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NSQ-100 - GUIDELINES – SECTION B

NUCLEAR SAFETY CULTURE

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ABSTRACT This document is the Section B to NSQ-100 Guidelines. Its objective is to help understand NSQ-100 requirements through some examples, recommendations or descriptions of industrial good practices. The Guidelines’ Section B is related to the Safety Culture requirements of NSQ-100 (Chapters 4.1.1 & 6.2.1). It could help in the drafting of nuclear safety culture trainings.

Summary

Chapter 1: Purpose of this section

Chapter 2: How was the concept of nuclear safety culture born?

Chapter 3: What is Nuclear Safety Culture?

Chapter 4: What are the components of Nuclear Safety Culture?

Chapter 5: How to understand and answer to NSQ100 requirements?

Chapter 6: Examples of tools to support nuclear Safety Culture

Annex 1: Example of particular technical characteristics : Defense in depth

Annex 2: AREVA “A practical guide for nuclear power plant equipment and services suppliers”, Edition 1, November 2007

Annex 3: Example of Tokai-Mura accident: results of a poor nuclear safety culture

Annex 4: Samples of questions from Appendix of INSAG-15

Annex 5: Bibliography

Version Date Comments 0 December 2011 Initial issue

1 September 2016 Update following changes in ISO 9001 and IAEA Standards

Copyright © 2016 NQSA, All rights reserved. "NSQ100 is a registered trademark and is owned respectively by NQSA.

These guidelines are protected by copyright and are the property of NQSA. No part of these guidelines may be reproduced, copied, downloaded or transmitted in any form

or by any mean without the prior written consent of NQSA".



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CHAPTER 1: PURPOSE OF THIS SECTION The present section refers to NSQ100 following chapters:

4.1.1. Nuclear safety culture

6.2.1 General

It’s reminded that the scope of this Section B of the guidelines is limited to the scope of NSQ-100 which mainly addresses Quality Management System issues within nuclear industry’s supply chain. The contents of this section could be used as a basis documentation to provide safety culture training inside the organization. However, to be efficient, such training shall be customized and completed to integrate, as appropriate (non-exhaustive list):

specific aspects of the nuclear project (e.g. technology of the nuclear reactor or nuclear plant),

particular characteristics of the organization, its management processes, production means and methods,

particular technical characteristics of the product supplied (see annex 1).

CHAPTER 2: HOW WAS THE CONCEPT OF NUCLEAR “SAFETY CULTURE” BORN?

The concept of nuclear Safety Culture (or Culture for Safety) became popular through the analysis of the 1986 Chernobyl nuclear accident and the publication of a report dedicated to this concept by an advisory expert group of the IAEA (INSAG-4). The Chernobyl accident, as well as other major accidents like TMI and Fukushima-Daiichi, has shown that the consideration of human and organizational factors are key elements to improve nuclear safety. This led to the development and implementation of some good practices such as root cause analysis, monitoring and independent assessments. According to IAEA reports, it is necessary to adopt an integrated approach that takes into account the complex interactions between people, organizations and technology. Therefore, in order to promote and strengthen safety culture, individuals and organizations need to:

continuously challenge or re-examine the prevailing assumptions about nuclear safety and the implications of decisions and actions that could affect nuclear safety,

adopt a systemic approach to safety that considers the interactions between human, organizational and technical factors. This approach needs to be taken through the entire life cycle of nuclear installations.

Continuous questioning and openness to learning from experience are the key to safety culture and are essential for everyone involved in nuclear industry activities. Safety must always come first.

SAFETY CULTURE IS NEVER DEFINITIVELY ACHIEVED AND IT IS ESSENTIAL

THAT LESSONS LEARNED FROM PAST EXPERIENCES ARE IMPLEMENTED

WITHIN THE ORGANIZATION TO REDUCE THE CHANCES OF RECURRENCE.



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CHAPTER 3: WHAT IS NUCLEAR SAFETY CULTURE?

First of all, it is necessary to understand what the term ‘ ’ means. CULTURE

Culture: “is a deeply-rooted, rather than superficial, phenomenon and hence fairly stable over time.”

“It is shared by people and relates primarily not to an individual but to a group, community or organization. Besides, it is a broad concept and covers all aspects of external and internal relationships in a group, community or organization.”

CULTURE IS FOR THE GROUP WHAT CHARACTER AND PERSONALITY ARE FOR INDIVIDUAL INPO – “Principles for a Strong Nuclear Safety Culture” – November 2004

What is “Nuclear Safety”?

