Wednesday, September 24, 2014

NAS Safety Culture Lessons Learned from Fukushima—Presentation to NRC

We reviewed the National Academy of Sciences’ (NAS) Fukushima Lessons Learned report on July 30, 2014.  As you recall, we were underwhelmed by the recommendations related to nuclear safety culture (SC).  Basically, the report said the NRC should maintain a strong SC at the facilities it regulates and maintain the agency’s independence.  In addition, the NRC and industry should increase the transparency of their efforts to assess and improve SC.

Two of the report’s authors presented the NAS findings to the NRC on July 31, 2014 as part of a panel of external stakeholders presenting Fukushima lessons learned.  This post, based on the meeting transcript*, reviews the SC-related comments at that meeting.  The NAS presenter repeated the report’s SC recommendations then added some comments about the differences between Japanese and American culture. (pp. 18-19)  He also noted that the SC chapter in the report exhibits a range of views of SC held by different members of the 21-person NAS committee. (p. 24)

The NAS presentation was one of six made by the external panel.  A five-member NRC staff panel reported separately on the agency’s Fukushima-related investigations and activities.  Only the NAS presentation mentioned SC; the other presentations focused on plant hardware, off-site equipment, and state and foreign regulatory activities.

Our Perspective

Although this was a busy meeting with a tight schedule, SC did warrant comments from the Commissioners:

Commissioner Magwood said “. . . I also agree with many of the points the Committee raised about safety culture. I think that the cultural and training issues may actually be more important than some of the hardware issues that we spend a lot of time talking about.  And that is something that has not got enough emphasis.” (p. 57)

Commissioner Svinicki said “I liked the simple statement that was made of nuclear safety culture is a big issue.”  She also appreciated that the committee had a “vibrant” discussion on SC. (pp. 73-74)

Bottom line: Given the number of presentations SC did not get short shrift from the Commission. The Commissioners acknowledged SC’s importance but there was no real discussion of the topic.

*  NRC, “Briefing on the Status of Lessons Learned from the Fukushima Dai-ichi Accident,” meeting transcript (July 31, 2014).  ADAMS ML14217A208.

Wednesday, September 10, 2014

A Safety Culture Guide for Regulators

This paper* was referenced in a safety culture (SC) presentation we recently reviewed.  It was prepared for Canadian offshore oil industry regulators.  Although not nuclear oriented, it’s a good introduction to SC basics, the different methods for evaluating SC and possible approaches to regulating SC.  We’ll summarize the paper then provide our perspective on it.  The authors probably did not invent anything other than the analysis discussed below but they used a decent set of references and picked appropriate points to highlight.

Introduction to SC and its Importance

The paper provides some background on SC, its origins and definition, then covers the Schein three-tier model of culture and the difference between SC and safety climate.  The last topic is covered concisely and clearly: “. . . safety climate is an outward manifestation of culture. Therefore, safety culture includes safety climate, but safety culture uniquely includes shared values about risk and safety.” (p. 11)  SC attributes (from the Canadian Nuclear Safety Commission) are described.  Under attributes, the authors stress one of our basic beliefs, viz., “The importance of safety is made clear by the decisions managers make and how they allocate resources.” (p. 12)  The authors also summarize the characteristics of High Reliability Organizations, Low Accident Organizations, and James Reason’s model of SC and symptoms of poor SC.

The chapter on SC as a causal factor in accidents contains an interesting original analysis.  The authors reviewed reports on 17 offshore or petroleum related accidents (ranging from helicopter crashes to oil rig explosions) and determined for each accident which of four negative SC factors (Normalization of deviance, Tolerance of inadequate systems and resources, Complacency, Work pressure) were present.  The number of negative SC factors per accident ranged from 0 (three instances) to 4 (also three instances, including two familiar to Safetymatters readers: BP Texas City and Deepwater Horizon).  The negative factor that appeared in the most accidents was Tolerance of inadequate systems and resources (10) and the least was Work pressure (4).

Assessing SC

The authors describe different SC assessment methods (questionnaires, interviews, focus groups, observations and document analysis) and cover the strengths and weaknesses of each method.  The authors note that no single method provides a comprehensive SC assessment and they recommend a multi-method approach.  This is familiar ground for Safetymatters readers; for other related posts, click on the “Assessment” label in the right hand column.

A couple of highlights stand out.  Under observations the authors urge caution:  “The fact that people are being observed is likely to influence their behaviour [the well-known Hawthorne Effect] so the results need to be treated with caution. The concrete nature of observations can result in too much weight being placed on the results of the observation versus other methods.“ (p. 37)  A strength of document analysis is it can evidence how (and how well) the organization identifies and corrects its problems, another key artifact in our view.

