Saturday, December 26, 2015

NRC IG Reviews DNFSB Organizational Culture and Climate

The Nuclear Regulatory Commission Inspector General (IG) provides IG services to the Defense Nuclear Facilities Safety Board (DNFSB), an independent government agency.  The DNFSB organizational culture and climate study* reviewed here was performed for the NRC IG by an outside consultant.

Summary of Methods and Results

The study’s methodology is familiar: Review relevant past reports, develop a survey instrument based on employee interviews and focus groups, administer the survey to all employees and interpret the results.

Themes (issues, shortcomings) brought up during the interviews included DNFSB’s handling of change management, communication, personnel development, leadership, internal procedures and performance management (aka personal recognition). (pp. 6-7)

The report compared the DNFSB survey results with three external norms: a cross-section of U.S. industry, U.S. employees working in Research and Development, and industries that have experienced significant changes with widespread employee impact.  The last group consists of organizations under stress because of reorganization, bankruptcy, layoffs, etc. (p. 14)

The report’s summary is not encouraging: “the general trend shows an unfavorable comparison for the DNFSB on all three external benchmarks, . . . Also, many employees feel they do not have the right tools and resources.  Along with that, 38 percent of employees say they plan to leave DNFSB in the next year.” (p. 4)

The employee survey had 14 categories, higher scores mean greater respondent agreement with positive traits.  Analyzing the survey responses in three different dimensions yielded one typical and two unusual results.  In our opinion, they suggest uneven DNFSB management effectiveness across the organization.

Across organizational groups, the General Manager and Admin/ Support groups scored above DNFSB averages on most categories; the Technical Director and Engineering groups scored below DNFSB averages on most categories. (p. 13)  In our experience, this is no surprise; bosses and admin people are usually more satisfied (or less dissatisfied) than the folks who have to get the work done.

Looking at employee tenure, employees with the shortest tenure scored the highest (this is typical) then the scores go downhill.  The longest tenured employees have the lowest scores, which is unusual; most organizations have a U-shaped curve, with newcomers and old timers the most satisfied. (p. 14)

By pay (GS or DN) level, “what is atypical is that the lowest-scoring group is not the lowest-level group, but instead the mid-level group, . . .” (p. 15)

The report identifies Sustainable Engagement (SE)** as a key category.  Using regression analysis, the authors identified five drivers (other survey categories) of SE, two that had acceptable survey scores and three that are candidates for organizational improvement interventions: communication, leadership and performance management. (p.17)  This is as close the report comes to suggesting what the DNFSB might actually do about their problems.

Our Perspective 

This report recognizes that DNFSB has significant challenges but it contains zero surprises.  It’s not even news.  The same or similar ground was covered by a Dec. 2014 organizational study performed for the DNFSB which we reviewed on Feb. 6, 2015.

Problems mentioned in the 2014 report include board dysfunctionality, communications, performance recognition, change management, frequent disruptive organizational changes, and the lack of management and leadership competence.  The 2014 report  included extensive discussion of possible organizational interventions and other corrective actions.

The NRC IG already knew change management was a serious challenge facing the DNFSB; it was mentioned in an Oct. 2014 IG report.***  That report was likely the impetus for this 2015 study.

The DNFSB has been in apparent disarray for over a year.  New members have been appointed to the Board this year, including a new chairman.  It remains to be seen whether they can address the internal challenges and, more importantly, provide meaningful recommendations to their single client, the U.S. Department of Defense.

Bottom line: This NRC IG consultant’s report adds little value to understanding the DNFSB’s organizational issues or developing effective corrective actions. 

*  Towers Watson, “DNFSB 2015 Culture and Climate Survey: Executive Overview of Key Findings” (Aug. 2015).  ADAMS ML15245A515.  Thanks to John Hockert for publicizing this report on the LinkedIn Nuclear Safety Culture forum.

**  Sustainable Engagement is defined as follows: “Assesses the level of DNFSB employees’ connection to the organization, marked by being proud to work at DNFSB, committing effort to achieve the goals (being engaged) having an environment that support productivity (being enabled) and maintaining personal well-being (feeling energized).” (p. 9)

**  H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.

Sunday, December 20, 2015

Fukushima and Volkswagen: Systemic Similarities and Observations for the U.S. Nuclear Industry

VW Logo (Source: Wikipedia)
Recent New York Times articles* have described the activities, culture and context of Volkswagen, currently mired in scandal.  The series inspired a Yogi Berra moment: “It’s deja vu all over again.”  Let’s look at some of the circumstances that affected Fukushima and Volkswagen and see if they give us any additional insights into the risk profile of the U.S. commercial nuclear industry.

An Accommodating Regulator

The Japanese nuclear regulator did not provide effective oversight of Tokyo Electric Power Co.  One aspect of this was TEPCO’s relative power over the regulator because of TEPCO’s political influence at the national level.  This was a case of complete regulatory capture.

The German auto regulator doesn’t provide effective oversight either.  “[T]he regulatory agency for motor vehicles in Germany is deliberately starved for resources by political leaders eager to protect the country’s powerful automakers, . . .” (NYT 12-9-15)  This looks more like regulatory impotence than capture but the outcome is the same.

In the U.S., critics have accused the NRC of being captured by industry.  We disagree but have noted that the regulator and licensees working together over long periods of time, even across the table, can lead to familiarity, common language and indiscernible mutual adjustments. 

Deference to Senior Managers

Traditionally in Japan, people in senior positions are treated as if they have the right answers, no matter what the facts facing a lower-ranking employee might suggest.  Members of society go along to get along.  As we said in an Aug. 7, 2014 post, “harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards.” 

The Volkswagen culture was a different but had the same effect.  The CEO managed through fear.  At VW, “subordinates were fearful of contradicting their superiors and were afraid to admit failure.”  A former CEO “was known for publicly dressing down subordinates . . .”  (NYT 12-13-15)

In the U.S., INPO’s singled-minded focus on the unrivaled importance of leadership can, if practiced by the wrong kind of people, lead to a suppression of dissent, facts that contradict the party line and the questioning attitude that is vital to maintain safe facilities.

Companies Not Responsible to All Legitimate Stakeholders

In the Fukushima plant design, TEPCO gave short shrift to local communities, their citizens, governments and first responders, ultimately exposing them to profound hazards.  TEPCO’s behavior also impacted the international nuclear power community, where any significant incident at one operator is a problem for them all.

Volkswagen’s isolation from public responsibilities is facilitated by its structure.  Only 12% of the company is held by independent shareholders.  Like other large German companies, the labor unions hold half the seats on VW’s board.  Two more seats are held by the regional government (a minority owner) which in practice cannot vote against labor. So the union effectively controls the board. (NYT 12-13-15)

We have long complained about the obsessive secrecy practiced by the U.S. nuclear industry, particularly in its relations with its self-regulator, INPO.  It is not a recipe for building trust and confidence with the public, an affected and legitimate stakeholder.

Our Perspective

The TEPCO safety culture (SC) was unacceptably weak.  And its management culture simply ignored inconvenient facts.

Volkswagen’s culture has valued technical competence and ambition, and apparently has lower regard for regulations (esp. foreign, i.e., U.S. ones) and other rules of the game.

We are not saying the gross problems of either company infect the U.S. nuclear industry.  But the potential is there.  The industry has experienced events that suggest the presence of human, technical and systemic shortcomings.  For a general illustration of inadequate management effectiveness, look at Entergy’s series of SC problems.  For a specific case, remember Davis-Besse, where favoring production over safety took the plant to the brink of a significant failure.  Caveat nuclear.

*  See, for example: J. Ewing and G. Bowley, “The Engineering of Volkswagen’s Aggressive Ambition,” New York Times (Dec. 13, 2015).  J. Ewing, “Volkswagen Terms One Emissions Problem Smaller Than Expected,” New York Times (Dec. 9, 2015).

Tuesday, November 17, 2015

Foolproof by Greg Ip: Insights for the Nuclear Industry

This book* is primarily about systemic lessons learned from the 2008 U.S. financial crisis and, to a lesser extent, various European euro crises. Some of the author’s observations also apply to the nuclear industry.

