Thursday, July 27, 2017

Nuclear Safety Culture: Another Incident at Pilgrim: Tailgate Party

The Cape Cod Times recently reported* on a security violation at the Pilgrim nuclear plant: one employee entering a secure area facilitated “tailgating” by a second employee who had forgotten his badge.  He didn’t want to go to Security to obtain clearance for entry because that would make him late for work.

The NRC determined the pair were deliberately taking a shortcut but were not attempting to do something malicious.  The NRC investigation also revealed that other personnel, including security, had utilized the same shortcut in the past to allow workers to exit the plant.  The result of the investigation was a Level IV violation for the plant.

Of course, the plant’s enemies are on this like a duck on a June bug, calling the incident alarming and further evidence for immediate shutdown of the plant.  Entergy, the plant’s owner, is characterized as indifferent to such activities. 

The article’s high point was reporting that the employee who buzzed in his fellow worker told investigators “he did not know he was not allowed to do that”.

Our Perspective 

The incident itself was a smallish deal, not a big one.  But it does score a twofer because it reflects on both safety culture and security culture.  Whichever category it goes in, the incident is a symptom of a poorly managed plant and a culture that has long tolerated shortcuts.  It is one more drop in the bucket as Pilgrim shuffles** toward the exit.

This case raises many questions: What kind of training, including refresher training, does staff receive about security procedures?  What kind of oversight, reminders, reinforcement and role modeling do they get from their supervisors and higher-level managers?  Why was the second employee reluctant to take the time to follow the correct procedure?  Would he have been disciplined, or even fired, for being late?  We would hope Pilgrim management doesn’t put everyone who forgets his badge in the stocks, or worse.

Bottom line: Feel bad for the people who have to work in the Pilgrim environment, be glad it’s not you or your workplace.

*  C. Legere, “NRC: Pilgrim workers ‘deliberately’ broke rules,” Cape Cod Times (July 24, 2017).  Retrieved July 26, 2017

**  In this instance, “shuffle” has both its familiar meaning of “dragging one's feet” and a less-used definition of “avoid a responsibility or obligation.”  Google dictionary retrieved July 27, 2017.

Wednesday, July 12, 2017

Nuclear Safety Culture (and Other) Problems in the U.S. Nuclear Weapons Complex

Los Alamos  Source: LANL
The Center for Public Integrity (CPI) has published a five-part report on safety lapses in the U.S. nuclear weapons complex—an array of facilities overseen by the Department of Energy (DOE).*  Overall, the report paints a picture of a challenged and arguably weak safety culture (SC).  Following is a summary of the report and our perspective on it.

Part I traces the history of radioactive criticality incidents (which have resulted in human fatalities) and near-misses at Los Alamos National Laboratory (LANL).  Analysis and production of plutonium pits, essential for maintaining the U.S. nuclear weapons inventory, has been halted for years because of concerns over safety issues.  In addition, almost all members of the site’s criticality analysis team quit over inadequate management support for the team’s efforts.

Part II discusses in more detail the impacts of the LANL shutdown.  Most significant, from our perspective, is a 2013 report that said “Management has not yet fully embraced its commitment to criticality safety.”  The 2013 report “also listed nine weaknesses in the lab’s safety culture that were rooted in a “production focus” to meet work deadlines. Workers say these deadlines are typically linked to financial bonuses.”

Speaking of bonuses, although the plant was not working, the contractors were judged to have exceeded expectations in getting ready to restart.  Accordingly, the contractors “received 74 percent or $10.7 million of the $14.4 million in profits available to them from the NNSA in the category that includes pit production and surveillance”

Part III covers incidents at other facilities and cultural shortcomings in the weapons complex.  It is the meatiest section of the report.  Most of the unfortunate events were industrial accidents (electric shocks, explosions, burns) but the nuclear hazard is always nearby because of the nature of the work.  Occasionally the nuclear factor is key, e.g., when LANL improperly packed a drum of waste they shipped to the Waste Isolation Pilot Plant where it exploded or when Nevada National Security Site personnel inhaled radioactive particles

This section captures the key point of the entire report: the DOE contractors make a lot of money ($2B in profit over the last 10 years), the financial rewards for safety are minimal and the financial penalties for accidents and such are minimal (1-3% of profits) and often waived.

Part IV details a 2014 incident in Nevada where over 30 personnel inhaled potentially cancer-causing uranium particles during laboratory experiments over a two-month period.  The researchers were annoyed by radiation alarms so they switched them off (which also turned off a safety ventilation system).  This was a self-inflicted wound that suggests a weak SC.

Part V focuses on a radiation exposure accident at the Idaho National Laboratory.  The accident occurred even though years before, the head of the safety committee had warned DOE managers about the hazards of handling the specific material involved in the accident.  The lab contractor made 92% of its contractually available profit that year.  The contractor has petitioned DOE to reimburse the contractor’s litigation expenses (including payouts to affected employees) associated with the accident.

NNSA’s Response

The National Nuclear Security Administration (NNSA) is a semi-autonomous agency within DOE that oversees U.S. nuclear weapons work.  In a statement** responding to the CPI report, the NNSA Administrator basically says the CPI report is incomplete and misleading with respect to LANL.  Unsurprisingly, he starts with “Safety is paramount . . . . [CPI] attacks the safety culture at . . .  (LANL) without offering all of the facts and the full context.”  However, he does not directly refute the CPI report, instead he provides the NNSA’s version of history: LANL paused operations because of concerns with the criticality safety program. Since then, “LANL has increased criticality safety staffing and demonstrated improvements in its performance of operational tasks.”  NNSA has withheld $82 million in fee payments to LANL.  Finally, LANL maintained its ability to fulfill its mission during the pause in operations.  Alternative facts?  You be the judge. 

Our Perspective 

The DOE says it wants safe production but is not willing to wield the hammer (higher financial incentives for safety and more penalties for unsafety) to drive that outcome.  In addition, DOE, constrained by Congress (which is bowing to their defense industry contributors), appears to deliberately understaff their own auditors and other procurement officials so they are unable to surface too many embarrassing problems. 

The contractors are rational.  They understand that production is the primary goal and they accept that bad things will occasionally happen in a hazardous environment.  They know they will make their profits no matter what happens, including facility shutdowns, because they can get paid for fixing problems they helped to create.

The CPI report is not shocking to us and it shouldn’t be to you.  (Click on the DOE label to see our many posts on DOE SC.)  It merely documents what has been, and continues to be, business as usual at nuclear weapons facilities.  If you can tolerate the overwrought writing, Part III is worth a look.           

*  The Center for Public Integrity, “Nuclear Negligence” (June 28, 2017).  Retrieved July 5, 2017.  According to Wikipedia, CPI “is an American nonprofit investigative journalism organization . . .”

The report describes problems at the Idaho National Laboratory and some NNSA facilities.  Overall, NNSA oversees eight sites that are involved with nuclear weapons: Kansas City National Security Campus (non-nuclear component manufacture), Lawrence Livermore National Laboratory (weapon design), Los Alamos National Laboratory (design and testing), Nevada National Security Site (testing), Pantex Plant (weapon assembly and disassembly), Sandia National Laboratories (non-nuclear component design), Savannah River Site (nuclear materials) and Y-12 National Security Complex (uranium components).

**  “Klotz Responds To Center For Public Integrity's Series On Safety Culture At NNSA Sites,” Los Alamos Daily Post (June 20, 2017).  Retrieved July 10, 2017