Monday, January 25, 2016

IAEA Urges Stronger Nuclear Safety Culture in Japan

The International Atomic Energy Agency (IAEA) recently completed a peer review of Japan's Nuclear Regulation Authority (NRA), a regulatory agency established in the aftermath of the 2011 Fukushima disaster.  Highlights of the review were discussed at an IAEA press conference.*

The IAEA review team praised the NRA’s progress in various areas, such as demonstrating independence and transparency, and made suggestions and recommendations for further improvement, primarily in the area of NRA staff recruiting and development.

The IAEA team also mentioned safety culture (SC), recommending “the NRA and nuclear licensees ‘continue to strengthen the promotion of safety culture, including by fostering a questioning attitude’.”

Our Perspective

We look forward to the IAEA’s final report which is due in about three months.  We are especially interested in seeing if there is comprehensive discussion and specific direction with respect to “fostering a questioning attitude.”  The Japanese nuclear industry in general and TEPCO (Fukushima’s owner) in particular certainly need to cultivate employees’ willingness to develop and consider open-ended questions such as “what if?” and “what can go wrong?”

More importantly, they also need to instill the necessary backbone to stand up in front of the bosses and ask tough questions and demand straight answers.  Lots of folks probably knew the Fukushima seawall wasn’t high enough and the emergency equipment in the basement was subject to flooding but everyone went along with the program.  That’s what has to change to create a stronger SC.

*  “IAEA praises reform of Japan's nuclear regulator,” World Nuclear News (Jan. 22, 2016).

Sunday, January 17, 2016

A Nuclear Safety Culture for Itinerant Workers

IAEA has published “Radiation Protection of Itinerant Workers”* a report that describes management responsibilities and practices to protect and monitor itinerant workers who are exposed to ionizing radiation.  “Itinerant workers” are people who work at different locations “and are not employees of the management of the facility where they are working. The itinerant workers may be self-employed or employed by a contractor . . .” (p. 4)  In the real world, such employees have many different names including nuclear nomads, glow boys and jumpers.

The responsibility for itinerant workers’ safety and protection is shared among various organizations and the individual.  “The primary responsibility for the protection of workers lies with the management of the operating organization responsible for the facilities . . . however, the employer of the worker (as well as the worker) also bear certain responsibilities.” (p. 2)

Safety culture (SC) is specifically mentioned in the IAEA report.  One basic management responsibility is to promote and maintain a robust SC at all organizational levels. (p. 11)  Specific responsibilities include providing general training in SC behavior and expectations (p. 131) and, where observation or problems reveal specific needs, targeted individual (or small group) SC training. (p. 93)

Our Perspective

This publication is hardly a great victory for SC; the report provides only the most basic description of the SC imperative.  Its major contribution is that it recognizes that itinerant nuclear workers deserve the same safety and protection considerations as other workers at a nuclear facility. 

Back in the bad old days, I was around nuclear organizations where their own employees represented the highest social class, contractors were regarded as replaceable parts, and nomadic workers were not exactly expendable but were considered more responsible for managing their own safety and exposure than permanent personnel.

One can make some judgment about a society’s worth by observing how it treats its lowest status members—the poor, the homeless, the refugee, the migrant worker.  Nuclear itinerant workers deserve to be respected and treated like the other members of a facility’s team.

*  International Atomic Energy Agency, “Radiation protection of itinerant workers,” Safety reports series no. 84 (Vienna, 2015).

Sunday, January 10, 2016

Targeted Safety Culture Assessment at Columbia Generating Station

Columbia Generating Station
The Columbia Generating Station (CGS) got into trouble with the NRC when two members of the security department were found to have been willfully inattentive to their duties on multiple occasions over three years (2012-2014).  What they were doing was not disclosed because it was a security-related matter.  The situation was summarized in a recent newspaper article* and the relevant NRC documents** provide some additional details.

Energy Northwest (CGS’s owner) opted for the NRC’s Alternative Dispute Resolution (ADR) process.  The agreed-upon corrective actions and penances are typical for ADR settlements: conduct a common cause evaluation, install new cameras and increase supervision if the cameras aren’t working, revise and present training, prepare a statement on willful misconduct’s consequences and have personnel sign it, prepare a "lessons learned" presentation for plant personnel and an industry gathering (aka public atonement), revise procedures and conduct a targeted nuclear safety culture (SC) assessment of the security organization at CGS.  Oh, and pay a $35K fine.

