 I think let us get it started now. The next presentation from me is about enhancing safety culture through organizational learning. In the previous session, Peter was talking about the safety culture. And we had seen a lot of principles, safety culture is a culture which is evolving in an organization if we follow certain principles. So some of the principles he was telling like people or the trust permeates the organization. You know everybody is accountable for nuclear safety. So like that there are several principles which support a good safety culture in a nuclear organization. And there are many good documents available about safety culture. And those principles you can see from those good documents. But each of these principles are supported by several attributes. If we see these attributes in an organization we say that that particular principle is well maintained or well established in those organizations. So in my presentation what I am going to talk about is how organizational learning is helping to promote nuclear safety or rather performance in an organization. So organizational learning is one of the important principles if it is embraced in an organization can derive significant benefits for promoting safety culture and safety performance in an organization. And if you look here there are four points that are given four attributes. If these four attributes are present in an organization we can say that that organization has a good organizational learning. It has seriously taken organizational learning into picture and they wanted to improve. The first one is the organization values operating experience. They give good importance to operating experience that's coming from their own organization. That's coming from the fleet of their organization and from external to those organizations. And the important thing is the underlying lessons learned from significant industry and station events are used effectively to improve performance. What does it mean? What does it mean they use operating experience? They need to identify the underlying causes behind those events whether it is a significant big event or a minor event. What are those underlying causes and what are the lessons that can be learned from those events and how that can be incorporated into the organizational processes and programs. The third one is there are established processes to identify, resolve and improve from latent organizational weaknesses. You will come across several organizational weaknesses, latent weaknesses as you progress through the nuclear power program and how they are going to be captured, how they are going to be analyzed and how the results are going to be implemented for successful performance improvement. And finally, how the organization cultivates a continuous learning environment. If these four attributes are present in any organization, we would say that it has a good organizational learning. So in this presentation, I'm trying to give you two examples. We are going to see how two examples of an event that happened in the industry and how they analyzed, how they identified the causes and how they learned the lessons just to give an idea that how industry is using the operating experience to learn, learn these, learn from these events. It's not going to be that easy to understand the whole scenario behind these events, but don't bother about it. I'm trying, I will try to make it as simple as possible for you to understand the important aspects of the event evolution. And finally, you will be able to appreciate the, how they arrived at the causes and the contributors for this event. So the first example is about a reactor's cram and safety injection caused by human errors during a maintenance activity. This happened in one of the PWR units. And the task is a very simple task. They were trying to measure a voltage across a safety system battery. There are safety systems used in the, you know, in a nuclear power station for many purposes. One of the maintenance requirement is to periodically test the voltage across those terminals to make sure that those batteries are having the, you know, the remaining life or required performance standards. A simple system, they use a multimeter, typically if you see a simple meter, two terminals put it on the battery and see how much voltage. Very simple task. The lead technician was giving direction. There are four people in this scenario, two lead technicians and two trainee technicians. The lead technician was giving directions and the trainee technician was actually performing the task. And the trainee technician connected the terminals to the multimeter terminals to the rectifier. The rectifier is the, a component associated with the battery. And after this, they saw loss of power supply to the safety related switch board. The entire switch board lost power supply after just connecting these two terminals to the, to the rectifier. And followed by that, there was a automatic reactor scram, the turbine trips and the station loses the 400 kilovolt power supply, electrical power supply. The reactor coolant pumps, which circulates water to the reactor coolant, also trips after this. Immediately seeing that the loss of power supply to the safety system switch board, the technician resets the power supply to the switch board. There is a, you know, there will be a circuit breaker which trips the power supply. The technician immediately tries to reset it. And he, when he resets, safety injection actuates. At the press, the next, what happens is the primary system relief wall opens several times and a diaphragm and a relief tank ruptures. The entire thing calls for 12 days of shutdown to investigate and normalize the plant. So I will go in detail about how this event happened in more detail. But before that, I give a little understanding about the electrical system of a station. Then only you will be able to understand the, this event. In a nuclear power station, we have different classes of power supply. This is the, you know, the high voltage power supply, the 6.6 kV. This is normally derived from the grid. The station transformer supplies or the grid supplies this power supply. We would say this is the least reliable power supply available in the station. Normally the reactor coolant pumps, the heavy loads in the system, non-safety loads are driven by this power supply. So you can see this also has a backup. It has, it can be fed from the station generator or it can be fed from the grid or it can be fed from the another safety source. Next we have, next level we have as, you know, the diesel generators, the