Influencing SC

This chapter covers leadership and the regulator’s role.  The section on leadership is well-trod ground so we won’t dwell on it.  It is a major (but in our opinion not the only) internal factor that can influence the evolution of SC.  The statement that “Leaders also shape the safety culture through the allocation of resources” (p. 42) is worth repeating.

The section on regulatory influence is more informative and describes three methods: the regulator’s practices, promotion of SC, and enforcement of SC regulations.  Practices refer to the ways the regulator goes about its inspection and enforcement activities with licensees.  For example, the regulator can promote organizational learning by requiring licensees to have effective incident investigation systems and monitoring how effectively such systems are used in practice. (p. 44)  In the U.S. the NRC constantly reinforces SC’s importance and, through its SC Policy Statement, the expectation that licensees will strive for a strong SC.

Promoting SC can occur through research, education and direct provision of SC-related services.  Regulators in other countries conduct their own surveys of industry personnel to appraise safety climate or they assess an organization’s SC and report their findings to the regulated entity.**  (pp. 45-46)  The NRC both supports and cooperates with industry groups on SC research and sponsors the Regulatory Information Conference (which has a SC module).

Regulation of SC means just what it says.  The authors point out that direct regulation in the offshore industry is controversial. (p. 47)  Such controversy notwithstanding, Norway has developed  regulations requiring offshore companies to promote a positive SC.  Norway’s experience has shown that SC regulations may be misinterpreted or result in unintended consequences. (pp. 48-50)  In the nuclear space, regulation of SC is a popular topic outside the U.S.; the IAEA even has a document describing how to go about it, which we reviewed on May 15, 2013.  More formal regulatory oversight of SC is being developed in Romania and Belgium.  We reported on the former on April 21, 2014 and the latter on June 23, 2014.

Our Perspective

This paper is written by academics but intended for a more general audience; it is easy reading.  The authors score points with us when they say: “Importantly, safety culture moves the focus beyond what happened to offer a potential explanation of why it happened.” (p. 7)  Important factors such as management decision making and work backlogs are mentioned.  The importance of an effective CAP is hinted at.

The paper does have some holes.  Most importantly, it limits the discussion on influencing SC to leadership and regulatory behavior.  There are many other factors that can affect an organization’s SC including existing management systems; the corporate owner’s culture, goals, priorities and policies; market factors or economic regulators; and political pressure.  The organization’s reward system is referred to multiple times but the focus appears to be on lower-level personnel; the management compensation scheme is not mentioned.

Bottom line: This paper is a good introduction to SC attributes, assessments and regulation.

*  M. Fleming and N. Scott, “A Regulator’s Guide to Safety Culture and Leadership” (no date).

**  No regulations exist in these cases; the regulator assesses SC and then uses its influence and persuasion to affect regulated entity behavior.

Thursday, September 4, 2014

DNFSB Hearings on Safety Culture, Round Two

DNFSB Headquarters
On August 27, 2014 the Defense Nuclear Facilities Safety Board (DNFSB) convened the second of three hearings “to address safety culture at Department of Energy defense nuclear facilities and the Board’s Recommendation 2011–1, Safety Culture at the Waste Treatment and Immobilization Plant.”*  The first hearing was held on May 28, 2014 and heard from industry and federal government safety culture (SC) experts; we reviewed that hearing on June 9, 2014.  The second hearing received SC expert testimony from the U.S. Navy, the U.S. Chemical Safety and Hazard Investigation Board and academia.  The following discussion reviews the presentations in the order they were made to the board. 

Adm. Norton's (Naval Safety Center) presentation** on the Navy’s SC programs was certainly comprehensive with 32 slides for a half-hour talk (plus 22 backup slides).  It appears the major safety focus has been on aviation but the Center’s programs also address the afloat communities (surface, submarine and diving) and Marines.  The programs make heavy use of surveys and unit visits in addition to developing and presenting training and workshops.  Not surprisingly, the Navy stresses the importance of leadership, especially personal involvement and commitment, in creating a strong SC.  They recognize that implementing a strong SC faces a direct challenge from other organizational values such as the warfighter mentality*** and softer challenges in areas such as IT (where there are issues with multiple systems and data problems).

Program strengths include the focus on leadership (leadership drives climate, climate drives cultural change) and the importance of determining why mishaps occurred.  The positive influence of a strong SC on decision making is implied.

