Safety Culture at the NRC Regulatory Information Conference

NRC Public Meeting

The NRC held their annual Regulatory Information Conference (RIC) March 11-13, 2014.  It included a session on safety culture (SC), summarized below.*

NRC Presentation

The NRC presentation reviewed their education and outreach activities on the SC Policy Statement (SCPS) and their participation in IAEA meetings to develop an implementation strategy for the IAEA Nuclear Safety Action Plan. 

The only new item was Safety Culture Trait Talk, an educational brochure.  Each brochure covers one of the nine SC traits in the SCPS, describing why the trait is important and providing examples of associated behaviors and attitudes, and an illustrative scenario. 

It appears only one brochure, Leadership Safety Values and Actions, is currently available.**  A quick read suggests the brochure content is pretty good.  The “Why is this trait important?” content was derived from an extensive review of SC-related social science literature, which we liked a lot and posted about Feb. 10, 2013.  The “What does this trait look like?” section comes from the SC Common Language initiative, which we have reviewed multiple times, most recently on April 6, 2014.  The illustrative scenario is new content developed for the brochure and provides a believable story of how normalization of deviance can creep into an organization under the skirt of an employee bonus program based on plant production.

Licensee Presentations

There were three licensee presentations, all from entities that the NRC has taken to the woodshed over SC deficiencies.  Presenting at the RIC may be part of their penance but it’s interesting to see what folks who are under the gun to change their SC have to say.

Chicago Bridge & Iron, which is involved in U.S. nuclear units currently under construction, got in trouble for creating a chilled work environment at one of its facilities.  The fixes focus on their Safety Conscious Work Environment and Corrective Action Program.   Detailed activities come from the familiar menu: policy updates, a new VP role, training, oversight, monitoring, etc.  Rapping CB&I’s knuckles certainly creates an example for other companies trying to cash in on the “Nuclear Renaissance” in the U.S.  Whatever CB&I does, they are motivated to make it work because there is probably a lot of money at stake.  The associated NRC Confirmatory Order*** summarizes the history of the precipitating incident and CB&I’s required corrective actions.

Browns Ferry has had SC-related problems for a long time and has been taken to task by both NRC and INPO.  The presentation includes one list of prior plant actions that DIDN’T work while a different list displays current actions that are supposedly working.  Another slide shows improvement in SC metrics based on survey data—regular readers know how we feel about SC surveys.  The most promising initiative they are undertaking is to align with the rest of the TVA fleet on NEI 09-07 “Fostering a Strong Nuclear Safety Culture.”  Click on the Browns Ferry label to see our posts that mention the plant.

Fort Calhoun’s problems started with the 2011 Missouri River floods and just got worse, moving them further down the ROP Action Matrix and forcing them to (among many other things) complete an independent SC assessment.  They took the familiar steps, creating policies, changing out leadership, conducting training, etc.  They also instituted SC “pulse” surveys and use the data to populate their SC performance indicators.  Probably the most important action plant owner OPPD took was to hire Exelon to manage the plant.  Fort Calhoun’s SC-related NRC Confirmatory Action Letter was closed in March 2013 so they are out of the penalty box.

Bottom line: The session presentations are worth a look.


*  RIC Session T11: Safety Culture Journeys: Lessons Learned from Culture Change Efforts (Mar. 11, 2014).  Retrieved April 25, 2014.  Slides for all the presentations are available from this page.

**  “Leadership Safety Values and Actions,” NRC Safety Culture Trait Talk, no. 1 (Mar. 2014).  ADAMS ML14051A543.  Retrieved April 25, 2014.

***  NRC Confirmatory Order EA-12-189 re: Chicago Bridge and Iron (Sept. 16, 2013).  ADAMS ML13233A432.  Retrieved April 25, 2014.

NRC Non-Regulation of Safety Culture: Fourth Quarter Update

NRC SC Brochure ML113490097

On March 17, July 3 and October 17, 2012 we posted on NRC safety culture (SC) related activities with individual licensees. This post highlights selected NRC actions during the fourth quarter, October through December 2012. We report on this topic to illustrate how the NRC squeezes plants on SC even if the agency is not officially regulating SC.

Prior posts mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking significant SC-related activities. It appears none of those plants has resolved its SC issues.

