We report in this post on a situation that developed at Indian Point more than two years ago and was just recently closed out via NRC notices of violation to an individual (a Chemistry Manager for Entergy Nuclear Operations) and to Entergy Nuclear Operations itself.
What should we make of another willful misconduct episode? A misguided individual who made some bad choices but where the actual impact on safety (per Entergy and the NRC) was not significant? The individual resigned (and plead to a felony conviction and probation), corrective actions to reinforce proper behaviors have been taken, and violations issued...what difference does it make?
The Events Surrounding the Misconduct
We are attaching a series of references as they contain more detail than we can recount in a blog post. In particular Reference 4 provides the most comprehensive rendition of the relevant events. Very briefly this is what occurred: During 2011 routine testing of diesel fuel oil at Indian Point (IP), as required by Tech Specs, indicated that the limits on particulate concentration were exceeded. The Chemistry Manager with responsibility for this testing did not report (initiate Condition Reports) the anomalous results which would have resulted in the reserve fuel oil storage tank (RFOST) being declared inoperable. The LCO is 30 days and if operability was not restored, shutdown of both IP units would have been required. [Ref 2, Cover Letter] In early 2012 as part of a systems engineering self-assessment, the anomalous results and lack of reporting were identified. The Chemistry Manager falsely indicated that re-sampling and testing had been performed which were acceptable. He subsequently made false data entries to support this story.
A short time later employee concerns were filed via the Entergy Ethics Line and the Employee Concerns Program (ECP). Entergy initiated an investigation using outside attorneys (Morgan Lewis). At the same time the NRC initiated an Office of Investigations (OI) investigation. The Chemistry Manager refused to cooperate in the investigation and resigned. Subsequent testing of the fuel oil indicated limits were being exceeded and compensatory actions were taken. Pursuant to the investigations the Chemistry Manager admitted willful misconduct. The US Attorney issued a criminal complaint and ultimately the manager plead to a felony and received probation. Entergy was cited for a Severity Level III violation, civil penalty waived.
Further Observations
Plowing through the documentation of this issue left us with a few lingering questions. One is with regard to the sanitized LER that Entergy submitted to the NRC in August 2012. The LER makes no mention of the filing of employee concerns, investigation by outside attorneys or the NRC OI investigation. For that matter the LER never mentions that the cause of the event was willful misconduct by a department manager. Rather it characterizes the situation in the abstract - as a failure to use the corrective action program. In other words a whole lot was happening in the background which would cast the event in a different light, including its potential significance.*
While the cited violations are linked to the misconduct of the Chemistry Manager, it appears there had been ongoing issues within the Chemistry Department for some time: entering test data diligently, understanding the significance of the data, and initiating CRs. “The circumstances surrounding the violations are of concern to the NRC because they indicate a lack of consideration for (and/or knowledge of) TS requirements by ENO Chemistry staff. The NRC also noted that the Chemistry Manager would not have had the opportunity to commit the violations had ENO staff exhibited the proper regard for the site TS.” [Ref 4, p. 4] But in its chronology of events, Entergy contends that in March 2102 there was “no reason to question the integrity of former Chemistry Manager…” [Ref 4, Encl 2, slide 15]. Perhaps not the integrity, but what about management effectiveness?
Further context. Entergy gives itself credit for how it responded to the evolving situation. They highlight that a self-assessment team identified the anomalies (true), that employees raised concerns through established programs (true), that Entergy conducted an investigation (true). [Ref 4, Encl 2, slide 35] But what is missing is that normal business processes (management oversight, QA audits, or Chemistry Department personnel) did not identify the anomalies prior to the self-assessment; that employees felt the need to use the Ethics Line and the ECP rather than directly raising within the management chain; that upon discovery of the anomalies, it appears that Entergy went to great lengths to avoid declaring that the fuel oil did not meet specs.** The net result is that the RFOST was able to be maintained as operable for almost three months before definitive action was taken to filter the oil. [Ref 4, Encl 2, slides 17-21]
Why?
The most interesting and relevant question posed by these events is why did the Chemistry Manager take the actions he did? “The Manager said that he falsified the data because he needed more time to prove his theory [that the IP Chemistry Department’s sampling practices were poor] and incorporate new test methods, and he had not wanted the plant to unnecessarily shut down.” [Ref 2, Encl 1] That is the extent of what the NRC reports on its investigation of the motive of the Chemistry Manager. An employee for 29 years undertakes a series of deliberate violations of his professional responsibilities “to prove his theory”. Perhaps.
