(Ed. note: We have asked Bill Mullins to develop occasional posts for Safetymatters. His posts will focus on, but not be limited to, the Hanford Waste Treatment Plant aka the Vit Plant.)
In a recent post the question was posed: “Can reality in the nuclear operating environment be similar (to the challenges of production pressures on scientists), or is nuclear somehow unique and different?”
In a prior post a Chief Nuclear Officer is quoted: “ . . the one issue is our corrective action program culture, our -- and it’s a culture that evolved over time. We looked at it more of a work driver, more of a -- you know, it’s a way to manage the system rather than . . . finding and correcting our performance deficiency.”
Another recent post describes the inherently multi-factor and non-linear character of what we’ve come to refer to as “Nuclear Safety Culture.” Bob Cudlin observed: “We think there are a number of potential causes that are important to ensuring strong safety culture but are not receiving the explicit attention they deserve. Whatever the true causes we believe that there will be multiple causes acting in a systematic manner - i.e., causes that interact and feedback in complex combinations to either reinforce or erode the safety culture state.”
I’d like to suggest a framework in which these questions and observations can be brought into useful relationship for thinking about the future of the US National Nuclear Energy Enterprise (NNEE).
This week I read yet another report on the Black Swan at Fukushima – this one representing views of US Nuclear industry heavy weights. It is just one of perhaps a dozen reviews, complete or on-going, that are adding to the stew pot of observations, findings, and recommendations about lessons to be learned from those “wreck the plant” events. I was wondering how all this “stuff” comes together in a manner that gives confidence that the net reliability of the US NNEE is increased rather than encumbered.
Were all these various “nuclear safety” reports scientific papers of the type referred to in the recent news story, then we would understand how they are “received” into the shared body of knowledge. Contributions would be examined, validations pursued, implications assessed, and yes, rewards or sanctions for work quality distributed. This system for the conduct of scientific research is very mature and has seemingly responded well to the extraordinary growth in volume and variety of research during the past half-century.
In the case of the Fukushima reports (and I’d suggest as validated by the corresponding pile of Deepwater Horizon reviews) there is no process akin to the publishing standards commonly employed in science or other academic research. In form, industrial catastrophes are typically investigated with some variation of causal analysis; also typically a distinguished panel of “experts” is assembled to conduct the review.
The credentials of those selected experts are relied upon to lend gravity to report results; this is generally in lieu of any peer or independent stakeholder review. An exception to this occurs when legislative hearings are convened to receive testimony from panel members and/or the responsible officials implicated in the events – but these second tier reviews are more often political theater than exercises in “seeking to understand.”
Since the TMI accident this trial by Blue Ribbon Panel methodology has proliferated; often firms such a BP hire such reviews (e.g. the Baker Panel on Texas City) to be done for official stakeholders that are below the level of regulatory or legislative responsibility. In the case of Deepwater Horizon and Fukushima it has been virtually open season for interested parties with any sort of credentialed authority (i.e. academic, professional society, watchdog group, etc.) to offer up a formal assessment of these major events.
And today of course we have the 24 hour news cycle with its voracious maw and indiscriminate headline writers; and let’s not forget the opinionated individuals like me – blogging furiously away with no authentic credentials but personal experience! How, I ask myself, does “sense-making” occur across the NNEE in this flurry of bits and bytes – unencumbered by the benefit of a reasoning tradition such as the world of scientific research? Not very well would be my conclusion.
There would appear to be an unexamined assumption that some mechanisms do exist to vet all the material generated in these investigation reports, but that seems to be susceptible to the kind of “forest lost for the trees” misperception cited in the Chief Nuclear Officer’s quote regarding corrective action systems becoming “the way we think about managing work.”
I can understand how, for a line manager at a single nuclear plant site that is operating in the main course of its life cycle, a scarce resource pot would lead to focusing on every improvement opportunity you’d like to address appearing as a “corrective action.” I would go a step further and say that given the domination of 10 CFR 50 Appendix B on the hierarchical norms for “quality” and “safety” that managing to a single “list” makes sense – if only to ensure that each potential action is evaluated for its nuclear licensing implications.
At the site level, the CNO has a substantial and carefully groomed basis for establishing the relative significance of each material condition in the plant; in most instances administrative matters are brightly color-coded “nuclear” or “other.” As we move up the risk-reckoning ladder through corporate decision-making and then branching into a covey of regulatory bodies, stockholder perspectives, and public perceptions, the purity of issue descriptions degrades – benchmarks become fuzzy.
The overlap of stakeholder jurisdictions presents multiple perspectives (via diverse lexicons) for what “safety,” “risk,” and “culture” weights are to be assigned to any particular issue. Often the issue as first identified is a muddle of actual facts and supposition which may or may not be pruned upon further study. The potential for dilemmas, predicaments, and double-binding stakeholder expectations goes up dramatically.
I would suggest that responses to the recent spate of high-profile nuclear facility events, beginning with the Davis-Besse Reactor Pressure Vessel Head near-miss, has provoked a serious cleavage in our collective ability to reason prudently about the policy, industrial strategy, and regulatory levels of risk. The consequences of this cleavage are to increase the degree of chaotic programmatic action and to obscure the longer term significance of these large-scale, unanticipated/unwelcome events, i.e., Black Swan vulnerabilities.
In the case of the NNEE I hypothesize that we are victims of our own history – and the presumption of exceptional success in performance improvement that followed the TMI event. With the promulgation of the Reactor Oversight Process in 1999, NRC and the industry appeared to believe that a mature understanding of oversight and self-governance practice existed and that going forward clarity would only increase regarding what factors were important to sustained high reliability across the entire NNEE.
That presumption has proven a premature one, but it does not appear from the Fukushima responses that many in leadership positions recognize this fact. Today, the US NNEE finds itself trapped in a “limits to growth system.” That risk-reckoning system institutionalizes a series of related conclusions about the overall significance of nuclear energy health hazards and their relationship to other forms of risk common to all large industrial sectors.
The NNEE elements of thought leadership appear to act (on the evidence of the many Fukushima reports) as if the rationale of 10 CFR 50 Appendix B regarding “conditions adverse to quality” and the preeminence of “nuclear safety corrective actions” is beyond question. It’s time to do an obsolescence check on what I’ve come to call the Nuclear Fear Cycle.
Quoting Bob Cudlin again: “Whatever the true causes we believe that there will be multiple causes acting in a systematic manner - i.e., causes that interact and feedback in complex combinations to either reinforce or erode the safety culture state.” You are invited to ponder the following system.
(Mr. Mullins is a Principal at Better Choices Consulting.)