Program weaknesses can be inferred from what was not mentioned.  For example, there was no discussion of the importance of fixing problems or identifying hard-to-see technical problems.  More significantly, there was no mention of High Reliability Organization (HRO) attributes, a real head-scratcher given that some of the seminal work on HROs was conducted on aircraft carriers. 

Adm. Eccles' (Navy ret.) presentation**** basically reviews the Navy’s SUBSAFE program and its focus on compliance with program requirements from design through operations.  Eccles notes that ignorance, arrogance and complacency are challenges to maintaining an effective program.

Mr. Griffon's (Chemical Safety Board Member) presentation***** illustrates the CSB’s straightforward approach to investigating incidents, as reflected in the following quotes:

“Intent of CSB investigations are to get to root cause(s) and make recommendations toward prevention.” (p. 3)

While searching for root causes the CSB asks: “Why conditions or decisions leading to accident were seen as normal, rational, or acceptable prior to the accident.” (p. 4)

CSB review of incident-related artifacts includes two of our hot button issues, Process Safety Management action item closure (akin to a CAP) and the repair backlog. (p. 5)  Griffon reviews major incidents, e.g., Texas City and Deepwater Horizon.  For Deepwater, he notes how certain decisions were (deliberately) incompletely informed, i.e., did not utilize readily available relevant information, and thus are indicative of an inadequate SC. (p. 16)  Toward the end Griffon observes that “Safety culture study/change must consider inequalities of power and authority.” (p. 19)  That seems obvious but it doesn’t often get said so clearly.

We like the CSB’s approach.  There is no new information here but it’s a quick read of what basic SC should and shouldn’t be.

Prof. Meshkati's (Univ. of S. Cal.) presentation^ compares the cultures at TEPCO’s Fukushima Daiichi plant and Tohoku Electric’s Onagawa plant.  It is mainly a rehash of the op-ed Meshkati co-authored back in March 2014 (and we reviewed on March 19, 2014.)  The presentation adds something we pointed out as an omission in that op-ed, viz., that TEPCO’s Fukushima Daini plant eventually managed to shut down safely after the earthquake and tsunami.  Meshkati notes approvingly that Daini personnel exhibited impromptu, but prudent, decision-making and improvisation, e.g., by flexibly applying emergency operation procedures. (p. 37)

Prof. Sutcliffe (John Hopkins Univ.) co-authored an important book on High Reliability Organizations (which we reviewed on May 3, 2013) and this academically-oriented presentation^^ draws on her earlier work.  It begins with a familiar description of culture and how its evolution can be influenced.  Importantly it shows rewards (including money) as a key input affecting the link between leaders’ philosophy and employees’ behavior. (p. 6) 

Sutcliffe discusses how failure to redirect action (in a situation where a change is needed) can result from failure of foresight or sensemaking, or being overcome by dysfunctional momentum.  She includes a lengthy example featuring wildland firefighters that illustrates the linkages between cues, voiced concerns, search for disparate perspectives, situational reevaluation and redirected actions.  It’s worth a few minutes of your time to flip through these slides.

Our Perspective

For starters, the Naval Safety Center's
activities may be too bureaucratic, with too many initiatives and programs, and focused mainly on compliance with procedures, rules, designs, etc.  It’s not clear what SC lessons can be learned from the Navy experience beyond the vital role of leadership in creating a cultural vision and attempting to influence behavior toward that vision.

The other presenters added nothing that was not already available to you, either through Safetymatters or from observing SC tidbits in the information soup that flows by everyone these days.

Subsequent to the first hearing we reported that Safety Conscious Work Environment (SCWE) issues exist at multiple DOE sites (see our July 8, 2014 post).  This should increase the sense of urgency associated with strengthening SC throughout DOE.  However, our bottom line remains the same as after the first hearing: “The DNFSB is still trying to figure out the correct balance between prescription and flexibility in its effort to bring DOE to heel on the SC issue.  SC is a vital part of the puzzle of how to increase DOE line management effectiveness in ensuring adequate safety performance at DOE facilities.” 

*  DNFSB Aug. 27, 2014 Public Hearing on Safety Culture and Board Recommendation 2011-1.  There is a video of the hearing available.

**  K.J. Norton (U.S. Navy), “The Naval Safety Center and Naval Safety Culture,“ presentation to DNFSB (Aug. 27, 2014).

***  “Anything, anywhere, anytime…at any cost”—desirable warfighter mentality perceived to conflict with safety.” (p. 11)

****  T. J. Eccles (U.S. Navy ret.), “A Culture of Safety: Submarine Safety in the U. S. Navy,” presentation to DNFSB (Aug. 27, 2014).