One of the final corrective actions implemented for this event occurred in December 2013 when the General Manager for Plant Operations briefed the Department Managers on deliberate misconduct. Included was a statement, "If we have to shutdown the plant we will do so". [Ref 4, Encl 2, slide 32] Without reading too much into a single bullet point, one wonders if this is a tacit acknowledgment by Entergy that the Chemistry Manager may have been influenced to do what he did because he did not want to be the cause of a plant shutdown.
We would be very interested to see how much probing was done by the NRC investigators, or Entergy’s attorneys, of this individual’s motive, particularly in terms of any perceived pressure to keep the plant operating. Such pressure needn’t come from Entergy, it seems self-evident that Indian Point’s licensing situation and the long standing political opposition within New York State poses an existential threat to the plant. If his motive was just a matter of a revised test “theory”, were these the first out-of-spec fuel oil test results on his watch? If there had been others, how were they handled? How long had he been in the position? Had he initiated any other actions prior to this time to investigate the testing protocol? As we noted in our post dated September 12, 2013 regarding the NRC’s Information Notice on willful violations, in none of the cited examples did the NRC provide any perspective on the motives of the individuals or the potential effects of the environment within which they were working.
Safety and Safety Culture
How does all of this shed any light on safety and safety culture?
A key dimension of safety culture is the accurate assessment of safety significance. The position of Entergy, and adopted by the NRC***, was that the actual impact of the violations on reactor safety was not significant. [Ref 4, Encl 2, slide 36] Also note that NRC finds that all of this is in the ROP category for “green” significance. The argument is a familiar one. TS limits are conservative and below what is actually “OK”. And if particulates are a problem there are filters on the diesel generators, and these can be changed out during operation of the diesels if necessary. This is a familiar characterization - safety significance is evaluated within the strict boundaries of the NRC’s safety construct of design basis assumptions, almost exclusively hardware based. As we noted in our September 24, 2013 post, this ignores the larger environment and “system” within which people actually function.
The Synergy Safety Culture Survey conducted from Feb to April 2012 is cited as finding a “healthy work environment in Chemistry Department” - yet this was at the very time test results were being falsified by the manager and employees were resorting to the ECP to raise issues. Other assessments by the NRC and INPO also did not identify issues. [Ref 4, Encl 2, slide 29]. There is reference to an “independent investigation” of the employee concerns but the documentation does not reveal who did the investigation or its findings. The investigation found “no one interviewed” had a reluctance to raise an issue. Nowhere is the prior use of the Ethics Line and ECP by several individuals on an anonymous basis explained.
Something that is hard to square is the NRC assertion that there is a strong link between willful violations and safety culture, and the results of these various assessments at Indian Point by Synergy, the NRC and INPO. So if there is a link, and safety culture assessments don’t reveal its presence, are the assessments valid? Or if the assessments are valid, is there really a link with willful misconduct?
Here’s our take. Willful misconduct is an indication of an issue with the safety culture. But the issue arises out of a broader and more complex context than the NRC or industry is willing to address. At Indian Point there is an overriding operating context where the extension of the plants’ operating licenses is being contested by powerful political forces in New York State. If the licenses are not extended, the plants close and people lose their jobs. This is not theoretical as the Entergy-owned plant, Vermont Yankee, is doing just that. If you are an employee at Indian Point, you must feel that pressure every day. When an issue comes up such as failed diesel fuel tests that could result in temporary shutdown of both units, it is an additional threat to the viability of the plant. That pressure can create a powerful desire to rationalize the fuel tests are not valid and/or that slightly contaminated fuel isn’t a significant safety concern because…[see Entergy and NRC agreement that it is not a significant safety concern]. So there is a situation where there is an immediate and significant penalty (shutdown of both units) versus a test result that may or may not be valid or of real safety significance. The result: deliberate misconduct in burying the test results but also very possibly (I am speculating) the individual and others in the organization can still believe that safety is not impacted. As actions are consistent with “real” safety significance, it preserves the myth that safety culture is still healthy.
