Monday, July 13, 2015

Fixing General Motors’ Culture—Any Lessons for Nuclear?

GM Headquarters
In a recent interview* with LinkedIn, General Motors CEO Mary Barra discussed her plan for fixing GM’s culture.  The interviewer asked what needs to change, what about known problems like the “GM nod”** and the siloed organization, and what is the key to the improvement process?  The following quotes are excerpted from her answers.  Do they suggest a clear vision for the future culture and/or a satisfactory action plan?

“. . . get everyone engaged, working together, and bringing the best ideas forward[.]”

“. . . I never accepted the GM nod.  If somebody said in a meeting they were going to do something, I expect you to do it.”

“We've got to model [working across the organization].”

“[We have to] own each other's problems.”

“So our goal is to be the safety leader. We're really driving a zero-defect mentality.”

“If we can get in a room and really, you know, argue it out constructively and everybody's views get on the table, we'll make better decisions.”

“. . . we've got to earn the trust of every single employee by demonstrating the way we behave.”

Our Perspective

We realize this was not some carefully crafted article for the Harvard Business Review but there are too many soft spots in this recipe for fixing the culture to let this interview slide by without comment.

Let’s begin with the positives.  Barra promotes respect for ideas; that’s a positive feedback loop and a good thing.  Senior management modeling desired behavior and working to earn employee trust are both essential for cultural change.  Safety leadership is certainly a laudable goal.  

The nod is a little more problematic.  Maybe Barra never accepted the nod but plenty of other folks did.  Is modeling the desired behavior sufficient to create change?  How long will it take?  What else might need to be done?

Shared ownership of problems is a good start but how does GM establish, model and inculcate a process that obtains permanent problem resolutions going forward?

Barra also believes an insider (like her) is better suited for changing the culture than an outsider.  We agree an insider may have a better handle on recognizing when employees are trying to spin a situation in their favor but an outsider can bring a clear view of the performance gap between an organization’s current state (e.g., its characteristics, priorities and processes) and where it needs to be.

Some ingredients are missing.  Most importantly, there is no mention of the powerful cost/finance feedback loop that contributed to GM’s quality problems.  Wringing pennies out of product costs was a major goal for years.  What roles will cost consciousness and management financial incentives play going forward?

In another area, how is the management decision making process changing other than arguing things out?

Bottom line: There are no lessons for nuclear in the GM CEO’s outline of her cultural change initiative.  In fact, her proclamations sound just like nuclear managers’ braying when they try to convince regulators, the media and the public that something, anything is happening to address perceived cultural issues.  But what usually isn’t happening is some in-depth analysis of how their organizational system functions.

*  D. Roth, “Mary Barra's Got a Plan for Fixing GM's Culture (and Only an Insider Can Pull it Off),” LinkedIn interview (July 6, 2015).  Safetymatters co-founder Bob Cudlin first spotted and called attention to this article.

**  The “GM nod” was “where employees would commit to being on board with a decision, then ignore it [later.]”

Friday, July 3, 2015

New Safety Culture Assessment at the Hanford Waste Treatment Plant

Hanford WTP
The Department of Energy (DOE) recently released the latest safety culture (SC) assessment report* for the Hanford Waste Treatment Plant (WTP or “vit plant”) project.  The 2015 report follows similar SC assessments conducted in 2011 and 2014, all of which were inspired by the Defense Nuclear Facilities Safety Board’s scathing 2011 report on SC at the WTP.  This post provides a brief overview of the report’s findings then focuses on the critical success factors for a healthy SC.

Assessment Overview

The 2011, 2014 and 2015 assessments used the same methodology, with multiple data collection methods, including interviews, Behavioral Anchored Rating Scales (BARS)** and a SC survey.  Following are selected highlights from the 2015 report.

DOE’s Office of River Protection (ORP) has management responsibility for the WTP project.  In general, ORP personnel feel more positive about the organization’s SC than they did during the 2014 assessment.  Feelings of confusion about ORP’s more collaborative relationship with Bechtel (the prime contractor) have lessened.  ORP management is perceived to be more open to constructive criticism.  Concerns remain with lack of transparency, trust issues and the effectiveness of the problem resolution process.

