Wednesday, July 30, 2014

National Research Council: Safety Culture Lessons Learned from Fukushima

The National Research Council has released a report* on lessons learned from the Fukushima nuclear accident that may be applicable to U.S. nuclear plants.  The report begins with a recitation of various Fukushima aspects including site history, BWR technology, and plant failure causes and consequences.  Lessons learned were identified in the areas of Plant Operations and Safety Regulations, Offsite Emergency Management, and Nuclear Safety Culture (SC).  This review focuses on the SC aspects of the report.

Spoiler alert: the report reflects the work of a 24-person committee, with the draft reviewed by two dozen other individuals.**  We suggest you adjust your expectations accordingly.

The SC chapter of the report provides some background on SC and echoes the by-now familiar cultural issues at both Tokyo Electric Power Company (TEPCO) and Japan’s Nuclear Energy Agency.  Moving to the U.S., the committee summarizes the current situation in a finding: “The U.S. nuclear industry, acting through the Institute of Nuclear Power Operations, has voluntarily established nuclear safety culture programs and mechanisms for evaluating their implementation at nuclear plants. The U.S. Nuclear Regulatory Commission has published a policy statement on nuclear safety culture, but that statement does not contain implementation steps or specific requirements for industry adoption.” (p. 7-8)  This is accurate as far as it goes.

After additional discussion of the U.S. nuclear milieu, the chapter concludes with two recommendations, reproduced below along with associated commentary.

An Effective, Independent Regulator

“RECOMMENDATION 7.2A: The U.S. Nuclear Regulatory Commission and the U.S. nuclear power industry must maintain and continuously monitor a strong nuclear safety culture in all of their safety-related activities. Additionally, the leadership of the U.S. Nuclear Regulatory Commission must maintain the independence of the regulator. The agency must ensure that outside influences do not compromise its nuclear safety culture and/or hinder its discussions with and disclosures to the public about safety-related matters.” (pp. S-9, 7-17)

In the lead up to this recommendation, there was some lack of unanimity on the subject of whether the NRC was sufficiently independent and if some degree of regulatory capture has occurred.  The debate covered industry involvement in rule-making, Davis-Besse and other examples.

We saw one quote worth repeating here: “The president and Senate of the United States also play important roles in helping to maintain the USNRC’s regulatory independence by nominating and appointing highly qualified agency leaders (i.e., commissioners) and working to ensure that the agency is free from undue influences.” (pp. 7-14/15)  We’ll leave it to the reader to determine if the executive and legislative branches met that standard with the previous NRC chairman and the two current commissioner nominees, both lawyers—one an NRC lifer and the other a former staffer on the Hill.

Snarky comment notwithstanding, the first recommendation is a motherhood statement and borderline tautology (who can envision the effective negation of any of the three imperative statements?)  More importantly, it appears only remotely related to the concept of SC; even at its simplest, SC consists of values and artifacts and there’s not much of either in the recommendation.

Increased Industry Transparency

“RECOMMENDATION 7.2B: The U.S. nuclear industry and the U.S. Nuclear Regulatory Commission should examine opportunities to increase the transparency of and communication about their efforts to assess and improve their nuclear safety cultures.” (pp. S-9, 7-17)

The discussion includes a big kiss for INPO.  “INPO has taken the lead for promoting a strong nuclear safety culture in the U.S. nuclear industry through training and evaluation programs.” (p. 7-10)  The praise for INPO continues in an attachment to the SC chapter but it eventually gets to the elephant in the room: “The results of INPO’s inspection program are shared among INPO membership, but such information is not made available to the public. . . . Releases of summaries of these inspections by management to the public would help increase transparency.” (p. 7-21)

The committee recognizes that implementing the recommendation “would require that the industry and regulators disclose additional information to the public about their efforts to assess safety culture effectiveness, remediate deficiencies, and implement improvements.” (p. 7-17)

At least transparency is a cultural attribute.  We have long opined that the nuclear industry’s penchant for secrecy is a major contributor to the industry being its own worst enemy in the court of public opinion. 

