WANO and NEA to Cooperate on Nuclear Safety Culture

World Nuclear News Oct. 4, 2017

According to an item* in World Nuclear News, the World Association of Nuclear Operators (WANO) and the Organisation for Economic Co-operation and Development’s Nuclear Energy Agency (NEA) signed a memorandum of understanding to cooperate on "the further development of approaches, practices and methods in order to proactively strengthen global nuclear safety."

One objective is to “enhance the common understanding of nuclear safety culture challenges . . .”  In addition, the parties have identified safety culture (SC) as a "fundamental subject of common interest" and plan to launch a series of "country-specific discussions to explore the influence of national culture on the safety culture".

Our Perspective

As usual, the press release touts all the benefits that are going to flow from the new relationship.  We predict the flow will be at best a trickle based on what we’ve seen from the principals over the years.  Following is our take on the two entities.

WANO is an association of the world's nuclear power operators.  Their objective is to exchange safety knowledge and operating experience among its members.  We have mentioned WANO in several Safetymatters posts, including Jan. 23, 2015, Jan. 7, 2015, Jan. 21, 2014 and May 1, 2010.  Their public contributions are generally shallow and insipid.  WANO may be effective at facilitating information sharing but it has no real authority over operators.  It is, however, an overhead cost for the economically uncompetitive commercial nuclear industry. 

NEA is an intergovernmental agency that facilitates cooperation among countries with nuclear technology infrastructures.  In our March 3, 2016 post we characterized NEA as an “empty suit” that produces cheerleading and blather.  We stand by that assessment.  In Safetymatters’ history, we have come across only one example of NEA adding value—when they published a document that encouraged regulators to take a systems view of SC.  See our Feb. 10, 2016 post for details.

No one should expect this new arrangement to lead to any breakthroughs in SC theory or insights into SC practice.  It will lead to meetings, conferences, workshops and boondoggles.  One hopes it doesn’t indirectly raise the industry’s costs or, more importantly, distract WANO from its core mission of sharing safety information and operating experience across the international nuclear industry. 


*  “WANO, NEA enhance cooperation in nuclear safety,” World Nuclear News (Oct. 4, 2017).

“New” IAEA Nuclear Safety Culture Self-Assessment Methodology

IAEA report cover

The International Atomic Energy Agency (IAEA) touted its safety culture (SC) self-assessment methodology at the Regulatory Cooperation Forum held during the recent IAEA 61st General Conference.  Their press release* refers to the methodology as “new” but it’s not exactly fresh from the factory.  We assume the IAEA presentation was based on a publication titled “Performing Safety Culture Self-assessments”** which was published in June 2016 and we reviewed on Aug. 1, 2016.  We encourage you to read our full review; it is too lengthy to reasonably summarize in this post.  Suffice to say the publication includes some worthwhile SC information and descriptions of relevant SC assessment practices but it also exhibits some execrable shortcomings.


*  IAEA, “New IAEA Self-Assessment Methodology and Enhancing SMR Licensing Discussed at Regulatory Cooperation Forum” (Sept. 22, 2017).

**  IAEA, “Performing Safety Culture Self-assessments,” Safety Reports Series no. 83 (Vienna: IAEA, 2016).

Nuclear Safety Culture: The Threat of Bureaucratization

We recently read Sidney Dekker’s 2014 paper* on the bureaucratization of safety in organizations.  It’s interesting because it describes a very common evolution of organizational practices, including those that affect safety, as an organization or industry becomes more complicated and formal over time.  Such evolution can affect many types of organizations, including nuclear ones.  Dekker’s paper is summarized below, followed by our perspective on it. 

The process of bureaucratization is straightforward; it involves hierarchy (creating additional layers of organizational structure), specialized roles focusing on “safety related” activities, and the application of rules for defining safety requirements and the programs to meet them.  In the safety space, the process has been driven by multiple factors, including legislation and regulation, contracting and the need for a uniform approach to managing large groups of organizations, and increased technological capabilities for collection and analysis of data.

In a nutshell, bureaucracy means greater control over the context and content of work by people who don’t actually have to perform it.  The risk is that as bureaucracy grows, technical expertise and operational experience may be held in less value.

