Organisational factors: Their definition and influence on nuclear safety - Final report

VTT Tiedotteita - Valtion Teknillinen Tutkimuskeskus

Volumn , Issue 2067, 2000, Pages 3-65

  Baumont, Geneviève ^a   Wahlström, Björn ^b   Solá, Rosario ^c   Williams, Jeremy ^d   Frischknecht, Albert ^e   Wilpert, Bernhard ^f   Rollenhagen, Carl ^g  

^a INSTITUT DE RADIOPROTECTION ET DE SÛRETÉ NUCLÉAIRE IRSN   (France)

^b VTT TECHNICAL RESEARCH CENTRE OF FINLAND   (Finland)

^c CIEMAT   (Spain)

^d Nuclear Safety Directorate   (United Kingdom)

^e Hauptabteilung fur die Sicherheit der Kernanlagen HSK   (Switzerland)

^f TECHNISCHE UNIVERSITÄT BERLIN   (Germany)

^g SwedPower ^*  (Sweden)

Author keywords

Nuclear power plants; Organisational assessment; Organisational development; Organisational performance; Safety assessments; Safety management

Indexed keywords

EID: 0034435756     PISSN: 12350605     EISSN: 14550865     Source Type: Book Series    
DOI: None     Document Type: Article

References (119)

1. Affichard, J. (Sous la direction de) "Décentralisation des organisations et problèmes de coordination, les principaux cadres d'analyse" Logiques Sociales. L'harmattan.
2. Aldrich, H. & Pfeffer, J. (1976). Organizations and their environments.
3. ANS-IAEA-OECD/NEA (1994). International Topical Meeting on Safety Culture in Nuclear Installations, Vienna, 24-28.4.
4. Aufort, C. & Desmares, E. (1995). Nuclear Safety and the sub-contracting of maintenance operations, presented at the OECD/NEA International Symposium on Human Factors and Organisation in NPP Maintenance Outage, Impact on Safety", Stockholm, Sweden, 19-21 June.
5. Baggen, R., Wilpert, B., Fahlbruch, B. & Miller, R. (1997). Computer Supported Event Analysis in Industry with High Hazard Potential. In: C. Guedes Soares (Ed.) Advances in Safety & Reliability. Vol. 1 (pp. 273-278). Oxford: Pergamon.
6. Baumont, G. (1995). Ergonomic Study of a French NPP Unit Outage. Paper presented at the OECD/NEA International Symposium on "Human Factors and Organization in NPP Maintenance Outage, Impact on Safety", Stockholm, Sweden, June 19-21.
7. Baumont, G., Ménage, F. & Bigot, F. (1997). Study of recovery of 120 events. Paper presented at the IAEA - OECD - IPSN-DES 327e meeting on Human Performance in Events, Chattanooga, USA.
8. Baumont, G. Modèle et méthode RECUPERARE Rapport IPSN-DES 371.
9. Baumont G., Charron S. & Tosello, M. Rapport IPSN/DES 363 : Facteurs humains et organisation des arrêts de tranche : enjeux pour la sûreté.
10. Becker, G., Hoffmann, S., Wilpert, B., Miller, R., Fahlbruch, B., Fank, M., Freitag, M., Giesa, H. G. & Schleifer, L. (1995). Analyse der Ursachen von "menschlichem Fehlverhalten" beim Betrieb von Kernkraftwerken (BMU-1996-454). Bonn: Bundesministerium für Umwelt, Naturschutz und Reaktorsicherheit.
11. Bourrier, M. (1996). Une analyse stratégique de la fiabilité organisationnelle: organisation du travail de maintenance dans quatre centrales nucléaires, en France et aux Etats-Unis. Unpublished PhD Dissertation, Institut d'Etudes Politiques de Paris, 2 volumes.
12. Bourrier, M., (1994). Compliance as a Strategy. Working Paper No 94-10, Institute of Governmental Studies, University of California, Berkeley.
13. Bourrier, M., (1996). Organising maintenance work at two American Nuclear Power Plants, Journal of Contingencies and Crisis Management, 4(2), 104-112.
14. Bourrier, M., (1998). Constructing Organizational Reliability: the problem of embeddness and duality. In J. Misumi, B. Wilpert & R. Miller (eds.), Nuclear Safety: a Human Factors Perspective, (chap. 2). London: Taylor and Francis.
15. Bourrier, M. (1999). Le nucléaire à l'épreuve de l'organisation. Collection Travail Humain. Edition Presse Universitaire de France.