Bechtel personnel were more positive than in either previous SC assessment.  Bechtel has undertaken many SC-related initiatives including the promotion of a shared mental model of the project by senior Bechtel managers.  In 2014, Bechtel Corporate’s role in project decision making was perceived to skew against SC concerns.  The creation of a new Bechtel nuclear business unit has highlighted the special needs of nuclear work. (pp. 2, 39)  On the negative side, craft workers remain somewhat suspicious and wary of soft retributions, e.g., being blamed for their own industrial mishaps or having their promotion or layoff chances affected by reporting safety issues.

See this newspaper article*** for additional details on the report’s findings. 

Critical Success Factors for a Healthy SC

We always look at the following areas for evidence of SC strength or weakness: management’s decision making process, recognition and handling of goal conflicts, the corrective action program and financial incentives.

Decision Making

Both ORP and Bechtel interviewees complained of a lack of basis or rationale for different types of decisions. (pp. 9, 16)  Some ORP and Bechtel interviewees did note that efforts to clarify decision making are in process. (pp. 13, 32)  Although the need to explain the basis for decisions was recognized, there was no discussion of the decision making process itself.  This is especially disappointing because decision making is one of the possible behaviors that can be included in a BARS analysis, but was not chosen for this assessment.

Goal Conflicts

Conflicts among cost, schedule and safety goals did not rise to the level of a reportable problem.  ORP interviewees reported that cost and schedule do not conflict with safety in their individual work. (p. 6)  Most Bechtel interviewees do not perceive schedule pressures to be the determining factor while completing various tasks. (p. 23)  Overall, this is satisfactory performance.

Corrective Action Program

We believe how well an organization recognizes and permanently resolves its problems is important.  Problem Identification and Resolution was one of the traits evaluated in the assessment.  ORP interviewees said that current safety concerns are being addressed.  The historical lack of management feedback on problem resolution is still a disincentive for reporting problems. (pp. 8-9)  Some Bechtel interviewees said “issue resolution with management engagement was the single most positive improvement in problem resolution, . . .” (p. 24)  This performance is minimally acceptable but needs ongoing attention.

Financial Incentives

DOE’s contract with Bechtel now includes incentives for Bechtel if it self-identifies problems (rather than waiting for DOE or some other party to identify them).  ORP believes the incentives are a positive influence on contractor performance. (p. 8)  Bechtel interviewees also believe the new contract has had a positive impact on the project.  However, Bechtel has a goal to reduce legacy issues and some believe the contract’s emphasis on new issues distracts from addressing legacy problems. (pp. 24-25)  The assessment had no discussion of either ORP or Bechtel senior management financial incentives.  The new contract conditions are good; ignoring senior management incentives is unacceptable.

Safety Conscious Work Environment (SCWE)

We usually don’t pay much attention to SCWE at nuclear power plants because it is part of the larger cultural milieu.  But SCWE has been a long-standing issue at various DOE facilities, as well as the impetus for the series of WTP SC assessments, so we’ll look at a few highlights from the SC survey data.

For ORP, mean responses to five of the six SCWE questions were higher (better) in 2015 vs 2014, and 2014 vs 2011.  However, for one question “Concerns raised are addressed” the mean is lower (worse) in 2015 vs 2014, and significantly lower in 2015 vs 2011.  This may indicate an issue with problem resolution. (p. B-2) 

For Bechtel, mean responses to all six SCWE questions were significantly higher (better) in 2015 vs 2014.  However, the 2011 data were not included so we cannot make any inference about possible longer-term trends. (p. B-5)  What is shown is good news because it appears people feel freer to raise safety concerns.  Interestingly, Bechtel’s mean 2015 responses were 5-13% higher (better) than ORP’s for all questions.

Both ORP and Bechtel are showing acceptable performance but continued improvement efforts are warranted.

Our Perspective

The Executive Summary and Conclusions suggest ORP and especially Bechtel have turned the corner since 2014. (pp. v, 37)  This is arguably true for SCWE but we’d say the jury is still out on improvement in the broader SC, based on our look at the BARS data.