* As stated in the NRC Enforcement Policy (on page 9, section 2.2.1.d): “Willful violations are of particular concern because the NRC’s regulatory program is based on licensees and their contractors, employees, and agents acting with integrity and communicating with candor. The Commission cannot tolerate willful violations. Therefore, a violation may be considered more significant than the underlying noncompliance if it includes indications of willfulness.” [NRC Information Notice 2013-15]
** The sequence of events starting in March 2012 in response to RFOST sample (by off-site testing lab) being out of spec: the RFOST is declared inoperable but a supervisor declares that the sample test method was not appropriate, the department procedure is revised to allow on-site testing of a new sample (what was site review process? procedure revision appears to have occurred and become effective in one day), and the test results are now found acceptable. This allows the RFOST to be declared operable. Without telling anyone, the former Chem Mgr sends a split sample for off-site testing and it comes back over spec. Why wouldn’t plant management have required a split sample in the first place to verify on-site test? Two employee concerns are filed, the ML investigation is initiated and the Chemistry Manager resigns. At the next sampling in mid-April, once again the on-site analysis finds the sample to be within spec but management now requires outside testing in light of the resignation of the Chemistry Manager. Outside test indicates out-of-spec but an “evaluation” concludes that the in-house results are valid and RFOST remains “operable”. Another month goes by and sample is taken in late May. Sample sent outside, late June results indicate out-of-spec. This time the RFOST is declared inoperable. Not clear if late May sample was tested on-site (or why not) and why this time the outside test result is deemed valid. A final footnote, one of the corrective actions for this event was to discontinue on-site oil analysis but no discussion of why, or why it had been approved in the first place.
*** “the underlying technical findings would have been evaluated as having very low safety significance (i.e. green) under the Reactor Oversight Process (ROP) because the higher fuel oil particulate concentration would not have impacted the ability of the EDGs to fulfill their safety function.” [Ref 4, p. 3]
(Ed. note: This is Safetymatters’ second post on the Phase 1 WIPP report. Bob and I independently saw the report, concluded it raised important questions about DOE and its investigative process and headed for our keyboards. We will try to get an official response to our posts—but don’t hold your breath.)
Earlier this week the DOE released its Accident Investigation Report on the Radiological Release Event at the Waste Isolation Pilot Plant. The report is a prodigious effort in the just over two months since the event. It is also a serious indictment of DOE’s management of WIPP and arguably, the DOE itself. There is however a significant flaw in the investigation and report: the investigators were kept on too tight a leash. Itemization of failures, particularly pervasive failures, without pursuing how and why they occurred is not sufficient. It also highlights the essence and value of systems analysis - identifying the fundamental dynamics that produced the failures and solutions that change those dynamics.
At first blush the issuance of yet another report on safety issues and safety management performance at a DOE facility would hardly merit a rush to the keyboard to dissect the findings. Yet we believe this report is a tipping point in the pervasive and continuing issues at DOE facilities and should be a call for much more aggressive action. It doesn’t take long for the report to get to the point in the Executive Summary:
“The Board identified the root cause of Phase 1 of the investigation of the release of radioactive material from underground to the environment to be NWP’s and CBFO’s management failure to fully understand, characterize, and control the radiological hazard.” [emphasis added] (p. ES-6) NWP is Nuclear Waste Partnership, the contractor with direct management responsibility for WIPP operations, and CBFO is the Carlsbad Field Office of the DOE.
To complete the picture the investigation board also found as a contributing cause, that DOE Headquarters oversight was ineffective. So in sum, the board found a total failure of the management system responsible for radiological safety at the WIPP.
Interestingly there has been a rather muted response to this report. The DOE issued the report with a strikingly neutral press release quoting Matt Moury, Environmental Management Deputy Assistant Secretary, Safety, Security, and Quality Programs: “The Department believes this detailed report will lead WIPP recovery efforts as we work toward resuming disposal operations at the facility.” And Joe Franco, DOE’s Carlsbad Field Office Manager: “We understand the importance of these findings, and the community’s sense of urgency for WIPP to become operational in the future.”* (We note that both statements focus on resumption of operations versus correction of deficiencies.) New Mexico’s U.S. Senators Udall and Heinrich called the findings “deeply troubling” but then simply noted that they expected DOE management to take the necessary corrective actions.** If there is any sense of urgency we would think it might be directed at understanding how and why there was such a total management failure at the WIPP.
To fully appreciate the range and depth of failures associated with this event one really needs to read the board’s report. Provided below is a brief summary of some of the highlights that illustrate the identified issues:
- Implementation of the NWP Conduct of Operations Program is not fully compliant with DOE policy; - NWP does not have an effective Radiation Protection Program in accordance with 10 Code of Federal Regulations (CFR) 835, Occupational Radiation Protection; - NWP does not have an effective maintenance program; - NWP does not have an effective Nuclear Safety Program in accordance with 10 CFR 830 Subpart B, Safety Basis Requirements; - NWP implementation of DOE O 151.1C, Comprehensive Emergency Management System, was ineffective; - The current site safety culture does not fully embrace and implement the principles of DOE Guide (G) 450.4-1C, Integrated Safety Management Guide [note: findings consistent with findings of the 2012 SCWE self assessment results]; and DOE oversight of NWP was ineffective; - Execution of CBFO oversight in accordance with DOE O 226.1B was ineffective; and - As previously mentioned, DOE Headquarters (HQ) line management oversight was ineffective. (pp. ES 7-8)
Many of the specific deficiencies cited in the report are not point in time occurrences but stem from chronic and ongoing weaknesses in programs, personnel, facilities and resources.
