Safety Culture Across Organisational Borders:
Skill and Formalisation
Johan Berglund
Post-Doctoral Research Fellow
Department of Skill and Technology
Linnaeus University
Sweden
[email protected]
Kingston University
Kingston Business School
Working Paper No. 2014/1
Abstract
Although the application and in-depth understanding of rules and instructions are dependent
on experience, in a technological culture like that of the Nuclear Power Industry the pursuit of
formalisation is strong. Discussing the accidents at Forsmark 1 in 2006 and Fukushima
Daiichi in 2011, this paper aims to highlight the impact of practical proficiency on the quality
work of high-risk organisations. Addressing the key role of experience-based knowledge in a
reliable safety culture, this will include discussions on what ways supplementary training and
further education can trigger and support the informal learning of professional activities, as
well as the kind of ongoing reflexivity needed to spawn risk awareness and critical thinking.
Arguably, on a long-term basis, it is the cultural changes and its various adverse impacts on
dialogue, skill, personal judgement and individual responsibility that will pose the greater risk
to the safety of nuclear power plants, and other high-risk facilities. When it comes to safety
and quality, the addition of more rules and instructions is not enough. It can even be
counterproductive.
KEYWORDS: skill, nuclear industry, risk, safety culture, formalisation, supplementary
training, civil contingencies
1. Introduction
The target audience of this working paper are lecturers and researchers concerned with areas
of Risk and Civil Contingencies, as well as those interested in issues of Quality, skill and
further education. My intention is to establish a link between safety cultures and issues of
quality within high-risk organisations on the one hand, and the development of experiencebased skill and knowledge on the other; a link that, I will argue, is vital in building up and
maintaining a reliable safety culture on a long-term basis.
Nuclear power remains one of the most significant examples of high-risk industry, in terms of
its potential for catastrophe, and the politics and psychology that surrounds it; it is in our
consiousness, and preferably we want to know as little about it, and the risks that goes with it,
as possible. There is also considerable secrecy attached to it, and for that reason we tend to
regard it as an entity of its own, despite of the many similarities it has with other areas of
work. Accidents and incidents incessantly put in question what is often referred to as the
safety culture of these high-technology facilities, and of various power plants. Subsequent to
the misfortunes at the nuclear station Forsmark 1 in 2006, on the East Coast of Sweden, where
the defence-in-depth reactor safety system did not operate sufficiently due to a short circuit in
a 400 kV switchyard outside the plant, which affected other parts of the facility in unexpected
ways, this accident was later described as the culmination of a long-term decline in safety
culture.1 Ultimately, the operatives at Forsmark were able to untangle the situation without
any harmful effects. This was not the case, however, with the accident at Fukushima Daiichi
in 2011, where a huge amount of radioactive material was emitted into the environment.
The strong requirements for safety are a cause of formalisation, that is to make modes of
operation standardised, and to transform the collective knowledge of individuals into ruleguided instructions to be adhered to by all members of staff; promoting the objectives of
transparency and codification, creating a larger basis for organisational knowledge. In turn.
this tends to lead to a lesser emphasis on the experience-based know-how of human
professionals, like the operators of nuclear power plants. Even so, this remains a substantial
constituent of any dependable safety culture, while codified knowledge must be interpreted
1
Cf. Background: The Forsmark incident 25th July 2006, published by the Analysis Group at KSU (The Swedish
Nuclear Training and Safety Centre), and Larsson, L. & von Bonsdorff, M. (2007): Ledarskap för säkerhet, an
independant report discussing the developments leading up to the accident at Forsmark in 2006.
and applied in real-time situations of practice. Besides, from encountering a great variety of
situations and course of events, experienced personnel seem to develop what has been
characterised as the skill of anticipation, a probing perception, which implicates a capacity to
manage the unexpected. This requires a long-term attention of practice, and the acquisition of
“readily available, tacit knowledge”, a capacity to act in situations that are undetermined.2
Safety culture is a contested concept, and a complex phenomenon. Organisations, much like
societies, are created by humans, and knowledge is developed in social and situational
contexts. In high-risk industries there is a tendency to equate learning with certain changes in
observable behaviour, as against fixed standards. Within the Nuclear Power Industry there is a
strong reliance on formal schemes of production, i.e. on codified knowledge, and like many
industries it is facing the challenges of a major generational change: in both technology and
workforce. To meet these challenges, alongside the demands for a higher level of safety, the
industry has perpetually attempted to standardise its methods and mode of operations. Apart
from technological fixes, manuals, instructions and checklists have been modelled for nearly
every conceivable situation; documentation and systems of co-ordination that have become
larger and larger, and more and more prevalent.
As has been demonstrated in the field of Skill and Technology, adult professionals learn
through examples, by means of analogical thinking.3 From this viewpoint, learning is an
outcome of reflection upon real-time events, and experiences. Supplementary training, as
applied within the Nuclear Power Industry, can be used to promote formalisation, or new
technology. The introduction of new technology in the work place, or persistent demands for
formalisation, raise certain concerns; the ability of human professionals run a long-term risk
of being hollowed out, not given the opportunity to practice their own ability of judgement,
for reflection and critical thinking. This was established independently in case studies in
Sweden and Japan in the early 1980s, in the aftermath of the progression of a technological
culture.4
2
Sennett, R. (2008): The Craftsman, pp. 172-178.
See Göranzon, B., & Florin, M. Eds. (1992): Skill and Education: Reflection and Experience. The focus of this
research area has been on case-studies, examples and analogies that high-light something, or some aspects, of the
knowledge of experienced professionals within different areas of expertise.
4
See Göranzon, B. (2009) [1990]: The Practical Intellect – Computers and Skills.
3
This, in turn, raises issues of quality. The fact that experienced personnel often are able to
untangle a variety of unforeseen situations and upsets, which sometimes occur in high-risk
facilities, makes this an urgent matter. The erosion of skill, in connection to generation shifts,
formalisation, and other long-term cultural changes of work, must be taken into account in
conjunction with the phenomena of risk and safety culture. My PhD Thesis (Royal School of
Technology, 2011) explores these issues from an epistemological point of view; it discusses
the uses of training, and the role of experience-based knowledge in the safety cultures of
nuclear power plants. Apart for increased demands of formalisation, a major concern in
Sweden has been that of an ageing workforce, especially in regard to plant personnel; other
aggravating circumstances include the decision taken in the early 1980s, of phasing out
nuclear power by the year of 2010. This has been postponed, also bringing into concern the
issue of ageing facilities. Another major concern has been the increase of output and revenue,
and persistant demands of cutting costs for operation and maintenance, continuing today to
redesign production systems to maximise efficiency.5 Accordingly, safety might not be the
only concern for the management of high-risk organisations.
When we talk about risk, we usually mean negative incidents or events, which are in some
way conceivable; that we do not know for sure will happen, but can happen.6 What would be
considered normal, or acceptable, during the rocky, initial period of nuclear power would be
deemed unacceptable today, due to higher demands on safety and revenue. This working
paper will be developed further through the following empirical cases: (1) The Official Report
of the Fukushima Nuclear Accident Independent Investigation Commission, NAIIC, released
during the summer of 2012; (2) the explorative study Safety Culture Across Organisational
Borders, a Dialogue Seminar series with participants from different sectors of industries
where issues of safety are essential; (3) the extensive empirical material on the Nuclear Power
Industry that has been generated since 2008, in collaboration between the Department of Skill
and Technology at the Royal Institute of Technology (KTH) and the Swedish Nuclear Safety
and Training Centre (KSU), an affiliate to Vattenfall; (4) the Master of Skill and Technology
at Linnaeus University is an educational initiative that can confront some of the issues
elaborated in this paper, such as extensive formalisation of work, a foundation of which being
the Humanities, Epistemology of Practice and Philosophy of Language. In such a context,
Berglund, J. (2013): Den nya taylorismen – om säkerhetskulturen inom kärnkraftsindustrin. (The New
Taylorism – On Safety Culture. PhD Thesis, rev. ed., Royal School of Technology, Stockholm.)
6
Cf. Spiegelhalter, D. in Skinns, Scott, and Cox, Eds. (2011): “Quantifying uncertainty”, p. 17.
5
seminars and student thesis will provide fresh perspective on issues of skill and knowledge
development within various professional fields.
The methodology that have been used is primarily hermeneutical, where discourse and
exchanges between researcher and informants have taken place over longer periods of time,
during which I have had my interpretations repeatedly validated and rectified, through various
groups of informants, of various backgrounds. The method that has been used to reflect upon
issues of skill, quality, safety and apporaches to traning within this sector of industry is the
Dialogue Seminar Method7, where reflection is qualified through dialogue in smaller groups;
each participant prepares a seminar through the reading of a joint text, as well as the writing
of a shorter reflection with regard to their own experience. As the participants begin to see,
and are able to articulate more of which they did not know that they knew, the aim of such
seminar series is what could be described as the discovery of praxis. The idea is that
experiences that are not exactly the same from one person to another can not be transferred in
a strict manner, but elucidated and developed via different people in between, with a key role
for dialogue.
The exploration of skill, and what methods can be utilised to support experience-based
knowledge, are essential to this study. The objective of this working paper is to arrive at some
measures of practical relevance that can help to improve the uses of training and further
education in high-risk activities; to prevent technological risk, erosion of skill, and an overall
deterioration of quality.
2. The New Taylorism
In recent decades, dialogue-based participatory research has, apart from the learning agenda,
been concerned with the developments of the way traditional business structure works, with
its top-down procedures of decision-making. This, essentially, contrasts with the tradition
represented by Frederick W. Taylor, who in the early 20th century developed the theory of
scientific management, based on utility maximisation and standardisation of work. From a
taylorist point of view, the efficiency of work could be achieved only through enforced
7
Göranzon, B., Hammarén M. & Ennals R., Eds. (2006): Dialogue, Skill and Tacit Knowledge. Wiley. In
addition to this I have done study visits at the annual training of plant personnel at Swedish power stations
Forsmark 3, and Ringhals 3/4.
standardisation and co-ordination, by means of detailed instruction developed by specialists or
management experts; ensured by scientific or scientific-like procedure. Hence, a higher level
of understanding and efficiency is equated to a higher level of codification and uniformity.
Taylor believed in transferring control, and thinking, from the factory floor upwards. 8 For the
feasibility of scientific management, it was a dilemma of sort that the mass of experience, the
knowledge of the workers, were not in the hands of the managerial experts, who then would
have been more apt to evaluate what mode of operation would be the most efficient, or
adequate, for each task:
Under scientific management the ”initiative” of the workmen (that is, their hard work,
their good-will, and their ingenuity) is obtained with absolute uniformity and to a
greater extent than is possible under the old system [...] The managers assume, for
instance, the burden of gathering together all of the traditional knowledge which in the
past have been possessed by the workmen and then of classifying, tabulating, and
reducing this knowledge to rules, laws and formulae which are immensely helpful to
the workmen in doing their daily work.9
Formalisation of work often aims at making organisations, and work itself, more effective,
transparent, and legible; in my studies on the Nuclear Power Industry it became evident that
formalisation of work had significantly increased over the past decade, in which case many
people within various sectors of the industry expressed concerns with regard to this tayloristic
tendency pushing too far the formalisation of knowledge. From the established course of
events, incidents, and near-misses, gathered from commercial power plants all over the world,
new standards and best practices are frequently being implemented into local practices.
Commonly known as Operating Experience, collection and revision of “experiences”,
advocated by supervisory authorities like IAEA and international organisations like WANO,
has a learning agenda; a kind of formalised experience that is commended to plant
organisations worldwide through benchmarking. Typically, such promotion of “excellence”
and emulation of best practices are imposed on organisations through management in order to
improve operational safety, reliability and effectiveness; but also to receive higher appraisal
by WANO Peer Review, or the IAEA Operational Safety Review Team (OSART), aiming at,
widely, the upper quartile level in regard to WANO safety leading indicators. Nevertheless,
these developments also contain certain risks. If the safety and quality of nuclear power plants
are by and large equated to the observance of rules and regulations, facilities like these, as
political scientist James C. Scott has argued, would in fact be less effective:
8
9
Taylor, F. W. (2007) [1911]: The Principles of Scientific Management, pp. 30-31.
Ibid., p. 34.
the formal order encoded in social-engineering designs inevitably leaves out elements
that are essential to their actual functioning. If the factory were forced to operate only
within the confines of the roles and functions specified in the simplified design, it
would quickly grind to a halt. [...] The more schematic, thin, and simplified the formal
order, the less resilient and the more vulnerable it is to disturbances outside its narrow
parameters.10
This indicates some of the short-comings of Taylorism and enforced standardisation: No
factory, power plant, or work place organisation can sustain safety, or effectiveness, without
the unplanned interventions of an experienced workforce. Another key factor is the
interpretations made by the management of each power plant of the secret reports, and
recommended areas of improvement, suggested by the WANO Peer Review team, or OSART.
