| 1. |
- Falk, Thomas, et al.
(författare)
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Challenges in performing technical safety reviews of modifications : A case study
- 2012
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 50:7, s. 1558-1568
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Tidskriftsartikel (refereegranskat)abstract
- The aim of the present study, is to identify strengths and weaknesses of the technical safety review process at a Swedish Nuclear Power Plant (NPP). In this context, the function of safety reviews are understood as expert judgements on proposals for design modifications. 1" Design modifications" are here understood as alterations of an existing design. 1 and redesign of technical systems (i.e. commercial nuclear reactors), supported by formalised safety review processes. The chosen methodology is using two complementary methods: interviews of personnel performing safety reviews, and analysis of safety review reports from 2005 to 2009.The study shows that personal integrity is a trademark of the review staff and there are sufficient support systems to ensure high quality. The partition between primary and independent review is positive, having different focus and staff with different skills and perspectives making the reviews, which implies supplementary roles. The process contributes to " getting the right things done the right way" . The study also shows that though efficient communication, feedback, processes for continuous improvement, and " learning organizations" are well known success factors in academia, it is not that simple to implement and accomplish in real life.It is argued that future applications of safety review processes should focus more on communicating and clarifying the process and its adherent requirements, and improve the feedback system within the process.
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| 2. |
- Kahlbom, Ulf, 1964-
(författare)
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Säkerhetsvärdering av organisationsförändringar vid storskalig kärnteknisk verksamhet : Problem, utmaningar och förslag på lösning
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This study addresses safety issues related to organizational change within safety critical operations, focusing on large-scale nuclear technology operations. Failures in safety critical operations can lead to unacceptable consequences for both man and environment. Given this, a decreased safety level due to organizational change is undesirable. It is, however, estimated that about 75 % of all general organizational changes fail to achieve the goals that are set up for the change (Boonstra, 2004). It is thus important to evaluate the safety impact of a proposed organizational change before it can be accepted for implementation. There is, however, a lack of methods for evaluating the safety impact due to organizational change, and there is also a need for developing knowledge in this field. The dissertation hence concerns safety evaluation of organizational change, with the general aim to develop knowledge in the area of safety evaluation of organizational change, and also to develop a method for safety evaluation of organizational change. In the thesis, a literature review is presented which deals with significant parts of three areas relevant for the above aim: organizational change, decision theory, and safety science. The empirical parts of the study can be divided into two parts. The first part is concerned with the identification of the dynamic aspects of organizational change in nuclear technology organizations. This part was performed by collecting and analyzing data from an already implemented organizational change. The data sources were primarily interviews, internal organizational documentation, and one survey. The second part is concerned with the development and application of a method for evaluating the safety impact due to organizational change. This part was performed by departing from an action research framework, and the developed method was applied to two different but related organizational changes in nuclear technology organizations. The results from the second part primarily concerned experiences related to applying the method for safety evaluation. In the light of the answers to the research questions that were set up for the study some important results are presented. One important result is the developed method, validated from an action research perspective. Other important results are the identification of situations that affect the rational decision making process when performing a safety evaluation, and the presentation of some reasons that explains why these situations occur. Other important tentative conclusions, primarily drawn from the literature review of the study, are that there might be an inherent contradiction between common routines for organizational change processes versus risk- and safety analysis, and that there might also be a contradiction between safety culture and the management literature encouragement of risk taking.
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| 3. |
- Lindberg, Anna-Karin, et al.
(författare)
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Learning from accidents : what more do we need to know?
- 2010
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 48:6, s. 714-721
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Tidskriftsartikel (refereegranskat)abstract
- A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.
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| 4. |
- Lundberg, Jonas, et al.
(författare)
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Strategies for dealing with resistance to recommendations from accident investigations
- 2012
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Ingår i: Accident Analysis and Prevention. - : Elsevier. - 0001-4575 .- 1879-2057. ; 45, s. 455-467
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Tidskriftsartikel (refereegranskat)abstract
- Accident investigation reports usually lead to a set of recommendations for change. These recommendations are, however, sometimes resisted for reasons such as various aspects of ethics and power. When accident investigators are aware of this, they use several strategies to overcome the resistance. This paper describes strategies for dealing with four different types of resistance to change. The strategies were derived from qualitative analysis of 25 interviews with Swedish accident investigators from seven application domains. The main contribution of the paper is a better understanding of effective strategies for achieving change associated with accident investigation.
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| 5. |
- Lundberg, Jonas, et al.