16. Bourrier, M., (in press). Elements for Designing a Self-Correcting Organization: Examples from Nuclear Power Plants. In M. Baram & A. Hale (eds.), Safety management and the Challenge of Organizational Change, (chap. 8). Amsterdam: Elsevier.
17. Byrom, N. T. and Corbridge, J. (1997). A Tool to Assess Aspects of an Organisation's Health and Safety Climate. In Proceedings of an International Conference on Safety Culture in the Energy Industries. 22-24 September 1997, University of Aberdeen.
18. Carroll, J. S. (1995). Incident reviews in high-hazard industries: Sense-making and learning under ambiguity and accountability. Industrial and Environmental Crisis Quarterly, 9, 175-197.
19. Carroll, J. S., Sterman, J. & Marcus, A. A. (1998). Losing the Maintenance Game : How Mental Models Drive Organizational Decisions. In R. N. Stern & J. J. Halpern (eds.) Debating Rationality: Non-rational Aspects of Organizational Decision Making. Ithaca, NY: Cornell University ILR Press.
20. Carroll, J. S. (1998). Organizational learning activities in high-hazard industries: The logics underlying self-analysis. Journal of Management Studies, 35, 699-717.
21. Carroll, J. S. (1998). Safety culture as an ongoing process: Culture surveys as opportunities for enquiry and change. Work and Stress, 12, 272-284.
22. Carroll, J. S., Rudolph, J., Hatakenaka, S. & Boldrini, M. (1999). The Difficult Handoff from Incident Investigation to Implementation. Presented at NeTWork, Bad Homburg.
23. Carroll, J. S. & Hatakenaka, S. (1999). Developing a Safety Conscious Work Environment at Millstone Nuclear Power Station. Presented at INCPO III, Mihama, Japan.
24. Charron, S. & Tosello, M. (1995). Assessing Safety from the point of view of the human factor in the nuclear industry. Paper presented at the meeting "Safety culture in nuclear installations", Vienna, Austria, April 24-28.
25. Chevalier, F. & Segala, M. (1996). Organisational Behaviour and Change in Europe, Case Studies. Sage publications.
26. Clarke, L. & Perrow, C. (1996). Prosaic organisational failures, American Behavioral Scientist, Vol. 39, No. 8.
27. Commission of inquiry for an international review of Swedish nuclear regulatory activities (1996). Swedish nuclear regulatory activites, Volume 1 - an assessment, Government Official Reports, SOU 1996:73,
28. Volume 2 - descriptions, Government Official Reports, SOU 1996:74.
29. Dahlgren, K. & Olson, J. (1994). Organizational Factors and Nuclear Power Plant Safety: A Process Oriented Approach. In Proceedings of PSAM II, San Diego, USA, March 20-25. Plenum Publishing Co.
30. D'Iribarne, P. (1989). La logique de "l'Honneur". Collection sociologie Le seuil Paris.
31. D'Iribarne, P. (1999). Culture et Mondialisation. L'harmattan Paris.
32. Fahlbruch, B. & Wilpert, B. (in press). Event analysis as problem solving process. In: A. Hale, M. Freitag & B. Wilpert (Eds.), After the Event - From Accident to Organizational Learning. Amsterdam: Elsevier.
33. Friedberg, E. (1994). Le Pouvoir et la Règle. Dynamiques de l'action organisée, Edition du Seuil.
34. Grote, G. & Künzler, C. (1996). Safety Culture and its reflections in job and organizational design: Total Safety Management. In A. V. Gheorghe (Ed.), Integrated regional health and environmental risk assessment and safety management. International Journal of Environment and Pollution, 6, pp. 618-631. (Pubitemid 126519571)
35. Grote, G., Künzler, C. & Klampfer, B. (1997). Understanding safety culture in organizations - the concept of Total Safety Management and its practical use in audit instruments. In C. Guedes Soares (Ed), Advances in Safety and Reliability - Proceedings of the ESREL'97 International Conference on Safety and Reliability (pp. 71-78). Oxford: Elsevier.