For ORP, the BARS data mean scores are higher for 4 (out of 10) behaviors in 2015 vs 2014, but only higher for 1 behavior in 2015 vs 2011. (p. B-1)  The least charitable interpretation is ORP’s view of itself has not yet re-achieved 2011 levels.  For Bechtel the BARS data shows a bit brighter picture.  Mean scores are higher for 6 (out of 10) behaviors in 2015 vs 2014, and higher for 4 behaviors for 2015 vs 2011. (p. B-4)

The format of the report is probably intended to be reader-friendly but it mixes qualitative interview data and selected quantitative data from BARS and the survey.  The use of modifiers like “many” and “some” creates a sense of relative frequency or importance but no real specificity.  It’s impossible to say how much (if any) cherry picking of the interview data occurred.****

We also wonder about the evaluation team’s level of independence and optimism.  This is the first time DOE has performed a WTP SC assessment without the extensive use of outside consultants.  Put bluntly, how independent was the team’s effort given DOE Headquarters’ desire to see improvements at WTP?  And it’s not just HQ; DOE is under the gun from Congress, the DNFSB, the Government Accountability Office, and environmental activists and regulators to clean up their act at Hanford.

We want to see a stronger SC at Hanford but we’ll go with Ronald Reagan on this report: “Trust, but verify.”

*  DOE Office of Enterprise Assessments, “Follow-up Assessment of Safety Culture at the Hanford Site Waste Treatment and Immobilization Plant” (June, 2015).  We have followed the WTP saga for years; please click on the Vit Plant label to see our related posts.

**  Behavioral Anchored Rating Scales (BARS) quantitatively summarize interviewees’ perceptions of their organization using specific examples of good, moderate, and poor performance.   There are 17 possible organizational behaviors in a BARS analysis, but only 10 were used in this assessment:  Attention to Safety, Coordination of Work, Formalization, Interdepartmental Communication, Organizational Learning, Performance Quality, Problem Identification and Resolution, Resource Allocation, Roles and Responsibilities and Time Urgency. (p. C-2)

***  A. Cary, “DOE: Hanford vit plant safety culture shows improvement,” Tri-City Herald (June 26, 2015).

****  The report also includes multiple references to the two organizations’ behavioral norms that were inferred from the survey data.  It’s not exactly consultant mumbo-jumbo but it’s too complicated to attempt to explain in this space.

Thursday, June 25, 2015

Safety Culture at Arkansas Nuclear One

Arkansas Nuclear One (credit: Edibobb)
Everyone has heard about the March 31, 2013 stator drop at Arkansas Nuclear One (ANO).  But there was also unsatisfactory performance with respect to flood protection and unplanned scrams.  As a consequence, ANO has been assigned to column 4 of the NRC’s Action Matrix where it will receive the highest level of oversight for an operating plant.

When a plant is in column 4 the NRC takes a particular interest in its safety culture (SC) and ANO is no exception.  NRC required ANO to have an independent (i.e., outside third party) SC assessment, which was conducted starting in late 2014.  While the assessment report is not public, some highlights were discussed during the May 21, 2015 NRC staff briefing of the Commissioners on the results of the April 15, 2015 Agency Action Review Meeting.*

NRC Presentation

The bulk of the staff presentation was a soporific review of agency progress in a variety of areas.  But when the topic turned to ANO, the Regional Administrator responsible for ANO was quite specific and minced no words.  Following are the key problems he reviewed.  See if you can connect the dots on SC issues based on these artifacts.

Let’s start with the stator drop.  ANO’s initial root cause evaluation did not identify any root or contributing causes related to ANO’s own performance, but rather focused solely on the contractor.  After the NRC identified ANO’s failure to follow its load handling procedure, ANO conducted another root cause evaluation and identified their own organizational performance issues such as inadequate project oversight and non-conservative decision making. (pp. 28-29)

The stator drop damaged a fire main which caused localized flooding.  This led to an extended condition review which identified various equipment and structures that could be subject to flooding.  The NRC inspectors pointed out deficiencies in the condition review and identified corrective actions that likely would not work.  In addition, earlier flooding walkdowns completed as part of the NRC’s post-Fukushima requirements failed to identify the majority of the flood protection deficiencies.  These walkdowns were also performed by a contractor.  (pp. 29-31)

