Man – Technology – Organization (MTO/ITO)

Dept. of Nuclear Power Plant Safety

Swedish Radiation Safety Authority

Lars Axelsson

Human Factors Specialist

Section of

Man Technology Organisation

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About the

Swedish Radiation Safety Authority

under the Ministry of the Environment

budget approx. 400 million SEK

300+ employees

About the

Swedish Radiation Safety Authority

under the Ministry of the Environment

DG Mats Persson

budget approx. 400 million SEK

300 employees

office in Solna

Swedish Nuclear Power Inspectorate (SKI)

– MTO Section

Swedish Radiation Protection Institute (SSI)

Merged in 2008

became Swedish Radiation Safety Authority

(SSM)

Closed in 2005

Organization

(Hu)Man

Technology

Three Mile Island 1979

MTO in Sweden was a result of

TMI 1979.

The interaction of man technology

organization

MTO stands for the interaction between humans,

technology, and organization. MTO refers to a

system perspective on how radiation and nuclear

safety are affected by the relationship between:

• Humans’ abilities and limitations

• Technical equipment and the surrounding

environment

• The organization and the opportunities it

provides

There are two ways to look at the human

contribution in safety problems

PERSON approach:

Focuses on individual persons errors and mistakes.

Actions aimed towards people at the operator level (the

sharp end).

SYSTEM approach (SSM’s view):

Traces contributing factors back into the whole system.

Actions aimed towards situations and organizations.

SYSTEM approach

Incidents and accidents are caused by a linked

series of failures in defenses, barriers and control

functions that has been established to protect

from known and unknown dangers.

The important questions are:

• How and why did the system fail?

• What can we do to reduce the risk that will happen again?

James Reason

The technical systems must be able to handle

errors (not based on 100% human efforts)

People must be supported to report mistakes

Important to create a fair and just organizational

culture where the reasons for mistakes are

investigated, corrected and learned from

Proactive and reactive prevention efforts

Human error is inevitable and cannot be eliminated

To err is human, we can not change people's basic conditions but we can change the conditions that people work in

An accident is often the result of a chain of events

There is very seldom one single cause to an accident. Instead there are many contributing factors.

Important to have knowledge in factors that affect the performance of individuals, groups and organizations

Humans, management and organizations

should be discussed not only in terms of their

limitations, errors and shortcomings but also

in terms of their strengths in stopping a chain

of events, in learning, inventing and

improving.

MTO

The concept is well established both in the

industry and within the regulator in Sweden.

The Section of Man Technology Organization at SSM consists of 12 Human Factors Specialists. We are responsible for the oversight at nuclear power plants in the following areas:

•Safety management and organizational issues (E.g. Quality assurance, management systems, organisational changes)

•Safety culture (also responsible for the departments coordination of safety culture)

• Competence, fitness for duty, suitability, education and staffing, knowledge management

• Working conditions

• MTO perspective/Ergonomics of control room work and modifications, and other plant modifications

• Incident analysis and risk analysis from an MTO-perspective (and operational experience)

The SSM regulations concerning safety in nuclear

facilities (SMFS 2008:1) have explicit

requirements and general recommendations in

the above-mentioned areas

The SSM regulations are based on IAEA safety

standards and guidance

Section of Man Technology Organization

Lars Axelsson

Safety culture/

safety management

Oskarshamn

Anne Edland

Head of Section

Eva Brusell

Administrator

Per Chaikiat

Safety culture/

Ringhals

Anna Bärjegård

Safety assessments, internal

audits, self-monitoring

Oskarshamn

Johan Enkvist Competence/Knowledge magmt

Radiation protection in healthcare

Oskarshamn

Yvonne Liljeholm-

Johansson

Modernisation /human factors of control room work /Forsmark

Petra Sjöström Safety management

system/ New regulations/

Cecilia Wahlund Final disposal/

Studsvik, Svafo/SKB

Aino Obenius

Mowitz Modernisation /human

factors of control room work /Ringhals

Steve Selmer Ergonomics/Working

conditions/Organisation,

security

/Westinghouse

Karin Lindström Organisation/

Forsmark

Andreas Kjellin Event investigations /operational

experience

Ringhals

We need to have professional skills and

competence in the following areas

Management systems and quality assurance

Management, organization and safety -

organizational functions and operations,

organizational change

Psychological aspects of individuals, groups and

organizations

Safety culture and leadership for safety

Methods and principles of competence assurance

and for ensuring adequate staffing

Suitability requirements and suitability

assessment

Physical, psychological, social, technical and

organizational conditions that affect people's

abilities and motivation,

Control room work and plant modification with

MTO perspective incl. ergonomic aspects of

human-system interface

Investigation of events and conditions with regard

to Man Technology Organization

HRA

Together with specialists from other

departments we inspect, review, make

decisions, sustain requirements and

recommendations, make investigations,

initiate research, and participate in

international collaboration in these areas

Regulatory activities

Regulatory activities

All inspections and reviews cover specific

parts of the management system relevant to

inspection/review area

Inter-disciplinary teams – always a site

inspector participating

Regulatory Processes at SSM

Safety

Reviews

Notification

of Plant

Modification ABG

Experience and skills

of SSM-staff for example

International co-operation

Indicators

Risk

contribution -

PSA

Planning and bud-

geting/Prioritisation

Plant Surveillance

Inspections

Investigation

and Research

ASK RASK

Event analysis and

operational feed-back

Regulatory

Actions:

