Washington, D.C. June 8, 2005

1. Energy Facility Contractors Group Washington, D.C. June 8, 2005

2. The Challenge of Changing Organizational Culture----Building A Safety Conscious Work Environment Billie Pirner Garde Clifford & Garde Washington, D.C.

3. “How Are We Going to Build a Safety Conscious Work Environment?”

4. Safety Culture or SCWE ? • Safety Culture and Safety Conscious Work Environment are two distinct but related concepts: • Safety Culture refers to the necessary attention, personal dedication and accountability of all individuals engaged in any activity that has a bearing on safety; • SCWE refers to the willingness of employees to identify safety concerns without fear of reprisal or apathy. • SCWE is an attribute of Safety Culture EFCOG June 2005

5. DOE Definition of Safety Culture “The safety culture of an organization is the product of individual and group values, attitudes, competencies, and patterns of behaviors that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs.” DOE Implementation Plan for DNFSB Recommendation 2004-1, Dec. 2004, p. 48 EFCOG June 2005

6. Safety Relies Upon the Free Flow of Information Throughout The Organization Overt Retaliation…. Discouragement…. Lack of responsiveness…. Lack of Competence…. Hierarchal Suffocation. EFCOG June 2005

7. Chernobyl - 1986 Chernobyl disaster resulted in international acknowledgment of importance of safety culture in avoiding unacceptable consequences, and use of term. EFCOG June 2005

8. EFCOG June 2005

9. “Obviously A Major Malfunction” EFCOG June 2005

10. Unacceptable Consequences “No fundamental decision was made at NASA to do evil; rather, a series of seemingly harmless decisions were made that incrementally moved the space agency toward a catastrophic outcome.… No rules were violated; there was no intent to do harm. Yet harm was done. Astronauts died.” Diane Vaughan, The Challenger Launch Decision 409-410 (1996) EFCOG June 2005

11. Fatal Blind Spot “The [Shuttle] program’s structure was a source of problems, not just because of the way it impeded the flow of information, but because it has had effects on the culture that contradict safety goals. NASA’s blind spot is it believes it has a strong safety culture…” Columbia Accident Investigation Board (CAIB), Chapter 8, page 203. EFCOG June 2005

12. EFCOG June 2005

13. EFCOG June 2005

14. Lessons Not Learned In neither [the Challenger or Columbia] impending crisis did management recognize how [organization] structure and hierarchy can silence employees, and take appropriate mitigating actions, such as polling participants, soliciting dissenting opinions, or bringing in outsiders who might have a different perspective or useful information, to overcome the organizational constraints. CAIB, page 202. EFCOG June 2005

15. “Leaders create culture, it is their responsibility to change it.”CAIB, at 203.

16. EFCOG June 2005

17. What the NRC Did About Safety Culture After Chernobyl • Benchmarked Good Safety Cultures; • Established Expectations for Licensees; • Strengthened internal regulations against retaliation for raising concerns (10 CFR 50.7); • Issued SCWE policy statement identifying SCWE attributes (May, 1996 and October, 2004); • Aggressively investigates retaliation allegations; • Monitors licensee SCWE performance indicators. • Takes Enforcement Action. EFCOG June 2005

18. NRC Expectations The NRC expects that licensees will establish and maintain a safety conscious work environment in which employees feel free to raise concerns both to their own management and the NRC without fear ofretaliation. May 1996 SCWE Policy Statement October 2004 SCWE Policy Update EFCOG June 2005

19. Millstone 1996 Order Millstone issues were a wake-up call on SCWE concerns: EFCOG June 2005

20. The Ultimate Question Would I lose my job for that??? Sorry! I can’t afford to lose my job. Would you raise a nuclear safety concern? EFCOG June 2005

21. Davis-Besse 2002 Incident Davis-Besse incident was the result of a lack of safety culture. DB - A Hole in the HeadStainless steel liner bulged, but did not fail EFCOG June 2005

22. Alyeska Pipeline 1991 - 1999 • Exxon Valdez clean up failure; • Spy “sting” on critics and employees; • Congressional investigations, increased regulatory oversight, multiple lawsuits by employees and critics; • Complete loss of public confidence; • Collapse of internal safety culture. EFCOG June 2005

