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Function and content of a safety management prospectus

T/AST/072 – Issue 1

Issue date:

12 May 2009

Review date:

12 May 2013

Open Government Status:

Fully Open

Approved by :

A N Hall

1 Purpose and scope

Policy

1.1  The primary responsibility for the safety of a nuclear installation rests with the licensee.  Before granting a nuclear site licence HSE must be satisfied that the licence applicant will have an adequate management structure, safety management arrangements and resources to discharge the obligations associated with operating a nuclear site.  It is HSE’s policy, promulgated in ‘The licensing of nuclear installations [190KB ’, that the licence applicant should submit a safety management prospectus (SMP) demonstrating those capabilities. Thus the SMP is a fundamental element of the licensing basis.

1.2  The licensee should be able to demonstrate continuing licensability throughout the lifecycle of the site. The coherent approach to safety management described in the SMP incorporating organisation, resources and management systems should remain visible to senior management and be reviewed from time to time and updated as necessary to reflect changing needs. A SMP would also need to be submitted as part of any application for relicensing an existing licensed site.

1.3  Comments on this guide, and suggestions for future revisions, should be made and recorded in accordance with Office for Nuclear Regulation's standard procedures. Comments made from outside ONR should be sent via ndenquiries@hse.gov.uk

Scope

1.4  For convenience the term ‘safety management prospectus’ has been used throughout this document.  However nuclear licensees’ responsibilities to people and society extend beyond nuclear safety, and the licence applicant may wish to adopt an integrated management approach, consistent with the expectations of IAEA (GS-R-3), to its business and the way in which safety, environment, security and safeguards are managed.  Indeed, HSE and EA have recognised that an integrated Management Prospectus is a strategic document that can be used to underpin the initial demonstration of a licensable and permissible organisation, and a statement to this effect will be placed on the HSE and EA websites.

Purpose

1.5  This Technical Assessment Guide (TAG) informs regulatory assessment of the safety management prospectus submitted by a licence applicant.  It sets out expectations of the use, role and remit of an SMP and these are reflected in the ‘elements’ set out in Section 4, ‘Advice to Inspectors’.  The relationship between the safety management prospectus, which sets the strategy, and the Nuclear Baseline describing the organisation, resource and competence aspects, is also addressed.

2 Relationship to licence and other relevant UK legislation, policy and guidance

The Management of Health and Safety at Work Regulations 1999 [2]:  These regulations describe employer’s responsibilities, addressing the requirements for control and co-operation with outside undertakings, together with appropriate arrangements for effective planning , organisation, control and monitoring and review. 

"Reg.5.  Health and safety arrangements

(1)  Every employer shall make and give effect to such arrangements as are appropriate, having regard to the nature of his activities and the size of his undertaking, for the effective planning, organisation, control, monitoring and review of the preventive and protective measures.

(2)  Where the employer employs five or more employees, he shall record the arrangements referred to in paragraph (1)."

Nuclear Site Licence Condition 14 – Safety Documentation:  HSE considers that the licensee’s arrangements for producing and assessing safety cases under LC14 should address organisational as well as technical factors.   Taken together the safety management prospectus and the Nuclear Baseline should demonstrate that the licensee (or applicant) has adequate management structures, capability and staffing levels to discharge the obligations connected with holding a Nuclear Site Licence.  They can therefore be regarded as major components of an "organisational safety case". 

T/AST/065 Function and Content of the Nuclear Baseline:  This TAG supports the philosophy and approach of the Safety Management Prospectus TAG. Both are written to address current needs and reflect the revised Safety Assessment Principles (SAPs).

T/AST/049 Use of Contractors and Intelligent Customer Capability:  This TAG addresses aspects of contractor selection, oversight and control including the Intelligent Customer capability.

T/AST/039 Management for Safety:  revised version in preparation

The Licensing of Nuclear Installations, 2007 [3]:  ‘The Licensing of nuclear installations’ includes (at para 2.18, page 17) a list of matters for inclusion in the safety management prospectus on Page 17.  This TAG provides a strategic framework for development of the SMP with regulatory expectations set in context.

3  Relationship to SAPs, WENRA Guidance and IAEA Safety Standards

3.1  Relevant SAPs

Fundamental principles
FP.1	Responsibility for safety		The prime responsibility for safety must rest with the person or organisation responsible for the facilities and activities that give rise to radiation
FP.2	Leadership and management for safety		Effective leadership and management for safety must be established and sustained in organisations concerned with, and facilities and activities that give rise to, radiation risks.
Leadership and management for safety
MS.1		Leadership	Directors, managers and leaders at all levels should focus the organisation on achieving and sustaining high standards of safety and on delivering the characteristics of a high reliability organisation.
MS.2		Capable organisation	The organisation should have the capability to secure and maintain the safety of its undertakings.
MS.3		Decision making	Decisions at all levels that affect safety should be rational, objective, transparent and prudent.
MS.4		Learning from experience	Lessons should be learned from internal and external sources to continually improve leadership, organisational capability, safety decision making and safety performance.

