VI

Influence of Leadership and Hierarchy on Safety and Security Culture

Session six of the conference covered the influence of leadership and hierarchy on safety and security culture. The session included talks from James Ellis, Luciano Pagano Jr., and Sonja Haber and was moderated by Donald Alston

Nuclear Leadership – James Ellis, Stanford University

Admiral Ellis began with the question of next steps and emphasized leadership. Recalling a saying from his navy career, “They’re not lessons learned just because you write them down. You actually have to learn them,” he stated that the question about what comes next is just as important as who oversees and shepherds the work that must follow. The single most important factor in shaping the present and the future of the nuclear industry is leadership. Noting that the participants are those leaders, he thanked them for their personal commitment.

Admiral Ellis emphasized the leader’s role in creating an organizational culture and, ultimately, a nuclear safety and security culture. But no matter how passionate one leader is in his or her pursuit, that individual cannot do it alone, cannot be everywhere, and cannot personally oversee all the complexities of a nuclear enterprise. The leader must create an organization that is similarly committed in training both leaders and workers in the pursuit of excellence, both in routine operation and in emergencies. In a crisis when, despite every best effort of a leader and team, things have simply not gone as desired, leadership requires different skills and a different focus.

Despite the plethora of complex definitions that the workshop has reviewed, an organization’s culture is simply the reflection of the organization—of its practices, its real values, its shared experiences, and its leadership. Efforts to define, measure, and consider how best to shape nuclear safety and security cultures have led to confusion and the belief that it is too hard.

But it is not too hard, Admiral Ellis said. Leaders, along with their own leadership teams, intentionally or not, shape cultures every day. According to

organizational culture expert Dr. Edgar Schein, former Massachusetts Institute of Technology professor and a longtime member of the Institute of Nuclear Power Operations (INPO) Advisory Council, leadership creates and changes cultures, while management and administration act within a culture. There are many indicators available to leaders that provide insight into the organization’s culture and the nature and effectiveness of their leadership. But once we have solved the cultural mystery as best we can or decided on the culture we want, we must not allow ourselves to be convinced that the shaping of a positive culture requires a program, checklist, or handbook, or that it can be infused by pill, injection, all-day meetings, a company-wide poster contest, or the most expensive of corporate consultants.

Organizational culture is not a figment of the regulator’s imagination, the latest in pop psychology, or some recent management trend. It is real and important. Mohandas Gandhi once said, “A nation’s culture resides in the hearts and in the soul of its people.” And so it is with the nuclear industry. But as we acknowledge that changing the culture takes time, Admiral Ellis said that we cannot let that become an excuse for inaction. With the right incentives, behaviors can change overnight.

The nuclear industry has adopted a definition of safety culture: An organization’s values and behaviors modeled by its leaders and internalized by its members that serve to make nuclear safety the overriding priority. This definition, with a few changes, could be applied to any of the cultures resident in an organization, including security culture. The many cultures resulting from the organizational, geographic, and role variations within companies must all reside comfortably within an overall corporate culture.

The vast enterprise’s participants encompass much more than nuclear generation or research assets. This inhomogeneity presents an additional challenge of recognizing and even reconciling different cultures within a single organization. While corporate culture may not be homogeneous, it must still be solid. A solid corporate culture is necessary but not sufficient for a strong safety culture. A fatally flawed corporate culture, however, does guarantee a weak safety culture.

Admiral Ellis said that leadership and culture, like nature, abhor a vacuum. Left to their own devices, without standards, expectations, guidance, and accountability—in other words, without leadership—an organization and its cultures can arrive at many end states. Few of them are good. Admiral Ellis relayed a favorite nautical quote attributed to Justice Oliver Wendell Holmes: “Greatness lies not in where we stand but in what direction we are moving. We must sail, sometimes with the wind and sometimes against it, but sail we must and not drift, not lie at anchor.” We either shape our culture or surrender the responsibility for shaping it to those winds and currents that will always swirl around us. The choice is ours.

In answering the question of how one shapes a culture, Admiral Ellis advocated hearing the thoughts of participants from around the world who have

contributed to the courses, seminars, and meetings that are part of the industry. He then described six mechanisms that leaders use to embed their beliefs, values, and assumptions identified in Dr. Schein’s seminal study, Organizational Culture and Leadership.¹ While these mechanisms do not constitute the culture, they are visible artifacts of an emerging culture and create the climate of the organization.

