Friday, March 25, 2016

Nuclear Safety Culture Problem at TVA: NRC Issues Chilling Effect Letter to Watts Bar

Watts Bar  Source: Wikipedia
The U.S. Nuclear Regulatory Commission (NRC) recently sent a “chilling effect letter”* (CEL) to the Tennessee Valley Authority (TVA) over NRC’s belief that reactor operators at TVA’s Watts Bar plant do not feel free to raise safety concerns because they fear retaliation and do not feel their concerns are being addressed.  The NRC questions whether the plant’s corrective action program (CAP) and Employee Concerns Program have been effective at identifying and resolving the operators’ concerns.  In addition, NRC is concerned that plant management is exercising undue influence over operators’ activities thereby compromising a safety-first environment in the control room.

TVA officials must respond to the NRC within 30 days with a plan describing how they will address the issues identified in the CEL.

What’s a Chilling Effect Letter?

“CELs are issued when the NRC has concluded that the work environment is “chilled,” (i.e., workers perceive that the licensee is suppressing or discouraging the raising of safety concerns or is not addressing such concerns when they are raised).”**

Our Perspective

The absence of fear of retaliation is the principal attribute of an effective safety conscious work environment (SCWE) which in turn is an important component of a strong safety culture (SC).  Almost all commercial nuclear plants in the U.S. have figured out how to create and maintain an acceptable SCWE.

TVA appears to be an exception and a slow learner.  This is not a new situation for them.  As the CEL states, “a Confirmatory Order (EA-09-009, EA-09-203) remains in effect to confirm commitments made by TVA for all three [emphasis added] nuclear stations to address past SCWE issues.”

We have reported multiple times on long-standing SC problems at another TVA plant, Browns Ferry.  And, as we posted on Apr. 25, 2014, Browns Ferry management even made a presentation on their SC improvement actions at the 2014 NRC Regulatory Information Conference.

NRC raised questions about the Watts Bar CAP.  As we have long maintained, CAP effectiveness (promptly responding to identified issues, accurately characterizing them and permanently fixing them) is a key artifact of SC and a visible indicator of SC strength.

As regular readers know, we believe executive compensation is another indicator of SC.  The recipient of the CEL is TVA’s Chief Nuclear Officer (CNO).  According to TVA’s most recent SEC 10-K,*** the CNO made about $2.1 million in FY 2015.  Almost $1 million of the total was short-term (annual) and long-term incentive pay.  The components of the CNO’s annual incentive plan included capability factor, forced outage rate, equipment reliability and budget performance—safety is not mentioned.****  The long-term plan included the wholesale rate excluding fuel, load not served and external measures that included an undefined “nuclear performance index.”  To the surprise of no one who follows these things, the CNO is not being specifically incentivized to create a SCWE or a strong SC.

Bottom line: This CEL is just another brick in the wall for TVA.   

*  C. Haney (NRC) to J.P. Grimes (TVA), “Chilled Work Environment for Raising and Addressing Safety Concerns at the Watts Bar Nuclear Plant” (Mar. 23, 2016) ADAMS ML16083A479.

**  D.J. Sieracki, “U.S. Nuclear Regulatory Commission Safety Culture Oversight,” IAEA  International Conference on Human and Organizational Aspects of Assuring Nuclear Safety (Feb. 24, 2016), p. 115 of “Programme and Abstracts.”

***  Tennessee Valley Authority SEC Form 10-K (annual report) for the fiscal year ended Sept. 30, 2015.  Executive compensation is discussed on pp. 152-77.

****  The calculation of the annual incentive plan payouts for named executives included a corporate multiplier based on six performance measures, one of which was safety performance based on the number of recordable injuries per hours worked, i.e., industrial safety.  The weights of the six components are not shown.

Thursday, March 17, 2016

IAEA Nuclear Safety Culture Conference

The International Atomic Energy Agency (IAEA) recently sponsored a week-long conference* to celebrate 30 years of interest and work in safety culture (SC).  By our reckoning, there were about 75 individual presentations in plenary sessions and smaller groups; dialog sessions with presenters and subject matter experts; speeches and panels; and over 30 posters.  It must have been quite a circus.

We cannot justly summarize the entire conference in this space but we can highlight material related to SC factors we’ve emphasized or people we’ve discussed on Safetymatters, or interesting items that merit your consideration.

