INSAG-4（Safety_Culture）安全文化

SAFETY SERIES No.75-INSAG-4 INTERNATIONAL ATOMIC ENERGY AGENCY, VIENNA, 1991 CATEGORIES IN THE IAEA SAFETY SERIES A new hierarchical categorization scheme has been introduced, according to which the publications in the IAEA Safety Series are grouped as follows: Safety Fundamentals (silver cover) Basic objectives, concepts and principles to ensure safety. Safety Standards (red cover) Basic requirements which must be satisfied to ensure safety for particular activities or application areas. Safety Guides (green cover) Recommendations, on the basis of international experience, relating to the ful- filment of basic requirements. Safety Practices (blue cover) Practical examples and detailed methods which can be used for the application of Safety Standards or Safety Guides. Safety Fundamentals and Safety Standards are issued with the approval of the IAEA Board of Governors; Safety Guides and Safety Practices are issued under the authority of the Director General of the IAEA. An additional category, Safety Reports (purple cover), comprises independent reports of expert groups on safety matters, including the development of new princi- ples, advanced concepts and major issues and events. These reports are issued under the authority of the Director General of the IAEA. There are other publications of the IAEA which also contain information important to safety, in particular in the Proceedings Series (papers presented at symposia and conferences), the Technical Reports Series (emphasis on technological aspects) and the IAEA-TECDOC Series (information usually in a preliminary form). SAFETY CULTURE A report by the International Nuclear Safety Advisory Group The following States are Members of the International Atomic Energy Agency: AFGHANISTAN ALBANIA ALGERIA ARGENTINA AUSTRALIA AUSTRIA BANGLADESH BELGIUM BOLIVIA BRAZIL BULGARIA BYELORUSSIAN SOVIET SOCIALIST REPUBLIC CAMEROON CANADA CHILE CHINA COLOMBIA COSTA RICA COTE D'lVOIRE CUBA CYPRUS CZECHOSLOVAKIA DEMOCRATIC KAMPUCHEA DEMOCRATIC PEOPLE'S " REPUBLIC OF KOREA DENMARK DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ETHIOPIA FINLAND FRANCE GABON GERMANY GHANA GREECE GUATEMALA HAITI HOLY SEE HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KENYA KOREA, REPUBLIC OF KUWAIT LEBANON LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LUXEMBOURG MADAGASCAR MALAYSIA MALI MAURITIUS MEXICO MONACO MONGOLIA MOROCCO MYANMAR NAMIBIA NETHERLANDS NEW ZEALAND NICARAGUA NIGER NIGERIA NORWAY PAKISTAN PANAMA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL QATAR ROMANIA SAUDI ARABIA SENEGAL SIERRA LEONE SINGAPORE SOUTH AFRICA SPAIN SRI LANKA SUDAN SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC THAILAND TUNISIA TURKEY UGANDA UKRAINIAN SOVIET SOCIALIST REPUBLIC UNION OF SOVIET SOCIALIST REPUBLICS UNITED ARAB EMIRATES UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND UNITED REPUBLIC OF TANZANIA UNITED STATES OF AMERICA URUGUAY VENEZUELA VIET NAM YUGOSLAVIA ZAIRE ZAMBIA ZIMBABWE The Agency's Statute was approved on 23 October 1956 by the Conference on the Statute of the IAEA held at United Nations Headquarters, New York; it entered into force on 29 July 1957. The Head- quarters of the Agency are situated in Vienna. Its principal objective is "to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world". © IAEA, 1991 Permission to reproduce or translate the information contained in this publication may be obtained by writing to the International Atomic Energy Agency, Wagramerstrasse 5, P.O. Box 100, A-1400 Vienna, Austria. Printed by the IAEA in Austria February 1991 SAFETY SERIES No. 75-INSAG-4 SAFETY CULTURE A report by the International Nuclear Safety Advisory Group INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA, 1991 The International Nuclear Safety Advisory Group (INSAG) is an advisory group to the Director General of the International Atomic Energy Agency, whose main functions are: (1) To provide a forum for the exchange of information on generic nuclear safety issues of international significance; (2) To identify important current nuclear safety issues and to draw conclusions on the basis of the results of nuclear safety activities within the IAEA and of other information; (3) To give advice on nuclear safety issues in which an exchange of information and/or additional efforts may be required; (4) To formulate, where possible, commonly shared safety concepts. THIS SAFETY SERIES IS ALSO PUBLISHED IN FRENCH, RUSSIAN AND SPANISH SAFETY CULTURE, IAEA, VIENNA, 1991 STI/PUB/882 ISBN 92-0-123091-5 ISSN 0074-1892 FOREWORD by the Director General With the intention of strengthening the IAEA's contribution to ensuring the safety of nuclear power plants, leading experts in nuclear safety were invited by the Agency to form the International Nuclear Safety Advisory Group (INSAG). This group serves mainly as a forum for the exchange of