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.”