Nuclear Safety Culture:

An Organizational Development Model

Patrick W. O’Hara

Pending @ March 2001

Revised 1/2003

Introduction

The nuclear power industry has identified "Safety Culture" as a key factor to remaining competitive in a deregulated energy market. Nuclear plants with "Weak Safety Cultures" have been identified as being a predisposed to poor safety performance, and at a greater risk for actual safety problems. Recent examples of poor safety culture in nuclear plants include the melt down of Chernobyl in the Ukraine, and the Tokaimura nuclear accident in Japan. The economic and social costs of poor performance threatens the end of nuclear energy as a viable energy alternative, and leaving the U.S. with a 20 percent gap in the nation's electrical capacity. Despite the importance of "Safety Culture" to the industry, nuclear power operators have had difficulty achieving it, or duplicating the results of industry top-performers. Often a "hidden culture" emerges that represents the difference between safety expectations and actual performance.

Three factors generally hinder safety culture implementation and management. First, there is no universally accepted definition of "safety culture" or model for implementation. Many definitions focus on key points of safety culture, but are predisposed to sub-optimization due to its limited view. Any definition of nuclear safety culture must consider the systemic and dynamic relationships inherent in the industry. Second, nuclear operators rely too heavily on organizational culture to yield "safety culture," and later find that actual performance often falls short of expectations. Organizational culture provides a foundation for "safety culture" to grow, but is not just the result of a value emphasis on safety. Safety culture is a state of organizational maturity, which relies on static engineered values and constraints, to drive behavior and process. Third, attempts to manage Safety culture too often focus on short-term compliance-based technical solutions, rather than long-term commitment-based organizational transformation.

This paper addresses these three issues by proposing "Safety Culture" as an organizational development model designed to transform the nuclear operation to a high-performance sociotechnical system that meets industry expectations of safety, reliability, and cost competitiveness. There are five major goals to this model. The first goal is to maximize safety performance, as evidenced by accident rates, human performance error rates, and reduction of uncertainty and risk in operations. The second goal is to maximize the resources of the organization, through innovative utilization of human resources and sociotechnical components. A third goal is to realign relationships among policy makers, plant management, and workers to a commitment-based organization that minimizes conflict in the workplace through strong top-down safety initiatives driven by bottom-up buy-in. The fourth goal is to build a strategic mechanism that emphasizes a long-term operating focus over short-term market demands. The fifth, and most important element, is to provide a self-sustaining organizational mechanism to assure that safety culture is developed, properly managed, and passed on to new members.

What is Safety Culture?

There are several definitions of safety culture common to the nuclear industry, but most are relatively segmented, and do not take into consideration the dynamics of the industry or its systemic nature, which drives the need for a holistic approach to the organization.[1] The question remains: What is Safety Culture?

The International Atomic Energy Commission defines Safety Culture as the “assembly of characteristics and attitudes in organizations and individuals that, as an overriding priority, nuclear power plant safety issues receive the attention warranted by their significance.”[2] This definition draws out three important points. First, is the importance of safety culture as a driver of attitudes. Second, is the need for multi-tiered involvement of the entire organization, and the individual members. Third, is the importance of safety as the overriding priority. Although this definition receives the most widespread acceptance, it says little of the interrelationships inherent within the organization.

Merritt and Helmreich define Safety Culture as “a group of individuals guided in their behavior by their joint belief in the importance of safety, and their shared understanding that every member willingly upholds the group’s norms and will support other members to a common end.”[3] Their definition adds two more points that are important; that every member participates and that they do it willingly through a joint belief in safety rather than for compliance.

Zhuravlyov considers Safety Culture a “mentality” or mindset of the organization or individual in dealing with aspects of the organization.[4] He presents safety culture as a shared paradigm, which he believes affects all activity and interaction. His definition describes the pervasiveness of safety culture in the way people think and work.

Wert defines Safety Culture as “a work environment where a safety ethic permeates the organization and people’s behavior focuses on accident prevention through critical self-assessment, proactive identification of management and technical problems, and appropriate, timely, and effective resolution of the problems before they become crises.”[5] This definition embraces “management” as a key factor in refining safety culture, and emphasizes the importance of proactive measures and continuous improvements.

Geller’s concept of “Total Safety Culture” describes a culture in which everyone actively cares for the safety and health of others.[6] As with TQM, Geller’s focus of Total Safety Culture is the management of process, recognizing those factors that are upstream, and the results found downstream. The key to his definition is the active nature of safety culture.

The British Health and Safety Commission defines safety culture as “the product of the individual and group values, attitudes, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs.”[7] This definition is significant because it identifies the importance of commitment -- which results from relationships; and proficiency – which results from training and operating experience.

Drawing upon these individual perspectives, it is apparent that safety culture must transcend all levels of the organization without being distorted by the segmentation inherent in different levels of the organization. It must be a culture of inclusion, where every member has a role and feels responsible, to actively, willingly and with principle, place priority on safety in influencing collective behaviors. Furthermore, it must engender the various interrelationships and interactions involved with the various stages of the work processes. Thus, the definition developed herein requires both behavior and process based initiatives together, and must serve as the basis of safety culture in high-risk organizations.

This work defines safety culture as an amalgamation of collective behaviors and engineered work processes, that recognize the dynamic and systemic relationships between workers and their environment, which seek to reduce the risks of operational error and uncertainty through a shared-mindset that drives an emphasis on inclusion, participation, and forward-thinking of all members in the organization. This view of safety culture is a departure from common perceptions that rely solely on technical discipline as the basis of safety systems.

Why Not Rely on Organizational Culture?