NUCLEAR SAFETY IS: THE ACHIEVEMENT OF PROPER OPERATING CONDITIONS, PREVENTION OF

ACCIDENTS OR MITIGATION OF ACCIDENT CONSEQUENCES, RESULTING IN

PROTECTION OF WORKERS, THE PUBLIC AND THE ENVIRONMENT FROM UNDUE

RADIATION HAZARDS.

IAEA Safety Requirements No. GS-R-3 “The Management System for Facilities and Activities”

What is “Safety Culture”?

SAFETY CULTURE IS: THAT ASSEMBLY OF CHARACTERISTICS AND ATTITUDES IN ORGANIZATIONS AND

INDIVIDUALS WHICH ESTABLISHES THAT, AS AN OVERRIDING PRIORITY, NUCLEAR

PLANT SAFETY ISSUES RECEIVE THE ATTENTION WARRANTED BY THEIR

SIGNIFICANCE.

IAEA, Safety Series No.75-INSAG-4, 1991 – “Safety Culture”

AN ORGANIZATION’S VALUES AND BEHAVIORS - MODELED BY ITS LEADERS AND

INTERNALIZED BY ITS MEMBERS - THAT SERVE TO MAKE NUCLEAR SAFETY THE

OVERRIDING PRIORITY.

INPO – “Principles for a Strong Nuclear Safety Culture” – November 2004

“Engineering issues have received close attention from the nuclear community over many years. However, it is only in the last decade or so that organizational and cultural issues have been identified as vital to achieving safe operation.” [Mohamed El Baradei - Director General - IAEA, No.INSAG-13, 1999]



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CHAPTER 4: WHAT ARE THE COMPONENTS OF NUCLEAR SAFETY CULTURE?

Safety Culture has two general components:

1. Necessary framework within an organization and responsibility of the management hierarchy,

2. Attitude of staff at all levels in responding to and benefiting from the framework.

Safety culture must take into account the: Organizational aspects, such as:

ensuring availability of resources (human, financial, work environment ...), identifying all staff whose activities may affect safety of the product to raise safety culture awareness, strict respect of the Quality Management System implemented.

Individual contributions to Safety Culture including:

commitment to Safety and Safety Culture, use of all applicable procedures, conservative decisions , reporting of near misses and failures, identification of all unsafe factors and conditions, continuous improvement of Safety and quality, knowledge of responsibilities and interfaces.

A QUESTIONING ATTITUDE,

A RIGOROUS AND PRUDENT APPROACH, AND

NECESSARY COMMUNICATION

ARE ALL ASPECTS OF AN EFFECTIVE SAFETY CULTURE IN INDIVIDUALS

IAEA, Safety Series No.75-INSAG-4, 1991 – “Safety Culture”

Safety Culture is characterized by

optimal interaction of

individuals and organization to ensure nuclear

safety SAFETY CULTURE

ATTITUDINAL

ORGANIZATIONS INDIVIDUALS

STRUCTURAL



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CHAPTER 5: HOW TO UNDERSTAND AND ANSWER TO NSQ100 REQUIREMENTS? The main difference between “general corporate culture” and “nuclear safety culture” is that nuclear safety culture affects the concept of radiation risks and their potential large effects: “Safety’ encompasses the protection of people and the environment against radiation risks and the safety of facilities and activities that give rise to radiation risks” [GSR Part 2 - §1.10]. This makes nuclear industry different and requires a set of organizational values that place nuclear safety as the top priority of an organization. Furthermore, the purpose of safety culture is to ensure that anyone from senior management to shop floor, is committed to nuclear safety, from design definition stage to dismantling through manufacturing, commissioning, operating and maintenance related activities. The following table identifies some provisions for each NSQ-100 safety culture requirement (Non-exhaustive)

NSQ-100 requirements Examples of provisions

4.1

.1. N

ucle

ar

safe

ty c

ulture

The organization shall promote and support a strong safety culture:

Top management shall be able to demonstrate his own implication and commitment to safety through :

formal communication (Written: nuclear safety policy, memos, internal notes; Verbal: meetings, conferences),

visible presence in the field activities of the organization, clear definition of nuclear safety objectives (either in the quality

assurance program / plan or in the organization management manual itself),

…..

