european rail human and organisational factors seminar 2018€¦ · haste. (4g) •operators...

European Rail Human and Organisational

Factors Seminar 2018

Oversight of Safety Culture in Nuclear Facilities

Neli Vasileva

Bulgarian Nuclear Regulatory Agency

European Rail Human and Organisational Factors Seminar 2018

Status of nuclear facilities

European Rail Human and Organisational Factors Seminar 2018 2

Governmental and legal framework

The state regulation of the safe use of nuclear energy

and ionizing radiation and the safe management of

radioactive waste and spent nuclear fuel in Bulgaria is

covered by the

Act on the safe use of nuclear energy (ASUNE)

ASUNE is effected by BNRA Chairman

an independent specialised authority of the executive

power with competence specified in the act


Regulatory body

The BNRA Chairman has power to:

➢authorise the activities under the act

➢oversee compliance with the safety requirements and

conditions of authorizations

➢undertake enforcement measures and impose administrative

penalties

➢develop and submit to the CM the regulations on the

implementation of the Act


Regulatory body


•Counci

l of

Min

iste

rs

Prime Minister

Deputy Prime Minister

Deputy Prime Minister for European Policies

Coordination and Institutional Affairs

BNRA

Chairman

Deputy Prime Minister for EU Funds and Economic

Policies

Ministry of Energy

KNPPSE RAW

Deputy Prime Minister

5

IAEA Safety standards

2006 2016 2006/2009

Fundamental Safety

Principles Safety RequirementsSafety Guides


SF-1. Fundamental safety principles

3.12. Leadership in safety matters has to be demonstrated at the highest levels in an organization. Safety has to be achieved and maintained by means of an effective management system. The management system also has to ensure the promotion of a safety culture……..

3.13. ………Safety culture includes:• Individual and collective commitment to safety on the part of the leadership,

the management and personnel at all levels;• Accountability for safety of organizations and of individuals at all levels;• Measures to encourage a questioning and learning attitude and to discourage

complacency with regard to safety

Principle 3: Leadership and management for safety Effective leadership and management for safety must be established and sustained in organizations concerned with, and facilities and activities that give rise to radiation risks.


GSR Part 2. Leadership and management for

safety

5.1. All individuals in the organization shall contribute to fostering and sustaining a strong safety culture 5.2 Senior managers and all other managers shall advocate and support:(a) A common understanding of safety and of safety culture …..; (b) Acceptance by individuals of personal accountability for their attitudes and conduct with regard to safety(c) An organizational culture that supports and encourages trust, collaboration, consultation and communication; (d) The reporting of problems ……. including the timely ….reporting back of actions taken;(e) Measures to encourage a questioning and learning attitude ... and to discourage complacency with regard to safety; (f) The means by which the organization seeks to enhance safety and to foster and sustain a strong safety culture, and using a systemic approach (…..interactions between technical, human and organizational factors are duly considered)………

Requirement 12: Fostering a culture for safety Individuals in the organization, from senior managers downwards, shall foster a strong safety culture. The management system and leadership for safety shall be such as to foster and sustain a strong safety culture.


IAEA Safety guides

GS-G-3.1 Application of management system for facilities and

activities

2.36. A strong safety culture has the following important characteristics:

➢Safety is a clearly recognized value➢Leadership for safety is clear➢Accountability for safety is clear➢Safety is integrated into all activities➢Safety is learning driven

The characteristics encompass 37 attributes

GS-G-3.5 The Management System for Nuclear Facilities

Appendix I - Further explains the 37 attributes


Requirements on safety culture

Act of the safe use of nuclear energy

Art. 16 Anyone using nuclear energy or sources of ionising radiation or

involved in radioactive waste management and spent fuel management

is required to:

1. comply with nuclear safety, radiation protection and physical

protection requirements, standards and rules during the performance

of the relevant activity and to establish and sustain an effective

management system for the respective activities, giving priority to

safety and ensuring high level of safety culture….