Topics We Care About

A Systems Viewpoint

Given that the IAEA has promoted a systemic approach to safety and it was a major conference topic it’s no surprise that many participants addressed it.  But we were still pleased to see over 30 presentations, posters and dialogues that included mention of systems, system dynamics, and systemic and/or holistic viewpoints or analyses.  Specific topics covered a broad range including complexity, coupling, Fukushima, the Interaction between Human, Technical and Organizational Factors (HTOF), error/incident analysis, regulator-licensee relationships, SC assessment, situational adaptability and system dynamics.

Role of Leadership

Leadership and Management for Safety was another major conference topic.  Leadership in a substantive context was mentioned in about 20 presentations and posters, usually as one of multiple success factors in creating and maintaining a strong SC.  Topics included leader/leadership commitment, skills, specific competences, attributes, obligations and responsibilities; leadership’s general importance, relationship to performance and role in accidents; and the importance of leadership in nuclear regulatory agencies. 

Decision Making

This was mentioned about 10 times, with multiple discussions of decisions made during the early stages of the Fukushima disaster.  Other presenters described how specific techniques, such as Probabilistic Risk Assessment and Human Reliability Analysis, or general approaches, such risk control and risk informed, can contribute to decision making, which was seen as an important component of SC.

Compensation and Rewards

We’ve always been clear: If SC and safety performance are important then people from top executives to individual workers should be rewarded (by which we mean paid money) for doing it well.  But, as usual, there was zero mention of compensation in the conference materials.  Rewards were mentioned a few times, mostly by regulators, but with no hint they were referring to monetary rewards.  Overall, a continuing disappointment.   

Participants Who Have Been Featured in Safetymatters

Over the years we have presented the work of many conference participants to Safetymatters readers.  Following are some familiar names that caught our eye.
  Page numbers refer to the conference “Programme and Abstracts” document.
We have to begin with Edgar Schein, the architect of the cultural construct used by almost everyone in the SC space.  His discussion paper (p. 47) argued that the SC components in a nuclear plant depend on whether the executives actually create the climate of trust and openness that the other attributes hinge on.  We’ve referred to Schein so often he has his own label on Safetymatters.

Mats Alvesson’s presentation
(p. 46) discussed “hyper culture,” the vague and idealistic terms executives often promote that look good in policy documents but seldom work well in practice.  This presentation is consistent with his article on Functional Stupidity which we reviewed on Feb. 23, 2016.

Sonja Haber’s paper (p. 55) outlined a road map for the nuclear community to move forward in the way it thinks about SC.  Dr. Haber has conducted many SC assessments for the Department of Energy that we have reviewed on Safetymatters. 

Ken Koves of INPO led or participated in three dialogue sessions.  He was a principal researcher in a project that correlated SC survey data with safety performance measures which we reviewed on Oct. 22, 2010 and Oct. 5, 2014.

Najmedin Meshkati discussed (p. 60) how organizations react when their control systems start to run behind environmental demands using Fukushima as an illustrative case.  His presentation draws on an article he coauthored comparing the cultures at TEPCO’s Fukushima Daiichi plant and Tohoku Electric’s Onagawa plant which we reviewed on Mar. 19, 2014.

Jean-Marie Rousseau co-authored a paper (p. 139) on the transfer of lesson learned from accidents in one industry to another industry.  We reviewed his paper on the effects of competitive pressures on nuclear safety management issues on May 8, 2013.

Carlo Rusconi discussed (p. 167) how the over-specialization of knowledge required by decision makers can result in pools of knowledge rather than a stream accessible to all members of an organization.  A systemic approach to training can address this issue.  We reviewed Rusconi’s earlier papers on training on June 26, 2013 and Jan. 9, 2014.

Richard Taylor’s presentation (p. 68) covered major event precursors and organizations’ failure to learn from previous events.  We reviewed his keynote address at a previous IAEA conference where he discussed using system dynamics to model organizational archetypes on July 31, 2012.

Madalina Tronea talked about (p. 114) the active oversight of nuclear plant SC by the National Commission for Nuclear Activities Control (CNCAN), the Romanian regulatory authority.  CNCAN has developed its own model of organizational culture and uses multiple methods to collect information for SC assessment.  We reviewed her initial evaluation guidelines on Mar. 23, 2012

Our Perspective

Many of the presentations were program descriptions or status reports related to the presenter’s employer, usually a utility or regulatory agency.  Fukushima was analyzed or mentioned in 40 different papers or posters.  Overall, there were relatively few efforts to promote new ideas, insights or information.  Having said that, following are some materials you should consider reviewing.

From the conference participants mentioned above, Haber’s abstract (p. 55) and Rusconi’s abstract (p. 167) are worth reading.  Taylor’s abstract (p. 68) and slides are also worth reviewing.  He advocates using system dynamics to analyze complicated issues like the effectiveness of organizational learning and how events can percolate through a supply chain.