Finally, ANO did not report an April 2014 Unit 2 trip as an unplanned scram because the trip occurred during a planned down power evolution.  After prodding by the NRC inspectors, ANO reclassified this event as an unplanned scram. (pp. 31-32)

Overall, the NRC felt it was driving ANO to perform complete evaluations and develop effective corrective actions.  NRC believes that ANO’s “cause evaluations typically don't provide for a thorough assessment of organizational and programmatic contributors to events or issues.” (p. 35)  Later, in response to a question, the Regional Administrator said “I think the licensee clearly needs to own the performance gaps, ensure that their assessments in the various areas are comprehensive and then identify appropriate actions, and then engage and ensure those actions are effective. . . . I don't want to be in a position where our inspection activities are the means for identifying the performance gaps.” (p. 44)

Responding to a question about ANO’s independent SC assessment, he said “one of the key findings . . . was that there's an urgent need to internalize and communicate the seriousness of performance problems and engage the site in their strategy for improvement.” (p. 45)

Entergy Presentation

A team of Entergy (ANO’s owner) senior managers presented their action plan for ANO.  They said they would own their own problems, improve contractor oversight, identify their own issues, increase corporate oversight and improve their CAP.

With respect to culture, they said “We're going to change the culture to promote a healthy, continuous improvement and to not only achieve, but also to sustain excellence.” (pp. 70-71)  They are benchmarking other plants, analyzing ANO’s issues and adding resources including people with plant performance recovery experience. 

They took comfort from the SC assessment conclusion “That although weaknesses exist, the overall safety culture at ANO is sufficient to support safe operation." (p. 72)

In response to a question about important takeaways from the SC assessment, Entergy referred to the need for the plant to recognize that performance has got to improve, the CAP must be more effective and organizational programmatic elements are important.  In addition, they vowed to align the organization on the performance gaps (and their significance) and establish a sense of urgency in order to fix them. (pp. 80-81)

Our Perspective

Not to be too cynical, but what else could Entergy say?  When your plant is in column 4, a mega mea culpa is absolutely necessary.  But Entergy’s testimony read like generic management arm-waving invoking the usual set of fixes.

Basically, the ANO culture endorses a “blame the contractor” attitude, accepts incomplete investigations into actual events and potential problems, and is content to let the NRC point out problems for them.  Where did those values come from?  Is “increased oversight” sufficient to create a long-term fix?

ANO naturally gives a lot of weight to the SC assessment because its findings appear relatively simple and apparently actionable.   Somewhat surprisingly, the NRC also appears to give this assessment broad credibility.  We think that’s misplaced.  The chances are slim of such an assessment identifying deep, systemic cultural issues although we admit we don’t know the assessment details.  Did the assessment team perform document reviews, conduct focus groups or interviews?  If it was a survey, it only identified the most pressing issues in the plant’s safety climate.

Taking a more systemic view, we note that Entergy has a history of SC issues over many plants in its fleet.  Check out our Feb. 20, 2015 post for highlights on some of their problems.  Are ANO’s problems just the latest round of SC Whac-A-Mole at Entergy?

Entergy has always had a strong Operations focus at its plants.  The NRC’s confidence in ANO’s operators is the main reason that plant is not shut down.  But continuously glorifying the operators, particularly their ability to respond successfully to challenging conditions, is like honoring firefighters while ignoring the fire marshal.  The fire marshal role at a nuclear plant is played by Engineering and Maintenance, groups whose success is hidden (thus under-appreciated) in an ongoing series of dynamic, non-events, viz., continuous safe plant operation.  That’s a cultural issue.  By the way, who gets the lion’s share of praise and highest status at your plant?

*  “Briefing on Results of the Agency Action Review Plan Meeting,” public meeting transcript (May 21, 2015).  ADAMS ML15147A041.

