the February 2010, 

workshop definition and traits 

of a positive safety culture. The 

term ‘‘security’’ is not included 

in either the definition or the 

traits. The Commission agrees 

that an overarching safety culture 

addresses both safety and security 

and does not need to single 

out ‘‘security’’ in the definition. 

However, to ensure that security 

is appropriately encompassed 

within the Statement of Policy, 
SAFETY CULTURE EDUCATIONAL RESOURCE 57

a preamble to the traits has 

been added and the robust 

discussion of security, including 

the importance of considering the 

interface of safety and security 

that was included in the draft 

Statement of Policy, has been 

retained in the Statement of 

Policy. 

2. The Commission agrees 

that including the traits in the 

Statement of Policy will serve to 

clarify the intent of the policy. The 

draft policy statement published 

in the November 2009, FRN did 

not include the characteristics 

(now described as ‘‘traits’) in 

the actual Statement of Policy. 

The staff developed the draft 

characteristics based on a variety 

of sources, including the 13 safety 

culture components used in the 

ROP. The characteristics included 

significantly more detail than the 

traits included in the Statement 

of Policy. The staff’s basis for the 

original decision to include the 

characteristics in another section 

of the draft policy statement but 

not in the actual draft Statement 

of Policy was three-fold: first, 

it would keep the Statement of 

Policy brief and concise; second, 

it would maintain the Statement 

of Policy at a high level; and 

third, it would not invalidate the 

characteristics’ standing as part 

of the draft policy statement to 

place them in another section 

of the draft policy statement. 

The November 6, 2009, FRN 

that contained the draft policy 

statement specifically requested 

comments on whether the 

characteristics should be included 

in the Statement of Policy. Some 

commenters indicated that they 

would prefer not to include the 

traits in the actual Statement of 

Policy or that they agree with 

the original decision to include 

the traits in their own section of 

the policy statement. However, 

several commenters indicated 

that adding the traits to the 

Statement of Policy itself would 

help to clarify the Commission’s 

expectations. Because the traits in 

question were developed by the 

stakeholders at the February 2010, 

workshop to provide a high-level 

description of the areas important 

to a positive safety culture, the 

level of detail that was included 

in the draft characteristics is not 

present in the traits. Thus, even 

with inclusion of the traits, the 

Statement of Policy remains brief 

and concise; in addition, this 

approach provides high-level 

detail that was not in the draft 

Statement of Policy. Including 

the traits in the Statement of 

Policy rather than as part of the 

policy statement visually supports 

their standing as part of the 

Commission’s expectation that 

these are areas that members of 

the regulated community should 

consider as they develop a 

positive safety culture. Finally, as 

the Statement of Policy points out, 

the list of traits was not developed 

for inspection purposes nor does 

it represent an all-inclusive list 

of areas important to a positive 

safety culture. 

3. Implementation is not directly 

addressed in this policy statement, 

which sets forth the overarching 

principles of a positive safety 

culture. This discussion is not 

included because the Commission 

is aware of the diversity of its 

regulated community (which 

includes, for example, industrial 

radiography services; hospitals, 

clinics and individual practitioners 

involved in medical uses of 

radioactive materials; research 

and test reactors; large-scale fuel 

fabrication facilities; as well as 

operating nuclear power plants 

and the construction of new 

facilities where operations will 

involve radioactive materials 

with the potential to affect 

public health and safety and 

the common defense and 

security) and recognizes that 

implementation will be more 

complex in some settings than 

others. The NRC program 

offices responsible for licensing 

and oversight of the affected 

entities intend to work with 

their constituents, who bear the 

primary responsibility for safely 

handling and securing regulated 

materials, to address the next 

steps and specific implementation 

issues. Nevertheless, before 

implementation issues are 

addressed, the regulated 

community can begin assessing 

their activities to identify areas 

for enhancement. For example, 

industry representatives 

could begin to identify tacit 

organizational and personal goals 

that, at times, may compete with 

a safety-first focus and develop 

strategies for adjusting those 

goals. Some monetary incentive 

or other rewards programs 

could work against making a 

safe decision. Current training 

programs may not address safety 

culture and its traits or how those 

traits apply to dayto- day work 

activities. Identification of both 

strengths and weaknesses related 

to safety culture in the regulated 

community will be helpful in 

understanding implementation 

strategies. 
58 U.S. NUCLEAR REGULATORY COMMISSION

4. The final Statement of 

Policy includes a statement that 

the Commission recognizes 

the diversity of the various 

organizations that are included in 

the Statement of Policy and the 

fact that some organizations have 

already spent significant time and 

resources in the development 

of programs and policies to 

support a positive safety culture. 

The Commission will take these 

efforts into consideration as the 

regulated community addresses 

the Statement of Policy. 

5. Because there seemed 

to be some questions about 

the Commission’s use of a 

policy statement rather than a 

regulation, the staff provided 

a brief discussion of the 

differences in the September 

17, 2010, FRN, pointing out that 

policy statements, while not 

enforceable, guide the activities 

of the NRC staff and express 

the Commission’s expectations. 

The Commission reiterates the 

conclusion of the discussion 

provided in the September 2010, 

FRN that while the option to 

consider rulemaking exists, the 

Commission believes at this time, 

that developing a policy statement 

is a more effective way to engage 

stakeholders. 