Standardisation is set out to improve safety and efficiency. If quality and safety are to be
maintained in the long run, however, operatives are in need of sufficient conditions in order to
develop skill and unfettered judgement. Besides, skill and ability need to be maintained over
time.
To compare nuclear power plants worldwide, as carried out by organisations like INPO and
WANO, and, from the aggregate of measurable indicators like the number of unscheduled
stoppages, or the number of days of unscheduled stoppage, toreview which facilities are best
performers, can have unwanted consequences. In the early 1990s Forsmark was hailed as one
of the best power plants in the world, but was later, after the events in 2006, regarded as
somewhat of a problem child; some sort of decline had occurred over a period of ten to fifteen
years. In retrospect, complacency alongside a culture of self-containment has been put
forward as contributing to these unfortunate developments, also characterised as a long-term
decline in safety culture, mainly due to a lack of a long-term strategy of leadership, promoting
safety over profit.11
Over recent decades, the sociologist Richard Sennett has argued that the kind of rocky 19th
Century capitalism that inspired the theories of Karl Marx, on labour as a source of alienation,
has experienced something of a revival. The strong emphasis of modern-day working life on
flexibility has spawned new forms of uncertainty: ”the steady, self-disciplined worker has lost
10
11
Scott, J. C. (1998): Seeing like a state, p. 351.
Larsson, L. & von Bonsdorff, M. (2007): p. 10.
his audience”.12 Within many businesses, managers are more or less obliged to streamline, or
reinvent, their organisations; this has become the general way of showing investors that the
company is to be reckoned with. Typically, large consultancy firms are brought in to push as
well as legitimise the downsizing and re-engineering of organisations, “creating a decisive
break with the past”, reducing staff as well as the number of approved methods and modes of
operation. Still, many such efforts fail, and have also proved to be counter-productive, as
”business plans are discarded and revised; expected benefits turn out to be ephemeral; the
organisation loses direction”.13
In the 1990s, corporations such as Wal-Mart, alongside Japanese manufacturers like Toyota,
Nissan and Honda became benchmarks of a new economy, whose enterprise systems and
productivity numbers have been promoted by economists as well as global management
consulting firms like McKinsey and Accenture, who specialises in re-engineering, where
consultants are trained in streamlining businesses of all sorts. 14 Today, re-engineering of work
has found its way into all types of professional activities, even medical care:
The goal is to standardize and speed up medical care so that insurance companies can
benefit from the efficiencies of mass production: faster treatment of patients at
reduced cost, with increased profits earned on increased market share.15
This can be exemplified by the wide-ranging remodelling of the British National Health
Service (NHS) over the past decade. With the intention to modernise the nation’s health care
and medical care, the people in charge of the NHS adopted the so called Ford Model, which
revolutionised American car industry in the early 20th Century, taking the division of labour
to an extreme, in which output is measured in terms of targets that are entirely quantitative.16
Technically, this means that doctors are reviewed by the number of tumours or cirrhoses they
have treated, and how much time spent with each patient, rather than how many patients that
were successfully treated. In other European countries, a number of reports in recent years
have pointed to a widespread discontent among doctors and nursing staff, that their skills in
dealing with patients are being “frustrated by the push for institutional standards”, leading
12
Sennett, R. (2006): The Culture of the New Capitalism, p. 78.
Sennett, R. (1999): The Corrosion of Character, p. 49.
14
Head, S., “They’re Micromanaging your Every Move”, The New York Review of Books, August 16, 2007, p.
42. Cf. Head, S., “Inside the Leviathan”, The New York Review of Books, December 16, 2004, and
http://www.accenture.com/Global/Services/By_Industry/Retail/Client_Successes/RetailProgram.htm.
15
Head, S. (2007): p. 42.
16
Ibid., p. 47.
13
towards a deprofessionalisation of doctors and health personnel.17 The debate in Scandinavia
points to a similar conclusion, as rationalisations of medical care have led to various sorts of
quality gaps. Most notably, doctors and nursing staff have had to spend more and more time
on administration, and less and less time with patients. This is relevant also to other areas of
the public sector like schools, universities, and the police.18
According to Jerome Groopman, physicians and nursing staff every so often have to diagnose
from insufficient information of a patient’s condition, and in many cases narratives are
fragmental or inconclusive. To attain an overall picture, with regard to various symptoms, as
well as a patient’s lifestyle and catamnesis, is bound to take time, experience, and ability of
judgement. Analogically, Groopman compares an experienced doctor with a detective, who,
working with loose ends, “when the clues are confusing” or scarce, ultimately have to decide
on a proper treatment:
[...] we most need a discerning doctor when a diagnosis is not obvious, when the clues
are confusing, when initial tests are inconclusive. No simple technology can serve as a
surrogate for the probing human mind.19
This is relevant also to skill and ability among operatives of nuclear power stations, within
which accidents are often the cause of minor, independent faults whose consequences interact
simultaneously, between different levels of these high-technological systems. When facing
the improbable, plant personnel are sometimes forced to take quite creative measures to
handle such courses of events, aggravated by insufficient or contradictive information. The
supply of experiences and observations among skilled operatives provide a presence of the
unexpected in every-day practice (i.e. the skill of anticipation). Hence, the human factor is a
potentially strong link in a reliable safety culture: the ability to manage the unexpected is vital
to the skill that operatives within this type of industry develop over time. The day-to-day
surveillance of the process, and of the facilities, is more complex than often assumed, and to
experienced operatives it will always contain an element of the unforeseen. Thus, the human
17
Ibid., p. 46.
See for instance the articles of Swedish journalist Maciej Zaremba, the last of which published in Dagens
Nyheter Kultur, 3 March, 2013, pp. 11-14. Cf. Bo Jansson, Lena Nitz, and Marie Wedin, ”Våra yrken har
kidnappats av ekonomiernas modeller”, DN Debatt June 24th, 2013; http://www.dn.se/debatt/vara-yrken-harkidnappats-av-ekonomernas-modeller/
19
Groopman, J. (2009): “Diagnosis: What Doctors Are Missing”, The New York Review of Books, 5-18
November, p. 26. The basis of the article is the book by professor of medicine Jonathan A. Edlow, The Deadly
Dinner Party and Other Medical Detective Stories, Yale University Press, 2009. Cf. Perrow, C. (1999): p. 27.
18
ability of learning to read patterns, of for instance a certain process, becomes vital in the
operational safety of high-risk facilities.20
“The knowledge ideal of our era is theoretical and intimately related to the concept of a
model,” claim Gustafsson and Mouwitz at the National Centre for Mathematics Education in
Gothenburg, abstractions delineated with the support of one or more examples:
A model is perceived as general, i.e. it claims applicability to a variety of new
situations, it should be able to approximate reality, and be applicable to the
complexity of specific cases in the future, as well as able to explain or forecast
concrete future events. A model is explicitly formulated [...] to be able to be
communicated through education. Since the model should be able to explain the
complexity it has been extracted from, some practical complications arise. In many
cases, successive adaptation between the model and the individual case is required for
its application to be possible. Sometimes a real situation creates such intensive
“resistance” that the model must be revised or rejected. If the problem has to be
resolved quickly, the model must be replaced by the hands-on knowledge and skills of
the labour force, as when an unanticipated error suddenly occurs, for example, with a
nuclear power facility.21
This is typical also of the knowledge ideal of the Nuclear Power Industry, and it is an accurate
description, as implied, of the knowledge that goes into instructions and enterprise systems.
While the model is conceived as all-embracing, practical proficiency has another texture; it is
of a more analogical type. These analogies consist of a number of situations and examples,
connected with one another, where each new situation is compared and related to previous
examples and experiences, building up a proficiency, or skill, which has “a more or less
general applicability without claiming the generality of a model”.22
Professional knowledge is individual as well as collective, developing from theory as well as
from the experience of individuals working together. Still, the acquisition of skill does not
follow along any lines of linear development; it detours and encounters various forms of
resistances. Novices and beginners must learn to recognise these resistances, to sense the
difficulties encountered instead of ”aggressively conducting war against them”.23 Most people
have the capacity to become skilful at something, within a certain area. The problem today,
according to Sennett, is that society in general does not encourage, or explain to the individual
person, that he or she has the long-term potential to learn far beyond the contexts of formal
20
Perby, M-L. (1995): Konsten att bemästra en process, p. 195-196.
Gustafsson, L. & Mouwitz, L. (2008): Validation of adults’ proficiency – fairness in focus, pp. 18-19.
22
Ibid., p. 19. Manuals and technical instructions within the Nuclear Power Industry are protected by secrecy.
23
Sennett, R. (2008): pp. 226-230.
21
education. Young people are rather encouraged to secure a portfolio of various skills, whereas
skill in a sense of craftsmanship is based on “slow learning” and on habit.24
As Michael Power has discerned, management control has taken new forms. Numerous
standards for risk management have been produced, creating new demands for proof and
evidence of action.25 Subsequently, the highest quality is being replaced by the right quality.
Adaptation to the more and more costly processes of control and auditing, an “expanding and
self-preserving structure”, has become next to synonymous to issues of quality and legitimacy
within professional activities like schools, hospitals, and universities. This in turn, will require
some sort of reflexivity, or readiness to the fact that, sometimes, there might not be any true
need for such arrangements:
Reflexivity will require an institutional confidence to dismantle as well as construct
audit arrangements. Regulatory sensitivity about what makes organizations like
schools and hospitals effective is necessary, a sensitivity which involves decisions
about how to leave individuals alone to get on with their work as much as how to
monitor them. This in turn will require recognition of the manner in which practices
are perpetuated isomorphically because they have become legitimate and not
necessarily because they have been even moderately effective in achieving goals.26
When Taylorism is brought up today, it is often in relation to the far-reaching measures of
streamlining the work tasks of highly qualified personnel. Besides, Taylorism of today is
often accompanied by a short-term push for organisational change and profit maximisation. In
many professional activities a concealed, or hidden, Taylorism has crept up on us, as with the
re-engineering of medical care in the US and many European countries in recent years, where
the aim has been to speed up the average time doctors spend with patients, making each
member of staff see more patients during the same period of time, but also to re-design work
itself, directing the very contents of these meetings. Many times, rationalisations such as these
have an obscure albeit strong, administrative impact.27 Through these cultural changes, hence,
new varieties of Taylorism are spawned.
24
Ibid., p. 265.
Power, M. (2007): Organized Uncertainty – Designing a world of Risk Management, pp. 1-3ff.
26
Power, M. (1997): The Audit Society – Rituals of Verification, p. 145. Power makes a distinction between
auditing, or an auditing style of monitoring, orientated towards complience, control and normative standards,
and inspection, or a inspective style of management, focusing on evaluation, and on substance. Nonetheless, as
in the case of extensive formalisation, divisions like these are sometimes obscured, and difficult to discriminate.
27
Cf. Ibid., pp. 27-31.
25
3. The Highly Improbable
When in 1972 the term “Information Society” was first used in a Japanese futurological study,
and the prospects of computerisation of working life flourished, there was a widespread belief
that Artificial Intelligence (AI) would have replaced manual knowledge and initiative by the
year 2000. In 1985, however, evaluators had begun noticing characteristic adversities in these
developments. The term functional autism was coined to highlight this decline in ability, “the
phenomenon of people who work for a long time in a computerised environment, with its
characteristic view of reality falling into categories of black/white, right/wrong, experiencing
difficulties in confronting reality”.28
All technology is conjoint with risks, and as risk analyst Nassim Nicholas Taleb has pointed
out, “the improbable”, or “the unexpected”, is never well-defined; concepts like these are not
stable, but dependant on the one individual or group making the judgements.29 In this sense,
the imaginative and critical thinking of plant personnel, gathered from long-term experience
as well as training, become an essential ingredient of a reliable safety culture.30 In other
words, it is the operatives that make the decisions at times of uncertainty and crisis, and
although they have a huge amount of manuals and instructions as support, they might also
have to act on their own judgement and experience.
On March 11 2011, the tsunami caused by the Great East Japan Earthquake flooded and
destroyed the emergency diesel generators, the seawater cooling pumps, the electric wiring
system, and the DC power supply for Units 1, 2 and 4 of the Fukushima Daiichi nuclear
facility, run by the Tokyo Electric Power Company (TEPCO), resulting in loss of power, apart
from an external supply to Unit 6 from an air-cooled emergency diesel generator. Most Units
of the facility lost power, but the flooding did not damage only the power supply. The tsunami
also destroyed buildings, equipment installations and other machinery, while seawater from
the tsunami flooded the entire building area. All in all, the loss of electricity made it difficult
to cool down the reactors, while also resulting in the sudden loss of monitoring equipment
28
Göranzon, B. (2009) [1990]: pp. 139-140. The futurological studies referred to are: Japan Computer Usage
Development Institute: The Plan for Information Society – a National Goal Toward Year 2000, Computerization
Committee, Final Report, May 1972, and National Institute for Research Advancement (NIRA): Comprehensive
study of microelectronics, 1985.