A basic tenant of this work is that organizational culture provides the foundation for safety culture, but the sociotechnical system (STS) provides the framework to bring it into fruition. The STS approach recognizes the dynamic relationship between management, workers, and their environment – procedures, technology, and operating experience. Some experts might disagree with a definition that dilutes the emphasis on the values, attitudes, and behaviors that create identity and pervades the organization. However, many experts would agree that safety excellence is not the result of any singular strategy.[8] Organizational culture generally limits itself to attitudes, beliefs, and behaviors of members, whereas the STS addresses both behavior and process. While there is general agreement that these elements are important to safety culture, it is not an end in itself. Some experts estimate that 90 percent of culture – the norms, values, and assumptions -- lie below the surface.[9] Safety Culture must always be on the surface: It needs to be static, pervasive, understood, and practiced uniformly by all members of the organization. When organizations or regulators question why a variety of safety cultures (or hidden cultures) exists within one organization, it only reinforces the notion that the underlying values of the organization are negatively influenced and changed by their internal and external environment. Furthermore, experience and membership in labor organizations or professional groups create sub-cultures that become variations of organizational norms, or may even at times alter the norm. For this reason, experts agree that culture, or value-based safety systems, are difficult to achieve and maintain for a long-time.[10]

Organizational culture is also susceptible to unrealistic self-concept, and ultimately to complacency. Bax believes that this is because the shared experience between the various levels of the organization is limited.[11] Harvey, Bolam, and Gregory also concluded that the basic conceptualizations of safety differ between management and employees, and potentially among different plants.[12] Moreover, the differences in attitudes and backgrounds not only lead to different frames of reference, but they also may hinder effective communication.[13] Such observation validates the need for an engineered component to safety culture, which is outside of the realm of shared experience.

Pool explains that safety culture, which he refers to as “institutional” in nature, is rooted in conviction, and acts as a safety mechanism to guard against omission, or directives that may degrade safety and reliability.[14] His concept paints a picture of safety culture as a mechanism to create realignment based on principal, rather than cultural norms or business decisions. Another key point is the external influence and mandate of safe operation as a social construct, which is placed on the industry, yet may not be adequately represented within organizational values.[15]

Organizational culture is the foundation for safety culture, but cannot yield safety culture by itself. Safety culture is more than the organizational values, attitudes and beliefs. It is based on activity and interaction.[16] Organizational culture is generally passive and only managed when it is seriously misaligned with organizational goals. Safety culture is active and continuous: It involves a continuous process of growth and maturity. Walker and Maune express it as an evolution in safety that builds upon itself through three levels of organizational maturity.[17] The first level involves a visible, proactive vision and commitment to safety. The second level involves the addition of world-class safety processes and proven safety programs. The final level reflects a culture that values workers and effectively integrates both objective and subjective domains of safety. This is the stage where the sociotechnical system begins, and the key organizational factor that separates marginal performers from the industry’s best.

The Effects of Relationships

Modeling the interrelationships inherent in the nuclear organization reveals much about the dynamics that influence behavior and culture at the various levels of the organization. Each level is confronted with a different set of conflict, or dynamics, which challenge the attitudes, values, and behavior that must remain static in a nuclear safety culture. Figure one below models the various levels of the nuclear organization. The first level of the organization is described as corporate policy, which reflects the guidance for organizational competitiveness through product differentiation and market segmentation. This policy is directly influenced by stockholder expectations of maximization of shareholder value and return on investment. Corporate policy is also indirectly influenced by the concerns of stakeholders, whose expectations for public welfare also influence regulatory policy and public perception. Thus, corporate policy formulation must satisfy the expectations of both stockholders and stakeholders in order to operate in a capital market system where public perception can greatly influence the life-cycle of operations.

The second level is plant policy, which is influenced by corporate policy in a one-way top-down fashion. Plant policy is also affected by the direct influence of regulatory policy, which is indirectly affected by the stakeholders and industry policy makers. Thus, plant policy must meet the mandate of corporate policy, whose overriding priority is profitability, while concurrently calming stakeholders. Corporate expectations may be in conflict with industry and regulatory operating priorities of safety and reliability as well. In traditional power organizations, corporate policy may encompass both conventional and nuclear power generation, and thus may not capture the operating constraints of nuclear plant management at the operating level. Plant policy makers are more likely to give feedback to the industry policy makers, and ask for guidance in meeting corporate objectives, or ameliorating regulatory concerns through innovative practices. Industry and regulatory policy makers are constantly debating: attempting to create a shared experience, which may be used to augment respective policy in order to satisfy top-down mandates.

Figure 1

The third level is expressed as plant management, who are expected to implement plant policy, and meet the expectations of all of the levels above -- those who directly or indirectly influence policy. Although the operational mandate from plant policy is top-down one way, plant management becomes the first level of bi-directional communications with lower levels. Plant management’s interaction with lower levels is both formal – those interactions involved in passing on policy expectations – and informal – those that are based on personal expectations and beliefs. The forth level, which encompasses the plant workers, are influenced internally by union policy – the contract – and through interaction with management. Plant management may receive feedback, both formal and informal, through workers or through union channels. External unions may have a lesser influence on plant workers, but they are always a factor when dealing with negotiations or grievances. Plant workers are subjected to another level, which encompasses the operating environment – managing operating experience, working with procedures, and interfacing with technology. This level represents a dynamic interrelationship, which creates or restrains high-performance, yet is out of the direct control of those who must operate within it. The procedures must integrate with technology, and workers must have the experience and mindset for procedural adherence and safe interaction with technology. This dynamic generates conflict between the components of the operating environment, and is expressed through plant workers both directly to the supervisors, and indirectly through the union. Plant management becomes the focus of this conflict, because they are ultimately responsible for implementation of the various policy levels, but are also accountable for the actions of the workers, and the expectations of regulatory, industry, and public policy makers.

