International Railway Safety Conference Paul Thomas CB FREng FCGI Chairman RSSB

HMS VANGUARD

Safety – why bother? Moral Legal Direct cost Reputation Poor Safety = Bad Business

THORP leak British Nuclear Group has released its board of inquiry report into the leak at Sellafield’s Thorp plant. A design error led to a leak of highly radioactive liquor while defective culture at the plant delayed detection for nine months. The exceptionally frank report lists the following management systems as having shortcomings which contributed to the event: safety case; procedures and systems of work; hazard reporting systems; training; supervision; design; maintenance; and plant modification. The report states that a ‘new plant’ culture existed and Thorp was simply not expected to leak. Nuclear Engineering International

Leadership & Responsibility “Responsibility is a unique concept... You may share it with others, but your portion is not diminished. You may delegate it, but it is still with you... If responsibility is rightfully yours, no evasion, or ignorance or passing the blame can shift the burden to someone else. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible.” Admiral Hyman G Rickover USN

People Competence/Training & Assessment Supervision/Management Just Culture/Near Hit & Incident reporting Standards & Expectations

Windscale Programme pressures Competence Appropriate procedures

Three Mile Island Inadequate training Lack of OE feedback Consequences INPO

Chernobyl Bad design Operational pressures Lack of safety culture WANO

Fukushima Plant shut down successfully UNTIL Tsunami hit Periodic review

Peer Review Expert Peers 3 week visit POs & Cs Evidence – White Cards Feedback meeting Strengths AFIs Follow up visit Formal report

Final thoughts “It is necessary for you to learn from others' mistakes. You will not live long enough to make them all yourself” “I have a son. I love my son. I want everything that I do to be so safe that I would be happy to have my son operating it. That‘s my fundamental rule.”