- ensuring a common understanding of the key aspects of safety culture within the organization

Insuring a common understanding of Safety Culture aspects is of critical importance for Nuclear Safety. Thus, management shall make sure that the concepts and practices of Safety Culture are perceived in a coherent and common manner through effective transverse communication and use of the management system and documentation. Reasons for different perceptions of safety culture principles include differences between:

teams within the same organization, generations/levels of experience, cultures/countries, …

For example, even when performing the same work, a night shift and a day shift may differ in the way they understand safety culture requirements which could lead to significant breach of nuclear safety principles. In order to avoid this problem, management shall perform safety culture assessments to verify that safety culture principles are well understood. Furthermore, the tools used to communicate safety culture principles, such as IT tools and resources, should be adapted to the different generations of personnel. This difference of perception of safety culture appears, also, when dealing with multinational companies: When defining the safety culture procedures, management shall take into account the differences in cultures and shall make sure that all requirements are well understood and provided in an appropriate language.



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NSQ-100 requirements Examples of provisions

4.1

.1. N

ucle

ar

safe

ty c

ulture

- providing the means by which the organization supports individuals and teams in carrying out their tasks safely and successfully, taking into account the interaction between individuals, technology and the organization

Such means include, as appropriate:

Communications towards the staff, individuals, …

Documents tracing decisions such as management review report,

Organization’s charts and definitions of roles and responsibilities (available for all staff),

Good working conditions with regard to time pressures; workload and stress by demonstrating adequacy of project / contract necessary resources against allocated ones (human and material).

Systematic development of Individual competences in order to meet the requirements (training…).

Easy availability of documentation, procedures and instructions (written in an understandable manner for the final users),

a working environment in which staff can raise safety issues without fear of harassment, intimidation, retaliation or discrimination (open reporting of deviations and errors is encouraged).

Addressing, in a timely manner, safety issues through effective actions.

- reinforcing a learning and questioning attitude at all levels of the organization

A learning attitude includes the ability to:

Recognize and diagnose deviations,

Formulate and implement solutions,

Monitor the effects of corrective actions.

A questioning attitude prevails and shall be cultivated at all organizational levels, through training, internal communication, periodic sensitization, use of the management system, … Individuals at all levels of the organization must accept personal responsibility towards safety culture attitudes.

- providing the means by which the organization continually seeks to develop and improve its safety culture.

Case 1 Organization mainly dedicated to nuclear fabrications:

Performance indicators on safety culture,

Periodic assessment on safety culture implementation, including the staff awareness and behavior,

Organizational experience and operating experience (both internal and external lessons learned) are used,

Reporting, particularly in management review.

Case 2 Organizations with punctual nuclear contracts:

Project assessment on safety culture,

Reporting, particularly in management review.

6.2

.1 G

enera

l

Personnel involved in the realization of the product shall be trained on the importance of their tasks and of the eventual consequences on the nuclear safety of any malfunction or error in their activities

A formal training plan is established and monitored. Training contents must be:

consistent with all topics described above,

adapted to each level/function of the staff,

practical with examples linked to the organization and to product manufactured or service supplied.



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CHAPTER 6: EXAMPLES OF TOOLS TO SUPPORT NUCLEAR SAFETY CULTURE

How to support Safety Culture Communication?

The organization could communicate on Safety Culture through different supports: leaflets, posters, events, training sessions, quizzes, regular communication during workshop meetings… The major principles used to communicate on safety culture could be:

EVERYONE IS PERSONALLY RESPONSIBLE FOR NUCLEAR SAFETY

LEADERS DEMONSTRATE A COMMITMENT TO SAFETY

TRUST PERMEATES THE ORGANIZATION

DECISION-MAKING REFLECTS “SAFETY FIRST”

NUCLEAR TECHNOLOGY IS RECOGNIZED AS SPECIAL AND UNIQUE

ORGANIZATIONAL LEARNING IS EMBRACED

NUCLEAR SAFETY UNDERGOES CONSTANT EXAMINATION

SAFETY IS THE RESULT OF THE COMMITMENT OF ALL TO THINK AND ACT

A QUESTIONING ATTITUDE IS CULTIVATED :

What are my responsibilities?

How do they relate to safety?

Do I have the necessary knowledge to proceed?

What are the responsibilities of others?

Are there any unusual circumstances?

Do I need assistance?

What can go wrong?

What could be the consequences of failure or error?

What should be done to prevent failures?