(författare)
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What you find is not always what you fix : How other aspects than causes of accidents decide recommendations for remedial actions
- 2010
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Ingår i: Accident Analysis and Prevention. - : Elsevier BV. - 0001-4575 .- 1879-2057. ; 42:6, s. 2132-2139
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Tidskriftsartikel (refereegranskat)abstract
- In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.
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| 6. |
- Rankin, Amy, et al.
(författare)
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Resilience in everyday operations : A framework for analyzing adaptations in high-risk work
- 2014
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Ingår i: Journal of Cognitive Engineering and Decision Making. - : SAGE Publications. - 1555-3434 .- 2169-5032. ; 8:1, s. 78-97
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Tidskriftsartikel (refereegranskat)abstract
- Managing complexity and uncertainty in high-risk sociotechnical systems requires people to continuously adapt. Designing resilient systems that support adaptive behavior requires a deepened understanding of the context in which adaptations take place, of conditions and enablers to implement these adaptations, and of their effects on the overall system. Also, it requires a focus on how people actually perform, not how they are presumed to perform according to textbook situations. In this paper, a framework to analyze adaptive behavior in everyday situations in which systems are working near the margins of safety is presented. Further, the variety space diagram has been developed as a means to illustrate how system variability, disturbances, and constraints affect work performance. The examples that underlie the framework and the diagram are derived from nine focus groups with representatives working with safety-related issues in different work domains, including health care, nuclear power, transportation, and emergency services.
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| 7. |
- Reiman, T., et al.
(författare)
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Competing values, tensions and trade-offs in management of nuclear power plants
- 2012
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Ingår i: Work. - 1051-9815 .- 1875-9270. ; 41:1, s. 722-729
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Tidskriftsartikel (refereegranskat)abstract
- The specific goal of the study is to look how tensions, competing values and trade-offs manifest in the management of nuclear power plants. Second goal is to inspect how existing frameworks, such as Competing Values Framework, can be used to model the tensions. Empirical data consists of thirty interviews that were conducted as part of a NKS study on safety culture in the Nordic nuclear branch. Eight trade-offs are identified based on a grounded theory based analysis of the interview data. The competing values and potential tensions involved in the trade-offs are discussed.
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| 8. |
- Reiman, Teemu, et al.
(författare)
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Does the concept of safety culture help or hinder systems thinking in safety?
- 2014
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Ingår i: Accident Analysis and Prevention. - : Elsevier BV. - 0001-4575 .- 1879-2057. ; 68, s. 5-15
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Tidskriftsartikel (refereegranskat)abstract
- The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic.
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| 9. |
- Reiman, Teemu, et al.
(författare)
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Human and organizational biases affecting the management of safety
- 2011
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Ingår i: Reliability Engineering & System Safety. - : Elsevier BV. - 0951-8320 .- 1879-0836. ; 96:10, s. 1263-1274
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Tidskriftsartikel (refereegranskat)abstract
- Management of safety is always based on underlying models or theories of organization, human behavior and system safety. The aim of the article is to review and describe a set of potential biases in these models and theories. We will outline human and organizational biases that have an effect on the management of safety in four thematic areas: beliefs about human behavior, beliefs about organizations, beliefs about information and safety models. At worst, biases in these areas can lead to an approach where people are treated as isolated and independent actors who make (bad) decisions in a social vacuum and who pose a threat to safety. Such an approach aims at building barriers and constraints to human behavior and neglects the measures aiming at providing prerequisites and organizational conditions for people to work effectively. This reductionist view of safety management can also lead to too drastic a strong separation of so-called human factors from technical issues, undermining the holistic view of system safety. Human behavior needs to be understood in the context of people attempting (together) to make sense of themselves and their environment, and act based on perpetually incomplete information while relying on social conventions, affordances provided by the environment and the available cognitive heuristics. In addition, a move toward a positive view of the human contribution to safety is needed. Systemic safety management requires an increased understanding of various normal organizational phenomena - in this paper discussed from the point of view of biases - coupled with a systemic safety culture that encourages and endorses a holistic view of the workings and challenges of the socio-technical system in question.
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| 10. |
- Reiman, T., et al.
(författare)
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Identifying the typical biases and their significance in the current safety management approaches
- 2010
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Ingår i: 10th International Conference on Probabilistic Safety Assessment and Management 2010, PSAM 2010. - 9781622765782 ; , s. 2186-2197
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Konferensbidrag (refereegranskat)abstract
- The aim of the article is to describe a set of biases in safety management practices and their possible consequences for safety. We will outline main biases of safety management in four thematic areas: beliefs about individual behavior, beliefs about organizations, safety models and safety management methods. A common theme underlying the biases is a lack of systems view on safety. A systemic safety management takes into account people, technology and organization and their interaction in equal terms. Furthermore, such an approach can shift focus from people to technology to organizational aspects depending on their current safety significance.
