On June 4, 2014 the NRC announced a revised agency-wide non-concurrence process (NCP) on their blog.* A key objective of the NCP is “to ensure that a non-concurrence is heard, understood, and considered by employees included in the concurrence process so that the non-concurrence informs and supports the decisionmaking process.”**
The NRC performed an assessment*** of the prior NCP using multiple data sources, including the NRC’s 2012 Safety Culture and Climate Survey (SCCS) and an April 2013 survey targeted at employees who had been involved with the NCP as submitters or participants (employees who have responded to non-concurrences).
The assessment identified both strengths and weaknesses with the then-existing NCP. In general, participants were aware of the NCP and were willing to use it. However, “some users of the process felt they faced negative consequences, or that their views were not reflected in final decisions.” (blog post) The assessment also included a bevy of planned actions to address NCP weaknesses.
For us, the interesting question is what does the assessment say or what can be inferred, if anything, with respect to the NRC’s safety culture (SC). This post focuses on SC-related topics mentioned in the assessment that help us answer that question. Leadership Commitment
Leadership commitment is an area of concern and planned actions. (p. 4) “Data from several sources indicates that many of the responding employees are still uncertain about management’s support of the NCP. . . . management was just going through the motions. . . .[some employees] thought the process was biased . . .supervisors using the process indicated that they were concerned management would view it as a negative reflection on them [the supervisors].” (p. 11) In the targeted survey, “more than half of submitters are concerned about management’s support of the NCP.” (p. 7)
Planned actions include “support managers in emphasizing their personal commitment to the welcoming of sharing differing views and the value of using the NCP in support of sound regulatory decisionmaking. . . . Management should demonstrate this [NCP is a positive] clearly and frequently through their actions and communications. . . . Staff will continue to support a variety of outreach activities and communication tools, such as EDO Updates, monthly senior management meetings, all-supervisor meetings, senior leadership meetings, Yellow Announcements, all-hands meetings, brown bag lunches, seminars, and articles in the NRC Reporter and office-level newsletters.” (p. 18) Whew! Potential Negative Consequences of Submitting a NCP
From the SCCS report the assessment highlights that “Forty-nine percent of employees believe that the NCP is effective (37 percent don’t have an opinion on the effectiveness of the NCP and 14 percent believe that the NCP is not effective).” (p. 6) That 14 percent looks low but because there are only about a dozen NCP filings per year, it might actually reflect that a lot of people who use the process end up disappointed. That view is supported by the targeted survey where “the majority of submitters believed that the rationale for the outcome was not clearly documented and that they experienced negative consequences as a result of submitting a non-concurrence.” (p. 7)
We reviewed the SCCS on April 6, 2013. We noted that “The consultants' cover letter identified this [DPO/NCP] as an area for NRC management attention, saying the agency was “Losing significant ground on negative reactions when raising views different from senior management, supervisor, and peers.””
Planned actions include “proactively fostering an environment that encourages and supports differing views . . . evaluating the merits of infusing NCP key messages into existing training, including reinforcing that supervisors and managers will be held accountable for their actions. . . . consider training for all supervisors to address concerns of retaliation and chilling effect for engaging in the NCP. . . . hosting panel discussions including previous NCP submitters and participants . . . promote NCP success stories . . . evaluating the merits of establishing an anti-retaliation policy and procedures to address concerns of retaliation and chilling effect for engaging in the NCP. (p. 20) Note these are all staff activities, management doesn’t have to do anything except go along with the program.
Goal Conflict
Goal conflict is another problem area. The assessment notes “many responding employees commented they felt pressure to meet schedules at the expense of quality.” (p. 17) That issue was also highlighted in the 2012 SCCS and could well be the source for the comment in the assessment.
Our Perspective
An effective NCP is important. We believe NCP or some functionally equivalent practice should be more widely utilized in the world of formal organizations.
But it is easy to read too much into the NCP assessment. The primary data input was the 2012 SCCS and that is relatively old news. Another key input was the targeted survey. However, the number of survey respondents was small because only a handful of people use the NCP.**** Based on the negative responses of the submitters, it appears that NRC needs to do a better job of administering the NCP, especially in the areas of (1) convincing submitters that their concerns were actually considered (even if ultimately rejected) and (2) ensuring there are no negative consequences associated with using the NCP. These are real process implementation challenges but the NCP-related issues do not reflect some major, new problem in the agency’s SC.