In short, the various levels of relationships and modes of feedback have great influences on organizational behavior, many of which cannot be captured on such a simple model. Nonetheless, this model creates reasonable doubts that traditional reliance on corporate policy to formulate and retain safety culture is achievable, and refocuses the importance on the bottom-levels of the organization, where the conflict is the greatest. It also shows a divergence between plant operations and corporate policy, and a concentration of accountability on management for meeting external expectations. Admiral Rickover, the Nuclear Navy’s visionary, understood this well and often broke from the conventional Navy’s policy directives to drive safety and reliability based on principal.[18] Consequently, the resulting consolidation of the nuclear power industry that is resulting from deregulation may indeed eliminate the conflict at the higher levels by creating a corporate level that is more open to ameliorating the operating constraints that create conflict at the lower levels. The industry needs to adopt safety culture as a sociotechnical system, which recognizes and manages these dynamics, while achieving the engineered goals of safety and reliability through the management of behavior and work processes.

The Elements of the Sociotechnical System

Using a sociotechnical systems approach emphasizes several key issues, which may otherwise be discounted through traditional cultural and management systems. Modern STS theory continually emphasizes three vital issues,[19] which reinforce long-term operating objectives. The first is purpose of the system, which in the nuclear industry’s case is maximizing safety and reliability. The second is the social and resource constraints, which captures the nuclear industry’s burden of heavy regulation, competitive disadvantage, poor public perception, and interrelationships of the workforce through all levels of the organization. The third is the dynamics of the sociotechnical system, which involve the interface of humans with machines and technology in a highly centralized and prescriptive work environment. The emphasis on this last element is the focus of the developmental model. The assumption made here is that managing the dynamics of the STS will yield the safety, reliability, and cost-competitiveness that the industry demands, while managing public perception and regulatory compliance issues.

The macroergonomic STS approach allows for a top-down engineering of the various levels of the organization, work systems, and jobs that reflect management expectations and industry values. This approach considers four basic subsystems, dealing with personnel, technology, the organization, and the environment. The goal of the macroergonomic system is to harmonize work systems at all levels to improve productivity, job satisfaction, health and safety, and employee commitment.[20] Organizational issues such as management styles, job design, participative problem solving, psychological stress, job satisfaction, performance effectiveness, and quality of work life issues are actively addressed as part of the system. At its best and most effective, building safety culture is a sociotechnical development that combines changes in perception and expectation with technological improvements.[21] Pasmore contends that sociotechnical organizational development has proven more successful than any other system in improving bottom-line organizational effectiveness while simultaneously paying attention to human values.[22] Dankbaar explains that STS design emphasizes organizational solutions over technical solutions,[23] essentially reinforcing the role of labor-management relations plays in performance management. Dankbaar’s approach compliments the nuclear industry’s strategic positioning as it is forced to seek competitiveness through its allocation of human resources rather than through technological innovations that would otherwise have to be shared with other nuclear licensees. An important element of safety culture that is embraced in an STS is the integration of individual error recording into system-wide improvements that support future error prevention and lessons learned. The STS approach also drives the holistic view that recognizes the added dynamics of the union-management relationship. Pidgeon explains that the politics of union-management relationships often get in the way of safety culture, and may negatively influence organizational subcultures,[24] theorizing that the mind-set of protecting union rights could suppress the worker’s duty to uphold and reinforce industry values. Adler and Dougherty further explain that an STS approach helps build shared understanding between unions and management about organizational strategy and business ideas.[25]

Safety as a Common Ground

Safety is an appropriate common ground for the nuclear sociotechnical system for three important reasons. First, safety is a core operating objective for the nuclear industry. Second, safety parallels quality in TQM through the emphasis on managing upstream factors that affect performance. Third, safety has been a proven area of agreement that helps ameliorate adversarial union-management relationships. In short, safety as a shared experience has the propensity to overcome many of the short-term market demands of a deregulated market, while meeting management expectations, industry values, while ameliorating and stakeholder concerns -- thus reinforcing operational safety as a strong policy basis.

The emphasis on safety is a core-operating objective in the nuclear industry. Safety is viewed as a “social construct,” whereby “absolute safety” represents the antithesis of error or negation of risk.[26] The basis of a safe worker is his forward-thinking nature, an awareness of the dynamic work environment, the consideration of potential hazards, and being prepared with contingencies for negatives responses to worker inputs. In short, the worker is not working blindly or distracted by ancillary issues, but is either in full control of his work and environment, or aware of its constraints. The safe worker maintains strict procedural adherence and participates in organizational learning systems that provide real-time improvement opportunities. The emphasis on safety means that workers communicate their needs to management, and management removes barriers to workplace excellence.

Safety, like the focus on quality in TQM, focuses on upstream factors that affect safety. This creates an emphasis on process – the way people work and the tools they use – and articulates how their role affects factors downstream. Safety relies on proper planning, maintaining appropriate resources, and adequately staging them. Safety as a common ground facilitates the forward thinking necessary to avert negative events, because the employee is thinking ahead at what could go wrong, and how to control the environment. Likewise, the expectation remains that an employee should display a questioning attitude and discontinue work if any element of the activity has not been planned for, or is unable to be controlled. Safety builds the shared mindset that workers should not “work around” procedural deficiencies or poorly designed or deteriorating equipment. All employees in the system need to be involved, providing support to bring each stage of the process into alignment with organizational goals that focus on safety, reliability, and cost competitiveness. The emphasis on safety as a common ground is designed to include all members into this emphasis, despite their role in the organization, and unleash the latent potential of the organization to avert or control breakdowns in processes. Consistent with Perrow’s preoccupation with failure,[27] employees operating in high-risk organizations (HRO) must realize that they are prone to error-likely situations, and overcompensate for them through strict procedural adherence, redundant communications, and participation in organizational learning programs to utilize lessons learned in work being performed, as well as document experiences for future work.