36. Haber, S. B., O'Brien, J. N., Metlay, D. S. & Crouch, D. A. (1991). Influences of Organizational Factors on Performance Reliability. NUREG/CR-5538, US Nuclear Regulatory Commission, Washington, DC, USA.
37. Haber, S. B. (1989). Development of a Regulatory Organizational and Management Review Method. AECB Project No. 2.341.2 Report.
38. Haber, S. B. (1994). Organizational Processes and Nuclear Power Plant Safety, Reliability Engineering and System Safety, 45, 75-83.
39. Hammar, L., Wahlström, B. & Simola, K. (1998). Modernisation for Maintaining and Improving Safety at Nordic Nuclear Power Plants, NKS/RAK-1(97)R13, February, ISBN 87-7893-038-3.
40. Hofstede, G. (1997). Cultures and organizations; software of the mind, McGraw-Hill.
41. Hollnagel, E. (1998). Cognitive Reliability and Error Analysis Method. London: Elsevier.
42. Hollnagel, E. (1996). Reliability analysis and operator modelling, Reliability Engineering and System Safety, 52, 327-337.
43. Hurst, N. W. (1991). Immediate and underlying causes of Vessel Failures: Implications for including management and organisational factors in quantified Risk Assessment. Institution of Chemical Engineers Symposium series No. 124, pp. 155-173.
44. Hurst, N. W. & Ratcliffe, K. B. (1993). Development of a Structured Audit Technique for the Assessment of Safety Management Systems (STATAS). Institution of Chemical Engineers Symposium Series No. 134, pp. 315-339.
45. IAEA (1991). Safety Culture, a report by the International Nuclear Safety Advisory Group, IAEA Safety Series No. 75-INSAG-4.
46. IAEA (1994). ASCOT Guidelines: Guidelines for organizational self-assessment of safety culture and for reviews by the Assessment of Safety Culture in Organizations Team, IAEA-TECDOC-743, International Atomic Energy Agency, May, Vienna.
47. IAEA (1997). Example of Safety Culture Practices, Safety Reports Series No. 1, STI/PUB/1039.
48. IAEA (1998). Nuclear power plant organization and staffing for improved performance: Lessons learned, TECDOC-1052, International Atomic Energy Agency, Vienna, November.
49. IAEA (1998). Developing Safety Culture in Nuclear Activities - Practical Suggestions to Assist Progress, Safety Reports Series No. 11, STI/PUB/1064.
50. IAEA (1998). Selection, competency development and assessment of nuclear power plant managers, IAEA-TECDOC-1024, International Atomic Energy Agency, Vienna, June.
51. IAEA (1998). Technical Committee Meeting on Safety Culture Self-Assessment Highlights and Good Practices, Vienna, 3-5 June.
52. IAEA (1999). Management of operational safety in nuclear power plants, INSAG-13, International Atomic Energy Agency, Vienna.
53. Ishikawa, K. (1990). Introduction to Quality Control. Tokyo: 3A Corporation.
54. Jacobs, R. & Haber, S. B. (1994). Organizational processes and Nuclear Power Plant Safety, Reliability Engineering and System Safety, 45, 75-83.
55. Johnson, W. (1980). MORT Safety Assurance Systems. Marcel Dekker Inc.
56. th rev), February 3.
57. La Porte, T. R., Roberts, K., Rochlin, G. & Schulman (1987). High Reliability Organizations: The research Challenge. Revision of T. R. La Porte, High Reliability Organizations: The problem and its research dimensions. Working paper, University of California at Berkeley, Institute of Governmental Studies.
58. Laaksonen, J., Reiman, L. & Ojala, M. Safety Culture - The Finnish Approach, 5.5.1998.
59. Lehtinen, E., Wahlström, B. & Piirto, A. (1995). Management of safety through performance indicators for operational maintenance, International Conference on Advances in Operational Safety of Nuclear Power Plants, Vienna, 4-8 September.
60. Loiselle, G. (1998). Utilisation des facteurs organizationnels dans les analyses d'événements et inclusion dans un exercice d'autoévaluation de la culture de sûreté. Paper presented at the Workshop on Organisational Factors, Boettstein, Switzerland, June 14-19.