On the other hand, perceptions of negative responses to rocking the boat in general or senior management’s lack of commitment to inclusive programs and “safety first” are SC signals to which attention must be paid. If Staff trains their 10 gauge shotgun of interventions on these possibly systemic issues then some actual good could come out of this.
“Non-concurrence” means an employee has a problem with a document the employee had a role in creating or reviewing. For example, the employee might hold a different view on a technical matter or disagree with a proposed decision.
The NCP appears to be more formal and documented than the NRC Open Door policy and less restrictive than the Differing Professional Opinions (DPO) program which is reserved for concerns on established NRC positions.
The Defense Nuclear Facilities Safety Board (DNFSB) has been busy in the safety culture (SC) space. First, their Chairman’s May 7, 2014 presentation on preventing major accidents provides a window into how the DNFSB views safety management and SC in the DOE complex. Second, the DNFSB’s meeting on May 28, 2014 heard presentations on SC concepts from industry and government experts. This post reviews and provides our perspective on both events.
Chairman’s Presentation
This presentation was made at a DOE workshop.* Chairman Winokur opened with some examples of production losses that followed incidents at DOE facilities and concluded the cost of safety is small compared to the cost of an accident. He went on to discuss organizational factors that can set the stage for accidents or promote improved safety performance. Some of these factors are tied to SC and will be familiar to Safetymatters readers. They include the following:
Leadership
The presentation quotes Schein: “The only thing of real importance that leaders do is to create and manage culture.” (p. 13) This quote is used by many in the nuclear industry to support a direct and complete connection between leadership and an organization’s culture. While effective leadership is certainly necessary, we have long argued for a more nuanced view, viz., that leaders influence but do not unilaterally define culture. In fact, on the same page in Organizational Culture, Schein says “Culture is the result of a complex group learning process that is only partially influenced by leader behavior.” **
Budget and production pressures and Rewards that favor mission over safety
As Winokur pointed out, it is unfortunately true that poor safety performance (accidents and incidents) can attract resources while good safety performance can lead to resources being redirected. Good safety performance becomes taken for granted and is largely invisible. “Always focus on balancing mission and safety. There will always be trade-offs, but safety should not get penalized for success.” (p. 19)
On our part, we feel like we’ve been talking about goal conflicts forever. The first step in addressing goal conflicts is to admit they exist, always have and probably always will. The key to resolving them is not by issuing a safety policy, it is to assure that an entity’s decision making process and its reward and compensation system treat safety with the priority it warrants.
Decision making
Winokur says “Understand the nature of low-probability, high-consequence accidents driven by inadequate control of uncertainty, not cause-effect relationships . . .” (p. 14) and “Risk-informed decision making can be deceptive; focus on consequences, as well as probabilities.” (p. 16) These observations are directly compatible with Nicholas Taleb: “This idea that in order to make a decision you need to focus on the consequences (which you can know) rather than the probability (which you can’t know) is the central idea of uncertainty.”*** See our June 18, 2013 post for a discussion of decisions that led to high-consequence (i.e., really bad) outcomes at Crystal River, Kewaunee and San Onofre.
There is no additional material in the presentation for a few important factors, so we will repeat earlier Safetymatters commentary on these topics.
Complacency and Accumulated residual risks that erode the safety margin
We have pointed out how organizations, especially high reliability organizations, strive to maintain mindfulness and combat complacency. Complacency leads to hubris (“It can’t happen here”) and opens the door for the drift toward failure that occurs with normalization of deviance, constant environmental adaptations, “normal” system performance excursions, group think and an irreducible tendency for SC to decay over time.
Lack of oversight
This refers to everyone who has the responsibility to provide competent, timely, incisive assessment of an entity’s activities but fails to do so. Their inaction or incompetence neither reinforces a strong SC nor prods a weak SC to improve.
DNFSB Hearing with SC Expert Presentations
This was "the first of two hearings the Board will convene to address safety culture at Department of Energy defense nuclear facilities and the Board’s Recommendation 2011–1, Safety Culture at the Waste Treatment and Immobilization Plant."**** This hearing focused on presentations by SC experts: Sonya Haber (an SC consultant to DOE), NRC and NASA. The experts’ slide presentations and a video of the hearing are available here.
Haber hit the right buttons in her presentation but neither she nor anyone else mentioned her DOE client's failure to date to integrate the SC assessments and self-assessments DOE initiated at various facilities in response to Recommendation 2011-1. We still don’t know whether WTP SC problems exist elsewhere in the DOE complex. We commented on the DOE’s response to 2011-1 on January 25, 2013 and March 31, 2014.