Ip’s overarching thesis is that steps intended to protect a system, e.g., a national or global financial system, may over time lead to over-confidence, increased risk-taking and eventual instability.  Stability breeds complacency.**  As we know, a well-functioning system creates a series of successful outcomes, a line of dynamic non-events.  But that dynamic includes gradual changes to the system, e.g., innovation or adaptation to the environment, that may increase systemic risk and result in a new crisis or unintended consequences

He sees examples that evidence his thesis in other fields.  For automobiles, the implementation of anti-lock braking systems leads some operators to drive more recklessly.  In football, better helmets mean increased use of the head as a weapon and more concussions and spinal injuries.  For forest fires, a century of fire suppression has led to massive fuel build-ups and more people moving into forested areas.  For flood control, building more and higher levees has led to increased economic development in historically flood-prone areas.  As a result, both fires and floods can have huge financial losses when they eventually occur.  In all cases, well-intentioned system “improvements” lead to increased confidence (aka loss of fear) and risk-taking, both obvious and implicit.  In short, “If the surroundings seem safer, the systems tolerate more risk.” (p. 18)

Ip uses the nuclear industry to illustrate how society can create larger issues elsewhere in a system when it effects local responses to a perceived problem.  Closing down nuclear plants after an accident (e.g., Fukushima) or because of green politics does not remove the demand for electric energy.  To the extent the demand shortfall is made up with hydrocarbons, additional people will suffer from doing the mining, drilling, processing, etc. and the climate will be made worse.

He cites the aviation industry as an example of a system where near-misses are documented and widely shared in an effort to improve overall system safety.  He notes that the few fatal accidents that occur in commercial aviation serve both as lessons learned and keep those responsible for operating the system (pilots and controllers) on their toes.

He also makes an observation about aviation that could be applied to the nuclear industry: “It is almost impossible to improve a system that never has an accident. . . . regulators are unlikely to know whether anything they propose now will have provable benefits; it also means that accidents will increasingly be of the truly mysterious, unimaginable variety . . .” (p. 252)

Speaking of finance, Ip says “A huge part of what the financial system does is try to create the fact—and at times the illusion—of safety.  Usually, it succeeds; . . . On those rare occasions when it fails, the result is panic.” (p. 86)  Could this description also apply to the nuclear industry? 

Our Perspective

Ip’s search for systemic, dynamic factors to explain the financial crisis echoes the type of analysis we’ve been promoting for years.  Like us, he recognizes that people hold different world views of the same system.  Ip contrasts the engineers and the ecologists:  “Engineers satisfy our desire for control, . . . civilization’s needs to act, to do something, . . .” (p. 278)  Ecologists believe “it’s the nature of risk to find the vulnerabilities we missed, to hit when least expected, to exploit the very trust in safety we so assiduously cultivate with all our protection . . .” (p. 279)

Ip’s treatment of the nuclear industry, while positive, is incomplete and somewhat simplistic.  It’s really just an example, not an industry analysis.  His argument that shutting down nuclear plants exacerbates climate harm could have come from the NEI playbook.  He ignores the impact of renewables, efficiency and conservation.

He doesn’t discuss the nuclear industry’s penchant for secrecy, but we have and believe it feeds the public’s uncertainty about the industry's safety.  As Ip notes, “People who crave certainty cannot tolerate even a slight increase in uncertainty, and so they flee not just the bad banks, the bad paper, and the bad country, but everything that resembles them, . . .” (p. 261)  If a system that is assumed [or promoted] to be safe has a crisis, even a local one, the result is often panic. (p. 62)

He mentions high reliability organizations (HROs) focusing on their avoiding catastrophe and “being a little bit scared all of the time.” (p. 242)  He does not mention that some of the same systemic factors of the financial system are at work in the world of HROs, including exposure to the corrosive effects of complacency and system drift. (p. 242)

Bottom line: Read Foolproof if you have an interest in an intelligible assessment of the financial crisis.  And remember: “Fear serves a purpose: it keeps us out of trouble.” (p. 19)  “. . . but it can keep us from taking risks that could make us better off.” (p. 159)

*  G. Ip, Foolproof (New York: Little, Brown, 2015).  Ip is a finance and economics journalist, currently with the Wall Street Journal and previously with The Economist.

**  He quotes a great quip from Larry Summers: “Complacency is a self-denying prophecy.”  Ip adds, “If everyone worried about complacency, no one would succumb to it.” (p.263)

Monday, November 2, 2015

Cultural Tidbits from McKinsey

We spent a little time poking around the McKinsey* website looking for items that could be related to safety culture and found a couple.  They do not provide any major insights but they do spur us to think of some questions for you to ponder about your own organization.

One article discussed organizational redesign** and provided a list of recommended rules, including establishing metrics that show if success is being achieved.  Following is one such metric.

“One utility business decided that the key metric for its efficiency-driven redesign was the cost of management labor as a proportion of total expenditures on labor.  Early on, the company realized that the root cause of its slow decision-making culture and high cost structure had been the combination of excessive management layers and small spans of control.  Reviewing the measurement across business units and at the enterprise level became a key agenda item at monthly leadership meetings.” (p. 107)

What percent of total labor dollars does your organization spend on “management”?  Could your organization’s decision making be speeded up without sacrificing quality or safety?  Would your organization rather have the “right” decision (even if it takes a long time to develop) or no decision at all rather than risk announcing a “wrong” one?

A second article discussed management actions to create a longer view among employees,*** including clearly identifying and prioritizing organizational values.  Following is an example of action related to values.

“The pilots of one Middle East–based airline frequently write incident reports that candidly raise concerns, questions, and observations about potential hazards.  The reports are anonymous and circulate internally, so that pilots can learn from one another and improve—say, in handling a particularly tricky approach at an airport or dealing with a safety procedure.  The resulting conversations reinforce the safety culture of this airline and the high value it places on collaboration.  Moreover, by making sure that the reporting structures aren’t punitive, the airline’s executives get better information and can focus their attention where it’s most needed.”

How do your operators and other professionals share experiences and learning opportunities among themselves at your site?  How about throughout your fleet?  Does documenting anything that might be construed as weakness require management review or approval?  Is management (or the overall organization) so fearful of such information being seen by regulators or the public, or discovered by lawyers, that the information is effectively suppressed?  Is your organization paranoid or just applying good business sense?  Do you have a culture that would pass muster as “just”?

Our Perspective

Useful nuggets on management or culture are where you find them.  Others’ experiences can stimulate questions; the answers can help you better understand local organizational phenomena, align your efforts with the company’s needs and build your professional career.

*  McKinsey & Company is a worldwide management consulting firm.

**  S. Aronowitz et al, “Getting organizational redesign right,” McKinsey Quarterly, no. 3 (2015), pp. 99-109.

***  T. Gibbs et al, “Encouraging your people to take the long view,” McKinsey Quarterly (Sept. 2012).

Monday, October 12, 2015

IAEA International Conference on Operational Safety, including Safety Culture

IAEA Building
Back in June, the International Atomic Energy Agency (IAEA) hosted an International Conference on Operational Safety.*  Conference sessions covered Peer Reviews, Corporate Management, Post-Fukushima Improvements, Operating Experience, Leadership and Safety Culture and Long Term Operation.  Later, the IAEA published a summary of conference highlights, including conclusions in the session areas.**  It reported the following with respect to safety culture (SC):

“No organization works in isolation: the safety culture of the operator is influenced by the safety culture of the regulator and vice versa. Everything the regulator says or does not say has an effect on the operator. The national institutions and other cultural factors affect the regulatory framework. Corporate leadership is integral to achieving and improving safety culture, the challenge here is that regulators are not always allowed to conduct oversight at the corporate management level.”

Whoa!  This is an example of the kind of systemic thinking that we have been preaching for years.  We wondered who said that so we reviewed all the SC presentations looking for clues.  Perhaps not surprisingly, it was a bit like gold-mining: one has to crush a lot of ore to find a nugget.