Krause and Hidley make two important distinctions about the union environment, which validate the importance of safety as an element in the change model.[28] First, the unionized workforce is more difficult to work with, based on divergent subcultures and suspicions that have developed through union-management relationships. Second, unions are not generally interested in the behavior-based approach to performance issues. [29] Third, both union and management see safety as being too important to be adversarial, and consider the initiative to be a long-term solution to many workplace issues. Furthermore, unions see the emphasis on safety as the driver of several changes, such as a no-fault approach to worker error, a focused attention on working conditions, an emphasis on zero-injury rates, and an opportunity for expanded employee input and representation. STS practitioners know that without getting union support, implementation becomes practically impossible. The success of the STS is directly related to the leader’s ability to foster worker commitment to industry operating principles and participation in the high-performance work system. Workers must believe in the operating goals, take ownership in their work, and know how their individual contributions bring about high-performance. Safety culture as a organizational development model brings about such a workforce, and meets the dynamic demands of the HRO.

What Does a Safety Culture Look Like?

A properly implemented safety culture yields the same core components found in other high performance work systems, such as Total Quality Management (TQM), and creates organizational synergy. The difference is the common ground, or shared experience, which is based on safety rather than quality. Either system realigns the organization to a high-performance work system that unleashes latent potential, while reducing the costs associated with human performance error.

The safety culture is characterized by a strong corporate identity and organizational commitment.[30] All employees understand the goals of the organization, and the personal contributions necessary to achieve them. Top management provides the basis of the system, while the bottom-up involvement of line-workers drives and regulates the system. There are little “us vs. them” attitudes between labor and management, which is an important consideration when dealing with an industry that is highly unionized. Both worker and management must commit to culture management and organizational learning, using the shared value of safety as the basis of the STS. All members are involved in the continuous process of safety culture, and realize it is not a short-term strategy.

Management makes an overt commitment to the STS, and provides the authority and resources to make it work. Communication flows multi-directionally among management and workers. Communication occurs organizationally from top to bottom, bottom to top, and side-to-side. The flow of communication is thorough enough to dispel rumors and make all employees feel involved. Employees at all levels are encouraged to contribute ideas and suggestions for improvements. Employees rarely feel left out. There is an overriding feeling of openness, where employees feel comfortable raising issues and concerns without fear of reprisal. Investigations of events and root causes focus on organizational processes, not persons. There is no blaming. Moreover, there is an inherent willingness of employees to accept responsibility and accountability.

The organization has a heavy commitment to employee training, fitness of equipment, and a pleasing work environment. Employees receive on-going training about workplace safety and the reduction of risk in operations. All employees are aware of the importance of safety systems and the duality of their roles during emergent times: each employee has a primary operational role and is trained in a secondary role to support plant contingencies. The organization makes the same commitment to process safety as it expects of behavioral safety from its workers. All employees are equipped with the knowledge and tools necessary to carry out the task and make sound decisions.[31] Maintenance backlogs are carefully monitored, and kept to a minimum. Everyone in the organization understands the demands of regulatory compliance, but focus their efforts beyond the minimum to achieve high-performance.

Emphasis on performance is expected at all levels. Strict procedural adherence becomes the basis of all work. Workers recognize inaccurate, unworkable, or poor documentation as a signal to stop work after stabilizing safety systems. Work is not performed unless the associated outcomes have been anticipated: work is not by trial and error, but performed thoroughly pre-planned work packages that incorporate and lessons learned and industry operating experience. Contingences are always planned for. Workers demand complete work packages, and the resources to do the job. Human error is minimized through procedure adherence, self-checking, and peer review. Performance errors or safety incidents are promptly reported and documented with the expectation of learning from the event, and helping others avoid the same. The emphasis on safety performance is pervasive, and considered as important as other dimensions of employee appraisals. All employees are committed to the systems of organizational learning, problem identification, and corrective actions – the sum of which reinforces culture management. The goal is to create a workforce that knows what needs to be done and why. Systems are in place to pass on this organizational knowledge to new members. Workers who raise issues and participate are rewarded for supporting long-term strategic goals. Workers are heavily involved in all aspects of the organization. They are constantly providing feedback from the front line to plant policy makers. Line employees provide input and review for all operating procedures. Employees feel empowered, and often give their full support to help find alternative solutions to the organization’s problems.[32] Relationships are both horizontal and vertical, which minimal segmentation or compartmentalization among work groups, thus promoting an overall sense of teamwork throughout the entire organization . Employees know how their work affects others, both internally and among other departments.

Employees at all levels display personal accountability. They take ownership for their work, problems they identify, and other issues of importance to them. Management provides the resources and necessary environment for this to take place. Employees never say “I don’t care,” or “its not my job.” Workers accept responsibility for their own actions, and seek to understand how their actions influence the system. Employees share a common concern for the safety, health, and well-being of their coworkers. Housekeeping rarely becomes a problem. There is strong coworker support, nearly mirroring family relationships. Workers look out for each other’s safety and performance, yet remain dedicated to the principals of safety and reliability as the overriding priority, rather than submitting to collusive pressures that may otherwise overshadow the industry’s operating principles. Employees freely give feedback on performance amongst themselves, and to their supervisors. Everyone is expected to display a questioning attitude rather than follow orders blindly: Workers fully understand the ramifications of their actions and raise concerns over actions that could have an adverse effect on organizational goals. These creative tensions serve to protect against the complacency that follows success and deviations from performance expectations.