Winokur asked Haber about the NRC's "safety first" view vs. the DOE's "mission/safety balance." The question suggests he may be thinking the "balance" perspective gives the DOE entities too much wiggle room to short change safety in the name of mission.
The NRC presenter was Stephanie Morrow. Her slides recited the familiar story of the evolution of the SC Policy Statement and its integration into the Reactor Oversight Process. She showed a new figure that summarized NRC’s SC interests in different columns of the ROP action matrix. Chairman Winokur asked multiple questions about how much direction the NRC gives the licensees in how to perform SC assessments. The answer was clear: In the NRC’s world, SC is the licensee's responsibility; the NRC looks for adequacy in the consideration of SC factors in problem resolution and SC assessments. Morrow basically said if DNFSB is too prescriptive, it risks ending up "owning" the facility SC instead of the DOE and facility contractor.
Our Perspective
The Chairman’s presentation addressed SC in a general sense. However, the reality of the DOE complex is a formidable array of entities that vary widely in scope, scale and missions. A strong SC is important across the complex but one-size-fits-all approaches probably won’t work. On the other hand, the custom fit approach, where each entity has flexibility to build its SC on a common DOE policy foundation doesn’t appear to lead to uniformly good results either. The formal hearing to receive presentations from SC industry experts evidences that the DNFSB is gathering information on what works in other fields.
Bottom line: The DNFSB is still trying to figure out the correct balance between prescription and flexibility in its effort to bring DOE to heel on the SC issue. SC is an vital part of the puzzle of how to increase DOE line management effectiveness in ensuring adequate safety performance at DOE facilities.
* P.S. Winokur, “A User’s Guide to Preventing Major Accidents,” presentation at the 2014 Nuclear Facility Safety Programs Annual Workshop (May 7, 2014). The workshop was sponsored by the DOE Office of Environment, Health, Safety, and Security. Thanks to Bill Mullins for bring this presentation to our attention.
** E. Schein, Organizational Culture and Leadership (San Francisco, CA: Jossey-Bass, 2004), p. 11.
*** N. Taleb, The Black Swan (New York: Random House, 2007), p. 211.
We have long promoted a systems view of nuclear facilities and the overall industry. One consequence of that view is an openness to possible systemic problems as the root causes of incidents in addition to searching for malfunctioning components, both physical and human.
One system where we see this openness is the air transport industry—the air carriers and the Federal Aviation Administration (FAA). The FAA has two programs for self-reporting of incidents and problems: the Voluntary Disclosure Reporting Program (VDRP) and the Aviation Safety Action Program (ASAP). These programs are discussed in a recent report* by the FAA’s Office of Inspector General (OIG) and are at least superficially similar to the NRC’s Licensee Event Reporting and Employee Concerns Program.
What’s interesting is that VDRP is receptive to the reporting of both individual and systemic issues. The OIG report says the difference between individual and systemic is “important because if the issue is systemic, the carrier will have to develop a detailed fix to address the system as a whole—whereas if the issue is more isolated or individual, the fix will be focused more at the employee level, such as providing counseling or training.” (p. 7) In addition, it appears both FAA programs are imbued with the concept of a “just culture,” another topic we have posted about on several occasions and which is often associated with a systems view. A just culture is one where people are encouraged to provide essential safety-related information, the blame game is aggressively avoided, and a clear line exists between acceptable and unacceptable behavior.
Now the implementation of the FAA programs is far from perfect. As the OIG points out, the FAA doesn't ensure root causes are identified or corrective actions are sufficient and long-lived, and safety data is not analyzed to identify trends that represent risks. Systemic issues may not always be reported by the carriers or recognized by the FAA. But overall, there appears to be an effort at open, comprehensive communication between the regulator and the regulated.
So why does the FAA encourage a just culture while the nuclear industry seems fixated on a culture of blame? One factor might be the NRC’s focus on hardware-centric performance measures. If these are improving over time, one might infer that any incidents are more likely caused by non-hardware, i.e., humans.