Our Perspective

This report looks like what it is: a crowd sourced effort by a focus group of academics using the National Academy of Sciences’ established bureaucratic processes.  The report is 367 pages long, with over 350 references and a bunch of footnotes.  The committee’s mental model of SC focuses on organizational processes that influence SC. (p. 7-1)  I think it's fair to infer that their notion of improvement is to revise the rules that govern the processes, then maximize compliant behavior.  Because of the committee’s limited mental model, restricted mission*** and the real or perceived need to document every factoid, the report ultimately provides no new insights into how U.S. nuclear plants might actually realize stronger SC.

*  National Research Council Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants, “Lessons Learned from the Fukushima Nuclear Accident for Improving Safety of U.S. Nuclear Plants” Prepublication Copy.  Downloaded July 26, 2014.  The National Research Council is part of the National Academy of Sciences (NAS).  Thanks to Bill Mullins for bringing this report to our attention.

**  The technical advisor to the committee was Najmedin Meshkati from the University of Southern California.  If that name rings a bell with Safetymatters readers, it may be because he and his student, Airi Ryu, published an op-ed last March contrasting the culture of Tohoru Electric with the culture of TEPCO.  We posted our review of the op-ed here.

***  The committee was tasked to consider causes of the Fukushima accident, conclusions from previous NAS studies and lessons that can be learned to improve nuclear plant safety in certain specified areas.  The committee was directed to not make any policy recommendations that involved non-technical value judgments. (p. S-10)

Thursday, July 24, 2014

Palisades: Back in the NRC’s Safety Culture Dog House

Our last Palisades post was on January 30, 2013 where we described the tortuous logic the NRC employed to conclude Palisades’ safety culture (SC) had become “adequate and improving.”  Or was it?  The NRC has recently parlayed an isolated Palisades incident into multiple requirements, one fleet-wide, to strengthen SC.  Details follow, taken from the resulting Confirmatory Order.*

The Incident

A Palisades security manager asked a security supervisor to cover a 2-hour partial shift because another supervisor had requested time off on Christmas Eve 2012.  Neither the manager nor the supervisor verified the supervisor had the necessary qualifications for the assignment.  He didn’t, which violated NRC regulations and the site security plan.  The problem came to light when two condition reports were written questioning the manager’s decision. (pp. 2-3)

How the Incident was Handled and Settled

Entergy requested Alternative Dispute Resolution (ADR), a process whereby the NRC and the licensee meet with a third party mediator to work out a resolution acceptable to both parties.

The Consequences

Entergy’s required corrective actions include what we’d expect, viz., action to improve and ensure adherence to security procedures.  In addition, Entergy is required to take multiple actions to strengthen SC.  These actions are spelled out in the Confirmatory Order and focus on several SC traits: (1) Leadership, Safety Values and Actions; (2) Problem Identification and Resolution; (3) Personal Accountability; (4) Work Processes; (5) Environment for Raising Concerns; and (6) Questioning Attitude and Proceeding In the Face of Uncertainty. (p. 4)

Specific requirements relate to (1) actions already implemented or to be implemented via Palisades’ Security Safety Conscious Work Environment Action Plan, (2) revising a Condition Review Group procedure to ensure the chairman considers whether the person assigned to a condition report is sufficiently independent, (3) developing and presenting a case study throughout the Entergy fleet that highlights the SC aspects of the event and (4) discussing the SC aspects of the issue with Palisades staff at three monthly tailgate meetings. (pp. 4-6, 11-12)

Our Perspective

The incident appears localized and the NRC said it had very low security significance.  Maybe Entergy thought they’d avoid any sort of penalty if they requested ADR.  Looks to us like they gambled and lost.  The NRC must think so, they are fairly gloating over the outcome.  In the associated press release, the Region III Administrator says: “Using the ADR process allowed us to achieve not only compliance with NRC requirements, but a wide range of corrective actions that go beyond those the agency may get through the traditional enforcement process”.**

Is the NRC using an elephant gun to shoot a mouse?  Or is there some unstated belief that Palisades’ SC is not as good as it should be and/or Entergy as a whole doesn’t properly value SC*** and this is a warning shot?  Or is something else going on?  You be the judge.