Decisions

Enforcements

Early signs – examples from a plant

Deviations from the instructions

The Leadership more focused on Technology

than Humans

Deficiencies in testing after maintenance

Deficiencies in plant documentation

Solutions are implemented without sufficient

preparation

Recommended solutions are not implemented

Events with similar causes reoccur

Safety culture

SSM has no specific requirement on safety

culture

The general regulatory code (SSMFS 2008:1)

based on management for safety

Current requirements cover aspects of safety

culture

SSM will introduce a specific requirement for

safety culture

Safety culture

Targeted safety culture inspections and minor

inspections/site visits

– Addressing some aspects of SC

Examples of themes

Management of ambiguous operational

situations or other weak signals

Understanding of and attitudes towards Human

Performance tools (PJB, PJD, TO, ODM)

Safety Department’s role and authority

Leadership for safety

Security measures and their potential impact on

reactor safety and the safety culture

Safety culture

Requires also other forms of

exchange and other ways for

dialogue:

More discussion and

encouragement

Communicate also the positive

Must find patterns

Have a constructive and open

relationship with the licensees

Advising and supporting

licensees – research, seminars

In oversight we must not just look for

the symptoms. Instead should we look

for

PATTERNS

The patterns will lead us to where the

facility / organization is vulnerable

Strategy

Capture safety culture observations from all SSM

regulatory work (inspections, minor inspections,

reviews)

– ”Other notable observations”

– Hallway discussions

– Oversight database offers opportunity to indicate

SC concern

Unsorted safety concerns

Well grounded ”gut-feeling” about safety

culture issues as input to daily regulatory

activities and discussions

Input to planning of specific Safety Culture

activities

Analysis of gathered information

– Clusters/patterns

Expert judgements on safety culture

Requires behavioural sciences competence

Enhancing the quality

Inhouse safety culture training for all inspectors and oversight staff in SSM

1) Seminar (3 hrs) – General overview of culture, safety culture, risk

assumptions, importance of leadership, etc.

2) Workshop (2,5-3 hrs) – More in-depth discussions on cultural issues and how to

capture those in our regulatory activities

– The presentations from the seminar and workshop provide some guidance – guidance will be developed

Managers?

Safety culture characteristics

Management's commitment to

safety

Visible leadership

Safety is given high priority

A systems perspective on safety

Safety has a strategic and

commercial value

No conflict between safety and

production

Proactive approach and a long-

term perspective

Good management of change

Quality of documentation and

instructions

Rules and instructions are

followed

Adequate staffing with the

required skills

Good resource allocation

MTO expertise

Clear roles and clear

responsibility and authority

Teamwork

Transparency and

communication

Motivation and job satisfaction

Involving all employees

Good working conditions in

terms of time, workload and

stress

Organisational Learning

(IAEA)

Symptoms of a weakening safety culture

Lack of self-evaluation processes

Problems with orderliness

Lost organizational memory

Quality and Security Division has low status

Lack of a comprehensive approach by senior management

Lack of ownership

Isolates himself

Lack of learning

Reluctance to share or collaborate

Inability to deal with deficiencies found during independent external safety assessments

Regulatory Shortcomings

Lack of systematic approach to safety

Instructions unaudited

Incidents are not analyzed

Resources are insufficient

Deviations are increasing in number

Growing number of remaining items of corrective actions

No operational readiness or maintenance

Employee concerns about safety are not taken care of immediately

Disproportional focus on technical issues

(IAEA)

Proactive work

Several research projects procured by SSM on

safety culture

Planning for ’informal’ seminar with licensees on

safety culture

Safety culture of SSM

No real interest within regulatory body some

years ago

IAEA IRRS 2011 – and Fukushima

Now need for activities…

Sida 39

Safety culture of SSM

Started working with the SSM culture in the

spring 2013

Focus:

– How the regulator act in its oversight and what impact

the activitites have on the licensees

– The important issue is if the influence is what we want it

to be and if it is good at all times

– SSM reason for existence (Mission and vision: ”a society

safe from the effects of radiation”)

– Holistic perspective

Challenge

Senior management’s role in the safety culture

of the regulator

The difference between occupational safety and

safety connected to our mission as a regulator

The impact we have on the licensees safety

vs. cables on the floor, car travel to the plants, and security

issues (locked doors, USB sticks)

Sida 41

Lobbying for engaging senior managers

Senior management meeting

Section managers forum

All managers meeting – ’preparatory meeting’

Who has a strong impact on safety

culture?

Who lead and manage the work?

Who prioritize the activities of the regulator?

Who signs off on inspection/review reports?

Who signs off regulatory decisions?

Sida 43

Sida 44

YOU!

SSM day May 2013

– All managers participation

– Break out sessions with all staff – managers acted as

facilitators

SSM day Dec 2013

– Invited speaker and presentation of the results from the

breakout sessions

Have material for more analysis

Have been in contact with university for

independent safety culture evaluation

Responsibility unclear…

Responsibility for supporting the work delegated

to MTO section from 2015

Sida 46

We need to look in the mirror

What we see depends on what we are

willing to see… or what we want to see…

“Culture hides much more than it reveals, and

strangely enough, what it hides, it hides most

effectively from its own participants.”

Edward T. Hall

What does your iceberg look like?

Fukushima

Listen to the Japanese

Continue to learn from lessons already learned

and dig for more experiences

Use the mirror as the most important safety tool

– Our own context

– Adapt lessons

– ’Best Practice' is always contextual, and cannot be

universal

Stay humble

The creation, implementation and continuation of

a strong and effective organization with a strong

nuclear safety culture is never completed, takes

daily attention and work…

…and we at SSM also still have a lot of work to

do…

Thank you for your attention

Any questions?