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| 11. |
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| 12. |
- Reiman, Teemu, et al.
(författare)
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On the relation between culture, safety culture and safety management
- 2014
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Ingår i: PSAM 2014 - Probabilistic Safety Assessment and Management.
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Konferensbidrag (refereegranskat)abstract
- Safety can be considered an emergent phenomenon, making a systems view imperative if the aim is to evaluate or develop the safety of an entire sociotechnical system. This paper deals with one important component of the systems view - the relation between culture and management. Specifically, we will inspect how the concepts of culture and safety culture can be used in conjunction with the concept of safety management in facilitating a more dynamic systems view on safety. The paper proposes a model of eight cultural archetypes and illustrates how these relate to both safety culture and safety management in organizations.
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| 13. |
- Reiman, T., et al.
(författare)
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Professionals' beliefs about nuclear safety - An interview study in the nordic nuclear branch
- 2012
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Ingår i: 11th International Probabilistic Safety Assessment and Management Conference and the Annual European Safety and Reliability Conference 2012, PSAM11 ESREL 2012. - 9781622764365 ; , s. 6533-6541
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Konferensbidrag (refereegranskat)abstract
- The aim of the study was to characterize the definitions of nuclear safety among technical and safety professionals in the Nordic nuclear industry. Secondly, the aim was to inspect the relation between the definition of nuclear safety and the kind of indicators the respondents would use to evaluate nuclear safety in a power plant. The study illustrated that there was no shared definition of nuclear safety among the Nordic nuclear safety community. The definitions formed six groups: safety as limiting the consequences of radiation, safety as process control, safety as a way of working, safety as a mindset, safety as adherence to standards, and unclear or circular argument. These safety definitions had no direct relationship to the evaluation focus the respondents favoured. Four major evaluation foci were identified: 1) focus on organizational practices and processes, 2) focus on technical and structural safety, 3) focus on operating experience and 4) focus on plant management. In order to integrate the many aspects of risk and safety found among professionals, it seems essential to develop at least some sort of basic model which people can agree upon. Indicators discovered in this study can be one starting point in formulating such a model.
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| 14. |
- Reiman, T., et al.
(författare)
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Reconceptualization of the competing values framework tailored for management of nuclear power plants
- 2012
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Ingår i: 11th International Probabilistic Safety Assessment and Management Conference and the Annual European Safety and Reliability Conference 2012, PSAM11 ESREL 2012. - 9781622764365 ; , s. 6562-6571
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Konferensbidrag (refereegranskat)abstract
- Focus on safety vs. focus on production/economy is often mentioned as opposing goals, at least in the short term. Other potentially conflicting values and goals have also been identified, such as centralization and decentralization. The specific goal of the study is to describe and discuss how tensions, competing values and tradeoffs manifest in the management of nuclear power plants and particularly how safety may be affected. A second goal is to inspect how some existing conceptual frameworks can be used to model these tensions.
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| 15. |
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| 16. |
- Rollenhagen, Carl
(författare)
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Can focus on safety culture become an excuse for not rethinking design of technology?
- 2010
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 48:2, s. 268-278
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Tidskriftsartikel (refereegranskat)abstract
- Two generic organisational contexts associated with technological designs in relation to safety culture are discussed: (1) operating organisations using existing technologies, and (2) design organisations as producers of technologies. It is argued that the concept of safety culture, if misused, may lead to the adoption of non-effective change strategies in the operational context. On the other hand, it is also argued that design organisations should invest more attention to issues commonly subsumed under the concept of safety culture. In this case, however, the concept of safety culture has to be adapted to fit the demands facing design organisations. Issues of morality and their association with the safety culture concept will be discussed. It is suggested that a stronger focus on understanding innovation and safety together should nourish future research about culture's influence on design and safety.
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| 17. |
- Rollenhagen, Carl
(författare)
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Event investigations at nuclear power plants in Sweden : Reflections about a method and some associated practices
- 2011
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 49:1, s. 21-26
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Tidskriftsartikel (refereegranskat)abstract
- The MTO-E method for event investigation is described in the light of almost 20 years of usage in the Swedish nuclear industry. Various problems are addressed in the context of the method, e.g. accident models, causality, the use of the barrier concept, the meaning of safety culture, and the process of going from problem identification to problem solving. It is argued that future applications of in-depth investigations should focus more on (innovative) methods when suggesting remedial actions as a consequence of information derived from event investigations.
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| 18. |
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| 19. |
- Rollenhagen, Carl, et al.