*  C.D. Pederson (NRC) to A. Vitale (Entergy), “Confirmatory Order Related to NRC Report No. 05000255/2014406 and OI Report 3-2013-018; Palisades Nuclear Plant” (July 21, 2014).  ADAMS ML14203A082.

**  NRC Press Release “NRC Issues Confirmatory Order to Entergy Regarding Palisades Nuclear Plant,” No. III-14-031 (July 22, 2014).

***  Entergy has had SC issues at other plants.  Click on the Entergy label for our related commentary.

Tuesday, July 22, 2014

The European Union Shows Stronger Interest in Nuclear Safety Culture

Council of the EU building
The Council of the European Union (EU) recently updated its 2009 Nuclear Safety Directive.  The revised directive’s objectives include strengthening national regulatory authorities, increasing public transparency on nuclear safety matters and promoting an effective nuclear safety culture.  The last objective caught our eye and is the subject of this post.

Safety Culture in the 2009 Nuclear Safety Directive*

Safety culture (SC) did not get a lot of attention in the 2009 directive.  Specifically, “The establishment of a strong safety culture within a nuclear installation is one of the fundamental safety management principles necessary for achieving its safe operation.” (p. L 172/19)  That was it.

Safety Culture in the 2014 Amended Directive**

SC treatment in this version is more expansive.

“Indicators for an effective nuclear safety culture include, in particular: the commitment at all levels of staff and management within an organisation to nuclear safety and its continuous improvement; the promotion of the ability of staff at all levels to question the delivery of relevant safety principles and practices to continuously improve nuclear safety; the ability of staff to report safety issues in a timely manner; the identification of the lessons learnt from operational experience; and the systematic reporting of any deviation from normal operating conditions or arrangements relevant to accident management that have the potential to have an impact on nuclear safety.” (p. 10)

The foregoing is then restated in the form of requirements.  “Member States shall ensure that the national framework requires that the competent regulatory authority and the licence holder take measures to promote and enhance an effective nuclear safety culture. Those measures include in particular:

(a) management systems which give due priority to nuclear safety and promote, at all levels of staff and management, the ability to question the effective delivery of relevant safety principles and practices, and to report in a timely manner on safety issues, in accordance with Article 6(d);

(b) arrangements by the licence holder to register, evaluate and document internal and external safety significant operating experience;

(c) the obligation of the licence holder to report events with a potential impact on nuclear safety to the competent regulatory authority; and,

(d) arrangements for education and training, in accordance with Article 7.” (p. 28)

Our Perspective

We are pleased to see the EU strengthen its position on SC’s role in promoting and maintaining safe nuclear operations.  The 2014 version of the safety directive is obviously a major improvement over 2009.  The paragraph on management systems gives “due priority” to safety and reflects the notions of a Safety Conscious Work Environment and an Employee Concerns Program.

The other requirements on recording operating experience, reporting significant events and arranging training create a minimally acceptable framework for nuclear operations.

We recognize that this EU directive is a top-level policy document so we don’t expect any specifics but there are two other SC-related items that merit mention at the policy level.

One, the management system should have a top-level goal of identifying and correcting problems in a timely manner.  This is perhaps the most important artifact of a strong SC.  Such a goal should not be limited to issues like equipment problems but cover everything from plant siting to daily operations.

Two, the management system should include reference to an executive compensation scheme that rewards safety performance and the maintenance of a strong SC.

*  “Council Directive 2009/71/EURATOM of 25 June 2009 establishing a Community framework for the nuclear safety of nuclear installations,” Official Journal of the European Union (July 2, 2009).