Most of the ore for the quote was provided by a SC panelist who was not one of the SC speakers but a Swiss nuclear regulator (and the only regulator mentioned in the SC session program).  Her slide bullets included “The regulatory body needs to take different perspectives on SC: SC as an oversight issue, impact of oversight on licensees’ SC, the regulatory body’s own SC, [and] Self-reflection on its own SC.”  Good advice to regulators everywhere.

As far as we can tell, no presenter made the point that regulators seldom have the authority to oversee corporate management; perhaps that arose during the subsequent discussion.

SC Presentations

The SC presentations contained hearty, although standard fare.  A couple were possibly more revealing, which we’ll highlight later.

The German, Japanese and United Kingdom presentations reviewed their respective SC improvement plans.  In general these plans are focused on specific issues identified during methodical diagnostic investigations.  The plan for the German Philippsburg plant focuses on specific management responsibilities, personnel attitudes and conduct at all hierarchy levels, and communications.  The Japanese plan concentrates on continued recovery from the Fukushima disaster.  TEPCO company-wide issues include Safety awareness, Engineering capability and Communication ability.  The slides included a good system dynamics-type model.  At EDF’s Heysham 2 in the UK, the interventions are aimed at improving management (leadership, decision-making), trust (just culture) and organizational learning.  As a French operator of a UK plant, EDF recognizes they must tune interventions to the local organization’s core values and beliefs.

The United Arab Emirates presentation described a model for their new nuclear organization; the values, traits and attributes come right out of established industry SC guidelines.

The Entergy presenter parroted the NRC/INPO party line on SC definition, leadership responsibility, traits, attributes and myriad supporting activities.  It’s interesting to hear such bold talk from an SC-challenged organization.  Maybe INPO or the NRC “encouraged” him to present at the conference.  (The NRC is not shy about getting licensees with SC issues to attend the Regulatory Information Conference and confess their sins.)

The Russian presentation consisted of a laundry list of SC improvement activities focused on leadership, personnel reliability, observation and cross-cultural factors (for Hanhikivi 1 in Finland).  It was all top-down.  There was nothing about empowering or taking advantage of individuals’ knowledge or experience.  You can make your own inferences.

Management Presentations

We also reviewed the Management sessions for further clues.  All the operator presenters were European and they had similar structures, with “independent” safety performance advisory groups at the plant, fleet and corporate levels.  They all appeared to focus on programmatic strengths and weaknesses in the safety performance area.  There was no indication any of the groups opined on management performance.  The INPO presenter noted that SC is included in every plant and corporate evaluation and SC issues are highlighted in the INPO Executive Summary to a CEO.

Our Perspective

The IAEA press release writer did a good job of finding appealing highlights to emphasize.  The actual presentations were more ordinary and about what you’d expect from anything involving IAEA: build the community, try to not offend anyone.  For example, the IAEA SC presentation stressed the value in developing a common international SC language but acknowledged that different industry players and countries can have their own specific needs.

Bottom line: Read the summary and go to the conference materials if something piques your interest—but keep your expectations modest.

*  International Atomic Energy Agency, International Conference on Operational Safety, June 23-26, 2015, Vienna.

**  IAEA press release, “Nuclear Safety is a Continuum, not a Final Destination” (July 3, 2015).

Friday, October 2, 2015

Training Materials for Teaching NRC Personnel about Safety Culture

This is a companion piece to our Aug. 24, 2015 post on how the NRC effectively regulates licensee safety culture (SC) in the absence of any formal SC regulations.  This post summarizes a set of NRC slides* for training inspectors on SC basics and how to integrate SC information and observations into inspection reports.

The slides begin with an overview of SC, material you’ve seen countless times.  It includes the Chernobyl and Davis-Besse events, the Schein tri-level model and a timeline of SC-related activities at the NRC.

The bulk of the presentation shows how SC is related to and incorporated in the Reactor Oversight Process (ROP).  The starting point is the NRC SC Policy Statement, followed by the Common Language Initiative** which defined 10 SC traits.  The traits are connected to the ROP using 23 SC aspects.  Aspects are “the important characteristics of safety culture which are observable to the NRC staff during inspection and assessment of licensee performance” (p. 13)  Each SC aspect is associated with one of the ROP’s 3 cross-cutting areas: Human Performance (14 aspects), Problem Identification and Resolution (6 aspects) and Safety Conscious Work Environment (3 aspects).  During supplemental and reactive inspections there are an additional 12 SC aspects to be considered.  Each aspect has associated artifacts that indicate the aspect’s presence or absence.  SC aspects can contribute to a cross-cutting theme or, in more serious cases, a substantive cross-cutting issue (SCCI).***

The integration of SC findings into inspection reports is covered in NRC Inspection Manual Chapter 0612 and NINE different NRC Inspection Procedures (IPs). (p. 30)  In practice, the logic chain between a SC aspect and an inspection report is the reverse of the description in the preceding paragraph.  The creation of an inspection report starts with a finding followed by a search for a related SC cross-cutting aspect.  Each finding has one most significant cause and the inspectors should “find the aspect that describes licensee performance that would have prevented or precluded the performance deficiency represented by that cause.” (p. 33)

Our Perspective

This is important stuff.  When NRC inspectors are huddled in their bunker evaluating their data and observations after reviewing your documentation, crawling around your plant and talking with your people, the information in these slides provides the road map for their determination of how one or more alleged SC deficiencies contributed to a performance problem which resulted in an inspection finding.

Think of the SC aspects as pegs on which the inspectors can hang their observations to beef up their theory of why a problem occurred. Under routine conditions, there are 23 pegs; under more stringent inspections, there are 35 pegs.  That’s a lot of pegs and none of them is trivial which means your organization’s response may consume sizable resources.

We’ll finish with a more cheery thought:  If you get to the point where the NRC is going to conduct an independent assessment of your SC, their team will follow the guidance in IP 95003.  But don’t worry about their competence, “IP 95003 inspection teams will receive "just-in-time" training before performing the inspection.” (p. 43)

Bottom line: If it looks like controlling oversight behavior and quacks like a bureaucrat, then it probably is de facto regulation.

*  NRC Training Slides, “Safety Culture Reactor Oversight Process Training” (July 10, 2015).  ADAMS ML15191A253.  The slides include other material, e.g., a summary of the conditions under which the NRC can “request” a licensee to perform a SC assessment, a set of case studies and sample test questions for trainees.

**  The Common Language Initiative led to NUREG-2165, “Safety Culture Common Language” which was published in early 2014 and we reviewed on April 6, 2014.

***  There are some complicated decision rules for determining when a problem is a substantive cross-cutting issue and these are worth reviewing on pp. 27-28.

Monday, September 21, 2015

Notes on Regulatory Capture

NRC Public Meeting
A couple of recent local news items discuss a too-cozy relationship between regulators and the supposedly regulated, to the detriment of ratepayers and ordinary citizens.  Neither is nuclear-related but they may give us some ideas on how regulatory capture might (or does) manifest in the nuclear industry.

PG&E and the CPUC

First up is an article* about Pacific Gas and Electric Co. (PG&E) and the California Public Utilities Commission (CPUC).  PG&E is responsible for the deadly 2010 gas main explosion in San Bruno, CA.  It was later revealed that PG&E was involved in private, i.e., secret, lobbying to get the CPUC judge it wanted to handle the case.  An as investigation later concluded, such ex parte discussions gives the utilities an advantage over other participants in the regulatory process.

The article concentrates on remedial legislation working its way through the system.  One bill would close the loophole that allows secret meetings between the CPUC and a regulated entity under certain conditions.  Another would create an independent inspector general for the agency.

Berkeley Zoning Adjustment Board 

This editorial** focuses on a city zoning board that is stuffed with members whose background is in the development industry.  It quotes at length local resident James McFadden who has some excellent observations about the nature of regulatory capture in this situation.

“Although many people are quick to assume that capture means corruption, they really are different things.

“Capture is more of an aligning of economic world views, not necessarily to any monetary advantage, often just to make one's job easier or more pleasant in dealing with people on a day to day basis . . . .