The Agency Action Review Meeting (AARM) “is a meeting of the senior leadership of the agency, and its goals are to review the appropriateness of agency actions taken for reactor material licensees with significant performance issues.” (pp. 3-4)

Tuesday, June 9, 2015

Training....Yet Again

U.S. Navy SEALS in Training
We have beat the drum on the value of improved and innovative training techniques for improving safety management performance for some time.  Really since the inception of this blog where our paper, “Practicing Nuclear Safety Management,”* was one of the seminal perspectives we wanted to bring to our readers.  We continue to encounter knowledgeable sources that advocate practice-based approaches and so continue to bring them to our readers’ attention.  The latest is an article from the Harvard Business Review that calls attention to, and distinguishes, “training” as an essential dimension of organizational learning.  The article is “How the Navy SEALS Train for Leadership Excellence.”**  The author, Michael Schrage,*** is a research fellow at MIT who reached out to a former SEAL, Brandon Webb, who transformed SEAL training.  The author contends that training, as opposed to just education or knowledge, is necessary to promote deep understanding of a business or market or process.  Training in this sense refers to actually performing and practicing necessary skills.  It is the key to achieving high levels of performance in complex environments. 

One of Webb’s themes that really struck a chord was: “successful training must be dynamic, open and innovative…. ‘It’s every teacher’s job to be rigorous about constantly being open to new ideas and innovation’, Webb asserts.”  It is very hard to think about much of the training in the nuclear industry on safety culture and related issues as meeting these criteria.  Even the auto industry has recently stepped up to require the conduct of decision simulations to verify the effectiveness of corrective actions - in the wake of the ignition switch-related accidents. (see our
May 22, 2014 post.)

In particular the reluctance of the nuclear industry and its regulator to address the presence and impact of goal conflicts on safety continues to perplex us and, we hope, many others in the industry.   It was on the mind of Carlo Rusconi more than a year ago when he observed: “Some of these conflicts originate high in the organization and are not really amenable to training per se” (see our
Jan. 9, 2014 post.)  However a certain type of training could be very effective in neutralizing such conflicts - practicing making safety decisions against realistic fact-based scenarios.  As we have advocated on many occasions, this process would actualize safety culture principles in the context of real operational situations.  For the reasons cited by Rusconi it builds teamwork and develops shared viewpoints.  If, as we have also advocated, both operational managers and senior managers participated in such training, senior management would be on the record for its assessment of the scenarios including how they weighed, incorporated and assessed conflicting goals in their decisions.  This could have the salutary effect of empowering lower level managers to make tough calls where assuring safety has real impacts on other organizational priorities.  Perhaps senior management would prefer to simply preach goals and principles, and leave the tough balancing that is necessary to implement the goals to their management chain.  If decisions become shaded in the “wrong” direction but there are no bad outcomes, senior management looks good.  But if there is a bad outcome, lower level managers can be blamed, more “training” prescribed, and senior management can reiterate its “safety is the first priority” mantra.

*  In the paper we quote from an article that highlighted the weakness of “Most experts made things worse.  Those managers who did well gathered information before acting, thought in terms of complex-systems interactions instead of simple linear cause and effect, reviewed their progress, looked for unanticipated consequences, and corrected course often. Those who did badly relied on a fixed theoretical approach, did not correct course and blamed others when things went wrong.”  Wall Street Journal, Oct. 22, 2005, p. 10 regarding Dietrich Dörner’s book, The Logic of Failure.  For a comprehensive review of the practice of nuclear safety, see our paper “Practicing Nuclear Safety Management”, March 2008.

**  M. Schrage, "How the Navy SEALS Train for Leadership Excellence," Harvard Business Review (May 28, 2015).

***  Michael Schrage, a research fellow at MIT Sloan School’s Center for Digital Business, is the author of the book Serious Play among others.  Serious Play refers to experiments with models, prototypes, and simulations.

Friday, June 5, 2015

NRC Staff Review of National Research Council Safety Culture Recommendations Arising from Fukushima

On July 30, 2014 we reviewed the safety culture (SC) aspects of the National Research Council report on lessons learned from the Fukushima nuclear accident.  We said the report’s SC recommendations were pretty limited: the NRC and industry must maintain and monitor a strong SC in all safety-related activities, the NRC must maintain its independence from outside influences, and the NRC and industry should increase their transparency about their SC-related efforts.

The NRC staff reviewed the report’s recommendations, assessed whether the agency was addressing them and documented their results.*  Given the low bar, it’s no surprise the staff concluded “that all NAS’s recommendations are being adequately addressed.” (p.1)  Following is the evidence the staff assembled to show the NRC is addressing the SC recommendations.