Firstly, one of the most powerful mechanisms that founders, leaders, managers, or even colleagues have for communicating what they believe in or care about is what they systematically pay attention to. This focus can mean anything, from what they notice and comment on to what they measure, control, reward, and in other ways deal with systematically. Even casual remarks and questions that are consistently geared to a certain area can be as potent as formal control mechanisms and measurements.

Secondly, in times of crisis the role of a leader is especially important in shaping or reinforcing values and procedures, as the leader’s behavior is often stripped of its calm veneer. Crises are especially important in shaping and transmitting culture. It is then that the organizations can be bound together by the shared challenge, and that emotional involvement contributes to intense learning. People look to leadership at this time for assurance and strength, and signs of panic and anger can send powerful and disturbing signals.

Thirdly, in this time of financial challenge, cultural signals are created by budgeting processes. Beyond the priorities indicated by the resource distribution, the importance conveyed by the acceptable level of debt, the minimum cash flow, and the expected dividend level all transmit messages well beyond the boardroom about the importance of an optimized capital structure, the acceptable level of risk, and the level of innovation and strategic vision allowed, as well as the real priority placed on safety and security. Efforts to control costs are important, but especially in the beginnings of a new nuclear endeavor, if the signal being sent is that only costs are important—and not safety, security, and effectiveness—bad outcomes can result in both areas.

Fourthly, founders and leaders of organizations generally know that their visible behaviors are powerful communicators of assumptions and values. Many use video presentations to outline philosophies in trainings for new employees. However, there is a difference between a message delivered from a staged setting and those received from informal observation of the leader. The informal, everyday messages are the more powerful teaching and coaching mechanisms.

Fifthly, how leaders allocate rewards and status—both the nature of the behavior rewarded and punished and the nature of the rewards and punishments themselves—carries a message. Members of an organization learn values from their own experiences with the performance appraisal and promotion system, as well as from their observations and discussion of what the organization rewards

_____________________

¹Schein, Edgar H., 2010. Organizational Culture and Leadership. 4th ed. San Francisco: John Wiley & Sons.

and punishes. What is important, in Dr. Schein’s view, are the practices: what really happens, not what is espoused, published, or preached.

Finally, who is hired into an organization can, intentionally or not, signal the values and behaviors that the leader endorses. Hiring for technical qualifications or experience meets only part of the organization’s needs, and the recruiting process must understand all dimensions a new employee brings. The identification and advancement of those deemed the most deserving are powerful signals to the organization of expected or accepted cultural norms. And how clearly but compassionately the organization deals with the need to remove employees from positions of responsibility sets both performance expectations and cultural norms.

Admiral Ellis stated that he was not prescribing a specific approach to cultural change. Any approach to cultural change must factor in what can work within the existing culture to create an improved culture. However, one element must be shared: The culture must be fair, and, most importantly, must be perceived as fair. “Miracle on the Hudson” pilot Sully Sullenberger, who saved all the passengers and crew onboard his ill-fated flight, is an avid and career-long student of aviation safety and the cultures necessary to support it. In an interview with Katie Couric, he stated: “For 42 years, I’ve been making small, regular deposits in this bank of experience, education, and training. And on January 15th, the balance was sufficient so that I could make a very large withdrawal.” That day, Captain Sullenberger was carrying in his suitcase Sidney Dekker’s book Just Culture, which describes failures of organizations, even or especially those that consider themselves to have high accountability. It draws clear distinctions between a positive culture of accountability and a negative culture of blame. Dekker draws on numerous case studies to highlight that the focus after tragic events is often to move too quickly to castigate and even criminalize the individual involved, while systematically ignoring the many contributing factors that put the employee in a vulnerable position set up to fail.

Admiral Ellis said that in an attempt to paint a picture, even if in broad strokes, of an aspirational nuclear culture, there are two dimensions to consider: our corporate or organizational cultures and our overarching industry culture. We need not—and, arguably, should not—aspire to be carbon copies of each other, he said, even as we peek behind the curtain and realize that we have a great deal of commonality in the bedrock principles on which our individual cultures sit. We should focus on our strengths and explore how to build them proactively in ways that enable, motivate, and even inspire our teams. The bedrock of the culture of the nuclear industry must remain an unwavering commitment to nuclear safety. This commitment is described in the nuclear industry’s Principles for a Strong Nuclear Safety Culture,² now known as “Traits,”³ and is

_____________________

²INPO, 2004. Principles of a Strong Nuclear Safety Culture. Available at http://www.nrc.gov/about-nrc/regulatory/enforcement/INPO_PrinciplesSafetyCulture.pdf.

nested in the context of both an accountable and a just culture. The key to future success will be the ability to sustain the industry’s focus and develop the next generation of leaders who understand, embrace, and advance this principle.