“Captured individuals . . . don't see their behavior as incorrect.  They have forgotten that their role is to provide oversight and protection to the public . . . Their public meetings evolve into patronizing facades of democracy.

“. . . For the most part, capture is about creating a pleasant working environment with those in industry who they deal with on a daily basis.  It is a slow and insidious process that strikes at the heart of human psychology which allows us to work in groups. . . . When we-the-public show up and complain, we become the opponent to be ignored.

“. . . The [public] meeting becomes a dance of false empowerment where getting through the meeting on time is more important than focusing on important issues or input from the public.”

Our Perspective

Do you see any of the above behavior in the nuclear industry?  Here’s a clue to get you started: the mental model for all federally regulated or controlled activities, viz., the infamous “iron triangle” of special interests, Congress and federal bureaucrats.  In the nuclear space, utility lobbyists and industry organizations encourage/pressure Congress for favorable treatment in exchange for support at election time.  Congress leans on the NRC when job losses are threatened because of a lengthy plant shutdown or costly “over regulation.”  The NRC listens to or cooperates with industry “experts” when it is considering new policies, regulations or interpretations.  We believe the iron triangle is alive and well in the nuclear industry but is nowhere near as scurrilous as, say, the welfare system.

(Now the anti-nukes also lobby Congress and certain members of Congress are relentless critics of the NRC.  Do the scales balance?  And where does the clash of lobbying titans leave Joe Citizen?)

Expanding on one side of the triangle, nuclear utilities make efforts to build organizational, professional and personal relationships with the NRC because it’s in their direct economic interest to do so.  In the other direction, don’t NRC personnel try to get along with utility people they see on a regular basis?  Who wants to alienate everybody all the time?  The NRC tries to avoid being too cozy with the utilities but they can’t completely avoid it.  They are in the same business and speak the same language.  However, it’s far from scandalous, like the relationship between the former Minerals Management Service and the offshore drilling industry.  And there is no overactive revolving door between the NRC and industry.

What about outsiders who try to influence policy?  At the top, gadflies who address agency-wide issues or work with HQ personnel may eventually get a seat at the table.  But in the field, Jane Citizen making a statement at a meeting concerning the local plant probably doesn’t have as much leverage.  Consider how difficult it is for the average whistleblower to have an impact.

The Wikipedia entry on regulatory capture cites Princeton professor Frank von Hippel, Barack Obama, Joe Biden, Greenpeace, the Union of Concerned Scientists and the Associated Press to support the position that the NRC has been “captured.”  Has the NRC been too accommodating to the industry?  You be the judge.

There is an old saying: “Familiarity breeds contempt.”  That’s true in some cases.  In other situations, familiarity breeds—greater familiarity.

*  J. Van Derbeken, “CPUC reform bills on governor’s desk,” San Francisco Chronicle (Sept. 15, 2015).  Questionable conduct flowed both ways.  It also came to light that the then-President of the CPUC appeared to offer his support for PG&E’s (and other utilities’) positions on regulatory cases in return for their contributions to his favorite political causes.  That’s called influence peddling.

**  B. O'Malley, “Berkeley's Zoning Board Slouches Toward Birthing Its Monster,” Berkeley Daily Planet (Sept. 13, 2015).  The Daily Planet is an online progressive (lefty) newspaper in Berkeley, CA.

Thursday, September 10, 2015

DNFSB Hearing on Safety Culture Progress at the Waste Treatment and Immobilization Plant (WTP)

The WTP aka the Vit Plant
On August 26, 2015 the Defense Nuclear Facilities Safety Board (DNFSB) held a hearing in the Hanford area to receive testimony from senior DOE officials representing DOE Headquarters, the Office of River Protection (ORP) and the WTP project regarding the current status of DOE efforts to improve safety culture (SC) at the WTP.  A senior DNFSB staff member also testified on DOE’s SC improvement efforts.

There is a video of the meeting but no transcript is yet available.* 

The panel of DOE managers enumerated the work that has been undertaken to improve SC at the WTP.**  Based on their written submittals, it is predictable and not especially interesting material.  Selected excerpts follow:

G. Podonsky (DOE HQ) – “. . . positive turn in the safety culture.  However, much work remains . . . . As our assessments of safety culture indicate, management often has a more positive outlook on the state of the safety culture than do the workers.”

K. Smith (ORP Mgr) – This is mostly a laundry list of actions, initiatives and putative progress.  “. . . ORP’s safety culture today . . .  is improving and headed in the right direction. . . . But there are areas that still need work . . .”

W.F. Hamel Jr. (Federal Project Director WTP) – This focuses on more specific, project-level actions.  “We believe we have made significant strides. . . . sustaining a healthy safety culture requires persistence and consistency at all levels of the organization . . .”  He gave a shout out to Bechtel for progress in improving their SC and the Safety Conscious Work Environment (SCWE).

After the panel completed their presentation, the DNFSB staff member responsible for overseeing WTP (and other DOE) SC efforts had ten minutes to provide the staff perspective on DOE’s efforts.  He summarized the SC assessments that have taken place at the WTP and other facilities in the DOE complex.***  His testimony had more “howevers” than a Consumer Reports review of a mediocre automobile.  For example, DOE’s original plan was developed prior to the 2012 SC assessment and did not include the latter’s findings.  DOE modified their plan for Hanford but it was not applied to other DOE facilities.  The DOE themes did not address the root causes the DNFSB identified in their 2011 Recommendation.  He was also critical of the DOE’s extent of condition review.

He was asked one question by the meeting chair: “Is the bad (i.e., not supportive of SC) management behavior identified in 2011 still occurring?”  The answer was “It’s mixed. Some yes and some no.”  The chair was clearly not happy with that answer after four years of effort.

Our Perspective

The DOE bureaucrats identified a passel of SC-related improvement activities and claim progress is being made but there is still work to accomplish.  The testimony of the DNFSB staffer was less optimistic.  A statement contributed for the record by an anonymous “concerned engineer” includes examples that look like they came straight from the bad old days.****  We have reviewed most the DOE/WTP assessments, action plans and progress reviews on Safetymatters; click on the DOE or WTP label to see related posts.  Call us harsh, but we don’t believe there will be any substantive changes in the way business is conducted at Hanford until the bad stuff starts leaching into the Columbia River.

On a slightly brighter note, the DNFSB is back to full strength with five members, including a new chairman.  From looking at the press releases, it appears they have added folks with federal/military backgrounds and middling technical exposure.  The new chair is a career technical functionary whose last stint was at the White House.  It’s hard to get All-Stars for a toothless agency.  What they can contribute to oversight of DOE remains to be seen.  We wish them well.

*  The video is here.  Testimony and statements are available here but most are scanned copies which means quotes have to be retyped and may not totally accurate.  For an overview of the meeting see A. Cary, "National board hears safety culture is improving at Hanford vit plant," Tri-City Herald (Aug. 26, 2015).

**  Statement for the Record and Additional Information of G. Podonsky, Office of Enterprise Assessments (Aug. 26, 2015).  Testimony of K. Smith, Manager, Office of River Protection (Aug. 26, 2015).  Testimony of W.F. Hamel Jr., Federal Project Director, Waste Treatment and Immobilization Plant (Aug. 26, 2015).

***  Testimony of D.B. Bullen, Group Lead, Nuclear Programs and Analysis, DNFSB.  The question and answer are not verbatim but paraphrased from the exchange between Bullen and the chair that occurs from about 1:52 to 1:55 in the video.

****  Statement from concerned engineer (Aug. 26, 2015).

Monday, August 24, 2015

NRC Regulation of Safety Culture: How They Do It

We have griped many times about how the NRC does, in fact, regulate (i.e., control or direct) licensee safety culture (SC) even though the agency claims it doesn’t because there is no applicable regulation.