All members of the organization share a high-level of job satisfaction. They find the involvement in all aspects of the organization rewarding and enriching. Employees enjoy coming to work and willingly accept challenges and constraints when called upon. Absenteeism decreases, and employee health costs decline. There is low turnover, and employees recommend the company as a fine place to work. Unions have low grievance rates with management because they work closely with management on all work issues. Both understand the rippling ramifications of their actions, or inactions. Employees display a high level of moral, and participate in work-related or sponsored events both on the job and off. There is a high level of trust and integrity among all levels of the organization.

Signs of a Failing Safety Culture

Some may focus on the utopian nature of this description of “what a safety culture looks like” and wonder about its validity. This validation of safety culture as a performance enhancer is rooted more in the characteristics of a poor safety culture, which historically has led to poor performance and a chain of negative events that put the goals of safety, reliability, and cost-competitiveness at risk.[33] The effects of the breakdown in safety culture are easily identified through the status of the physical plant, employee-mindset, labor-management relations, and the work process.

The condition of the physical plant is probably the greatest contributor to negative safety culture because the operating environment has a widespread influence on all factors of performance. Degraded equipment, unreliable performance, and even poor appearance of components are both a result and characteristic of negative safety culture. This symptom manifests itself in a maintenance backlog and prioritization of work that may send conflicting messages to employees and negatively influence their mindset. Poor housekeeping is also a symptom of a failing safety culture and reinforces negative behaviors. Workers cannot feel good about their role in creating high-performance when they feel uncomfortable about their environment or are unwilling to take ownership for it.

The greatest problem with employee mindset is often the lack of ownership that an employee feels to the workplace and task. Thus, a failing safety culture is characterized by several visible behavioral characteristics. There is often a “hidden culture,” which represents the cultural reality or norm, rather than industry policy or the corporate mission statement. The “hidden culture” can be reinforced by organizational sub-cultures such as those of the Union or Line management, or through the organizational factors such as the work process. The divergence between the “hidden culture,” organizational culture and the engineered component of safety culture represents an overt breakdown, which negatively influences employee-mindset. Employees are reluctant to get involved because ignoring a problem is easier, and often more acceptable to the “hidden-culture” than confronting it. Employees begin to feel powerless to change or control their environment, and become acceptant of that change. Employees soon fail to recognize safety concerns or stop reporting them because their environment has conditioned them to think that the situation is either acceptable, or their concern will be looked upon negatively. This is classic expectancy theory: If the employee does not feel that their effort will be received positively, they will likely avoid the behavior.[34] The manifestation is an organization that knows it has problems but fails to address them, or they continually defer them. This detracts from the physical plant, and is characterized by maintenance backlogs or constantly failing equipment. In the same manner, negative employee mindset and failing safety culture is visualized through poor housekeeping, and a less than pleasant work environment.

The manner in which labor is managed also reveals much about safety culture. Adversarial labor-management relations promote an “us vs. them” attitude, reinforce negative assumptions, and often perpetuate a self-fulfilling prophecy that becomes an anchor to poor performance. The exclusive focus on behavior without addressing process reveals a lack of true commitment to performance improvements. This is articulated through a “blaming culture,” which seeks to assign responsibility or fault to those who rarely have the resources to avoid or solve root cause problems. Management displays this through increased disciplinary actions, while the union addresses this through increased grievances. Both are a measure of failing safety culture because neither addresses the real issues affecting performance. Adversarial relations also contribute to the compartmentalization of work, and the employee-mindset of “not my job” or “I don’t care.” Poor labor-management relations also serve as a distraction to work in high-risk organizations, which should be providing a worry-free work environment that allows workers to fully focus on tasks without thinking about extraneous issues that may hinder performance.

The work process of the STS is defined as the dynamic interaction between procedures, technology, and operating experience. Procedures recognize the highly prescriptive work environment necessary to mitigate risk, reduce operational uncertainty, and manage regulatory compliance. Procedures also incorporate lessons learned from experience, thus reducing the disparity in performance between workers that have performed a task numerous times, from one that has never performed a task. Technology encompasses the equipment in the plant, and the physical and mental tools that workers use to maintain it. Operating experience is the lessons learned from operations that contribute to risk reduction and performance enhancement, and that have been learned either first hand or though a system of sharing among operators. In a safety culture, these three sociotechnical components integrate with the plant workers and continually change to reflect present conditions and levels of knowledge. The breakdown in safety culture occurs when emphasis is not placed on developing or maintaining procedures that integrate changes in technology and operating experience. In a failing safety culture there is little emphasis on procedural adherence, and deviations or “work-arounds” become the norm. The de-emphasis on any one of the components devalues improvements in the others. When employees stop demanding revision, safety culture has likely bottomed out. The common results of this breakdown are the reinforcement of negative employee mindset, a declining physical plant, and repeat performance errors – all of which conflict with the goals of safety, reliability, and cost-competitiveness.