The Safety Assessment Principles are considered throughout this TAG as part of an integrated system for delivery.  They are relevant to various safety management prospectus elements; there is not a one to one correlation as by their nature there is some degree of overlap. Specific reference is made to the relevant SAP in this TAG where appropriate.

3.2  WENRA:  This TAG is consistent with the January 2008 publication of Reactor Safety Reference Levels; Issue [4] B which deals with organisational issues.  The following paragraphs are key WENRA points which are embodied in the concept of the safety management prospectus:

Para 1.1 addresses a justified organisation "The organisational structure for safe and reliable operation of the plant, and for ensuring an appropriate response in emergencies, shall be justified and documented."

Para 1.2 requires management of change: "The adequacy of the organisational structure, for its purposes according to 1.1, shall be assessed when organisational changes are made which might be significant for safety."

Para 3.1 states resource assessment for the organisational structure is needed. "The required number of staff for safe operation, and their competence, shall be analysed in a systematic and documented way".

Para 3.5  addresses employee/contractor resource balance: "The licensee shall always have in house, sufficient competent staff to understand the licensing basis of the plant (e.g. Safety Analysis Report or Safety Case and other documents based thereon), as well as to understand the actual design and operation of the plant in all plant states".

Para 3.6 addresses the intelligent customer role: "The licensee shall maintain, in house, sufficient and competent staff and resources to specify, set standards manage and evaluate safety work carried out by contractors".

3.3  IAEA Fundamental Safety Principles

Principle 1: Responsibility for safety
The prime responsibility for safety must rest with the person or organization responsible for facilities and activities that give rise to radiation risks.
This Principle cites the responsibility of the Licensee for safety throughout the lifecycle of a facility or activity. It affirms the Licensee’s responsibility for establishing and maintaining the right skills and competences.

Principle 3: Leadership and Management for Safety
Effective leadership and management for safety must be established and sustained in organizations concerned with, and facilities and activities that give rise to, radiation risks.

3.4  IAEA Safety Guide NS-G-2.4 "The Operating Organization for Nuclear Power Plants" includes some elements that are embodied in the Nuclear Baseline and safety management prospectus as a means of justifying and describing the organisation.

3.5  IAEA GS-R-3 The Management System for Facilities and Activities:  IAEA GS-R-3 has many links to issues addressed in the preparation and maintenance of an effective SMP: examples are reproduced in Annex 1 to this TAG.

4 Advice to Inspectors

4.1  Safety Management Prospectus Aims and Approach

4.1.1  The safety management prospectus plays an important part in the demonstration of a ‘licensable’ organisation.  It provides a strategic, overarching demonstration of how nuclear safety is managed within the organisation and shows how the management controls are appropriate and sufficient.  This will include showing how the direction and control of the organisation, and its management system and staffing arrangements, will ensure safety in the context of its activities and the nuclear  hazards to which they give rise.  It can thus be described as a fundamental element of "the safety case for nuclear safety management".

4.1.2  The SMP should be proportionate to, and reflect, the organisation’s work activities. It should state how policies and objectives enable work to be performed in a safe, efficient and effective manner. It should tell the ‘story’ of what the organisation does; the associated hazards and the way the organisation manages risk. It should not be merely a summary of safety management systems.

4.1.3  Although ONR expects a prospective licensee to produce an SMP as part of its licensing submission, the overall view of the way that organisation, resources and management system combine to manage safety as described in the SMP should remain visible and understood by the licensee and its Board throughout the life of the licensed site.  The elements addressed in the SMP may be located in different parts of the licensee’s management system and an established licensee may not wish to maintain a single SMP document which could, in effect, duplicate these elements.  The SMP may therefore include a route map to show where and how these different elements are managed and how they are maintained. 

