What Needs to be Changed based on Lessons … Needs to be Changed based on Lessons Learned from Chernobyl. V.N. Abramova Professor of Psychology [email protected] Obninsk Y OINPE

What Needs to be Changed based on Lessons Learned from

Chernobyl. V.N. Abramova

Professor of Psychology

[email protected]

Obninsk

Y OINPE MEPhI OSRC

“Prognoz International Conference on Human and Organizational Aspects of

Assuring Nuclear Safety Exploring 30 Years of Safety Culture

IAEA, Vienna, Austria 22–26 February 2016

mailto:[email protected]

mailto:[email protected]

• Obninsk Institute for Nuclear Power Engineering (OINPE) in National Research Nuclear University (NRNU) of Moscow Engineering Physics Institute («MEPhI»)

• Scientific Research Center (SRC) “PROGNOZ”,

V. Abramova 2016 IAEA Safety Culture Conference

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Fig.1 The presentation of safety culture (INSAG-4)


DEFINITION OF RESPONSIBILITIES

DEFINITION AND CONTROL OF SAFETY

PRACTICES

QUALIFICATIONS AND TRANING

REWARDS AND SANCTIONS

AUDIT, REVIEW AND COMPARISON

MANAGERS' COMMITMENT

COMMUNICATION

ARIGOROUS AND PRUDENT

APPROACH

QUESTIONING ATTITUDE

SAFETY CULTURE

INDIVIDUALS’ COMMITMENT

POLICY LEVEL COMMITMENT

SELF-REGULATION

RESOURCES

MANAGEMENT STRUCTURES

STATEMENT OF SAFETY POLICY

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Fig. 2. Psychological aspects of the safety culture

Safety culture

Individuals’ commitment

A rigorous and prudent approach

Managers' commitment

Policy level commitment

Statement of safety policy

Management structures

Resources of qualitative personnel

Self-regulation, business activity in high quality organizational

culture ensuring

Efficient definition of authority and responsibility

Implementation control

Personnel training and assessment of competence

and responsibility

There is the effective encourage and sanctions system on Best Practice

encouragement

The work and procedure improvement, aimed at safety culture

improvement

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Questioning attitude

Communication, technical documents

keeping

Fig. 3. The «lesson» concept


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Acknowledgement of negative event

Understanding: what has happened, how it has happened and effort to understand why negative events are taking place

Organizational factors of industrial environment; Safety culture; Human values in work environment; Person psychology Psychophysiology features

Learning a lesson from an incident:

Forming taboo attitude - prohibition to do (repeat) incorrect operation in future.

Fig. 4. A directions of activities an lessons learning from

Chernobyl catastrophe

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Technical shortcomings

reactor constructional

defect correcting in

Chernobyl and its NPP analogous.

The concept and methodology instruments of safety culture forming. Practical activities for safety culture enhancement.

Enhancement of NPP

equipment safety. Quality

enhancement of NPP

personal education.

The lowering of social attention for Chernobyl

lessons. The work in

NPP for analysis and reduction of low level significance

breach.

The experience of widely adopted conception and methodology instruments of safety culture in NPP. The assessment of experience.

1986

1987 - 1993

1994-2000 2001-2008 2009-2016

Fig. 5 . Systematic approach to manage nuclear power plant human resources


Control actions of external environment

System of activities on HR management

Success enhancement of staff activities and NPP reliability

Programs on solving individual problems of employee personal professional development in nuclear industry

Programs on solving problems of social management in changing conditions of the market and social security

Ensuring professional and psychological readiness, self-control, discipline and commitment at every employee level. Development of labor motivation and safety.

Elaboration and implementation of social security policy and ensuring high living standards of staff. Boosting effectiveness of organizational measures.

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Fig.6. The Lessons Learned from Chernobyl, Human Factor’s role.


“… in general the Chernobyl NPP 1986 staff is described as quite ordinary, mature, well-formed, consisting of qualified specialists at the level recognized in the country as satisfactory. The staff was no better, yet no worse than other NPPs teams. These conclusions indicate that failures and errors were made by the staff not because the Chernobyl NPP employees had some “outstanding” characteristics » [INSAG-7, p.39]).

