NSQ100 Guidelines - Section B - Safety Culture - 2011 December...1. Until Three Mile Island (TMI) accident in 1979, design quality was considered as key issue to ensure nuclear safety

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Copyright © 2011 NQSA, All rights reserved.

ABSTRACT This document is the Section B to NSQ-100 Guidelines. Its objective is to help to the understanding of NSQ-100 requirements through some examples or recommendations and descriptions of industrial good practices. The Guidelines Section B is related to the Safety Culture requirements of NSQ100 (Chapters 4.1.1 & 6.2.1). It could be an help in the drafting of safety culture training.

Summary

� Chapter 1: Purpose of this section

� Chapter 2 : Nuclear Safety

� Chapter 3 : Safety Culture

� Chapter 4: How to understand the NSQ100 requirements?

� Chapter 5: Example of tools to support Safety Culture

� Annex 1: Bibliography

� 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: result of poor safety culture

Copyright © 2011 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

and 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:

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Contents of this section could be used as basis documentation to provide safety culture training inside the organization. CHAPTER 2: NUCLEAR SAFETY

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

In other words, nuclear safety is composed by:

Technological aspects +

Organizational aspects +

Human aspects Taking into account all these aspects, an organization participates to reduce risks of accident and its consequences. This guide focuses on safety culture with in history, definition, examples, assessment…

SAFETY CULTURE

NUCLEAR SAFETY



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CHAPTER 3: SAFETY CULTURE

Brief History of Safety Culture

“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].

History of emergence of Safety Culture in 3 major steps:

1. Until Three Mile Island (TMI) accident in 1979, design quality was considered as key issue to ensure nuclear safety. Risks were identified and assessed were only on a technological way.

2. Further to this TMI accident, the human factors were taken into account. Root cause analysis allows to identify failures in man machine interface. Technical system controlled by humans who must be able to identify in any time status of the system and be able to decide relevant actions.

3. Further to Chernobyl accident in 1986, the safety approach was completed by organizational aspect.

The concept of Safety Culture comes from the nuclear industry. It is a direct result of the Chernobyl

accident. A brief history shows that it appeared clearly in a publication called the IAEA Safety

Culture (1991) and known as the INSAG-4.

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Definition of Safety Culture

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

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

In other words, the purpose of safety culture is to ensure that anyone from senior management

to shop floor , from design definition to dismantling through manufacturing, commissioning,

operating and maintenance, is committed to safety in a structured organization managing

interfaces and communication.

Concept of Culture

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

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

Difference between nuclear safety culture and corpo rate culture The main differences of nuclear safety culture compared with general corporate culture touch on the concept

of core hazards and the potential large effects associated with the dispersion of radioactive substances. It is

this fact that makes nuclear power different and that demands a set of organizational values that place

nuclear safety as the top priority of an organizati on .



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Safety Culture is

characterized by optimal

interaction of individuals

and organization

to ensure nuclear safety

Components of 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.

Importance of Quality Management System In order to achieve a high level of nuclear safety, the organization has to define the scope of its management system related to the nuclear contract (what is nuclear safety for your organization). This scope has to be documented either in the quality assurance program / plan or in the organization management manual itself.

The Quality Management System supports a good Safety Culture by:

� Quality Manual, Procedures, Policy, Audits,

� Project management,

� Process Descriptions,

� Risk Assessment,

� Design Reviews,

� Verification & Validation (Design, Development, Product),

� Training / Qualification,

� Management Reviews,

� Supplier Assessment.

Safety culture must take into account the following organizational aspects, for example:

⇒ Ensure availability of resources (human, financial, work environment ...),

⇒ Identify all staff whose activities may affect safety of the product (IFS) to raise safety culture awareness,

⇒ Strictly follow the Quality Management System implemented.

SAFETY CULTURE

ATTITUDINAL

ORGANIZATIONS INDIVIDUALS

STRUCTURAL



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Personal contributions to Safety Culture Personal contributions to Safety Culture:

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Safety Culture is characterized by everyone acting in a way which is safety oriented and with awareness of

their own responsibility according to their own abilities, existing tools and competencies, as well as by the

formation of an environment which is conducive to high level of Safety.

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



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CHAPTER 4: HOW TO UNDERSTAND THE NSQ100 REQUIREMENTS? The answers to requirements presented below are not exhaustive. “4.1.1. Nuclear safety culture The organization shall promote and support a strong safety culture by:

Top management shall be able to demonstrate his own implication and commitment to safety through formal communication (Written : nuclear safety policy, memo, internal notes ; Verbal : meeting, conference)

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

The concept of Safety Culture appears:

• in procedures, instructions… • in communications towards the staff, individuals… • in documents tracing decisions : management review report…

Organization charts and definitions of roles and responsibilities are available for all the staff.

- 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

Good working conditions exist with regard to time pressures, workload and stress by demonstrating adequacy of project / contract necessary resources against allocated ones (human and material). There is systematic development of individual competences (training…). Documentation and procedures are easily available and written in understandable manner for the final users. The management should establish 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.

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

Learning is facilitated through the ability to :

• recognize and diagnose deviations, • formulate and implement solutions and • monitor the effects of corrective actions.

A questioning attitude prevails and is cultivated at all organizational levels, through training, internal communication, periodic sensitization…



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- 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 General 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 5: EXAMPLE OF TOOLS TO SUPPORT SAFETY CULTURE

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

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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?

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

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In order to provide the means by which the organization continually seeks to develop and improve its safety culture, periodical assessment should be performed. The assessment could be based on five characteristics that are defined in the IAEA safety standards:

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Appendix of INSAG-15 (see Bibliography) proposes “Example of questions for assessing personal

contributions to the enhancement of safety culture ”.

108 questions are proposed to all members of an organization (from the boardroom to the shop floor).

The questions are not intended to be exhaustive.

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 review critically their actions and behavior and to consider how they personally can contribute

to enhancing safety.

This process can itself be a useful contributor to improving safety culture. It is also recommended that

regulatory bodies establish a parallel set of questions for use in their own organizations. Included in this set

would be questions that relate to the potential for the regulator to influence the safety culture of the operating

organization, both positively and negatively.



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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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Below indicators could be use to monitor implementation of Safety Culture:

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

� Number of non conformance during external audits on Safety Culture subjects,

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

� Number of non conformance during internal audits on Safety Culture subjects,

� 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 raised during inspection.



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� 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-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

� IAEA Safety Requirements No. GS-R-3 “The Management System for Facilities and Activities” http://www-pub.iaea.org/MTCD/publications/PDF/Pub1252_web.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.



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Tokai-mura 1999Usual Procedure

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precipitation tank

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� 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.

� 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 are exposed to elevated radiation doses below the annual maximum.

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

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

� 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.

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Documents

NSQ100 Guidelines - Section B - Safety Culture - 2011 December...1. Until Three Mile Island (TMI) accident in 1979, design quality was considered as key issue to ensure nuclear safety