But perhaps we can gain greater insight into why one industry is more accepting of systemic issues by looking at system-level factors, specifically the operational (or actual) coupling among industry participants versus their coupling as perceived by external observers.**
As a practical matter, the nuclear industry is loosely coupled, i.e., each plant operates more or less independently of the others (even though plants with a common owner are subject to the same policies as other members of the fleet). There is seldom any direct competition between plants. However, the industry is viewed by many external observers, especially anti-nukes, as a singular whole, i.e, tightly coupled. Insiders reinforce this view when they say things like “an accident at one plant is an accident for all.” And, in fact, one incident (e.g., Davis-Besse) can have industry-wide implications although the physical risk may be entirely local. In such a socio-political environment, there is implicit pressure to limit or encapsulate the causes of any incidents or irregularities to purely local sources and avoid the mention of possible systemic issues. The leads to a search for the faulty component, the bad employee, a failure to update a specific procedure or some other local problem that can be fixed by improved leadership and oversight, clearer expectations, more attention to detail, training etc. The result of this approach (plus other industry-wide factors, e.g., the lack of transparency in certain oversight practices*** and the “special and unique” mantra) is basically a closed system whose client, i.e., the beneficiary of system efforts, is itself.
In contrast, the FAA’s world has two parts, the set of air carriers whose relationship with each another is loosely coupled, similar to the nuclear industry, and the air traffic control (ATC) sub-system, which is more tightly coupled because all the carriers share the same airspace and ATC. Because of loose coupling, a systemic problem at a single carrier affects only that carrier and does not infect the rest of the industry. What is most interesting is that a single airline accident (in the tightly coupled portion of the system) does not lead to calls to shut down the industry. Air transport has no organized opposition to its existence. Air travel is such an integral part of so many people’s lives that pressure exists to keep the system running even in the face of possible hazards. As a consequence, the FAA has to occasionally reassert its interest in keeping safety risks from creeping into the system. Overall, we can say the air transport industry is relatively open, able to admit the existence of problems, even systemic ones, without taking an inadvertent existential risk.
The foregoing is not intended to be a comprehensive comparison of the two industries. Rather it is meant to illustrate how one can apply a simple systems concept to gain some insights into why participants in different industries behave differently. While both the FAA and NRC are responsible for identifying systemic issues in their respective industries, it appears FAA has an easier time of it. This is not likely to change given the top-level factors described above.
“VDRP provides air carriers the opportunity to voluntarily report and correct areas of non-compliance without civil penalty. The program also provides FAA important safety information that might not otherwise come to its attention.“ (p. 1) ASAP “allows individual aviation employees to disclose possible safety violations to air carriers and FAA without fear that the information will be used to take enforcement or disciplinary action against them.” (p. 2)
** “Coupling” refers to the amount of slack, buffer or give between two items in a system.
*** For example, INPO’s board of directors is comprised of nuclear industry CEOs, INPO evaluation reports are delivered in confidence to its members and INPO has basically unfettered access to the NRC. This is not exactly a recipe for gaining public trust. See J.O. Ellis Jr. (INPO CEO), Testimony before the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (Aug. 25, 2010). Retrieved from NEI website May 27, 2014.
The GM story continues to unfold on a daily basis. We’ve already lost track of the number of recalls as it appears that any and every possible safety defect from prior years has been added to the recall list. This is reminiscent of the “problem” nuclear plants in the 1990s - NRC mandated improvement programs precipitated an avalanche of condition reports into the plants’ Corrective Action Programs, requiring immense resources and time to sort out and prioritize the huge volume of issues.
In our prior post on GM product safety issues, we critiqued the structure of management’s independent review being conducted by attorney Anton Valukas based in part on the likelihood that GM’s legal department would be a subject of the review. Asking the chairman of a law firm with a long standing relationship with GM, to pull this off seemed, at a minimum, to be unnecessary, and potentially could undermine the credibility of the assessment. Now we see in further reporting of the GM issues by the New York Times* that in fact GM’s lawyers are becoming a key focus of the investigation. The implication is that GM’s lawyers may have been the gate keepers on information related to the Cobalt ignition switches and/or been enablers of a decision process that did not result in aggressive action.
Of greater interest is the Consent Order** entered into by GM and the United States Department of Transportation, National Highway Traffic Safety Administration. The headline was the $35 million civil penalty but there were more interesting nuggets within the order. Among a series of required actions by GM to improve timeliness and data to support safety defect evaluations were three actions specifically focusing on safety decision making. One is to ensure that safety issues are expeditiously brought to the attention of “committees and individuals with authority to make safety recall decisions.” (p. 10)*** Second, GM will have to meet with the NHTSA on a monthly basis for one year to review its decision making on potential safety issues. And third,
“GM shall meet with NHTSA no later than 120 calendar days after execution of this Consent Order to conduct simulations—i.e., an exercise to discuss hypothetical scenarios, for the purpose of assessing the effectiveness of the improvements [in processes and analytics to identify safety-related defects]…” (p. 9, emphasis added) We find the emphasis of the Consent Order both fascinating and appropriate. It emphasizes decision making - the process, timeliness, engagement of appropriate participants, and transparency - as essential to assuring appropriate outcomes. It opens that process to scrutiny by the NHTSA through monthly reviews of actual decisions. And most strikingly, it requires the conduct of decision simulations to verify the effectiveness of the improvements.