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The Chernobyl accident in 1986 resulted from the overlap of many circumstances, from politics and decision-making at the governmental level to reactor design drawbacks and wrong actions of the staff due to gaps in professional training programs and regulations.

0

10

20

30

40

50

60

70

L F K 1 2 3 4 5 6 7 8 9 0

"эталон оперативного персонала АЭС" оперативнй персонал ЧАЭС

L, F, K scales evaluate reliability of results. Norm – 50 т-points

[1] health concerns.

[2] tension, depression level.

[3] ostentation, desire to impress.

[4] inclination to neglect social norms.

[5] masculinity, ascendance, inclination to leadership.

[6] persistence, determination, suspiciousness.

[7] hypochondria, self-doubt.

[8] identity, emotional coldness and aloofness.

[9] level of activeness, optimism, carelessness.

[0] desire to control and limit contacts with public.


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Fig. 7. Comparison of average data in MMPI test sampling «NPP operating personnel reference» (78 people, 1986) and the Chernobyl NPP operating personnel sampling (19 people) in pre-accident period

0

1

2

3

4

5

6

7

8

9

10

A B C E F G H I L M N O Q1 Q2 Q3 Q4 MD

"эталон оперативного персонала АЭС" оперативнй персонал ЧАЭС

[А] emotions, sociability, responsiveness. [B] maturity, activeness of thinking. [C] emotional stability, self-control. [E] independence, ascendance. [F] relaxed behavior, activity. [G] scrupulosity, commitment to sense of duty, responsibility. [H] inclination to risk, fearlessness, vigor. [ I] gentleness, sentimentality, sensitivity [L] elevated self-assessment, lack of trust, coldness.

[M] pragmatic attitude, realism, earthiness of interests. [N] reserve, ethics, gallantry of manners. [O] anxiety, tension,sensitivity . [Q1] flexibility of thinking, easy change of opinions. [Q2] autonomy, independence from the group.

[Q3] behavior self-control, discipline, accounting for public

opinion. [Q4] dissatisfaction, anxiety, tension. [MD] need for approval, desire to look better.


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Fig. 8. Comparison of average data on R. Cattell16-ФЛО, «С» form, «NPP

operating personnel» sampling (78 people , 1986) and the Chernobyl NPP operating personnel sampling (19 people, prior to the accident)

Fig.9. The Lessons of global and national importance

At the state level and the industry executive level the activities of specialists and executives having safety-priority competences to provide correctly legal support of the industry companies, to guarantee competent, scientifically-based decision-making regarding nuclear power development strategy in the country are envisaged. At this level of activities the requirements to feasible selection of sites for new NPP power units and construction quality are high. Special attention is paid to identifying preferences in the choice of the safest and most economical nuclear reactors for new projects viewing science and technology evolution within the future decades.


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Рис. 10. The Lessons of individual importance level

Accident lessons have the following stages for every person: • Getting information on accident event; • Assessment of importance, role of accident event in production

activities; • Assessment of personality meaning regarding the accident event in

further activities; • Drawing up a psychological prohibition (taboo) to repeat conditions

or actions resulting in accidents of this or other type; • Memorizing and practical utilization of rules prohibiting to repeat

conditions or actions resulting in accidents of similar or other type; • Only actions elaborated on the basis of acquired lesson are allowed.


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Fig. 11. Factors influencing the processes of taboo formation on execution improper actions in personnel behavior.


Health Emotions

HUMAN VALUES

Happiness Health High job results Family, Home, Children; Interesting job

Safety; Taboo to repeated error Comfortable work environment; Favorable climate; Career…

Psychological attitudes:

Management of personnel success (knowledge, principles, laws, rules, instructions, standards, guidelines, regulations ...)

Social attitude

Meaning attitude

Situation attitude

Goal set

(readiness )

Executive set (readiness)

Motives

Performance, Act

Functional condition (state)

of person

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Fig. 12. 30 years later: what should be changed

Accepting Strategies on Safety Culture and Organizational Factors Enhancement are urgent into two major strategic areas: retrospective and perspective. In retrospective area positive achievements and negative experience – disorders in plant operation are studied. The main instrument in this activity is disorders analysis, as precursor events and factors in events. Direct (immediate) and root causes for disorders, corrective actions to prevent their re-occurrence and to prevent them in further on are identified.