What do I do if a fault occurs?

What changes do I need to take into account?

How do I implement these changes?

…

During Safety Culture training, it is important to underline that:

TO ERR IS HUMAN, CONCEALMENT IS UNACCEPTABLE



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How to assess Safety culture?

In order to provide the means by which the organization continually seeks to develop and improve its safety culture, periodical assessments at all levels of the organization should be performed by designated, competent and independent individuals. The results of such assessments should be communicated at all levels of the organization and their learned lessons acted upon in order to boost safety culture.

The safety culture assessment should be based on five characteristics that are defined in the IAEA safety standards:

Safety is a clearly recognized value;

Leadership for safety is clear;

Accountability for safety is clear;

Safety is integrated into all activities; and

Safety is learning-driven.

There are many means for assessing safety culture. For example, appendix of INSAG-15 proposes an “Example of questions for assessing personal contributions to the enhancement of safety culture” at all levels of the organization (from the boardroom to the shop floor).These questions are not intended to be exhaustive.

Samples of questions from Appendix of INSAG-15 are given in annex 4.

INSAG encourages operating organizations to use these questions as a basis for discussion and to consider developing them further as ‘prompts’ which might be made available to encourage everyone in the organization to critically review their actions and behavior and to consider how they personally can contribute to enhancing safety.

Examples of Safety Culture indicators

The following indicators could be used to monitor the implementation of Safety Culture:

Number of people trained on Safety Culture (Target = 100%),

Number of non-conformances during external and/or internal audits on Safety Culture subjects,

Number of internal audits related to Safety Culture carried out during the last 3 years,

Level of staff safety culture awareness through personal enquiries,

Ratio of non-conformances raised by the employee on the spot (auto control) versus the ones

rose during inspection.



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Annex 1 : Example of particular technical characteristics : Defense in depth

When relevant and in order to adapt these general guidelines to particular technical characteristics of the product supplied, as mentioned in Chapter 1, it could be necessary, to take into account that Safety culture is a prerequisite for effective implementation of defense in depth measures. According to IAEA INSAG-10 “Defense in depth in nuclear safety” publication, defense in depth means the deployment of “different levels of equipment and procedures” so that nuclear safety is not jeopardized.

SAFETY CULTURE IS BROADLY RELEVANT TO ALL AREAS RELATED TO DEFENSE IN DEPTH AND

IS PARTICULARLY IMPORTANT FOR OPERATIONAL SAFETY.

IAEA, No.INSAG-10, 1996 – “Defense in Depth in Nuclear Safety”

ORGANIZATIONS AND INDIVIDUALS INVOLVED IN ACTIVITIES THAT MAY HAVE AN IMPACT

AT EACH LEVEL OF DEFENSE NEED TO BE COMMITTED TO A STRONG SAFETY CULTURE.

IAEA, No.INSAG-10, 1996 – “Defense in Depth in Nuclear Safety”



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Annex 2 : “A practical guide for nuclear power plant equipment and services suppliers”,

AREVA - Edition 1, November 2007



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Annex 3 : Example of Tokai-Mura accident : results of a poor Safety Culture

The facts

Usual procedure was the procedure approved

by the Authorities

Amended procedure was the usual procedure

modified by the production department without validation by the Safety and Quality Department

Applied procedure was a worker’s adaptation

of the amended procedure, by mixing fuel in a bucket rather than in the dissolving tank and pouring the content directly into the precipitation tank rather than into the buffer tank, in order to speed up the process.

The consequences

Uranium was enriched to 18.8% rather than to

max. 5% as usual. Critical mass in the precipitation tank was

reached. A blue flash indicated the commencement of

nuclear fission. Criticality excursion continued intermittently for 20 hours.

3 technicians who were directly exposed are hospitalized with high radiation doses; 2 die within 7 months.

56 further employees were exposed to elevated radiation doses below the annual maximum.

21 (including firemen) were exposed to elevated radiation doses while draining the cooling water.

5 hours after the start of the nuclear fission local residents were evacuated within a 350 m radius of the plant, 207 being exposed.

The lessons learned

Procedures must not be changed without prior

consultation and approval. Procedural steps must not be skipped just to

speed up the process. Unusual procedures must be supervised

particularly carefully. All employees must be regularly trained and

informed. Contingency plans must be set up and

established.