The diagnosis and cure to the underlying problems or root cause, necessitates a sociotechnical perspective that recognizes the complexity of interactions between policy, management, workers, and their environment. The solution to this problem generally rests in closing the gap between the achievement of planned outcome through engineered goals and methods, and reality. This requires an approach where proper culture is set through plant level policy and remains static based on engineered principals that receive the full support of corporate sponsors. The culture must encourage bottom-up reinforcement from the entire line organization, and supported by proper leadership --- both of which are the cornerstones to overcoming the barriers to safety culture. In short, using safety culture as the basis of an organizational development model aligns culture and leadership to address the issues that detract from the long-term performance of the organization.

Setting the Foundation through Culture

An earlier discussion of the relationship between organizational culture and safety culture concluded that organizational culture does not yield safety culture. The two are not the same, yet they are not mutually exclusive either. A firm organizational culture must be in place before a safety culture can take root, or become self-sustaining. Organizational culture generally refers to the set of norms, values, behavior patterns, or traditions found within organizations. Schein models culture as having three levels, which he categorizes as artifacts, espoused values, and basic underlying assumptions.[35] The three levels serve to describe how members behave, what they believe, and why. Organizational culture provides the stability and protocol for all interaction within the group. It serves as a mechanism that defines the acceptable parameters of behavior and constraining activities to those that reinforce the espoused values of the organization. Culture also serves as a mechanism to promote learning and assimilation with new members, and will perpetuate over time.

The artifacts of the nuclear organization include the characteristics of its member’s visible behavior and the work process, which have been termed throughout this work as a sociotechnical system. These artifacts encompass many of the organizational factors inherent within high-risk organizations (HRO). Jacobs and Haber identified five general categories of organizational factors that influence the degree to which artifacts reinforce the nuclear industry’s espoused values of safety and reliability. The first is the emphasis placed on policy and procedures, and their adherence. The second stresses the level of multidimensional and redundant communication, both internally and externally. The third is based on decision making, which they define as goal prioritization and organizational learning. The fourth reflects human resource allocation, which includes areas such as performance evaluation, managing technical knowledge, and training. The fifth is based on culture, which they distinguish as emphasis on ownership, safety culture, and time urgency.

The espoused values are the source of identity and core mission, which Schein believes provide the moral function guiding its members. HROs operate within the framework of safety and reliability -- to the point of being preoccupied with failure -- articulating the need to be in control of all activities and manage risk. Safety culture represents the espoused values of HRO culture, which the industry recognizes as being essential for continued operations. As such, all HROs must share common espoused values of safety and reliability and support the standardization of safety culture policy across the industry globally. Competitiveness and market segmentation does not come from diversity in operating policy, but through its utilization of human resources. What is unique for the HRO is that espoused values must be the same for all industry operators, and not subject to the augmentation that results from operating experience or membership in sub-groups. One nuclear expert likened the safety culture component to a religion, saying, “either you have it or you don’t.”[36] Safety culture depends on its members practicing what the safety engineers preach: The measure of safety culture becomes how closely the artifacts of the organization represent the espoused values of the industry. Thus, safety culture provides a static engineered component to the organizational culture that drives perpetual questioning of basic underlying assumptions, and seeks to close the gap between written policy and actual performance. Hence, the principles of nuclear safety force change on the two other levels of culture, rather than have all three respond to internal or external influences independently.

The basic assumptions represent those unconscious, taken-for-granted beliefs, perceptions, thoughts, and feelings that normally formulate values and actions. Schein’s model proposes that basic underlying assumptions are learned over time through organizational interaction, operating experience, and organizational learning: they become the basis of changes to espoused values and artifacts. The dynamics of these relationships create a potential for a constant state of change, whereby new assumptions influence how the organization thinks and acts. An example would be the complacency that often results from successful operations. Knowledge gained from nuclear culture assessments has shown the importance of organizational maturity from the construction phase through operations to be an important consideration in the effectiveness of organizational management.[37] Often, the influence of founding members involved in the construction and start-up phase are strongly embedded into the culture, and hinder the growth of the organization through founding assumptions and operating constraints that reflect original engineered design-basis rather than real-time operating experience. Conversely, successful operations predispose complacency to an unsuspecting organization and may suppress the conservative decision-making that created the success in favor of greater risk-taking in operations to meet business pressures. Therefore, success may create an organizational self-concept that is not anticipatory of failure – the prerequisite of the HRO. Often organizations that have embraced failure emerge as the strong operators in the end, as they have experienced the “cognitive reconstruction” and appropriate self-concept to facilitate multilevel commitment to culture management and organizational learning programs that maintain high-performance.

Culture provides an important reinforcing role within the organization, yet is only effective if its takes into consideration the dynamics of the interrelationships of the organizational members. Thus, the culture must reinforce the expectations of regulators, those of management, and its workers. Each organizational sub-group has the propensity to break away or deviate from the engineered norm. The sociotechnical system and division of labor is designed to create a system of checks and balances that guard against the failure of any singular component within the system. However, no technical system can manage the collusive pressures that drive either how members behave or the acceptance of behavior that deviates from those aligned with the organizational goals of safety and reliability. Collusion is found at all levels of the organization. For instance, high-performing nuclear operators that accept the poor performance of fellow nuclear operators are not reinforcing the industry’s goals of safety and reliability. Consequently, they are jeopardizing public perceptions of their own operations. Industry regulators that overlook problems or downplay their significance in order to protect the industry are reinforcing poor performance and negative behaviors. Management decisions that are influenced by fiscal concerns in the prioritization of work or investment -- over safety and reliability -- reveal collusive pressures driven by the fear of poor performance evaluations that may result from an inability to meet budget constraints. Many workers do not report adverse findings or procedural workarounds because it may make a job more time consuming or place “blame” on someone in the work process. Co-worker collusion is probably the most powerful, and is often reinforced through labor organizations.

