Chernobyl: 30 Years On – Lessons in Safety Culture
Late at night on 26 April 1986 in the then USSR, a team of nuclear workers prepared to conduct a test on Reactor 4 of the Chernobyl nuclear power plant as part of an otherwise routine shutdown. The exercise was to test a modified safety system and determine how long the reactor’s steam turbines would continue to power to the main coolant pumps following a loss of main electrical power supply.
In order to achieve the test conditions automatic shutdown devices were inhibited and the emergency core cooling system shut-down. We the total clarity of hindsight we know this was particularly high risk because the particular RMBK-1000 reactor design is unstable at the low power levels (c7%) being tested. The test was also to be started by one shift and completed in the early morning by another, with potential shift handover and circadian low factors. A previous attempt had failed, potentially heightening the pressure to complete it on this shutdown.
At 01:24 the reactor was shook by two massive explosions. Over the coming months many emergency workers were to die and many more members of the off site population exposed to harmful levels of radiation, with widespread environmental effects across many countries.
Some reports suggest the operator’s actions were ‘violations‘, however as the World Nuclear Association notes:
The 1991 report by the State Committee on the Supervision of Safety in Industry and Nuclear Power on the root cause of the accident looked past the operator actions.
It said that while it was certainly true the operators placed their reactor in a dangerously unstable condition (in fact in a condition which virtually guaranteed an accident) it was also true that in doing so they had not in fact violated a number of vital operating policies and principles, since no such policies and principles had been articulated.
Additionally, the operating organisation had not been made aware either of the specific vital safety significance of maintaining a minimum operating reactivity margin, or the general reactivity characteristics of the RBMK which made low power operation extremely hazardous.
Safety Culture and Chernobyl
The Chernobyl accident was analysed by the International Atomic Energy Agency‘s International Nuclear Safety Advisory Group (INSAG):
INSAG concluded that the need to create and maintain a ‘safety culture’ is a precondition for ensuring nuclear power plant safety. The concept of ‘safety culture’ relates to a very general concept of dedication and personal responsibility of all those involved in any safety related activity at a nuclear power plant.
Inculcation of a safety culture requires that, in training personnel for nuclear plants, particular emphasis be placed on the reasons for the establishment of safety practices and on the consequences in terms of safety of failures on the part of personnel to perform their duties properly. Special emphasis must be placed on the reasons for the establishment of safety limits and the consequences in terms of safety of violating them.
Safety culture presupposes total psychological dedication to safety, which is primarily created by the attitude of the administrative staff of the organizations engaged in the development and operation of nuclear power plants.
In INSAG publications, the concept of safety culture has been extended beyond the purely operational aspects to cover all types of activities at all stages in the lifetime of a nuclear power plant which may affect its safe operation. It even covers the highest spheres of administration, including the legal and governmental ones which, according to the concept, must create a national climate in which attention is paid to nuclear safety on a daily basis.
If the Chernobyl accident is assessed in terms of this safety culture concept, it can be seen that not only those involved in the operational stage lacked an adequate safety culture, but also those involved in other stages of the lifetime of a nuclear power plant (designers, engineers, constructors, equipment manufacturers, ministerial and regulatory bodies, etc.).
James Reason, Professor Emeritus, University of Manchester, who wrote the 1997 classic Managing the Risks of Organizational Accidents has said that it was Chernobyl that stimulated his interest in the human and organisational factors of major accidents.
