Structure for Management of Weak and Diffuse Signals
After the mid-16th century, samurai general Motonari Mohri had conquered a big part of Japan he feared that a crisis might arise in his country due to rivalry of local samurai leaders. He let his three sons band together, like a bundle of three arrows, to counter the threat. His reasoning was that one arrow can easily be broken. A bundle of three arrows cannot be broken.
Yamamori & Mito (1993)
SKI has, in a few recent events at Nuclear Power Plants (NPPs) in Sweden, found indications of weaknesses in the licensees’ ability to handle weak signals, or diffuse symptoms of problems, and an inability to take proper actions in a reasonable time.
Most of the problems that arise in everyday operations are, on the whole, anticipated and therefore easy to recognize and manage. Operations as well as the rest of the organization (maintenance, technical and chemical analysis, etc.), try to keep up a constant state of unease and wariness in its ongoing search for deviations. In addition, clear-cut ways of reporting the discovered problem must be present for everyone to follow. The reason is simply that a problem that stays with whoever discovers it, is a problem that remains unknown.
The Swedish Nuclear Power Plants (NPPs) were good at identifying problems, including the more diffuse deviations, so the issue here was not a problem of perceiving weak signals. The problem was to translate the signal into something that could be seen as a safety issue with a potential to grow much larger.
Different parts of the NPP organization have their own meetings and ways of discussing and analyzing occurring problems. There are also many decision forums on different levels of the organizations. One major meeting, where representatives from different parts of the organization are invited, is the daily planning meeting, which is held both during general operations and outages. This is an important part of the organizational structure that supports the immediate evaluation of concern.
The daily morning meetings served to state the unit’s operational readiness and were generally considered efficient. One factor that affected the efficiency of this meeting was that it was considered a meeting of the operations department. Although other departments were present, the forum was not treated as an opportunity for representatives from other parts of the organization to put problems on the table and give a diffuse problem a chance to get consulted by the different competencies present. A contributing factor was that it was optional for representatives from the other parts of the organization to attend the meeting. Representatives from the independent safety department present at the meetings were, most of the time, just silent observers and did not comment on issues even when it was clear that some input could have been useful.
This meant that the daily planning meeting was a missed opportunity to get different opinions on potential safety-critical issues out in the open. Neither were decisions looked at from different viewpoints. Diffuse problems could therefore slip through the organizational structure of meetings.
Interestingly enough, this daily morning meeting was seen as an important meeting with the potential to catch vague problems. Yet what the NPPs thought was a cornerstone in an efficient structure for managing problems, was in fact a ‘barrier’ full of holes. The imagined efficiency of the meeting was not actually grounded in reality.
The daily meeting needed better routines in place to make the forum stronger and actually live up to its potential. The attendance of representatives from key departments of the organization was made obligatory. The agenda was updated with checkpoints where every representative had the possibility, and obligation, to report potential safety problems – diffuse symptoms that might need further analysis or action – so the forum could discuss and decide on a line of action. Decisions taken since the last meeting, regarding vague problems, were now expected to surface at the meeting. The focus clearly shifted from the operations view to a system view of the problems popping up in the meeting. It is emphasized that detected problems somewhere in the organization must be made known and should be given full attention in a forum where different competencies are present.
Of course, this daily planning meeting can lead to other investigative meetings where people from different parts of the organization are present and this type of meetings can also be held ad hoc at odd hours whenever it is necessary. But the daily planning meeting remains the forum where the current problems should be discussed to get the overall view of the state of the reactor unit.
Corresponding meetings at higher levels of the organization are as important as the one described above. These meetings must also have the same type of structure and process. The meetings’ members should have different organizational background and perspectives and act as ‘opponents’ to decisions taken.
Any discovered unclear deviation, especially problems originating in parts of the organization other than operations, must not lead to operating with anomalies with unknown causes. Strange deviations need the attention of many parts of, and all levels of, the organization for fast action. Different organizational parts and levels that act as opponents to decisions taken or ongoing analysis, reduces the risks for staying on the wrong operating track and makes responses to weak signals and diffuse safety states and unforeseen events easier.
Yet just to have different forums is not sufficient. More important than that is what information is discussed and how it is communicated at meetings between which attendees.
This text has only looked into one of several ways of keeping the organization more resilient; in this case keeping up the resistance to vague problems by having a clear structure for dealing with these problems early on, thereby preventing them from growing into big safety issues. My ending is like my beginning: When different competencies band together like a bundle of arrows the ability to counter threats and remain strong is improved and the organization and its defences will rebound from threats instead of being broken.