This doesn’t mean bureaucracy is a bad thing.  In many environments, bureaucratization has led to visible benefits, primarily a reduction in harmful incidents.  But it can lead to unintended, negative consequences including:

• Myopic focus on formal performance measures (often quantitative) and “numbers games” to achieve the metrics and, in some cases, earn financial bonuses,
• An increasing inability to imagine, much less plan for, truly novel events because of the assumption that everything bad that might happen has already been considered in the PRA or the emergency plan.  (Of course, these analyses/documents are created by siloed specialists who may lack a complete understanding of how the socio-technical system works or what might actually be required in an emergency.  Fukushima anyone?),
• Constraints on organizational members’ creativity and innovation, and a lack of freedom that can erode problem ownership, and
• Interest, effort and investment in sustaining, growing and protecting the bureaucracy itself.
  

Our Perspective

We realize reading about bureaucracy is about as exciting as watching a frog get boiled.  However, Dekker does a good job of explaining how the process of bureaucratization takes root and grows and the benefits that can result.  He also spells out the shortcomings and unintended consequences that can accompany it.

The commercial nuclear world is not immune to this process.  Consider all the actors who have their fingers in the safety pot and realize how few of them are actually responsible for designing, maintaining or operating a plant.  Think about the NRC’s Reactor Oversight Process (ROP) and the licensees’ myopic focus on keeping a green scorecard.  Importantly, the Safety Culture Policy Statement (SCPS) being an “expectation” resists the bureaucratic imperative to over-specify.  Instead, the SCPS is an adjustable cudgel the NRC uses to tap or bludgeon wayward licensees into compliance.  Foreign interest in regulating nuclear safety culture will almost certainly lead to its increased bureaucratization.  

Bureaucratization is clearly evident in the public nuclear sector (looking at you, Department of Energy) where contractors perform the work and government overseers attempt to steer the contractors toward meeting production goals and safety standards.  As Dekker points out, managing, monitoring and controlling operations across an organizational network of contractors and sub-contractors tends to be so difficult that bureaucratized accountability becomes the accepted means to do so.

We have presented Dekker’s work before, primarily his discussion of a “just culture” (reviewed Aug. 3, 2009) that tries to learn from mishaps rather than simply isolating and perhaps punishing the human actor(s) and “drift into failure” (reviewed Dec. 5, 2012) where a socio-technical system can experience unacceptable performance caused by systemic interactions while functioning normally.  Stakeholders can mistakenly believe the system is completely safe because no errors have occurred while in reality the system can be slipping toward an incident.  Both of these attributes should be considered in your mental model of how your organization operates.

Bottom line: This is an academic paper in a somewhat scholarly journal, in other words, not a quick and easy read.  But it’s worth a look to get a sense of how the tentacles of formality can wrap themselves around an organization.  In the worse case, they can stifle the capabilities the organization needs to successfully react to unexpected events and environmental changes.


*  S.W.A. Dekker, “The bureaucratization of safety,” Safety Science 70 (2014), pp. 348–357.  We saw this paper on Safety Differently, a website that publishes essays on safety.  Most of the site’s content appears related to industries with major industrial safety challenges, e.g., mining.

Nuclear Safety Culture: Another Incident at Pilgrim: Tailgate Party

Pilgrim

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

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

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

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

Our Perspective 

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

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

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


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

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

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

Los Alamos  Source: LANL

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

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

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

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

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

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

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

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

NNSA’s Response

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

Our Perspective 

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

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

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


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

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

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

Learning About Nuclear Safety Culture from the Web, Maybe

The Internet  Source:Wikipedia

We’ve come across some Internet content (one website, one article) that purports to inform the reader about nuclear safety culture (NSC).  This post reviews the content and provides our perspective on its value.

NSC Website

It appears the title of this site is “Nuclear Safety Culture”* and the primary target is journalists who want an introduction to NSC concepts, history and issues.  It is a product of a group of European entities.  It is a professional looking site that covers four major topics; we’ll summarize them in some detail to show their wide scope and shallow depth. 