Benoît Bernard described the Belgian regulator’s five years of experience assessing nuclear plant SC.  Note that lessons learned are described in his abstract (p. 113) but are somewhat buried in his presentation slides.

If you’re interested in a systems view of SC, check out Francisco de Lemos’ presentation
(p. 63) which gives a concise depiction of a complex system plus a Systems Theoretic Accident Models and Processes (STAMP) analysis.  His paper is based on Nancy Leveson’s work which we reviewed on Nov. 11, 2013.

Diana Engström argued that nuclear personnel can put more faith in reported numbers than justified by the underlying information, e.g., CAP trending data, and thus actually add risk to the overall system.  We’d call this practice an example of functional stupidity although she doesn’t use that term in her provocative paper.  Both her abstract (p. 126) and slides are worth reviewing.

Jean Paries gave a talk on the need for resilience in the management of nuclear operations.  The abstract (p. 228) is clear and concise; there is additional information in his slides but they are a bit messy.

And that’s it for this installment.  Be safe.  Please don’t drink and text.

*  International Atomic Energy Agency, International Conference on Human and Organizational Aspects of Assuring Nuclear Safety: Exploring 30 years of Safety Culture (Feb. 22–26, 2016).  This page shows the published conference materials.  Thanks to Madalina Tronea for publicizing them.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety Culture discussion group. 

Thursday, March 10, 2016

Leadership and Safety Culture

Cover of the first issue
It’s an election year in America and voters are assessing candidates who all claim they can provide the leadership the country needs.  A recent article* in The New Yorker offers a primer on the nature of leadership.  The article is engaging because we talk a lot about leadership in the nuclear industry in areas ranging from general management to molding or influencing culture.**  Following are some highlights from the article.

For starters, leadership can mean different things to different people.  The article cites a professor who found more than 200 definitions in the modern leadership literature.  Of necessity, the author focused on a small subset of the literature, starting with sociologist Max Weber who distinguished between “charismatic” and “bureaucratic” leadership.

The charismatic model is alive and well; it’s reflected in the search for CEOs with certain traits, e.g., courage, decisiveness, intelligence or attractiveness, especially during periods of perceived crisis.  Unfortunately, the track record of such people is mixed; according to one researcher, “The most powerful factor determining a company’s performance is the condition of the market in which it operates.” (p. 67)

The bureaucratic model focuses on process, i.e., what a leader actually does.  Behaviors might include gathering information on technology and competitors, setting goals, assembling teams and tracking progress, in other words, the classic plan, organize, staff, direct and control paradigm.  But a CEO candidate’s actual process might not be visible or not what he says it is.  And, in our experience, if the CEO cannot bring strategic insight or a robust vision to the table, the “process” is a puerile exercise.

So how does one identify the right guy or gal?  Filtering is one method to reduce risk in the leader selection process.  Consider the nuclear industry’s long infatuation with admirals.  Why?  One reason is they’ve all jumped through the same hoops and tend to be more or less equally competent—a safe choice but one that might not yield out-of-the-ballpark results.  A genuine organizational crisis might call for an unfiltered leader, an outsider with a different world view and experience, who might deliver a resounding success (e.g., Abraham Lincoln).  Of course, the downside risk is the unfiltered leader may fail miserably.

If you believe leadership is learnable, you’re in luck; there is a large industry devoted to teaching would-be leaders how to empower and inspire their colleagues and subordinates, all the while evidencing a set of pious virtues.  However, one professor thinks this is a crock and what the leadership industry actually does is “obscure the degree to which companies are poorly and selfishly run for the benefit of the powerful people in charge.” (p. 68)

The author sees hope in approaches that seek to impart more philosophy or virtue to leaders.  He reviews at length the work of Elizabeth Samet, an English professor at the U.S. Military Academy (West Point).  She presents leadership through a wide-angle lens, from General Grant’s frank memoirs to a Virginia Woolf essay.  To gain insight into ambition, her students read “Macbeth.”  (Ooops!  I almost typed “MacTrump.”)    

Our Perspective

The New Yorker article is far from a complete discussion of leadership but it does spur one to think about the topic.  It’s worth a quick read and some of the author’s references are worth additional research.  If you want to skip all that, what you should know is “. . . leaders in formal organizations have the power and responsibility to set strategy and direction, align people and resources, motivate and inspire people, and ensure that problems are identified and solved in a timely manner.”***

At Safetymatters, we believe effective leadership is necessary, but not sufficient, to create a strong safety culture (SC).  Not all aspects of leadership are important in the quest for a strong SC.  Leaders need some skills, e.g., the ability to communicate their visions, influence others and create shared understanding.  But the critical aspects are decision-making and role modeling.