blue ones here once. Here another diesel, two diesel generators. They supply power to this, this, you know, the switch board or the bus. We call it a bus. And these are normally fed by the grid. If the grid power supply fails, the diesel generators come online and they feed the power supply to this. We say this is an emergency power supply, much more reliable than this power supply. The next level, the highest level is, you know, the DC power supply system, 48 volt DC, some industry uses 110 volts, but generally a DC power supply is used for control and protection purposes. You know, in a nuclear power station we have several critical control functions, several critical reactor protection functions. All those protection and safety functions are controlled by, I mean, provided by power supply from this source. And they normally take power supply from the grid. The diesel generator feeds it when there is no power supply here. And even if the diesel generator fails, there is a battery backup here. The batteries are designed to provide for sufficient number of times so that the plant is brought to a safe shutdown state. So in this particular scenario, the maintenance technicians are working on this battery. They're trying to measure a voltage across these batteries and find out if they're healthy or not. So it's just a five-minute check they're going to do. Now let's see in detail what happened in detail little bit. Unit was operating at full power. It's a periodic test, means once in three months or once in six months, means it's a routine job. It's not a new job or anything, the people are used to this job. And on a 48 volt DC power system, as per procedure, normally they measure the voltage across the battery terminals. But in this case, contrary to the procedure, voltage measurement was performed on the energized rectifier. If I go back to the picture, you can see they're supposed to measure the voltage here, but they choose to measure in this rectifier because it's same. If you measure the voltage here or if you measure the voltage here, it's one and the same. It's correct. But the procedure calls were measuring it on the battery terminals, but these guys were doing it on the rectifier. We'll see what's the consequence of it later. Then as I told you, there were four people, two lead technicians and two trainee technicians. So the trainee technician was performing the job and the lead technician was giving the directions. So the lead technician asked him a question, but the trainee thought it's an order for him to execute. You remember, he's asking a question, but the trainee misinterprets or misunderstands that it's a direction for him to perform. The question is, what will happen if you put this multimeter into the current mode and measure? You know, this small meter which is used for measuring voltage, it has several buttons. You can measure voltage, you can measure current, you can measure resistance. So these guys are going to measure voltage, but if you put it in the current mode, what happens? He was asking a question. So he thought it's an order, put it in the current mode and measure. So what he does is he puts it in current mode and then attaches to the rectifier terminal. So it's little electrical, don't bother about it. If you put it on the current mode, it actually short circuits the two terminals of the battery. Don't do it anywhere in a high voltage battery, it's harmful. There are several incidents that happen. If you wrongly put it in the current mode and measure the voltage, it short circuits and then the protection trips the power supply to the circuit. This is what has happened on the day the power supply caused a short circuit and resulted in normal power supply to the switch board was lost. The people are immediately they realized it's a mistake they have done. So what has happened is the battery power supply lost for an unknown reason. There is a battery which is backing up because now this the electrical, you know, the rectifier trip and there is a battery backup, that is also stopped for an unknown reason. So there is a complete loss of power supply of the safety related 48 volt DC switch board. So the total power supply is lost. And this caused the following, automatic reactor scram, opening of the strip down transformer circuit breakers. Because I told you this DC power supply controls and protects many functions. It feeds power supply to many things. So because they all lost power supply, we lost the 400 kV power supply. And there is a normal pressurizer spray is also lost. That means the pressurizer spray means it's used for putting a spray into the pressurizer and then reduce the pressure of the system. You add more spray, the pressure comes down. So you lose control on maintaining the pressure in the primary system. And the last one is loss of CVCS let down system. It's a controlled volume system. It allows some amount of water being taken from the primary system to maintain purification and to maintain the chemistry and also to maintain the pressure. So once this is lost, you again lose the function of maintaining the pressure in the primary system. So a simple event of just measuring a voltage across two terminals. Imagine it has resulted into a significant problem for the operators. But the maintenance team is not aware. The maintenance guys are working in a different area from the, they're disconnected from the control room. They're working in a different place. They are not aware that the reactor had scram. They are not knowing that there is a loss of 48 volt supply and that has caused all these problems to the plant. So they started re-energizing the switch here. They started resetting the switch here and started closing it back. Because they know that because they put it on the wrong side. That's why it got tripped. So you want to reset it. But when you reset it, this is the, you know, you can look at the picture here. The work area is like this. This is the rectifier on which they work. And these are the two circuit breakers which are providing the power supply from the rectifier and to the rectifier. So they trip, so they're very nearby. But there is a red label there, you can see red warning that says that if you reset this breaker, there is a chance for emergency injection or the what do you call that in a water injection into the reactor is possible. That's what is written there. But they did not realize this. They just went for resetting it. And then as a result of that safety injection, CVC has let down line closed, primary pressure increased. Don't bother about it, why it happened. These are