A Safety Culture Framework
The IAEA has developed a framework for ‘strong’ safety culture consisting of five characteristics: Each of these five characteristics have a series of attributes:
(1) SAFETY IS A CLEARLY RECOGNIZED VALUE
(a) The high priority given to safety is shown in documentation, communications and decision making
(b) Safety is a primary consideration in the allocation of resources
(c) The strategic business importance of safety is reflected in the business plan
(d) Individuals are convinced that safety and production go hand in hand
(f) Safety conscious behaviour is socially accepted and supported (both formally and informally)
(2) LEADERSHIP FOR SAFETY IS CLEAR
(a) Senior management is clearly committed to safety
(b) Commitment to safety is evident at all levels of management
(c) There is visible leadership showing the involvement of management in safety related activities
(d) Leadership skills are systematically developed:
(e) Management ensures that there are sufficient competent individuals
(f) Management seeks the active involvement of individuals in improving safety
(h) Management shows a continual effort to strive for openness and good communication throughout the organization
(i) Relationships between managers and individuals are built on trust:
(3) ACCOUNTABILITY FOR SAFETY IS CLEAR
(a) An appropriate relationship with the regulatory body exists that ensures that the accountability for safety remains with the licensee
(b) Roles and responsibilities are clearly defined and understood
(c) There is a high level of compliance with regulations and procedures
(d) Management delegates responsibility with appropriate authority to enable clear accountabilities to be established
(e) ‘Ownership’ for safety is evident at all organizational levels and for all personnel
(4) SAFETY IS INTEGRATED INTO ALL ACTIVITIES
(a) Trust permeates the organization
(b) Consideration of all types of safety, including industrial safety and environmental safety, and of security is evident
(c) The quality of documentation and procedures is good
(d) The quality of processes, from planning to implementation and review, is good
(e) Individuals have the necessary knowledge and understanding of the work processes
(f) Factors affecting work motivation and job satisfaction are considered
(g) Good working conditions exist with regard to time pressures, workload and stress
(h) There is cross-functional and interdisciplinary cooperation and teamwork
(i) Housekeeping and material conditions reflect commitment to excellence
(5) SAFETY IS LEARNING DRIVEN
(a) A questioning attitude prevails at all organizational levels
(b) Open reporting of deviations and errors is encouraged
(c) Internal and external assessments, including self-assessments, are used
(d) Organizational experience and operating experience (both internal and external to the installation) are used
(e) Learning is facilitated through the ability to recognize and diagnose deviations, to formulate and implement solutions and to monitor the effects of corrective actions
(f) Safety performance indicators are tracked, trended and evaluated, and acted upon:
(g) There is systematic development of individual competences
Safety Leadership and Culture Resources
We highly recommend this case study: ‘Beyond SMS’ by Andy Evans (our founder) & John Parker in Flight Safety Foundation‘s, AeroSafety World, May 2008 which discusses the importance of culture, safety leadership and the practical experience developing safety leadership skills across managers and supervisors in an international air operator. You may also be interested in these Aerossurance articles:
- How To Develop Your Organisation’s Safety Culture practical advice on the value of safety leadership and an aviation example of safety leadership development.
- How To Destroy Your Organisation’s Safety Culture a cautionary tale of how poor leadership and communications can undermine safety.
- The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa a real life example of safety leadership and how the stock markets reacted badly until O’Neill’s focus on safety, responding to employee suggestions and continuous improvement (not mere compliance) started to created exceptional business performance.
- Culpable Culture of Compliance? which looks at what happens when the culture is only about compliance without understanding risk
- James Reason’s 12 Principles of Error Management
- Back to the Future: Error Management
- Challenger Launch Decision – 30 Years On
Prof James Reason published this paper in 1998: Achieving a safe culture: theory and practice
Prof Patrick Hudson proposed the following model (developed from earlier work by Ron Westrum):
When discussing this model, Hudson wittily explains why brown was chosen as the colour for the pathological to whom bad things just happen…
In a Health and Safety Executive (HSE) report from 2000 this similar model was proposed:
However, the authors caution “the model is provided to illustrate the concept and it is not intended to be used as a diagnostic instrument”.
In June 2013, The Hon. Mr Justice Haddon-Cave addressed delegates at Piper 25 (a conference to mark the 25th anniversary of Piper Alpha offshore disaster in the North Sea, in which 167 workers died). His paper was entitled “Leadership and Culture, Principles and Professionalism, Simplicity and Safety – Lessons from the Nimrod Review”, a report issued in October 2009, following the loss of Royal Air Force (RAF) Nimrod XV230:
Piper 25: Presentation Transcript
A paper by the Health and Safety Laboratory is worth attention: High Reliability Organisations [HROs] and Mindful Leadership. Mindfulness is developed further in a paper by the Future Sky Safe EU research project and by Andrew Hopkins at the ANU.
The International Association of Oil and Gas Producers (IOGP) has also published the report: Shaping safety culture through safety leadership
Malcolm Brinded also discusses leadership and how good safety performance and good business performance go hand in hand:
UPDATE 6 November 2015: Ed Shein gave a presentation: So You Want to Create a Culture? which emphasised understanding the change you want to achieve.
UPDATE 11 January 2016: You may like this Forbes article Do You Know What’s Really Driving Your Organizational Culture? This make 4 key points:
- Culture is a collective concept.
- You may need some outside perspective to get an unbiased view.
- Don’t jump to conclusions. What you see isn’t always what you get and may result addressing symptoms rather what is creating them.
- Understand the why behind the what.