29
Taleb, N. (2010): The Black Swan – The Impact of the Highly Improbable, pp. 43-46; 51-55.
30
Snow, C. P. (1998):. The Two Cultures, p. 62, delineates the concept of culture as intellectual development,
development of the mind, or development of those qualities and faculties that characterise our humanity, a nation
or a group of people, of which in this context the latter are the more applicable.
such as scales, meters, and other control functions in the central control room, but also given
the fact that lighting and communications were highly affected. Ultimately, decisions and
responses to the accident had to be made “on the spot by operational staff at the site, absent
valid tools and manuals”.31
Constance Perin, researcher at MIT, has distinguished three logics of control, or cultural
dimensions of safety, which regiment matters on American Power Plants: The calculating
logic of deduction, assessing various levels of risk related to high-technological systems; the
real-time logic of operatives, extracted from local practice, countervailing any deficiencies in
construction or technology in a wider sense; the ability to sense, translate and monitor the
array of signals, alarms and messages given out by these systems. Thirdly, the policy logic
directs the judgements and considerations of management, between production targets and the
security directives given by the regulatory authorities. According to Perin, there is also a
hierarchical “inherited caste system of credibility” within this sector of industry, where the
formalised knowledge of the calculating logic, and to some extent the policy logic, set the
standards, procedures and guidelines with regard to practice. In other words, the “experiencedistant”, quantitative knowledge of engineers and risk management has high status and a well
developed terminology, whereas the experience-near know-how of the operating personnel is
essentially tacit, albeit key to the successful operation of nuclear power plants:
To calculate risk levels for reactor designs, engineers move through a series of
deductions to shape high-level control concepts into risk estimates, then into the
algorithms, thresholds, and standards that become the design basis, the technical
specifications, and the procedures and rules for maintaining control. Once reactors are
operating, real-time logics reduce and handle risks that design calculations have not
anticipated.32
From the perspective of the NAIIC, all these logics of control were in some way inadequate.
Similar to other high-technology, nuclear plants do not always behave as calculated or
expected. System upsets and disturbances occur from time to time, and operating experiences
is not always transferable to other power plants. When facing the unexpected, the real-time
logic of the operating staff has little choice but to draw on “memories, observations,
experience and judgement” in order to manage anomalies like the system accident, or other
improbable misadventures. Hence, disturbances outside the narrow parameters of calculating
Kurokawa, K. et al. (2012): The National Diet of Japan – The Official report of the Fukushima Nuclear
Accident Independent Investigation Commission, NAIIC (Executive Summary), p. 14.
32
Perin, C. (2007): Shouldering Risks – The Culture of Control in the Nuclear Power Industry, p. 198.
31
logics have to be interpreted and dealt with by the “hierarchically inferior” skill and knowhow of plant personnel:
Even though model-makers themselves may be aware of the limits of their
simplifications, models may find themselves doing more heavy lifting than intended
when the world goes its own way. What model language calls “ill-structured”
problems or “system upsets” are more likely to be real-world situations made more
intractable by overstructured expectations that a technology will and should perform
as modelled.33
Chairman Kiyoshi Kurokawa, of the National Independent Investigation Commission
(NAIIC), claims that the Fukushima accident is to be regarded as a man-made rather than a
natural disaster. Despite of its excellence in engineering and manufacturing, the Commisson
points at some ingrained conventions of Japanese culture: “our reflexive obedience; our
reluctance to question authority; our devotion to ‘sticking with the programme’; our
groupism; and our insularity.”34 Interestingly, this in-depth critique of Japanese culture was
touched upon in the English preface, not in the original report. While the concept of insularity
is precarious, the NAIIC typically blames the incapacity in Japanese mentality for critical
thinking, to admit failure and ambiguity. According to the report, Japan’s nuclear industry did
not in any effective way absorb the lessons learned from, for instance, Three Mile Island or
Chernobyl, and national regulators are accused of “ignoring international safety standards” on
a general basis.35
Professor Akira Omoto, a member of the Atomic Energy Commission of Japan, with a
background in both IAEA and TEPCO, who has investigated the Fukushima accident, also
highlights cultural impacts as decisive, such as the lack of critical thinking and questioning
attitude, on both a national and organisational level, as well as within the nuclear community
as such. Similar to the NAIIC, he points to an overall complacency, overconfidence and lack
of professionalism due to heavy outsourcing. Besides, there has been a strong parochialism
within the nuclear community, and lack of dialogue; the priorities of risk management have
been on cost-plus tariffs and the relation with local governors, not safety and continuous
improvements. But despite of the extreme events, according to Omoto the circumstances of
the accident were not unique to Japan. Arguably, there are salient features of Japanese
national culture that has contributed to the ultimate catastrophe. The Japanese think and act as
33
Ibid., p. 203.
Kurokawa, K. et al. (2012): p. 9.
35
Ibid., p. 20.
34
a group: there is a strong collectivism, uncertainty avoidance, as well as lack of independant
challenge; this also made its mark on the safety culture of specific power plants. Cultural
attitudes are not easy to change, but one of the key issues of the Omoto study is the pervasive
alterations of the public educational system from the 1970s onwards and its long-term impacts
on culture. In other words, certain aspects of a culture are liable to change, for instance
through the educational system, making this a matter of relevance to other countries as well.
Accordingly, there seem to have been some sort of overall loss of ‘thinking capabilities’, less
reflective and critical thinking within society as a whole. In Japan, education has become
more and more a matter of “transfer of knowledge” rather than “learning how to think”.
Omoto also points to a culture in engineering with a tight emphasis on component quality and
reliability, but with a lack of “big picture thinking”, distracted by detail and formalism.36
According to external plant evaluations of The Institute of Nuclear Power Operations (INPO),
the Fukushima Daiichi power plant was in immaculate condition up to the accident in March
2011, although there had been some problems at other power stations run by TEPCO. The
risks with regard to future earthquakes and tsunamis were known to chief executives, but on
the whole considered highly improbable. These facilities, hence, had great performance
records and excellent house-keeping, but were still not prepared for the worst. The focus of
training was mainly on the expected, and there was little readiness for worst case scenarios,
reflecting, arguably, the downsides of being successful. Besides, there was a consensus
culture, typical of the Japanese, where employees were not encouraged to disagree with
managers.37 Even if there also was a culture of continuous improvement, such as Quality
Circles, it arguably was not enough to untangle the Japanese aversion towards disagreement
and the challenge of authority.
4. The Projection of Quality
The concept of functional autism corresponds to the kind of hollowing out of skill and ability
delineated in Swedish studies of working life in the 1980s, for instance in the aftermath of
computerised administration of social insurance offices nationwide. Here too, a decline in
skill among the personnel had occurred over time, in regard to the fortitudes of decision-
Omoto, Akira, Presentation at IVA’s Conference Centre, Stockholm, November 29th, 2013.
Presentation on the Fukushima Daiichi accident in March 2011 by Wade Green, former Department Manager
at INPO, at a Vattenfall workshop at Arlanda, Sweden, March 6, 2013.
36
37
making and personal judgement. One implication of this analysis was the need to confront and
counterbalance such long-term tendencies of decline within the educational system, alongside
the exaggeration of science and technology of our time; another implication was to maintain
the division within professional practices, between doing something and writing a general rule
for it.38
In recent years, tendencies of this kind of hollowing out of skill and ability have been outlined
within the Nuclear Power Industry, in which technology and enforced standardisation have
taken precedence over manual skill and knowledge.39 Within this sector of industry there are
strong requirements to demonstrate what means of control each organisation disposes of. But,
by increasing the number of processes or instructions, one does not necessarily enhance the
overall safety of operations; at worst, to lean on formal systems of codification become a way
of escaping responsibility and critical thinking. The desire to make reality more legible and
manipulable has partly to do with safety. But it is also connected to international
benchmarking, and an increased focus on commercialism; a declared intention to link culture
and values to certain market-related targets. This growing emphasis on commercialism can
have various effects on different layers of organisations, and can also have consequences for
the safety culture of a nuclear power station, if taking focus from issues of relevance from a
safety perspective to those in charge of the operation.40
In high-risk industries, standardisation signifies quality, credibility and legitimacy. In a
taylorist manner, extensive measures are being taken to monitor human action, as illustrated
by the fact that the human factor is being regarded as the main source of error within hightechnology systems. Accordingly, the behaviour of plant personnel is being presented as
inadequate, or inauspicious. Even so, time and again operating personnel, the human factor,
saves technology when encountering the unforeseen. Experience-based skill reduces risk, due
to the fact that skilled operatives have become familiar to a great variety of occurrences and
situations. Merely observing instructions is not a “venture”, but can still be adventurous,
while all can not be anticipated or codified. Quite the reverse, serious incidents and accidents
38
Göranzon, B. (2009) [1990]: p. 126f. Scott, J. C. (1998): p. 356, points to a similar, paradoxical texture with
regard to the kind of designs for life and production that tend to diminish the skills, agility, initiative, and morale
of their “intended beneficiaries”, and so undermine human capacity in the long run. The concept used by Scott to
characterise the corrosion of local and experience-based knowledge, what he refers to as Métis, is institutional
neurosis.
39
Cf. Berglund, J. (2013): pp. 71-102.
40
Spelplats 3.2006, s 77. Cf. pelplats 3.2009, s 60; Spelplats 3.2010, s 66.
typically result from minor faults or deficiencies in one part of a system, interacting with
other parts or units in unexpected ways. When this occurs, operatives are usually faced with
ambiguous or mysterious course of events, where they are obliged to take independent,
sometimes quite creative, measures to steer clear of danger. Charles Perrow calls such series
of minor failures system accidents, or “normal accidents”. High-technological systems, over
time, have proved to be more complex than instantly assumed; new devices are frequently
provided, but even as to countervail established faults or deviances, these amplifications can
in themselves spawn new such accidents:
(Technological fixes), including safety devices, sometimes create new accidents, and
quite often merely allow those in charge to run the system faster, or in worse weather,
or with bigger explosives. [...] We have produced designs so complicated that we
cannot anticipate all the possible interactions of the inevitable failures; we add safety
devices that are deceived or avoided or defeated by hidden paths in the systems. The
systems have become more complicated because either they are dealing with more
deadly substances, or we demand they function in ever more hostile environments or
with ever greater speed and volume.41
This corresponds to the developments in Sweden, where all power plants have been upgraded
both for prolonged longevity and increased capacity. According to Perrow, this indicates
something of a utopian mentality within the Nuclear Power Industry, i.e. that the power plants
operating now are consistently being made safer and safer with added technology. These
upgradings can also be implemented due to increased production pressures, or other matters
of effectiveness. In addition, the complexity of the facilities and the efficiency measures of
management has often turned out to be an ominous combination.42 It is not always the
operators’ fault when things go wrong; technology can fail, something that the operating staff
must be able to untangle.
To inexperienced shift teams, the prospects of managing the improbable are poor; to
experienced operators system accidents are likely to appear more linear and manipulable. The
knowledge that can be extracted from technical analysis of such incidents, however, is
unlikely to be of very much relevance as to the detection and management of future system
accidents. According to Perrow, these are complex processes that can be to some extent
“described, but not really understood”, and they are usually detected by means of doubt and
discovery, practical know-how that has reduced accidents within the Nuclear Power Industry
41
42
Perrow, C. (1999): Normal Accidents: Living with High-Risk Technologies, p. 11.
Ibid., p. 79.
to a large extent. Even so, operatives frequently get the blame for upsets and incidents of all
sorts, like the Harrisburg accident.43 But more technology does not necessarily mean better
safety.
Except for the potential of unexpected interactions, there is more at risk: Apart from the
complexities of the system accident, there may be situations where chief executives ignore the
repeated warning signals of their personnel, or other warnings, proceeding with unsafe
practices.44 From time to time, the short-term interests of companies and organisations
overshadow the various measures and perspectives needed to protect society from industrial
accidents and disasters in the long run. Typically, deregulations of electric power markets in
the 1980s and 90s have led to a concentration of power in the hands of a few major
companies:
[...] to reduce costs while increasing output and revenues, the industry took its place
on the ”re-engineering” bandwagon beginning in the 1980s and continuing today to
redesign work and production systems to maximize efficiency.45
Competitiveness of markets, in general, creates ”a short run perspective and cost-cutting to
increase profits”, including measures such as outsourcing, downsizing, and cost-savings on
maintenance. In this case it also has created competition between various energy sources.