61. Merry, M. (1998). Assessing the safety culture of an organization, Nuclear Europe Worldscan, No. 3-4, pp. 52-53.
62. Merry, M. (1999). Influence of national and organizational cultures on safety culture, Nuclear Europe Worldscan, No. 1-2, pp. 58-59.
63. Martín Marquínez, A. (1996). Organización y Seguridad Nuclear: Cultura de Seguridad (Organisation and nuclear safety: safety culture), Conferencia pronunciada en el Aula Club, Sociedad Nuclear Española. Colección Otros Documentos CSN 1. 1996.
64. Martz, H. F. & Picard, R. (1998). On comparing PRA results with operating experience. Reliability Engineering and System Safety, 59, 187-199. (Pubitemid 128393935)
65. McCarthy, J. C., Healey, P. G. T., Wright, P. C. & Harrison, M. D. (1997). Accountability of work activity in high-consequence work systems: human error in context, Int. J. Human-Computer Studies, Vol. 47, pp. 735-766. (Pubitemid 127375975)
66. Miller, R., Freitag, M. & Wilpert, B. (1997). Development and Test of a Classification Scheme for Human Factors in Incident Reports. In IAEA (Ed.), Organizational Factors Influencing Human Performance in Nuclear Power Plants (IAEA-TECDOC-943) (pp. 21-25). Vienna: International Atomic Energy Agency.
67. Miller, R., Wilpert, B., Baggen, R. & Fahlbruch, B. (1997). Operational Safety Support by Advanced Information Technologies in Relationship to Modern Management Structures. Paper presented at the OECD "Workshop on Human Performance in Chemical Process Safety", München, 24-27 June, 1997.
68. Mintzberg, H. (1982). Structure et dynamique des organisations. Editions d'organisation Paris.
69. Mintzberg, H. (1991). The effective organization: Forces and form, Sloan Management Review, pp. 54-67.
70. Misumi, J., Wilpert, B. & Miller, R. (1999). Nuclear Safety: A Human Factors Perspective. London: Taylor & Francis.
71. Mizuno, S. (1988). Management for Quality Improvement. The Seven New QC Tools. Cambridge, MA: Productivity Press.
72. National Academy for Nuclear Training (1990). Root Cause Analysis Training Course, March.
73. Nevis, E. C., DiBella, A. J., Gould, J. M. (1995). Understanding organizations as learning systems, Sloan Management Review, Winter, pp. 73-85.
74. OECD/NEA (1998). Improving reporting and coding of human and organisational factors in event reporting, NEA/CSNI/R(97)15, Organisation for Economic Cooperation and Development, April.
75. OECD/NEA (1999). Identification and Assessment of Organisational Factors related to the Safety of NPPs, NEA/CSNI/R(98)17, Volume 1 & Volume 2, State-of-the-Art Report - February.
76. Ontario Hydro Report to Management: Evaluation Findings and Recommendations July 21, 1997.
77. Olson, J. & Thurber, J. (1991). Learning in nuclear power plants. Paper presented at the consultants meeting "The influence of Organization and Management on the Safety of NPPs and Other Complex Industrial Systems", IAEA & IIASA, WP-91-28.
78. Perrow, C. (1984). Normal Accidents. Living with High-Risk Technologies. New York: Basic Books.
79. Pitblado, R. M., Williams, J. C. & Slater, D. H. (1990). Quantitative Assessment of Process Safety Programs. Plant/Operations Progress, 9, 3, 169-172.
80. Quality Systems Inspection Handbook (1993). Prepared by Battelle Seattle Research Center for the Swedish Nuclear Power Inspectorate (SKI).
81. Rochlin, G. & von Meier, A. (1994). Nuclear Power Operations: A Cross-Cultural perspective, Annual Review of Energy and the Environment, 19, 153-187.
82. Rochlin, G., La Porte, T. & Roberts, K. (1987). The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea, Naval War College Review, 76-91.
83. Sagan, S. D. (1993). The limits of safety: Organizations, Accidents, and Nuclear Weapons. Princeton: University Press.
84. Semmer, N. & Regenass, A. (1999). Situational Assessment of Safety Culture. In J. Misumi, B. Wilpert & R. Miller (eds.), Nuclear Safety: A Human Factor Perspective, London: Taylor and Francis.