UPDATE 5 May 2016: The UK Confidential Incident Reporting and Analysis System (CIRAS) has released the presentations from their ‘Safety Culture Under Strain’ conferences held in London and Edinburgh in April 2016. Aerossurance attended the excellent Edinburgh event.
Also, the UK Rail Accident Investigation Branch (RAIB) commented in a new investigation report:
UPDATE 1 August 2016: We also recommend this article: Leicester’s lesson in leadership, published in The Psychologist.
UPDATE: 28 August 2016: We look at an EU research project that recently investigated the concepts of organisational safety intelligence (the safety information available) and executive safety wisdom (in using that to make safety decisions) by interviewing 16 senior industry executives: Safety Intelligence & Safety Wisdom. They defined these as:
Safety Intelligence the various sources of quantitative information an organisation may use to identify and assess various threats.
Safety Wisdom the judgement and decision-making of those in senior positions who must decide what to do to remain safe, and how they also use quantitative and qualitative information to support those decisions.
UPDATE 19 September 2016: It’s worth listening to Todd Conklin’s podcast interview with Prof Ed Schein.
UPDATE 22 September 2016: NTSB Board Member Robert L. Sumwalt presented Lessons from the Ashes:
The Critical Role of Safety Leadership to an audience in Houston, TX. Its worth noting the emphasis made of safety as a ‘value’ and of alignment across an organisation. He illustrates that presentation with two charts that show the differences in perception of safety at Metro-North:
UPDATE 26 September 2016: John Bersin writes: Data Proves that Culture, Values, and Career are Biggest Drivers of Employment Brand. When it comes to recommending your organisation to others:
An employee’s rating of “culture and values” is 4.9 times more predictive of a company recommendation than salary and benefits. The second most important factor is “career opportunities,” which is 4.5 more important than salary and benefits. The third factor is “confidence in senior leadership,” which is approximately 4 times more predictive than salary and benefits.
UPDATE 29 September 2016: Culture Change is Not About Navel Gazing
…addressing culture is extremely important for business success however organizations need to be informed about whether they will actually get measurable performance results from the approach that is being suggested. Don’t be fooled…an approach that sounds like an interesting behavioral experiment or a snazzy tech solution is not usually a good one.
UPDATE 30 September 2016: Talking leadership: Julia Fernando on understanding culture to enable compassionate care in the NHS.
The difficulty is that once a culture is set and norms are established, it can be hard to change the status quo. Changing a culture of fear and blame can therefore be difficult. Leadership plays a vital role in driving forward such changes…
UPDATE 30 October 2016: For a more general discussion on culture see: New research and a new understanding about culture change in organisations. This discusses the ‘Mosaic Theory’ explaining that:
In the last few years our understanding of culture and how we take on cultural attributes has shifted away from the idea that culture is a homogeneous solid entity to the understanding that:
- Cultures are dynamic, ever changing entities
- Cultures don’t exist nor can be defined on their own. All cultures are in fact made up of a mosaic of different sets of behaviours, thinking and beliefs from a wide range of sources.
- Individuals navigate the range of cultures they encounter and learn to ‘fit in’. So for example our family will have a culture that most likely is very different from the culture at work or from a social group.
- From an individual’s perspective cultures are made up of identifiable layers or tiles which are shared or not shared between the various cultures they encounter on a daily basis.
In a follow up article, The 3 Main Conclusions and Findings from New Research about Culture Change in Organisations, it was noted that research has shown that at work “most people take their cultural cues for behaviour and beliefs from the following areas of their life” in descending order:
- The culture of the organisation
- The culture of their profession
- Experience (Age)
- Their family values
- Their nationality and ethnicity equally
- Whether they come from an urban or rural area, so rural or urban cultural values
UPDATE 8 December 2016: Aerossurance founder, Andy Evans, presented on the topic of safety leadership at a UK CAA helicopter safety culture seminar today.
UPDATE 16 February 2017: See also our article Consultants & Culture: The Good, the Bad and the Ugly
UPDATE 1 March 2017: Safety Performance Listening and Learning – AEROSPACE March 2017
Organisations need to be confident that they are hearing all the safety concerns and observations of their workforce. They also need the assurance that their safety decisions are being actioned. The RAeS Human Factors Group: Engineering (HFG:E) set out to find out a way to check if organisations are truly listening and learning.
The result was a self-reflective approach to find ways to stimulate improvement.
