Wednesday, August 20, 2014


The International Atomic Energy Agency (IAEA) offers an Operational Safety Review Team (OSART) program where international teams of experts conduct in-depth reviews of nuclear power plant operational safety performance.  Performance is reviewed in various areas such as management, training, operations, maintenance, etc.  The reports also include comments about plant safety culture (SC).  IAEA has conducted scores of OSART reviews, including U.S. power plants.  This post covers SC-related findings for the U.S. plants; we are interested in what kinds of SC strengths and weaknesses the teams identify during their approximately two-week visits.

North Anna (2000)

This is the earliest OSART report available in the NRC ADAMS database.  There are two versions of the report, one distributed to NRC Commissioners on Nov. 30, 2000* and another released by IAEA on Feb. 12, 2001.**  Both versions include generally complimentary language related to SC saying management is committed to safety and continuous improvement is nurtured. (p. 7 in 2000 report)  In the Operations area the report notes “Policies and management verbal communication are consistent and emphasize the importance of safety first.  Safety culture is referred to at several hierarchical levels of the plant.” (p. 31 in 2000 report)

There is an interesting discrepancy between the two versions.  The first report says “The emphasis the plant is making on self-assessment and improving human performance to bring about a sustaining safety culture is presently balancing the perception of increased cost drivers and short term budgeting.” (p. 13)  This hints at a cost vs. safety goal conflict, a serious challenge to maintaining a strong SC.  However, the second report does not include that statement, instead noting elsewhere that “In the teams opinion, however, there is presently little resource margin to absorb increased demands and although the highly motivated staff continue to look for ways to improve, the potential for complacency and demotivation from the prospect of long term challenges with aging facilities and equipment and tightening budget poses a risk to maintaining that performance.” (p. 9)  Is this just a more politic way of saying the same thing or does it reflect an actual watering down of the report?

Brunswick (2005)

The report*** covers the initial visit and the follow-up visit 19 months later.  SC is treated more thoroughly than in earlier reviews: “An important element of the OSART review is the identification of those findings that exhibit positive and negative attributes of safety culture.” (p. 7)  At Brunswick positive SC attributes included a questioning attitude of all personnel, a strong self-assessment program, and adherence to established procedures.  Improvement opportunities included the need for increased attention for continuous improvement, greater use of self criticism when observing safety systems and components, and further expanding external operating experience activities. (p. 10) 

The team’s in-depth review of the corrective action program (CAP) provides a look at the SC in practice.  “The corrective action programme is very strong and closely monitored.” (p. 97)  Aging mechanisms, especially corrosion, are a challenge for the corrective action program (p. 69) but the plant’s response led to this issue being closed during the follow-up visit.  Rework is analyzed by a committee to address effective corrective actions (p. 57) but maintenance backlogs require constant attention. (p. 59)  After the team’s initial visit the plant developed a new system for classifying condition reports; at follow-up the team observed “Based on the new graded system, the plant is improving opportunities to focus analyses and resources in accordance with the significance of the events.” (p. 100)  Overall, this seems reflective of a SC that supports both the CAP and efforts to improve it.

Another finding reflecting SC was that the plant Management Succession Planning and Development Program did not include safety performance in talent assessment, ranking or as a specified core skill.  Brunswick claimed these factors were implicitly considered but strengthened the program to explicitly include nuclear safety, radiation safety and industrial safety goals for each plant staff member.  The review team found this action sufficient to close the issue. (pp. 21-22)  This is also indicative of a culture that encourages improvement efforts.

Arkansas Nuclear One (2008) 

The positive SC attributes in this report**** include a strong Human Performance program with a focus on continuous improvement, a rigorous and conservative approach when planning and performing tasks, and a willingness of staff to correct each other’s behavior without waiting to be corrected by management.  In addition, conservative decision making is a core value within the management team.  Problem areas include long standing defects throughout the plant (and first attempts to fix problems that do not always work), policies such as overtime and time pressure on outage schedule that suggest the plant is “cost” driven, and the benchmarking program does not work from a broad international base. (pp. 4-5, 34).  Both an ineffective CAP and a cost-driven plant (i.e, goal conflict between cost and safety) reflect a weak SC.

Seabrook (2011)

In the Seabrook report***** SC strengths include consistent reinforcement of key values by the management team and no evidence of production taking precedence over safety.  Opportunities for improvement include a more aggressive approach to addressing long term issues, thus reducing the potential for staff normalization to less than excellent conditions. (pp. 4, 45)

A positive observation is that plant communications stress safety as the no. 1 priority. (p. 7)  Another is that Seabrook has a problem reporting culture based on a low-threshold and high-volume reporting system. (pp. 2, 56)  Personnel who report problems outside their area of responsibility are recognized with a “Good Catch” award.  Personnel writing lots of condition reports is generally a good thing but some corrective actions are closed prematurely. (pp. 54-56, 59)

More significantly, plant problems include a lack of resolution of long term issues, plant material condition deterioration and degraded equipment conditions. (pp. 2, 44-45)  Significant backlogs exist in the CAP, work orders and procedure change requests. (p. 8)  Work backlogs are an indication of a culture that lives with issues rather than resolving them.

Seabrook SC standards are summarized as “very positive” (p. 4) and maybe they are, but the reality of backlogs and unresolved long-term issues is inconsistent with a strong SC. 

Our Perspective

It’s probably unrealistic to expect a group of foreigners to visit a U.S. plant for two weeks and come up with significant SC insights.^  The summaries of SC positives and negatives appear to be relatively superficial but findings in the functional areas can offer a look at the actual underlying SC.  Some of the OSART observations and findings on key artifacts provide information from which we can infer the strength of SC at a plant being reviewed. 