85. Schein, E. H. 1992. Organizational Culture and Leadership. 2nd ed. Jossey-Bass: San Francisco.
86. Short, J. F. & Clarke, L. (1992). Organizations, uncertainties and Risk, Boulder, Co: Westview Press.
87. SKI Inspection Guidebook - Maintenance (1994). Prepared by Battelle Seattle Research Center for the Swedish Nuclear Power Inspectorate (SKI).
88. Solá, R., Vaquero, C. & Garcès, I. (1999). Influence of organization and management on nuclear power plants safety. A literature review prepared by CIEMAT for CSN (Consejo de Seguridad Nuclear), Madrid, Spain. ISBN 84-7834-357-1
89. Solá, R., Vaquero, C. & Garcés, M. I.: "Investigación sobre la evaluación y modelación de la organización y dirección en la seguridad de las centrales nucleares". Enero, 1998. Preparado por Ciemat para CSN. ISBN 84-7834-322-9
90. Swaton, E. & Wahlström, B. (eds.) (1991). The influence of organization and management on the safety of NPPs and other complex industrial systems, International Institute for Applied Systems Analysis, WP-91-28, July, Laxenburg, Austria.
91. System Safety Society (1993). System Safety Analysis Handbook.
92. USNRC (1991). Influence of Orgnizational Factors in Performance Reliability, NUREG/CR-5538/BNL-NUREG-52301.
93. USNRC (1997). Evaluation Criteria for Communications-Related Corrective Action Plans, NUREG-1545, February.
94. USNRC (1993). The Human Performance Investigation (HPIP), Systems Improvements, Inc. And Concord Associates, Inc, NUREG/CR-5455.
95. Wahlström, B. (1992). Organizational factors in nuclear safety, IAEA Technical Committee Meeting on "Impact of Management and Organization on the Safe Operation of Nuclear Power Plants, J4-TC-804, 31.8-4.9, Vienna, Austria.
96. Wahlström, B. (1994). Some cultural flavors of safety culture, ANS - IAEA - OECD/NEA International Topical Meeting on Safety Culture in Nuclear Installations, Vienna, 24-28.4.
97. Wahlström, B. (1996a). Systems safety in the high-tech industrial environments; technology and human reliability, Proceedings of the International Symposium Work in the Information Society, 20-22 May, People and Work Research Reports 8, Finnish Institute of Occupational Health, Helsinki, Finland.
98. Wahlström, B. (1996b). Safety Culture and Communication; A comparison between Finnish and Swedish practices in nuclear safety, presented on the ESREDA Autumn Seminar / SRD Association Annual Conference - "Communicating Safety", 22-23 October, Culham (Oxford), UK.
99. Wahlström, B. (1996c). Findings from a comparative study on Finnish and Swedish practices in nuclear safety, presented on the Second International Conference on HF-Research in Nuclear Power Operations, 28-30 November, Berlin.
100. Wahlström, B., Laakso, K. & Tamminen, A. (1987). Thoughts on how to maintain organizational effectiveness at a nuclear power plant, International Conference on Nuclear Performance and Safety, 28 September-2 October, Vienna, Austria.
101. Wahlström, B. & Pyy, P. (1997). Finnish and Swedish practices in nuclear safety; findings from a comparative study, IEEE Sixth Conference on Human Factors and Power Plants, June 8-12, Orlando, Florida.
102. Vaquero, C., Garcés, M. I. & Rodríguez, J.: "Impact of organisation and management on complex technological systems safety-the nuclear lessons" (in press). International Journal of Technology Management.
103. Williams, L. G., Gardner, P. H. & Woodhouse, P. A. (1994). Review of Regulatory Activities Associated with Safety Culture and Management of Safety at UK Nuclear Installations. In Conference Proceedings of the International Topical Meeting on Safety Culture in Nuclear Installations, Vienna: American Nuclear Society, April 1995, pp. 13-22.