In the May 2013 issue of the Harvard Business Review, A. G. Lafley, then the chairman and chief executive officer (CEO) of Proctor & Gamble, wrote an article on the most important aspects senior leaders can concentrate on, irrespective of the organization’s position in the business or economic cycle.⁴ Lafley takes on the conventional wisdom that suggests a leader is primarily a coach and a utility infielder, in American baseball terms, dropping in to solve problems where they crop up. In fact, he says, a leader has a very specific job that only he or she can do because all others in the organization focus much more narrowly and almost always internally. In the article, entitled “What Only the CEO Can Do,” he offers several specific, externally focused tasks of a leader. And the most important of them is shaping values and standards—defining the culture.

Admiral Ellis said that there will always be tasks in business, in society, in government, and in our nations that only the elite can do, but it is in the setting of standards that leadership is most needed. As Fareed Zakaria has said, “Standards represent society at its highest aspirations, not its complex realities.” When leaders acknowledge that there are certain standards for behavior, they signal their goals to society.

Admiral Ellis posed a final question: What is it we stand for and strive for at this pivotal time in the nuclear industry’s history? In other words, is there a creeping sense that the way we have always done it is as good as it can get and that it is good enough? Or are we, those of us decades into this effort and those of you newly joining this journey, together ready to acknowledge still the appropriateness and elusiveness of our goal of excellence and our unique role in its achievement? President Harry Truman, once said, “Men make history, and not the other way around. In periods where there is no leadership, society stands still. Progress occurs when courageous, skillful leaders seize the opportunity to change things for the better.” And Winston Churchill said, simply, “The price of greatness is responsibility.” What is our responsibility as leaders, in times of change and challenge, or, even worse, in times of crisis, large and small?

Admiral Ellis offered several closing points: First, in a time of crisis, a leader and his or her team must manage anxiety. Recent university studies have shown that when people’s anxiety goes up due to the challenges they face, they often lose the very capabilities they need the most: the ability to think clearly, to prioritize what needs to be done, to think outside of the box, and finally, and most importantly, to act. Dr. Edgar Schein has said that in times of great difficulty one of

_____________________

³U.S. Nuclear Regulatory Commission, 2012. Traits of a Healthy Nuclear Safety Structure. See, http://pbadupws.nrc.gov/docs/ML1303/ML13031A707.pdf.

⁴Lafley, A. G., May 2009. “What Only the CEO Can Do”Harvard Business Review. Available at https://hbr.org/2009/05/what-only-the-ceo-can-do.

the most important roles of the leadership team is to absorb anxiety through clear communication, a demonstrated understanding of the problem, and swift and conclusive action to deal with the looming realities. All of us are human, too, and if we are not careful, we can unwittingly find ourselves creating anxiety rather than absorbing it.

Next, especially in times of crisis, leaders must be brutally honest with their stakeholders, with their team, and with themselves. This honesty must be born of a real and complete understanding of the crisis and its depth, but must also bring an optimism that the team will emerge stronger and better. In what author Jim Collins calls the “Stockdale Paradox,” Vice Admiral James Stockdale, a Vietnam era prisoner-of-war, told him, “This is a very important lesson. You must never confuse faith that you will prevail or succeed in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.”

Leaders must deliver results, and in a time of crisis, this is particularly important. You find your organization spinning continuously, jumping from one half-mission to another in the face of a full-blown crisis. Someone simply needs to get the job done. According to Robert Kaplan, in his book Warrior Politics,⁵ for Machiavelli, a policy is defined by its outcome. If it is not effective, it cannot be virtuous. This is not an argument in favor of the end that justifies the means. Rather, it is merely noting that without an end, the means, however well-intended, are simply not sufficient.