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Fig. 13. 30 years later: what should be changed

In retrospective area, negative experience manifests in disorders of a NPP operation due to technology, procedures or human factors deficiencies. However, any disorders in technology or procedures deficiencies are results from errors made either by NPP personnel directly, or people maintaining technology, procedures at the previous stages. Human factor is a part of all disorders. The scale of disorders depends on time coincidence or on aligning a logical chain of objective conditions and facts regarding wrong actions, or manifestations of human error consequences (wrong decisions or actions) at previous stages.

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Fig.14. 30 years later: what should be changed

In retrospective area, in the sense of organizational culture and safety culture human factor role is determined and maintained at every stage of life-cycle and creation /implementation of development policy and industry functioning. The following packages of works or stages can be singled out: - providing for scientific studies and feasibility study of economic and technical development in the industry, - analysis of human resources for the industry needs, - setting forth development strategy, staff training, - decision-making regarding the industry development, identifying tactic steps in its policy and strategy, adoption of programs on the industry development,

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- identifying geographic locations for new industry facilities taking into account seismic, engineering-geological and demographic conditions, - construction of the industry facilities, - scientific theoretic development, equipment calculations and designing to ensure safe and high-performance operation of the industry facilities, - equipment installation, adjustment and start-up, commissioning, - operation, repairs and upgrade of facilities, - extension of operating period, decommissioning of facilities.

Fig. 15. 30 years later: what should be changed Y OINPE MEPhI OSRC

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In perspective area it is important to organize and to implement proper development projects for the whole industry development projects, and every company functioning projects on technical level and human behavior level. To organize production it is necessary to create optimum models of successfully operating technology and people, and rules on following those models with due regard to the accumulated experience in strategic and short-term (tactical) industry development plans. Human behavior at all levels of responsibility represents the biggest modeling (or designing) difficulty. Methodology base of designing human behavior is constituted by the human sciences: psychology, sociology, ergonomics, economics and, of course, technical sciences, defining the contents and the essence of personnel activities, their role as a participant of technological process.

Fig. 16. 30 years later: what should be changed Y OINPE MEPhI OSRC

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Fig. 17. 30 years later: Global Projects

Currently under the conditions of social and political instability in the world, development of the project on providing high organizational and safety culture in the nuclear industry worldwide is relevant. The project should include the following: - concept elaboration and creation of scientific-methodical complex to manage human factor risks in the nuclear power industry; - development of educational complex on formation of professional competences in human factor area, staff activities reliability, safety culture and organizational culture for higher education institutions training nuclear industry staff for and/or providing continued advanced training; - setting up a system of knowledge regarding personnel psychology to be applied in professional activities of equipment designers, specialists on technology operation and staff management at all stages of life-cycle in nuclear organizations;

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Fig. 18. Global Projects

-organizing educational-training complexes to form psychological readiness to work by every graduate in universities training staff for nuclear power organizations, to train and correct professionally important qualities - such as responsible work attitude, stress resistance, self-control, functional state self-regulation, other psychological professionally important personality traits and psychophysiological specifics; - outfitting educational organizations, training centers with high-performance equipment, including usage of noncontact methods to obtain bio data aimed at training functional state self-regulation and self-control under stress circumstances.

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Global Projects

Correction of professional and educational standards is required to train specialists and engineers for NPPs aimed at achieving adequate ratio between these standards and staff training with due account for technical progress and safety culture: - enhancement of professional training quality regarding future technical personnel within the academic period at universities/institutes to ensure high level of safety culture and organizational culture of production in the nuclear power organizations; - enhancement of human resources management quality in the nuclear industry by means of improving professional training quality in higher-education institutions. -setting up scientific-methodology base for advanced training departments in the system of post-graduate training, in training divisions of organizations and companies, in other organizations

having potentially hazardous technologies.

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Fig.19. The logical structure of risk management concept .