Fearing the effects of deregulation on future profits, many companies within the nuclear
industry began to adopt new strategies to deal with this new situation. While some companies
managed to improve operating efficiency, others were looking to cut operating costs by
reducing maintenance costs and employee costs considerably at their plants, one example
being the Millstone facility in Connecticut. Even though top management of these facilities
was aware of the risks of taking deep cuts in current maintenance expenses, their management
consultants at McKinsey were called in to do the “justifying study”.46
A few years later, in an internal memo, some of the consequences of these cost cuttings were
exposed. Despite of increased profits, required inspections were not conducted, there was a
failure to repair leaks and identify corrosion in cooling pipes that were not maintained; the
43
Ibid., pp. 84-85.
Perrow, C. (2011): The Next Catastrophe, pp. 9-10. We can here talk about different types of failure, like that
of operatives, management or executive failure, the complex interactions of the system accident, or ‘ideological’
failures of deregulation; demarcations that can be useful for analytical purposes.
45
Perin, C. (2007): pp. 3-4.
46
Perrow (2011): pp. 155-156.
44
organisation was also unable to train instructors, and experienced employees were now
leaving. In addition, the Nuclear Regulatory Commission (NRC) in the US noted that whistleblowers were fired or mistreated for reporting safety violations, and in the mid-1990s the
NRC had no choice but to, as more problems were discovered, shut down all three of the
Millstone power plants, not allowing to restart without substantial improvements.47 This is a
key example to illustrate how the priorities of executives and upper management can inflict a
blow to the safety of high-risk facilities, and to the safety cultures of high-risk organisations.
Over the last decade there have been similar problems at Swedish power plants, with minor
upsets and incidents, as executives have been focusing on cutting maintenance costs and
operational costs, while at the same time upgrading these facilities in order to increase
production.48 Like the case of the Millstone facility in the 1990s has shown, this is not without
risks, considering the number of unscheduled stoppages at Swedish power plants in recent
years. While executives and top management continue to reduce costs, there may be a minor
impairment here, another small deterioration there. Meanwhile, it is difficult if not impossible
to get hold of the overall, crucial losses of quality that emerges over a longer period of time:
Thus, the short-run savings that accumulate with cutting corners on maintenance and
safety can be expected to dominate management thinking at the top, middle, and
bottom. Since any untoward consequences of short-run savings are unlikely to appear,
if they ever do, until the distant future, management can escape accountability.49
Even though deregulation itself will not necessarily lead to the kind of relegation of safety
that, according to some reports, has taken place within large sections of corporations like the
Swedish, government controlled Vattenfall, especially up to the incident at Forsmark 1 in
2006, it seems to have fostered a culture of short-sightedness. In the case of Forsmark, there
have been insufficient long-term maintenance of facilities, shorter periods of recruitment
freezes, a reduction in the time each operator must spend as a trainee before being allowed
into the control room, as well as in the time spent in supplementary training and education.
Parts of this may be explained by an increased cash-consiousness of executives and upper
management, but also due to the ambiguity of political decision-making.50
47
Ibid., pp. 157-164.
Berglund, J. (2012): Säkerhet och ekonomisk rationalisering, p. 31f.
49
Perrow, C. (2011): p. 144.
50
Cf. Larsson & von Bonsdorff (2007): p. 14. In the case of Vattenfall, cutting corners on maintenance and
operational safety, alongside savings on personnel and training, can also be linked to dubious company takeovers abroad; see for instance http://www.svd.se/naringsliv/nyheter/sverige/vattenfall-visar-prov-pa48
Continuing reductions of costs, by means of downsizing or outsourcing, is likely to have
various kinds of negative effects on the overall quality of practice, and on a dependable safety
culture. There is reason to assume that the negligence of experience-based skill and tacit
knowledge can have similar consequences. In other words, conditions important to the safety
cultures of specific power plants must include the development and maintenance of skill and
practical knowledge among plant personnel. In a long-term perspective, deterioration of
quality, or the erosion of skill, run a risk of leading towards some sort of organisational limbo,
a downward spiral in the process of which previous success formulas fall into oblivion, or to
‘an imaginary place for lost or neglected things’.51 In high-risk activities, this might lead to
disaster.
5. The Reducing of Thinking
Lave and Wenger argue that learning is essentially a process of participation in various
communities of practice, where learning is conceived as ”an integral and inseparable aspect of
social practice”.52 Consequently, if these aspects of professional skill were to be ignored, the
risk is that knowledge will be regarded as a commodity, and the learning individual an object
upon which a certain knowledge is to be transmitted. This can also manifest itself in “conflicts
between learning to know, and learning to display knowledge for evaluation”.53 Essentially,
the type of knowledge referred to here is knowledge of familiarity, the knowledge we extract
from a culture, or environment, informally. Tacit knowledge relates more broadly to the limits
of systematically verbalise human proficiency, collective as well as individual. Unlike the
propositional knowledge of manuals and instructions, knowledge of familiarity and
knowledge expressed in skill, from doing something over and over, are by and large aspects,
or dimensions, of knowledge which we are unable to fully articulate. As philosopher Hans
Larsson has elucidated, it is experience-based knowledge that cultivates intuition and personal
judgement among human professionals.54
An immense library of distinguishable situations is built up on the basis of experience.
[…] We doubtless store many more typical situations in our memories than words in
desperation_7973096.svd. Cf. Hutchins, D. (2008): Hoshin Kanri – The Approach to Continuous Improvement,
pp. 27-28.
51
Cf. Berglund, J. (2013): p. 184f. Perin, C. (2007): pp. 257-267; Scott, J. C. (1998): p 350f.
52
Lave, J. & Wenger, E. (1991): Situated learning – Legitimate peripheral participation, p. 31.
53
Ibid., p. 112.
54
Larsson, H. (1997): Intuition, p. 77f.
our vocabularies. Consequently, such situations of reference bear no names and, in
fact, seem to defy complete verbal description.55
Typically, acquiring skill begins with the following of certain rules, and a key characteristic
about rule-following, once it has matured in the course of practice, is that the act of following
a rule in a given situation, in a particular setting, seems to defy complete articulation. Within a
praxis, rule-following takes place pursuant to certain representative styles or patterns. Hence,
such “intransitive rules” are embedded in action as part of practice; it is in how we follow a
rule, or act, in current situations of practice that we are able to fully express our professional
skill and knowledge.56
An elementary factor in what is usually called experience is that experienced
individuals are able to manage a variety of improbable or unexpected situations. Just
as it is not possible to define an unexpected situation beforehand, in all likelihood our
ability to manage the situation should not lead up to appreciation that we must be able
to articulate the knowledge that makes this management of the unexpected possible.57
There is a compulsive element in the rule-following within certain praxises; it usually has its
own tacit coherencies and foundations that have developed over time, between people of the
same environment. When someone has become experienced, he or she enters the phase of a
potential surpassing of rule-guided knowing that; this is not an act of objection, but learning to
master a great variety of situations, in a manor that will able one to extend the boundaries of
these rules, or styles of action, whenever the circumstances require us to. Due to this open
character of rule-following, that it admits of variation, and that we are able to act upon our
judgement and tacit knowledge, becoming a skilled professional implicates being able to
manage the unexpected, or undetermined.58
Hence, expert professionals operate on principles they are unable to fully articulate. This also
links with modern science, notably the new interdisciplinary research field of
neuroeconomics, where it is established that the utility perceived when the outcome of a
person’s actions, choices, and decisions is actually experienced is a key factor to human
Dreyfus, H. & Dreyfus, S. (1986): Mind over Machine – The Power of Intuition in the Era of the Computer, p.
32. The authors in fact intend to separate “skill” and “knowledge”. Following this line of argument, the concept
of tacit knowledge is ruled out. What cultivates skill, accordingly, is tacit experience rather than tacit knowledge,
if in a strict sense following the arguments of this book.
56
Johannessen, K. S., in Göranzon, Hammarén, and Ennals Eds. (2006): “Rule following, intransitive
understanding and tacit knowledge: An investigation of the Wittgensteinian concept of practice as regards tacit
knowing”, pp. 268-269ff.
57
Janik, A. (1991b): p. 117. My translation.
58
Ibid. pp. 112-116.
55
learning and decision-making. It seems that these experienced utilities are computed into the
long-term memory of the brain, more precisely the orbifrontal cortex, to guide future actions,
enabling good decisions to be made under conditions of uncertainty:
Therefore, it can be hypothesised that we learn about decision utilities for different
actions through trial and error based on the experienced utility we obtained when
taking those actions (or similar actions) in the past.59
In other words, “by repeatedly taking particular actions and then observing the outcomes of
those actions”, with a key role for analogical thinking and reflection, one is able to produce
risk-sensitive decision-making, based on previously encountered utilities and associations.
This will elucidate further the ability underlying what Perin refers to as the real-time logics of
nuclear operatives. It is also an indication that new employees are likely to be less able in
managing the unexpected, due to a lack of hands-on experience. This does not necessarily
cause us to sleep better at night, but it can give us clues to why the knowledge of experienced
personnel is vital in the maintenance of reliable safety cultures. Professional skill is the
knowledge of the actor, or participant. The acquired understanding underlying the capacity of
good decision-making lies not in the assimilation of theory, or abstraction, but in knowledge
relating to sensory impression and experience. In the writings of Chief Encyclopaedists Denis
Diderot (1713-1784), like Rameau’s Nephew and The Paradox of the Actor, this is addressed
in the process of Enlightenment. The paradox of the actor means that actors are never quite
consistent in playing their roles, an analogy to professionals in other areas of expertise. His or
her skill and performance is deepened through the virtues of repetition, in playing their part
over and over; this division of theory and practice pointing to that dialogue is “the appropriate
medium for reflection on the things we know, up to the moment we are asked about them”.60
If everything were to be articulated by means of scientific method, Diderot anticipated a
development where humans would no longer have access to their sensory experiences, and the
kind of ingenuity and perception spawned thereby; a peculiar smell, a false sound, something
that does not feel right.61 This also represents a counterweight to the abstract classifications of
Enlightenment discourse, the belief in the powers of rational inquiry “to understand, to order
O´Doherty, J. P., “Decisions, risk and the brain”, in Skinns, Scott, and Cox, Eds. (2011): p. 47.
Göranzon, B. Ed. (1995): Skill, Technology and Enlightenment: on Practical Philosophy, p. 6.
61
Josephs, H. “Rameau’s Nephew: A Dialogue for the Enlightenment”, in Göranzon, B. & Florin, M., Eds.
(1991): Dialogue and Technology – Art and Knowledge, p. 151.
59
60
and to finally master and control the objects of human knowledge”.62 What Frederick W.
Taylor, himself a supporter of piecemeal transformation, did not pay much attention to was
those dimensions of professional knowledge that defy complete articulation. Besides, he had a
seemingly limited appreciation for the kind of conditions operatives are in need of to acquire,
as well as to maintain, skill and ability in the long run. In his view the main incentive to
perform good work was simply money, and he was so convinced that detailed instructions,
describing the optimal way of performing each task, should bring the best out of each and
every operative.63
In some high-risk industries, like the operating of nuclear power plants, traceability and
standardisation have become next to synonymous to issues of quality. Meanwhile, the
experience-based knowledge that forms the basis of manuals and instructions is liable to
corrosion; future generations might read these instructions literally. Even if regulatory
authorities like the Swedish SSM (Strålsäkerhetsmyndigheten) desire an equal relationship to
plant management, they seem to push these organisations towards increased legibility, higher
demands for proof and evidence of action. Besides, trying to speed up the learning of plant
personnel, which has been called for at some power plants, is also likely to impoverish the
knowledge of these organisations. As I have found in my research on the nuclear industry, the
knowledge ideal of instructions, checklists, and systems of regulation have been increasingly
favoured at the expenses of experience-based know-how. This “narrowing of vision”, making
possible a higher degree of schematic knowledge, may lead, and have to some extent already
led, to a process in which the critical thinking and reflection of plant personnel is reduced.64
This kind of reflection and thinking, typically, is intimately connected to the informal learning
that is building up skill and practical proficiency in the long run.
Many of the informants that participated in the above mentioned study point to the fact that
operatives nowadays are clever at detail, but often lack the overall picture, and perception.
Where formalisation is stretched, there are reasons to suspect that it proceeds at the expenses
of the ingenuity of human professionals, and their”subtleties of application”.65 Likewise, the
progressive utilitarianism of F. W. Taylor was accompanied by a reservation as to the risks of
swift and radical change. In his words, these developments ought to be guided by ”the right
62
Ibid., p. 148.
Taylor, F. W. (2007): pp. 31-33; 105-112.
64
See Berglund, J. (2013): pp. 81-110; 201f.
65
Scott, J. C. (1998): p. 316.
