Why Safety Cultures Degenerate

And How To Revive Them

Johan Berglund

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781134765898
• Edition: 1
• Topic: Business
• Subtopic: Business Education
• Index: Business

From Chernobyl to Fukushima, have we come full circle, where formalisation has replaced ambiguity and a decadent style of management, to the point where it is becoming counter-productive? Safety culture is a contested concept and a complex phenomenon, which has been much debated in recent years. In some high-risk activities, like the operating of nuclear power plants, transparency, traceability and standardisation have become synonymous with issues of quality. Meanwhile, the experience-based knowledge that forms the basis of manuals and instructions is liable to decline. In the long-term, arguably, it is the cultural changes and its adverse impacts on co-operation, skill and ability of judgement that will pose the greater risks to the safety of nuclear plants and other high-risk facilities. Johan Berglund examines the background leading up to the Fukushima Daiichi accident in 2011 and highlights the function of practical proficiency in the quality and safety of high-risk activities. The accumulation of skill represents a more indirect and long-term approach to quality, oriented not towards short-term gains but (towards) delayed gratification. Risk management and quality professionals and academics will be interested in the links between skill, quality and safety-critical work as well as those interested in a unique insight into Japanese culture and working life as well as fresh perspectives on safety culture.

1Introduction: Skill and Formalisation

This book concerns areas of risk and civil contingencies, along with issues of quality, skill and learning. My objective is to establish a link between the safety and quality of high-risk activities on the one hand and experience-based knowledge on the other, a link that, I will argue, is crucial in the build-up and maintenance of a reliable safety culture. My key subject of investigation is the Fukushima Daiichi accident of 11 March 2011, the most severe nuclear accident since Chernobyl in 1986. In a wider context, I have looked into why safety cultures degenerate and how they can be revived. As the learning that goes into skill are associated with local and social contexts, it has been necessary to consider various background factors, broadly-based issues, which are likely to have an impact on other issues of importance, while not necessarily being the more obvious focal point of analysis; for instance underlying cultural factors or long-term cultural changes of work. In other words, wider implications of the Fukushima accident that go beyond the technical aspects of the events that have been described in detail in numerous reports, considering issues of significance across organisational borders, and to society.

Thus, nuclear operations remains one of the most notorious examples of high-risk industry in terms of its potential for catastrophe and with the politics and psychology that surrounds it; it is in our consciousness. There is considerable secrecy attached to this sector of industry and for that reason we tend to regard it as an entity of its own, despite the various similarities it has with other sectors of industry. Accidents and incidents relentlessly put in question what is often referred to as the safety culture of these high-technology systems and facilities. Subsequent to the misfortunes at the nuclear plant Forsmark 1 on the east coast of Sweden in 2006 – where the defence-in-depth reactor safety system did not operate sufficiently, due to a short circuit in a 400 kV switchyard outside the plant which affected other levels of the facility in unexpected ways – this accident was described as “the culmination of a long-term decline in safety culture”.¹ Ultimately, operatives at Forsmark were able to untangle the situation without any harmful effects. This was not the case, however, with the accident at Fukushima Daiichi, where huge amounts of radioactive material were emitted into the environment.²

The 15-metre tsunami that hit the east coast of Japan on March 2011 disabled the cooling of three Fukushima Daiichi reactors, as all three cores melted in a matter of a few days, causing a severe nuclear accident. After a couple of weeks, the three reactors were by and large stable with water addition. While there have been no recorded deaths from radiation so far, for decades to come this area of Japan will be effectively uninhabitable, whereas up to this point more than 150 000 people have been evacuated. At this time it is impossible to say when this area will be habitable. Evidence also reveals that many non-human organisms, from plants, insects and birds to monkeys, have been significantly impacted by the radioactive releases in the form of genetic damage and high mortality. In addition, within an area of 20 km up to approximately 300 km from the destroyed power plants, there has been various other effects, on the ocean as well as the entire ecosystem, related to the Fukushima disaster.³