We would like to see greater attention to how important decisions are made at a plant.  Decision making was only mentioned in passing (North Anna, p. 31) or a simple statement like plant performance indicators are a key input to decision making. (ANO, p. 6)

Finally, compensation and reward systems appear to be outside the OSART scope but we know these are critical to reinforce safety-related behavior and overall SC.

*  J.D. Lee (NRC) to NRC Commissioners, “IAEA Report on OSART Mission at North Anna Power Station, January 22 to February 10, 2000” (Nov. 30, 2000).  ADAMS ML010160525.

**  IAEA, “Report of the OSART Mission to the USA North Anna Nuclear Power Plant 22 January to 10 February 2000” (Released Feb. 12, 2001).  ADAMS ML010470115.

***  IAEA, “Report of the OSART Mission to the Brunswick Nuclear Plant United States of America 9-25 May 2005 and Follow Up Visit 4-8 December 2006” no date.  ADAMS ML071100006.

****  IAEA, “Report of the OSART Mission to the Arkansas Nuclear One Nuclear Power Plant United States of America 15 June – 2 July 2008
no date.  ADAMS ML083440148.

*****  P. Freeman (Seabrook) to NRC, “IAEA Final Report OSART Mission to Seabrook Nuclear Power Plant USA 6-23 June 2011” (Mar. 16, 2012).  ADAMS ML12081A105.

^  A partial view is suggested in the Foreword to the Seabrook report where the authors note that an OSART review represents a “snapshot in time.”  In fairness, it would be equally unrealistic to expect a team of Americans to visit a foreign plant and develop a deep understanding of plant culture in a similar time period.


  1. Lew,

    Thank you for the excellent longitudinal slice along a pathway which few in the US may be familiar with as an independent source of perspective on our National Nuclear Energy Enterprise.

    I'm going to suggest some counterpoint reflections which I think add up to a hypothesis that while these assessments might benefit the individual plants, they provide only fragments of useful insights regarding US Nuclear Safety Culture - at least as encompassed by this from the INSAG-4 forward:

    "The present report deals with the concept of Safety Culture as it relates to organizations and individuals engaged in nuclear power activities, and provides a basis for judging the effectiveness of Safety Culture in specific cases in order to identify potential improvements.

    "The report is intended for use by governmental authorities and by the nuclear industry and its supporting organizations. Prepared by a highly authoritative body, it should help to promote Safety Culture. It is intended to stimulate discussion and to promote practical action at all levels to enhance safety."

    It has generally been the assumption in many National Nuclear Energy Enterprises (but not all) that the particular plant or site operating organization is the fundamental unit of work for purposes of nurturing and manifesting NSC. This presumption appears to be doctrinaire in oversight groups such as IAEA, NEA, and the Nuclear Regulatory aspects of the EU - it is difficult to conclude a different view pertains in USNRC, INPO, NEI, or WANO.

    This assumption persists against what would appear to be the clear evidence of how breakdowns in the full NNEE - from top to bottom - were implicated in the major disasters at Chernobyl and Fukushima. It has always been my reading of INSAG-4 that its Principal Risk Insights are drawn in regard to Significant Issues Risk Management, particularly as reflected in those aspects of NNEE governance that only persons with high authority and substantial resource discretion can legitimate.

    Since the time of TMI, and largely before, rigorous configuration management, quality controlled manufacture and construction, conduct of operations and maintenance discipline, radiological protection, and most other site level functions of effective performance have benefited from a sufficiently detailed standards basis.

    Before TMI, the Significant Risk Management Issue which went unaddressed was basically this: the standards which existed were sufficient for a small nuclear industry of highly competent professional staff many with the status of Plant Startup "plank owners" (i.e. an expert-based management system).

    In the 1970's the US NNEE expanded far too rapidly and beyond the Resilience of those expert operations cadres. The industry response to create INPO and the NRC response to provide more detailed expectations of management effectiveness and down to lower levels of details in areas like fire protection, LCO compliance, and emergency management all evolved from that assumption that each plant comprised the natural unit of assessment for evidence of improved performance.

    Although the SALP process and more recently the ROP, as well as INPO reviews do include evaluation of corporate performance the context remains almost exclusively characterized as "corporate supporting the plant." It is against this tunnel vision that the Safety Matters leading indicators (e.g. Decision Making, Management Incentives, and Corrective Action) provide both contrast, and as is reiterated here the basis for substantive unease.

  2. Continued:

    Certainly we should not be ignoring questions for the ANO owners, INPO, and the NRC regarding what missed influence the OSART cautions about outage pressures had in the run up to the subsequent fatality associated with a dropped turbine rotor and the rather startling nuclear safety knock-on effects identified by the NRC's review of this event. It would also be a meaningful event were the program champions for the OSART review to conduct a followup assessment on that question of Return on Significant Management Issue Risk Insight as identified in 2008.

    The difficulty of course is that none of the regular high level conversations sponsored by IAEA or NRC (e.g. the RIC) appear to convene such inquiries. Every time I get going on this topic I find myself going to the NRC Safety Culture information web pages to see what's new under Safety Culture Case Studies - - its now over two years since the Policy was promulgated and there is nothing new; none yet relates to an actual situation in the NNEE.

    I suggest we are left, largely disappointed, with the predicament suggested by your final footnote - why conduct these international team reviews if it is not for the purpose of assessing whether those features considered to be common to all effective programs - independent of specific implementing details - are in fact recognizable to a highly qualified group such as comprise these Teams?


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