Finally, we must not confuse management with leadership, though both are important. In a recent speech, American Senator John McCain described his grandfather, the commander of an aircraft carrier battle group in World War II, who lived and loomed larger than life. As an admiral, he rolled his own cigarettes, smoked constantly, and swore and drank more than he should have. He was known as one of the U.S. Navy’s best cursers; probably not the sort of recognition one would want today. “Slew” was his call sign, and James Michener described him in Tales of the South Pacific as an ugly, old aviator. But he was more than that, especially to his men. He was a leader. Senator McCain goes on to say that today we hear a lot about management and not enough about leadership. Good managers are plentiful. In fact, our nation graduates more than 150,000 MBAs every year. But true leaders are rare. The difference, and the reason that leadership always trumps management, is that leadership is the art of inspiring others to perform far beyond their self-imposed limits.

In no other time in the history of the nuclear industry has focused, effective, and inspirational leadership been more important, Admiral Ellis said. The ancient aphorism comes to mind: If not us, then who? If not now, then when?

_____________________

⁵Kaplan, Robert D., 2002. Warrior Politics: Why Leadership Demands a Pagan Ethos. Vintage.

Insights on the Role Played by Leadership and Hierarchy in Organizational Culture – Luciano Pagano Jr., CTMSP - Brazilian Navy Technology Center in São Paulo

Admiral Pagano presented on the role played by leadership and hierarchy in organizational culture using the example of the Centro Tecnológico da Marinha em São Paulo (CTMSP)—the Brazilian Navy Technology Center in São Paolo.

He first explained the reasons for concern at CTMSP. The Aramar Experimental Center houses a nuclear fuel production cycle, including conversion to uranium hexafluoride, enrichment, fuel fabrication, fuel assembly, use in a nuclear reactor, and placement into a repository. The conversion, enrichment, and fuel fabrication stages are conducted under strict International Atomic Energy Agency safeguards. There is also a small pressurized water reactor used as a land prototype for naval propulsion, not yet in operation.

Given these sensitive facilities, Admiral Pagano described the measures CTMSP takes on safety and security. The recent Safety Program, with a budget in excess of two million dollars for the 2014 to 2016 time frame, seeks to address the following: healthy radiological protection, industrial safety, chemical safety, operations and fire prevention, human resources, quality assurance, environmental management, and security. A multidisciplinary group from across the organization has been appointed to flesh out the program. The main objectives of the program are as follows:

• The creation of a Safety Culture Committee subordinate to the CEO
• Fostering organizational attitude towards safety
• Establishment of the Safety Management System
• Enhancement of the Quality Assurance System
• Enforcement of the regulatory guides
• Training

Over the past four years, CMTSP has invested 1.8 million dollars in training, leading 787 classes and more than 62,000 hours of training for more than 3,066 employees.

Finally, Admiral Pagano presented insights on the role of leadership. The leadership must commit to and provide systemic tools to enhance safety. It must provide substantial training opportunities and engender a commitment to safety among employees. Lastly, the leadership must always maintain a proactive attitude towards safety.

Cultural Issues that Influence Safety and Security Culture – Sonja Haber, Human Performance Analysis Corporation

Dr. Haber gave the final presentation of the workshop, which focused on cultural issues that influence safety and security culture. She challenged the par-

ticipants to think in a different way about what is meant when talking about culture. What we are really talking about are different types of cultures, she said: culture within organizations, safety culture, security culture, and national culture. We are talking about factors; about things that are influenced by the culture.

She put forth a working definition of organizational culture based on characteristics of the work environment, such as the dalliance, rules, and common understandings that influence employees’ perceptions and attitudes. Perception is important because perception drives behavior. We perceive human nature as fundamentally good, and that perception dictates our behavior when meeting someone new. With different, perhaps negative, perceptions of mankind, we might behave less amicably on first acquaintance. Similarly, if employees perceive that an organization places a high priority on safety or security, then when they come to work every day they behave in a way that reflects that perception or belief.

Dr. Edgar Schein, when asked about the term safety culture, stated that in a world of culture there is no such thing as a safety culture. There is only a culture that promotes or facilitates safety or security performance. So the culture is the foundation, and the norms, the values, the beliefs, the perceptions, and the attitudes—all of which compose culture—drive behavior towards safety, towards security risk, or towards production. Culture drives the performance of an entity, and the shared norms and values and beliefs create that culture.

Safety and security then parallel each other because they are each aspects of performance that are driven by culture, Dr. Haber said. The similarities are probably much stronger than we think. Turning briefly to Dr. Edgar Schein’s model of artifacts, claimed values, and basic assumptions, Dr. Haber postulated that while artifacts and claimed values are easier to observe, what drives the culture and behavior are the basic assumptions.