A complete description of the agency’s approach was provided in 2010 NRC staff testimony* before the Atomic Safety and Licensing Board.  Note this testimony was given before the Safety Culture Policy Statement was issued but we believe it depicts current practices.  The key point is that “Oversight of an operating reactor licensee’s safety culture is implemented by the ROP [Reactor Oversight Process].” (p. 17)  Following are some lengthy quotes from the testimony and you can decide whether or not they add up to “regulation.”

“The ROP provides for the oversight of a licensee’s safety culture in four ways.  First, the ROP provides for the review of a licensee’s safety culture in a graded manner when that licensee has significant performance issues.  The level of the staff’s oversight is determined by the safety significance of the performance issues.  This review and evaluation is described in the ROP’s supplemental inspection program . . . An IP 95002 inspection is usually performed when a licensee enters [column 3] . . . of the ROP Action Matrix. . . [In certain circumstances] the NRC will request the licensee to perform an independent safety culture assessment.  An IP 95003 inspection is performed when a licensee enters [column 4] . . . of the ROP Action Matrix.  When this occurs, the NRC expects [emphasis added] the licensees to perform a third-party safety culture assessment.  The staff will review the results of the assessment and perform sample evaluations to verify the results.

“Second, the ROP’s reactive inspection program evaluates a licensee’s response to an event, including consideration of contributing causes related to the safety culture components, to fully understand the circumstances surrounding an event and its probable causes.

“Third, the ROP provides continuous oversight of licensee performance as inspectors evaluate inspection findings for cross-cutting aspects.  Cross-cutting aspects are aspects of licensee performance that can potentially affect multiple facets of plant operations and usually manifest themselves as the root causes of performance problems. . . .**

“Fourth, the ROP provides for the review of a licensee’s safety culture if that licensee has difficulty correcting long-standing substantive cross-cutting issues.  In these cases, the NRC will request the licensee to perform a safety culture assessment, and the NRC Staff will evaluate the results and the licensee’s response to the results.” (pp. 18-19)  In addition, “The ROP assessment process looks at long-standing substantive cross-cutting issues to determine if safety culture assessments need to be performed and reviewed.” (p. 24)  Significantly, “Safety culture is addressed through the use of cross-cutting issues which do not relate to the Action Matrix column that a plant may be placed in.” (p. 32)

Our Perspective

In our opinion, SC is regulated via a linkage to ongoing NRC activities.  Outputs from NRC inspection activities performed under the aegis of regulation (i.e., law) are used to assess licensee SC and force licensees to perform activities, e.g., SC assessments or corrective actions***, that the licensees might not choose to perform of their own free will.

The reality is NRC “requests” or “expectations” are like a commanding officer’s “wishes”; the intelligent subordinate understands they have the force of orders.  Here’s how the agency describes the fist inside the glove: “If the NRC requests a licensee to take an action, and the licensee refuses, the Agency can perform that action (i.e., the safety culture assessment) for them.” (p. 29)  We assume the NRC would invoke its regulatory authority to justify such an assessment.  But what licensee would want an under-experienced posse of federal inspectors, who expect to find problems because why else would they be assigned to the task, running through their organization?

Occasionally, the NRC drops the veil long enough to reveal the truth.  An NRC staffer (one of the witnesses who sponsored the ASLB testimony described above) recently made a presentation to the Korean nuclear regulator.  It included a figure that summarizes the SC aspects of the ROP Action Matrix.  Under columns 3 and 4, the figure says “may request” and “request” the licensee to conduct a SC assessment.  However, on the next page, the presentation bullets are more forthcoming: “For Plants in Columns 3 . . . and 4 . . . NRC requires [emphasis added] Licensee to conduct third party safety culture assessment which is reviewed by NRC.”****

We’re not opposed to the NRC squeezing licensees to strengthen their SC.  We just don’t like hypocrisy and doublespeak.  Perhaps the agency takes this convoluted approach to controlling SC to support their claim they don’t interfere with licensee management.  We don’t believe that; do you?

NRC Staff Testimony of V.E. Barnes et al Concerning Safety Culture and NRC Safety Culture Policy Development and Implementation before the Atomic Safety and Licensing Board (July 30, 2010) revised Sept. 7, 2010.  ADAMS ML102500605.

**  The ROP framework includes three cross-cutting areas (human performance, problem identification and resolution, and safety conscious work environment) which contain nine safety culture components. (p. 23)

***  This is another leverage point for the agency.  They make sure SC assessment findings are entered in the licensee’s corrective action program (CAP).  Then they use their regulatory authority over the CAP to ensure it is useful and effective, i.e., that SC corrective actions are implemented. (p. 30)

****  M. Keefe, “Incorporating Safety Culture into the Reactor Oversight Process (ROP),” presentation to the Korea Institute of Nuclear Safety (June 2-3, 2015), pp. 5-6.  ADAMS ML15161A109.

Tuesday, August 18, 2015

CPUC Proposes to Probe PG&E’s Culture

CPUC Headquarters (Source: Coolcaesar on en.wikipedia)
Yesterday’s edition of a Bay Area newspaper included a report* on a California Public Utilities Commission (CPUC) proposal to undertake a deep review of Pacific Gas & Electric’s (PG&E) culture and governance.  This is part of the long tail of consequences, including fines and criminal charges, the company has experienced in the aftermath of the Sept. 9, 2010 gas main explosion in San Bruno, CA.

The author got a Georgetown law professor (Scott Hempling) to opine on the situation and he had a couple of interesting observations:

“. . . for any utility, perhaps the most significant potential root cause of subpar performance is a culture of a entitlement, arising from the fact that the utility does not have to compete to maintain its monopoly.”

As to whether the CPUC has the authority to order changes at PG&E, he said “If it's not the PUC, then perhaps the state Legislature.  That monopoly that PG&E has was not granted by God.  It's not in the U.S. Constitution.  It is granted either by the PUC or the state Legislature."

What would your state regulator find if they stuck a probe into your organization?  Would there be a significant reading on the entitlement meter?

Diablo Canyon

At Safetymatters our major concern is with nuclear safety culture (SC) so it’s natural to ask how or even if the proposed review could affect Diablo Canyon.  On the surface, the answer is no probable impact.  PG&E’s problems and accidents have been concentrated in its gas business.  And from the get-go, PG&E has worked to isolate Diablo Canyon from the rest of the company.  But the plant’s many implacable opponents constitute a wild card in this situation.  You can bet they will do everything they can to get the scope of any CPUC review to include Diablo Canyon’s SC and operations.

*  G. Avalos, “San Bruno aftermath: PUC eyes broad probe of PG&E,” Contra Costa Times online (Aug. 17, 2015).

For more details on the CPUC proposal, see their press release: “CPUC Set to Consider Investigation into PG&E’S Culture and Governance to Ensure Safety is a Priority” (Aug. 17, 2015).

Wednesday, August 12, 2015

A Quiet Conclusion to Millstone’s TDAFW Pump Problem

On Jan. 15, 2015 we posted about the long time it took Millstone to correctly evaluate and fix a problem with a turbine-driven auxiliary feedwater (TDAFW) pump.  The lengthy problem resolution caught the attention of the plant’s state overseer and the NRC.  We wondered if the event was a harbinger of some slippage in Millstone’s safety culture (SC).

The NRC conducted a supplemental inspection into the pump issue and published their results in late July.*  Because this inspection was conducted using Inspection Procedure 95001, one NRC action was to verify that the licensee’s root cause evaluations appropriately considered SC.  The inspectors’ SC findings, summarized below, are on pp. 7-8 of the report details.

Dominion (Millstone’s owner) identified SC-related weaknesses in three cross-cutting areas:

Problem Identification and Resolution and Human Performance, Conservative Bias

The licensee identified several instances where evaluations of issues or events were not complete, evaluations were less than timely and/or thorough and corrective actions were not sustainable.  In addition, the licensee identified instances of inadequate decision making and bypassing the Corrective Action Program (CAP) program implementation.

The corrective action in both areas was to make changes in the organizational behavior through station leadership stand downs and by improving the scheduling of daily CAP related meetings to ensure adequate engagement in the processing and review of CAP products.

