Executive summary
Date(s) of inspection:
July 2025
Aim of inspection
The inspection was to provide ONR with confidence in NNB GenCo (HPC) Ltd’s implementation of its organisational learning arrangements, following recent changes.
The inspection included a review of a sample of investigation reports, and the effectiveness of the implementation of actions. It will also look at how HPC are formally capturing lessons learnt from these events and examples of how these lessons are applied at HPC and outside the project, as well as any assessments of effectiveness.
Subject(s) of inspection
- CDM 15 - Rating: Not rated
- LC7 - Incidents on the site - Rating: Amber
Key findings, inspector's opinions and reasons for judgement made
The inspection team found that there been progress made in developing the arrangements, however implementation of those arrangements is not yet providing the required outputs and improvements in line with relevant good practice (TIG 7). Repeat events are still being seen on site and a review of a sample of investigation reports indicated that root causes are not being identified to enable the learning to be implemented on site and shared as required.
The inspection team reviewed arrangements, sampled a number of investigation reports, spoke to those involved in the investigations and conducted a site tour to check for evidence of learning on site.
Following the independent review of learning commissioned by the Board in 2024, the action plan to address the identified improvements was shared, 25% of the actions are now left to be closed. The delay in closing the actions is partially due to the Safety & Schedule Assurance (S&SA) directorate change earlier this year. The action plan now needs to be completed with then an effectiveness review conducted.
The team found that the arrangements had improved in line with regulatory expectation including a Project Organisation Learning (OL) Strategy now in place, setting out the governance framework and arrangements, which includes a clear line of sight to the Board via the Executive Sponsor. Further resources for the learning and improvement team (L&I) are still to be put in place following the Safety and Schedule Assurance (S&SA) MoC earlier in the year. And training for those holding key organisational learning roles outside the Learning and Improvement (L&I) team need to be reviewed to ensure they meet the needs of the individuals and project.
ONR welcomed the fact that discussions during the inspection were open and transparent. However the discussions did highlight instances where previous related incidents on site are not being considered and incorporated into the investigation and therefore the final report.
Overall we concluded, based on the evidence provided, that there are shortfalls in implementation of arrangements in relation to organisational learning on site against the LC7 requirements and the underpinning regulatory expectations. An AMBER rating was assigned with an agreed L3 Regulatory Issue raised setting out clear actions to address the shortfalls. Specifically, these were around the need for an increase in resources, a review of training provision, instigation of a key governance meeting, and improvements to applicable procedures.
Conclusion
The inspection looked at the implementation of organisational learning on site.
The inspection team found that there has been progress made in developing the arrangements, however implementation of those arrangements is not yet providing the required outputs and improvements in line with relevant good practice (TIG 7). Repeat events are still being seen on site and a review of a sample of investigation reports indicated that root causes are not being identified to enable the learning to be implemented on site and shared as required.
We concluded that based on the evidence provided, organisational learning on site by the Licensee (who is both Client & Principal Contractor), is not being adequately implemented by NNB GenCo (HPC) Ltd in line with regulatory good practice. On this basis, an AMBER rating was assigned with an agreed L3 Regulatory Issue raised setting out clear actions to address the shortfalls.