information on nuclear safety issues of international significance and formulates, where possible, common safety concepts. The term 'Safety Culture' was first introduced in INSAG's Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident, published by the IAEA as Safety Series No.75-INSAG-l in 1986, and further expanded on in Basic Safety Principles for Nuclear Power Plants, Safety Series No.75-INSAG-3, issued in 1988. Since the publication of these two reports, the term Safety Culture has been used increasingly in the literature in connection with nuclear plant safety. However, the meaning of the term was left open to interpretation and guidance was lacking on how Safety Culture could be assessed. The present report deals with the concept of Safety Culture as it relates to organizations and individuals engaged in nuclear power activities, and provides a basis for judging the effectiveness of Safety Culture in specific cases in order to identify potential improvements. The report is intended for use by governmental authorities and by the nuclear industry and its supporting organizations. Prepared by a highly authoritative body, it should help to promote Safety Culture. It is intended to stimulate discussion and to promote practical action at all levels to enhance safety. CONTENTS SUMMARY 1 1. INTRODUCTION 3 2. DEFINITION AND CHARACTER OF SAFETY CULTURE 4 3. UNIVERSAL FEATURES OF SAFETY CULTURE 5 3.1. REQUIREMENTS AT POLICY LEVEL 5 3.1.1. Statements of safety policy 7 3.1.2. Management structures 8 3.1.3. Resources 8 3.1.4. Self-regulation 9 3.1.5. Commitment 9 3.2. REQUIREMENTS ON MANAGERS 9 3.2.1. Definition of responsibilities 10 3.2.2. Definition and control of working practices 10 3.2.3. Qualifications and training 11 3.2.4. Rewards and sanctions 11 3.2.5. Audit, review and comparison 12 3.2.6. Commitment 12 3.3. RESPONSE OF INDIVIDUALS 13 4. TANGIBLE EVIDENCE 15 4.1. GOVERNMENT AND ITS ORGANIZATIONS 15 4.2. OPERATING ORGANIZATION 16 4.2.1. Corporate policy level 16 4.2.2. Power plant level 17 4.2.2.1. The working environment 17 4.2.2.2. Individual attitudes 18 4.2.2.3. Plant safety experience 19 4.3. SUPPORTING ORGANIZATIONS 19 5. CONCLUDING COMMENTS 21 Appendix: SAFETY CULTURE INDICATORS 22 A.I. Government and its organizations 22 A.2. Operating organization 23 A.3. Research organizations 29 A.4. Design organizations 30 MEMBERS OF THE INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP 31 SUMMARY The response to a previous publication by the International Nuclear Safety Advisory Group (INSAG), No. 75-INSAG-3, Basic Safety Principles for Nuclear Power Plants', indicated a broad international interest in expansion of the concept of Safety Culture, in such a way that its effectiveness in particular cases may be judged. The present report responds to that need. It is directed especially to the senior management of all organizations whose activities affect nuclear plant safety. In embarking on a report on Safety Culture, INSAG was faced with the fact that the concept has not been fully charted in previous studies, and there is no consensus on the meaning of Safety Culture. In seeking to develop views that will be commonly shared and have important value in application, INSAG found it neces- sary to explore deeply the general factors which contribute to a satisfactory nuclear safety regime. The outcome is a document which represents the common view of INSAG members. The first proposition presented by INSAG is the definition of Safety Culture: Safety culture is that assembly of characteristics and attitudes in organiza- tions and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance. This statement was carefully composed to emphasize that Safety Culture is attitudinal as well as structural, relates both to organizations and individuals, and concerns the requirement to match all safety issues with appropriate perceptions and action. The definition relates Safety Culture to personal attitudes and habits of thought and to the style of organizations. A second proposition then follows, namely that such matters are generally intangible; that nevertheless such qualities lead to tangible manifestations; and that a principal requirement is the development of means to use the tangible manifestations to test what is underlying. INSAG takes the view that sound procedures and good practices are not fully adequate if merely practised mechanically. This leads to a third proposition: that Safety Culture requires all duties important to safety to be carried out correctly, with alertness, due thought and full knowledge, sound judgement and a proper sense of accountability. 1 INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP, Basic Safety Principles for Nuclear Power Plants, Safety Series No. 75-INSAG-3, IAEA, Vienna (1988). 