63
spirit”; the incentives of scientific management and enforced standardisation should be the
greater good of the establishment and, ultimately, the whole of society. With the kind of
short-sightedness generated in recent decades, this is not always the case.66
Arguably, the influence of Knowledge Management-type theories has to a large extent
superseded that of Taylorism within many businesses. As De Vos et al. (2002) has argued,
although tools and techniques may differ, in both principles one of the main targets has been
to foster a capacity for quicker and more “effective” learning within organisations, promoting
the objectives of transparency and codification, in creating common knowledge; to make
individual knowledge accessible through certain information systems, experience systems, or
“expert systems”.67
The idea behind expert systems is to formalise the knowledge of the expert, gathered from
long-term experiences. The goal is enhanced reliability and precision, as well as to make the
practical knowledge systemised and more easily accessible to newly recruited staff. 68 In a
Taylorist tradition the purpose is also to create new knowledge, transcending the old one, and
formal workplace education is supposed to be the main source of learning. Within a tradition
of Knowledge Management, sharing knowledge between individuals is usually regarded as
non-problematic. Though it makes a distinction between different types of knowledges, the
main objective is to convert tacit knowledge into explicit knowledge, making it portable,
exchangeable, and less dependant on specific groups, or individuals. Dissemination of tacit
knowledge within organisations is set to occur by means of codification, or through models
and metaphors, albeit no one is assumed to have an exclusive responsibility for the creation of
common knowledge, as within a Taylorist tradition:
Underlying the theme of conversion of knowledge, from tacit to explicit, (in
Knowledge Management) there is hidden the same desire observed in Taylorism,
namely that of formalization and exteriorisation of personal knowledge, for the
purpose of converting it into organizational knowledge. Authors often insist on the
importance of this kind of knowledge, but they also emphasize the difficulty of
managing it.69
66
Taylor, F. W. (2007): pp. 113-115. Cf. Sennett, R. (2006): p. 168f.
De Vos et al. (2002): “Knowledge in question: from Taylorism to Knowledge Management”, p. 8, referring
primarily to Nonaka, I. & Takeuchi, H., The Knowledge Creating Company. Oxford University Press, 1995.
68
Josefson, I., in Göranzon, B. Ed. (1995): ”A Confrontation between Different Traditions of Knowledge – An
example from Working Life”, p. 261f.
69
De Vos et al. (2002): p. 11.
67
Typically, Knowledge Management-type theories and attempts of formalising the knowledge
of organisations run out of fashion, once enough establishments come to realise that it does
not work, that it becomes too expensive, or ineffective. Still, to codify knowledge and make it
less dependent on individuals makes for an attractive package to many work place
organisations. For instance, the promises of management sciences seem to provide a remedy
for the anxieties that we often associate with generational shifts and the transfer of
knowledge. As the panel discussion at 3rd WANO Knowledge Management Workshop in
Paris 2010 manifests, Knowledge Management is an area of many strategies, and banners:
”To have the right knowledge in the right place, for the right people at the right time”, is
suggested by John Day, Head of Knowledge Management at Sellafield in North England.
More specifically, to ensure that operatives have the right knowledge at hand. Julio
Benavides, Training Manager at one of Centrales Nucleares Almaraz facilities outside of
Madrid, takes it one step further. He argues that Knowledge Management is all about “how to
achieve that the guy, for instance an operator, makes the right decision in the right manner, at
the right time”. In other words, to make sure that plant personnel have the right instructions,
the proper training, or workplace education, in order to make the right decisions, in the right
manner, and at the right occasion. David Gilchrist, Head of Nuclear Operations at Italian
Enel, stresses that, within the Nuclear Power Industry,”basically everything becomes
knowledge” that can be disseminated and surveyed, but that it is considerably more difficult
than that: What can and should be done is “to systematise as far as possible the things that can
be dealt with”, in order to delimit what cannot be controlled and monitored. Many participants
in the workshop assent, in conjunction with this discussion, to the fact that there is a tendency
within the nuclear industry to overrate or overemphasis the value of formalised knowledge.
Previous generations have learned more independently, by trial and error, doubt and
discovery, while today’s training is focused towards enforced standardisation and information
seeking; where to find the right instructions in the exhaustive documentations that constitute
the codified basis of operating organisations.70 The impact of Knowledge Mangagement-type
methods and strategies point to the fact that the Nuclear Power Industry is affected also by
general trends and tendencies of society and other sectors of industry, that it is not an isolated
entity.
70
WANO 3rd Knowledge Management Workshop, 17 mars, 2010, WANO Paris Centre, Neuilly-sur-Seine.
6. The Measurement of Performance
The main approach used to design and evaluate programmes when training nuclear plant
personnel is SAT, Systematic Approach to Training, promoted by both WANO and IAEA.
The aim of this Knowledge Management-method, accepted as international best practice, is to
distinguish and break up relevant skills and qualifications, identifying specific tasks to be
trained, in order to utilise training for performance improvement. The SAT method was
developed for the US Air Force in order to speed up and make learning more effective; to
learn what you need to know, and not what is nice to know, on the basis of task analysis,
narrowing the vision of training, and of learning itself.71 To make training more efficient, each
part of the work is analysed in terms of what knowledge, abilities, and attitudes are to be
demanded to perform a certain task. The result of these analyses will form the basis of
training and formal education. The idea is that each task has a clear starting point and a clear
end, a limited continuance, that can be observed and pinpointed. This, essentially, echoes the
ideals of Taylorism.
Similar to medical care, it is also demanded that incidents and deviations from normal
procedure are to be reported and documented into an all-embracing enterprise system. The
system used within Swedish plants, in order to make nuclear power safe, is CAP (Corrective
Action Programme). Promoted by WANO and SSM, the idea behind this, by reporting all
sorts of incidents and digressions from “normality”, is to avoid the recurrence of error, as well
as to share experiences within the organisations. An ideal condition is defined, where
everything is considered to be safe, from which any deviation is reported and registered. Out
of this, new rules and recommendations are being issued, from risk assessment by means of
the trending of various upsets and incidents. But, this is essentially a model of reality, not
reality itself. The positives of this may well be to get people to actually report in the first
place, to a greater extent encourage this kind of endeavor. The negatives, on the other hand, if
relying to heavily on a system like this in the calculation of error and performance, might be
that: In focusing on quantity, such as the trending of events, upsets and incidents, assessing
the probability of future risks and accidents, does one detect the “black swan”, so to speak;
that one deviation, minor change, or upset, that can lead to a serious accident if not perceived
and dealt with? In any case, there seem to be some sort of “ingrained tendency in humans to
71
Berglund, J. (2013): pp. 91-96.
underestimate outliers”.72 Besides, there might still be immanent causes that can spawn
accidents at various untoward circumstances, and events, upsets, near misses, incidents and
accidents may not be triggered by the same causes.
Various attempts have been made to define the notion of safety culture, and to measure it; to
distinguish certain performance indicators in order to evaluate the safety cultures of power
plants world wide. The purpose of developing approaches in order to evaluate the
performance of different power plants, in comparence to other plants, has been to arrive at
objective methods and characteristics, adaptable to the entire industry. This can still be
counterproductive, and misguiding, while many key issues of operation are often excluded in
these measurements.73
Ultimately, safety responsibilities reside in the companies themselves, while supervision is
handled by national regulatory authorities. I have argued that WANO, established after the
Chernobyl accident in 1986, has contributed to increased formalisation within the Nuclear
Power Industry, promoting the adoption of benchmarking and best practices.74 Some people
have disagreed with me, stating the fact that the pursuing of WANO guidelines is voluntary,
not compulsory. When a WANO Peer Review team visited the Ringhals facility on the West
Coast of Sweden in April of 2013, typical remarks were deficient behaviours in relation to the
use of management tools such as Self-Regulation, Pre-Job Briefing and Post-Job Debriefing,
and in general; in the control room and around the power plant itself. Furthermore, the review
team pointed out that procedures and methods of work were not always uniform, and in
accordance with industry best practice, as advocated by, for instance, WANO themselves, that
is an international selection of highly experienced individuals from all over the industry. All
Swedish power plants have had the strategy of reaching the upper quartile level of the WANO
safety leading indicators. There has also been a tendency among Swedish nuclear facilities in
recent years that one prepares for peer reviews and inspections rather than for reality.
Recently though, WANO have also highlighted trends and indications observed in the last
couple of years pointing at some of the downsides of enforced standardisation. In a recent
Significant Operating Experience Report (SOER), a summarising analysis on Significant
Event Reports (SERs), "Operator Fundamentals Weaknesses", a fundamental point of analysis
72
Taleb, N. (2010): p. 141f.
Perin, C. (2007): p. 15.
74
See Berglund, J. (2013): pp. 87f.
73
was: an overreliance on processes and procedures, promoting a compliance-based approach to
tasks, and a “checklist mentality”. Operating Experience has shown two recurring problems of
recent years, regarding the use of formalised procedures and human performance tools:
(1) Operators followed procedures exactly as written, but did not have the necessary
knowledge to know how the plant should respond to a certain situation or condition. (2)
Events have occurred when operatives did not follow procedures as written, or did not use
human performance techniques properly to support procedure use.75
This may seem contradictory, but corresponds to the empirical data on the Swedish Nuclear
Industry, which have been developed in collaboration between the Department of Skill and
Technology at KTH, and the Swedish Nuclear Safety and Training Centre between 20082013.76 Here, too, many informants bear witness to the fact that, following the upgradings of
facilities, the supply of more “accurate” information in the control room, and the fact that the
sheer amount of rules and instructions have increased, there has been an overall decline in the
process perception of plant personnel:
In recent years, many instructors have observed flaws and deficiencies in the process
perception of some operatives and in some cases there have been necessary to go over
certain moments of training repeatedly. On some occasions operators have followed
specific instructions in the simulator point by point, turned pages at the end, and
unthinkingly went through an extra page without responding. In other words, he had
not been aware of, and considered, the next step of sequence.77
Örjan, Operational Manager at Forsmark, believes that the pursuit of formalisation within the
Nuclear Power Industry in recent years, in establishing detailed rules and regulations rather
than frameworks, has entangled its various partners into a system that has now become
difficult to find a way out of. There has, for instance, been ambiguity around situations where
operatives have taken the right steps, or measures, but not followed a given instruction.
Though it is the symbiosis of instructions and operator know-how that is assumed to assure
quality, to make operations safe and reliable, in environments where dialogue and divergency
are ruled out, the risk of stagnation is immanent:
What is our reaction when something goes wrong? We have an inclination to blame it
on an ambiguous instruction, which we immediately make more explicit. And so we
75
Interview with Hans Ehdwall, Senior Advisor at the Swedish Nuclear Safety and Training Centre (KSU), and
a former WANO Interfacing Officer (WIO), Stockholm, October 18th, 2013.
76
A large part of this empirical material is documented in the periodical Spelplats, see Literature.
77
Mats, Head of Training, KSU Oskarshamn, Spelplats 1.2011, p. 30, my translation.
keep going until we have a mountain of instructions, so detailed that there is little
room left for human manoeuvre. [...] We have a complex process to master, based on
thousands of instalments that can vary in regard to each other unendingly. This
implies that a given situation is never the same as another. For that reason, there is
important for operatives and personnel in all areas of the facility to sense this process,
and to observe deviations by means of intuition. It is impossible to consciously
process all this information in real-time. Rather, the information forms a pattern that
operators must learn to recognise, and read. This important know-how can not be
captured by any instruction, neither taught in training. The only way to get hold of this
knowledge is to dwell in these specific environments, and to actually manage the
process over a long period of time.78
According to Örjan, we need to add one aspect to the concept of quality, the kind of personal
judgement, perception and awareness that cannot be explicitly measured, or formalised. The
upgraded technology is not predictable in the same way as the old one, and there are a number
of combinations that are difficult to foresee. When, in the control room, the process is being
presented in a new and “improved” manner, this is no guarantee to that the performances of
experienced staff members will improve. The amount of new signals, and the information that
plant personnel have access to today, does not necessarily improve the potential of operatives
to read patterns, and minor changes, to estimate the “well-being of the process”. The sheer
amount of information today is simply too extensive.79
This approach may be regarded as too informal when it comes to high-risk industries. But
these aspects of skill, knowledge and quality, based on slow learning beyond the context of
formal education, is in fact vital to the maintenance of a reliable safety culture, in analogy to
the aquirement of skill and manual knowledge in other areas of proficiency:
Sometimes it’s imagined that becoming skilled means finding the one right way to
execute a task, that there is a one-to-one match between means and ends. A fuller path
of development involves learning to address the same problem in different ways. The
full quiver of techniques enables mastery of complex problems; only rarely does one
single right way serve all purposes. The rhythm of building up skill can take a long
time to produce results.80
The fact that international organisations like WANO have begun to highlight the risks with
regard to checklist mentalities, as well as compliance-based safety cultures, and that they now
seem to have set aside the concept of Knowledge Management, may indicate a progression of
the organisation as such, alongside its approaches to safety and quality. Question is: What
78
Örjan, writings prior to Dialogue Seminar on Safety Culture, 4 November, 2010, at The Royal School of
Technology, Stockholm.
