1. Introduction
The nuclear industry and the US Nuclear RegulatoryCommission (NRC) explicitly recognized the importanceof management and organizational factors to nuclear facilitysafety in the aftermath of the accident at Three Mile Island(TMI) Unit 2. Following the Chernobyl accident, the Inter-national Nuclear Safety Advisory Group (INSAG) intro-duced the term `safety culture' to denote the managementand organization factors that are important to safety [1].Although INSAG intends `safety culture' to capture all themanagement and organizational factors relevant to safeplant operation, many investigators use the term morenarrowly. `Safety culture' is often used to denote an elementof organizational culture, that, in turn, is a component of thebroader term `management and organizational factors.'Although major accidents often involve an unsafe act (orfailure to act) by an individual, they may also involve condi-tions created by an organization that can magnify the conse-quences. The NRC's investigation of the accident at TMIreported to the Commissioners and the public that, The onetheme that runs through the conclusions we have reached isthat the principal deciencies in commercial reactor safety today are not hardware problems, they are managementproblems [2]. Later the report stated, The NRC, for itspart, has virtually ignored the critical areas of operatortraining, human factors engineering, utility managementand technical qualications. That sentence captures thebasis for much of the NRC's regulatory agenda in theyears following the accident, as well as the industry'sagenda to improve plant operations.The NRC's post-TMI action plan included a large numberof issues under the general heading of human factors. Themajor categories included operator qualications andtraining, stafng levels and working conditions, the man±machine interface, emergency operating procedures, humanreliability, and organizational and management effective-ness.Independent of the initiatives that the NRC undertook, theindustry saw a need to improve the quality of nuclear opera-tions. The Institute of Nuclear Power Operations wasestablished by the electric utilities that owned and operatednuclear power plants to foster excellence in plantoperations.Condence in facility management and human per-formance within the international nuclear power communitywas severely damaged by the Chernobyl accident in 1986.In its report of the Chernobyl post-accident review meeting[1], INSAG stated that, The vital conclusion drawn is theimportance of placing complete authority and responsibilityfor the safety of the plant on a senior member of the operational staff of the plant. Formal procedures, properlyreviewed and approved, must be supplemented by thecreation and maintenance of a `nuclear safety culture.
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