Losing the Scent
As mentioned in the opening paragraph we feel that while the report is of significant value it contains a shortcoming that will likely limit its effectiveness in correcting the identified issues. In so many words the report fails to ask “Why?” The report is a massive catalogue of failures yet never fully pursues the ultimate and most relevant question: Why did the failures occur? One almost wonders how the investigators could stop short of systematic and probing interviews of key decision makers.
For example in the maintenance area, “The Board determined that the NWP maintenance and engineering programs have not been effective…”; “Additionally, configuration management was not being maintained or adequately justified when changes were made.”; “There is an acceptance to tolerate or otherwise justify (e.g., lack of funding) out-of-service equipment.” (p. 82) And that’s where the analysis stops.
Unfortunately (but predictably) what follows from the constrained analysis are equally unfocused corrective actions based on the following linear construct: “this is a problem - fix the problem”. Even the corrective action vocabulary becomes numbingly sterile: “needs to take action to ensure…”, “needs to improve…”, “need to develop a performance improvement plan…”, “needs to take a more proactive role…”.
We do not want to be overly critical as the current report reflects a little over two months of effort and may not have afforded sufficient time to pull the string on so many issues. But it is time to realize that these types of efforts are not sufficient to understand, and therefore ultimately correct, the issues at WIPP and DOE and institutionalize an effective safety management system.
On Feb. 14, 2014, an incident at the Department of Energy (DOE) Waste Isolation Pilot Plant (WIPP) resulted in the release of radioactive americium and plutonium into the environment. This post reviews DOE’s Phase 1 incident report*, with an emphasis on safety culture (SC) concerns.
From the Executive Summary
The Accident Investigation Board (the Board) concluded that a more thorough hazard analysis, coupled with a better filter system could have prevented the unfiltered above ground release. (p. ES-1)
The root cause of the incident was Nuclear Waste Partnership’s (NWP**, the site contractor) and the DOE Carlsbad Field Office’s (CBFO) failure to manage the radiological hazard. “The cumulative effect of inadequacies in ventilation system design and operability compounded by degradation of key safety management programs and safety culture [emphasis added] resulted in the release of radioactive material . . . and the delayed/ineffective recognition and response to the release.” (pp. ES 6-7)
The report presents eight contributing causes, most of which point to NWP deficiencies. SC was included as a site-wide concern, specifically the SC does not fully implement DOE safety management policy, “[t]here is a lack of a questioning attitude, reluctance to bring up and document issues, and an acceptance and normalization of degraded equipment and conditions.” A recent Safety Conscious Work Environment (SCWE) survey suggests a chilled work environment. (p. ES-8)
The report includes 31 conclusions, 4 related to SC. “NWP and CBFO have allowed the safety culture at the WIPP project to deteriorate . . . Questioning attitudes are not welcomed by management . . . DOE has exacerbated the safety culture problem by referring to numbers of [problem] reports . . . as a measure of [contractor] performance . . . . [NWP and CBFO] failed to identify weaknesses in . . . safety culture.” (pp. ES 14-15, 19-20)
The report includes 47 recommendations (called Judgments of Need) with 4 related to SC. They cover leadership (including the CBFO site manager) behavior, organizational learning, questioning attitude, more extensive use of existing processes to raise issues, engaging outside SC expertise and improving contractor SC-related processes. (ibid.)
Report Details
The body of the report presents the details behind the conclusions and recommendations. Following are some of the more interesting SC items, starting with our hot button issues: decision making (esp. the handling of goal conflict), corrective action, compensation and backlogs.
Decision Making
The introduction to section 5 on SC includes an interesting statement: “In normal human behavior, production behaviors naturally take precedence over prevention behaviors unless there is a strong safety culture - nurtured by strong leadership.” (p. 61)
The report suggests nature has taken its course: WIPP values production first and most. “Eighteen emergency management drills and exercises were cancelled in 2013 due to an impact on operations. . . .Management assessments conducted by the contractor have a primary focus on cost and schedule performance.” (p. 62) “The functional checks on CAMs [continuous air monitors] were often delayed to allow waste-handling activities to continue.” (p. 64) “[D]ue consideration for prioritization of maintenance of equipment is not given unless there is an immediate impact on the waste emplacement processes.” (p. ES-17) These observations evidence an imbalance between the goals of production and prevention (against accidents and incidents) and, following the logic of the introductory statement, a weak SC.
