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The systemic approach to safety

ITO

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This thinking is not new…

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A systemic approach to safety in the

Kemeny report of TMI

” When we say that the basic problems are people-related,

we do not mean to limit this term to shortcomings of

individual human beings -- although those do exist. We

mean more generally that our investigation has revealed

problems with the "system" that manufactures, operates,

and regulates nuclear power plants.”

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IAEA 5

Akira Kawano, Senior Manager at Tokyo Electric Power Company,

presentation at IEM5:

“The cause of the accident should not be treated merely as a natural disaster due to an enormous tsunami being something difficult to anticipate. We believe it is necessary to seriously acknowledge the result that TEPCO failed to avoid an accident which might have been avoided if ample preparations had been made in advance with thorough use of human intellect.”

Acknowledgement by TEPCO

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Conclusion from IEM5

IEM5 – International Experts Meeting on Human and Organizational

Factors in Nuclear Safety in the Light of the Accident at the Fukushima

Daiichi Nuclear Power Plant

Chairperson’s Report:

”Several considerations were identified during the meeting for the

development of an integrated approach to safety. In particular, the

need to complement the traditional approach to safety with an ITO

systemic approach was emphasized.”

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The current nuclear safety approach

• The common approach in nuclear safety is an analytical approach –

we break down the systems into smaller parts to make it manageable

and to ensure nothing is left unattended – we compartmentalize

• Necessary due to the complexity of nuclear technology and its

application

• Provides robustness for most predicted and unpredicted situations.

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The current nuclear safety approach

• The common approach in nuclear safety is to break down the

systems into smaller parts to make it manageable and to ensure

nothing is left unattended – we compartmentalize

• Necessary due to the complexity of nuclear technology and its

application

• Provides robustness for most predicted and unpredicted situations.

BUT…

• Working with each aspect separately does not give the full picture of

the system

• Tends to overemphasise technical factors – a strong belief that if the

technology works, the plant is safe

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Individual, Technical and Organizational Factors

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The systemic approach to safety – ITO

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• A systemic approach to safety means that we comprehend the whole

systems interplay between individuals, technology and organization

(ITO)

• As the whole ITO system is fare to complex for one individual to

comprehend, an integrated approach is needed, which invites different

competencies and thinking

• Understanding the dynamics of the ITO interactions helps us to

evaluate their ability to produce safety outcomes more effectively

• Safety outcomes emerges from ITO interactions

• A systemic approach to safety offers a complementary safety

perspective

The systemic approach to safety – ITO

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The complexity of the system…

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• A systemic approach to safety means that we comprehend the whole

systems interplay between individuals, technology and organization

(ITO)

• As the whole ITO system is fare to complex for one individual to

comprehend, an integrated approach is needed, which invites different

competencies and thinking

• Understanding the dynamics of the ITO interactions helps us to

evaluate their ability to produce safety outcomes more effectively

• Safety outcomes emerges from ITO interactions

• A systemic approach to safety offers a complementary safety

perspective

• More dimensions are needed to comprehend the global system of

interactions

The systemic approach for global nuclear safety

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Including the outside world

Corporate

organization

Regulator

Government

TSOs

International

organizations

Vendor

Contractors

Customers Public media

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“You are only as strong as your weakest link”

The systemic approach to safety capitalizes on understanding the

strengths as well as the vulnerabilities in all factors influencing

nuclear safety

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Principles of ITO (1):

Balance emphasis on all ITO factors

Clear that technical factors require both generic and specialist knowledge

– but so does the area of Human and Organizational Factors. Needed expertise... • Human factor engineering – Human-technical system interfaces,

ergonomy, etc. • Organizational issues – Leadership, management systems,

organizational and safety culture, etc. • Competence, education and training – Proper training programs and

methods, simulator training, knowledge management, etc. • Cognitive psychology – Desicion-making, risk perception, cognitive

capacities and limitations, etc • And more …

...and various associated methodologies One expert cannot cover all of this comprehensively

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Why not keep it simple?

• Why introduce a “new” concept that just adds to the complexity of

working with this?

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Why not keep it simple?

• Why introduce a “new” concept that just adds to the complexity of

working with this?

• It is complex!

• ITO factors are never isolated, but interact dynamically and are

interdependent of each other.

• Collaboration between experts on all three ITO factors lets us make

more efficient use of all the expertise available, both technical and non-

technical

• A systemic approach to safety offers a complementary safety

perspective

IAEA …Thank you for your attention

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The complexity of the system…(2)

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