NPP Sources of risk

Equipment, technology

Human Factor Procedure

Human resources

Human resources management

Risk management

Human resources and Human

Factors Management

In normal operation

conditions

In accident management

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Fig.20. The management of Human Factors Risks in concept of Safety culture enhancement of Nuclear Industry (generalization of many researchers opinions)

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Human performance assessment

Personnel development

Human factor risk

management

Personnel selection

Safety culture enhancement

Personnel stimulation

Social security and

psychological support for personnel

Work with personnel

on job places

Organization designing and costs

optimization

Knowledge management

FSUE VO “Safety”of

Russia

Concern

“Rosenergoatom”

GC “Rosatom”

HR Department

Minhelpsocdevelop. of

Russia

Federal Medical- Biophysical Agency

Department Safety and Extreme

Situations

Obninsk Research Center “Prognoz”

Research Lab MEPhI, RMC, others

Federal Medicine- Biophysical Centre

Regional Medicine Centre

Socially psychology

work, The

Conflicts Settlement

Participation in the work of Commissions

on Investigation

Failures

Ergonomic examination of the workers places and rules

Psychological Rehabilita-

tion, Correction

Conducting Databases

Inspections of

personnel

Psycho-physiological

control before work, Inspections

of Personnel

Medical Psycho-

physiological

professional selection

Fig.2. TASKS DIRECTIONS of PSYCHOLOGICAL MAINTENANCE LABORATORIES of the ENTERPRISES BRANCHES

MEPhI

Y


Fig. 21. Sources of risks to repeat failure events in NPP operation

The most frequent reasons for repeated similar failures are such circumstances as

• Deficiencies in organizing NPP operation and management • Inadequate employee motivation

No smaller are the risks to repeat failures due to • Hidden construction and installation errors • Ergonomic and technology drawbacks of procedures,

regulatory documents. Deficiencies of professional training as well as professionally

important personal qualities, functional state and ergonomic drawbacks of job places are most often the reasons for single failures.

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Fig.22. Organization-functional structure, objectives and tasks of human factor risk management system.

Risk management system: Ensuring high organizational culture and safety culture

On designing stage Ensuring high quality and successful operation of people and technology: Calculations. Documentation. Designing. Physics. Ergonomics. Technologies. Installation. Adjustments. Acceptance. Elaboration of operational procedures, Technical regulatory documentation, Rules, Instructions.

On operation stage: Activities, electrical power generation Ensuring success

Failure prevention: High and low importance failure conditions and risks control. Measures on risk reduction.

Failure reasons analysis. Prevention of failure re-occurrence, corrective actions.


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Self-actualization of craft

Human competence fulfillment.

Real achievements

Achievements more than

expenditure

Motivation of advance is

actualize

Prognosis of success is to be

borne out

Personality characteristics,

health are normal

Development of career, of

person, social protection

Compliance with the

requirements

of technology and safety culture

Recognition of person

achievements by

environment

Fig.23. The structure of performance professional successfulness of worker

Working efficiency


Performance success

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CONCEPTS

2. Concept of professional competences

1. Concept of job analysis

3. Concept of professional standards

Словарь профессиональных компетенций

Словарь профессиональных компетенций

Professional capacity dictionary

Банк профессиограмм

Банк профессиональных стандартов

Professiogram профессиограмм Professiogram data bank

Professional профессиональных стандартов Professional standards bank

Measuring and pattern matching system of Professional standards for individual data

The form of Professional capacity distribution

Tasks of human resources management in NPP

Assessment of personal successfulness

Optimization of labour organization and work remuneration from position of valuable proportionality.

Enhancement of organizational and safety culture

Fig.24. An infrastructure and components of Success Management Concept In production activity at atomic

facilities 4. Success

Management Concept of

professional activity

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Fig. 25. Principle scheme of professional reliability and successfulness maintenance of NPP personnel management

system (generalization of trade researchers opinions).