Browns Ferry

An NRC supplemental inspection report* contained the following comment on a licensee root cause analysis: “Inadequate emphasis on the importance of regulatory compliance has contributed to a culture which lacks urgency in the identification and timely resolution of issues associated with non-compliant and potentially non-conforming conditions.” Later, the NRC observes “This culture change initiative [to address the regulatory compliance issue] was reviewed and found to still be in progress. It is a major corrective action associated with the upcoming 95003 inspection and will be evaluated during that inspection.” (Two other inspection reports, both issued November 30, 2012, noted the root cause analyses had appropriately considered SC contributors.)

An NRC-TVA public meeting was held December 5, 2012 to discuss the results of the supplemental inspections.** Browns Ferry management made a presentation to review progress in implementing their Integrated Improvement Plan and indicated they expected to be prepared for the IP 95003 inspection (which will include a review of the plant's third party SC assessment) in the spring of 2013.

Fort Calhoun

SC must be addressed to the NRC’s satisfaction prior to plant restart. The NRC's Oct. 2, 2012 inspection report*** provided details on the problems identified by the Omaha Public Power District (OPPD) in the independent Fort Calhoun SC assessment, including management practices that resulted “. . . in a culture that valued harmony and loyalties over standards, accountability, and performance.”

Fort Calhoun's revision 4 of its improvement plan**** (the first revision issued since Exelon took over management of the plant in September, 2012) reiterates management's previous commitments to establishing a strong SC and, in a closely related area, notes that “The Corrective Action Program is already in place as the primary tool for problem identification and resolution. However, CAP was not fully effective as implemented. A new CAP process has been implemented and root cause analysis on topics such as Condition Report quality continue to create improvement actions.”

OPPD's progress report***** at a Nov. 15, 2012 public meeting with the NRC includes over two dozen specific items related to improving or monitoring SC. However, the NRC restart checklist SC items remain open and the agency will be performing an IP 95003 inspection of Fort Calhoun SC during January-February, 2013.^

Palisades

Palisades is running but still under NRC scrutiny, especially for SC. The Nov. 9, 2012 supplemental inspection report^^ is rife with mentions of SC but eventually says “The inspection team concluded the safety culture was adequate and improving.” However, the plant will be subject to additional inspection efforts in 2013 to “. . . ensure that you [Palisades] are implementing appropriate corrective actions to improve the organization and strengthen the safety culture on site, as well as assessing the sustainability of these actions.”

At an NRC-Entergy public meeting December 11, Entergy's presentation focused on two plant problems (DC bus incident and service water pump failure) and included references to SC as part of the plant's performance recovery plan. The NRC presentation described Palisades SC as “adequate” and “improving.”^^^

Other Plants

NRC supplemental inspections can require licensees to assess “whether any safety culture component caused or significantly contributed to” some performance issue. NRC inspection reports note the extent and adequacy of the licensee’s assessment, often performed as part of a root cause analysis. Plants that had such requirements laid on them or had SC contributions noted in inspection reports during the fourth quarter included Braidwood, North Anna, Perry, Pilgrim, and St. Lucie. Inspection reports that concluded there were no SC contributors to root causes included Kewaunee and Millstone.

Monticello got a shout-out for having a strong SC. On the other hand, the NRC fired a shot across the bow of Prairie Island when the NRC PI&R inspection report included an observation that “. . . while the safety culture was currently adequate, absent sustained long term improvement, workers may eventually lose confidence in the CAP and stop raising issues.”^^^^ In other words, CAP problems are linked to SC problems, a relationship we've been discussing for years.

The NRC perspective and our reaction

Chairman Macfarlane's speech to INPO mentioned SC: “Last, I would like to raise “safety culture” as a cross-cutting regulatory issue. . . . Strengthening and sustaining safety culture remains a top priority at the NRC. . . . Assurance of an effective safety culture must underlie every operational and regulatory consideration at nuclear facilities in the U.S. and worldwide.”^^^^^

The NRC claims it doesn't regulate SC but isn't “assurance” part of “regulation”? If NRC practices and procedures require licensees to take actions they might not take on their own, don't the NRC's activities pass the duck test (looks like a duck, etc.) and qualify as de facto regulation? To repeat what we've said elsewhere, we don't care if SC is regulated but the agency should do it officially, through the front door, and not by sneaking in the back door.

