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No Failure to Communicate

Of course, an aircraft carrier is a unique situation, and there is no reason to think that what works there would be effective in a commercial setting with civilian employees. But when the Berkeley project examined a completely different sort of high-reliability organization, the researchers tracked its success to a similar set of principles.

The Diablo Canyon nuclear power plant, operated by Pacific Gas & Electric, lies just west of San Luis Obispo, Calif., on the Pacific coast. Although its construction was dogged by controversy and ended up taking 17 years and costing $5.8 billion, the plant has by all accounts proved to be one of the country’s best run and safest since it opened in 1985.

Like the aircraft carriers, Diablo Canyon appears at first to be a rigidly run hierarchy, with a formal chain of command leading up to a plant manager who is also a vice president of Pacific Gas & Electric. And it has a thick stack-a tower, really-of regulations telling employees how to do their jobs. This is how the regulators want it. Since Three Mile Island, the Nuclear Regulatory Commission has tried to ensure safety by insisting that nuclear plants follow an even more detailed set of rules. Plants are rated according to how many times they violate the regulations, and a pattern of violations will lead to closer supervision by the NRC and fines that, in serious cases, can run into hundreds of thousands of dollars.

But Paul Schulman, a political scientist at Mills College in Oakland who has collaborated with La Porte, Roberts, and Rochlin, has found that Diablo Canyon has another side-a more active, probing, learning side. Despite the hierarchy and the regulations, the organization is constantly changing, questioning accepted practice and looking for ways to do things better. It is not the same sort of change found on aircraft carriers, where the steady turnover of personnel creates a cycle of learning the same things over and over again plus a gradual improvement of technique. Diablo Canyon maintains a relatively stable group of employees who know their jobs well. Nonetheless, the nuclear plant is as dynamic as the carrier.

The reason, Schulman says, is that the plant has cultivated an institutional culture rooted in the conviction that nuclear plants will always surprise you. The result is two sets of decision-making procedures at the plant. The first, and more visible, consists of well-established rules for what to do in a particular situation. Some are carried out by computer, others by people. In general, Schulman says, this set of rules is designed to guard against errors of omission-people not doing something that they should.

But Diablo Canyon employees also work hard to avoid errors of commission-actions that have unexpected consequences. Because a nuclear plant is so complex, employees must constantly think about what they’re doing to avoid causing the system to do something unexpected and possibly dangerous.

This means that although the plant is constantly adding to its standard procedures as people learn more about the right approaches and spot new ways that things might go wrong, no one believes the organization will ever be able to write everything down in a book. Thus the plant management chooses employees partly on the basis of how well they will fit into such a flexible, learning-oriented culture. The least desirable employee, Schulman reports, is one who is too confident or stubborn.

This sort of continuous learning and improvement would not be possible if the Diablo Canyon organization were strictly hierarchical. Hierarchies may work for systems that are “decomposable”-that is, that can be broken into autonomous units-but a nuclear plant is, by its nature, tightly coupled. A modification to the steam generators can have implications for the reactor, or a change in maintenance procedures may affect how the system responds to the human operators. Because of this interdependence, the various departments in the plant must communicate and cooperate with one another directly, not through bureaucratic channels.

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