OPERATING

SUBSYSTEMS

«Rosenergoatom»

Concern and its

branches

PERSONNEL

PROFESSIONAL

RELIABILITY

NPP SAFETY AND

EFFECTIVE

OPERATION

NPP OPERATION

PROVIDING

SUBSYSTEMS

Management,

services

Adverse factors

(Organizational factors,

social-psychological

climate, ergonomics)

social safety, ecology,

external relations, welfare

Support of psychological

readiness and motivation

Support of physical

endurance

Psychophysiological

support

Risks of

Performance

Design ,

Personnel

training

Ergonomic

support

INTERNAL FACTORS

Professional

qualifications

Job relevant

individual

traits

Safety Culture Phisycal state ,

Health,

Psychophysiology

Medical

support

Social security

Job

implementation

Risks of

declinations

of external

conditions

Risks of

discrepancy to

work requirements

Personnel professional SUCCESSFULNESS

Feedback. Risks of a feedback absence

SUPPORT SUBSYSTEMS for CORRECTION and ACCIDENT PREVENTION

EXTERNAL FACTORS


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Fig. 26. Why are important social security and NPP staff fare?

Whipping up the situation in communities of staff, the formation of protest motivations, aspirations to defend their rights

Errors in the work of the staff

The increase in the number of diseases, decreased performance and working capacity, abnormalities in attention, memory, thinking,

coordination of movements.

Socio-economic, socio-political upheavals, crises, the threat of unemployment, recession, lowering the standard of living and quality of life.

The deterioration of the socio-psychological climate, decrease of psycho-emotional state, psychosomatic disorders among employees.

Breach of order in the job places

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Fig.27. The amendments in educational standards for NPP personnel preparation.

Whipping up the situation in communities of staff, the formation of protest motivations, aspirations to defend their rights

The increase in the number of diseases, decreased performance and working capacity, abnormalities in attention, memory, thinking,

coordination of movements.

Higher-education institutions curriculum and programs training staff for the nuclear power industry must have disciplines on psychological training, as well as on basic psychology application skills in further production activities. Educational standards must be adequate to professional personnel standards at particular departments and positions of the nuclear power companies and must contain educational materials of the following levels: -level of motives and psychological sets for safety priority in future NPP personnel system of values (creation of safety culture); - level of professional knowledge regarding psychology and psychophysiology, work capacity of a working person as an object in designing man-machine systems in future professional activity of a student;

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Fig.28. The amendments in educational standards

- level of professional psychological knowledge of a person as a member of working team (regarding management, leadership, group consolidation, group interaction, personnel success management, psychological climate and other issues); - ergonomic level of job places, level of equipment and technologies, technical documentation (instructions, labor regulations, orders and others). Within the human factor educational disciplines in NPP safety practical studies on organizational culture development, safety culture should be included, as well as basic psycho emotional state self-regulation trainings, self-control and success self-assessment for students.

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1. Professiogram analysis of NPP staff positions;

2. Development of professional competences for OAO «Energoatom» positions;

3. Development of professional standards;

4. Elaboration of staff success management methods for ОАО «Energoatom».

5. Enhancement of analytical methods regarding staff wrong actions based on the developed professional standards

Objectives:

• Characteristics of labor costs and job requirements to the subjects of activities in NPP staff positions;

• Vocabulary of professional competences to enhance quality of job places for OAO «Energoatom» positions;

• Reference positions and professional standards in labor organization at NPP job places;

• Regulations, scales and methods to assess and stimulate success for optimization of ОАО «Energoatom» labor remuneration system.

• Quality enhancement of psychologists activities in commissions investigating NPP failure reasons.

Action Plan:

Enhancement of NPP Management System and Staff Success Assessment


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Fig.29. Determination of error type in the level of psychological assessment in causal analysis of operational events

The errors of personnel as a cause of operational NPP event

Intention - conscious infringement of NPP

operation

Intention – unconscious

error

«Simplification of task»

«Rationalization»

Flagrant error, Violation

Mistake: Lack of competence

Slip

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Motivation; 32,0%

Organizational factors; 28,7%Functional state; 8,2%

Professional competence; 4,1%

Characteristics of thinking, memory,

attention; 3,3%

The latent ergonomic errors of the project

and installation; 5,7%

Ergonomic characteristics of the

operational documentation; 8,2%

Ergonomic characteristics of a

workplace; 4,1%

Mode of work and rest; 3,3%

Ergonomic defects of technology; 1,6%

Сonflict; 0,8%

Fig.30. Some results of analysis of wrong personnel actions as causes in events of infringements in

work on the NPP

35 V. Abramova 2016 IAEA Safety Culture

Conference 3/10/2016

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А) Based on the international experience and national experience from every country under the conference resolution: 1) To single out the learned lessons given in INSAGs 2) To identify positive experience of certain countries to be shared by other countries 3) To identify the experience that needs up-date. To prepare (propose) action plan. 4) To set up a working group to make proposals on

- organizing psychological support of NPP staff and nuclear

facilities staff (trade psychological service) - methodology of activities on NPP organizational and safety culture.