79
Spelplats 1.2011, pp. 40-42.
80
Sennett, R. (2012): Together – The Rituals, Pleasures and Politics of Cooperation, p. 201.
approaches to training and further education can be utilised to support the reflective processes
of experience-based skill and knowledge?
7. Learning and Formal Education
In high-hazard activities, the training of operatives should have the purpose of being able to
operate in settings that are particular and undetermined, where some facts are unknown.
Experience-based knowledge has to evolve over time, enabling the work of “reflection and
imagination”.81 This is the kind of rule-following through which someone learns to carry out a
specific task in the first place, imitating a model, or role model, gradually learning to take
significant variation into account; building up one’s own rhythm and personal judgement.82
Even if human professionals are able to describe a great deal of what they know, these are the
very processes that seem to defy complete articulation. From an analyst’s point of view, the
aim is usually to break up relevant skills and qualifications, to divide work into separate tasks,
and to identify specific tasks to be trained. To extract and differentiate; to define certain tasks
as qualified, others as unqualified, or procedural. In this manner, professional knowledge is
divided into building-blocks that can be detached and reassembled, while adjustments are
being made to one block or another. This, essentially, is the logic of re-engineering and
technological change. In the interdisciplinary research field of Skill and Technology, rather,
professional skill is conceived as a cohesive entity, based on intrinsic associations that cannot
be decomposed.83
Our knowledge, in an occupation for example, is in three parts: the knowledge we acquire by
practising the occupation (knowledge expressed in skill), the knowledge we gain by
exchanging experience with colleagues and fellow-workers (knowledge of familiarity) and
finally the knowledge we can learn by studying the subject (propositional knowledge). [...] The
relationship between the three kinds of knowledge in a practice may be expressed like this: we
interpret theories, methods and rules by means of the familiarity and experience we have
acquired through our participation in a practice. [...] We may conclude from this argument on
the relationship between the different kinds of knowledge that, if we remove from an activity
the experiential knowledge and the knowledge of familiarity, we are also emptying it of its
propositional knowledge.84
As for supplementary training and further education, this is not insignificant. Nevertheless,
the above mentioned study on nuclear education and supplementary training points to the fact
81
Sennett, R. (2008): p. 295.
Sennett, R. (2004): Respect in a world of inequality, p. 232.
83
Perby, M-L. (1995): pp. 188-189ff.
84
Göranzon, B. in Göranzon, Hammarén & Ennals Eds. (2006): “Tacit Knowledge and Risks”, p. 190.
82
that the emphasis of training has shifted from what is often referred to as process perception,
towards enforced standardisation. It has been convenient to observe ”false behaviour” rather
than to support the experience-based skill of operatives; the kind of comprehension that go
beyond those instructions and manuals that constitute the basis of training is nevertheless
difficult to pinpoint. Besides, setting up various efficiency targets to fulfil can motivate higher
costs for training.85
Nowadays, there are less faults and deviations then previously at the power plants built in the
1970s or 80s; initially the untried plants had plenty of system upsets and deficiencies.
Likewise, there has also been a decrease when it comes to learning from everyday practice
and experience, partly due to increased automatisation. On the other hand, there is a potential
“ageing problem” ahead after decisions have been made to extend the life of nuclear plants
designed to run for twenty to thirty years, for instance due to the fact that the decision to
abolish nuclear power in countries like Sweden has been withdrawn:
Our database of accidents cannot tell us how serious the aging might be. We don’t
even have very good evidence as to whether the reliability of our plants is stable,
going up, or going down. Numerous measures are available; but they point in different
directions and are hard to interpret. Perhaps the most clear and simple one is the
number of serious incidents (i.e. near misses). Here the news is mixed. The number
dropped from 0, 32 per reactor year in 1988 to a low of 0, 04 in 1997, perhaps
reflecting a maturing of the industry and few plants coming online. But it then rose to
0, 213 in 2001 – about twenty-one serious incidents a year if there are one hundred
plants operating all year – perhaps reflecting the aging problem.86
These numbers reflect the operation of US power plants, which in an international perspective
are estimated to be at the top end in terms of safety and reliability, but this evolutionary curve
corresponds to the situation at Swedish power plants where availability numbers have fallen
considerably over the last decade. In other words, we have plants designed for twenty to thirty
years of operation, and we are looking to extend their lives by another twenty years. The rise
in number of incidents might also reflect the long-term effects of a reduction in maintenance
costs, and operating costs in general. In a Swedish context there is also the issue of an ageing
workforce, the challenge of an ongoing generation shift in terms of plant personnel and other
members of staff. Consequently, recurrent training in full-scale simulators has become more
accentuated, practicing such course of events and disturbances that nowadays rarely occur.
85
86
Cf. Spelplats 1.2009, p. 40, and Spelplats 3.2009, pp. 65-67.
Perrow, C. (2011): p. 142.
Stressing the importance of experience-based skill and learning does not mean there is no
need for administrative systems, as support, keeping regulations, instructions and information
up-to-date. What we do not want is overconfidence in propositional knowledge, or an erosion
of skill and critical thinking among operatives and other nuclear practitioners.87
An ordinary work shift today is usually a matter of surveillance. Besides, employees that are
being enrolled today are not of the same background as during the build-up period of nuclear
power in countries like Sweden, when, most notably, people with an experience from machine
work at sea, and from the Marine, were recruited. Apart from the fact that these people had
technical skills, they brought in an attitude of learning, and more specifically the importance
of learning from everyday practice, that all participation in practice is learning, as well as to
share knowledge with others. As within the nuclear industry, in the Marine you train to
prepare for things that are hopefully never going to happen. In other words, these people
brought with them a positive cultural impact on learning, maintaining the division of theory
and practice.88
Due to the lack of learning from everyday practice, “hands-on” recurrent training in full-scale
simulators has become more stressed. With this kind of training, it is often assumed,
operatives are able to prepare for real-time course of events, allowing them to cool down in
stressful situations. In my study of the annual simulator training of nuclear operators at
Forsmark 3, the main target was to make each shift team perform and communicate in a
similar manner. The task was for each group to detect unacceptable Core Oscillations in the
reactor in a simulated scenario. As it was, each of the six shift teams unraveled the scenario
differently, much to the dissatisfaction of the instructors. They would have wanted all groups
to act in the same way, namely, to identify the unwanted oscillations in temperature by means
of a small techological device, the more recently implemented 520-alarm, as the colour of its
displayed measured value shifted from green to yellow.89
The shift from analogical to digital technology has given rise to uncertainties that are now
being addressed in training and further education. Arguably, the shift to digital screens has
also dwarfed the ability of human professionals to read patterns, and, by means of sensory
87
Berglund, J. (2013): p. 76f.
Spelplats 1.2009, p. 20, and Spelplats 3.2009, pp. 69-70; 79.
89
Berglund, J. (2013): p. 44f.
88
impression and experience, learn how to detect minor changes in a process. Today, there are
less patterns to read. If a certain risk, or incident, occurs rarely, we tend to underestimate its
likelyhood, but if something does happen, like the terrorists attacks of 9/11, or the accident at
Fukushima Daiichi, we instead tend to overstate the risk of similar events occurring in the
near future.90 The increased tendency of unacceptable Core Oscillations detected in recent
years, mainly due to modifications to the composition of fuel, was being addressed by the
implementation of new technology for this particular upset, in this case the 520-alarm. Even if
this is addressed in training, and learning is equated to a harmonisation of thinking, while
adjustments are being made to one “block” of knowledge or another, we will not know what
comes next, or what is really that “black swan”, which may lead to serious accidents.
There is also a risk that formal educational qualifications do not cover the actual needs of
today. When discussing issues of learning and recurrent training, educators have observed
that, in the simulator, operatives tend to solve problems, or situations, in different ways. As in
the case of the Forsmark facility, the units of Forsmark 1, 2, and 3 have different cultures that
have emerged over time. This was partly due to tradition, and the principles of leadership that
prevailed, the fact that there was competition for many decades between the three blocks, and
these differences can also be spotted in training. In the simulator, operatives by and large
reach the same targets yet differently, and with slightly different approaches. For many years
there was little or no communication between the blocks. Nowadays, on the contrary, one has
to struggle to pursue something of one’s own.91
Today, full-scale simulators are used in the training of operatives in many high-risk industries.
Still, there are many differences between various organisations, although the main goal, to
have good operators, has not change. Some groups, like physicians, are not used to feedback,
and in, for instance, the shipping industry it has been unusual that people are called back for
‘requalification’, unlike the nuclear industry, or the aviation industry. Nonetheless, the
increased significance of further education has highlighted the role of good instructors’ skills.
In Sweden, pedagogical approaches have been largely didactic, with an emphasis on tests of
short term memory. Operatives are typically regarded as not being flexible enough, for
instance in adapting to new technology, not eager enough to learn, or to adopt new methods
90
Cf. Skinns, L., Scott, M., & Cox, T. Eds. (2011): p. 85f.
Dialogue seminar, 13 September, 2012, at the Royal School of Technology, Stockholm, with participants from
the Swedish Nuclear Industry.
91
and best practices. Likewise, scenarios are usually goal-orientated, from trends and analysis of
Operational Experience, with instructors anxious not to promote “false behaviour”. In fact, the
overall prospect has been one of control, to monitor people in such a way that the impact of
the “irrational” human factor is minimised.92
In the recurrent training of plant personnel, the pursuit of formalisation is manifested. As it
seems, many instructors get stuck in error prevention, trying themselves to claim all the right
answers, in which case dialogue and debriefing are obscured. To enhance the awareness of
instructors, for instance about the division between theory and practice, or on different
learning needs between different groups, or individuals, will be a key issue. Dieckmann et al.
(2009), in discussing medical simulation, stresses the importance of debriefing, as well as to
acknowledge that simulators are not reality; even if the authentic aspect of simulations are
often underlined, as in the Nuclear Power Industry, there are limits as well as opportunities to
this educational tool. On the contrary, to depart from realism, and the fact that simulator
settings are not reality, can in itself favour learning, in effectively using the as-if character of
simulation. After a session, discussions can take place more openly, for instance around what
the participants have learned through their participation in these scenarios. Participants might
perform actions that are not anticipated during the design of a scenario; the ideal is not to
mimic reality but to create a safe educational environment for learning and self-reflection.
Reflecting on the common experiences made during the scenario becomes vital in order to
promote learning, while the role of instructors will be to give feedback, ask questions that can
trigger reflection, and to involve those ‘silent participants’ less active during the scenario.93
Arguably, there is also a difference when it comes to learning, whether the participants know,
or do not know, what will happen during these sessions. In nuclear simulations it is fairly easy
to design scenarios where the operators are likely to end up in situations where the mere
following of instructions will be misguiding: Occasionally, participants in these training
activities, overseen by the instructors, might find themselves in positions or situations that are
legitimate under one instruction, but illegitimate according to another instruction. This is not
92
Berglund, J. (2013): p. 42f.
Dieckmann, P. et al. (2009): “The art and science of debriefing in simulation – Ideal and practice”, pp. 287292.
93
to depart from reality; it rather reflects some of the limits of formalisation and rule-guided
knowing what.94
At the same time, simulations are not always the answer. It can not least be difficult to
simulate everything that goes on simultaneously in real-time. For example, within maritime
industry one activity that has proved typically hard to simulate is the mooring of larger ships,
or vessels. It contains elements of difficulty that cannot be learned from simulator training;
the only way to get hold of this knowledge is to dwell in these specific environments, to sense
and observe.95 If there is something like an element of creativity within high-risk industries, it
is to do with the nurturing of a ‘questioning attitude’, critical thinking, or mild paranoia,
when it comes to issues of safety and reliability. This element will have to be sustained,
alongside a positive cultural impact on learning and responsibility; within a certain work
culture, or praxis, there are indirect sources of quality that have to be nourished. From the
likes of WANO there have been numerous efforts to promote such an attitude within the
nuclear industry, but also to formalise the deliberative reasoning of action by means of
training, and Human Performance Tools such as Pre-Job Briefing and STARC (Stop, Think,
Act, Review, and Communicate), a method for “self-control”, which has been launched as one
of the kingpins of reliable safety cultures within this sector of industry; there are courses for
everything, a new rule for every mistake. Ultimately, more rules and instructions becomes the
answer to everything. Experienced operatives, on the other hand, are sometimes reluctant to
undertake some education; they would rather work than attend courses in “how to take an
initiative”, or “how to write an instruction”.96
Even if a quality system, or formalisation in general, is important to the organisation as such,
it has meant that the competence of skilled personnel has had to be supplemented by duties
such as the management of documentation, while few people involved seem to have the
overall picture. Besides, most methods and manuals within the area of safety culture, supplied
by WANO, promoting for instance a “questioning attitude”, do not take cultural differencies
into account. They are based on standardisation,that everyone should act accordingly, in the
exact same manner. They rather take for granted that people around the world are the same,
94
Berglund, J. (2013): p. 81f.