Human Performance, Procedure Adherence

The licensee identified instances where corrective actions were not completed as written. Dominion’s corrective actions include CAP group reviews for specified corrective action assignments, implementing a Corrective Action Review Board coordinator and restricting manager level functions in the central reporting system to department managers.

Overall, the inspectors determined that Dominion’s root cause, extent of condition, and extent of cause evaluations appropriately considered SC components.

Our Perspective

The SC fixes are from the everyday menu: more management involvement, better oversight and improved organizational practices.  The report also mentioned additional traditional fixes (upgraded procedures, more training and the development of relevant case studies) applied to other aspects of how and how well the plant investigated its handling of the pump problem.  Taken together, they are concrete, if not exactly momentous, actions to improve a vital organizational process, i.e., the CAP.  In addition, the fixes are consistent with the plant's position that the TDAFW pump problem was a localized issue.

We would like to see a more systemic investigation of SC-related factors but the actions taken reflect an acceptable SC and reinforce our perception that Dominion (unlike Millstone’s former owner) takes safety seriously.

*  R.R. McKinley (NRC) to D.A. Heacock (Dominion), “Millstone Power Station Unit 3 – NRC Supplemental Inspection Report 05000423/2015010 and Assessment Follow-Up Letter” (July 22, 2015).  ADAMS ML15202A473.

Tuesday, August 4, 2015

Obtain Better Decisions by Asking Better Questions

We’re currently experiencing a reduced flow of quality feedstock into our safety culture mill.  But we did see a reference to a Harvard Business Review (HBR) article* that’s worth a quick read.

The authors’ thesis is the pressure on business to make decisions ever more quickly means important questions may never get asked, or even considered, which leads to poor decision-making.  Their proposed fix is to ask more, better questions to help frame decisions.  They suggest four types of questions, presented in the consultant’s favorite typology:  the two-by-two matrix.  In this case, one axis is the View of the Problem (wide or narrow) and the other is the Intent of the Question (to affirm or discover), as shown in the following figure.

Types of Questions to Improve Decision Making  (Source Mu Sigma)

Clarifying questions are focused on helping participants or managers understand what has happened so far, e.g., the data gathered or partial decisions already made.  People often don’t ask these questions because of cultural pressures to move forward, or they tend to make assumptions and fill in any missing parts themselves.**

Adjoining questions explore related aspects of the problem utilizing available information, e.g., how the results of this analysis could be applied elsewhere. 

Funneling questions are focused on learning more about the analysis to date.  How was an answer derived?  What were your assumptions?  What are the root causes of this problem?  The authors opine that most analytical teams usually do a good job of asking this type of question.

Elevating questions raise broader issues and create opportunities to make new connections between individual decisions, e.g., what are the larger issues or trends we should be concerned about?

There is a cultural dimension to question asking, particularly the unspoken rules about what types of questions can be asked, and by whom, in the decision making process.  Leaders need to encourage people to ask questions and co-workers need to be tolerant of the question askers rather than pushing to obtain and deliver an answer.

Our Perspective

The information in this article is hardly magical.  Most of us recognize that the best investigators and managers know What kind of questions they are asking and Why.  But we do have a few exercises for you to think about.   

For starters, look at the questions suggested or prescribed in your official problem-solving or problem analysis recipes.  Do they omit any types of questions that could add value to your immediate situation, bigger picture issues or the overall process?

What’s your problem solving culture like?  How are people treated who ask questions, especially devil’s advocate questions, that don’t add instant value to the search for an answer?

Finally, consider Millstone’s issue with a turbine-driven auxiliary feedwater pump (which we reviewed on Jan. 15, 2015).  Could more extensive questioning during the initial analysis phase have more quickly led the investigators to a correct understanding of the problem?    

*  T. Pohlmann and N.M. Thomas, “Relearning the Art of Asking Questions,” Harvard Business Review on-line (Mar. 27, 2015).  The authors are not famous professors.  They are two consultants with a Mu Sigma, a Big Data company, who are publishing under the HBR aegis.  That doesn’t disqualify their work, it’s just something to keep mind as they describe a construct their firm uses.

**  For an informative and entertaining essay on how people develop their own models of what’s going on in the world, even when they are wildly misinformed, check out “We Are All Confident Idiots.”

Monday, July 13, 2015

Fixing General Motors’ Culture—Any Lessons for Nuclear?

GM Headquarters
In a recent interview* with LinkedIn, General Motors CEO Mary Barra discussed her plan for fixing GM’s culture.  The interviewer asked what needs to change, what about known problems like the “GM nod”** and the siloed organization, and what is the key to the improvement process?  The following quotes are excerpted from her answers.  Do they suggest a clear vision for the future culture and/or a satisfactory action plan?

“. . . get everyone engaged, working together, and bringing the best ideas forward[.]”

“. . . I never accepted the GM nod.  If somebody said in a meeting they were going to do something, I expect you to do it.”

“We've got to model [working across the organization].”

“[We have to] own each other's problems.”

“So our goal is to be the safety leader. We're really driving a zero-defect mentality.”

“If we can get in a room and really, you know, argue it out constructively and everybody's views get on the table, we'll make better decisions.”

“. . . we've got to earn the trust of every single employee by demonstrating the way we behave.”

Our Perspective

We realize this was not some carefully crafted article for the Harvard Business Review but there are too many soft spots in this recipe for fixing the culture to let this interview slide by without comment.

Let’s begin with the positives.  Barra promotes respect for ideas; that’s a positive feedback loop and a good thing.  Senior management modeling desired behavior and working to earn employee trust are both essential for cultural change.  Safety leadership is certainly a laudable goal.  

The nod is a little more problematic.  Maybe Barra never accepted the nod but plenty of other folks did.  Is modeling the desired behavior sufficient to create change?  How long will it take?  What else might need to be done?

Shared ownership of problems is a good start but how does GM establish, model and inculcate a process that obtains permanent problem resolutions going forward?

Barra also believes an insider (like her) is better suited for changing the culture than an outsider.  We agree an insider may have a better handle on recognizing when employees are trying to spin a situation in their favor but an outsider can bring a clear view of the performance gap between an organization’s current state (e.g., its characteristics, priorities and processes) and where it needs to be.

Some ingredients are missing.  Most importantly, there is no mention of the powerful cost/finance feedback loop that contributed to GM’s quality problems.  Wringing pennies out of product costs was a major goal for years.  What roles will cost consciousness and management financial incentives play going forward?

In another area, how is the management decision making process changing other than arguing things out?

Bottom line: There are no lessons for nuclear in the GM CEO’s outline of her cultural change initiative.  In fact, her proclamations sound just like nuclear managers’ braying when they try to convince regulators, the media and the public that something, anything is happening to address perceived cultural issues.  But what usually isn’t happening is some in-depth analysis of how their organizational system functions.

*  D. Roth, “Mary Barra's Got a Plan for Fixing GM's Culture (and Only an Insider Can Pull it Off),” LinkedIn interview (July 6, 2015).  Safetymatters co-founder Bob Cudlin first spotted and called attention to this article.

**  The “GM nod” was “where employees would commit to being on board with a decision, then ignore it [later.]”

Friday, July 3, 2015

New Safety Culture Assessment at the Hanford Waste Treatment Plant

Hanford WTP
The Department of Energy (DOE) recently released the latest safety culture (SC) assessment report* for the Hanford Waste Treatment Plant (WTP or “vit plant”) project.  The 2015 report follows similar SC assessments conducted in 2011 and 2014, all of which were inspired by the Defense Nuclear Facilities Safety Board’s scathing 2011 report on SC at the WTP.  This post provides a brief overview of the report’s findings then focuses on the critical success factors for a healthy SC.

Assessment Overview

The 2011, 2014 and 2015 assessments used the same methodology, with multiple data collection methods, including interviews, Behavioral Anchored Rating Scales (BARS)** and a SC survey.  Following are selected highlights from the 2015 report.

