1. IAEA International Atomic Energy Agency The Human and Organizational Part of Nuclear Safety Monica Haage – m.haage@iaea.org International Specialist on Safety Culture and Systemic Approach to Safety (The interaction between Human, Technical & Organizational Factors) Operational Safety Section / NSNI/ Department of Nuclear Safety and Security

2. IAEA Safety is more than the technology

3. IAEA Safety Paradigm The technical factors are advanced and robust The safety principles are well developed The safety review services and assessments are effective The safety processes are advanced and well developed All these are well structured and provides high level of safety But, the underlying factors to accidents are not be found solely in the technology – they are systemic weaknesses related to the human and organizational constraints These are typically related to: How the technology is maintained How the safety principles and safety standards are implemented How the safety review services are assessments are utilized How the improvement activities are implemented By the humans and the organization(s)

4. IAEA International Atomic Energy Agency

5. IAEA Systemic Weaknesses Human, organizational & cultural weaknesses are consistently identified as cross-cutting contributors to significant events: Insufficient understanding of the complexity of ‘reality’ by leaders (‘good news’ cultures, failure to encourage constructive challenge, compartmentalization) Insufficient connection and integration across consultant/ contractor/vendor network Insufficient understanding of nuclear/process safety issues in decision-making and actions Normalisation of abnormal conditions or deviations Failure to learn from previous events and experiences Complacency Inability to invite the full intelligence of the organizational members into improvement processes Inadequate systemic approach to safety in oversight and supervision

6. IAEA 2.6. HUMAN AND ORGANIZATIONAL FACTORS – Observations and Lessons (2) Observation: While the stakeholders involved in the accident at the Fukushima Daiichi NPP were aware of the possibility of the single safety issues related to the accident in advance, they were not able to anticipate, prevent or successfully mitigate the outcome of the complex and dynamic combination of these issues within the sociotechnical system. Lesson Learned: To proactively deal with the complexity of nuclear operations, the results of research on complex sociotechnical systems for safety need to be taken into account by all stakeholders involved. A systemic approach to safety needs to be taken in event and accident analysis, considering all stakeholders and their interactions over time.

7. IAEA International Atomic Energy Agency Systemic Approach to Safety - The interaction between Human, Technical and Organisational factors (HTO)

8. IAEA Safety Principle SF-1 The Interaction between individuals, technology and the organization 3.14. “An important factor in a management system is the recognition of the entire range of interactions of individuals at all levels with technology and with organizations. To prevent human and organizational failures, human factors have to be taken into account and good performance and good practices have to be supported.”

9. IAEA Safety Standard GS-G-3.5 The Interaction between individuals, technology and the organization 2.32.”All safety barriers are designed, constructed, strengthened, breached or eroded by the action or inaction of individuals. Human factors in the organization are critical for safe operation and they should not be separated from technical aspects. Ultimately, safety results from the interaction of individuals with technology and with the organization.” 2.33. ”The concept of safety culture embraces this integration of individuals and technical aspects.

10. IAEA Safety Standard GS-G-3.5 The Interaction between individuals, technology and the organization 2.34. “In a strong safety culture, there should be a knowledge and understanding of human behaviour mechanisms and established human factor principles should be applied to ensure the outcomes for safety of individuals–technology–organization interactions. This could be achieved by including experts on human factors in all relevant activities and teams.”

11. IAEA International Atomic Energy Agency Systemic Approach to Safety - The interaction between Human, Organisational and Technical factors (HTO)

12. IAEA Examples of Organizational Factors Organizational Factors (OF): Vision and objectives Strategies Business Models Integrated Management System Continuous improvements Decision making process Knowledge management Priorities Communication Contracting Work environment Culture etc

13. IAEA Examples of Technical Factors Technical Factors (TF): Design Existing technology Hard ware/Soft ware PSA/DSA Technical Specifications I/C Quality of material Equipment etc

14. IAEA Examples of Human Factors Human Factors (HF): Human capabilities Human constraints Perceived work environment Motivation Individuals understanding Emotions etc

15. IAEA Licensees HOF/SC Areas 1(2) Human Factor Engineering Human Reliability Analysis HTO Analysis – event and proactive analysis Human Factor trainings including Mock-ups Human Performance tools Operational Experience / internal and external Simulator training with special attention on HOF Emergency drills Outage with special attention on HOF and safety culture Reviews on organizational change Safety culture continuous improvements including assessments

16. IAEA Licensees HOF/SC Areas 2(2) HTO review and monitoring Integrated Management Systems Leadership development programmes Competence building Knowledge management Reward and sanction system Safety Conscious Work Environment Operational Decision Making/Conservative Decision Making

17. Complexity and Systemic Challenges in relation to Safety Organizational Factors (OF): Alignment of vision and objectives Clear and appropriate strategies Current Integrated Management System Continuous improvements Priorities Transfer of knowledge Openness of communication Contractor management Systematic and continuous improvements of safety culture etc Technical Factors (TF): Existing technology Advanced technology Automation Analogue/digital Modifications etc Human Factors (HF): Job readiness Cooperation and teamwork Learning and reflection Stress and fatigue Motivation Individuals understanding Trust Self-management etc

18. IAEA 4. Personal and behavioural competences 4.1 Analytical thinking and problem solving 4.2 Personal effectiveness and Self Management 4.3 Communication 4.4 Team work 4.5 Management and Leadership 4.6 Safety Culture These are all related to human and organizational factors (HOF) and safety culture. There are three levels of competences in these areas 1. Generic level – All should have a know-how level. Competence level 1: to know what what HOF and safety culture means in practice and to be able to identify strengths or weakness 2. Expert level – Specialized experts which have experience and training in HOF/SC. Competence level 2: to analyze and review safety cases 3. Specialist level – Specialist with behavior and social science degree. Competence level 3: to perform complex analyzes to identify underlying dynamics related to HOF/SC

19. The IAEA marks 30 years of work with strengthening safety culture worldwide 22 to 26 February 2016 TOPICS Safety Culture/Culture for Safety Human and Organizational Factors Leadership and Management for Safety The Systemic Approach to Safety (The Interaction between Human, Technical and Organizational Factors) Resilience Engineering High Reliability Organizations

20. IAEA …Thank you for your attention