Tuesday, April 13, 2010

Vermont Yankee (part 5) - Muddy Water

In our April 5, 2010 post re Vermont Yankee we provided some initial thoughts on the report of the independent investigator regarding misleading statements provided by Entergy personnel to Vermont regulators, as contained in Entergy’s March 31, 2010 response to a March 1, 2010 NRC Demand for Information.* The Entergy filing also provides more detail on follow-up actions including an assessment of current site safety culture. In this post, we offer some additional observations and questions.
First, in our initial March 3, 2010 post regarding the VY situation, we disputed a prediction made by a third party that the administrative actions taken by Entergy for certain employees might have a detrimental effect on the safety culture at the plant - due to the way Entergy is treating its employees. In reality it appeared to us that any detrimental impact on safety culture would be more likely if Entergy had not taken appropriate actions. In Entergy’s report to the NRC, they provide the results of a follow-up assessment confirming that after the personnel actions employees were even more likely to raise concerns.
Also in our initial post we speculated that the Vermont Yankee events could have consequences for Entergy’s proposed spinout of six nuclear plants into a separate subsidiary. Since then Entergy has announced the cancellation of the spinout after a decision by New York re the extension of permits for their Indian Point plants.
However, after a careful review of the March 31 Entergy response, we are still left with water that is more than a little bit muddy. Entergy says a Synergy assessment a few months before the reporting event found safety culture at Vermont Yankee to be strong. After the event, Entergy states safety culture is strong or stronger, and with regard to the replaced staff, Entergy “continues to have confidence in the integrity of the affected employees.” Strong safety culture and organizational integrity are not supposed to add up to this kind of outcome. How then did things go wrong? How did the misleading statements to Vermont regulators come about and what was the cause?
A fundamental element of all nuclear plant problem resolution/corrective action programs is a determination of not just what happened, but why. Cause in other words, and in significant situations, the root cause. The root cause that led to eleven employees, including managers and site executives, being relieved of duties and disciplined is not contained in the Entergy materials. In fact, most of the focus appears to be on the safety culture of the plant staff both before and after the incident came to light and the personnel actions taken. Those actions and information appear to be reassuring in regards to the plant staff - but the plant staff was not where the problem occurred. There is also considerable emphasis on the fact that the managers have been replaced with competent substitutes. But haven’t those new managers been placed in exactly the same situation as the former managers were in? If it is not clear why the former managers failed to meet performance standards, then how is one confident that the replacements will do so?
As we have pointed out in other posts, the response to safety culture failures too often stresses the “values and beliefs” of personnel as the beginning and end of safety culture. We have argued that the situational parameters, including competing goals and interests, are at least as important if not paramount in trying to understand such issues.
What was the situation at Vermont Yankee and to what extent, if any, did it have an effect? The VY management team was operating in an environment where significant business decisions were in play. One was the extension of the operating license for VY which required approval by both the NRC and by the Vermont Senate. A second was the pending proposed spinout of nuclear units, including VY, into a separate subsidiary, a spinout that was expected to be worth billions of dollars to Entergy. SEC and other regulatory filings had been made by Entergy for the spinout and approvals were being sought from state regulators and the NRC.
Entergy’s March 31 NRC submittal also states, “Finally, neither the underlying report of investigation which led to the discipline, nor the interviews of the AFEs, identified any credible evidence to suggest that any weakness in the work environment or site safety culture contributed to a reluctance by anyone to provide clarifying or supplemental information to the relevant state officials. Indeed, there is no credible evidence that any of the AFEs are -- or were -- reluctant to report safety concerns or any other matter of potential regulatory significance or legal non-compliance.”
Does this mean that situational factors such as business priorities were evaluated and found not to be a contributor? If so, how was this done and what is the basis for such a conclusion? Or were such competing priorities acknowledged as potential influences and able to be dealt with as part of the management system? What other situational factors might have been present and to what effect?

*ADAMS Accession Number ML100910420
**ADAMS Accession Number ML100990409

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