*****  M.A. Griffon (Chem. Safety Bd.), “CSB Investigations and Safety Culture,” presentation to DNFSB (Aug. 27, 2014).

^  Najm Meshkati, “Leadership and Safety Culture: Personal Reflections on Lessons Learned,” presentation to DNFSB (Aug. 27, 2014).  Prof. Meshkati was also the technical advisor to the National Research Council’s safety culture lessons learned from Fukushima report which we reviewed on July 30, 2014.

^^  K.M. Sutcliffe, “Leadership and Safety Culture,” presentation to DNFSB (Aug. 27, 2014).

Wednesday, August 20, 2014


The International Atomic Energy Agency (IAEA) offers an Operational Safety Review Team (OSART) program where international teams of experts conduct in-depth reviews of nuclear power plant operational safety performance.  Performance is reviewed in various areas such as management, training, operations, maintenance, etc.  The reports also include comments about plant safety culture (SC).  IAEA has conducted scores of OSART reviews, including U.S. power plants.  This post covers SC-related findings for the U.S. plants; we are interested in what kinds of SC strengths and weaknesses the teams identify during their approximately two-week visits.

North Anna (2000)

This is the earliest OSART report available in the NRC ADAMS database.  There are two versions of the report, one distributed to NRC Commissioners on Nov. 30, 2000* and another released by IAEA on Feb. 12, 2001.**  Both versions include generally complimentary language related to SC saying management is committed to safety and continuous improvement is nurtured. (p. 7 in 2000 report)  In the Operations area the report notes “Policies and management verbal communication are consistent and emphasize the importance of safety first.  Safety culture is referred to at several hierarchical levels of the plant.” (p. 31 in 2000 report)

There is an interesting discrepancy between the two versions.  The first report says “The emphasis the plant is making on self-assessment and improving human performance to bring about a sustaining safety culture is presently balancing the perception of increased cost drivers and short term budgeting.” (p. 13)  This hints at a cost vs. safety goal conflict, a serious challenge to maintaining a strong SC.  However, the second report does not include that statement, instead noting elsewhere that “In the teams opinion, however, there is presently little resource margin to absorb increased demands and although the highly motivated staff continue to look for ways to improve, the potential for complacency and demotivation from the prospect of long term challenges with aging facilities and equipment and tightening budget poses a risk to maintaining that performance.” (p. 9)  Is this just a more politic way of saying the same thing or does it reflect an actual watering down of the report?

Brunswick (2005)

The report*** covers the initial visit and the follow-up visit 19 months later.  SC is treated more thoroughly than in earlier reviews: “An important element of the OSART review is the identification of those findings that exhibit positive and negative attributes of safety culture.” (p. 7)  At Brunswick positive SC attributes included a questioning attitude of all personnel, a strong self-assessment program, and adherence to established procedures.  Improvement opportunities included the need for increased attention for continuous improvement, greater use of self criticism when observing safety systems and components, and further expanding external operating experience activities. (p. 10) 

The team’s in-depth review of the corrective action program (CAP) provides a look at the SC in practice.  “The corrective action programme is very strong and closely monitored.” (p. 97)  Aging mechanisms, especially corrosion, are a challenge for the corrective action program (p. 69) but the plant’s response led to this issue being closed during the follow-up visit.  Rework is analyzed by a committee to address effective corrective actions (p. 57) but maintenance backlogs require constant attention. (p. 59)  After the team’s initial visit the plant developed a new system for classifying condition reports; at follow-up the team observed “Based on the new graded system, the plant is improving opportunities to focus analyses and resources in accordance with the significance of the events.” (p. 100)  Overall, this seems reflective of a SC that supports both the CAP and efforts to improve it.

Another finding reflecting SC was that the plant Management Succession Planning and Development Program did not include safety performance in talent assessment, ranking or as a specified core skill.  Brunswick claimed these factors were implicitly considered but strengthened the program to explicitly include nuclear safety, radiation safety and industrial safety goals for each plant staff member.  The review team found this action sufficient to close the issue. (pp. 21-22)  This is also indicative of a culture that encourages improvement efforts.

Arkansas Nuclear One (2008) 

The positive SC attributes in this report**** include a strong Human Performance program with a focus on continuous improvement, a rigorous and conservative approach when planning and performing tasks, and a willingness of staff to correct each other’s behavior without waiting to be corrected by management.  In addition, conservative decision making is a core value within the management team.  Problem areas include long standing defects throughout the plant (and first attempts to fix problems that do not always work), policies such as overtime and time pressure on outage schedule that suggest the plant is “cost” driven, and the benchmarking program does not work from a broad international base. (pp. 4-5, 34).  Both an ineffective CAP and a cost-driven plant (i.e, goal conflict between cost and safety) reflect a weak SC.