Elements of a safety management prospectus

4.1.4  The format of the SMP is for each licence applicant to develop to best suit its needs but there should be a narrative thread covering the issues addressed above.  Hence the safety management prospectus is a strategic document which:

1. provides a clear description of the type of activities carried out on the licensed site(s) as a basis for showing how the safety management arrangements set out in the SMP are appropriate and proportionate to the specific hazards, risks and scale of operations; 
2. describes how the organisational structure meets the nuclear safety management needs of the business;
3. sets out the organisation’s approach to the governance of nuclear safety.  This requires high-level descriptions of the systems and processes for monitoring, directing and controlling activities;
4. provides the strategy for developing and maintaining a licensable organisation with suitable resources and competences to deliver nuclear safety;
5. outlines how a ‘learning organisation’ is fostered, showing how the organisation absorbs and responds to lessons both from within and outside the organisation.  The communication of safety information should also be addressed.
6. describes the organisation’s approach to managing change. 

These SMP ‘elements’ are expanded upon in the remainder of this TAG.

4.1.5  The Inspector should consider:

1. Does the SMP embrace the elements described in this TAG? 
2. Does the SMP adequately set out the organisation’s strategic approach, supported by evidence of implementation and signposts to the relevant detail in the management system?
3. Has the SMP been "signed off" by the Chief Executive of the licence applicant, and is there demonstrable awareness and understanding of its function and content?
4. Does the SMP merely reproduce policies and system architecture without evidence of how this works in practice?  (if so it will be little more than an index and will not help to show an effective approach to management for nuclear safety);
5. Taken as a whole, does the SMP adequately demonstrate the licensability of the organisation?

4.2  SMP Element 1 - Activities:  "The SMP should provide a clear description of the type of activities carried out on the licensed site(s) showing how the safety management arrangements set out in the SMP are appropriate and proportionate to the specific hazards, risks and scale of operations".

4.2.1  This section of the SMP should:

• Describe the type of undertaking, setting out the nature of the work and the scale of operations.  Where the licence applicant will operate more than one licensed nuclear site, or is applying for a licence for an additional site, the structure of the SMP may need to be adapted accordingly.  Generic issues – such as governance and the organisation’s approach to learning from experience – can be covered in an overarching corporate document.  However this may need to be supplemented by site specific documentation justifying local arrangements.  In such cases the combination of the generic SMP and the justification of local practices will provide the licensing basis for a specific site;
• Consider all activities with the potential to impact on nuclear safety, whether they will be carried out by the licensee itself, by contractors under the control of the licensee, or by tenants in facilities on the site(s). 
• Give a clear indication of the stage of the life-cycle each site has reached, e.g. installation, commissioning, operation, decommissioning etc.;
• State whether the licensee’s activities are stable in terms of the lifecycle or whether they are in transition between, say, operation and decommissioning;
• Describe the nuclear safety implications of interfaces with other systems and facilities (e.g. adjoining nuclear sites, wind farms etc).

4.2.2  The link between the activities described in this section and the organisation’s capabilities, addressed in section 4.5, should be clear.  High level nuclear safety management arrangements (dealt with in detail in later sections) should also be introduced. For example, outline descriptions of how the organisation maintains control and direction of the site(s), and compliance with the nuclear site licence.

4.2.3  The level of detail should be sufficient to demonstrate that the management arrangements and control measures are appropriate and commensurate with the hazard.  The licence applicant must understand the effect of interactions with other operations, either within the control of the operator or outside:  the effect of changes to these operations can then be assessed.

4.2.4  Reference should be made to documents which give more detail of the hazards and risks associated with operations. For example, the site safety case and facility safety cases contain in-depth descriptions of operations, hazards and risk and should be signposted.

4.2.5  Where a licence applicant sub-lets part(s) of its site(s) the arrangements for managing relationships with tenants, and overseeing their activities where appropriate, should be summarised and referenced to supporting documents.

4.2.6  The Inspector should consider:

1. Is there an adequate description of the nuclear activities carried out by the licence applicant?
2. Does the description of activities clearly establish the nuclear safety significance of the site(s) so that the SMP is proportionate?
3. Is there a clear description of the status of activities on the site (e.g. phase of commissioning, decommissioning, new build etc)
4. Are interactions with either other, non-nuclear operations or operators described?
5. Are arrangements for oversight of activities in tenanted facilities adequately described?

4.3  SMP Element 2 – Organisational structure:  "The safety management prospectus should describe how the organisational structure meets the nuclear safety management needs of the business."

4.3.1  The SMP should include the corporate body’s safety policy statement, setting out the nuclear safety aims of the licence applicant, and summarise how the organisation is structured, populated and managed to deliver those aims. The SMP makes clear the links between the site’s activities, safety policy and management system and Nuclear Baseline (see below).