Tokai-mura 1999Usual Procedure

HNO3 U3O8

dissolving tank

buffer tank

precipitation tank

U3O8

with water cooling

system

2

1

shipping

Tokai-mura 1999Amended Procedure

HNO3U3O8

dissolving tank

buffer tank

precipitation tank

U3O8

with water cooling system

2

1

shipping

Tokai-mura 1999Applied Procedure

HNO3U3O8

dissolving tank

buffer tank

1 geometry-inherent safety

2 reading point for volume and concentration

precipitation tank

U3O8

with water cooling system

2

1

shipping



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Annex 4 - Samples of questions from Appendix of INSAG-15

QUESTIONS FOR MEMBERS OF BOARDS OF DIRECTORS

(5) Do I have the necessary experience and knowledge of safety, and nuclear safety in particular, in

order to make sound judgments and take action on the issues before us?

(6) Do I visit my plants regularly and give attention to safety issues?

QUESTIONS FOR CHIEF NUCLEAR OFFICERS AND EXECUTIVE OFFICERS

(2) Have we published an agreed clear statement of our expectations for safety?

(10) Did I visibly support my staff the last time that they stopped operations for safety reasons?

QUESTIONS FOR THE STATION DIRECTOR AND SENIOR MANAGERS

(4) Was safety the first item discussed in our last management meeting?

(8) The last time that we were behind schedule, did I allow shortcuts to be taken?

QUESTIONS FOR MIDDLE MANAGERS

(2) When was I last in the plant and visibly taking an interest in safety matters?

(6) Did the staff who are going to use our procedures help to write them?

(19) Do my staff fully understand the potential safety consequences of mistakes which they may

make?

QUESTIONS FOR FIRST LINE SUPERVISORS

(4) Are our procedures simple to understand and to follow?

(7) Am I aware which ‘work-arounds’ exist — and am I still allowing them?

QUESTIONS FOR THE SHOP FLOOR

(1) Do I always understand a task before carrying it out?

(8) Do I know what to do if something goes wrong?

(14) Am I taking shortcuts?



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Annex 5 - Bibliography

IAEA, Safety Series No.75-INSAG-4, 1991 – “Safety Culture – A report by the international nuclear safety advisory group”.

http://www-pub.iaea.org/MTCD/publications/PDF/Pub882_web.pdf

IAEA, No.INSAG-10, 1996 – “Defence in Depth in Nuclear Safety. – A report by the international nuclear safety advisory group”. http://www-pub.iaea.org/MTCD/publications/PDF/Pub1013e_web.pdf

IAEA, No.INSAG-13, 1999 – “Management of Operational Safety in Nuclear Power Plants. – A report by the international nuclear safety advisory group”.

http://www-pub.iaea.org/MTCD/publications/PDF/P083_scr.pdf

IAEA, No.INSAG-15, 2002 – “Key Practical Issues in Strengthening Safety Culture – A report by the international nuclear safety advisory group”. http://www-pub.iaea.org/MTCD/publications/PDF/Pub1137_scr.pdf

IAEA Bulletin 50-1 – September 2008 – “The mindset of nuclear safety, by Giovanni Verlini"

http://www.iaea.org/Publications/Magazines/Bulletin/Bull501/50102014749.pdf

General Safety Requirements No. GSR Part 2

http://www-pub.iaea.org/MTCD/publications/PDF/Pub1750web.pdf

IAEA Safety Guides No. GS-G-3 “Application of the Management System for Facilities and Activities”


INPO – “Principles for a Strong Nuclear Safety Culture” – November 2004 http://www.nrc.gov/about-nrc/regulatory/enforcement/INPO_PrinciplesSafetyCulture.pdf

AREVA “A practical guide for nuclear power plant equipment and services suppliers”,

Edition 1, November 2007.

AREVA “Nuclear Safety by interaction of Individual and Organisation”. Rev.B Stand.:

02/2007.


http://www-pub.iaea.org/MTCD/publications/PDF/Pub1013e_web.pdf

http://www-pub.iaea.org/MTCD/publications/PDF/P083_scr.pdf

http://www-pub.iaea.org/MTCD/publications/PDF/Pub1137_scr.pdf

http://www.iaea.org/Publications/Magazines/Bulletin/Bull501/50102014749.pdf

http://www-pub.iaea.org/MTCD/publications/PDF/Pub1750web.pdf


http://www.nrc.gov/about-nrc/regulatory/enforcement/INPO_PrinciplesSafetyCulture.pdf