Seabrook (2011)

In the Seabrook report***** SC strengths include consistent reinforcement of key values by the management team and no evidence of production taking precedence over safety.  Opportunities for improvement include a more aggressive approach to addressing long term issues, thus reducing the potential for staff normalization to less than excellent conditions. (pp. 4, 45)

A positive observation is that plant communications stress safety as the no. 1 priority. (p. 7)  Another is that Seabrook has a problem reporting culture based on a low-threshold and high-volume reporting system. (pp. 2, 56)  Personnel who report problems outside their area of responsibility are recognized with a “Good Catch” award.  Personnel writing lots of condition reports is generally a good thing but some corrective actions are closed prematurely. (pp. 54-56, 59)

More significantly, plant problems include a lack of resolution of long term issues, plant material condition deterioration and degraded equipment conditions. (pp. 2, 44-45)  Significant backlogs exist in the CAP, work orders and procedure change requests. (p. 8)  Work backlogs are an indication of a culture that lives with issues rather than resolving them.

Seabrook SC standards are summarized as “very positive” (p. 4) and maybe they are, but the reality of backlogs and unresolved long-term issues is inconsistent with a strong SC. 

Our Perspective

It’s probably unrealistic to expect a group of foreigners to visit a U.S. plant for two weeks and come up with significant SC insights.^  The summaries of SC positives and negatives appear to be relatively superficial but findings in the functional areas can offer a look at the actual underlying SC.  Some of the OSART observations and findings on key artifacts provide information from which we can infer the strength of SC at a plant being reviewed. 

We would like to see greater attention to how important decisions are made at a plant.  Decision making was only mentioned in passing (North Anna, p. 31) or a simple statement like plant performance indicators are a key input to decision making. (ANO, p. 6)

Finally, compensation and reward systems appear to be outside the OSART scope but we know these are critical to reinforce safety-related behavior and overall SC.

*  J.D. Lee (NRC) to NRC Commissioners, “IAEA Report on OSART Mission at North Anna Power Station, January 22 to February 10, 2000” (Nov. 30, 2000).  ADAMS ML010160525.

**  IAEA, “Report of the OSART Mission to the USA North Anna Nuclear Power Plant 22 January to 10 February 2000” (Released Feb. 12, 2001).  ADAMS ML010470115.

***  IAEA, “Report of the OSART Mission to the Brunswick Nuclear Plant United States of America 9-25 May 2005 and Follow Up Visit 4-8 December 2006” no date.  ADAMS ML071100006.

****  IAEA, “Report of the OSART Mission to the Arkansas Nuclear One Nuclear Power Plant United States of America 15 June – 2 July 2008
no date.  ADAMS ML083440148.

*****  P. Freeman (Seabrook) to NRC, “IAEA Final Report OSART Mission to Seabrook Nuclear Power Plant USA 6-23 June 2011” (Mar. 16, 2012).  ADAMS ML12081A105.

^  A partial view is suggested in the Foreword to the Seabrook report where the authors note that an OSART review represents a “snapshot in time.”  In fairness, it would be equally unrealistic to expect a team of Americans to visit a foreign plant and develop a deep understanding of plant culture in a similar time period.

Thursday, August 7, 2014

1995 ANS Safety Culture Conference: A Portal to the Past

In April 1995 the American Nuclear Society (ANS) sponsored a nuclear safety culture (SC) conference in Vienna.  This was a large undertaking, with over 80 presentations; the proceedings are almost 900 pages in length.*  Presenters included industry participants, regulators, academics and consultants.  1995 was early in the post-Soviet era and the new openness (and concerns about Soviet reactors) led to a large number of presenters from Russia, Ukraine and Eastern Europe.  This post presents some conference highlights on topics we emphasize on Safetymatters.

Decision Making

For us, decision making should be systemic, i.e., consider all relevant inputs and the myriad ways a decision can affect consequences.  The same rigor should be applied to all kinds of decisions—finance, design, operations, resource allocation, personnel, etc.  Safety should always have the highest priority and decisions should accord safety its appropriate consideration.  Some presenters echoed this view.