Requirements on safety culture

Regulation on ensuring the safety of nuclear power plants

Chapter two. Operating organization

Section II. Management System

Art. 8. (1) The operating organization shall implement and continually improve the

management system, which main objectives are ensuring and improving safety of the

NPP and promoting and supporting high safety culture of the staff

Art. 25 Managers at all levels demonstrate, encourage and support types of behavior and attitudes that support sustainable and high safety culture. Managers activities reinforce an open reporting, a learning and questioning attitude as well as preparedness for conditions challenging safety

Art. 26 The MS provides means to systematically develop, promote and support the expected behavior, values and basics beliefs which lead to high level of SC. The adequacy and effectiveness of these means is assessed as part of the self-assessment and management system review


Oversight of safety culture

➢ The regulatory oversight of SC is part of the oversight process

➢ The oversight process combines compliance based verifications and a

proactive approach and improves safety by:

• Checking mandatory compliance with regulations and licenses

• Identifying potentially weak areas of performance that if allowed to

progress could result in non-compliance with the regulations

➢ The Oversight of Safety Culture mainly utilizes the proactive

approach to identify and influence the need to reinforce both individual

and organizational behaviors for the continuous enhancement of

safety


Process Diagram

Safety Culture Data CollectionPotential SC facts collected throught BNRA oversight programme

Safety Culture Data ReviewReview of the collected SC facts and possible causes

Safety Culture Data Classification and TrendingClassificatio of the SC facts related to SC items – Formulation of SC issues

Reporting to the LicenseeFeedback to the licensee

Follow-up Verification of the progress of the implementation of action plan


Sources of safety culture data

• Interviews with licensees’ staff

• Observation of conditions and activities in the field

• Review of event reports (including low-level and near-miss reports)

• Information and data gathered from common meetings between regulators and licensees

• Review of documentation

The focus is on interviews and observations which enable the inspectors to create an impression on the values, believes, attitudes and behavior of personnel


Data collection

Seeking facts through Observations in the field

• Effective application of policies, programs and procedures by supervisors and workers

• Attitudes, capabilities and performance of supervisors and workers

• Managerial and supervisory presence in the field

• Communication, either verbal (supervisor to worker, worker to supervisor, worker to worker) or through posted information (notices)

• Evidence of open reporting (deficiencies labeled, reporting facilities available and utilized)

• Adequacy of facilities and their present status (temporary modifications, operator work-around and aids)

• Condition of equipment and systems

• Cleanliness and preservation


Data collection

Dealing with Interviews and Discussions

➢ The aim of interviews and discussions is not to evaluate individual qualities or weaknesses of people but to collect individual opinions, perceptions of particular situations:

• the way the people understand their role in the organization

• the difficulties they have in performing their activities, their opinions on the origin of these difficulties

• their vision about the policy and its implementation

➢ The information is purely subjective and represents the factual opinions of the interviewee

➢ The analysis of these “facts” will consist in “making objective” this data:

• opinions should be compared to identify consensus and discrepancies

• opinions should also be compared to data from observations and documents

➢ The result of these comparative analyses will provide an objective picture of the overall situation


Data classification

• Data classification

compares the observed

Safety Culture (“what is

really done”) with the Safety

Culture characteristics

(“what is prescribed”) to

determine the existence of

any gaps (potential safety

culture issues), and if

possible why they exist


Interviews(& Information

exchanges)

Observations Events analyses

SC Items

SC facts

Safety Culture Characteristics

What gap? Why this gap?

Document reviews

17

Data classification


Data trending

➢ This trending supports the identification and formulation of safety

culture issues, which will be reported to the licensee

➢ The formulation of safety culture issues should be based on the

different methods for data collection to get a comprehensive

picture of the maturity of the licensee’s organization in terms of

safety culture

➢While specific data may not provide a view on the safety culture

of the organization as a whole, evidence of certain safety culture

items not being met in several areas and processes may provide

a clear indication of a problem that would warrant increased

regulatory oversight


Reporting and follow-up

➢ The results has to be reported on regular basis

• SC issues and possible areas for improvement for the licensee

• SC issues requiring further analysis by the NPP to identify and correct root causes

➢ A meeting will be requested to discuss the findings and their implications. For the areas for which improvements are necessary, an action plan may be requested from the NPP, however

➢ As the SC oversight relies mainly on a proactive approach, informal exchanges with the licensee is necessary

➢ The progress of implementation of the action plan and associated improvement in safety culture is verified


Guidance for Safety culture data collection

➢ Based on the nine areas of BNRA inspection process: • Management, Organization and