DOE’s Office of River Protection (ORP) has management responsibility for the WTP project.  In general, ORP personnel feel more positive about the organization’s SC than they did during the 2014 assessment.  Feelings of confusion about ORP’s more collaborative relationship with Bechtel (the prime contractor) have lessened.  ORP management is perceived to be more open to constructive criticism.  Concerns remain with lack of transparency, trust issues and the effectiveness of the problem resolution process.

Bechtel personnel were more positive than in either previous SC assessment.  Bechtel has undertaken many SC-related initiatives including the promotion of a shared mental model of the project by senior Bechtel managers.  In 2014, Bechtel Corporate’s role in project decision making was perceived to skew against SC concerns.  The creation of a new Bechtel nuclear business unit has highlighted the special needs of nuclear work. (pp. 2, 39)  On the negative side, craft workers remain somewhat suspicious and wary of soft retributions, e.g., being blamed for their own industrial mishaps or having their promotion or layoff chances affected by reporting safety issues.

See this newspaper article*** for additional details on the report’s findings. 

Critical Success Factors for a Healthy SC

We always look at the following areas for evidence of SC strength or weakness: management’s decision making process, recognition and handling of goal conflicts, the corrective action program and financial incentives.

Decision Making

Both ORP and Bechtel interviewees complained of a lack of basis or rationale for different types of decisions. (pp. 9, 16)  Some ORP and Bechtel interviewees did note that efforts to clarify decision making are in process. (pp. 13, 32)  Although the need to explain the basis for decisions was recognized, there was no discussion of the decision making process itself.  This is especially disappointing because decision making is one of the possible behaviors that can be included in a BARS analysis, but was not chosen for this assessment.

Goal Conflicts

Conflicts among cost, schedule and safety goals did not rise to the level of a reportable problem.  ORP interviewees reported that cost and schedule do not conflict with safety in their individual work. (p. 6)  Most Bechtel interviewees do not perceive schedule pressures to be the determining factor while completing various tasks. (p. 23)  Overall, this is satisfactory performance.

Corrective Action Program

We believe how well an organization recognizes and permanently resolves its problems is important.  Problem Identification and Resolution was one of the traits evaluated in the assessment.  ORP interviewees said that current safety concerns are being addressed.  The historical lack of management feedback on problem resolution is still a disincentive for reporting problems. (pp. 8-9)  Some Bechtel interviewees said “issue resolution with management engagement was the single most positive improvement in problem resolution, . . .” (p. 24)  This performance is minimally acceptable but needs ongoing attention.

Financial Incentives

DOE’s contract with Bechtel now includes incentives for Bechtel if it self-identifies problems (rather than waiting for DOE or some other party to identify them).  ORP believes the incentives are a positive influence on contractor performance. (p. 8)  Bechtel interviewees also believe the new contract has had a positive impact on the project.  However, Bechtel has a goal to reduce legacy issues and some believe the contract’s emphasis on new issues distracts from addressing legacy problems. (pp. 24-25)  The assessment had no discussion of either ORP or Bechtel senior management financial incentives.  The new contract conditions are good; ignoring senior management incentives is unacceptable.

Safety Conscious Work Environment (SCWE)

We usually don’t pay much attention to SCWE at nuclear power plants because it is part of the larger cultural milieu.  But SCWE has been a long-standing issue at various DOE facilities, as well as the impetus for the series of WTP SC assessments, so we’ll look at a few highlights from the SC survey data.

For ORP, mean responses to five of the six SCWE questions were higher (better) in 2015 vs 2014, and 2014 vs 2011.  However, for one question “Concerns raised are addressed” the mean is lower (worse) in 2015 vs 2014, and significantly lower in 2015 vs 2011.  This may indicate an issue with problem resolution. (p. B-2) 

For Bechtel, mean responses to all six SCWE questions were significantly higher (better) in 2015 vs 2014.  However, the 2011 data were not included so we cannot make any inference about possible longer-term trends. (p. B-5)  What is shown is good news because it appears people feel freer to raise safety concerns.  Interestingly, Bechtel’s mean 2015 responses were 5-13% higher (better) than ORP’s for all questions.

Both ORP and Bechtel are showing acceptable performance but continued improvement efforts are warranted.

Our Perspective

The Executive Summary and Conclusions suggest ORP and especially Bechtel have turned the corner since 2014. (pp. v, 37)  This is arguably true for SCWE but we’d say the jury is still out on improvement in the broader SC, based on our look at the BARS data.

For ORP, the BARS data mean scores are higher for 4 (out of 10) behaviors in 2015 vs 2014, but only higher for 1 behavior in 2015 vs 2011. (p. B-1)  The least charitable interpretation is ORP’s view of itself has not yet re-achieved 2011 levels.  For Bechtel the BARS data shows a bit brighter picture.  Mean scores are higher for 6 (out of 10) behaviors in 2015 vs 2014, and higher for 4 behaviors for 2015 vs 2011. (p. B-4)

The format of the report is probably intended to be reader-friendly but it mixes qualitative interview data and selected quantitative data from BARS and the survey.  The use of modifiers like “many” and “some” creates a sense of relative frequency or importance but no real specificity.  It’s impossible to say how much (if any) cherry picking of the interview data occurred.****

We also wonder about the evaluation team’s level of independence and optimism.  This is the first time DOE has performed a WTP SC assessment without the extensive use of outside consultants.  Put bluntly, how independent was the team’s effort given DOE Headquarters’ desire to see improvements at WTP?  And it’s not just HQ; DOE is under the gun from Congress, the DNFSB, the Government Accountability Office, and environmental activists and regulators to clean up their act at Hanford.

We want to see a stronger SC at Hanford but we’ll go with Ronald Reagan on this report: “Trust, but verify.”

*  DOE Office of Enterprise Assessments, “Follow-up Assessment of Safety Culture at the Hanford Site Waste Treatment and Immobilization Plant” (June, 2015).  We have followed the WTP saga for years; please click on the Vit Plant label to see our related posts.

**  Behavioral Anchored Rating Scales (BARS) quantitatively summarize interviewees’ perceptions of their organization using specific examples of good, moderate, and poor performance.   There are 17 possible organizational behaviors in a BARS analysis, but only 10 were used in this assessment:  Attention to Safety, Coordination of Work, Formalization, Interdepartmental Communication, Organizational Learning, Performance Quality, Problem Identification and Resolution, Resource Allocation, Roles and Responsibilities and Time Urgency. (p. C-2)

***  A. Cary, “DOE: Hanford vit plant safety culture shows improvement,” Tri-City Herald (June 26, 2015).

****  The report also includes multiple references to the two organizations’ behavioral norms that were inferred from the survey data.  It’s not exactly consultant mumbo-jumbo but it’s too complicated to attempt to explain in this space.

Thursday, June 25, 2015

Safety Culture at Arkansas Nuclear One

Arkansas Nuclear One (credit: Edibobb)
Everyone has heard about the March 31, 2013 stator drop at Arkansas Nuclear One (ANO).  But there was also unsatisfactory performance with respect to flood protection and unplanned scrams.  As a consequence, ANO has been assigned to column 4 of the NRC’s Action Matrix where it will receive the highest level of oversight for an operating plant.

When a plant is in column 4 the NRC takes a particular interest in its safety culture (SC) and ANO is no exception.  NRC required ANO to have an independent (i.e., outside third party) SC assessment, which was conducted starting in late 2014.  While the assessment report is not public, some highlights were discussed during the May 21, 2015 NRC staff briefing of the Commissioners on the results of the April 15, 2015 Agency Action Review Meeting.*

NRC Presentation

The bulk of the staff presentation was a soporific review of agency progress in a variety of areas.  But when the topic turned to ANO, the Regional Administrator responsible for ANO was quite specific and minced no words.  Following are the key problems he reviewed.  See if you can connect the dots on SC issues based on these artifacts.