all the consequences. And the pressure is a relief valve open several times because the pressure is increasing because you're not able to maintain the pressure in the primary system, the relief valve open several times. And because of that, one of the two diaphragms and the relief rupture tank, relief pressure tank. There is a pressure vessel on which all these relief water goes. And that tank pressure is increasing because of that the rupture disc failed. And finally it resulted in 12 days of outage for even the investigation and rectification and coming back. So what do you think are the main causes of this event in your own opinion? If you are, I just explained to you what has really happened. Using your own judgment, can you tell what are the probable causes for this event? Pardon? Human error? Yeah, good human, human error. Communication gaps? Communication gaps? Can you be more specific? What is, where is the communication gap here? Yeah, okay. Pardon me? Very good. Procedure is not followed or I mean rather going out of procedure, yeah? And control room, yeah? Of course, we do not know what was the communication, it could be. Need to? Need to be trained well. Need to be trained well, okay. What's the training because it's just measuring, it's over? Yeah, but then you mean to say the lead technician is aware. He was just asking him a question, what would happen? Yeah, he was trying to teach him, actually. But then he misunderstood, the problem is not lack of training. The trainee technician is trying to do the job under the control of the lead technician. The lead technician is very smart. He knows if he puts it on current mode, it's going to trip. But he was asking a question to him, if I put it on current mode, what would happen? But the trainee misunderstands it as an order and then he does it. So it's not a problem with training, it's a problem with communication, as somebody said. He understood the communication in a wrong way. That's what I would put it, okay? Like, yeah, it's a good point, actually. It's one of the things. They reset it without communicating with control room. Do they have authority to reset the safety system breaker without knowing what exactly happened in control room? Does he have authorization to do that? He is authorized to do maintenance. Is he authorized to do this work? That's a good point. I think a lot of inputs you have already told most of the things. But one of the most important thing is lack of risk assessment. If you look at the morning lecture which Peter was talking about in a nuclear industry, there are activities, you know, how do you, the risk has got two factors, you told. One is the consequence or the other one is the probability. In this case, the probability of error is very, very less. It's a very simple event. But the consequence is very high because he's working on a safety system. But did they do a proper risk assessment on this activity? Did this job receive the attention that deserved received in a nuclear power plant? That are the question. We'll see it in more detail in the next slides. The next one is a distracting environment. I mean, distracting environment in the sense you answered it in a different way. There were four people. Why do they need four people in such an activity? You just need measurement and then two people are good enough. When you have too many people in activity, there is chances of distraction. Two guys would be talking and two guys would be doing and they may not be knowing what's happening around. You know, that's one of the reasons when they analyze, they identify human error reduction tools. You said that already there is a human error. Why did human error happen? They were not using any human error reduction tools. I will get into that little bit in detail in my next slides. So let's look at lack of risk assessment. The test was conceived by the station as a low risk activity. They didn't think that it's a, it's just measuring a terminal voltage. They were looking at it. They were not looking at the consequences. And no pre-job briefing and contingency plan was in picture. You know, what is a pre-job briefing? Any of you are aware of a pre-job briefing typically done in a nuclear industry? Any idea? Pre-job briefing is before an activity is started. All these stakeholders, all the people who are involved in the job meet together for about five minutes, 10 minutes, depending on the intensity of the activity. And then they discuss on two things. What is to be achieved? What is to be avoided? Or what is to be accomplished? And what is to be avoided? And what are the error likely situations that can happen here? In this activity, there is an operation team. There is an maintenance team, electrical maintenance team. Two teams are involved. Did they talk to each other? No. Was there a pre-job brief? No. If only they talked, they told the control room that I'm going to work on this. If it trips, what should I do? Yeah, it would lead to a safety injection and you should not reset it, right? This information was known to them. Probably this event would not have happened. Industry has a practice of pre-job briefing and having a contingency plan. If something goes wrong, what we should do on that? Deviating procedure, somebody told yes. The procedure calls for measuring it at the battery terminals, but then they measured it at the rectifier, maybe for convenience or ease of doing or something. But then that had an element of problem for this event. Oh, sorry. Performing voltage measurement in wrong location. Posted warning sign was ignored. We know that. Distracting environment. Four people, instead of two peoples. They were trying to conduct a shadow training. They're trying to make them get trained into this job. But then you can do them shadow training, but you cannot involve them in doing it. And if you do it in a way that you want to train them, their role should be very clear. So unclear roles and responsibilities of lead technicians, workers and trainees, these are the contributing factors under distracting environment. Finally, the human error prevention tools not used. No pre-job brief, which we have seen. Procedure adherence, procedure was calling for measuring in the terminals of the battery, but they did it in another way. There was no procedure adherence. There was no three-way communication. You know what is three-way communication? We were talking about communications. Three-way communication or repeat-back communication, which is very well used in the aircraft industry and the nuclear industry. It's a very good communication tool. Repeat-back is