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).

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