Safety management and organisatorial learning (MANOR): MANOR summary report

Nuclear power plants are complex socio-technical systems. In addition to complexity of technology, overall system complexity arises from the organizing of work, standard operating procedures, decision-making routines and daily work practices. Work is specialised, meaning that tasks require special know-how which takes long to acquire. The chain of operations involves many different parties and technical fields. The daily work in is increasingly carried out through various technologies, information systems and electronic tools. This has led to decrease in craftwork where people were able to immediately see the results of their work. In addition to inherent complexity, different kinds of internal and external changes bring new challenges for safety management. For example, organizations keep introducing new technology and upgrading or replacing old technology. Technological changes influence the social aspects of work, such as information flow, collaboration and power structures. Different kinds of business arrangements, such as mergers, outsourcing or privatisation, also have a heavy impact on social matters and culture. The exact nature of the impact is often difficult to anticipate and the safety consequences of organizational changes are challenging to manage [8]. Due to the complexities of the system the boundaries of safe activity are becoming harder and harder to perceive. At the same time economic pressures and strive for efficiency push organizations to operate closer to the boundaries and shrink unnecessary slack. Over time, organizations can drift into failure [2]. In the recent years safety researchers have started to develop new approaches for analysing and supporting human and organizational reliability and the overall safety of the system. The current state-of-the-art safety science strives towards more realistic and comprehensive view on organizational activity. Humans are not only sources of failures, but also the creators of safety and reliability, as well as the guardians and last line of defence against the unruly technology. Sociotechnical systems have their own internal logics of functioning, which must be understood if safety is sought to be managed and a sound safety culture created. The understanding of the dynamics of the sociotechnical system is the key to understanding system safety.