like, if I want to say something to you, say for example, I'm talking to a doctor on an emergency situation. I want to know his phone number or clinic address. I ask him, what is the address? He says, x, y, z, so on and so forth. Then I repeat and then tell him, is it x, y, z? Then he says, yes. So I send the communication. He sends the communication, I acknowledge it, and then he confirms it, three ways. So a nuclear power plant, the good practice is that people follow repeat-back communication or three-way communication to make sure that we understand it correctly. If only the lead technician used a three-way communication to the trainee technician, probably you would not have understood the question as a wrong one. Does it make sense to you? There is something called self-checking and time-out when sure. And I will not go into that. It's too much. Some of the self-checking is checking ourselves, making sure that I'm everything what I'm doing is correct, coming out of all my daydreams and other activities and making sure that I'm on the right place, I'm on the right equipment before I start doing it. Industry typically calls star, stop, think, act, review. So we'll not go into that. And another one is the time-out and ensure. Whenever you are not sure, take some time, think and then act. Don't be in a hurried manner, don't do anything. In this case, if you see when the power supply was lost, he was immediately hurrying to reset it. He wanted to restore the power supply without knowing what would be the consequence of resetting it. If only he had taken a time-out and then consulted the control room, what would happen if I reset this? Probably safety injection would not have taken place. So what are the contributing causes? There are weaknesses in nuclear safety culture. You can see it's not using human error prevention tools. Acting outside of normal, I mean operating equipment in recovery attempt without approval of operators. He was operating in equipment which is not under his domain. And lack of situational awareness and insufficient questioning attitude. Nobody was questioning. Morning we started questioning attitude is very important for nuclear safety culture. People are not challenging the actions of each other. Operating experience, very important for the topic on which we are discussing. There are several fleet experiences because there is no time, I'm not listing them. I can at least list some 10 to 15 events which had happened before this event had actually happened. And they were not aware or they were not using this operating experience. Similar events which doing such battery maintenance and they had loss of power supplies. It was not used correctly. And there was no common cause review. They were not doing a common cause analysis why it had happened. Lessons learned. Briefly, we'll see what are the lessons learned from this. Reinforce compliance with maintenance procedures, rigorous and timely methods for procedure revision including risk assessment for change requests should be in place. This is one of the recommendations after the incident they followed. Define clearly role and responsibility of maintenance workers, lead technicians and supervisors. Systematically use human performance error reduction tools during maintenance work. Take timeouts when facing unexpected situation before taking any action. And have safety culture as one part of maintenance fundamentals in a continuous way for an effective line of defense. And they review the risk of electrical work on safety related power supplies. The last one during risk assessment consider potential human errors. These are the lessons they learned from one. There is another one. Make sure what supervisor and line manager have sufficient knowledge of operational risk of the component and system they work on. Probably the supervisor or the lead person who was working, he was not having a good idea about operational risk. What would happen if I do? That's also possible. And lastly, the review and reinforce more rigorous evaluation of industry and fleet operating experience for applicability because they did not consider several incidents or events that had happened in the industry. So now they wanted to consider them. Why is this event important to us? This is a complicated event resulted from human errors that demonstrated weaknesses in nuclear safety culture. Operators were unaware why abnormal events were occurring. Impulsive non-violated actions were taken without considering the possible consequences before attempting corrective actions to reenergize the switchboard. What is, while this event occurred at a pressurized water reactor, do you think is it applicable only for pressurized water reactor? It's equally applicable to all type of reactors because the power supply system, the electrical systems are more or less similar in all type of designs. They all have a battery-powered emergency supply system. So this event can be used by almost all the units as an operating experience. So this even highlights the importance of a healthy nuclear safety culture at all levels of plant works and the need for rigorous and consistent use of human error reduction tools. That's about the first event. If you have any questions or anything you want to understand about the first event or you want to add something to the first event before we go into the second one, no? Okay, yeah. What is pre-briefing, you want to know? I think I will talk about that in the lunch break or something to you, maybe because of time I wanted to, it can be, I can tell you a little more elaborately what's a pre-job briefing, how is it done? That would be good. Okay, I move on to, yeah. Very good comment, excellent. In fact, industry uses such instruments for such critical applications. The instrument has no provision to selection. You block them, you make it only available for, in fact, I have no time, I can share in my own plan we had an incident in which one fellow lost two of his eyes. He was measuring a, in a battery directly he was maintaining, the battery has an acid, hydrochloric acid, he was measuring the voltage, and then the hydrogen gas is produced when the battery is charging and discharging. So the short circuit exploded the battery and the impact part into the glass. I think he lost one nigh or part of one nigh or something. Based on that, industry has learned that to block it whenever you measure a voltage on high capacity batteries they always use only the voltage mode. Thanks for the comment, yeah? Yeah, you see, when you are analyzing an event sometimes it's not possible to find the