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The systemic approach to safety
ITO
IAEA
International Atomic Energy Agency
This thinking is not new…
IAEA
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.”
IAEA
IAEA
Acknowledgement by TEPCO
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.”
IAEA
5
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.
IAEA
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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The systemic approach to safety – ITO
• 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
IAEA
The complexity of the system…
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IAEA
The systemic approach for global nuclear safety
• 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
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Including the outside world
Corporate
organization
Contractors
Government
Regulator
TSOs
Vendor
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International
organizations
Public media
Customers
“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 nontechnical
• A systemic approach to safety offers a complementary safety
perspective
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IAEA
…Thank you for your attention
The complexity of the system…(2)
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IAEA