Emphasis on Safety Culture (pp. 25-26) 

In 1989, after Peach Bottom plant operators were caught sleeping on the job, the NRC issued a “Policy Statement on the Conduct of Nuclear Power Plant Operations.”   The policy statement focused on personal dedication and accountability but also underscored management’s responsibility for fostering a healthy SC.

In 1996, after Millstone whistleblowers faced retaliation, the NRC issued another policy statement, “Freedom of Employees in the Nuclear Industry to Raise Safety Concerns without Fear of Retaliation.”  This policy statement focused on the NRC’s expectation that all licensees will establish and maintain a safety-conscious work environment (SCWE).

In 2002, after discovery of the Davis-Besse reactor pressure vessel’s degradation, the Reactor Oversight Process (ROP) was strengthened to detect potential SC weaknesses during inspections and performance assessments.  ROP changes were described in Regulatory Issue
Summary 2006-13, “Information on the Changes Made to the Reactor Oversight Process to More Fully Address Safety Culture.”

In 2004, INPO published “Principles for a Strong Nuclear Safety Culture.”  In 2009, an industry/NEI/INPO effort produced a process for monitoring and improving SC, documented in NEI 09-07 “Fostering a Strong Nuclear Safety Culture.”  We reviewed NEI 09-07 on Jan. 6, 2011.

In 2008, the NRC initiated an effort to define and expand SC policy.  The final Safety Culture Policy Statement (SCPS) was published on June 14, 2011.  We posted eight times on the SCPS effort before the policy was issued.  Click on the SC Policy Statement label to see both those posts and subsequent ones that refer to the SCPS. 

An Independent Regulator (pp. 26-27)

The Energy Reorganization Act of 1974 established the NRC.  Principal Congressional oversight of the agency is performed by the Senate Subcommittee on Clean Air and Nuclear Safety, and the House Subcommittee on Energy and the Environment.  It’s not clear how the NRC performing obeisance before these committees contributes to the agency’s independence.

The NRC receives independent oversight from the NRC’s Office of the Inspector General and the U.S. Government Accountability Office.

Perhaps most relevant, the U.S. is a contracting party to the international Convention on Nuclear Safety.  The NRC prepares a periodic report describing how the U.S. fulfills its obligations under the CNS, including maintaining the independence of the regulatory body.  On March 26, 2014 we posted on the NRC’s most recent report.

Industry Transparency (pp. 27-28)

For starters, the NRC touts its SC website which includes the SCPS and SC-related educational and outreach materials.

In March 2014, the NRC published NUREG-2165, “Safety Culture Common Language,” which
documents a common language to describe SC in the nuclear industry.  We reviewed the NUREG on April 6, 2014.

That’s all.

Our Perspective 

We’ll give the NRC a passing grade on its emphasis on SC.  The “evidence” on agency independence is slim.  Some folks believe that regulatory capture has occurred, to a greater or lesser degree.  For what it’s worth, we think the agency is fairly independent.

The support for industry transparency is a joke.  As we said in our July 30, 2014 post, “the nuclear industry’s penchant for secrecy is a major contributor to the industry being its own worst enemy in the court of public opinion.”     

NRC Staff Review of National Academy of Sciences Report, “Lessons Learned from theFukushima Dai-ichi Nuclear Accident for Improving Safety of U.S. Nuclear Plants” (Apr. 9, 2015).  ADAMS ML15069A600.  The National Research Council is part of the National Academy of Sciences.

Tuesday, May 26, 2015

Safety Culture “State of the Art” in 2002 per NUREG-1756

Here’s a trip down memory lane.  Back in 2002 a report* on the “state of the art” in safety culture (SC) thinking, research and regulation was prepared for the NRC Advisory Committee on Reactor Safeguards.  This post looks at some of the major observations of the 2002 report and compares them with what we believe is important today.

The report’s Abstract provides a clear summary of the report’s perspective:  “There is a widespread belief that safety culture is an important contributor to the safety of operations. . . . The commonly accepted attributes of safety culture include good organizational communication, good organizational learning, and senior management commitment to safety. . . . The role of regulatory bodies in fostering strong safety cultures remains unclear, and additional work is required to define the essential attributes of safety culture and to identify reliable performance indicators.” (p. iii) 

General Observations on Safety Performance 

A couple of quotes included in the report reflect views on how safety performance is managed or influenced.