23. DOE AND SAFETY CULTURE EFCOG June 2005

24. DOE’s “Lessons Learned” The DOE committed to an assessment of the lessons learned by NASA and the NRC as a result of the loss of the Columbia and the near miss at Davis-Besse, in response to DNFSB Recommendation 2004-1; which was adopted in its entirety by the Secretary of Energy in December, 2004. EFCOG June 2005

25. Does ISM, By Itself, Provide the Tools to Improve Safety Culture Throughout the DOE Complex? “It is our belief that robust implementation of ISM could lead [DOE] and its contractors to a stronger safety culture….However, without robust and active support by [DOE] Senior Management, ISM will not lead to an enduring [DOE] safety culture, nor is ISM specifically designed to improve an organization’s safety culture.” NNSA, CAIBLessons Learned Report, February 19, 2004, p. 4 . “ EFCOG June 2005

26. Integrated Safety Management ISM plus behavioral attributes and a plan to develop, measure and monitor progress toward building a safety culture. EFCOG June 2005

27. Building A Robust Safety Culture Is An Art and a Science • “Safety Culture” is not the soft side of management issues – it is the hardest! • “Safety Culture” can be built, or re-built, using proven organizational development; methodologies, but a bad culture will not simply evolve into a good one by declaration; • “Safety Culture” behaviors are often counter-intuitive and must be learned and reinforced; • Driving fear and apathy out of workplace, i.e. SCWE, takes consistent performance management and mitigation strategies. EFCOG June 2005

28. Key Elements Of Culture Change • Leaders must “make the case” for change; • The organization must collectively identify the desired “end state” for the new work environment, i.e., behavioral attributes; • The management team must understand the baseline issues and challenges facing organization under each attribute; • There must be a single, clear set of behavioral expectations for everyone, and additional expectations for leadership; EFCOG June 2005

29. Key Elements Of Culture Change (cont’d) • There must be measurable performance indicators; • There must be a dedicated infrastructure to guide culture change and establish new norms; • The organization needs to receive training on new skill sets and new expectations; • Work plans to address problem areas and behaviors should be developed and worked; and • Progress should be measured regularly through self assessments and external reviews. EFCOG June 2005

30. Taking on the Challenge! EFCOG June 2005

31. “We have a vision of a people-based future. We know our work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” Ed Aromi, President of CH2M Hill - Hanford August 23, 2004, General Delivery Message EFCOG June 2005

32. Commitment Conservatism in Safety Decisions Problem Identification & Resolution Training Adequacy Self-Assessment Trust Communications Free Flow of Information Alternative Avenues for Concerns People Management Prevention of Retaliation Work Environment Attributes(Examples) EFCOG June 2005

33. Assessment of the Current State EFCOG June 2005

34. Behavioral Expectations For Everyone

35. Nuclear Organization Key SCWE Performance Measures EFCOG June 2005

36. Commitment to Free Flow of Information EFCOG June 2005

37. Training, Training, Training Preventing Retaliation Communications Training Management Training 101 Listening Skills

38. SCWE Infrastructure • Additional support is needed to assist organization in making change: • Executive involvement in personnel decisions that may impact safety culture; • SCWE mentors and advice to assure consistency and fairness; • Alternative avenues for minority opinions or employee concerns. EFCOG June 2005

39. Preventing the Unacceptable Consequences “If I look back on it now… I should have done everything in my power to get it stopped. I should have taken over the meeting and all that. But, no, really I’m not that grade structure or anything.” Bob Ebeling, Interview, March 19, 1986 Diane Vaughan, The Challenger Launch Decision (1996)

40. Preventing the Unacceptable Consequences “I felt like going in there and interrupting or waiting until they got through ... but I didn’t … I said, ‘Mike, did you hear that she got that we are still not finished [with the foam Strike Issue] … Mike said to me, ‘Well, what are the rules for engaging a manager here? What is the protocol for doing that?’ ... And I remember saying ‘Mike, for an issue like this, where we have a flight safety concern, I don’t think the protocol should matter. It shouldn’t matter at all. … Rocha left without speaking to Ham.” CommCheck, Mike Cabbage and William Harwood, 2004 EFCOG June 2005

41. Preventing the Unacceptable Consequences EFCOG June 2005

42. Preventing the Unacceptable Consequences EFCOG June 2005

43. Preventing the Unacceptable Consequences “The prudent response of the production technicians as they saw unexpected behavior of the explosive provided the only effective barrier preventing a drop of explosives with potentially unacceptable consequences. …” EFCOG June 2005

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