UPDATE 15 March 2017: The first Future Sky Safety public workshop was held on the 8-9 March, 2017 in Brussels, at Eurocontrol Headquarters. Among the presentations of note were:
- easyJet’s experience of our first safety culture survey by Siân Blanchard and David Cross of easyJet. It particular this discussed a collaborative approach to safety across organisations, in what easyJet has termed ‘the Luton Stack’.
- Safety intelligence and middle managers – the undiscovered country? by Corinne Bieder, Airbus/ENAC
UPDATE 22 March 2017: Which difference do you want to make through leadership? (a presentation based on the work of Jim Kouzes and Barry Posner). Note slide 6 in particular:
UPDATE 25 March 2017: In a commentary on the NHS annual staff survey, trust is emphasised again:
Developing a culture where quality and improvement are central to an organisation’s strategy requires high levels of trust, and trust that issues can be raised and dealt with as an opportunity for improvement. There is no doubt that without this learning culture, with trust as a central behaviour, errors and incidents will only increase.
UPDATE 12 April 2017: See our article: Leadership and Trust
UPDATE 25 May 2017: What makes change harder or easier:
Before you adopt any popular new management approach, it pays to analyze the implicit values embedded in it. Then ask yourself: How well will those values fit our existing organizational culture?
UPDATE 30 May 2017: This slightly cynical piece discusses corporate values: How Corporate Values Get Hijacked and Misused. The message is not that values are unimportant but that only defining values, or defining faux-values is worthless.
UPDATE 31 May 2017: The US National Transportation Safety Board (NTSB) commented on the poor organisational culture and leadership after the loss of de Havilland DHC-3 Otter floatplane, N270PA in a CFIT in Alaska and the loss of 9 lives: All Aboard CFIT: Alaskan Sightseeing Fatal Flight
UPDATE 24 December 2017: The Leader’s Guide to Corporate Culture
UPDATE 7 April 2018: Investigators Criticise Cargo Carrier’s Culture & FAA Regulation After Fatal Somatogravic LOC-I. A Shorts 360 N380MQ, operated by SkyWay Enterprises as a Part 135 flight on contract to FedEx crashed in the Caribbean after the crew likely suffered a Somatogravic Illusion raising the flaps on a dark night in 2014. The lack of an FAA SMS regulation for Part 135, the operator’s poor safety culture and implications for the wider industry culture stand out in a thoughtful accident report.
UPDATE 13 January 2019: Pathological to Generative. Moving up the Regulation Culture Ladder with Bruce.
UPDATE 4 February 2019: A recent survey shows that employees feel less positive about their workplace culture than their employers. Five actions are proposed:
- Address where your culture and your strategy clash: “No culture is all good or all bad. Every culture has emotional energy within it that can be leveraged” says Jon Katzenbach.
- Change your listening tours: “It takes more than ordinary listening to get a true understanding of the culture at your organization. Instead, challenge and foster healthy debate and real feedback from people across departments and across levels. Connect with people who are emotionally astute and who have insight into what people care about most.”
- Identify the “critical few” behaviors that will shift your culture: “Cultures don’t change quickly, but a disciplined focus on these “critical few” can accelerate and catalyze a purposeful evolution. As people begin to adopt the behaviors, take time to recognize and reward those people for focusing on those behaviors, too.”
- Step into the “show me” age: “Right away, do something that’s visible and concrete. If it succeeds and sends a positive message, repeat it–early and often. Then, encourage others to do the same. When your people see you leading by example, they’re more likely to follow suit.”
- Commit to culture as a continual, collaborative effort: ” …42% of respondents believe that their organization’s culture has remained static for the last five years. 23% of employees report that leaders of their organizations have tried culture change or evolution of some form, but acknowledge that the efforts resulted in no discernible improvements. Influencing culture is hard, and most leaders declare victory too soon. It can’t be a “one-off” project, nor can it be implemented top-down. Prepare to persevere through obstacles if you want long-term, sustainable change. The more ambitious the effort, the more time and more input from people at all levels it will demand”.
UPDATE 14 December 2019: A “culture of safety” is lacking at the Massachusetts Bay Transportation Authority (MBTA) “according to a scathing report by three outside experts“.
For more details on the accident read: INSAG-7, The Chernobyl Accident: Updating of INSAG-1, A report by the International Nuclear Safety Advisory Group, IAEA, Safety Series No. 75-INSAG-7, 1992, (ISBN: 9201046928) https://www.youtube.com/watch?v=vnjzVNG18jo&feature=player_detailpage