Administration

• Training and Qualification

• Operation

• Maintenance

• Technical Support

• Operational Experience Feedback

• Radiation Protection

• Chemistry

• Emergency Planning and Preparedness

➢ Each area contains a list of

statements

➢ Each statement has a suggested

alignment to an Safety Culture

“Item” indicated in brackets

➢ The alignment requires some

judgement since the

observations will not always

exactly match one of the

statements


Area Management - example

• The resource allocation policy takes into consideration safety priorities. (1b)

• Senior management monitors the performance of the plant and takes necessary initiatives and measures to ensure that safety is continuously improved. (2b)

• A clearly defined and understood organizational structure exists,

including all necessary interfaces. (3b)

• The NPP regulations relating to the conditions of work, such as working hours and safety support the safe operation of the power plant. (4g)

• The necessary pool of knowledge, skills, attitudes and safety expertise is sustained and long-term policy objectives for human resources are met. (5g)


Area Operations - example

• There is sufficient numbers of shift authorized operators and other staff for the reliable accomplishment of assigned tasks. (1b)

• For any major changes to reactor power a pre-job briefing occurs explaining the effects of the change and resolving any procedural conflicts, policies, work distractions or contingency actions prior to making the power change. (2b)

• Shift crews routinely monitor the condition of systems and components and appropriately record the plant status and parameters and all automatic or manual actions. (3e)

• Operators perform their activities in an atmosphere of avoiding haste. (4g)

• Operators understand the required standards for procedure compliance, communications and notifications of plant status. (5b)

European Rail Human and Organisational Factors Seminar 2018 23v

Recording safety culture facts

Inspector

• Once identified by an

inspector any

potential safety

culture fact is

reported on a

specific Safety

culture data

collection sheet


Reviewing safety culture facts

Division head

➢ Each sheet initiated by an inspector is reviewed to:

• assesses it for adequacy and completeness

• requires additional information if needed

• proposes the classification of the potential safety culture fact into relevant safety culture characteristics and items


Assessing safety culture facts

SC Assessment Board

• confirms the classification of the potential SC facts

• requires additional information if necessary

The sheets are completed and summarized and then transmitted to the Database


Trending safety culture facts

DB Structure

• The different clusters addressed in the sheets enable the establishment of several matrices - SC characteristics or items X functional areas orphysical areas or divisions

• These matrices support the trending analysis, and therefore the formulation of the SC issues


Examples


Inspections

Performed at Kozloduy NPP in 2012, 2014, 2018 to check:

➢ Organization of activities related to SC, responsibilities,

organizational structure

➢ SCC activities

➢ Internal documents

➢ SC self-assessment

• methodology of implementation

• results (areas for improvement and strength and good

practices identified)

• planned measures for improvement

• effectiveness of fulfilled measuresEuropean Rail Human and Organisational Factors Seminar 2018

29

Inspections

Recommendations:

➢ broadening of the scope of SCC activities to ensure the continuous monitoring of

SC and identifying and carrying out actions for its improvement

➢ annual planning of activities to allow for assessment of particular elements of SC

based on different data sources

➢ specifying all sources of data for carrying out assessment of individual attributes

of SC (analyses of events, analysis of operational experience, self-assessment

indicators, analysis of personnel motivation, analysis of training, annual reports)

➢ taking into account the expert judgement of each member of the SCC in the

decision making process, in relation to the SCC assigned analytical functions

➢ specifying rules for postpone and control of unfulfilled planned measures

➢ development of full set of documents, guiding the activities of SCC


Competence - key factor for success

➢ Common understanding of the concept of safety culture

➢ Understand the characteristics of a strong safety culture, specifying the organizational performance or attitudes in a nuclear facility

➢ Knowledge and skills of methods for collecting data

➢ Knowledge and skills in recognizing relevant information and formulating

findings

➢ Ability and skills to identify warning flags that could potentially indicate a

decline in safety culture

➢ Ability to oversee SC in specific inspection areas

➢ The training of the inspectors needs to be a continuous process in order

to improve their ability to identify potential SC facts and the possible

causes for their existence, during the normal inspection practice


Thank you!

european rail human and organisational factors seminar 2018€¦ · haste. (4g) •operators...

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