4.3.2  This will include describing how functions, responsibilities and reporting relationships are managed from the Board down. This should encompass all roles needed to carry out all activities for which the site is licensed, including normal operations and emergencies.  It is to be expected that the functions described will normally include, but not be restricted to:

• Authorisation and control of nuclear safety related work
• Control of contractors,
• Appointment of suitably qualified and experienced staff
• Authorisation and assurance of technical specifications and designs, for example maintenance specifications
• Technical subject matter expertise for all topics necessary for nuclear safety, including ‘intelligent customer’ roles where expertise is contracted out (ref. T/AST/049 Use of Contractors and Intelligent Customer Capability)
• Provision of safety management advice
• Safety case production
• Independent challenge and assurance of safety management and safety cases
• Nuclear Safety Committee specification, appointment and function
• Emergency response and control

4.3.3  The SMP should include top level organisation charts with reference to where full organisational charts are to be found, e.g. the Nuclear Baseline. It should also make clear the relationship between the organisation holding the licence and any other organisation with which significant interactions are required to deliver nuclear safety, such as owners, vendors and ‘parent’ organisations (see Element 3 ‘Governance’ below).  There should be some indication that potential impacts upon nuclear safety management from this relationship are recognised and addressed.

4.3.4  For new or restructuring organisations it is preferable that the licence applicant should be able to describe ‘design principles’ around which its organisation will be constructed. This might consider such matters as numbers of layers of hierarchy, length of decision making chains, spans of managerial control and the policy for contractorisation.

4.3.5  The SMP should include a description of the approach taken to ensuring that the licence applicant has the all the capabilities necessary to deliver nuclear safety and the safety case.  This should include how it ensures that it retains sufficient expertise in, or at least ‘intelligent customer’ capability for, the full range of core technical competences required, (see Element 4 ‘Capability’ and T/AST/049 Use of Contractors and Intelligent Customer Capability). The SMP should describe how aspects of the organisation that may lead to vulnerabilities, such as reliance upon scarce or singleton expertise or specialist contractors, are identified and mitigated.

4.3.6  The SMP should summarise how the organisation ensures that it has sufficient numbers of qualified staff.  This should make reference to the Nuclear Baseline (see T/AST/065, Function and Content of the Nuclear Baseline) which should contain the detail of this substantiation whilst the SMP sets out the strategy and reviews its implementation (see Element 4 ‘Licensable Organisation’).

4.3.7  The requirements for emergency situations will differ from the day to day routine. It is important that the organisational structure for this different application is clear and that the organisation understands the different lines of control, communication and responsibility during emergency situations.

4.3.8  The Inspector should consider:

1. Is it clear how the organisation’s structure will deliver the nuclear safety policy and intended nuclear safety governance?
2. Has the structure been substantiated, e.g. through the Nuclear Baseline process?
3. For new or restructured organisations, have clear, appropriate design principles been established that facilitate management for nuclear safety?
4. Is there coherence between the SMP and the Nuclear Baseline?
5. Are the structures for steady state, restructuring and emergency situations clear?
6. Are there clear lines of control and allocation of responsibilities, including the functions set out above?
7. Does the SMP adequately describe the key aspects of nuclear safety management, including licence compliance and have the elements described in SAP Principles MS1 - MS4 been addressed?

4.4  SMP Element 3 – Governance of Nuclear Safety 1 :  "The SMP should set out the organisation’s approach to the governance of nuclear safety."

4.4.1  Nuclear safety governance refers to the processes and structures used to direct, manage, supervise, account for and assure the effectiveness with which an organisation delivers nuclear safety.  The SMP should therefore include a high-level description of the systems and processes for monitoring, directing and controlling activities, together with the organisation’s approach to developing and maintaining appropriate behaviours, including leadership behaviour and a culture that enhances nuclear safety.

4.4.2  The approach to governance should be embedded in the way the organisation works and in the leadership and management approaches to make it happen.  This starts with the Board of Directors and Executive who set the organisation’s strategic direction and manage safety significant activities. There should be a clear line of sight and clear lines of control traceable from the Board down to frontline safety performance.

4.4.3  A properly designed and implemented safety management system should be able to deliver the aims set out by The International Nuclear Safety Group (INSAG):

• To improve the safety performance of the organisation through the planning, control and supervision of safety related activities in normal, transient and emergency situations; 
• To foster and support a strong safety culture through the development and reinforcement of good safety attitudes and behaviours in individuals and teams so as to allow them to carry out their tasks safely.

The SMP should explain the main features of the management system and how it is implemented, although there need not be excess detail.  Further documentation of the system relevant to nuclear safety should be signposted.

4.4.4  The SMP should include sufficient information to assess the governance arrangements against the Leadership and Management Principles of the SAPs 2. It should set out company expectations regarding leadership and safety culture and describe how it ensures that Directors and managers demonstrate the appropriate behaviours. It should describe how governance of the business ensures that it remains within the law, including the terms of the nuclear site licence.