*  E.F. Guthrie (NRC) to J.W. Shea (TVA), “Browns Ferry Nuclear Plant NRC Supplemental Inspection Report 05000259/2012014, 05000260/2012014, 05000296/2012014” (Nov. 23, 2012) ADAMS ML12331A180.

**  E.F. Guthrie (NRC) to J.W. Shea (TVA), “Public Meeting Summary for Browns Ferry Nuclear Plant, Docket No. 50-259, 260, and 296” (Dec. 18, 2012) ADAMS ML12353A314.

***  M. Hay (NRC) to L.P. Cortopassi (OPPD), “Fort Calhoun - NRC Integrated Inspection Report Number 05000285/2012004” (Oct. 2, 2012) ADAMS ML12276A456.

****  T.W. Simpkin (OPPD) to NRC, “Fort Calhoun Station Integrated Performance Improvement Plan, Rev. 4” (Nov. 1, 2012) ADAMS ML12311A164.

*****  NRC, “Summary of November 15, 2012, Meeting with Omaha Public Power District” (Dec. 3, 2012) ADAMS ML12338A191.

^  M. Hay (NRC) to L.P. Cortopassi (OPPD), “Fort Calhoun Station – Notification of Inspection (NRC Inspection Report 05000285/2013008 ” (Dec. 28, 2012) ADAMS ML12363A175.

^^  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.

^^^  O.W. Gustafson (Entergy) to NRC, Entergy slides to be presented at the December 11, 2012 public meeting (Dec. 7, 2012) ADAMS ML12342A350. NRC slides for the same meeting ADAMS ML12338A107.

^^^^  K. Riemer (NRC) to J.P. Sorensen (NSP), “Prairie Island Nuclear Generating Plant, Units 1 and 2; NRC Biennial Problem Identification and Resolution Inspection Report 05000282/2012007; 05000306/2012007” (Sept. 25, 2012) ADAMS ML12269A253.

^^^^^  A.M. Macfarlane, “Focusing On The NRC Mission: Maintaining Our Commitment to Safety” speech presented at the INPO CEO Conference (Nov. 6, 2012) ADAMS ML12311A496.

NRC Non-Regulation of Safety Culture: Third Quarter Update

On March 17 we published a post on NRC safety culture (SC) related activities with individual licensees since the SC policy statement was issued in June, 2011.  On July 3, we published an update for second quarter 2012 activities.  This post highlights selected NRC actions during the third quarter, July through September 2012.

Our earlier posts mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking significant SC-related activities.  It looks like none of those plants has resolved its SC issues and, at the current rate of progress, I’m sure we’ll be reporting on all of them for quite awhile.

Browns Ferry

As we reported earlier, this plant’s SC problems have existed for years.  On August 23, TVA management submitted its Integrated Improvement Plan Summary* to address NRC inspection findings that have landed the plant in column 4 (next to worst) of the NRC’s Action Matrix.  TVA’s analysis of its SC and operational performance problems included an independent SC assessment.  TVA’s overall analysis identified fifteen “fundamental problems” and two bonus issues; for SC improvement efforts, the problems and issues were organized into five focus areas: Accountability, Operational Decision Making (Risk Management), Equipment Reliability, Fire Risk Reduction and the Corrective Action Program (CAP).

The NRC published its mid-cycle review of Browns Ferry on September 4.  In the area of SC, the report noted the NRC had “requested that [the Substantive Cross-Cutting Issue in the CAP] be addressed during your third party safety culture assessment which will be reviewed as part of the Independent NRC Safety Culture Assessment per IP 95003. . . .”**

Fort Calhoun

SC must be addressed to the NRC’s satisfaction prior to plant restart.   The Omaha Public Power District (OPPD) published its Integrated Performance Improvement Plan on July 9.***  The plan includes an independent safety culture assessment to be performed by an organization “that is nationally recognized for successful performance of behavior-anchored nuclear safety culture assessments.” (p. 163)  Subsequent action items will focus on communicating SC principles, assessment results, SC improvement processes and SC information.