Corrective Action
The corrective action program has problems. “The [Jan. 2013] SCWE Self-Assessment . . . identified weaknesses in teamwork and mutual respect . . . Other than completing the [SCWE] National Training Center course, . . . no other effective corrective actions have been implemented. . . . [The Self-Assessment also ]“identified weaknesses in effective resolution of reported problems.” (p. 63) For problems that were reported, “The Board noted several instances of reported deficiencies that were either not issued, or for which corrective action plans were not developed or acted on for months.” (p. 65)
Compensation
Here is the complete text of Conclusion 14, which was excerpted above: “DOE has exacerbated the safety culture problem by referring to numbers of ORPS [incident and problem] reports and other deficiency reporting documents, rather than the significance of the events, as a measure of performance by Source Evaluation Boards during contract bid evaluations, and poor scoring on award fee determinations. Directly tying performance to the number of occurrence reports drives the contractor to non-disclosure of events in order to avoid the poor score. [emphasis added] This practice is contrary to the Department’s goals of the development and implementation of a strong safety culture across our projects.” (p. ES-15) ‘Nuff said.
Backlogs
Maintenance was deferred if it interfered with production. Equipment and systems were allowed to degrade (pp. ES-7, ES-17, C-7) There is no indication that maintenance backlogs were a problem; the work simply wasn’t done.
Other SC Issues
In addition to our Big Four and the issues cited from the Executive Summary, the report mentions the following concerns. (A listing of all SC deficiencies is presented on p. D-3.)
Delay in recognizing and responding to events,
Bias for negative conclusions on Unreviewed Safety Question Determinations, and
Infrequent presence of NWP management in the underground and surface.
Our Perspective
For starters, the Board appears to have a limited view of what SC is. They see it as a cause for many of WIPP's problems but it can be fixed if it is “nurtured by strong leadership” and the report's recommendations are implemented. The recommendations are familiar and can be summed up as “Row harder!”*** In reality, SC is both cause (it creates the context for decision making) and consequence (it is influenced by the observed actions of all organization members, not just senior management). SC is an organizational property that cannot be managed directly.
The report is a textbook example of linear, deterministic thinking, especially Appendix E (46 pgs.) on events and causal factors related to the incident. The report is strong on what happened but weak on why things happened. Going through Appendix E, SC is a top-level blanket cause of nuclear safety program and radiological event shortcomings (and, to a lesser degree, ventilation, CAMs and ground control problems) but there is no insight into how SC interacts with other organizational variables or with WIPP’s external (political, regulatory, DOE policy) environment.
Here’s an example of what we’re talking about, viz., how one might gain some greater insight into a problem by casting a wider net and applying a bit of systems thinking. The report faults DOE HQ for ineffective oversight, providing inadequate resources and not holding CBFO accountable for performance. The recommended fix is for DOE HQ “to better define and execute their roles and responsibilities” for oversight and other functions. (p. ES-21) That’s all what and no why. Is there some basic flaw in the control loop involving DOE HQ, CBFO and NWP? DOE HQ probably believes it transmits unambiguous orders and expectations through its official documents—why weren’t they being implemented in the field and why didn’t DOE know it? Is the information flow from DOE to CBFO to NWP clear and adequate (policies, goals); how about the flow in the opposite direction (performance feedback, problems)? Is something being lost in the translation from one entity to another? Does this control problem exist between DOE HQ and other sites, i.e., is it a systemic problem? Who knows.****
Are there other unexamined factors that make WIPP's problems more likely? For example, has WIPP escaped the scrutiny and centralized controls that DOE applies to other entities? As a consequence, has WIPP had too much autonomy to adjust its behavior to match its perception of the task environment? Are DOE’s and WIPP’s mental models of the task environment similar or even adequate? Perhaps WIPP (and possibly DOE) see the task environment as simpler than it actually is, and therefore the strategies for handling the environment lack requisite variety. Was there an assumption that NWP would continue the apparently satisfactory performance of the previous contractor? It's obvious these questions do not specifically address SC but they seek to ascertain how the organizations involved are actually functioning, and SC is an important variable in the overall system.
Contrast with Other DOE SC Investigations
This report presents a sharp contrast to the foot-dragging that takes place elsewhere in DOE. Why can’t DOE bring a similar sense of urgency to the SC investigations it is supposed to be conducting at its other facilities? Was the WIPP incident that big a deal (because it involved a radioactive release) or is it merely something that DOE can wrap its head around? (After all, WIPP is basically an underground warehouse.) In any event, something rang DOE’s bell because they quickly assembled a 5 member board with 16 advisor/consultants and produced a 300 page report in less than two months.*****
Bottom line: You don't need to pore over this report but it provides some perspective on how DOE views SC and demonstrates that a giant agency can get moving if it's motivated to do so.