 “"The traditional approach to safety . . . has been retrospective, built on precedents. Because it is necessary, it is easy to think it is sufficient.  It involves, first, a search for the primary (or "root") cause of a specific accident, a decision on whether the cause was an unsafe act or an unsafe condition, and finally the supposed prevention of a recurrence by devising a regulation if an unsafe act,** or a technical solution if an unsafe condition." . . . [This approach] has serious shortcomings.  Specifically, ". . . resources are diverted to prevent the accident that has happened rather than the one most likely to happen."” (p. 24)

“"There has been little direct research on the organizational factors that make for a good safety culture. However, there is an extensive literature if we make the indirect assumption that a relatively low accident plant must have a relatively good safety culture." The proponents of safety culture as a determinant of operational safety in the nuclear power industry rely, at least to some degree, on that indirect assumption.” (p. 37) 

Plenty of people today behave in accordance with the first observation and believe (or act as if they believe) the second one.  Both contribute to the nuclear industry’s unwillingness to consider new ways of thinking about how safe performance actually occurs.

Decision Making, Goal Conflict and the Reward System

Decision making processes, recognition of goal conflicts and an organization’s reward system are important aspects of SC and the report addressed them to varying degrees.

One author referenced had a contemporary view of decision making, noting that “in complex and ill-structured risk situations, decisionmakers are faced not only with the matter of risk, but also with fundamental uncertainty characterized by incompleteness of knowledge.” (p. 43)  That’s true in great tragedies like Fukushima and lesser unfortunate outcomes like the San Onofre steam generators.

Goal conflict was mentioned: “Managers should take opportunities to show that they will put safety concerns ahead of power production if circumstances warrant.” (p.7)

Rewards should promote good safety practices (p. 6) and be provided for identifying safety issues. (p. 37)  However, there is no mention of the executive compensation system.  As we have argued ad nauseam these systems often pay more for production than for safety.

The Role of the Regulator

“The regulatory dilemma is that the elements that are important to safety culture are difficult, if not impossible, to separate from the management of the organization.  [However,] historically, the NRC has been reluctant to regulate management functions in any direct way.” (pp. 37-38)  “Rather, the NRC " . . . infers licensee organization management performance based on a comprehensive review of inspection findings, licensee amendments, event reports, enforcement history, and performance indicators."” (p. 41)  From this starting point, we now have the current situation where the NRC has promulgated its SC Policy Statement and practices de facto SC regulation using the highly reliable “bring me another rock” method.

The Importance of Context when Errors Occur 

There are hints of modern thinking in the report.  It contains an extended summary of Reason’s work in Human Error.  The role of latent conditions, human error as consequence instead of cause, the obvious interaction between producers and production, and the “non-event” of safe operations are all mentioned. (p. 15)  However, a “just culture” or other more nuanced views of the context in which safety performance occurs had yet to be developed.

One author cited described “the paradox that culture can act simultaneously as a precondition for safe operations and an incubator for hazards.” (p. 43)  We see that in Reason and also in Hollnagel and Dekker: people going about business as usual with usually successful results but, on some occasions, with unfortunate outcomes.

Our Perspective

The report’s author provided a good logic model for getting from SC attributes to identifying useful risk metrics, i.e., from SC to one or more probabilistic risk assessment (PRA) parameters.  (pp. 18-20)  But none of the research reviewed completed all the steps in the model. (p. 36)  He concludes “What is not clear is the mechanism by which attitudes, or safety culture, affect the safety of operations.” (p. 43)  We are still talking about that mechanism today.   

But some things have changed.  For example, probabilistic thinking has achieved greater penetration and is no longer the sole province of the PRA types.  It’s accepted that Black Swans can occur (but not at our plant).

Bottom line: Every student of SC should take a look at this.  It includes a good survey of 20th century SC-related research in the nuclear industry and it’s part of our basic history.