Dialogue Seminar, “Safety Culture across Organisational Borders”, March 4 th, 2013, at KTH.
96
These comments are summoned from a dialogue seminar series within the frameworks of this collaboration,
presented in Berglund, J. & Leijonberg, A., Eds. Spelplats 1.2012.
95
whereas in countries like Japan challenging of authority, for instance, is almost
unimaginable.97
When everyday work becomes a matter of information treatment, where manual skill and
knowledge are being replaced by technology, functional autism is spreading throughout this
sector of industry. Increasingly, grey areas are concealed by definition, as reality are falling
into categories of black and white, right and wrong; a technological culture within which
qualitative reports and methods are met with suspicion. More and more is about finding the
one right way to execute a specific task, influencing the direction of training and formal
education, which is becoming more system-based. Typically, as people of other backgrounds
have become more invoved in risk analysis, added root causes are taken into account, to the
frustration of more technically orientated collegues. Even if practical proficiency cannot be
obtained merely by following rules and checklists, or by means of Human Performance Tools,
there is a strong pursuit of standardisation typical of high-risk industries, creating something
of an illusion of quality. Besides, trying to delimit the human impact on safety and quality,
and on the facilities, may contribute to the hollowing out of skill and resilience among various
professional groups, a deterioration in the visualization of complexity in dealing with
difficulty, and in the ability to intervene in order to manage the unexpected. 98 Hence, the
conditions for building up skill are changing, from problem solving, learning to address the
same problem in different ways, where it can be continuously developed and improved, to the
kind of rule-following primarily concerned with finding a “one-to-one match” between means
and ends. On a long-term basis, this is likely to alter the character of skill itself.99
Arguably, the developments in recent decades have weakened the prospects of a more
dialogical, or open, form of co-operation within many sectors of industries. In Sweden, the
pursuit of formalisation within the nuclear industry, like the conformation to various targets of
quality and effectiveness, tends to create a growing gap between resource management and
practitioners, with less and less dialogue. Today, not even a CEO seems to be able to exert
much influence, due to extensive formalisation and the long-term cultural changes that have
followed. There used to be considerable dialogue around ideas, past and present; people
actually met, engaged in conversation, got to know each other, and exchanged ideas and
97
Examination Paper, Master of Skill and Technology, Linnaeus University, October 2013, Diana Engström,
Department of Nuclear Safety at the Swedish Nuclear Fuel and Waste Management Company (SKB).
98
Ibid.
99
Cf. Sennett, R. (2008): pp. 230-238.
competencies. In a way, reflexivity is being replaced by ‘the fetish of assertion’ so to speak,
communications in which “content is all that counts”, not human experience.100 In a sense, cooperation is restricted to forwarding documents and regulations between departments. What
has become more important is displaying a confidence that everything is coped with, and that
all risks are preventable.
Within many enterprises there is a tendency to mistake communication for informationsharing; where the latter is based on precision and definition, communication in a sense of a
dialogue is “as much about what is left unsaid as said”: Most people have a capacity to handle
complexity, to detect and distinguish what others mean but do not explicitly say, or are unable
to fully articulate. This, essentially, is a key aspect to dialogue, and a prerequisite for human
co-operation.101 A lot of the learning that goes into skill is informal. Hence it is often rather
unconscious, attached to specific environments and situations, and to some extent “hidden in
action”.102
As the pursuit for formalisation has accelerated, the proficiency of plant personnel is
increasingly evaluated against the consistency of meticulously elaborated models, which has a
strong impact on the focus of training and formal education. Still, replacing a knowledge ideal
based on analogical thinking, doubt and discovery, with one intimately related to the concept
of a model is likely to lead to a reducing of thinking and reflection on a long-term basis.
Arguably, there is a need to widen the exchanges of knowledge and experience, beyond the
current uses of training and formal education. When it comes to high-risk organisations like
nuclear power plants, there might as well be a need to recapture the concept of Quality, and its
vital connection to professional skill and ability.
8. The Concept of Quality revisited
In traditional behaviouristic methodology, not unlike Taylorism, learning equates to changes
in observable behaviour. Consequently, as philosopher Hans Skjervheim has pointed out,
when approaching human activities in this manner, actions, gestures, claims or propositions
are regarded as facts, as opposed to claims, gestures, actions and propositions that can be
100
Cf. Sennett, R. (2012): pp. 17-18; 127-129.
Ibid., pp. 20-29; 271-277.
102
Gustafsson, L. & Mouwitz, L. (2008): pp. 17-18.
101
taken up for discussion, engaging us in dialogue. In studies of professional skill, learning is
considered a result of reflection on actual experiences, personal as well as joint. In the
developments of this field of study it has been assumed to be an epistemological mistake to
explore professional knowledge in a manner of straightforward questionnaire; nor has a
positivistic approach of external observations been deemed feasible; clichés, stereotypes and
mock-ups often stand in the way.103
As implied, there are ways for enterprises and organisations to depart from the dominant role
of formal learning and enforced standardisation. In conclusion, I will discuss some alternative
approaches to quality work and further education that can empower people with insight into
their own knowledge as well as others, collectively, and to train people in critical thinking,
with a key role for dialogue, which can also work as a counterweight to the erosion of skill
within work place organisations, and the taylorist tendencies of high-risk activities.104
Experience is said to be transferred to, or matured into, knowledge once we reflect upon it.
However, the meaning attached to the concept of reflection can vary considerably, different
contexts of learning in between. Adrian Ratkić distinguishes six, partly overlapping, images
of reflection in connection with professional practice: The dedoublemént, or “role splitting”,
of contemplating something from different positions; analogical thinking; the act of “bending
one’s thoughts back”; the experimental “reflection-in-action” of Donald Schöns reflective
practitioner; the “puzzle solving” of a detective fitting pieces together, or looks for various
solutions to the same problem; the dialogical activity of “criss-crossing a landscape”, as
opposed to walking down the same trail of thought, or topic, where digressions are taken
seriously.105 Not all thinking is reflective still, and some of the thinking that goes into learning
is unreflective, and intuitive. According to Allan Janik, reflection is neither entirely conscious
nor unconscious: It is a sort of “hermeneutic” activity, a way of “finding orientation” in
situations of ambiguity, adversity, or disorder; where current practices no longer function, or
where we no longer understand our situation.106
103
Cf. Göranzon, B., & Florin, M. Eds. (1992): pp. 3-4ff.
Ratkić, A. (2012): “Images of reflection: on the meanings of the word reflection in different learning
contexts”, AI & Society, 25th Anniversary Volume, publ. online at www.springerlink.com.
105
Ibid.
106
Janik, A., ”Literature, Reflection, and the Theory of Knowledge”, in Göranzon, B. & Florin, M. (1991): p.
156.
104
To reflect, we sometimes need to go outside of ourselves, by means of a narrative, like a piece
of literature, which we can use as a mirror. Reading and writing can urge the reflective
processes of learning, and at the same time illuminate something of the complex character of
human experience. Everything cannot be evoked through sheer will.107 As C. P. Snow has
pointed out, as we read “our imaginations stretch wider than our beliefs”, unlike if we
construct “mental boxes to shut out what won’t fit”.108 In other words, reflection is not a
luxury, but a key constituent in the development of professional skill and knowledge.
Experience is not the only criteria of skill. To broaden our perception and thinking capabilities
are equally important. Our imagination and critical thinking must be exerted and elaborated,
not impoverished. Even so, production pressure, rationalisation, and redesigning of work, can
inhibit us, creating a fragmentation of time, while generating a personality type “constantly in
recovery”, unable to constructively challenge their everyday practice.109
One way of addressing these issues is by means of training and further education. This is not a
substitute for the knowledge we aquire from (other) education, or from practice, but an
endorsement, reinforcing the knowledge of human professionals rather than undermining it,
like in the Taylor system. With the Dialogue Seminar Method, developed in collaboration
between the Royal Institute of Technology and system development company Combitech,
reflection is brought about, or orchestrated, outside the work situation. In the reflective
activities promoted through this methodology, discussions on issues of quality will take its
departure from examples and analogies, rather than general models or abstractions; reflecting
in the process of dialogue, learning is also seen as arising from encounters with differences.
To nourish reflection and critical thinking is deemed more important, and achievable, than the
knowledge conversion promoted in management sciences like Knowledge Management and
Taylorism. The aim is to trigger those involved to reflect more effectively on the things we
know until we are asked about it; to broaden rather than to restrict the imaginative and critical
thinking of adult professionals. Rather than focusing heavily on a single problem, experience
development allows for uncertainty, digressions and dissagrements; to open up for different
opinions and experiences to come through, which may converge into fruitful criticism.110
107
Ibid., p. 157.
Snow, C. P. (1998): pp. 92-93.
109
Cf. Sennett, R. (1999): pp. 132-135.
110
Cf. Göranzon, B., Hammarén M. & Ennals R., Eds. (2006): p. 85f.
108
In other words, to address issues of quality in a meaningful way we are in need of a common
language, in order to see and identify the problems and difficulties in the first place. Referring
to it as experience development, in the case of Combitech this has become a method for
reflection around new projects and the development of new products. A Learning Lab, so to
speak, utilised in the training of newly recruited staff, and among experienced engineers,
“gathering experiences from a completed project, establishing a common language in a newly
formed group, or helping to specify a new product”.111
Experiences, as in this case, are developed, not transferred, between people of the same work
place, or in mixed groups of people doing different kinds of work, sharing a narrative or
personal example, making way for reflection and analogical thinking. Instead of adding new
rules and routines top-down, the alternative may well be to nurture a mistake, incident or
experience within a praxis, a section or department of organisation, making way for dialogue
on encounterings with situations where one’s knowledge, or praxis, have been tried or tested.
Hence, experience development is a way of making this kind of reflection and learning more
conscious, and to make experience more accessible for reflection; to fetch reality by means of
examples rather than models.112
It also involves creating a meeting-place in the organisation, in which the experiences
of others have the oppurtunity to expand one’s own horizons and make them more
complex. It should be recognised that the term meeting-place has a twofold meaning.
A physical meeting-place, certainly, a location where conversations can take place.
But it is more a question of creating the condition in which experience can meet
experience: bringing to life the vital examples that set tacit knowledge in motion. We
should also be aware of the twofold meaning of the term experience transfer (or
development). It means learning from the experience of others, but also qualifying
one’s own experience. In both cases, reflection has an impact on experience.113
In other words, the idea behind this methodology is to create a more reflective practice. To
high-risk organisations this can be a way of providing fresh perspectives, to formulate new
thoughts, and to enhance the overall risk awareness of operatives and other members of staff.
In analogy, the idea of so called Quality Leadership Practice, or Quality as Empowerment, is
to organise people in small-group improvement activities such as Quality Circles, which can
be applied to identify and unravel problems in their own work, presenting bottom-up solutions
See Backlund, G. & Sjunnesson, J., ”Better Systems Engineering with Dialogue”, in Göranzon, B.,
Hammarén M. & Ennals R., Eds. (2006): p. 135f.
112
Hammarén, M., ”Skill, Storytelling and Language: on Reflection as a Method”, in Göranzon, B., Hammarén
M. & Ennals R., Eds. (2006): p. 204.
113
Ibid., p. 206.
111
to management. Problem-solving in general is often a convenient activity for many newlyformed Quality Circles. Learning from each other, the opportunity to diverge is what fosters
development, and the self-empowerment of employees many times comes as a side effect of
small-group participative activities, as utilised by Japanese manufacturers like Toyota, Nissan
and Honda. As David Hutchins put it, “everyone likes quality”, but we may attach different
meanings to it. Enabling its co-workers to congregate around and address some of the more
urgent problems in their own work areas, such as inadequate job instructions, housekeeping
problems or safety issues like Risk identification, the purpose of Quality Circle-type activities
is also to influence practice, inducing a gradual transformation in job design:
To involve people successfully it is necessary to modify the Division of Labour
method to be able to incorporate the principles of craftsmanship. In other words, it is
necessary to introduce the concept of ‘self-control’ to reintroduce craftsmanship to
groups or teams of people.114
Combining the advantages of the Division of Labour approach with craftsmanship, by training
small groups of personnel that does the same or similar work in the identification and analysis
of weaknesses in their part of the organisation, and in problem solving, the purpose is also to,
like any craftsman, give each member of staff opportunity for continuous improvement; to
nourish the informal learning of practical proficiency. Arguably, the overall result can be
improved if people are delegated responsibility to do as good a work as possible, to nurture
mistakes and incidents within a praxis instead of setting up some sort of external inquiry, or
work group, which may not lead to the desired improvements within the organisation itself; to
motivate individuals that have reached a higher level of skill.115 These approaches to quality
work (Quality Circles and The Dialogue Seminar Method) might spawn the kind of ongoing
reflexivity promoted by the likes of Michael Power (see above), an organisational sensitivity
towards what make certain practices effective and legitimate not necessarily because they
have been successful in achieving goals, or getting good credentials by external review teams.