** NWP LLC was formed by URS Energy and Construction, Inc. and Babcock & Wilcox Technical Services Group, Inc. Their major subcontractor is AREVA Federal Services, LLC. All three firms perform work at other, i.e., non-WIPP, DOE facilities. NWP assumed management of WIPP on Oct. 1, 2012. From NWP website. Retrieved May 2, 2014.
*** To the Board's credit, they did not go looking for individual scapegoats to blame for WIPP's difficulties.
**** In fairness, the report has at least one example of a feedback loop in the CBFO-NWP sub-system: CBFO's use of the condition reports as an input to NWP’s compensation review and NWP's predictable reaction of creating fewer condition reports.
***** The Accident Investigation Board was appointed on Feb. 27, 2014 and completed its Phase 1 investigation on March 28, 2014. The Phase 1 report was released to the public on April 22, 2014.
The NRC held their annual Regulatory Information Conference (RIC) March 11-13, 2014. It included a session on safety culture (SC), summarized below.*
NRC Presentation
The NRC presentation reviewed their education and outreach activities on the SC Policy Statement (SCPS) and their participation in IAEA meetings to develop an implementation strategy for the IAEA Nuclear Safety Action Plan.
The only new item was Safety Culture Trait Talk, an educational brochure. Each brochure covers one of the nine SC traits in the SCPS, describing why the trait is important and providing examples of associated behaviors and attitudes, and an illustrative scenario.
It appears only one brochure, Leadership Safety Values and Actions, is currently available.** A quick read suggests the brochure content is pretty good. The “Why is this trait important?” content was derived from an extensive review of SC-related social science literature, which we liked a lot and posted about Feb. 10, 2013. The “What does this trait look like?” section comes from the SC Common Language initiative, which we have reviewed multiple times, most recently on April 6, 2014. The illustrative scenario is new content developed for the brochure and provides a believable story of how normalization of deviance can creep into an organization under the skirt of an employee bonus program based on plant production.
Licensee Presentations
There were three licensee presentations, all from entities that the NRC has taken to the woodshed over SC deficiencies. Presenting at the RIC may be part of their penance but it’s interesting to see what folks who are under the gun to change their SC have to say.
Chicago Bridge & Iron, which is involved in U.S. nuclear units currently under construction, got in trouble for creating a chilled work environment at one of its facilities. The fixes focus on their Safety Conscious Work Environment and Corrective Action Program. Detailed activities come from the familiar menu: policy updates, a new VP role, training, oversight, monitoring, etc. Rapping CB&I’s knuckles certainly creates an example for other companies trying to cash in on the “Nuclear Renaissance” in the U.S. Whatever CB&I does, they are motivated to make it work because there is probably a lot of money at stake. The associated NRC Confirmatory Order*** summarizes the history of the precipitating incident and CB&I’s required corrective actions.
Browns Ferry has had SC-related problems for a long time and has been taken to task by both NRC and INPO. The presentation includes one list of prior plant actions that DIDN’T work while a different list displays current actions that are supposedly working. Another slide shows improvement in SC metrics based on survey data—regular readers know how we feel about SC surveys. The most promising initiative they are undertaking is to align with the rest of the TVA fleet on NEI 09-07 “Fostering a Strong Nuclear Safety Culture.” Click on the Browns Ferry label to see our posts that mention the plant.
Fort Calhoun’s problems started with the 2011 Missouri River floods and just got worse, moving them further down the ROP Action Matrix and forcing them to (among many other things) complete an independent SC assessment. They took the familiar steps, creating policies, changing out leadership, conducting training, etc. They also instituted SC “pulse” surveys and use the data to populate their SC performance indicators. Probably the most important action plant owner OPPD took was to hire Exelon to manage the plant. Fort Calhoun’s SC-related NRC Confirmatory Action Letter was closed in March 2013 so they are out of the penalty box.
Bottom line: The session presentations are worth a look.
Two weeks ago we posted on NUREG-2165, a document that formalizes a “common language” for describing nuclear safety culture (SC). The NUREG contains a set of SC traits, attributes that define each trait and examples that would evidence each attribute. We expressed concern about how traits and attributes could and would be applied in practice to assess SC.
Well, we didn’t have to wait very long. This post reviews a recent International Nuclear Safety Journal article* that describes the SC oversight process developed by the Romanian nuclear regulatory agency (CNCAN). The CNCAN process uses the International Atomic Energy Agency (IAEA) SC definition and attributes and illustrates how attributes can be used to evaluate SC. Note that CNCAN is not attempting to directly regulate SC but they are taking comprehensive steps to evaluate and influence the licensee’s SC.
