Prerequisites for safety culture development

We started with Reason’s suggestion about the five subcultures, which constitute safety culture: Just, Reporting, Flexible, Informative and Learning Cultures. Afterwards, we identified in the literature (Table 1) the preconditions, which are common across all these elements, and the descriptors of Reason’s subcultures. In addition, we linked Reason’s subcultures with concepts of resilience engineering (i.e. anticipation, monitoring, response, learning), as shown in Table 2. These subculture types, common elements and descriptors comprised the benchmarking reference.

^{Table 1. Reason’s safety subcultures, and reference list for their operationalisation.}

^{Table 2. Connecting safety culture prerequisites and resilience abilities.}

Gap Analysis

The framework was used to analyse the safety culture guidance identified in the NPP planning documents and seven industry sectors: nuclear, aviation, healthcare, maritime, oil & gas, railway and defence (Table 3). The research team consulted the documentation published by international bodies and organisations per industry sector. Whereby such documents or bodies were not identified, it was decided to consider the ones available for the European region, and in case of inadequate resources in Europe, the North American region references were utilized. If more than one document about safety culture was available per industry sector, it was decided to assess the one(s) most recently published. Also, in most of the cases, there was more than one document linked to safety culture development and including references to each other; therefore, the researchers analysed the whole set of such published guidance per sector.

^{Table 3. Industry sectors documentation.}

Statistical calculations

In order to assess the degree of agreement amongst the NPP and the seven industry sectors, the researchers used two agreement measures: Fleiss Kappa and pairwise agreement. These measures were additional to the simple frequency calculations of the elements present in the documentation per industry and the NPP in total and per safety subculture / general prerequisites.

Interviews with the NPP’s staff

In addition to defining the set of prerequisites for developing safety culture and the results of the benchmarking, it was of high interest to explore the extent to which NPP’s policy and procedures (work-as-designed) are operated (work-as-done), and if any additional methods, tools, approaches, etc. are employed by managers. Under this scope, nine (9) interviews were conducted; this enabled the project team to obtain a more substantial picture of how the NPP develops its culture, and allowed to make more targeted recommendations.

Alignment analyses of the NPP’s safety culture planning, operation, and monitoring

Based on the systems engineering paradigm and the fundamental PDCA quality cycle, the planning, operation, and monitoring activities of safety culture at the NPP should be ideally aligned to each other (Karanikas, 2014). This means that what is planned should be operated, and subsequently monitored in order to achieve continuous interaction and improvement. Under this rationale, the researchers:

• Assessed the extent to which the feedback mechanisms, which the NPP has in place to monitor progress and effects of its planned safety culture initiatives, are aligned with the actual planning. In order to evaluate such a distance, the project team cross-referenced the NPP’s planning and monitoring documentation;
• Compared the interview results with the NPP’s safety culture planning as means to evaluate the extent to which managers implement what is planned;
• Consulted the NPP’s safety culture meta-analysis document in order to identify any differences between the findings mentioned in this document and the data collected during the interviews.

The research project showed that it was possible and relevant to compare the status in different industry sectors and the NPP, regarding the prerequisites for developing a safety culture.

Industry sectors

In terms of descriptors’ frequencies, the aviation domain scored highest and the maritime domain accumulated the lowest score. The nuclear industry scored higher than the industry average, and is listed fourth out of the seven industry sectors considered in the project.

The analysis per safety subculture and the general prerequisites showed that:

• Learning culture scored highest across all measures compared to other elements.
• Just culture is the most underrepresented element in average; there were no relevant references identified in the healthcare, defence and maritime domains.
• In average, industry sectors provide more guidance about the common organizational prerequisites and the informative and learning cultures than the just, flexible and reporting cultures.
• Even in the cases of high agreement in terms of frequencies and pairwise comparisons, the moderate Fleiss kappa values showed that such an agreement does not regard the same descriptors across the industry sectors and safety culture elements. Hence, the seven domains have approached safety culture in a diverse way.

Nuclear power plant under research

• Regarding the benchmarking:
  • NPP’s safety culture planning scored lower than the industry average and the nuclear industry when all safety descriptors were considered (i.e. general prerequisites and just, flexible, reporting, informative and learning cultures).
  • NPP has adequately planned for the common organizational prerequisites and the informative and learning subcultures.
  • NPP’s policy is insufficient and weak regarding the just, flexible and reporting subcultures.
• Safety is valued and comprises an area of continuous concern. However, the perspectives amongst managers regarding safety culture activities are highly diverse.
• Managers recognise the importance of effective communication as means to minimize the distance amongst the different organizational levels. However, management’s commitment to safety is not quite visible to the work floor.
• The NPP supports merely a compliance driven professional attitude, without recognising the existence and importance of flexibility and the need to decentralise risk management under defined and agreed boundaries and thresholds.
• The unacceptance of flexibility and variability hinders the ability to monitor and control them before they unfold to adverse events.

The research team recommended that the NPP must:

• Communicate, share and explain existing safety culture policy to all staff, starting from senior management and proceeding gradually to all organizational levels in the form of workshops.
• Consolidate its safety culture related policies in one single document.
• Based on the framework developed for the scope of the project, maintain and refine the safety culture elements and descriptors which are already planned.
• Monitor the existing elements in predetermined intervals.
• Ensure continuous interaction amongst the basic organizational functions of planning, operating and monitoring as means to establish a substantial and impactful improvement program in regard to safety culture and, in general, all organizational interventions.
• Gradually adopt the guidelines published by the nuclear authorities starting with an update of the NPP policy, and afterwards, communicating such a policy, obtaining acceptance by all levels and amending the monitoring instrument.
• Introduce smoothly the rest of the safety culture descriptors included in the framework but not yet adopted by the nuclear industry sector.

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^{CANSO (2008) Safety Culture Definition and Enhancement Process, Civil Air Navigation Services Organisation, Amsterdam.}

^{Casey, A. (2005). Enhancing Individual and Organizational Learning A Sociological Model. Management Learning, 36(2), 131-147.}

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^{ERA (2013). Application guide for the design and implementation of a Railway Safety Management System: Developing and Improving Safety Culture In The Organisation, European Railway Agency, Valenciennes.}

^{EU (2004). Directive 2004/49/EC on safety on the Community's railways, European Parliament and the Council.}

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^{IAEA (2002a), Safety Culture in Nuclear Installations: Guidance for Use in The Enhancement of Safety Culture, IAEA-TECDOC-1329, International Atomic Energy Agency, Vienna.}

^{IAEA (2002b), Key Practical Issues in Strengthening Safety Culture INSAG-15, International Atomic Energy Agency, Vienna.}

^{ICAO (2013), Safety Management Manual, International Civil Aviation Organization, Canada.}

^{IMO (1999). Principles of Safe Manning, Resolution A.890(21), International Maritime Organisation, London.}

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• Dr. Nektarios Karanikas, Aviation Academy
• Pedram Soltani, Aviation Academy
• Dr. Robert Jan de Boer, Aviation Academy
• Dr. Alfred Roelen, Aviation Academy
• Dr. Sidney Dekker, Griffith University

Dr. Nektarios Karanikas, n.karanikas@hva.nl