The NRC and OPPD met on September 11, 2012 to discuss NRC issues and oversight activities, and OPPD’s performance improvement plan, ongoing work and CAP updates.  OPPD reported that a third-party SC assessment had been completed and corrective actions were being implemented.****

Palisades

The NRC continues to express its concerns over Palisades’ SC.  The best example is NRC’s August 30 letter***** requesting a laundry list of information related to Palisades’ independent SC assessment and management's reaction to same, including corrective actions, interim actions in place or planned to mitigate the effects of the SC weaknesses, compliance issues with NRC regulatory requirements or commitments, and the assessment of the SC at Entergy’s corporate offices. (p. 5)

The NRC held a public meeting with Palisades on September 12, 2012 to discuss the plant’s safety culture.  Plant management’s slides are available in ADAMS (ML12255A042).  We won’t review them in detail here but management's Safety Culture Action Plan includes the usual initiatives for addressing identified SC issues (including communication, training, CAP improvement and backlog reduction) and a new buzz phrase, Wildly Important Goals.

Other Plants

NRC supplemental inspections can require licensees to assess “whether any safety culture component caused or significantly contributed to” some performance issue.#  NRC inspection reports note the extent and adequacy of the licensee’s assessment, often performed as part of a root cause analysis.  Plants that had such requirements laid on them or had SC contributions noted in inspection reports during the third quarter included Brunswick, Hope Creek, Limerick, Perry, Salem, Waterford and Wolf Creek.

One other specific SC action arose from the NRC’s alternative dispute resolution (ADR) process at Entergy’s James A. FitzPatrick plant.  As part of an NRC Confirmatory Order following ADR, Entergy was told to add a commitment to maintain the SC monitoring processes at Entergy’s nine commercial nuclear power plants.##

The Bottom Line

None of this is a surprise.  Even the new Chairman tells it like it is: “In the United States, we have . . . incorporated a safety culture assessment into our oversight program . . . . “###  What is not a surprise is that particular statement was not included in the NRC’s press release publicizing the Chairman’s comments.  Isn’t “assessment” part of “regulation”?

Given the attention we pay to the issue of regulating SC, one may infer that we object to it.  We don’t.  What we object to is the back-door approach currently being used and the NRC’s continued application of the Big Lie technique to claim that they aren’t regulating SC.


*  P.D. Swafford (TVA) to NRC, “Integrated Improvement Plan Summary” (Aug. 23, 2012)  ADAMS ML12240A106.  TVA has referred to this plan in various presentations at NRC public and Commission meetings.

**  V.M. McCree (NRC) to J.W. Shea (TVA), “Mid Cycle Assessment Letter for Browns Ferry Nuclear Plant Units 1, 2, and 3” (Sept. 4, 2012)  ADAMS ML12248A296.

***  D.J. Bannister (OPPD) to NRC, “Fort Calhoun Station Integrated Performance Improvement Plan Rev. 3” (July 9, 2012)  ADAMS ML12192A204.

**** NRC, “09/11/2012 Meeting Summary of with Omaha Public Power District” (Sept. 25, 2012)  ADAMS ML12269A224.

*****  J.B. Giessner (NRC) to A. Vitale (Entergy), “Palisades Nuclear Plant – Notification of NRC Supplemental Inspection . . . and Request for Information” (Aug. 30, 2012)  ADAMS ML12243A409.

#  The scope of NRC Inspection Procedure 95001 includes “Review licensee’s evaluation of root and contributing causes. . . ,” which may include SC; IP 95002’s scope includes “Determine if safety culture components caused or significantly contributed to risk significant performance issues” and IP 95003’s scope includes “Evaluate the licensee’s third-party safety culture assessment and conduct a graded assessment of the licensee’s safety culture based on evaluation results.”  See IMC 2515 App B, "Supplemental Inspection Program" (Aug. 18, 2011)  ADAMS ML111870266.

##  M. Gray (NRC) to M.J. Colomb (Entergy), “James A. FitzPatrick Nuclear Power Plant - NRC Integrated Inspection Report 05000333/2012003” (Aug. 7, 2012)  ADAMS ML12220A278.

###  A.M. Macfarlane, “Assessing Progress in Worldwide Nuclear Safety,” remarks to International Nuclear Safety Group Forum, IAEA, Vienna, Austria (Sept. 17, 2012), p. 3 ADAMS ML12261A373; NRC Press Release No. 12-102, “NRC Chairman Says Safety Culture Critical to Improving Safety; Notes Fukushima Progress in United States” (Sept. 17, 2012) ADAMS ML12261A391.