104. Williams, J. C. & Hurst, N. W. (1992). A Comparative Study of the Management Effectiveness of two technically similar Major Hazard Sites. In Major Hazards Onshore and Offshore. 20-22 October 1992, UMIST, Manchester. Institution of Chemical Engineers Symposium Series No. 130, pp. 73-83.
105. Wilpert, B. (1989). Conceptual Blindspots in Risk Management: Social Dynamics, Organization and Management. Paper presented at the Worldbank Workshop on Risk Management, Karlstad, Sweden 6-11 November 1989.
106. Wilpert, B. (1991). System Safety and Safety Culture. Paper prepared for the IAEA, IIASA Meeting on "The Influence of Organisation and Management on the Safety of NPPs and other Industrial.
107. Wilpert, B. (1993). Management - Risikofaktor in komplexen Systemen. In: Proceedings of 2nd World Congress on Safety Science, Vienna 21-24 November 1993. Budapest: Meeting Budapest Organizer Ltd., 92-107.
108. Wilpert, B. (1994). Sicherheitskultur und Lernen aus Ereignissen: Die Rolle von Berichtswesen und Ursachenanalysen. Sicherheitskultur im Kernkraftwerk. Seminarbericht 1994 der Eidgenössischen Kommission für die Sicherheit von Kernanlagen (KSA). Bern, 20. Januar 1994. Bern: Eidgenössische Kommission für die Sicherheit von Kernanlagen, 51-59.
109. Wilpert, B. (1996). Anpassung der Technik an den Menschen. In Schweizerische Vereinigung für Atomenergie (SVA) (Ed.), Der menschliche Faktor im KKW-Betrieb (pp. 12-13). Bern: Schweizerische Vereinigung für Atomenergie (SVA).
110. Wilpert, B. & Fahlbruch, B. (in press). Safety related interventions in interorganizational fields. In A. Hale & M. Baram (Eds.): Exploring the Safety - Management Link: Technologies, Cultures and New Organizational Principles. Amsterdam: Elsevier.
111. Wilpert, B., Fahlbruch, B. & Miller, R. (1996). Problems of Implementing a Systemic Approach to Safety Management. In A. F. Özok & G. Salvendy (Eds.), Advances in Applied Ergonomics (pp. 143-146). West Lafayette: USA Publishing Corporation.
112. Wilpert, B., Fahlbruch, B., Miller, R., Baggen, R. & Gans, A. (1999). Interorganizational Development in the German Nuclear Safety System. In J. Misumi, B. Wilpert & R. Miller (Eds.), Nuclear Safety: A Human Factors Perspective. London: Taylor & Francis.
113. Wilpert, B., Fank, M., Fahlbruch, B., Freitag, M., Giesa, H.G., Miller, R. & Becker, G. (1994). Weiterentwicklung der Erfassung und Auswertung von meldepflichtigen Vorkommnissen und sonstigen registrierten Ereignissen beim Betrieb von Kernkraftwerken hinsichtlich menschlichen Fehlverhaltens (BMU-1996-457). Bonn: Bundesministerium für Umwelt, Naturschutz und Reaktorsicherheit.
114. Wilpert, B., Freitag, M. & Miller, R. (1993). Analyse Human Factor-relevanter Aspekte anhand meldepflichtiger Ereignisse in Kernkraftwerken (GRS-A-2163). Köln: GRS Gesellschaft für Anlagen- und Reaktorsicherheit (GRS) mbH.
115. Wilpert, B. & Klumb, P. (1991). Sörfall Biblis A: Theoretische und pragmatische Überlegungen zu einer systematischen Betrachtung der Ereignisse. Zeitschrift für Arbeitswissenschaft, 45 (1) 51-54.
116. Wilpert, B. & Klumb, P. (1993). Social Dynamics, Organisation and Management: Factors Contributing to System Safety. In B. Wilpert & T. Qvale (Eds.), Reliability and Safety in Hazardous Work Systems: Approaches to Analysis and Design (pp. 87-94). Hove, UK: Lawrence Erlbaum Associates.
117. Wilpert, B., Miller, R. & Fahlbruch, B. (1997). SOL: Sicherheit durch Organisationales Lernen. Technische Überwachung, 38 (4), 40-43.
118. Wilpert, B. & Qvale, T. (Eds.) (1993). Reliability and Safety in Hazardous Work Systems: Approaches to Analysis and Design. Hove, UK: Lawrence Erlbaum Associates.
119. Wilson, D. C., Hickson, D. J., Miller, S. (1996). How organizations can overbalance: Decision overeach as a reason for failure, American Behavioral Scientist, Vol. 39, No. 8.