**  Council of the European Union, “Council Directive amending Directive 2009/71/Euratom establishing a Community framework for the nuclear safety of nuclear installations,” Interinstitutional File: 2013/0340 (June 30, 2014)

Tuesday, July 15, 2014

Vit Plant Safety Culture Update

Hanford Waste Treatment Plant
DOE released a June 2014 follow-up assessment* on safety culture (SC) at the Hanford Waste Treatment Plant (WTP or the Vit Plant).  This post provides our perspective on the assessment.  We will not review every facet of the report but will focus on aspects that we think are important to understanding the current state of SC at the WTP project.


Back in 2011, the Defense Nuclear Facilities Safety Board (DNFSB) called the WTP safety culture (SC) “flawed.”  Following the DNFSB report, DOE conducted an assessment of the WTP SC and concluded “that a significant number of staff within ORP [DOE’s Office of River Protection] and BNI [Bechtel National Inc.] expressed reluctance to raise safety or quality concerns for various reasons.” (p. 1) 

Like DOE’s 2011 report, the current one is based on multiple data sources: structured interviews, focus groups, observations and a culture survey.  The report identifies many SC-related interventions that have been initiated, and lists positive and negative findings from the data collected.  Detailed assessment results are reported separately for ORP and BNI.**
WTP’s Safety Conscious Work Environment (SCWE)—Voicing Concerns, Challenging Decisions, Fear of Retaliation

The 2011 DNFSB critique focused on the treatment of project personnel who raised technical issues.  Some of these personnel complained about retaliation for bringing up such issues.  These issues can be raised in the Employee Concerns Program (ECP), the Differing Professional Opinions (DPO) process and challenging management decisions.  In what is arguably the report’s most significant finding, perceptions of conditions in these areas are worse than they were in 2011 for ORP and unchanged for BNI. (pp. 4-5)

Supporting Details

Although ORP senior management pointed to recent reductions in ECP concerns, “[s]ome interviewees indicated that they perceived a chilled environment at ORP and they did not believe that ECP concerns and DPO issues were always addressed or resolved in a timely manner.  Additionally, some interviewees described being told by supervision not to write a DPO because it would be a career limiting decision.” (p. B-21)  Interviewees from both ORP and BNI said they lacked trust in the ECP. (pp. B-22/23)

Most ORP employees believe that constructive criticism is not encouraged. (p. 4)  Within ORP, only 30% of all ORP survey respondents (and 65% of managers) feel that they can openly challenge decisions made by management. (p. B-21)  In BNI/URS, the numbers are 45% of all respondents and 75% of managers. (p. B-22)

“The statement that management does not tolerate retaliation of any kind for raising concerns was agreed to by approximately 80% of the ORP, . . . 72% of the BNI and 80% of the URS survey respondents.” (pp. B-21-22)  In addition, “Anonymous PIERs [Project Issues Evaluation Reports] are used a lot because of fear of retaliation.” (p. B-23)  

All in all, hardly a ringing endorsement of the WTP SCWE.

Decision Making, Corrective Action and Compensation

Safetymatters readers know of our long-standing interest in how SC is reflected in these key artifacts.

Decision Making

“Interviewees provided some examples of where decision making was not perceived to reflect the highest commitment to safety”  Examples included downgrading or elimination of assessment findings, the margin of safety in corrective action plans and the acceptable level of risk for the project.  (p. B-9)  Looks like there's some room for improvement in this area.

Corrective Action

Within BNI, there are positive comments about the corrective action process but the assessment team “observed a lack of accountability for a backlog of corrective actions at a PIRB [Performance Improvement Review Board] meeting.  There is a perceived lack of accountability for corrective actions in timeliness, ownership, and quality, ...” (p. B-16)

“[O]nly about 18% of all ORP interviewee respondents believed that employees are encouraged to notify management of problems they observe and that there is a system that evaluates the problem and makes a determination regarding future action.” (p. 13)

Plenty of room for improvement here.


In the area of compensation, it appears some rewards for Bechtel are based on SC behaviors. (p. B-8)  We consider that a very positive development.