Initiatives such as this may also countervail the risk that formal education do not cover the
actual needs of today when it comes to learning and knowledge development. It is no doubt a
challenge to many high-risk organisations, not to end up in compliancy, with a clear-cut focus
on error prevention rather than learning.
114
Hutchins, D. (2008): p. 195.
See Berglund, J. & Friberg, N. (2012): Paradox inom kunskapssamhället – om erfarenheter från svensk
kärnkraftsindustri.
115
Extensive formalisation creates other risks, in terms of long-term consequences, not what will
happen toworrow. So when we talk of a Japanisation of working life in recent decades, are
we then witnessing a revival of Taylorism and Fordism in disguise? After World War II the
concept of scientific management was a strong influence on Japanese management theory.
Many enterprises inherited the basic ideas of Taylorism and Fordism. In the 1960s and
onwards this was supplemented by the introduction of Quality Circles and other small group
improvement activities, promoting a higher level of co-operation, empowerment and greater
involvment among workers in various parts of the organisation. Instead of continuing along
the lines of the Taylor system of management by specialists, where some do the necessary
thinking, that is to formulate work standards and procedures, whereas others simply do what
what they are prescribed to do, many companies were looking to strengthen their existing
organisations by engaging more members of staff in problem solving, and quality control,
creating a cooperative environment, which had a strong influence on Japanese management
literature and vice versa.116
As Japanese companies became market-leading within many sectors of industry, there has
been an increasing interest in their work methods, ideas, and principles of management. But
few Western approaches to Lean Manfacturing and Total Quality Management seem to have
recognised the importance of Quality Circles, or Self-Managed Workgroups, vital to the
continuous improvements and success stories of corporations like Toyota.117 In other words,
many Western Quality gurus and consultency agencies have made selective use of Japanese
experience:
it is necessary to establish systems and procedures for each department or function
throughout the organisation: a system for quality control, production control,
inventory control, budgetary control and so on. Many UK and Western companies
have been particularly good at this, probably as good as anyone in the world. But
systems do not motivate people and it is the management of people which has
presented the most problems.118
From a point of view of the supervisory agencies, an ideal situation would be to strive for an
equal relationship with their counterparts of the Nuclear Power Industry, on the basis of
dialogue. Arguably, there is as much risk involved for organisations to uncritically obey as to
Hutchins, D. (2008): pp. 215-216. See also Stewart, J. R., ”The Work Ethic, Luddities and Taylorism in
Japanese management literature”. Industrial Management, Nov 1, 1992, pp. 23-26.
117
Hutchins, D. (2008): p. 144f.
118
Ibid., p. 194.
116
discard any sort of external criticism.119 In Sweden, there is little prescribed when it comes to
safety culture, from the SSM, except for that the organisation must create fruitful conditions
as to the maintenance of safety and reliability. In the case of Japan, and the events leadning up
to accident at Fukushima Daiichi, the NAIIC claims that the Japanese Nuclear and Industrial
Safety Agency (NISA) were in cahoots with the Tokyo Electric Power Company (TEPCO), in
drawing a veil over the need for certain reinforcements. Although both parts were aware of
the risk of a station blackout (SBO) due to a tsunami larger than predicted in the estimations
of the Japan Society of Civil Engineers, nothing was done because “the probability was small
and other measures were in place”.120
Rather than demanding the implementation of structural reinforcements, the NAIIC blaims
NISA for stating that actions should be taken autonomously by operatives, and TEPCO for
not completing such reinforcement. According the NAIIC, NISA also asked the operators to
write a report on this matter, why the consideration of a possible station blackout was
unnecessary. Regulators also had a “negative attitude toward the importation of new advances
in knowledge and technology from overseas”.121 This, in turn, is assumed to reflect the
insularity of Japanese culture; while the accident at Chernobyl in 1986 can be traced back to
the deterioration of the Soviet Union and its varieties of Taylorism, some of the root causes of
the Fukushima catastrophe seem to be a result of the emergence of a culture of compliancy.
Ongoing reflexivity seems to have been missing in the safety culture of Fukushima Daiichi,
alongside a constructive amount of critical thinking. In this case the relationship between
regulatory agencies and industry were not so much equal as self-defeating. According to the
report, this was a partnership which ultimately mistoke the promotion of safety with the
promotion of nuclear energy, resulting in deficient disaster preparedness. As it was, no
regulations were created, and no protective step against the risk of core damage from tsunami,
in the interest of public safety, was taken:
From TEPCO’s perspective, new regulations would have interfered with plant
operations and weakened their stance in potential lawsuits. That was enough
motivation for TEPCO to aggressively oppose new safety regulations and draw out
negotiations with regulators via the Federation of Electric Power Companies (FEPC).
The regulators should have taken a strong position on behalf of the public, but failed
to do so. As they had firmly committed themselves to the idea that nuclear power
119
These arguments were developed at a seminar at the ABF association in Stockholm on the 11 th of April 2013,
on the safety of nuclear power plants in Sweden, arranged by the Swedish Society for Risk Sciences.
120
Kurokawa, K. et al. (2012): p. 16.
121
Ibid., p. 17.
plants were safe, they were reluctant to actively create new regulations. Further
exacerbating the problem was the fact that NISA was created as part of the Ministry of
Economy, Trade & Industry (METI), an organization that has been actively promoting
nuclear power.122
In other words, national supervisory authorities in Japan were previously not autonomous, and
neutral to commercial and political interests. The Commission also claims that TEPCO was
looking to avoid responsibility in blaming the accident on the highly improbable, the tsunami,
and not on the more predictable earthquake. Seemingly, they complied with the demands and
regulations of NISA, but ultimately failed to set their own standards of safety and quality.
Small group improvement-type activities have been used by competitive manufacturers to
find the “loose brick” in other companies that can give them an advantage in regard to their
competitors. In the nuclear industry the failure of one power station is also a loss of credibility
to other power plants. These activities can also be used to encourage all members of staff to
challenge the status quo of the organisation, to evaluate new benchmarks, to create a more
cooperative work environment, for employees to improve both as individuals and as teams.123
This has also been implemented within nuclear nuclear stations, like the Sellafield facility in
North West England, where Quality Circle-type activities have been used for many years.
Quality Circles have high status in countries like Japan. By discussing the context of
experience development, I have pointed to a wider significance in the use of small group
improvement activities, and further possibilities. What works in one organisation, or in one
country, may not necessarily work in another, and tsunamis are unlikely to pose a threat to
power stations in countries like Sweden. It is thus important that the quality work, and quality
program, of a specific organisation is in some sense unique, reflecting the “personality” of the
organisation and the people working there. The key numbers and indicators that are used to
follow up and evaluate the quality work of Swedish power plants also leave out aspects of
reality important to their actual functioning. Those approaches to supplementary training
discussed here, Quality Circle-type improvement activities, and the experience development
of the Dialogue Seminar methodology, provide opportunity for professionals to reflect, to
develop and improve their own work. But there are many traps, such as the uses of expensive
management consultants.124
122
Ibid., p. 17.
Hutchins, D. (2008): pp. 90-91.
124
Cf. ibid., pp. 7-11ff, and Göranzon, B., Hammarén M. & Ennals R., Eds. (2006): pp. 85-173ff.
123
A long-term development of skill provides a presence of the unexpected in every-day
practice, vital to the maintenance of a reliable safety culture. In high-risk organisations all
cannot be solved by instructions. There must still be a strong basis of practical proficiency, a
sense of individual responsibility, and a capacity for critical thinking. When it comes to safety
and quality, the addition of more rules is not enough. It can even be counterproductive.
9. Forward thinking
Leading up to the fateful accident at Fukushima Daiichi, two parallel movements can be
delineated in Japanese culture: Firstly, the introduction and implementation of Information
Society, an initiative in which all manual knowledge was to be formalised and computerised
by the year 2000, in part a response to the dominant role of the US at the time. Secondly, the
emergence of Quality Circles in the 1960s onwards, and similar improvement-type activities,
engaging people in problem solving, and forward thinking. Built on Japanese tradition and its
respect for professional skill, this was a way of making manufacturers more competitive on
the global market, emphasising the role of continuous improvements. Given the deficit of
independent and critical thinking in Japanese culture, when it comes to the Nuclear Power
Industry, and safety work, it seems to have been less successful.
Given the results of the National Independent Investigation Commission (NAIIC), some of
the ingrained conventions of Japanese culture were being accentuated. The NAIIC report and
its critique of the safety culture and emergency preparedness in Japan must be taken into
account when evaluating future civil contingencies, in regard to the Nuclear Power Industry
as well as other areas where issues of safety culture are seminal. It will also be of interest to
see if this report can be traced back to the Japanese invention of Information Society, with its
emphasis on formalisation of work and education, in which the phenomena of functional
autism was high-lighted. Are the calamities of Fukushima likely to have a background in such
a context? From Chernobyl to Fukushima, have we come full circle, where formalisation has
replaced ambiguity, and a decadent style of management, to the point where it is becoming
counterproductive, a kind of illusion of safety and quality, as organisations are being
smothered by the sheer amount of guidelines, rules and instructions?
If we accept that a culture is created from the development of those qualities and faculties that
characterise a specific group of people, like an organisation, this will mean that we can also
learn from a culture, informally, building on the human potential for dialogue, co-operation
and analogical thinking. In a viable work culture, there are indirect qualities, which cannot be
replaced by enforced standardisation, or a system of control and auditing. Besides, if we
imagined that experience is something that can be transferred different individuals in between,
between generations or organisations, this pre-supposes insight into the fact that experiencebased knowledge becomes a new knowledge among those who receive it. The underlying
theme of formalising personal knowledge, from tacit to explicit, highlights a fundamental
weakness of Knowledge Management, also distinguished in Tayorism. Through reengineering and technological change, new varieties of Taylorism are reemerging within
various sectors of industry, as well as the public sector, bringing on cultural changes with
adverse implications to the development and maintenance of skill and practical proficiency.
This has implications for safety cultures as well as other areas of work, where there are less
and less opportunity for personal judgement.
If adults’ proficiency, similar to craftsmanship, is based on slow learning and on habit, there
will have to be opportunity for reflection, doubt and discovery. Due to extended
rationalisations of work, or enforced standardisation, the capacity among human professionals
to reflect can be reduced or impoverished, which is likely to have negative effects on the longterm maintenance and development of skill. As regards the training and further education of
the Nuclear Power Industry, there is a strong emphasis on formalisation and the management
of instructions. One way of transforming society, to confront and counterbalance current
trends and tendencies of significance, is via the educational system. Education is an important
part of a culture; it is influenced by culture, but it is also a means of channeling a culture. An
educational initiative that can confront some of the issues elaborated in this paper is the
Master of Skill and Technology at Linnaeus University, the foundation of which being the
Humanities and Theory of Knowledge, where experience-based knowledge can be explored
and illuminated. Within work place organisations, the emphasis of training and further
education can be a key factor in maintaining a balance between skill and formalisation, for
instance when introducing new technology into the work place, or facing the challenges of a
generation shift. Voluntary small group improvement activities, or reflection activities, can be
an important part of that texture, with a key role for dialogue and experience development.
Within high-risk industries there are debates on how to ensure that the learning that comes
through training can be effectively applied and utilised. The executives of nuclear power
plants want to be assured that the money spent on supplementary training and formal
education have its proper “effects”, and preferably they would like those effects to be
measurable, albeit executives may not themselves have the knowledge they require from
others. The converse also applies: Knowledge extracted from concrete situations, and from a
culture, informally, must be reflected upon and further developed. One way of achieving this
may be through engaging more members of staff in problem-solving and analysis, such as the
assessment of benchmarks; challenging the status quo of the organisation, and to identify
areas and activities of work in which human capacities can be more fully engaged. In that case
recommendations and areas of improvment from the likes of the World Association of
Nuclear Operators (WANO) would not so much be a push for formalisation, but a provider of
tasks and puzzles to be evaluated and further developed by self-managed groups of plant
personnel, or other members of staff, informed by current practice. Besides, this is likely to
reduce the risk of modifications merely becoming quick fixes as to delight executives,
supervisory agencies, or other outside observers; manifesting itself in conflicts between
learning to know and learning to display knowledge for evaluation. The concept of
Knowledge Management can be rejuvenated by providing opportunity for dialogue and
reflection, orientated towards evaluation rather than control, in contrast to the codification and
disseminaton of knowledge promoted in the kind of management strategies currently regarded
as industry best practice.
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