Every decision the leader makes must show respect for the importance of safety.  The people will be quick to spot any gap between words and decisions.  Everyone knows that production, schedule and budget are important—failure to perform eventually means jobs and careers go away—but safety must always be a conscious and visible consideration.

Being a role model is also important.  Again, the people will spot any disregard or indifference to safety considerations, rules or practices.

There is no guarantee that even the most gifted leader can deliver a stronger SC.  Although the leader may create a vision for strong SC and attempt to direct behavior toward that vision, the dynamics of SC are complex and subject to multiple factors ranging from employees’ most basic values to major issues that compete for the organization’s attention and resources. 

To close on a more upbeat note, effective leadership is open to varying definitions and specifications but, to borrow former Supreme Court Justice Potter Stewart’s famous phrase, we know it when we see it.****

*  J. Rothman, “Shut Up and Sit Down,” The New Yorker (Feb. 29, 2016), pp. 64-69.

**  For INPO, leadership is sine qua non for an effective nuclear organization.

***  This quote is not from The New Yorker article.  It is from a review of SC-related social science literature that we posted about on Feb. 10, 2013.

****  Justice Stewart was talking about pornography but the same sort of Kantian knowing can be applied to many topics not amenable to perfect definition.

Thursday, March 3, 2016

2016 NEA Report on Fukushima Lessons Learned

Five years after the Fukushima disaster, the Nuclear Energy Agency (NEA) has released an updated report* on Fukushima lessons learned.  It summarizes NEA and member country safety improvements and corrective actions, including “efforts to understand and characterise the importance of strong nuclear safety cultures . . .” (p. 3)

Keep in mind that countries (not plant operators) comprise the NEA so safety culture (SC) discussion centers on government, i.e., regulatory, activities.  Selected SC-related excerpts from the report follow:

“Several NEA member countries have adopted a broad consideration of safety culture characteristics, including human and organisational factors, which include specific safety culture programmes that focus on attitudes towards safety, organisational capability, decision-making processes [including during emergencies] and the commitment to learn from experience.” (p. 11)

“Some [countries] have adopted a systematic consideration of safety culture characteristics in inspection and oversight processes. . . . These include periodic internal and external safety culture assessments.” (p. 29)

Desirable SC characteristics for a regulator (as opposed to a licensee) are discussed on pp. 40-42.  That may seem substantial but it’s all pulled from a different 2016 NEA publication, “The Safety Culture of an Effective Nuclear Regulatory Body,” which we reviewed on Feb. 10, 2016.  That publication had one point worth repeating here, viz., the regulator, in its efforts to promote and ensure safety, should think holistically about the overall regulator-licensee- socio-technical-legal-political system in terms of causes and effects, feedback loops and overall system performance. 

Our Perspective

This report may be a decent high-level summary of activities undertaken around the world but it is not sufficiently detailed to provide guidance and it certainly contains no original analysis.  The report does include a respectable list of Fukushima-related references.

Many of the actions, initiatives and activities described in the report are cited multiple times, creating the impression of more content than actually exists.  For example, the quote above from p. 11 is repeated, in whole or in part, in at least four other places.

If the NEA were a person, we’d characterize it as an “empty suit.”  While the summaries of and excerpts from the references, meetings, etc. are satisfactory, the NEA-authored top-level observations are often pro-nuclear cheerleading or just plain blather, e.g., “NEA member countries have continued to take appropriate actions to maintain and enhance the level of safety at their nuclear facilities, and thus nuclear power plants are safer now because of actions taken since the accident.  Ensuring safety is a continual process, . . .” (p. 11)**

*  Nuclear Energy Agency, “Five Years after the Fukushima Daiichi Accident: Nuclear Safety Improvements and Lessons Learnt,” NEA No. 7284 (2016).  The NEA is an arm of the Organisation for Economic Co-operation and Development (OECD).  This report builds on a 2013 report, “The Fukushima Daiichi Nuclear Power Plant Accident: OECD/NEA Nuclear Safety Response and Lessons Learnt.”

**  As a catty aside, the reputation of the NEA’s relatively new Director-General doesn’t exactly contribute to the agency’s respectability, his having been called “a treacherous, miserable liar,” “first-class rat” and “a tool of the nuclear industry” by an influential U.S. Senator during a 2012 Huffington Post interview.  At that time, the Director-General was a U.S. Nuclear Regulatory Commissioner.