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)

4 comments:

  1. It's a sad four decades of dysfunctional compliance and incompetent enforcement.

    See the comments at
    http://public-blog.nrc-gateway.gov/2015/01/23/nrc-finalizes-violations-for-arkansas-nuclear-one/comment-page-1/

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    Replies
    1. Thanks for the link to the NRC blog. It is a sad tale, with a long tail back in time.

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  2. The really sad thing is that NRC won't admit that inspection and enforcement deficiencies tacitly condoned the persistent noncompliance.

    Is there an elephant in the room?

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    1. We have often ragged on Entergy for cultural shortcomings. But it seems there's also something out of kilter in NRC Region IV (which oversees ANO). In the NRC 2012 SC survey results, which we reviewed April 6, 2013, Region IV was less favorable toward their Differing Professional Opinion process results, management's decisions being consistent with the NRC mission and strategic plan, and confidence in senior management than agency personnel in general. That's not be an elephant but it could be the tail!

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