The role of the Board and Executive team

4.4.5  The overall direction and control of a licence applicant is set at the Board and Executive level.  The balance of the Board should ensure there is appropriate focus on nuclear safety and the capacity for independent challenge.  Board members should have an awareness of the nuclear safety implications of their decisions and be intelligent customers for the safety related information they receive.  The SMP should embody a commitment to ensuring that only suitably qualified and experienced persons (SQEP) are appointed as Board directors or to the Executive team 3.

4.4.6  The SMP should define the collective and individual responsibilities of the Board as part of demonstrating that the organisation is capable and licensable.  The Board is accountable for the matters set out in the SMP including setting policy, standards, strategy and objectives for safety and ensuring that the structure and staffing are suitable.

4.4.7  The Board should have adequate means to give them a clear view of the nuclear safety risks and performance of the business including governance arrangements, and review status at appropriate intervals, taking its own view after clear and robust questioning. The means for providing this view should be diverse including a wide range of performance indicators, progress against objectives, nuclear safety assurance processes, external comparators or ‘benchmarks’, and operational experience feedback including investigations of nuclear safety incidents. 

4.4.8  The Executive team is responsible for implementing the policies and strategies developed by the Board and for imparting the right ethos for leadership and management.  This theme should run through the governance arrangements 4.

Decision making

4.4.9  The SMP should describe clearly how nuclear safety is taken into account in decision-making processes.  The SMP should describe how appropriate technical expertise and authority is applied and what the process is for ensuring that where there is conflict between safety and other business goals those mismatches are actively managed to ensure that safety is not compromised.  Where decisions have to be made on the basis of incomplete evidence or partial information then the SMP should describe the process by which it is ensured that decisions err on the side of caution.  In particular, the governance of emergency situations should be addressed.

4.4.10  The SMP should describe the licence applicant’s approach to the use of safety performance indicators and reward and incentive schemes intended to promote nuclear safety. 

The challenge function

4.4.11  The SMP should describe what arrangements exist to provide meaningful challenges to safety-related decisions and activities.  This should include arrangements for challenge / oversight of the SLC Board, as well as oversight of the licence applicant’s activities by the Board.  The role and experience of non-Executive Directors should be covered.

4.4.12  The role of committees, including the LC13 Nuclear Safety Committee, in the direction and oversight of nuclear safety of the site should be explained, including sub-committee structures.  As well as describing the roles of individual groups and committees, the explanation should show how they fit together to form a cohesive and robust element of the challenge function. 

The influence of associated bodies

4.4.13  Responsibility for governance of a licensee resides with the Board but other bodies are involved, directly or indirectly, who may be in a position to influence the behaviour of the licensee. The SMP should address the implications for managing nuclear safety of all key interfaces, for example:

• Parent Body Organisations, and their owners
• The Nuclear Decommissioning Authority
• Major contractors
• Purchasing organisations
• Vendor/Operator interfaces
• Parts of the business outside the licensee company

The main nuclear safety responsibilities on each side of the interface should be explained, and the SMP should describe the licence applicant’s strategy for handling these interfaces to ensure that safety management will not be influenced inappropriately. 

4.4.14  The Inspector should consider:

1. Are the respective roles of the Board and Executive team clearly described, and are clear lines of accountability and control traceable right through the organisation?
2. Are Board and Executive team members SQEP for their roles and intelligent customers for the information they receive on nuclear safety? 
3. Does the constitution of the Board facilitate independent challenge?
4. Does the organisation have clear governance objectives and have they been adequately cascaded?
5. Do the Board and Executive team receive timely and suitably diverse information on performance to inform business decisions?  Do they demonstrate conservatism in their approach to safety-related business decisions?
6. Are potential impacts upon the governance of nuclear safety from the influence of outside bodies such as parent organisations, NDA etc. recognised and addressed where appropriate?
7. Is there is an effective communication strategy to ensure the right information is available at the right time to aid decision making and oversight of performance, and to address stakeholder needs?  Are there effective communication routes for employees to raise issues including safety governance?
8. Is there a business risk assessment and assurance process including nuclear safety?  Are the interfaces with other business systems clear?
9. Do company policies on code of conduct, safety culture, reward framework etc support the governance system?
10. Is the role and remit of safety governance committees adequately factored into the licence applicant’s governance arrangements?
11. Is it clear how arrangements for direction and control of the site(s) are modified under emergency conditions?

4.5  SMP Element 4 – Organisational Capability:   "The SMP should provide the strategy for developing and maintaining a licensable organisation with suitable resources and competences to deliver nuclear safety."