Lessons. Things to Be Done (proposals) Sharing Experience.

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1) Recommendations to national leaders of the IAEA member states to support scientific development and practical advancements regarding human reliability and success in nuclear industry 2) To address the IAEA executives for approval to set up a permanent IAEA division (group) on human factor 3) To address the IAEA executives for support to open international projects on: - psychology and ergonomics issues in setting forth professional standards for NPP jobs - training of engineering and technical staff for NPP, elaboration and approval of educational standards and training programs including disciplines on staff reliability, -- development of methods and up-to-date techniques iп training NPP operators to the required psychological qualities including non-contact biotechnologies.

Lessons. Things to Be Changed B) It is necessary to draft:

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REFERENCES [1] DAHLGREN, K., Enhancing Safety Culture and Management Systems. http://www.sepr.es/html/recursos/descargables/Int-cult-seg-PG-sist-gest.pdf [2] HAAGE, M. IAEA Approach to Safety Culture, Leadership and Management for Safety // "The safety of nuclear technologies: safety culture at nuclear energy use facilities"//8-th International Nuclear forum 9-13 September 2013, St. Petersburg, 2013. [3] IAEA SAFETY SERIES NO.75-INSAG-7 The Chernobyl accident: Updating of INSAG-1, VIENNA, 1993. [4] IAEA SAFETY SERIES NO.75-INSAG-21 Strengthening the Global Nuclear Safety Regime, IAEA, VIENNA, 2006. [5] IAEA SAFETY SERIES NO.75- INSAG-23: Improving the International System for Operating Experience Feedback. VIENNA, 2008. [6] IAEA SAFETY SERIES NO.75- INSAG-25: A Framework for an Integrated Risk informed Decision making process. VIENNA, 2011. [7] Identification and Assessment of Organisational Factors Related to the safety of NPPs. State-of-the-Art Report// Nuclear Safety EA/CSNI/R(98)17 Feb. 1999 Expanded Task Force on Human Factors Principal Working Group No. 1 Volum 1 - 2. 2000.

http://www-pub.iaea.org/MTCD/publications/PDF/Pub1349_web.pdf




[8] Risk Assessment Activities for the Cold War Facilities and Environmental Legacies // NATO Advanced Study Institute, Bourgas, Bulgaria, 2 to 11 May 2000. [9] ABRAMOVA V.N. Organizational Psychology, Organizational Culture and Safety Culture in Nuclear Power Industry. Part 1: Psychology and Organizational Culture and Safety Culture Assessment Methods at Nuclear Plants. Obninsk: RG-SOCIS, 2009. [10] ABRAMOVA V.N. Organizational Psychology, Organizational Culture and Safety Culture in Nuclear Power Industry. Part 2: Psychology of Formation and Improvement of Organizational Culture and Safety Culture at Nuclear Plants. Obninsk: RG-SOCIS, 2011. [11] ABRAMOVA, V.N., FRISCHKNECHT, A., TOLSTYKH, V., Study of Unusual Events in Nuclear Power Plants by Psychological Means./ International Symposium on Reviewing The Safety of Existing Nuclear Power Plants. IAEA - NEA OECD, 8-11 October 1996, IAEA-SM-342/35, Vienna, (1997) [12] KOPCHINSKY,G.А., STEYNBERG, N.А., The Safety of Nuclear Power Plants/ Chernobyl recurrences to the past, with the present situation and about future times. “Osnova-Print”, Kiiv, U ( 2011). [13] MALYSHEV, V.P., Lessons to Overcome the Chernobyl Accident Consequences: 25 years Later //«Risk Analysis Problems», vol.8, 2011, No.2.


Thank you for your attention

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Documents

What Needs to be Changed based on Lessons … Needs to be Changed based on Lessons Learned from Chernobyl. V.N. Abramova Professor of Psychology [email protected] Obninsk Y OINPE