1 In its manifestation, Safety Culture has two major components: the framework determined by organizational policy and by managerial action, and the response of individuals in working within and benefiting by the framework. Success depends, however, on commitment and competence, provided both in the policy and managerial context and by individuals themselves. Sections 1 to 3 of the report develop the complementary ideas of the framework provided at the policy and managerial level and of individual responses. This is done in a general way so that the views expressed are applicable in any organization with responsibilities affecting nuclear safety. To make practical use of the work towards improving nuclear plant safety requires more substance. All those engaged in matters touching on nuclear safety are likely to insist that what is described is entirely characteristic of their own approach. All will say: "But this is what we do already". INSAG therefore judged it right to go further, and so the latter part of the report provides more detail on the tangible characteristics of a satisfactory Safety Culture in different kinds of organizations. In the main text this is in the form of statements of what should be expected. In the Appendix it is in the form of a series of questions, provided as an aid to self- examination by organizations rather than as a Yes/No checklist. Finally, in preparing this report, INSAG took care to avoid merely listing sound practices and requirements for satisfactory individual behaviour which, while no doubt worth restating, take matters little further. Instead, INSAG sought by way of propositions to analyse and illustrate the topic in more general ways, and to provide means by which organizations may examine and improve their own prac- tices, performance and working methods. On this basis, INSAG offers the report as a contribution to the further enhancement of nuclear plant safety. 1. INTRODUCTION 1. Except for what are sometimes called 'Acts of God', any problems arising at a nuclear plant originate in some way in human error. Yet the human mind is very effective in detecting and eliminating potential problems, and this has an important positive impact on safety. For these reasons, individuals carry heavy responsibility. Beyond adherence to defined procedures, they must act in accordance with a 'Safety Culture'. The organizations operating nuclear plants, and all other organizations with a safety responsibility, must so develop Safety Culture-as to prevent human error and to benefit from the positive aspects of human action. 2. The substance of Safety Culture is the means by which close attention to safety is achieved for both organizations and individuals. INSAG introduced the term Safety Culture in its Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident2. In its subsequent report, Basic Safety Principles for Nuclear Power Plants3, referred to in the following as INSAG-3, Safety Culture was high- lighted as a fundamental management principle. The present report responds to comments received after publication of INSAG-3 proposing that the concept of Safety Culture be clarified and so defined that its effectiveness could be confirmed in specific instances. 3. This report gives particular attention to operating organizations, because the link between human performance and plant safety is closest there. Yet the discussion extends to Safety Culture in all concerned, because the highest level of safety is achieved only when everyone is dedicated to the common goal. 4. The safety of the plant also depends critically on those who previously designed, constructed and commissioned it. A partial list of other contributors includes the background community of science and engineering, the governmental bodies responsible for regulation and those responsible for the underlying research. 5. INSAG-3 identified particular aspects of Safety Culture. It also dealt with matters not so identified but which represent practices important for achievement of the required human responses. What follows treats these practices as an essential component of Safety Culture. 2 INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP, Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident, Safety Series No. 75-INSAG-l, IAEA, Vienna (1986). 3 INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP, Basic Safety Prin- ciples for Nuclear Power Plants, Safety Series No. 75-INSAG-3, IAEA, Vienna (1988). 2. DEFINITION AND CHARACTER OF SAFETY CULTURE 6. Safety Culture is that assembly of characteristics and attitudes in organi- zations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance. 7. In INSAG-3 it was stated that Safety Culture "refers to the personal dedication and accountability of all individuals engaged in any activity which has a bearing on the safety of nuclear power plants". It was further stated to include as a key element "an all pervading safety thinking", which allows "an inherently questioning atti- tude, the prevention of complacency, a commitment to excellence, and the fostering of both personal accountability and corporate self-regulation in safety matters". 