4.5.1  The licence applicant should be able to demonstrate that at any time it has the capability to carry out its activities safely and is thus a ‘licensable’ organisation. Capability in this context means the right organisation with the correct level of resource and skills to match the activities and nature of the work.  There should be a visible link between the work to be done, the organisation controlling the work and the people to do it (in terms of numbers and competence).

4.5.2  The SMP should set out the strategy for ensuring the resource and competence profile of the organisation meets its nuclear safety needs, including day to day operations and emergency situations. It should show how the licence applicant’s resource management arrangements will accommodate changes in demand and changes in skill requirements for the current work programme and foreseeable future needs, to maintain licensability.  The resource strategy should bring this together, and explain the linkage with the Nuclear Baseline, through which it will be discharged. The SMP thus provides a route map to other parts of the safety management system which contribute to this process. The capability section of the SMP should:

• describe the resource strategy, i.e. how the licence applicant determines what ‘core’ capabilities it needs to retain in-house to remain in control of activities that could impact on nuclear safety under all foreseeable circumstances throughout the life cycle of the facility, and to remain legally compliant. The details will be in the Nuclear Baseline. This will include demonstrating that the licence applicant fully understands the Intelligent Customer and Design Authority 5 concepts, together with consideration of how the resource strategy will impact on these and other core capabilities both qualitatively and quantitatively;
• confirm that the safety management system and licence condition compliance arrangements apply to the whole organisation up to and including the Board and Executive team, i.e. there is no glass ceiling. This applies in particular to arrangements for LC10 and 12 (training, SQEP) and LC36 (management of change);
• set out the policy on the use and appointment of Duly Authorised Persons (DAPs) with an explanation of how this works in practice [N.B. this requirement may be addressed via reference to LC12 compliance arrangements]. This should cover the rationale behind posts being identified as requiring DAP status and the way this is overseen and maintained;
• include a clear policy and strategy on the use of contractors which informs the approach between retaining adequate in house competence and outsourcing additional capability and ensures that the licence applicant remains in full control of nuclear safety.  Where external resource is used there is a risk that the licence applicant’s capability to make judgements about the potential impact of work on nuclear sites could be affected.  Thus the SMP should:
  • describe how decisions will be made on the use of contract resource to supplement the licence applicant’s own workforce and show that the organisation understands and is controlling the employee : contractor balance. The licence applicant will need a process for monitoring this balance and the impact on its competence as a licensable organisation;
  • show how retention of core in-house skills and capability including Intelligent Customer and Design Authority requirements will be managed.  This will include a demonstration that the licensee can maintain and resource the roles that it has determined through the Nuclear Baseline should be kept in-house;
  • summarise the policy and arrangements for the selection, control and supervision of contractors, and for reviewing these arrangements;
  • demonstrate that the Executive team is aware of any significant effects on nuclear safety associated with its use of contractors; 6
  • the way in which contract resource is to be used and the vulnerabilities that may need to be managed
• describe how shortfalls in capability due to loss of in-house expertise or contract resource will be identified and dealt with. The SMP should outline the processes for planning, assessing, implementing and controlling contingency arrangements and, where appropriate, securing more permanent replacement.
• demonstrate how the processes for training and succession planning ensure capability levels are maintained. There should be signposts out to management arrangements.

This list is illustrative, not exhaustive.

4.5.3 Where project work is being implemented the SMP should show how the licence applicant’s resource strategy is proactively managed to ensure that resource profiles and organisational arrangements remain fit for purpose (see guidance on SMP element 6 in section 4.7 below).  This must include ensuring the continuing overall viability of the licensee, not only individual projects.

Knowledge management

4.5.4  As part of the capability maintenance arrangements the SMP should set out how the organisation ensures knowledge of the current processes, plant and equipment etc. is preserved in readily accessible media over time.

4.5.5  The Inspector should consider:

1. Is there a clear policy and strategy to maintain capability?
2. Is there a comprehensive resource strategy with evidence of proactive management including succession planning?
3. Does the SMP adequately describe the top level strategy for the direction and control of the resource profile including the strategy for developing and maintaining its core competence (this links closely to the demonstration of Capability)
4. Is there a process described in the SMP to put in place and monitor the Nuclear Baseline?
5. Is the core capability of the licence applicant clearly identified and safeguards in place to prevent it being degraded through inadequately controlled changes leading to over-reliance on contractors.
6. Is there evidence that organisational capability is kept under review to maintain a licensable organisation?
7. Does the Nuclear Baseline show clear lines of control with clear nuclear safety responsibilities?
8. Is there evidence that the licence applicant’s assumptions about capability needs are confirmed by evidence on the ground and the use of safety performance indicators?
9. If the work programme is phased in nature are there hold points to confirm capability needs for subsequent stages are met before the programme continues?
10. Is there evidence of a vulnerability analysis of the organisations capability and a resulting gap analysis?