Nuclear Safety Culture covers five sub-topics:

History traces the shift in attitudes toward and protection from ionizing radiation as the possible consequences became better known but the story ends in the 1950s.  Key actions describe the roles of internal and external stakeholders during routine operations and emergency situations.  The focus is on power production although medicine, industrial uses and weapons are also mentioned.  Definition of NSC starts with INSAG (esp. INSAG-4), then adds INPO’s directive to emphasize safety over competing goals, and a familiar list of attributes from the Nuclear Safety Journal.  As usual, there is nothing in the attributes about executive compensation or the importance of a systems view.  IAEA safety principles are self explanatory.  Key scientific concepts cover the units of radiation for dose, intake and exposure.  Some values are shown for typical activities but only one legal limit, for US airport X-rays, is included.**  There is no information in this sub-topic on how much radiation a person can tolerate or the regulatory limits for industrial exposure.

From Events to Accidents has two sub-topics:

From events to accidents describes the 7-level International Nuclear Event Scale (from a minor anomaly to major accident) but the scale itself is not shown.  This is a major omission.  Defence in depth discusses this important concept but provides only one example, the levels of physical protection between a fuel rod in a reactor and the environment outside the containment.

Controversies has two sub-topics:

Strengths and Weaknesses discuss some of the nuclear industry’s issues and characteristics: industry transparency is a double-edge sword, where increased information on events may be used to criticize a plant owner; general radiation protection standards for the industry; uncertainties surrounding the health effects of low radiation doses; the usual nuclear waste issues; technology evolution through generations of reactors; stress tests for European reactors; supply chain realities where a problem anywhere is used against the entire industry; the political climate, focusing on Germany and France; and energy economics that have diminished nuclear’s competitiveness.  Overall, this is a hodgepodge of topics and a B- discussion.  The human factor provides a brief discussion of the “blame culture” and the need for a systemic view, followed by summaries of the Korean and French document falsification events.

Stories summarizes three events: the Brazilian theft of a radioactive source, Chernobyl and Fukushima.  They are all reported in an overly dramatic style although the basic facts are probably correct.

The authors describe what they call the “safety culture breach” for each event.  The problem is they comingle overarching cultural issues, e.g., TEPCO’s overconfident management, with far more specific failures, e.g., violations of safety and security rules, and consequences of weak NSC, e.g., plant design inadequacies.  It makes one wonder if the author(s) of this section have a clear notion of what NSC is.

It isn’t apparent how helpful this site will be for newbie journalists, it is certainly not a complete “toolkit.”  Some topics are presented in an over-simplified manner and others are missing key figures.  In terms of examples, the site emphasizes major accidents (the ultimate trailing indicators) and ignores the small events, normalization of deviance, organizational drift and other dynamics that make up the bulk of daily life in an organization.  Overall, the toolkit looks a bit like a rush job or unedited committee work, e.g., the section on the major accidents is satisfactory but others are incomplete.  Importantly (or perhaps thankfully) the authors offer no original observations or insights with respect to NSC.  It’s worrisome that what the site creators call NSC is often just the safety practices that evolved as the hazards of radiation became better known. 

NSC Article

There is an article on NSC in the online version of Power magazine.  We are not publishing a link to the article because it isn’t very good; it looks more like a high schooler’s Internet-sourced term paper than a thoughtful reference or essay on NSC.

However, like the stopped clock that shows the correct time twice per day, there can be a worthwhile nugget in such an article.  After summarizing a research paper that correlated plants’ performance indicators with assessments of their NSC attributes (which paper we reviewed on Oct. 5, 2014), the author says “There are no established thresholds for determining whether a safety culture is “healthy” or “unhealthy.””  That’s correct.  After NSC assessors consolidate their interviews, focus groups, observations, surveys and document reviews, they always identify some improvement opportunities but the usual overall grade is “pass.”***  There’s no point score, meter or gauge.  Perhaps there should be.

Our Perspective

Don’t waste your time with pap.  Go to primary sources; an excellent starting point is the survey of NSC literature performed by a U.S. National Laboratory (which we reviewed on Feb. 10, 2013.)  Click on our References label to get other possibilities and follow folks who actually know something about NSC, like Safetymatters.


*  Nuclear Safety Culture was developed as part of the NUSHARE project under the aegis of the European Nuclear Education Network.   Retrieved June 19, 2017.