Loden and Rosener believe that the origins of collusion are rooted in the socialization process of each subgroup, and their adaptation to their environment.[38] They describe three types of collusive behavior that pervades sub-groups within the organization. Silence is one type of negative behavior, which represents a worker’s recognition of problems within the sociotechnical system, and his unwillingness to do anything about it. This passive behavior may be motivated by the dynamics of the sub-culture, or a “chilling-effect” from the organization for revealing problems that the organization does not want to deal with. Denial is a second form of collusion, which represents organizational denial that a problem exists, despite overwhelming evidence to the contrary. Denial is a strong sanctioned impediment to organizational change and high performance, because it devalues the initiator and sends a strong reinforcing message to others that are aware of problems, but have chosen to remain silent. Those that push issues are often termed “malcontents” or “whistleblowers” by those that deny the existence of problems. These people who operate on principle, often end up alienated from the various subcultures within the organization, and find they have made career-limiting moves. Active cooperation is the third type of collusion, and represents those actions that are actively perpetrated by members of the organization. Examples include falsification of documents, corrective actions that do not resolve the issues identified, or the exclusion of people from projects or decision-making that may have differing opinions or assumptions: the emphasis is placed on closing out work, rather than focusing on core objectives of promoting safety and reliability. In short, these collusive behaviors stifle participation and involvement, drive exclusion of certain groups from activities, and whittle away members’ commitment to the organization and its goals.

Subculture plays an important role in regulating organizational behavior, and strongly influences the sustainability of performance levels. It has the propensity to increase performance when it reinforces the espoused values of the industry: The subculture becomes the driving force of the bottom-up commitment of the line organization, and adds the impetus to overcome organizational barriers. On the other hand, a subculture that works against industry espoused values is just as powerful at destroying performance and drives the same impetus to block efforts for positive organizational change. The only means of effectively managing organizational subcultures is through the active management of human resource policies and labor relations: the goal is to include every member of the organization in operating strategy and performance goals, and reinforce individual contributions that align the worker with the espoused values of the industry rather than with the subculture. The overriding priority should be to manage subcultures in such a way that their interaction within the organization reinforces the organizational culture, which in turn must buttress the industry espoused values of safety culture. The emphasis on organizational learning, managing operating experience and knowledge transfer must also reinforce the underpinnings of safety culture. Proper implementation and management of human resource policies that reinforce the positive characteristics of safety culture create a self-sustaining culture of high-performance that inherently drives the industry’s goals of safety and reliability. The key to culture management, however, rests in the ability of a leader to manage culture, and not be managed by the protective properties of culture itself.

The Role of Leadership in Implementing Safety Culture

Bass and Avolio’s distinction between the transformational and transactional leader can be likened to the inner-conflict between compliance and setting the stage for high-performance: the choice between focusing on meeting short term goals or committing to a course of actions that becomes a pervasive element of the organization.[39] Their transformational leadership model focuses on four leadership interactions, which they believe promotes a high-performance workforce. They term the first interaction as employing idealized influence, or being a good role model. Without this, there will be no buy-in or positive shared experience to build a high-performance system upon. Second, leaders should behave in ways that motivate and inspire workers, what they term as inspirational motivation, and constantly provide meaning and challenge to their follower’s work. This cuts to the basic assumption that if workers do not see their work as important, or do not understand their contribution to the organization, that the likelihood of consistently maximizing individual performance is nil. Third, leaders should provide intellectual stimulation, and encourage workers to question basic assumptions and reframe problems. This provides the basis for unleashing latent resources, and stimulating changes that reposition the organization for competitiveness. The last interaction is based on individual consideration, which focuses on each individual‘s needs for achievement and growth. Furthermore, the transformational leader must be self-defining, and not subject to the collusive pressures of being a “team player,” which possibly could detract from the industry’s performance principles: a leader needs to be strong enough to confront his peers or superiors when policies infringe on industry operating principles.

Geller describes ten critical leadership qualities that affect the success of safety culture by promoting self-directed behavior and building personal responsibility in the workforce.[40] Leaders focus on process rather than results, and provide their followers with the resources for critical thinking and problem solving skills. Leaders educate their followers so that key principles behind procedures are understood: transferring the “what and why” will be the greatest challenge to the modern nuclear workforce as the reigns of the industry are handed over to a new generation of operators. Leaders use conditional statements, rather than focusing on absolutes, which inhibit creativity and stifle ownership. Leaders listen first, and take the time to learn another person’s perspective before offering direction, advice, or support: Active listening is the gatekeeper to promoting change or continuous improvement. Leaders promote ownership of both process and outcomes based on the worker’s self-motivation and sense of purpose to the organization. Leaders encourage choice rather than promote control because workers who experience more personal-control are more likely to actively care. Leaders set expectations rather than mandates: a mandate being other-directed rather than self-directed, the latter of which is the cornerstone of high-performance. Leaders are confident but uncertain, displaying a leadership duality which promotes innovation and initiative, by promoting confidence in workers and encouraging the search for more information or a better way: this quality is crucial to managing complacency. Leaders look beyond the numbers and realize that not everything that affects safety can be measured quantitatively. Instead, “leaders strive to increase self-esteem, self-efficacy, personal control, optimism and a sense of belonging throughout the work culture.” Leaders make more distinctions, putting people’s skills, attitudes, etc. on a continuum, rather than making assumptions that lead to stereotyping, prejudice, or conflict. Leaders determine the degree to which someone falls on a continuum and facilitates the mindset that behaviors are mutable with a proper developmental tool. Viewing the worker as a whole facilitates the “interpersonal trust” needed for a performance-based safety program.