4.6  SMP Element 5  -  Learning Organisation:  "The SMP should outline how a ‘learning organisation’ culture is fostered, showing how the organisation absorbs and responds to lessons from within and outside the organisation.  The communication of safety information should also be addressed."

4.6.1  The successful management of nuclear safety calls for the right culture and way of working to complement the right arrangements and procedures.  A truly ‘learning organisation’ reflects on information and experience to improve performance.  It does not rely on the fact that it has not had any significant accidents or incidents, but constantly strives to prevent future events.  It welcomes challenge and review into its day-to-day working and encourages feedback across the organisation.

4.6.2  The SMP should set out the process for establishing, implementing, assessing and continually improving the management system in line with IAEA Safety Requirements GS-R-3 7 such that nuclear safety is properly taken account of.   Descriptions should be given of the way the management system is designed, implemented, assessed and continually improved to ensure it appropriately supports the claims made in the SMP. Evidence that the system responds to both internal and external influences should be given.

4.6.3  A summary should be provided of how the full ‘plan, do, review’ learning cycle (as described in HSG65 8) is delivered through the management system and how this is directed and controlled.  The management system is part of ensuring a strong culture of leadership and management for safety; it should be possible to see how the leadership and management for safety SAPs are enacted through the design and operation of the management system.

4.6.4 The safety management prospectus should set out how the organisation will encourage an open, learning environment. It should include the process for monitoring the effectiveness of the management systems and standards achieved.

4.6.5  It should also show how a robust process for learning from operating experience – both within the organisation and from others within nuclear and other high hazard industries is established (SAP MS4).  There should be evidence of a process to ensure that what is learnt from experience is not only promulgated as necessary across the organisation from the Board and Executive team down, but taken up and embedded throughout the organisation. 

4.6.6  As part of the review and appraisal of performance there should be suitable measures to help monitor achievement and vulnerabilities. Care should be taken to choose measures that are real reflectors of nuclear safety performance, not merely those that are easy to measure. The approach taken to developing and using such indicators should be described in the SMP and should be consistent with the requirements of SAP MS4.

4.6.7  When the need for improvement is identified this should be followed up by a process of assessing the best option and putting it in place in a timely and comprehensive way. Part of this process should include checking to ensure the intended outcome has been achieved and reporting back on achievement. This process should apply across the organisation and embrace the Board and Executive team.

4.6.8  Understanding its processes and plant is vital to a learning organisation.  Ensuring knowledge is captured and managed is a key element of this process.  Knowledge management consists of three fundamental components: people, processes and technology and should be managed as an integrated resource 9.  Changing the shape and size of an organisation whether through downsizing or growth can affect the organisational knowledge base and needs careful management. The SMP should show how the organisation will ensure that knowledge of the current processes, plant and equipment etc. is preserved.

4.6.9  The Inspector should consider  whether the SMP provides:

1. a description of the learning and improvement process and how this is embedded across the organisation;
2. a strategy for performance measurement, which includes monitoring of leading indicators.  Senior managers should understand the basis of the measures and the limitations of lagging indicators in proactive management of safety;
3. evidence that the Board and senior managers demonstrate their commitment to learning and improvement.  This should include discussions on what there is to learn from the experience of other organisations both within and outside the nuclear community and focus on outcomes;
4. a process for learning from experience that looks within and outside the nuclear industry;
5. evidence of challenge and how this leads to improvement;
6. an adequate system for monitoring the implementation and effectiveness of the management system and modifying it to reflect learning and influences such as changing requirements
7. the basis for a communications strategy in place that supports the organisation’s vision, mission and change initiatives.  This should include how the organisation communicates with stakeholders;
8. a requirement for senior managers and plant managers across the organisation to lead by example and foster open communications through personal involvement;
9. evidence that the system of rewards and incentives supports the aims of a learning organisation;
10. evidence of how the Knowledge Management process works in practice to support the claims made in the SMP.  For example, knowledge capture from people retiring and moving on and after particular stages in the work programme to inform future work.

4.7  SMP Element 6 -  Managing Change and Maintaining Live and Effective Management Arrangements:  "The SMP should describe the organisation’s approach to managing change and ensuring that its management arrangements remain current and adequate. 