6. Vendors and suppliers of 

safetyrelated components have 

been included in this Statement 

of Policy. A few stakeholders 

have raised concerns about 

how implementation would 

be carried out, particularly 

in cases where vendors and 

suppliers are located outside of 

NRC jurisdiction. However, the 

Commission believes that vendors 

and suppliers of safety-related 

components should develop and 

maintain a positive safety culture 

in their organizations for the same 

reasons that other NRCregulated 

entities should do so. 

7. The final Statement of Policy 

adds the trait ‘‘Questioning 

Attitude’’ to the traits developed 

at the February 2010, workshop 

as an appropriate vehicle for 

addressing complacency. 

III. Statement of Policy 

The purpose of this Statement 

of Policy is to set forth the 

Commission’s expectation that 

individuals and organizations 

establish and maintain a positive 

safety culture commensurate 

with the safety and security 

significance of their activities 

and the nature and complexity of 

their organizations and functions. 

This includes all licensees, 

certificate holders, permit holders, 

authorization holders, holders 

of quality assurance program 

approvals, vendors and suppliers 

of safety-related components, and 

applicants for a license, certificate, 

permit, authorization, or quality 

assurance program approval, 

subject to NRC authority. The 

Commission encourages the 

Agreement States, Agreement 

State licensees and other 

organizations interested in nuclear 

safety to support the development 

and maintenance of a positive 

safety culture, as articulated in 

this Statement of Policy. 

Nuclear Safety Culture is 

defined as the core values and 

behaviors resulting from a 

collective commitment by leaders 

and individuals to emphasize 

safety over competing goals to 

ensure protection of people and 

the environment. Individuals 

and organizations performing 

regulated activities bear the 

primary responsibility for safety 

and security. The performance 

of individuals and organizations 

can be monitored and trended 

and, therefore, may be used 

to determine compliance with 

requirements and commitments 

and may serve as an indicator 

of possible problem areas in 

an organization’s safety culture. 

The NRC will not monitor or 

trend values. These will be the 

organization’s responsibility as 

part of its safety culture program. 

Organizations should ensure 

that personnel in the safety 

and security sectors have an 

appreciation for the importance 

of each, emphasizing the need 

for integration and balance to 

achieve both safety and security in 

their activities. Safety and security 

activities are closely intertwined. 

While many safety and security 

activities complement each other, 

there may be instances in which 

safety and security interests create 

competing goals. It is important 

that consideration of these 

activities be integrated so as not 

to diminish or adversely affect 

either; thus, mechanisms should 

be established to identify and 

resolve these differences. A safety 

culture that accomplishes this 

would include all nuclear safety 

and security issues associated 

with NRCregulated activities. 

Experience has shown 

that certain personal and 

organizational traits are present in 

a positive safety culture. A trait, in 

this case, is a pattern of thinking, 

feeling, and behaving that 

emphasizes safety, particularly 

in goal conflict situations, e.g., 

production, schedule, and the 

cost of the effort versus safety. It 

should be noted that although the 
SAFETY CULTURE EDUCATIONAL RESOURCE 59

term ‘‘security’’ is not expressly 

included in the following traits, 

safety and security are the 

primary pillars of the NRC’s 

regulatory mission. Consequently, 

consideration of both safety and 

security issues, commensurate 

with their significance, is an 

underlying principle of this 

Statement of Policy. 

The following are traits of a 

positive safety culture: 

(1) Leadership Safety Values and 

Actions—Leaders demonstrate 

a commitment to safety in their 

decisions and behaviors; 

(2) Problem Identification and 

Resolution—Issues potentially 

impacting safety are promptly 

identified, fully evaluated, and 

promptly addressed and corrected 

commensurate with their 

significance; 

(3) Personal Accountability—

All individuals take personal 

responsibility for safety; 

(4) Work Processes—The process 

of planning and controlling work 

activities is implemented so that 

safety is maintained; 

(5) Continuous Learning— 

Opportunities to learn about ways 

to ensure safety are sought out 

and implemented; 

(6) Environment for Raising 

Concerns—A safety conscious 

work environment is maintained 

where personnel feel free to 

raise safety concerns without 

fear of retaliation, intimidation, 

harassment, or discrimination; 

(7) Effective Safety 

Communication— 

Communications maintain a focus 

on safety; 

(8) Respectful Work 

Environment— Trust and respect 

permeate the organization; and 

(9) Questioning Attitude—

Individuals avoid complacency 

and continuously challenge 

existing conditions and activities 

in order to identify discrepancies 

that might result in error or 

inappropriate action. 

There may be traits not included 

in this Statement of Policy that are 

also important in a positive safety 

culture. It should be noted that 

these traits were not developed to 

be used for inspection purposes. 

It is the Commission’s 

expectation that all individuals 

and organizations, performing 

or overseeing regulated activities 

involving nuclear materials, 

should take the necessary steps to 

promote a positive safety culture 

by fostering these traits as they 

apply to their organizational 

environments. The Commission 

recognizes the diversity of these 

organizations and acknowledges 

that some organizations have 

already spent significant time and 

resources in the development 

of a positive safety culture. The 

Commission will take this into 

consideration as the regulated 

community addresses the 

Statement of Policy. 

Dated at Rockville, Maryland, 

this 8th day of June 2011. 

For the Nuclear Regulatory 

Commission. 

Annette L. Vietti-Cook, 

Secretary of the Commission. 

[FR Doc. 2011–14656 Filed 6–13–11; 

8:45 am] 

BILLING CODE 7590–01–P