The DNFSB report on the WTP was issued June 9, 2011; it said the WTP SC was “flawed.” Issues included discouraging technical dissent, goal conflicts between schedule/budget and safety, and intimidation of personnel. We posted on the DNFSB report June 15, 2011. The report’s recommendations included this one: that the Secretary of Energy “conduct an Extent of Condition Review to determine whether these safety culture weaknesses are limited to the WTP Project, . . .” (DNFSB, p. 6)
After some back-and-forth between DOE and DNFSB, DOE published their IP in December 2011. We reviewed the IP on Jan. 24, 2012. Although the IP contained multiple action items, our overall impression was “that DOE believes there is no fundamental safety culture issue. . . . While endlessly citing all the initiatives previously taken or underway, never does the DOE reflect on why these initiatives have not been effective to date.” So we were not exactly optimistic but DOE did say it would “conduct an Extent of Condition Review to find out whether similar safety culture weaknesses exist at other sites in addition to the WTP and whether there are barriers to strong safety culture at Headquarters and the Department as a whole (e.g., policies or implementation issues). The review will focus on the Safety Conscious Work Environment (SCWE) at each site examined.” (IP, p. 17) In other words, SC was reduced to SCWE from the get-go.****
Part of the DOE review was to assess SCWE at a group of selected DOE facilities. DOE submitted SC assessments covering five facilities to DNFSB on Dec. 12, 2012. We reviewed the package in our post Jan. 25, 2013 and observed “The DOE submittal contained no meta-analysis of the five assessments, and no comparison to Vit Plant concerns. As far as [we] can tell, the individual assessments made no attempt to focus on whether or not Vit Plant concerns existed at the reviewed facilities.” We called the submittal “foot dragging” by DOE.
Report on SCWE Self-Assessments
A related DOE commitment was to perform SCWE self-assessments at numerous DOE facilities and then evaluate the results to determine if SCWE issues similar to WTP’s existed elsewhere. It is important to understand that this latest report is really only the starting point for evaluating the self-assessments because it focuses on the processes used during the self-assessments and not the results obtained.
The evaluation of the self-assessments was a large undertaking. The evaluation team visited 22 DOE and contractor organizations and performed document reviews for 9 additional organizations, including the DOE Office of River Protection and Bechtel National, major players in the WTP drama.
Problems abounded. Self-assessment guidance was prepared but not distributed to all sites in a timely manner and there was no associated training. Each self-assessment team had a “subject matter expert” but the qualifications for that role were not specified. Data collection methods were not consistently applied and data analyses were of variable quality. As a consequence, the self-assessment approaches used varied widely and the results obtained had variable reliability.
The self-assessment reports exhibited varying quality. Some were satisfactory but “In many of the self-assessment reports, the overall conclusions did not accurately reflect the information in the data and analysis sections. In some cases, negative results were presented with a statement rationalizing or minimizing the issue, rather than indicating a need to find out more about the issue and resolve it. In other cases, although data and/or analysis reflected potential problems, those problems were not mentioned in the conclusions or executive summaries, which senior management is most likely to read.” (p. 7)
The evaluation team summarized as follows: “The overall approach ultimately used to self-assess SCWE across the complex did not provide for consistent application of assessment methodologies and was not designed to ensure validity and credibility. . . . The wide variation in the quality of methodologies and analysis of results significantly reduces the confidence in the conclusions of many of the self-assessments. Consequently, caution should be used in drawing firm conclusions about the state of SCWE or safety culture across the entire DOE complex based on a compilation of results from all the site self-assessments.” (p. iii)
“The Independent Oversight team concluded that DOE needs to take additional actions to ensure that future self-assessments provide a valid and accurate assessment of the status of the safety culture at DOE sites and organizations, . . .” (p. 8) This is followed by a series of totally predictable recommendations for process improvements: “enhance guidance and communications,” increase management “involvement in, support for, and monitoring of site self-assessments,” and “DOE sites . . . should increase their capabilities to perform self-assessments . . .” (pp. 9-10)
The steps taken to date do not inspire confidence in the DOE’s interest in determining if and what SCWE (much less more general SC) issues exist in the DOE complex. For the facilities that were directly evaluated, we have some clues to the existence similar problems. For the facilities that conducted self-assessments, so far we have—almost nothing.
There is one big step remaining: DOE also said it would “develop a consolidated report from the results of the self-assessments and HSS independent reviews.” (IP, p. 20) We await that report with bated breath.
For our U.S. readers: This is your tax dollars at work.
* DOE Office of Enforcement and Oversight, “Independent Oversight Evaluation of Line Self-Assessments of Safety Conscious Work Environment” (Feb. 2014).
** U.S. Dept. of Energy, “Implementation Plan for Defense Nuclear Facilities Safety Board Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant” (Dec. 2011).
*** Defense Nuclear Facilities Safety Board, Recommendation 2011-1 to the Secretary of Energy "Safety Culture at the Waste Treatment and Immobilization Plant" (Jun 9, 2011).
**** DOE rationalized reducing the scope of investigation from SC to SCWE by saying “The safety culture issues identified at WTP are primarily SCWE issues. . .” (p. 17) We posted a lecturette about SC being much more than SCWE here.