“Those who cannot remember the past are condemned to repeat it.” — George Santayana (1863-1952)

*  J.N. Sorensen, “Safety Culture: A Survey of the State-of-the-Art,” NUREG-1756 (Jan. 2002).  ADAMS ML020520006.  (Disclosure: I worked alongside the author on a major nuclear power plant litigation project in the 1980s.  He was thoughtful and thorough, qualities that are apparent in this report.)

**  We would add “or reinforcing an existing regulation through stronger procedures, training or oversight.”

Monday, April 27, 2015

INPO’s View on Fukushima Safety Culture Lessons Learned

In November 2011 the Institute of Nuclear Power Operations (INPO) published a special report* on the March 2011 Fukushima accident.  The report provided an overview and timeline for the accident, focusing on the evolution of the situation during the first several days after the earthquake and tsunami.  Safety culture (SC) was not mentioned in the report.

In August 2012 INPO issued an addendum** to the report covering Fukushima lessons learned in eight areas, including SC.  Each area contains a lengthy discussion of relevant plant activities and experiences, followed by specific lessons learned.  According to INPO, some lessons learned may be new or different from those published elsewhere.  Several caught our attention as we paged through the addendum: Invest resources to assess low-probability, high-consequence events (Black Swans).  Beef up available plant staffing to support regular staff in case a severe, long duration event inconveniently occurs on a weekend.  Evaluate the robustness of off-site event management facilities (TEPCO’s was inaccessible, lost power and did not have filtered ventilation).  Be aware that assigning most decision making authority to the control room crew (as TEPCO did) meant other plant groups could not challenge or check ops’ decisions—efficiency at the cost of thoroughness.  Conduct additional training for a high-dose environment when normal dosage limits are replaced with emergency ones.  Ensure that key personnel have in-depth reactor and power plant knowledge to respond effectively if situations evolve beyond established procedures and flexibility is required.

Focusing on SC, the introduction to this section is clear and unexpectedly strong: “History has shown that accidents and their precursors at commercial nuclear electric generating stations result from a series of decisions and actions that reflect flaws in the shared assumptions, values, and beliefs of the operating organization.” (p. 33)

The SC lessons learned are helpful.  INPO observed that while TEPCO had taken several steps over the years to strengthen its SC, it missed big picture issues including cultivating a questioning attitude, challenging assumptions, practicing safety-first decision making and promoting organizational learning.  In each of these areas, the report covers specific deficiencies or challenges faced at Fukushima followed by questions aimed at readers asking them to consider if similar conditions exist or could exist at their own facilities.

Our Perspective

The addendum has a significant scope limitation: it does not address public policy (e.g., regulatory or governmental) factors that contributed to the Fukushima accident and yielded their own lessons learned.***  However, given the specified scope, a quick read of the entire addendum suggests it’s reasonably thorough, the SC section certainly is.  The questions aimed at report readers are the kind we ask all the time on Safetymatters but we award INPO full marks for addressing these general, qualitative, open-ended subjects.  One question INPO raised that we have not specifically asked is “To what extent are the safety implications considered during enterprise business planning and budgeting?” (italics added)  Another, inferred from the report text, is “How do operators create complex, realistic scenarios (e.g., with insufficient information and/or personnel under stress) during emergency training?”  These are legitimate additions to the repertoire.  

The addendum is not perfect.  For example, INPO trots out the “special and unique” mantra when discussing the essential requirements to maintain core cooling capability and containment integrity (esp. with respect to venting at Fukushima).  This mantra, coupled with INPO’s usual penchant for secrecy, undermines public support for commercial nuclear power.  INPO can be a force for good when its work products, like this report and addendum, are publicly available.  It would be better for the industry if INPO were more transparent and if commercial nuclear power were characterized as a safety-intense industrial process run by ordinary, albeit highly trained, people.

Bottom line, you should read the addendum looking for bits that apply to your own situation.

*  INPO, “Special Report on the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station,” INPO 11-005 Rev. 0 (Nov. 2011).

**  INPO, “Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station,” INPO 11-005 Rev. 0 Addendum (Aug. 2012).  Thanks to Madalina Tronea for publicizing this document.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety discussion group.

***  Regulatory, government and corporate governance lessons learned have been publicized by other Fukushima reviewers and the findings widely distributed, including on Safetymatters.  Click on the Fukushima label to see our related posts.