Concerns Over ORP Working More Collaboratively with Bechtel

On the surface this looks like a positive change: two entities working together to achieve a common goal.  However, this has led to at least two concerns.  First, as described in the report, some ORP personnel believe ORP is abdicating or compromising its responsibility to perform oversight of Bechtel, in other words, ORP is more of a teammate and less of an umpire. (pp. B-4, -9, -14)  Second, and this reflects our perspective, changing the relationship between the entities can result in revised system dynamics, with old performance-oversight feedback loops replaced by new ones.  The rules of engagement have changed and while safety may still be the number one priority, the cultural milieu in which safety is achieved has also changed.

Another complication is caused by the role of Bechtel Corporate.  The report says corporate’s values and goals may not be well-aligned with BNI’s need to prioritize SC attributes and behavior.  This can lead to a lack of transparency in BNI decisions. (pp. 5, 7)  That may be a bit of weasel wording in the report; in more direct terms, corporate’s number one priority is for the money train to keep running.

Bottom Line on SC at WTP 

A strong SC is, in some ways, about respect for the individual.  The concerns that WTP personnel  express about using the ECP or DPO process, or challenging management decisions suggest that the WTP project has a ways to go to inculcate an adequate level of such respect.  More importantly, it doesn’t appear they have made any significant process toward that goal in the last few years.

Morale is an aspect of the overall culture and at the WTP, morale is arguably low because of lack of progress and missed schedules. (pp. 6, B-10)  There is undoubtedly plenty of work to do but on a day to day basis, we wouldn’t be surprised if some people feel their work is not meaningful.

*  DOE Office of Environment, Safety and Health Assessments (now the Office of Independent Enterprise Assessments), “Independent Oversight Follow-up Assessment of Safety Culture at the Waste Treatment and Immobilization Plant” (June, 2014).

**  ORP has line management responsibility for the WTP, BNI is the primary contractor and URS Corporation (URS) is a major subcontractor.

Tuesday, July 8, 2014

Catching Up on DOE’s SCWE Extent of Condition Review

Hanford Waste Treatment Plant
On May 29, 2014 DOE submitted its partial response to the Defense Nuclear Facilities Safety Board (DNFSB) Recommendation 2011-1 in a report* on DOE’s Safety Conscious Work Environment (SCWE) extent of condition review and recommended actions for ongoing safety culture (SC) improvement at DOE facilities.

(Quick history: The June 9, 2011 DNFSB report on DOE’s Hanford Waste Treatment Plant (WTP or the Vit Plant) said the WTP SC was “flawed.”  The report’s recommendations included that DOE should conduct an extent of condition review to determine whether WTP SC weaknesses existed at other DOE facilities.  DOE agreed to perform the review but focused on SCWE because, in DOE’s view, the issues at WTP were primarily SCWE related.)

This post summarizes the report’s findings then parses the details and provides our perspective.

 Report Findings and Recommendations

The report was based on data from eleven independent SC assessments and thirty-one SCWE self-assessments conducted by individual organizations.  The DOE review team processed the data through their analyzer and homogenizer to identify four primary SC attributes** to focus on for continuous improvement in DOE:
  • Demonstrated safety leadership
  • Open communication and fostering an environment free from retribution
  • Teamwork and mutual respect
  • Credibility, trust and reporting errors and problems
Further processing through the bureaucratizer yielded three recommended actions to improve the SC attributes:
  • Form a DOE SC Improvement Panel to ensure leadership and focus on DOE's SC initiatives
  • Incorporate SC and SCWE concepts and practices into DOE training
  • Evaluate contract language to incorporate clear references to SC  (pp. 3-4)
Our Perspective

We reviewed the DOE independent assessments on January 25, 2013 and the self-assessments on March 31, 2014.  From the former we concluded that issues similar to those found at the WTP existed at other DOE facilities, but to a lesser degree than WTP.  The self-assessments were of such varying quality and credibility that we basically couldn’t infer anything.***

The Analyzer

The DOE team reviewed all the assessments to identify specific issues (problems).  The team binned issues under the SC attributes in DOE's Integrated Safety Management System Guide and then counted the number of issues under each attribute; a higher count meant a more serious problem.  They performed a similar exercise to identify positive organizational trends (strengths) mentioned in the assessments. 