Our Perspective

The security SC assessment caught our eye because it is being conducted by a law firm, not a culture assessment specialist.  Maybe that’s because the subject is security-related, therefore sensitive, and this approach will ensure the report will never be made public.  It also ensures that the report will focus on the previously identified “bad apples” (who no longer work at the plant) and the agreed-upon ADR actions; the assessment will not raise any awkward management or systemic issues.

*  A. Cary, “Energy Northwest pays fine over Richland nuclear security,” Tri-City Herald (Jan. 5, 2015.)

**  A. Vegel (NRC) to M. Reddermann (Energy NW), Columbia Generating Station – NRC Security Inspection Report 05000397/2015405 and NRC Investigation Report No. 4-2014-009 (June 25, 2015).  ADAMS ML15176A599.  M. Dapas (NRC) to M. Reddermann (Energy NW), Confirmatory Order - NRC Security Inspection Report 05000397/2015407 AND NRC Investigation Report 4-2014-009 Columbia Generating Station (Sept. 28, 2015).  ADAMS ML15271A078.

Monday, January 4, 2016

How Top Management Decisions Shape Culture

A brief article* in the December 2015 The Atlantic magazine asks “What was VW thinking?” then reviews a few classic business cases to show how top management, often CEO, decisions can percolate down through an organization, sometimes with appalling results.  The author also describes a couple of mechanisms by which bad decision making can be institutionalized.  We’ll start with the cases.

Johnson & Johnson had a long-standing credo that outlined its responsibilities to those who used its products.  In 1979, the CEO reinforced the credo’s relevance to J&J’s operations.  When poisoned Tylenol showed up in stores, J&J did not hesitate to recall product, warn people against taking Tylenol and absorb a $100 million hit.  This is often cited as an example of a corporation doing the right thing. 

B. F. Goodrich promised an Air Force contractor an aircraft brake that was ultralight and ultracheap.  The only problem was it didn’t work, in fact it melted.  Only by massively finagling the test procedures and falsifying test results did they get the brake qualified.  The Air Force discovered the truth when they reviewed the raw test data.  A Goodrich whistleblower announced his resignation over the incident but was quickly fired by the company.  

Ford President Lee Iacocca wanted the Pinto to be light, inexpensive and available in 25 months.  The gas tank’s position made the vehicle susceptible to fire when the car was rear-ended but repositioning the gas tank would have delayed the roll-out schedule.  Ford delayed addressing the problem, resulting in at least one costly lawsuit and bad publicity for the company.

With respect to institutional mechanisms, the author reviews Diane Vaughan’s normalization of deviance and how it led to the space shuttle Challenger disaster.  To promote efficiency, organizations adopt scripts that tell members how to handle various situations.  Scripts provide a rationale for decisions, which can sometimes be the wrong decisions.  In Vaughan’s view, scripts can “expand like an elastic waistband” to accommodate more and more deviation from standards or norms.  Scripts are important organizational culture artifacts.  We have often referred to Vaughan’s work on Safetymatters.

The author closes with a quote: “Culture starts at the top, . . . Employees will see through empty rhetoric and will emulate the nature of top-management decision making . . . ”  The speaker?  Andrew Fastow, Enron’s former CFO and former federal prison inmate.

Our Perspective

I used to use these cases when I was teaching ethics to business majors at a local university.  Students would say they would never do any of the bad stuff.  I said they probably would, especially once they had mortgages (today it’s student debt), families and career aspirations.  It’s hard to put up a fight when the organization has so accepted the script they actually believe they are doing the right thing.  And don’t even think about being a whistleblower unless you’ve got money set aside and a good lawyer lined up.

Bottom line: This is worth a quick read.  It illustrates the importance of senior management’s decisions as opposed to its sloganeering or other empty leadership behavior.

*  J. Useem, “What Was Volkswagen Thinking?  On the origins of corporate evil—and idiocy,”  The Atlantic (Dec. 2015), pp.26-28.