**  The airport X-ray limit happens to be the same as the amount of radiation emitted by an ordinary banana.

***  A violation of the Safety Conscious Work Environment (SCWE) regulations is quite different.  There it’s zero tolerance and if there’s a credible complaint about actual retaliation for raising a safety issue, the licensee is in deep doo-doo until they convince the regulator they have made the necessary adjustments in the work environment.

Nuclear Safety Culture Update at Pilgrim and Watts Bar

Pilgrim

Watts Bar

A couple of recent reports address the nuclear safety culture (NSC) problems at Pilgrim and Watts Bar.  This post summarizes the reports and provides our perspective on their content.  Spoiler alert: there is not much new in this news.

Pilgrim

The NRC issued their report* on phase C of their IP 95003 inspection at Pilgrim.  This is the phase where the NRC conducts its own assessment of the plant’s NSC.  The overall finding in the cover letter is: “The NRC determined that programs and processes at PNPS [Pilgrim] adequately support nuclear safety and that PNPS should remain in Column 4.”  However, the letter goes on to detail a host of deficiencies.  The relative good news is that Pilgrim’s NSC shortcomings weren’t sufficiently serious or interesting to merit mention in the cover letter.

But the NRC had plenty to say about NSC in the main report.  Highlights include the finding that NSC is a “fundamental problem” at Pilgrim.  NSC gradually deteriorated over time and “actions to balance competing priorities, manage problems, and prioritize workload resulted in reduced safety margins.”  Staffing reduction initiatives exacerbated plant performance problems.  Personnel were challenged to exhibit standards and expectations in conservative decision-making, work practices, and procedure use and adherence.  Contributing factors to performance shortcomings include lack of effective benchmarking of industry standards and the plant’s planned 2019 permanent shutdown.  The NRC also noted weaknesses in the Executive Review Board, Employee Concerns Program and the Nuclear Safety Culture Monitoring Panel. (pp. 8-10)

Watts Bar

In April the TVA inspector general (IG) issued a report** castigating TVA management for allowing a chilled work environment (CWE) to continue to exist at Watts Bar.  The IG report’s findings included: TVA's analyses and its response to the NRC’s CWE letter were incomplete and inadequate; TVA's planned corrective actions are unlikely to have long-term effectiveness; precursors of the CWE went unrecognized by management; and management has inappropriately influenced the outcome of analyses and investigations pertaining to Watts Bar NSC/SCWE issues.  Staff stress, fear and trust issues also exist.

In response, TVA management pointed out the corrective actions that were taken or are underway since the first draft of the IG report was issued.  Additionally, TVA management “has expressly acknowledged management's role in creating the condition and its responsibility for correcting it."

Our Perspective

This is merely a continuation of a couple of sad stories we’ve been reporting on for a long time.  Click on the Entergy, Pilgrim, TVA or Watts Bar labels to get our earlier reports. 

The finding that Pilgrim did not adequately benchmark against industry standards is appalling.  Entergy operates a fleet of nuclear plants and they don’t know what industry standards are?  Whatever.  Entergy is closing all the plants they purchased outside their service territory, hopefully to increase their attention on their utility-owned plants (where Arkansas Nuclear One remains a work in progress). 

We applaud the TVA IG for shining a light on the agency’s NSC issues.  In response to the IG report, TVA management put out a typical mea culpa accompanied by claims that their current corrective actions will fix the CWE and other NSC problems.  Well, their prior actions were ineffective and these actions will also probably fall short.  It doesn’t really matter.  TVA is too big to fail, both politically and economically, and their nuclear program will likely continue to plod along forever.


*  D.H. Dorman (NRC) to J. Dent (TVA), “Pilgrim Nuclear Power Station – Supplemental Inspection Report (Inspection Procedure 95003 Phase ‘C’) 05000293/2016011 and Preliminary Greater-than-Green Finding” (May 10, 2017).  ADAMS ML17129A217.

**  TVA Inspector General, “NTD Consulting Group, LLC's Assessment of TVA's Evaluation of the Chilled Work Environment at Watts Bar Nuclear Plant - 2016-16702” (April 19, 2017).  Also see D. Flessner, “TVA inspector general says safety culture problems remain at Watts Bar,” Chattanooga Times Free Press (April 21, 2017).  Retrieved May 25, 2017.