CNCAN started with the 37 IAEA attributes and decided that 20 were accessible via the normal review and inspection activities. Some of the 20 could be assessed using licensee and related documentation, others through interviews with licensee and contractor personnel, and others by direct observation of relevant activities.
CNCAN recognizes there are limitations to using this process, e.g., findings that reflect a reviewer’s subjective opinion, the quality of match (relevance) between an attribute and a specific technical or functional area, the quality of the information gathered and used, and over-reliance on one specific finding. Time is also an issue. “[A] large number of review and inspection activities are required, over a relatively long period of time, to gather sufficient data in order to make a judgement on the safety culture of an organisation as a whole.” (p. 4)
However, they are optimistic about longer-term effectiveness. “. . . evidence of certain attributes not being met for several functional areas and processes would provide a clear indication of a problem that would warrant increased regulatory surveillance.” In addition, “[t]he implementation of the [oversight process] proved that all the routine regulatory reviews and inspections reveal aspects that are of certain relevance to safety culture. Interaction with plant staff during the various inspection activities and meetings, as well as the daily observation by the resident inspectors, provide all the necessary elements for having an overall picture of the safety culture of the licensee.” (ibid., emphasis added)
Our Perspective
We reviewed a draft of the CNCAN SC oversight process on March 23, 2012. We found the treatment of issues we consider important to be generally good. For example, in the area of decision making, goal conflict is explicitly addressed, from production vs. safety to differing personal opinions. Corrective action (CA) gets appropriate attention, including CA prioritization based on safety significance and verification that fixes are implemented and effective. Backlogs in many areas, including maintenance and corrective actions, are addressed. In general, the treatment is more thorough than the examples included in the NUREG.
However, the treatment of management incentives is weak. We favor a detailed evaluation of the senior managers’ compensation scheme focusing on how much of their compensation is tied to achieving safety (vs. production or other) goals.
So, do we feel better about the qualms we expressed over the NUREG, viz., that it is a step on the road to the bureaucratization of SC evaluation, a rigid checklist approach that ultimately creates an incomplete and possibly inaccurate picture of a plant’s SC? Not really. Our concerns are described below.
Over-simplification
For starters, CNCAN decided to focus on 20 attributes because they believed it was possible to gather relevant information on them. What about the other 17? Are they unrelated to SC simply because it might be hard to access them?
A second simplification is limiting the information search to artifacts: documents, interviews and observations. One does not have to hold some esoteric belief, e.g., that SC is an emergent organizational property that results from the functioning of a socio-technical system, to see that focusing on the artifacts may be similar to the shadows in Plato’s cave. Early on, the article refers to this problem by quoting from a 1999 NEA report: “the regulator can evaluate the outward operational manifestations of safety culture as well as the quality of work processes, and not the safety culture itself.” (p. 2)
Limited applicability
Romania has a single nuclear plant and what is, at heart, a one-size-fits-all approach is much more practical when “all” equals one. This type of approach might even work in, say, France, where there are multiple plants but a single operator. On the other hand, the U.S. currently has 32 operators reporting to 81 owners.** Developing SC assessment techniques that are comprehensive, consistent and perceived as fair by such a large group is not a simple task. The U.S. approach will continue to subsume SC evaluation under the ROP, which arguably ties SC evaluation to “objective” safety-related performance but unfortunately leads to de facto regulation of SC, less transparency and incomprehensible results in specific cases.***
(It could be worse. For an example, just look at DOE where the recent “guidance” on conducting SC self-assessments led to unreliable self-assessment results that can’t be compared with each other. For more on DOE, see our March 31, 2014 post or click on the DOE label at the bottom of this post.)
Bottom line
Ultimately the article can be summarized as follows: It’s hard, maybe impossible to directly evaluate SC but here’s what we (CNCAN) are doing and we think it works. We say a CNCAN-style approach may be helpful but one should remain alert to important SC factors that may be overlooked.
* M. Tronea, “Trends and Challenges in Regulatory Assessment of Nuclear Safety Culture,” International Nuclear Safety Journal, vol. 3 no. 1 (2014), pp. 1-5. Retrieved April 14, 2014. Dr. Tronea works for the Romanian nuclear authority (CNCAN) and is the founder/moderator of the LinkedIn Nuclear Safety group.
As most of our readers are aware General Motors has been much in the news of late regarding a safety issue associated with the ignition switches in the Chevy Cobalt. At the beginning of April the new CEO of GM, Mary Barra, testified at Congressional hearings investigating the issue. A principal focus of the hearings was the extent to which GM executives were aware of the ignition switch issues which were identified some ten years ago but did not result in recalls until this February. Barra has initiated a comprehensive internal investigation of the issues to determine why it took so many years for a safety defect to be announced.