Active Management through Labor Policy

Successful implementation of a self-sustaining nuclear safety culture requires augmentation of organizational human resource and labor policies that support and reinforce the organizational development model. Traditional views of these functions segment policy-making into five different areas -- work structure, staffing, training and development, compensation, and employee relations. Fundamentally, safety culture as an organizational development model provides the work structure that defines how individuals interact with their environment, how work is configured, how results are measured, and how to get employees involved. However, the complexity of relationships within the sociotechnical system supports a latent propensity that serves to breakdown the high-performance initiatives within the work structure through loss of employee commitment, compartmentalization of work, regressive relationships between employees and management, negative subcultural collusion, etc. Reinforcing organizational goals and values through appropriate and consistent organizational policies helps support the work structure, promotes workplace understanding, and provides the framework which keeps the safety culture development model from collapsing due to short-term pressures. There must be an emphasis on good citizenship, whereby every employee knows his role in creating high performance, and understands how to individually and collectively participate.

Staffing is probably the most challenging area of policy for the nuclear power industry, as the rebirth of the industry resulting from deregulation has created a situation where a majority of experienced operators will likely retire concurrently, around 2010. At the same time, there has been a significant reduction in pre-conditioned job candidates, largely because of military downsizing and changes in educational policies with respect to nuclear engineering. This poses a serious dilemma in an industry that is forced to compete based on its workforce utilization, especially when there is a declining pool of prequalified applicants. Staffing policy needs to support a proactive recruiting policy for pre-qualified candidates as well as attracting candidates that have the characteristics or aptitude to make them successful, such as the ability to assimilate into the safety culture and participate in a dynamic organizational learning process. Staffing policy should reinforce a proprietary workforce, developing core competencies from within, as well as promote lateral and upward mobility -- both of which support the systematic developmental experience that creates organizational intelligence. The focus of staffing should be to initiate and promote an atmosphere that fosters long-term employment possibilities. Employees who do not meet the appropriate standards of safety performance or acceptance of safety culture should receive further training, discipline, or perhaps termination.[41] The objective measure of a dysfunctional employee is the intentional recklessness or destructiveness of their actions: the employee knew that his actions would yield the negative result.

Training and development becomes equally important because of the need to “make” or build human resources from within, rather than “buy” or contract out. The reduction in prequalified job candidates from traditional recruitment sources facilitates the need to create more entry-level opportunities for developing candidates internally. Emphasis on culture assimilation, participation in corrective action programs and organizational learning should be the major criteria for determining suitability for employee training and development investments, as performance is related more to the employee’s ability to operate within the sociotechnical system rather than through the traditional foundations of education and skill. Achieving this task of growing a new generation of nuclear workers will require a highly defined mentoring system, which identifies potential candidates for mobility, and provides the internal support that manages relationships and progress through the major criterion.

Compensation policy should support employee retention and long-term employment relationships. The industry currently accomplishes this through a system of high-rent compensation: nuclear employees are paid significantly higher than their conventional power plant counterparts. Compensation should be skills-based, and encourage employees to become trained and qualified to perform a wider variety of tasks. This reduces compartmentalizing of work, and stimulates more efficient workforce utilization. Performance pay or bonuses should be based on both individual and team performance that accomplishes plant goals and reinforces individual contributions. Employee benefits should serve to reinforce performance expectations by helping the employee maintain good health and mindset, which are needed to meet the physical and mental demands of the high-risk organization.

Experts realize that industrial safety is largely dependent on the social and organizational context in which human labor is managed.[42] The relationship between plant management and its workers should encourage open relationships and multichannel communication that is not constrained through outmoded chains of command, or expanses of organizational layers. Delayering the organization and pushing more responsibility down to the level that actually performs the task reduces the performance gap, which arises through decision-making formulated away from the work it affects. Management must understand employee needs and find innovative solutions to workplace issues that constrain high-performance. Fundamental assumptions of organized labor should drive relationships that add value, rather than reduce all interaction to an adversarial mode. Labor-management relations should not cause distractions from safety related work. These issues should be handled swiftly and fairly to all parties involved. The more volatile and longer an issue is drawn out effects the risk of stress-induced distraction, which could lead to operator error and effect safety performance.[43] The need to create and maintain shared understanding and common ground is tantamount, and is best achieved through programs that protect the worker’s health and safety.

Summary

The concept of nuclear safety culture is more than a representation of organizational values, attitudes, and beliefs. It is an organizational development model that effectively manages the complex sociotechnical system inherent in the nuclear power industry. Properly implemented, safety culture will yield an operating emphasis on safety, reliability, and cost competitiveness. Organizational values and culture play an important role in developing a foundation for a safety-oriented culture, but a performance driven safety culture is the result of organizational maturity and engineered systems that affect behavior and processes. The success or failure of safety culture rests on the management of conflict at the lowest levels of the organization. Following a sociotechnical systems perspective, organizations can better manage the interaction between management, the worker, and their operating environment. Safety is developed as the emphasis of the sociotechnical system because it the cornerstone of nuclear industry operating goals, it has been a source of de-escalation between union and management, and it is an often-overlooked source of savings in labor-intensive organizations through managing upstream factors. The ethnographic view of safety culture reveals how the model maximizes the resources of the organization, realigns relationships, and drives a focus on long-term strategy. Conversely, the view of a failing safety culture articulates the real costs of poor workforce interaction and utilization, which is only effectively dealt with through changes in labor policy. Like any culture change effort, implementation is slow, and dependent on organizational culture management and principled leadership. This paper offers suggestions for implementation of safety culture through the active management of labor policy.

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