“Safety was (and still is) seen as being vital to the success of the industry and hence the analysis and assessment of safety became an integral part of management decision making” (p. 41); “. . . in daily practice: overriding priority to safety is the principle, to be taken into account before making any decision” (p. 66); and “The complexity of operations implies a systemic decision process.” (p. 227)

The relationship between leadership and decisions was mentioned.  “The line management are a very important area, as they must . . . realise how their own actions and decisions affect Safety Culture.  The wrong actions, or perceived messages could undermine the work of the team leaders” (p. 186); “. . . statements alone do not constitute support; in the intermediate and long-term, true support is demonstrated by behavior and decision and not by what is said.” (p. 732)

Risk was recognized as a factor in decision making.  “Risk culture yields insights that permit balanced safety vs.cost decisions to be made” (p. 325); “Rational decision making is based on facts, experience, cognitive (mental) models and expected outcomes giving due consideration to uncertainties in the foregoing and the generally probabilistic nature of technical and human matters.  Conservative decision making is rational decision making that is risk-averse.  A conservative decision is weighted in favor of risk control at the expense of cost.” (p. 435)

In sum, nuclear thought leaders knew what good decision making should look like—but we still see cases that do not live up to that standard.


Rewards or compensation were mentioned by people from nuclear operating organizations.  Incentive-based compensation was included as a key aspect of the TEPCO management approach (p. 551) and a nuclear lab manager recommended using monetary compensation to encourage cooperation between organizational departments. (p. 643)  A presenter from a power plant said “A recognition scheme is in place . . . to recognise and reward individuals and teams for their contribution towards quality improvement and nuclear safety enhancement.” (p. 805)

Rewards were also mentioned by several presenters who did not come from power plants.  For example, the reward system should stress safety (p. 322); rewards should be given for exhibiting a “caring attitude” about SC (p. 348) and to people who call attention to safety problems. (p. 527)  On the flip side, a regulator complained about plants that rewarded behavior that might cause safety to erode. (pp. 651, 656) 

Even in 1995 the presentations could have been stronger since INSAG-4** is so clear on the topic: “Importantly, at operating plants, systems of reward do not encourage high plant output levels if this prejudices safety.  Incentives are therefore not based on production levels alone but are also related to safety performance.” (INSAG-4, p. 11)  Today, our own research has shown that nuclear executives’ compensation often favors production.   

Systems Approach

We have always favored nuclear organizational mental models that consider feedback loops, time delays, adaptation, evolution and learning—a systems approach.  Presenters’ references to a system include “commercial, public, and military operators of complex high reliability socio-technical systems” (p. 260); “. . . assess the organisational, managerial and socio-technical influences on the Safety Culture of socio-technical systems such as nuclear power plants” (p. 308); “Within the complex system such as . . . [a] nuclear power plant there is a vast number of opportunities for failures to stay hidden in the system” (p. 541); and “It is proposed that the plant should be viewed as an integrated sociotechnical system . . .” (p. 541)

There are three system-related presentations that we suggest you read in their entirety; they have too many good points to summarize here.  One is by Electricit√© de France (EdF) personnel (pp. 193-201), another by Constance Perin (pp. 330-336) and a third by John Carroll (pp. 338-345). 

Here’s a sample, from Perin: “Through self-analysis, nuclear organizations can understand how they currently respond socially, culturally, and technically to such system characteristics of complexity, density, obscured signals, and delayed feedback in order to assure their capacities for anticipating, preventing, and recovering from threats to safety.” (p. 330)  It could have been written yesterday.

The Role of the Regulator

By 1995 INSAG-4 had been published and generally accepted by the nuclear community but countries were still trying to define the appropriate role for the regulator; the topic merited a half-dozen presentations.  Key points included the regulator (1) requiring that an effective SC be established, (2) establishing safety as a top-level goal and (3) performing some assessment of a licensee’ safety management system (either directly or part of ordinary inspection duties).  There was some uncertainty about how to proceed with compliance focus vs. qualitative assessment.

Today, at least two European countries are looking at detailed SC assessment, in effect, regulating SC.  In the U.S., the NRC issued a SC policy statement and performs back-door, de facto SC regulation through the “bring me another rock” approach.

So conditions have changed in regulatory space, arguably for the better when the regulator limits its focus to truly safety-significant activities.

Our Perspective

In 1995, some (but not all) people held what we’d call a contemporary view of SC.  For example, “Safety culture constitutes a state of mind with regard to safety: the value we attribute to it, the priority we give it, the interest we show in it.  This state of mind determines attitudes and behavior.” (p. 495)

But some things have changed.  For example, several presentations mentioned SC surveys—their design, administration, analysis and implications.  We now (correctly) understand that SC surveys are a snapshot of safety climate and only one input into a competent SC assessment.

And some things did not turn out well.  For example, a TEPCO presentation said “the decision making process is governed by the philosophy of valuing harmony highly so that a conclusion preferred by all the members is chosen as far as possible when there are divided opinions.” (p. 583)  Apparently harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards. 