8. Attributes such as personal dedication, safety thinking and an inherently ques- tioning attitude are intangible. Yet it is important to be able to judge the effectiveness of Safety Culture. INSAG has addressed this problem by starting from the perception that the intangible attributes lead naturally to tangible manifestations that can act as indicators of Safety Culture. 9. Good practices in themselves, while an essential component of Safety Culture, are not sufficient if applied mechanically. There is a requirement to go beyond the strict implementation of good practices so that all duties important to safety are carried out correctly, with alertness, due thought and full knowledge, sound judge- ment and a proper sense of accountability. 10. Thus what follows presents the relevant good practices, provides comments on the less tangible individual attitudes necessary and identifies characteristics that may be considered as measures of the effectiveness of Safety Culture. 3. UNIVERSAL FEATURES OF SAFETY CULTURE 11. In all types of activities, for organizations and for individuals at all levels, attention to safety involves many elements: — Individual awareness of the importance of safety. — Knowledge and competence, conferred by training and instruction of personnel and by their self-education. — Commitment, requiring demonstration at senior management level of the high priority of safety and adoption by individuals of the common goal of safety. — Motivation, through leadership, the setting of objectives and systems of rewards and sanctions, and through individuals' self-generated attitudes. — Supervision, including audit and review practices, with readiness to respond to individuals' questioning attitudes. — Responsibility, through formal assignment and description of duties and their understanding by individuals. 12. Safety Culture has two general components. The first is the necessary frame- work within an organization and is the responsibility of the management hierarchy. The second is the attitude of staff at all levels in responding to and benefiting from the framework. 13. These components are dealt with separately under the headings of Require- ments at Policy Level (Section 3.1) and Requirements on Managers (Section 3.2) and Response of Individuals (Section 3.3). Since Safety Culture particularly concerns individual performance, and since many individuals carry safety responsibilities, Section 3.3 is especially important. 14. Figure 1 illustrates the major components of Safety Culture, relating the text headings to this overall scheme. 15. In keeping with the practice ofINSAG-3, throughout the report the presenta- tion is in accordance with the assumption that the practices are in current use. The sense of the usage is that the circumstances described are those which this report seeks to promote. 3.1. REQUIREMENTS AT POLICY LEVEL 16. In any important activity, the manner in which people act is conditioned by requirements set at a high level. The highest level affecting nuclear plant safety is the legislative level, at which the national basis for Safety Culture is set. POLICY LEVEL COMMITMENT DEFINITION OF RESPONSIBILITIES DEFINITION AND CONTROL OF SAFETY PRACTICES QUALIFICATIONS AND TRAINING AUDIT, REVIEW AND COMPARISON STATEMENT OF SAFETY POLICY MANAGEMENT STRUCTURES RESOURCES SELF-REGULATION MANAGERS' COMMITMENT RIGOROUS AND PRUDENT APPROACH FIG. 1. Illustration of the presentation of safety culture. 17. Governments discharge their responsibilities to regulate the safety of nuclear plants and other potentially hazardous installations and activities in order to protect individuals, the public at large and the environment. Legislation is backed by the necessary advisory and regulatory bodies, which have sufficient staff, funding and powers to perform their duties and the freedom to do so without undue interference. In this way, national climates are fostered in which attention to safety is a matter of everyday concern. Governments also encourage international exchanges aimed at safety improvements and seek to minimize any commercial or political impediments to such exchanges. 18. Within an organization, similar considerations apply. Policies promoted at a high level create the working environment and condition individual behaviour. 19. Safety policies and their detailed implementation vary depending on the nature of the organization and the activities of its staff, but important common features can be defined. Sections 3.1.1 to 3.1.5 show how such commitment at the policy level is declared and supported. 3.1.1. Statements of safety policy 20. An organization pursuing activities with a bearing on nuclear plant safety makes its responsibilities well k