In a general sense this sounds all too familiar as the standard response to a significant safety issue. Launch an independent investigation to gather the facts and figure out what happened, who knew what, who decided what and why. The current estimate is that it will take almost two months for this process to be completed. Also familiar is that accountability inevitably starts (and often ends) at the engineering and low level management levels. To wit, GM has already announced that two engineers involved in the ignition switch issues have been suspended.
But somewhat buried in Barra’s Congressional testimony is an unusually revealing comment. According to the Wall Street Journal, Barra said “senior executives in the past were intentionally not involved in details of recalls so as to not influence them.”* Intentionally not involved in decisions regarding recalls - recalls which can involve safety defects and product liability issues and have significant public and financial liabilities. Why would you not want the corporation's executives to be involved? And if one is to believe the rest of Barra’s testimony, it appears executives were not even aware of these issues.
Well, what if executives were involved in these critical decisions - what influence could they have that GM would be afraid of? Certainly if executive involvement would assure that technical assessments of potential safety defects were rigorous and conservative - that would not be undue influence. So that leaves the other possibility - that involvement of executives could inhibit or constrain technical assessments from assuring an appropriate priority for safety. This would be tantamount to the chilling effect popularized in the nuclear industry. If management involvement creates an implicit pressure to minimize safety findings, there goes the safety conscious work environment and safety. If keeping executives out of the decision process is believed to yield “better” decisions, it says some pretty bad things about either their competence or ethics. Having executives involved should at least ensure that they are aware and knowledgeable of potential product safety issues and in a position to proactively assure that decisions and actions are appropriate. What might be the most likely explanation is that executives don’t want the responsibility and accountability for these types of decisions. They might prefer to remain protected at the safety policy level but leave the messy reality of comporting those dictates with real world business considerations to lower levels of the organization. Inevitably accountability rolls downhill to somebody in the engineering or lower management ranks.
One thing that is certain. Whatever the substance and process of GM’s decision, it is not transparent, probably not well documented, and now requires a major forensic effort to reconstitute what happened and why. This is not unusual and it is the standard course in other industries including nuclear generation. Wouldn’t we be better off if decisions were routinely subject to the rigor of contemporaneous recording including how complex and uncertain safety issues are decided in the context of other business priorities, and by whom?
* J.B. White and J. Bennett, "Some at GM Brass Told of Cobalt Woe," Wall Street Journal online (Apr. 11, 2014)
The NRC has issued NUREG-2165* which formalizes the safety culture (SC) common language that has been under development since the NRC SC Policy Statement (SCPS) was issued. On topics important to us the NUREG repeats word-for-word the text of a document** prepared after a common language workshop held January 29-30, 2013. Both documents contain a set of SC traits, attributes that define each trait and examples that would evidence each attribute. Because the language is the same, our opinion on the treatment of our important topics remains the same, as described in detail in our Feb. 28, 2013 post. Specifically, the treatment of
Decision making, including the treatment of goal conflicts, is Good;
Corrective action, part of problem identification and resolution, is Satisfactory;
Management Incentives is Unsatisfactory because the associated attributes focuses on workers, not managers, and any senior management incentive program is not mentioned; and
Work Backlogs are mentioned in a couple of specific areas so the overall grade is Minimally Acceptable. But we have one overarching concern that transcends our opinion of common language specifics. Our Perspective
Our biggest issue with the traits, attributes and examples approach is our fear it will lead to the complete bureaucratization of SC evaluation, either consciously or unconsciously. The examples in particular can morph into soft requirements on a physical or mental checklist. Such an approach leads to numerous questions. How many of the 10 traits does a healthy or positive SC exhibit?*** How many of the 40 attributes? Are the traits equally important? How about the attributes? Could the weighting factors vary across plant sites? How many examples must be observed before an attribute is judged acceptably present?
We understand the value of effective communications among regulators, licensee personnel and other stakeholders. But we worry about possible unintended consequences as people attempt to apply the guidance in NUREG-2165, especially in the NRC’s Reactor Oversight Process (ROP).****
*** The NUREG-2165 text describes a “healthy” SC while the SCPS (published as NUREG/BR-0500, Rev. 1, ADAMS ML12355A122) refers to a “positive” SC. The correct answer to “how many traits?” may be “more than ten” because the authors note “There may also be traits not included in the SCPS that are important in a healthy safety culture.” (p. 2)
**** The common language “initiative is within the Commission-directed framework for enhancing the ROP treatment of cross-cutting areas to more fully address safety culture.” (p. 3) This may require a little linguistic jujitsu since the SCPS says “traits were not developed for inspection purposes.”