Like an iceberg, 90 percent of culture is below the surface. That 10 percent above the surface is easy to see, but it is the 90 percent below that will help us understand why the Y-12 security breach happened and why the Davis-Besse reactor vessel-head degradation happened. And that is why many factors influence an understanding or assessment of culture.

Dr. Haber discussed examples of artifacts presented during the workshop in contrast to underlying assumptions. Alan Hanson asking the group if they knew where the safety exit was or about the hotel fire plan was a demonstration of artifacts and claimed values. Dr. Haber asked the audience a series of questions: Do you really know what the person sitting next to you feels and believes about those safety issues? Do you really understand their opinions about it? We all work in the field of safety and security culture. Safety is our top priority; it is a higher priority than production. But the organization’s parking lot has no safe walkways. Or people go down staircases without using the handrails while carrying equipment. But safety is our priority. So what do you really know about the people sitting next to you and how they behave towards safety or security

issues? You know what they tell you. You know what you have seen, what you have observed, but you do not really know their underlying assumption.

She asked the audience for an artifact around safety or security, and one participant offered dress code, such as personal protective equipment (PPE) as one safety artifact. Another participant mentioned an identity badge as a security artifact, and Dr. Haber agreed that both PPE and security screening for those entering the facility are observable artifacts. She also offered examples of claimed values, such as lost time and reduction of injuries in the safety context, and in the security context, the enjoinment “if you see something, say something.” Dr. Haber then asked the audience to provide a basic assumption for safety, and a participant suggested the assumption on how people are judged—whether they are praised for the knowledge, position, safety behavior, or other qualities. Dr. Haber offered another basic assumption about safety: that people always make mistakes. In security, one assumption might be that a facility is impenetrable, that is, breaches do not happen here.

She also asked about monitoring culture. In 1987 or 1988 Tom Murley, of the U.S. Nuclear Regulatory Commission, asked how we can incorporate the influence of organization and management on safety into probabilistic risk assessment (PRA). He said the idea was to quantify the notion now called safety culture and incorporate it into PRA for a quantitative assessment.

Dr. Haber managed a project on this topic at Brookhaven National Laboratory. In collaboration with George Apostolakis as well as colleagues from Penn State, their goal was to develop a methodology for qualifying forces integral to safety performance. This methodology has now been in use for many years, and the team performed the first safety culture assessment at Davis-Besse during the vessel-head outage. They also did the safety culture assessment at Vandellòs Nuclear Power Plant after their service water pipe break; at Äspö Hard Rock Laboratory, after their radioactive particle release; and across the U.S. Department of Energy. Efforts to look at culture are often performance oriented or reactive. Using these methods, Dr. Haber’s team is able to examine behaviors, which are the observables of the perceptions and assumptions. Given we act in different ways, based on different assumptions, they can look at the behavioral output of an individual or an organization.

Looking at safety culture is attempting to understand how that culture drives safety behaviors. Similarly, looking at security culture is attempting to understand how that culture drives security awareness or security behaviors. And while behavior is the visible outcome of culture, culture change will only come about getting at the basic assumptions. You can change the artifacts, the claimed values, and even some of the behaviors quickly. But culture change requires sustainment over a long period of time. Culture change at Davis-Besse took 3 to 5 years, not a single 4-hour training session, because real culture change requires a change in the basic assumptions, not only behaviors, artifacts, or claimed values.

Finally, Dr. Haber discussed key attributes of culture that influence both safety and security. She mentioned the complexity of the system—of the roles of

all the people and all the stakeholders involved. We need to understand the interdependencies and the codependencies of all the players contributing to a culture and driving that behavior. It is a mistake to think we can isolate one particular entity and one particular unit in a mishap as we saw at Fukushima, Dr. Haber said.

When visiting a facility, Dr. Haber asks for a tour of the facility led by a senior manager in order to observe the manager’s behavior concerning protocol. Do they tell her what they see before she tells them? Do they waive their personal protection equipment? Do they follow the procedures and protocols of the facility? Sometimes they do not. Senior managers and leaders really need to model those behaviors and to show everybody, not just their organization, but to the world, that these behaviors are their priority and they mean it. Communication is key. Senior managers need to ensure they are heard, receive feedback, and close the communication loop in order to create change in basic assumptions and even behaviors. And finally, trust is very important in creating the right environment where people can speak up when they should to ensure safe job performance or to help security awareness.