The provisions of the Consent Order establish a fundamentally new and better approach to rectifying deficiencies in safety performance and are consistent with themes we have been advocating for some time. It departs from the simplistic - blame some individuals, reinforce expectations, emphasize values and improve processes - catechism that is pursued within the nuclear industry and others as well. It seems to recognize that safety related decisions constitute the essence of assuring safety. Rather than just reviewing and investigating bad outcomes, the Consent Order opens the door to making the results of all ongoing decisions transparent and reviewable. Further it even calls for practicing the decision making process - through simulations - to verify the effectiveness of the process and the results. Practicing complex and nuanced safety decisions to improve the process and decision making skills - what an idea.
It is no news flash to our readers that we have not only advocated these approaches, we have developed prototype tools for these purposes. We have made the NuclearSafetySim simulation tool available for almost a year via this blog and linked to its website. What has been the result? While it is clear there have been many viewings of these materials, there has not been a single inquiry or follow-up by the nuclear industry, the NRC or INPO.**** At the same time there have been no initiatives within those groups to develop new or improved tools and methods for improving safety management. Why?
*** Including GM’s Executive Field Action Decision Committee and Field Performance Evaluation Recommendation Committee. (p. 9)
**** Ironically, the only serious interest has been expressed within the oil/gas industry which appears much more open to exploring innovative approaches.
In our April 16, 2014 post we discussed the evolving situation at General Motors regarding the issues with the Chevy Cobalt’s ignition switches. We highlighted the difficulties GM was encountering in piecing together how decisions were made regarding re-design and possible vehicle recalls, and who in the management chain was involved and/or aware of the issues. As we noted, GM had initiated an internal investigation of the matter with the results expected by late May.
In a recent Wall Street Journal article* there is some further perspective on how things are moving forward. For one, the GM Board has now instituted its own investigation of how information flowed to the Board and how it affected its oversight function. An outside law firm is conducting that investigation.
Perhaps of more interest are some comments in the article regarding the separate investigation being conducted on behalf of GM’s management. It is being conducted by a former U.S. attorney, Anton Valukas, who also happens to be Chairman of the law firm Jenner & Block. The WSJ article notes “some governance experts have questioned whether Mr. Valukas has enough of an arm's-length relationship with GM management. Jenner & Block has long advised GM management.” It does seem to raise a basic conflict of interest issue, providing legal services to GM and conducting an independent investigation. But a source quoted in the WSJ article notes that GM does not see a problem since “Mr. Valukas' own integrity is on the line…”
In terms of the specific situation it seems fairly clear to us that Valukas should not be performing the investigation on behalf of management. The Board of Directors should have initiated the primary investigation using an independent outside firm - essentially what it has now done but which is limited to the narrow issue of information flow to the Board. Having current management sponsor an investigation of itself using a firm with commercial ties to GM will not result in high confidence in its findings.
In a broader sense this situation models the contours of a wider problem associated with ensuring safety in complex organizational systems. In the GM case the assurance of a completely objective and thorough investigation seems to come down to the personal integrity of Mr. Valukas. While we have no reason to doubt his credentials or integrity, he is being placed in a situation where an aggressive investigation could have negative impacts on GM and its management - who are clients of Mr. Valukas’ law firm. In addition this investigation will involve products liability issues which inevitably involve GM’s internal lawyers; in all probability Valukas’ firm has professional relationships with these lawyers making it a particularly sensitive situation. It is certainly possible that Mr. Valukas will be immune to any implicit pressures due to these circumstances, but it is an approach that puts maximum reliance on the individual to do the “right” thing notwithstanding competing interests. And in any event, the perception of an investigation of this type will always be subject to some question where conflicts are present.
We also see an interesting analogy to nuclear operations where the reliance on safety culture is in essence, reliance on personal integrity. We are not implying there is anything wrong to expect and emphasize personal integrity, however all too often it becomes a panacea for countering significant costs or other impacts to operations and ensuring safety is accorded proper priority. And if things go wrong, it is the norm that individuals are blamed and often, replaced. In essence they failed the integrity test. Why they failed, the elephant in the room, is hardly ever pursued. Rarely if ever do corrective actions address minimizing or eliminating the influence of those conflicts, leaving the situation ripe for further failures.
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.