The strong requirements for safety within high-risk activities have triggered a greater level of formalisation, to make modes of operation standardised into “tasks”, creating a larger basis for organisational knowledge. Despite that, experience-based knowledge remains a substantial constituent of any dependable safety culture, as rules and instructions must be understood and applied in real-time situations of practice that are not simply dependent on any predefined goals or tasks to fulfil. From encountering a great variety of situations, skilled practitioners seem to develop what can be characterised as the skill of anticipation. This, in turn, requires acquisition of “readily available, tacit knowledge”, a capability to act in situations that are undetermined.⁴

Safety culture is a contested concept and a complex phenomenon. Organisations, much like societies, are created by humans, in which knowledge is developed in social and situational contexts. Besides, in high-risk activities there is an inclination to equate learning with positive changes in observable behaviour, as against fixed standards. Within the Nuclear Power Industry there is strong reliance on formal schemes of production, and on standard procedures, and like many industries it is now facing the challenges of a major generational shift in both workforce and technology. In addressing these challenges, manuals and instructions have been modelled for every possible situation; literally thousands of pages of regimentation and systems of coordination that are becoming larger and larger, and more and more predominant. How is this a problem?

As has been established in the study field of professional skill, human professionals learn through examples and analogical thinking between situations that are similar but non-identical.⁵ From this perspective, learning is rather the outcome of reflection upon real-time events and experiences. In the wake of nuclear accidents like Three Mile Island and Chernobyl, there have been strong pressures on utility companies to develop more comprehensive work procedures. Many of these accidents have also pointed the finger at (the notion of) the fallible human. Then again, trying to delimit the human factor through the introduction of new technology in the work place, or persistent demands for formalisation, will raise other concerns; the proficiency of skilled practitioners run a long-term risk of being undermined, not given enough opportunity for learning; to exert their ability of judgement, for reflection and critical thinking.⁶ For that reason, professionals in various fields of practice can be constrained by larger factors.

The fact that well-experienced personnel frequently are able to untangle a variety of unforeseen situations, which sometimes occur in high-risk facilities, makes this a matter of great urgency. Erosion of skill, in connection with generation shifts, extensive formalisation, as well as other long-term cultural changes of work, must be taken into account in conjunction with the phenomena of risk and safety culture.⁷ A major concern in Sweden has been that of an ageing workforce, especially with regard to plant personnel. Other aggravating circumstances include the decision taken in the early 1980s to phase out nuclear power by the year 2010. This has been postponed, bringing into concern the issue of ageing facilities. Another main concern internationally has been the increase of output and revenue in addition to persistent demands of cutting costs on operation and maintenance. In other words, to re-design production systems to maximise efficiency.⁸ Accordingly, safety might not be the only priority to the management of high-risk organisations.

This book is based on the following empirics: (1) The Official Report of the Fukushima Nuclear Accident Independent Investigation Commission, NAIIC, released in the summer of 2012, and related reports regarding the background factors of these events; (2) as visiting scholar at the Meiji University in Tokyo in the autumn of 2014, I got the opportunity to interview people from, or with great insight into, the Japanese nuclear industry. I also had the opportunity to visit the site of Fukushima Daiichi; (3) the broad empirical material on the Nuclear Power Industry in Sweden that has been generated since 2008, in collaboration between the KTH Royal Institute of Technology and the Swedish Nuclear Safety and Training Centre (KSU); (4) the launch of the new Master’s Programme in Skill and Technology at Linnaeus University, the basis of which being humanities, epistemology and the study of experience-based knowledge; an educational initiative that can confront some of the issues elaborated in this book.⁹