(författare)
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Professional subcultures in nuclear power plants
- 2013
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 59, s. 78-85
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Tidskriftsartikel (refereegranskat)abstract
- Using a safety climate survey as the point of departure, the present study explores some aspects of plant cultures vs. professional subcultures in three Swedish nuclear power plants (named A, B and C). The ratings on the safety climate survey by workers on power plant A were subjected to an exploratory factor analysis. A six-factor solution explained a total of 56.0% of the variance in the items included. The six factors were considered to measure Safety management, Change management and experience feedback, Immediate working group, Knowledge and participation, Occupational safety, and Resources. The six factor model was tested by running a confirmatory factor analysis on the ratings by workers on power plant B and C, respectively. The model fit for both plants was acceptable and supported the six factor structure. For each of the six factors, a 3 × 3 ANOVA was conducted on the ratings, with the three largest departments (Operation, Maintenance, Engineering support) and power plants (A, B, C) as the between-subjects factors. Differences between power plants as well as differences between departments were found for several factors. Overall, the differences between departments were larger than those between power plants. The results are discussed in terms of challenges for creating safety climate in organizations that harbor several professional subcultures.
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| 20. |
- Rollenhagen, Carl
(författare)
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Safety Culture and Safety Quality
- 2013
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Ingår i: Social and Ethical Aspects of Radiation Risk Management, Volume 19 (Radioactivity in the Environment). - : Elsevier. - 9780080450155 ; , s. 215-237
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Bokkapitel (refereegranskat)abstract
- Although much used, the concept of safety culture is associated with many meanings. In this chapter, it is argued that there are reasons to define safety culture in terms of values and competence related to safety, and to differentiate safety culture from what is here called "safety quality". It is argued that safety culture should be perceived as a relative construct in terms of how the value of safety relates to the manifold of other values simultaneously strived for. Safety culture is discussed in the context of value research (individual and organizational values) and safety quality is discussed in the context of human reliability analysis. Implications for safety management and assessment of safety culture and safety quality are discussed.
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| 21. |
- Rollenhagen, Carl, et al.
(författare)
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The context and habits of accident investigation practices : A study of 108 Swedish investigators
- 2010
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 48:7, s. 859-867
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Tidskriftsartikel (refereegranskat)abstract
- The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the 'human factor' was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices - particularly those conducted as part-time work in organizations.
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| 22. |
- Wahlstrom, Bjorn, et al.
(författare)
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Safety management : A multi-level control problem
- 2014
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Ingår i: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 69, s. 3-17
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Tidskriftsartikel (refereegranskat)abstract
- Activities in safety management build on a control metaphor by which control loops are built into the man, technology, organisational and information (MTOI) systems to ensure a continued safety of the operated systems. In this paper we take a closer look on concepts of control theory to investigate their relationships with safety management. We argue that successful control relies on four necessary conditions, i.e. a system model, observability, controllability and a preference function. The control metaphor suggests a division of the state space of the modelled system into regions of safe and unsafe states. Models created for selected subsystems of the MTOI-system provide a focus for control design and safety assessments. Limitations in predicting system response place impediments to risk assessments, which suggest that new complementary approaches would be needed. We propose that polycentric control may provide a concept to consider in a search for a path forward. We investigate approaches for modelling management systems and safety management. In spite of promises in the use of a control metaphor for safety management there are still dilemmas that have to be solved case by case. As a conclusion we argue that the control metaphor provides useful insights in suggesting requirements on and designs of safety management systems. The paper draws on experience from the Vattenfall Safety Management Institute (SMI), which started its operation in 2006.
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| 23. |
- Wahlström, B., et al.
(författare)
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Safety management - A multi-level control problem
- 2012
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Ingår i: 11th International Probabilistic Safety Assessment and Management Conference and the Annual European Safety and Reliability Conference 2012, PSAM11 ESREL 2012. - 9781622764365 ; , s. 6552-6561
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Konferensbidrag (refereegranskat)abstract
- Safety management is a crucial activity in maintaining acceptable safety levels of large hazardous industrial facilities. Risk analysis and safety engineering are two important activities of safety management by which safe designs of such facilities can be achieved. A continued safety during the operation of the facilities relies furthermore on successful and efficient experience feedback and management of change. Activities in safety management build on a control metaphor by which control loops built into the technical, peoples and organisational systems ensure safety of the facilities. In this paper we take a closer look on concepts of control theory to investigate their relationships with safety management. A conclusion of the paper is that the control metaphor provides useful insights in suggesting requirements to be placed on safety management. The paper draws on experience from the Vattenfall Safety Management Institute (SMI), which started its operation in 2006.
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