*  A. Carnino and G. Weimann, ed., “Proceedings of the International Topical Meeting on Safety Culture in Nuclear Installations,” April 24-28, 1995 (Vienna: ANS Austria Local Section, 1995).  Thanks to Bill Mullins for unearthing this document.

**  International Nuclear Safety Advisory Group, “Safety Culture,” Safety Series No. 75-INSAG-4, (Vienna: IAEA, 1991). INSAG-4 included a definition of SC, a description of SC components, and illustrative evidence that the components exist in a specific organization.

Wednesday, July 30, 2014

National Research Council: Safety Culture Lessons Learned from Fukushima

The National Research Council has released a report* on lessons learned from the Fukushima nuclear accident that may be applicable to U.S. nuclear plants.  The report begins with a recitation of various Fukushima aspects including site history, BWR technology, and plant failure causes and consequences.  Lessons learned were identified in the areas of Plant Operations and Safety Regulations, Offsite Emergency Management, and Nuclear Safety Culture (SC).  This review focuses on the SC aspects of the report.

Spoiler alert: the report reflects the work of a 24-person committee, with the draft reviewed by two dozen other individuals.**  We suggest you adjust your expectations accordingly.

The SC chapter of the report provides some background on SC and echoes the by-now familiar cultural issues at both Tokyo Electric Power Company (TEPCO) and Japan’s Nuclear Energy Agency.  Moving to the U.S., the committee summarizes the current situation in a finding: “The U.S. nuclear industry, acting through the Institute of Nuclear Power Operations, has voluntarily established nuclear safety culture programs and mechanisms for evaluating their implementation at nuclear plants. The U.S. Nuclear Regulatory Commission has published a policy statement on nuclear safety culture, but that statement does not contain implementation steps or specific requirements for industry adoption.” (p. 7-8)  This is accurate as far as it goes.

After additional discussion of the U.S. nuclear milieu, the chapter concludes with two recommendations, reproduced below along with associated commentary.

An Effective, Independent Regulator

“RECOMMENDATION 7.2A: The U.S. Nuclear Regulatory Commission and the U.S. nuclear power industry must maintain and continuously monitor a strong nuclear safety culture in all of their safety-related activities. Additionally, the leadership of the U.S. Nuclear Regulatory Commission must maintain the independence of the regulator. The agency must ensure that outside influences do not compromise its nuclear safety culture and/or hinder its discussions with and disclosures to the public about safety-related matters.” (pp. S-9, 7-17)

In the lead up to this recommendation, there was some lack of unanimity on the subject of whether the NRC was sufficiently independent and if some degree of regulatory capture has occurred.  The debate covered industry involvement in rule-making, Davis-Besse and other examples.

We saw one quote worth repeating here: “The president and Senate of the United States also play important roles in helping to maintain the USNRC’s regulatory independence by nominating and appointing highly qualified agency leaders (i.e., commissioners) and working to ensure that the agency is free from undue influences.” (pp. 7-14/15)  We’ll leave it to the reader to determine if the executive and legislative branches met that standard with the previous NRC chairman and the two current commissioner nominees, both lawyers—one an NRC lifer and the other a former staffer on the Hill.

Snarky comment notwithstanding, the first recommendation is a motherhood statement and borderline tautology (who can envision the effective negation of any of the three imperative statements?)  More importantly, it appears only remotely related to the concept of SC; even at its simplest, SC consists of values and artifacts and there’s not much of either in the recommendation.

Increased Industry Transparency

“RECOMMENDATION 7.2B: The U.S. nuclear industry and the U.S. Nuclear Regulatory Commission should examine opportunities to increase the transparency of and communication about their efforts to assess and improve their nuclear safety cultures.” (pp. S-9, 7-17)

The discussion includes a big kiss for INPO.  “INPO has taken the lead for promoting a strong nuclear safety culture in the U.S. nuclear industry through training and evaluation programs.” (p. 7-10)  The praise for INPO continues in an attachment to the SC chapter but it eventually gets to the elephant in the room: “The results of INPO’s inspection program are shared among INPO membership, but such information is not made available to the public. . . . Releases of summaries of these inspections by management to the public would help increase transparency.” (p. 7-21)

The committee recognizes that implementing the recommendation “would require that the industry and regulators disclose additional information to the public about their efforts to assess safety culture effectiveness, remediate deficiencies, and implement improvements.” (p. 7-17)

At least transparency is a cultural attribute.  We have long opined that 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. 