The methodology that has been used is primarily hermeneutical, where dialogue and exchanges between researcher and informants takes place over longer periods of time, during which I have had my interpretations validated and rectified. The method that has been used to illuminate key issues of skill, quality, safety and education within this sector of industry is the Dialogue Seminar Method,¹⁰ through which reflection is qualified through dialogue in smaller groups. Each participant prepares for a seminar by the reading of a shared impulse text as well as the writing of a short reflection based on their own experience. As the participants are able to articulate more of which they “did not know that they knew”, the objective of such a seminar series is what could be outlined as a sort of discovery of praxis. Experiences are not precisely the same from person to person, but they can be illuminated and developed by various people interactively; discovering something together with a key role for dialogue and analogical thinking. In other words, we have applied all these carefully thought-out performance tools and systems of risk assessment, not to mention a proper organisational design: But what is it that we actually do?

Typical of the last 15 years or so is the revival of Taylorism in disguise, so to speak. This “new” Taylorism, as it is suitable to label it, has spread all through society and reveals itself in attempts of complete regimentation of experience-based knowledge by means of instructions, audits, models and table sheets; in insistent demands on scientific-like knowledge and formal education; in the measurement of performance and proficiency; in re-engineering of work; in a narrowing of vision due to persistent demands on increased “efficiency” and profitability. This is what the New Taylorism is essentially about. As an ideology it is less coherent, less openly declared and, compared to historical Taylorism, arguably less conscious; it is “at once more general and more restricted”.¹¹ Also, its measures of control are more subtle, yet nonetheless effective, with immense impacts on modern-day work place organisations.

The exploration of human skill and what methods can be utilised to support experience-based knowledge are essential to this study. From this viewpoint, the analogical and critical thinking of operatives and plant personnel, gathered from hands-on experience as well as training, becomes an essential constituent of dynamic safety cultures.¹² Revolving around the Fukushima Daiichi nuclear accident, the objective is to arrive at some measures of practical application, which can help to improve and broaden quality work and the uses of training and further education in high-risk activities; to prevent technological risk, general deteriorations of safety and quality. When we talk of degeneration we usually refer to the state or process of decline; in terms of biology, degeneration usually means some sort of evolutionary decline, or loss of function, for instance in an organism or a species. In physical degeneration certain functions in cells or tissues are reduced, impairments which can be reversible. The same may well be true with regard to safety cultures and the quality of work place organisations in general, in which case degeneration is likely to transpire in the form of a worsening of moral qualities, or other qualities and faculties that characterise a certain group of people or a culture. When something degenerates it gets worse by some means. Likewise, degeneration is generally undesirable, a sort of antithesis to development and incremental change; from the Latin word degenerare, it originally means “to be inferior to one’s ancestors”.¹³

History of course knows the processes of development and degeneration and the various forms they can take. Yet the notion of degeneration is not always neutral. It can also be biased. Arguably, the best way of clarifying such corrosive processes is by means of examples from different sectors of industry, which is what I will be trying to do. The key issue, however, and arguably the biggest challenge, would be to recognise these long-term processes of decline or gradual deterioration before they become virtually irreversible. This, I hope, is among the things that this book will help to illuminate.

Notes

1Cf. Background: The Forsmark Incident 25th July 2006, published by the Analysis Group at KSU (The Swedish Nuclear Training and Safety Centre), and Larsson, L. and von Bonsdorff, M. (2007): Ledarskap för säkerhet (Leadership for Safety), an independent report discussing the developments leading up to the incident/accident at Forsmark in 2006.

2On the day of the accident three of the facility’s six reactors were operating at full power whereas the others were shut down for maintenance and refuelling. For a more detailed event summary of the Fukushima Daiichi accident, see INPO, “Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station” (2012): pp. 6–7.

3“Biological Effects of Fukushima Radiation on Plants, Insects, and Animals”, www.phys....

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• Acknowledgements
• 1 Introduction: Skill and Formalisation
• 2 The Separation of Knowing and Doing
• 3 The Shadows of Progress
• 4 The Projection of Quality
• 5 The Skill Factor
• 6 The Concept of Quality Revisited
• 7 Conclusions
• References
• Index