causes. That's the reason it's written unknown reason. When it's not so easy, an event has happened, you're trying to analyze it, why it has happened, how it has happened. There are thousands of interactions of components and you look at many, many event scenarios and then try to find out the causes. Based on this event, they could not establish a cause for why the battery also lost its power supply, failed to provide the cause. Now the second event, it's about inadvertent draining from the reactor vessel while at mid-loop conditions. I mean, it's a, you know, the reactor vessels, you know, which you have seen a pressure, the RPV or a reactor pressure vessel, the fuel is inside. In a refailing shutdown, they open the top cover for taking out part of the fuel and putting new fuel. And during the time, they also, you know, this is the reactor pressure vessel. They take out the cover, top cover and the fuel, the entire thing is flooded with water and then they take out the fuel assemblies partly and then put new fuel assemblies. Okay, the water level will be maintained somewhere here. And these are the two connections which connect to the circulating pump and the steam generator and the pressurizer. There are two connections, there are no valves here. So if I want to work on this pump, let's say I need to do some maintenance on the pump. So that means I need to drain water up to this. Otherwise, I'm not able to, I have no access. So what they do is typically lower the level in the vessel so that it allows maintenance here. It's a very critical activity. They monitor the level very carefully, but still it will be having a lot of margin. This picture is not very exact to the drawing. It's just showing, although only a few centimeters, there is more than a meter of a distance would be available. So this particular event when it happened, the plant was on refilling and it is on mid-loop operation. They were doing some maintenance on the steam generator or possibly on the pump. So I'll go back to. So the maintenance was being performed on a motor operated valve in the residual heat removal system. That means there is a, this is the main loop on the primary system. There is a residual heat removal system, which is safety system. Suppose these pumps and these heat exchangers are not available. You remove the heat by a residual heat removal system that takes connections from here somewhere. It takes water from here and puts back the water somewhere here through another system. So there are valves connected to this. So they are working on a valve which is attached here. You can imagine where the work is being done and when the reactor is on a mid-loop operation. Sorry. So the maintenance was being performed on a motor operated valve in RHR system. The maintenance is taking out the driver, the actuator, electric actuator, doing some replacements could be some bearings or replaced, gears are replaced and then they are putting it back in good condition. So the actuator was installed on the valve after completing the shop tests. You know, once you put back the actuator back into the valve, they need to set the limits, the open position and closed position. There are limit switches in the actuator. So they need to be set to the correct position to make sure that the valve is fully shared and fully open. So this can be done and actually you need to, in the field, you need to set it. So they were, the workers start beginning to stroking the valve to set the limit switches. At that time, control room observed there is a drop in pressure, reactor pressure was a level and about nine cubic meters of water was lost. Two field operators came to field for investigation and then again the level was restored by the gravity flow from a tank or from a low safety injection system. What's the consequence if the level goes below? Any idea? What would happen if the level goes further below? Pardon me? Yeah, that's good. You expose the core, the core can, the heat removal will get effective, very, very important. So this picture I put to make, give an explanation for that. So if you look at the reactor pressure vessel, this would be the connections. You can see the fuel, actually you can see the fuel and how those, you know, the connections are there. You can see good amount of distance is there between those connections. Even summary, in a little more detail, unit was at mid-loop operation. Maintenance was performed on a motor operated valve on the primary circuit, which is a first isolation valve. So first isolation valve means if this valve is open, chance of water to get out of the reactor pressure vessel. It was installed on the valve after the shop testing was completed. The work supervisor, there is a supervisor and technician. The technicians are performing and the supervisor is giving direction. He left the work area to call the main control room for permission to stroke the valve to set the limit switches. So we went to the phone to talk to the control room. I'm going to open or close this valve to set the limit switches. But before that, the contract workers, before the contract workers, before I mean began stroking the valve open to adjust the limit switches without permission from the supervisor of the control room. Before they could get the permission, the contract workers started stroking it and this action led to unexpected drop because the water was going out of the reactor vessel and the level dropped. The mid-loop level, special alarm actuated in control room and they immediately acted and they took some action to put back water into this. So this is how they restored the water back to the system. It's not important for us. What are the important aspects? What do you think in this situation, what went wrong here? Communication, obviously, control room to the plant without proper communication distorted, yes? Procedure, they didn't follow the procedure or rather a communication or procedure, okay? Let's go a little more deep. Risk assessment performed on outage maintenance work before the outage did not identify any task specific risk associated with the work on this one. Normally in a nuclear power station, they do outage planning six months or one year ahead. You know the refilling outage is hardly less than a month, three weeks or four weeks maximum. But the preparation and planning starts almost six months to one year ahead. So they list all activities, there will be thousands of activities done in an outage. So they do a risk assessment of each and every activity and then they sequence the activity in such a way that the risk is always maintained low. For