Wednesday, January 30, 2013

Talking Sheep at Palisades

In Lewis Carroll’s Through the Looking Glass, Alice and the White Queen advance into the chessboard's fifth rank by crossing over a brook together, but at the very moment of the crossing, the Queen transforms into a talking sheep.  Alice soon finds herself struggling to handle the oars of a small rowboat, where the Sheep annoys her with nonsensical shouting.  Now consider the NRC’s Nov. 9, 2012 followup inspection report* at Palisades related to the DC panel event and the Service Water pump coupling failure.  It brings to mind a similar picture - in this case inspectors struggling to propel a small rowboat of substance on a river of nonsensical jargon and bureaucratese.

Reading this inspection report (IR) reveals endless repetition of process details and findings of other reports, and astonishingly little substance or basis for the inspectors' current findings and conclusions.  The IR “assesses” the findings of the Palisades root cause analysis and associated extent of condition and corrective actions.  The discussion is deeply ingrained with yellow findings, white findings, crosscutting this and cornerstone that, a liberal dose of safety culture traits and lots of significance determinations.  Frankly it’s hard to even remember what started the whole thing.  Perhaps of most interest, the IR notes  that much of the Palisades management team was replaced in the period since these two events.
(p. 23)  Why?  Were they deemed incompetent? Unwilling to implement appropriate risk and safety priorities?  Or just sacrificial lambs? (more sheep).  It appears that these changes carried significant weight with the NRC inspectors although it is not specifically stated. 

Then there is this set of observations:

“During interviews the inspectors heard that there were concerns about staffing levels in multiple departments, but the site was aware and was actively working with Entergy corporate management to post and fill positions. . . Entergy Corporate was perceived by many on the site to be stifling progress in filling positions.  The many issues at Palisades and staffing problems have contributed to the organization becoming more reactive to addressing maintenance and equipment reliability issues versus being proactive in addressing possible problems.” (p. 23)

Which is it?  The site was actively working with Entergy or Entergy was stifling progress in filling positions?  Without further amplification or justification the IR delivers its conclusion: “The inspection team concluded the safety culture was adequate and improving.” (p. 24, emphasis added)  There is no discussion of how or on what basis the inspectors reached this conclusion.  In particular the finding of “improving” is hard to understand as it does not appear that this inspection team had previously assessed the safety culture at the site.

At one point the IR stumbles into a revealing and substantive issue that could provide significant insight into the problems at Palisades.  It describes another event at the plant with a lot of similarities to the DC panel. 

“The inspection team focused inspection efforts on ... an occurrence when, on May 14, 2012, workers erroneously placed a wire jumper between 115 Volt AC and 125 Volt DC circuits ...many of the actions and behaviors exhibited by the workers involved were similar in nature to the loss of DC bus event that occurred in September 2011...Those similar behaviors included the lack of a pre-job brief and discussion regarding the limitations of the work scope, workers taking action outside of the scope allowed by ‘toolpouch maintenance,’ supervisors failing to adequately challenge the workers, and workers proceeding in the face of uncertainty when unexpected conditions arose.” (p. 21)

So far so good.

“Many of the supervisors and managers the inspection team interviewed stated that the May 2012 near-miss was not a repeat event of the September 2011 event because the May 2012 near-miss involved only a handful of individuals, whereas the September 2011 occurrence involved multiple individuals across multiple organizations at Palisades. The inspectors agreed that the May 2012 near-miss involved fewer individuals, but there were individuals from several organizations involved in the near-miss. The inspectors concluded that the RCE assessment was narrow in that it stated only the field work team failed to internalize the cause and corrective actions from the September 2011 DC bus event. The inspectors concluded that other individuals, including the WCC SRO, CRS, and a non-licensed plant operator also exhibited behaviors similar to those of the September 2011 DC bus event.” (p. 21)

Still good but starting to wonder if the Palisades supervisors and managers really got the lessons learned from September 2011.

“The inspectors determined that, while the May 2012 near-miss shared some commonalities with the September 2011 event, the two conditions were not the result of the same basic causes. The inspectors reached this conclusion because the May 2012 near-miss did not result in a significant plant transient [emphasis added] and also did not exhibit the same site wide, organizational breakdowns in risk recognition and management that led to the September 2011 event.” (pp. 21-22)

Whoops.  First, what is the relevance of the outcome of the May 2012 event?  Why is it being alluded to as a cause?  Are the inspectors saying that if in September 2011 the Palisades personnel took exactly the actions they took but had the good fortune not to let the breaker stab slip it would not be a significant safety event?  

With regard to the extent of organizational breakdown, in the prior paragraph the inspectors had pushed back on this rationale - but now conclude the May 2012 event is different because it was not “site-wide”.  It is not clear how you square these arguments particularly if one goes back to the original root cause of  the DC panel event: 

“...senior leaders had not established a sufficiently sensitive culture of risk recognition and management, which resulted in the plant’s managers, supervisors, and workers not recognizing, accounting for, or preparing for the industrial safety risk and plant operational nuclear risk…” (p. 1) and, quoting from the licensee root cause analysis “site leadership at all levels was not sufficiently intrusive into work on panel ED-11-2.” (p. 13)

It is hard to see how the May 2012 event didn’t exhibit these same causes.  In addition, the “Why Staircase” in the Palisades root cause analysis (p. 21) does not identify or allude to the extent of involvement of multiple organizations - at all.  While we do not believe that such linear, “why” thinking is adequate for a complex system, it is the basis for what Palisades found and what the NRC inspectors accepted.

We’re not really sure what to make of this inspection effort.  On its face it doesn’t provide much of a basis for its conclusion that the safety culture is adequate and improving.  Perhaps the real basis is the new management team?  Or perhaps the NRC doesn’t really have many options in this situation.  If the current inspection found the weaknesses not to have been resolved, what could the NRC do?  Is there such a thing as an “inadequate” safety culture?  Or just safety culture that need improvement?  It seems the NRC’s safety culture construct has created a Looking Glass-like inversion of reality - maybe a convenient trope within the agency but increasingly a baffling and unsatisfying distraction to achieving competent nuclear safety management. 

Bottom line:  The NRC close out inspection is a baaaad report.

*  S. West (NRC) to A. Vitale (Entergy), “Palisades Nuclear Plant - NRC Supplemental Inspection Report 05000255/2012011; and Assessment Follow-up Letter” (Nov. 9, 2012) ADAMS ML12314A304.

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