Let’s start with the stator drop.  ANO’s initial root cause evaluation did not identify any root or contributing causes related to ANO’s own performance, but rather focused solely on the contractor.  After the NRC identified ANO’s failure to follow its load handling procedure, ANO conducted another root cause evaluation and identified their own organizational performance issues such as inadequate project oversight and non-conservative decision making. (pp. 28-29)

The stator drop damaged a fire main which caused localized flooding.  This led to an extended condition review which identified various equipment and structures that could be subject to flooding.  The NRC inspectors pointed out deficiencies in the condition review and identified corrective actions that likely would not work.  In addition, earlier flooding walkdowns completed as part of the NRC’s post-Fukushima requirements failed to identify the majority of the flood protection deficiencies.  These walkdowns were also performed by a contractor.  (pp. 29-31)

Finally, ANO did not report an April 2014 Unit 2 trip as an unplanned scram because the trip occurred during a planned down power evolution.  After prodding by the NRC inspectors, ANO reclassified this event as an unplanned scram. (pp. 31-32)

Overall, the NRC felt it was driving ANO to perform complete evaluations and develop effective corrective actions.  NRC believes that ANO’s “cause evaluations typically don't provide for a thorough assessment of organizational and programmatic contributors to events or issues.” (p. 35)  Later, in response to a question, the Regional Administrator said “I think the licensee clearly needs to own the performance gaps, ensure that their assessments in the various areas are comprehensive and then identify appropriate actions, and then engage and ensure those actions are effective. . . . I don't want to be in a position where our inspection activities are the means for identifying the performance gaps.” (p. 44)

Responding to a question about ANO’s independent SC assessment, he said “one of the key findings . . . was that there's an urgent need to internalize and communicate the seriousness of performance problems and engage the site in their strategy for improvement.” (p. 45)

Entergy Presentation

A team of Entergy (ANO’s owner) senior managers presented their action plan for ANO.  They said they would own their own problems, improve contractor oversight, identify their own issues, increase corporate oversight and improve their CAP.

With respect to culture, they said “We're going to change the culture to promote a healthy, continuous improvement and to not only achieve, but also to sustain excellence.” (pp. 70-71)  They are benchmarking other plants, analyzing ANO’s issues and adding resources including people with plant performance recovery experience. 

They took comfort from the SC assessment conclusion “That although weaknesses exist, the overall safety culture at ANO is sufficient to support safe operation." (p. 72)

In response to a question about important takeaways from the SC assessment, Entergy referred to the need for the plant to recognize that performance has got to improve, the CAP must be more effective and organizational programmatic elements are important.  In addition, they vowed to align the organization on the performance gaps (and their significance) and establish a sense of urgency in order to fix them. (pp. 80-81)

Our Perspective

Not to be too cynical, but what else could Entergy say?  When your plant is in column 4, a mega mea culpa is absolutely necessary.  But Entergy’s testimony read like generic management arm-waving invoking the usual set of fixes.

Basically, the ANO culture endorses a “blame the contractor” attitude, accepts incomplete investigations into actual events and potential problems, and is content to let the NRC point out problems for them.  Where did those values come from?  Is “increased oversight” sufficient to create a long-term fix?

ANO naturally gives a lot of weight to the SC assessment because its findings appear relatively simple and apparently actionable.   Somewhat surprisingly, the NRC also appears to give this assessment broad credibility.  We think that’s misplaced.  The chances are slim of such an assessment identifying deep, systemic cultural issues although we admit we don’t know the assessment details.  Did the assessment team perform document reviews, conduct focus groups or interviews?  If it was a survey, it only identified the most pressing issues in the plant’s safety climate.

Taking a more systemic view, we note that Entergy has a history of SC issues over many plants in its fleet.  Check out our Feb. 20, 2015 post for highlights on some of their problems.  Are ANO’s problems just the latest round of SC Whac-A-Mole at Entergy?

Entergy has always had a strong Operations focus at its plants.  The NRC’s confidence in ANO’s operators is the main reason that plant is not shut down.  But continuously glorifying the operators, particularly their ability to respond successfully to challenging conditions, is like honoring firefighters while ignoring the fire marshal.  The fire marshal role at a nuclear plant is played by Engineering and Maintenance, groups whose success is hidden (thus under-appreciated) in an ongoing series of dynamic, non-events, viz., continuous safe plant operation.  That’s a cultural issue.  By the way, who gets the lion’s share of praise and highest status at your plant?

*  “Briefing on Results of the Agency Action Review Plan Meeting,” public meeting transcript (May 21, 2015).  ADAMS ML15147A041.

The Agency Action Review Meeting (AARM) “is a meeting of the senior leadership of the agency, and its goals are to review the appropriateness of agency actions taken for reactor material licensees with significant performance issues.” (pp. 3-4)

Tuesday, June 9, 2015

Training....Yet Again

U.S. Navy SEALS in Training
We have beat the drum on the value of improved and innovative training techniques for improving safety management performance for some time.  Really since the inception of this blog where our paper, “Practicing Nuclear Safety Management,”* was one of the seminal perspectives we wanted to bring to our readers.  We continue to encounter knowledgeable sources that advocate practice-based approaches and so continue to bring them to our readers’ attention.  The latest is an article from the Harvard Business Review that calls attention to, and distinguishes, “training” as an essential dimension of organizational learning.  The article is “How the Navy SEALS Train for Leadership Excellence.”**  The author, Michael Schrage,*** is a research fellow at MIT who reached out to a former SEAL, Brandon Webb, who transformed SEAL training.  The author contends that training, as opposed to just education or knowledge, is necessary to promote deep understanding of a business or market or process.  Training in this sense refers to actually performing and practicing necessary skills.  It is the key to achieving high levels of performance in complex environments. 

One of Webb’s themes that really struck a chord was: “successful training must be dynamic, open and innovative…. ‘It’s every teacher’s job to be rigorous about constantly being open to new ideas and innovation’, Webb asserts.”  It is very hard to think about much of the training in the nuclear industry on safety culture and related issues as meeting these criteria.  Even the auto industry has recently stepped up to require the conduct of decision simulations to verify the effectiveness of corrective actions - in the wake of the ignition switch-related accidents. (see our
May 22, 2014 post.)

In particular the reluctance of the nuclear industry and its regulator to address the presence and impact of goal conflicts on safety continues to perplex us and, we hope, many others in the industry.   It was on the mind of Carlo Rusconi more than a year ago when he observed: “Some of these conflicts originate high in the organization and are not really amenable to training per se” (see our
Jan. 9, 2014 post.)  However a certain type of training could be very effective in neutralizing such conflicts - practicing making safety decisions against realistic fact-based scenarios.  As we have advocated on many occasions, this process would actualize safety culture principles in the context of real operational situations.  For the reasons cited by Rusconi it builds teamwork and develops shared viewpoints.  If, as we have also advocated, both operational managers and senior managers participated in such training, senior management would be on the record for its assessment of the scenarios including how they weighed, incorporated and assessed conflicting goals in their decisions.  This could have the salutary effect of empowering lower level managers to make tough calls where assuring safety has real impacts on other organizational priorities.  Perhaps senior management would prefer to simply preach goals and principles, and leave the tough balancing that is necessary to implement the goals to their management chain.  If decisions become shaded in the “wrong” direction but there are no bad outcomes, senior management looks good.  But if there is a bad outcome, lower level managers can be blamed, more “training” prescribed, and senior management can reiterate its “safety is the first priority” mantra.

*  In the paper we quote from an article that highlighted the weakness of “Most experts made things worse.  Those managers who did well gathered information before acting, thought in terms of complex-systems interactions instead of simple linear cause and effect, reviewed their progress, looked for unanticipated consequences, and corrected course often. Those who did badly relied on a fixed theoretical approach, did not correct course and blamed others when things went wrong.”  Wall Street Journal, Oct. 22, 2005, p. 10 regarding Dietrich Dörner’s book, The Logic of Failure.  For a comprehensive review of the practice of nuclear safety, see our paper “Practicing Nuclear Safety Management”, March 2008.

**  M. Schrage, "How the Navy SEALS Train for Leadership Excellence," Harvard Business Review (May 28, 2015).

***  Michael Schrage, a research fellow at MIT Sloan School’s Center for Digital Business, is the author of the book Serious Play among others.  Serious Play refers to experiments with models, prototypes, and simulations.