example, you have three safety trains, nobody gives permission to work on all these three safety trains at a time. The boundary valves, for example, in this case a boundary valve, people look at it carefully, can I give a boundary valve maintenance when there is a refilling outage going on? So that did not identify this activity as a risk involved activity. And they have a nuclear power station, they have a work planning system. There are many, many works coming up. It's a computer controlled work management system. It tracks what are all the works issued. If a work is issued on a train A and it would not allow you to issue a job on train B and train C. So in this particular station, they have a computerized work planning system, but it's not integrated with the planned lockout tagging system. Tagging system means, when they take an equipment to a different position, a valve, say for example, a valve is closed and then it should not be open for isolation purposes. They give and kept it closed condition. They put a tag in there, a red tag or a caution tag. That is to make sure that nobody operates it and make sure that it gives you safety for working on a particular equipment. So the tagging system and the work planning system are not integrated. This means the person who is going to tag the system was not aware that already it's a boundary valve. If they are integrated, you would know that they are together and they would not have acted on that. But many stations have an integrated tagging and work management system. Yeah, this is important point. Contract specialists may be unfamiliar with planned systems and not aware of planned rules and administrative processes that must be followed to help ensure nuclear safety. This is one of the important causes. These contractors who are working on the valve, they are specialists on the valve. They know how to do the valve in a very perfect condition, but they do not know the consequence of opening a valve or closing a valve. What would happen if they opened this valve? They do not know the importance of nuclear safety. They did not have an appreciation for the consequences that would result. They are the same thing which I was telling you. The supervisor thought, he assumed. He assumed that the specialists understood they were not to proceed with the limit switch. He did not reinforce them. He did not tell them in a pre-job briefing or in a clear terms that you must not work without my permission. He assumed that they know they should not operate the valve. And also this is another important thing. Many times it really happens in nuclear power plant. You are on time pressure. This is the end of a maintenance schedule. You know, the eight hour period is going to get over. The guys are very much interested in finishing this work and go home. So he is in a hurry. So he knows that he's going to get permission. Let me start before by the time he gets permission, nothing is going to happen. Let me start. So the time pressure because it's a closing ship duty, that's another factor that has added to it. Why I'm listing all these things where you used to have an appreciation that how industry uses the information, the cost analysis, how depth they go to do the analysis. Because these are important for promoting nuclear safety. You can do a very shallow operating experience analysis that doesn't bring out underlying causes in any event. But if you do a very clear thorough analysis, you can bring out all the underlying causes in an event. At the time of the event, it was accepted practice that work was allowed and blocked valves as long as the valve remains shut. I mean, there are some industry guidance and expectations that if blocked valve in the sense, it's a first isolation valve of an isolation valve. The first isolation valve, you can do maintenance as per this particular station's expectation that you are allowed to work on the valve as long as it's remained shut. You are not opening it, but you have a risk on that. But some stations don't allow it. They have very clear guidelines. They have some extra conditions for that. Workers were allowed by the procedure to operate the valve as long as they had permission of the main control room staff, even though the red blocking tag remained attached to the valve. This is another important point. I told you there is a red tag attached. It says, do not operate the valve. But still the station expectation or station procedure allows them to operate the valve if they have permission from control room. So this gives you a little bit cushion for you to go towards unsafe situation. Pre-job briefing of the work crews prior to beginning important of our hazardous work were not routinely performed. They were not having an expectation that a pre-job briefing should be done for hazardous work or works which has potential for events. The corrective actions following the previous event were not effective. Previous experience, similar events were not followed up or not regressively implemented to improve the performance. What can we learn? Are our risk assessments are needed prior to authorizing outage work on reactor coolant systems or safety system components? Pre-job briefings could have helped work better understand conditions of the reactor coolant system and the valve that they are working on. If there was a pre-job briefing, it gives an opportunity for the supervisor to tell the contract workers, it's very important for nuclear safety. We should not operate the valve without control room permission and it could have prevented a near miss event. Yeah. Except for unique or unusual circumstances, dictated by system design, work should not be allowed on system boundaries. This is industry practice. Except, there are certain very rare exceptions in which they put lot of contingency measures. They put additional people to make sure that they don't operate it. Otherwise, industry doesn't allow people to work on boundary valves on critical systems. So clear rules must be established that provide guidance on how boundary isolation valves are identified and for the actions that planned workers and operators may perform. Yeah, that's about the two events. Now I go a little about how this can be used for improving safety culture or improving the performance. This is operating, learning from experience improves your performance. You know, as a small kids fall dozen times a year and as we grow old, we learn from our own mistakes and we don't do that. We learn from our own mistakes. Same way, most animals, most creatures in the world do the same thing. We learn from our own