4.7.1  HSE considers that a licensee’s arrangements for producing and assessing safety cases under LCs 14 and 23 should address organisational as well as technical factors that could affect safety.  Inasmuch as the safety case should remain current, then the licence applicant should show that it has adequate arrangements to review, and keep the factors covered by the SMP, the nuclear baseline and other management arrangements, up to date.  With regard to new build, HSE may specify that the licensee shall not proceed to the next stage of construction/installation or commissioning without the Consent of the Executive under LCs 19(4) or 21(4), and may need to be satisfied that the licensee’s organisational capability is commensurate with the next stage proceeding prior to granting the Consent.  Prospective operators of new nuclear plants should therefore develop compliance arrangements which acknowledge that hold points may take account of organisational as well as technical factors relating to the installation and commissioning of plant.  Where appropriate, the SMP should describe the applicant’s approach to incorporating organisational hold points into its forward programme.

4.7.2  During times of change the factors addressed in the SMP, and those in the baseline, should receive particular scrutiny by the licensee as it needs to demonstrate that these are, and remain, compatible with continued licensability.  Arrangements should be described for ensuring that the factors covered within the SMP reflect contemporary arrangements for the control and direction of the business, and that they are adequate.  Any changes which could impact on the arrangements referred to in the SMP should be managed through the governance process and brought to the attention of the Board as appropriate (see 4.4, role of the Board and Executive team).

4.7.3  External events or changes, as well as those planned by the licensee,  may challenge some of the assumptions embodied in the SMP. These may necessitate contingency plans to deal with vulnerabilities. For example, changes in a key contract resource organisation may impact on the licensee capability and may require early action to manage the potential impact.

4.7.4  Systems to implement change control should be capable of dealing with the nature of the work for example; different phases of operation, new applications, new build, shadow working and so on.  These should form part of the suite of arrangements developed to address the requirements of LC 36 10.

4.7.5  Reviews of the arrangements described within the SMP should be carried out at intervals in line with either operational cycles or as defined within the management arrangements.  For example, there may be an annual management review.  In addition to planned reviews, triggers for review and revision of the factors addressed within the SMP will include:

• applications for new/ replacement licence(s), in support of which a revised SMP should be submitted;

• changes to the scale of operations, or transitions in the lifecycle of the plant, e.g. between installation of the plant and commissioning, or between operation and decommissioning;

• significant reorganisations, including downsizing or increased contractorisation;

• as part of a periodic review of safety 11.

4.7.6  The Inspector should consider:

1. Does the Licensee’s change management process include consideration of the impact of changes on the factors addressed within the SMP?
2. Is there an adequate understanding at Executive team and Board and Executive team level of the need for the factors addressed within the SMP to remain current?
3. Is there evidence that the factors addressed within the SMP are being kept up to date? Do they reflect the current situation? (e.g. records of changes etc)
4. Are intervals for reviewing the factors addressed within the SMP appropriate to the nature of the work/activities?
5. Would cumulative effects of less significant changes on the SMP be picked up by the change management system?
6. Would changes to the Nuclear Baseline which may impact upon the SMP be recognised? Is there evidence of this happening?
7. Are there suitable measures to show the success of changes that impact on the SMP and achievement of outcomes?

Annex 1 - IAEA Publication Number GS-R-3 The Management System for Facilities and Activities

IAEA GS-R-3 has many hooks to issues addressed through the construction and maintenance of an effective SMP. For example:

Section 3 talks about management commitment and states that: "Management at all levels shall demonstrate its commitment to the establishment, implementation, assessment and continual improvement of the management system and shall allocate adequate resources to carry out these activities."

Section 5.3 deals with demonstration of safety prior to granting a licence, particularly relevant in the NDA and new build arenas: "Prior to granting of an authorization, the applicant shall be required to submit a detailed demonstration of safety, which shall be reviewed and assessed by the regulatory body in accordance with clearly defined procedures."

Section 2.1 emphasises the need for a strategic management system: "A management system shall be established, implemented, assessed and continually improved. It shall be aligned with the goals of the organization and shall contribute to their achievement". The main aim of the management system shall be to achieve and enhance safety by:

• Bringing together in a coherent manner all the requirements for managing the organization;
• Describing the planned and systematic actions necessary to provide adequate confidence that all these requirements are satisfied."

Section 2.8 details some of the requirements of the management system which is of importance in determining the scope of the management prospectus: "The documentation of the management system shall include the following:

• The policy statements of the organization;
• A description of the management system;
• A description of the structure of the organization;
• A description of the functional responsibilities, accountabilities, levels of authority and interactions of those managing, performing and assessing work;
• A description of the processes and supporting information that explain how work is to be prepared, reviewed, carried out, recorded, assessed and improved."

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