Our Perspective

This report looks like what it is: a crowd sourced effort by a focus group of academics using the National Academy of Sciences’ established bureaucratic processes.  The report is 367 pages long, with over 350 references and a bunch of footnotes.  The committee’s mental model of SC focuses on organizational processes that influence SC. (p. 7-1)  I think it's fair to infer that their notion of improvement is to revise the rules that govern the processes, then maximize compliant behavior.  Because of the committee’s limited mental model, restricted mission*** and the real or perceived need to document every factoid, the report ultimately provides no new insights into how U.S. nuclear plants might actually realize stronger SC.

*  National Research Council Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants, “Lessons Learned from the Fukushima Nuclear Accident for Improving Safety of U.S. Nuclear Plants” Prepublication Copy.  Downloaded July 26, 2014.  The National Research Council is part of the National Academy of Sciences (NAS).  Thanks to Bill Mullins for bringing this report to our attention.

**  The technical advisor to the committee was Najmedin Meshkati from the University of Southern California.  If that name rings a bell with Safetymatters readers, it may be because he and his student, Airi Ryu, published an op-ed last March contrasting the culture of Tohoru Electric with the culture of TEPCO.  We posted our review of the op-ed here.

***  The committee was tasked to consider causes of the Fukushima accident, conclusions from previous NAS studies and lessons that can be learned to improve nuclear plant safety in certain specified areas.  The committee was directed to not make any policy recommendations that involved non-technical value judgments. (p. S-10)

Thursday, July 24, 2014

Palisades: Back in the NRC’s Safety Culture Dog House

Our last Palisades post was on January 30, 2013 where we described the tortuous logic the NRC employed to conclude Palisades’ safety culture (SC) had become “adequate and improving.”  Or was it?  The NRC has recently parlayed an isolated Palisades incident into multiple requirements, one fleet-wide, to strengthen SC.  Details follow, taken from the resulting Confirmatory Order.*

The Incident

A Palisades security manager asked a security supervisor to cover a 2-hour partial shift because another supervisor had requested time off on Christmas Eve 2012.  Neither the manager nor the supervisor verified the supervisor had the necessary qualifications for the assignment.  He didn’t, which violated NRC regulations and the site security plan.  The problem came to light when two condition reports were written questioning the manager’s decision. (pp. 2-3)

How the Incident was Handled and Settled

Entergy requested Alternative Dispute Resolution (ADR), a process whereby the NRC and the licensee meet with a third party mediator to work out a resolution acceptable to both parties.

The Consequences

Entergy’s required corrective actions include what we’d expect, viz., action to improve and ensure adherence to security procedures.  In addition, Entergy is required to take multiple actions to strengthen SC.  These actions are spelled out in the Confirmatory Order and focus on several SC traits: (1) Leadership, Safety Values and Actions; (2) Problem Identification and Resolution; (3) Personal Accountability; (4) Work Processes; (5) Environment for Raising Concerns; and (6) Questioning Attitude and Proceeding In the Face of Uncertainty. (p. 4)

Specific requirements relate to (1) actions already implemented or to be implemented via Palisades’ Security Safety Conscious Work Environment Action Plan, (2) revising a Condition Review Group procedure to ensure the chairman considers whether the person assigned to a condition report is sufficiently independent, (3) developing and presenting a case study throughout the Entergy fleet that highlights the SC aspects of the event and (4) discussing the SC aspects of the issue with Palisades staff at three monthly tailgate meetings. (pp. 4-6, 11-12)

Our Perspective

The incident appears localized and the NRC said it had very low security significance.  Maybe Entergy thought they’d avoid any sort of penalty if they requested ADR.  Looks to us like they gambled and lost.  The NRC must think so, they are fairly gloating over the outcome.  In the associated press release, the Region III Administrator says: “Using the ADR process allowed us to achieve not only compliance with NRC requirements, but a wide range of corrective actions that go beyond those the agency may get through the traditional enforcement process”.**

Is the NRC using an elephant gun to shoot a mouse?  Or is there some unstated belief that Palisades’ SC is not as good as it should be and/or Entergy as a whole doesn’t properly value SC*** and this is a warning shot?  Or is something else going on?  You be the judge.

*  C.D. Pederson (NRC) to A. Vitale (Entergy), “Confirmatory Order Related to NRC Report No. 05000255/2014406 and OI Report 3-2013-018; Palisades Nuclear Plant” (July 21, 2014).  ADAMS ML14203A082.

**  NRC Press Release “NRC Issues Confirmatory Order to Entergy Regarding Palisades Nuclear Plant,” No. III-14-031 (July 22, 2014).

***  Entergy has had SC issues at other plants.  Click on the Entergy label for our related commentary.