We could be picky and ask if all the issues (or strengths) were of essentially the same importance or magnitude but the team had a lot of data to review so we’ll let that slide.  Concurrently identifying strengths was a good idea; it harkens back to Peter Drucker who advised managers to build on strengths.****

The Homogenizer

Here’s where we begin to have problems.  The team focused on identifying SC attributes and developing recommendations that applied to or affected the entire Department, essentially boiling their results down to a one-size-fits-all approach.  However, their own data belies that approach.  For example, the Leadership attribute “Open communication and fostering an environment free from retribution” was identified as both an issue AND a strength. 

In plain English, some organizations don’t exhibit the desired communication attribute and others do.  One proper fix is to identify who is doing it right, define what exactly they’re doing, and develop a method for transferring that approach to the problem organizations.  The report even says this attribute “is an area in which management can learn lessons from those sites where it was deemed a strength so that best practices can become commonplace” but this statement is buried at the end of the report. (p. 22)

The DOE entities exhibit a wide variety of scale, scope, mission and organizational and technical complexity.  The Department’s goal should be to recognize that reality, develop it as an overall strength and then build on it to create site- or organization-specific interventions.

The Bureaucratizer

The proposed fixes would basically create a top-level coordinating and oversight group, enhance SC and SCWE training and modify contracts.  The recommendations reflect a concerted search for the lowest common denominator and a minimum amount of real change.

If the SC Improvement Panel is established, it should focus on setting or refining SC policy and ensuring those policies are implemented by line management, especially field management.  They should also be involved in evaluating major SC issues.  If things aren’t going well, this group should be the first to ask the hard “Why?” questions.  But most of the panel’s proposed tasks, viz., maintaining SC visibility, providing a forum for evaluating SC status and overseeing training improvements, are low-value make work.

“[S]afety culture training for all personnel, up and down the management chain, will be updated and/ or developed to ensure that roles and responsibilities are understood and personnel have the capabilities needed to play their part in continuously improving DOE's safety culture; . . .” (p. 24)  This is a standard fix for almost any perceived organizational problem.  It doesn’t require managers to do anything different.

Modifying contracts to incorporate clear references to SC is only a beginning.  What are the carrots and the sticks to incent the contractors to actually develop, measure and maintain an effective SCWE and strong SC?

Bottom Line

This report comports completely with an organization that resembles a fifty foot sponge.  You can kick it as hard as you like, your foot goes in deep and you think you’ve had an effect, but when you withdraw your foot, the organization fills in the hole like your kick never happened.  I thought I heard a loud pop on May 29.  I now realize it was likely DNFSB Chairman Winokur’s head exploding when he read this report.

But Wait, There’s More

Remember the question the DNFSB initially asked in 2011: Do WTP SC issues exist elsewhere in DOE?  Well, the answer is: “Review of assessment results from both [independent and self assessments] indicated there is a SCWE extent of condition that requires additional and ongoing actions to improve performance.” (p. 28, the penultimate page of the report)

*  J. Hutton (DOE) to P.S. Winokur (DNFSB) May 29, 2014 letter transmitting DOE Consolidated Report for DNFSB Recommendation 2011-1, Actions 2-8 and 2-9 (May 2014).

** DOE considers SC in three focus areas: Leadership, Employee Engagement and Organizational Learning.  Each focus area has a set of associated attributes that describe what a positive SC should look like. (pp. 4-5)

***  The report puts the self-assessments in the best possible light by describing them as learning experiences for the organizations involved. (p.9)

****  Drucker was referring to individuals but, in this case, we’ll stretch the blanket to cover organizations.  For individuals, weaknesses should not be ignored but the energy required to fix them, if it’s even possible, is often too great.  However, one should keep an eye on such weaknesses and not allow them to lead to performance failure.