experience. But also, this is experienced or invented by some genius Pythagoras many, many years ago. We don't learn it from our own, you know, knowledge or our own efforts. We just use it from some part of the world. There are many inventions, many such inventions available from many places. We don't reinvent it, rather we inherit them. So if you try to use those experiences, your growth is going to be like this. If you're going to learn from your own experience, you will only reach this height. In our industry, people can learn from the following. In nuclear industry, people can learn from their own in-house experiences. There are many, many experiences in their own station and also they have a lot of external operating experience they can learn. It could be from decades ago or it could be recent ones. You told about three events this morning, Fukushima, you know, the Three Mile Island and Chernobyl. Also, we talked about the David Busse. There are many, many events, recent ones and old ones. They teach a lot of lessons. There are many things that can be learned to improve our performance. So this is a famous quote by somebody. He says, fools say that they learn by experience. I prefer to profit by others' experience. So you choose what you want to be. There is a famous law, Heinrich's law. Anybody is aware of this Heinrich's law? Probably you've seen this, but the name is not familiar. You know, when people analyzed the accidents or something happening in an industry, they have a relation with the reference to the minor events and near misses and unsafe practices. So if some event has to happen, it has a relationship with the minor events. It has a relationship with near misses. It has a relationship with unsafe work behaviors. So if you control this part, if I try to make this base much smaller, I can prevent an accident. That's the basic philosophy of this triangle. So let's see an example. It's very easy to explain a lifting and rigging example. A guy is hit by a load, a fatal accident could be one. There are broken hand and by load injury. If you see, before somebody dies due to a fatal accident, you can definitely see many minor injuries or loss of limb, the loss of other parts. And also there could be load drop. Fortunately, no injuries are damaged to the components. That's near miss. Actually a load is falling, but still nobody dies, no injuries. It's a near miss, we call it. Something similar to the previous event. But if you look at the worker behavior, there are several things, four or five things listed here. Deficiencies in worker skills, lack of pre-job briefing, workers entering under load, use of deteriorated rigs, inadequate communication. It could be many, many more. So if we focus on the bottom part of it and try to reduce that, we have a control on reducing the accident. That's what this Hendricks law is trying to say. The root cause is common for all of this. So how industry uses this? As I told you, we have a lot of in-house operating experience. We also have domestic operating experience. We also get overseas operating experience from IAEA, from Vano, from any vendor organizations. A lot of information is available. Industry organizations use this operating experience to reduce their base of this unsafe work behaviors. And also to reduce their near misses. They also learn from their own near miss incidents. And one other thing comes here is that they do a job observation, which I will come in my next slides. How can you identify these unsafe work behaviors? Unless people go to the field and then see what's really happening in the field, you will not be able to capture them. Many stations have a very good job observation or work observation programs. They systematically go to the field and see how workers' behaviors are there in the plan. They take note down and have a database and analyze it. Tens of thousands of information they analyze and then come to know that what behaviors will promote in safety and performance. This is the last part of my presentation, which will tell you how we can use the observation operating experience for improving performance or how rather industry uses it. So this is what typically an observation process in a nuclear power plant, where they use select an activity for observation and they conduct an observation. They also provide coaching to correct the, correct the reinforced bad behaviors. I mean, correct bad behaviors and reinforce good behaviors and input it in a database every time. Whenever whatever you see, this is most important unless you capture them in a database and analyze, you will miss all those, the value behind those information and analyze them periodically and then they will tell you an identity area for improvement. There is some potential for weakness in this area. We are finding a lot of people are not wearing hard hats in this operating area. You're finding a lot of people not using procedures while working in batteries. These are the information you will get from these observations and then you can revise your management expectations and processes to improve it. This is typically followed by industry to improve performance. So if you look at it here, we have in a station how work is done, there is a management expectation, what we want, how people to behave and the people are provided with training and experience. We provide them training because they need skills to do the job and the experience also gives them the ability to do a good work. And finally there are processes like procedure, mechanisms or work control processes or work management system. These are all called processes in the power station and they help them to implement the work in a systematic way. The process plus behavior finally gives you the result. You may have an excellent process, you have the best work control process or work instructions, tools, everything. But if the worker behaviors are not good, your results are going to be problematic. You need to have both right. If you have good worker behaviors, if you have a bad process, then also no use. If you have, you need to have both of them right. So this is one method of triple loop learning we call it. So what is happening is we are observing basically the training and experience of the people. You can find out when you observe a work, if there is a weakness in the training or experiences. You can also observe if there is a weakness in the process. You can also observe a weakness in their behavior. Most important is behavior. You're looking for behavior. You're also looking for process and training. So you take these observations and then giving