Hanford WTP |
The specific reports are the DOE’s Implementation Plan (IP)** for the DFNSB’s review of safety culture at the WTP and the DOE's Office of Health, Safety and Security (HSS) current assessment of safety culture at the site. Neither is very satisfying but we’ll focus on the IP in this post.
What may be most interesting in the DOE IP package are the reference documents including the DNFSB review and subsequent exchanges of letters between the Secretary of Energy and the DNFSB Chairman. It takes several exchanges for the DNFSB to wrestle DOE into accepting the findings of the Board. Recall in the Board’s original report it concluded:
“Taken as a whole, the investigative record convinces the Board that the safety culture at WTP is in need of prompt, major improvement and that corrective actions will only be successful and enduring if championed by the Secretary of Energy.” (IP, p. 33)***
In DOE’s initial (June 30, 2011) response they stated:
“Even while DOE fully embraces the objectives of the Board’s specific recommendations, it is important to note that DOE does not agree with all of the findings included in the Board’s report.” (IP, p. 42)****
It goes on to state that “specifically” DOE does not agree with the conclusions regarding the overall quality of the safety culture. Not surprisingly this brought the following response in the DNFSB’s August 12, 2011 letter, “...the disparity between the [DOE’s] stated acceptance and disagreement with the findings makes it difficult for the Board to assess the response….” (IP, p. 46)***** Note that in the body of the IP (p. 4) DOE does not acknowledge this difference of opinion either in the summary of its June 30 response or the Board’s August 12 rejoinder.
We note that neither the DNFSB report nor the DOE IP is currently included among the references on Bechtel's Vit Plant website. One can only wonder what the take away is for Vit Plant personnel — isn’t there a direct analogy between how DOE reacts to issues raised by the DNFSB and how Vit Plant management respond to issues raised at the plant? Here’s an idea: provide a link to the safetymatters blog on the Vit Plant website. Plant personnel will be able to access the IP, the DNFSB report and all of our informative materials and analysis.
In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue. Their cause analysis focuses on inadequate expectation setting, more knowledge and awareness and (closer to the mark) the conflicting goals emerging in the construction phase (IP, pp. 5-8). While endlessly citing all the initiatives previously taken or underway, never does the DOE reflect on why these initiatives have not been effective to date. What is DOE’s answer? More assessments and surveys, more training, more “guidance”, more expectations, etc.
We do find Actions 1-5 and 1-6 interesting (IP, p. 16). These will revise the BNI contract to achieve “balanced priorities”. This is important and a good thing. We have blogged about the prevalence of large financial incentives for nuclear executives in the commercial nuclear industry and assessments of most, if not all, other significant safety events (BP gulf disaster, BP refinery fire, Upper Big Branch coal mine explosion, etc.) highlight the presence of goal conflicts. How one balances priorities is another thing and a challenge. We have blogged extensively on this subject - search on “incentives” to identify all relevant posts. In particular we have noted that where safety goals are included in incentives they tend to be based on industrial safety which is not very helpful to the issues at hand. Our favorite quote comes from our April 7, 2011 post re the gulf oil rig disaster and is taken from Transocean’s annual report:
We do find Actions 1-5 and 1-6 interesting (IP, p. 16). These will revise the BNI contract to achieve “balanced priorities”. This is important and a good thing. We have blogged about the prevalence of large financial incentives for nuclear executives in the commercial nuclear industry and assessments of most, if not all, other significant safety events (BP gulf disaster, BP refinery fire, Upper Big Branch coal mine explosion, etc.) highlight the presence of goal conflicts. How one balances priorities is another thing and a challenge. We have blogged extensively on this subject - search on “incentives” to identify all relevant posts. In particular we have noted that where safety goals are included in incentives they tend to be based on industrial safety which is not very helpful to the issues at hand. Our favorite quote comes from our April 7, 2011 post re the gulf oil rig disaster and is taken from Transocean’s annual report:
“...notwithstanding the tragic loss of life in the Gulf of Mexico, we [Transocean] achieved an exemplary statistical safety record as measured by our total recordable incident rate (‘‘TRIR’’) and total potential severity rate (‘‘TPSR’’).”
Our advice for the Vit Plant would be as follows. In terms of expectations, enforcing rather than setting, might be the better emphasis. Then monitoring and independently assessing how specific technical and safety issues are reviewed and decided. Training, expectations setting, reinforcement, policies, etc. are useful in “setting the table” but the test of whether the organization is embracing and implementing a strong safety culture can only be found in its actions. Note that the Board’s June 2011 report focused on two specific examples of deficient decision processes and outcomes. (One, the determination of the appropriate deposition velocity for analysis of the transport of radioactivity, the other the conservatism of a criticality analysis.)
There are two aspects of decisions: the process and the result. The process includes the ability to freely raise safety concerns, the prioritization and time required to evaluate such issues, and the treatment of individuals who raise such concerns. The result is the strength of the decision reached; i.e., do the decisions reinforce a strong safety culture? We have posted and provided examples on the blog website of decision assessment using some methods for quantitative scoring.
* The link to the thread is here. Search for "gorp" to see Mr. Mullins' comment.
** U.S. Dept. of Energy, “Implementation Plan for Defense Nuclear Facilities Safety Board Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant” (Dec. 2011).
*** IP Att. 1, DNFSB Recommendation 2011-1, “Safety Culture at the Waste Treatment and Immobilization Plant” (June 9, 2011).
**** IP Att. 2, Letter from S. Chu to P.S. Winokur responding to DNFSB Recommendation 2011-1 (June 30, 2011) p. 4.
***** IP Att. 4, Letter from P.S. Winokur to S. Chu responding to Secretary Chu’s June 30, 2011 letter (Aug. 12, 2011) p. 1.
*** IP Att. 1, DNFSB Recommendation 2011-1, “Safety Culture at the Waste Treatment and Immobilization Plant” (June 9, 2011).
**** IP Att. 2, Letter from S. Chu to P.S. Winokur responding to DNFSB Recommendation 2011-1 (June 30, 2011) p. 4.
***** IP Att. 4, Letter from P.S. Winokur to S. Chu responding to Secretary Chu’s June 30, 2011 letter (Aug. 12, 2011) p. 1.