a full feedback to make your management expectations changed or in a better way to make sure that the performance continuously improves. So this is done in a three levels. In the first level, it's called a coaching. You work on the coaching mode to improve performance. In the second level, you work to make better ideas. How can you develop better ideas to improve performance? And the third one is most important, wherein you generate what would affect the values and beliefs of the people. You can, that's most important. Let's briefly see what is it. In the first loop, you are observing the work. You are seeing a behavior. Let's say he's not wearing a helmet. He's not wearing a safety shoe. He's not following procedure. You correct them immediately. So it gives you some improvement, but the improvement is very incremental, very minor improvements, and it continues. So loop one helps, is useful in people achieving expected performance. You can achieve a performance what you expect. Examples, a worker use personal protective gear. Workers adhere to procedures. Workers self-check and peer-check actions and demonstrate a questioning attitude, procedures are revised and improved, et cetera. In the second loop, you are observing the, your observations are looking for a change in paradigms. You're not, you're not looking, you're looking for people are, people are following in the first loop. You are seeing people are not following safe practices. You're correcting those practices, but still the improvements are not substantial for you. You are not able to reduce the accidents. That means whatever you have achieved in the first loop is not good enough for improving your performance. Now you have to look for different ideas, change your paradigm. What else I can do for doing this, take it to your next higher level. That is what is the second loop, improve the process. Here we look at improving the process of the practices, not just the behaviors. So you get a greater change here. So loop two is an improvement path to use when continuing to do the same thing does not improve performance. So you look at, you know, there is a, you can improve the way you use procedures. Actually industry come up with, if you go to a nuclear industry, there are three categories of procedures. Procedures for continuous use, procedures for, you know, routine use. And the third one is for information use or something. The continuous use means activities which are very significant to the nuclear power plant, which has a safety potential. People have to have the procedure. Each step has to be read and then it has to be followed and then tick mark. You know, verbatim, it has to be followed. So these practices all came because of the loop two improvements. So I'll not go into that. One of the thing is the arc flash clatting. I would like to say that, you know, arc flash clothing. In an electrical equipment, when you work on a high voltage equipment, six KV or 220 KV high voltage equipments, there are, you know, 30 years, 40 years people, I mean, not even 30 years, 20 years ago, people used to have several burn injuries. People lost life when there is arc flashing when there is a short circuit in an electrical thing. It gives out the flash and then it burns the skin and many incidents were there. So industry invented an arc flash clothing and now there is no such incident. This is a shift in paradigm. They just wanted to, you know, earlier days they were just using all protections. They were using the gloves. They were following the procedures, but still people are getting burned because of this. So they thought industry invented a new thing called arc flash clothing. The third loop, the last one, this is most important, the third loop. When you want to make a significant improvement in the performance, we need to work on the third loop, which is going to affect the values and beliefs because this is affecting what the workers or the people of the nuclear power plant are thinking about an activity. So this is very difficult to do. It's not so easy to change my belief. I have certain belief. It's easy to change my belief. So industry leaders do some examples, actions to do this. For example, industry leaders created Vano to promote excellence in nuclear power plant operations. You know, Vano is a, I mean, previous speaker Peter was also talking about Vano and he was quoting about the nuclear safety principles from Vano. Vano was the organization founded in 1989. It was born because of Chernobyl accident. After the Chernobyl incident, they realized that there is not so much communication among the people around the world to promote safety and the performance of the nuclear power stations. Like INPO was formed, INPO is an Institute of Nuclear Power Operators in the US. It was founded after the three mile island accident. These are all big changes which affects the total industry a lot. So that is a big change. So Vano or INPO or such organizations, they promote safety and then take the safety level of the plant to a very high level. If you look at the safety of the plants 20 years or 30 years ago and what is today, there is a significant improvement and because of all these changes which have been contributed into the industry. Yeah, so finally, I mean, I just wanted to make a few conclusions that in a nuclear organization like a nuclear power plant, there will be a lot of opportunities to learn from internal and external operating experience in all phases of its life cycle. Though I was focusing my presentation only on an operating plant perspective, the examples, everything, there are plenty of opportunities when you are constructing, when you are commissioning or when you are decommissioning or doing any activity. So in every phase, you should have a mechanism to capture these operating experience and learn from those experiences. Effective implementation of an operating experience and a work observation program helps in significant improvement in safety and performance. There are many aspects of safety culture. There are many attributes for the safety culture but this is one of the most important one, the learning organization or how you use your own learning for improving performance. So if this is implemented, substantial improvement in safety culture can be achieved. So the last one is again, the repeat of the previous one in a different way. Ordinary men learn from his own mistakes and wise men learn from others' mistakes. So with that, I conclude my presentation and if you have any questions, I can take for few minutes, questions. Thank you very much. Thank you very much.