NRC Non-Regulation of Safety Culture: Second Quarter Update

NRC SC poster, ADAMS ML120810464.

On March 17th we published a post on NRC safety culture (SC) related activities with individual licensees since the SC policy statement was issued in June, 2011.  This post is an update, highlighting selected NRC actions from mid-March through June. 

Our earlier post mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking SC related activities.  It looks like none of those plants has resolved its SC issues. 

For Browns Ferry we reported that the NRC was reviewing the plant’s 2011 SC surveys.  Turns out that was just the tip of the iceberg.  A recent PI&R inspection report indicates that the plant’s SC problems have existed for years and are deep-rooted.  Over time, Browns Ferry has reported SC issues including production and schedule taking priority over safety (2008), “struggling” with SC issues (2010) and a decline in SC (2011).  All of this occurred in spite of multiple licensee interventions and corrective actions.  The NRC’s current view is “Despite efforts to address SC issues at the site, the inspectors concluded that the lack of full confidence in the CAP has contributed to a decline in the SC since the last PI&R inspection.”*  We don’t expect this one to go away anytime soon.

Fort Calhoun management had said that SC deficiencies had contributed to problems in their CAP.  During the quarter, they presented actions planned or taken to remediate their SC deficiencies.  On June 11th, the NRC issued a Confirmatory Action Letter with a lengthy list of actions to be completed prior to plant restart.  One item is “OPPD will conduct a third-party safety culture assessment . . . and implement actions to address the results . . . .”**  It looks like Fort Calhoun is making acceptable progress on the SC front and we’d be surprised if SC ends up being an item that prevents restart.  Last April we provided some additional information on Fort Calhoun here.

In Palisades’ case, the NRC is asking for an extensive set of information on the actions being taken to improve SC at the site.  The last item on the long list requests the latest SC assessment for Entergy’s corporate office.  (This is not simply a fishing expedition.  Entergy is in trouble at other nuclear sites for problems that also appear related to SC deficiencies.)  After the information is provided and reviewed, the NRC “believe[s] that a public meeting on the safety culture assessment and your subsequent actions would be beneficial to ensure a full understanding by the NRC, your staff, and the public.”***  Back in January, we provided our perspective on Palisades here and here.

New NRC SC activity occurred at Susquehanna as part of a supplemental inspection related to a White finding and a White performance indicator.  The NRC conducted an “assessment of whether any safety culture component caused or significantly contributed to the white finding and PI.”  The assessment was triggered by PPL’s report that SC issues may have contributed to the plant’s performance problems.  The NRC inspectors reviewed documents and interviewed focus groups, individual managers and groups involved in plant assessments.  They concluded “components of safety culture identified by PPL did not contribute to the White PI or finding, and that the recently implemented corrective actions appear to being well received by the work force.”****  We report this item because it illustrates the NRC’s willingness and ability to conduct its own SC assessments where the agency believes they are warranted.

Our March post concluded: “It’s pretty clear the NRC is turning the screw on licensee safety culture effectiveness, even if it’s not officially “regulating” safety culture.”  That still appears to be the case.


*  V.M. McCree (NRC) to J.W. Shea (TVA), Browns Ferry Nuclear Plant - NRC Problem Identification and Resolution Inspection Report 05000259/2012007, 05000260/2012007 and 05000296/2012007 and Exercise of Enforcement Discretion (May 28, 2012) ADAMS ML12150A219.

**  E.E. Collins (NRC) to D.J. Bannister (OPPD), Confirmatory Action Letter – Fort Calhoun Station (June 11, 2012)  ADAMS ML12163A287.

***  G.L. Shear (NRC) to A. Vitale (Entergy), Request for Information on SC Issues at Palisades Nuclear Plant (June 26, 2012) ADAMS ML12179A155.

**** D.J. Roberts (NRC) to T.S. Rausch (PPL Susquehanna), Susquehanna Steam Electric Station – Assessment Follow-Up Letter and Interim NRC 95002 Supplemental Inspection Report 05000387/2012008 (May 7, 2012) ADAMS ML12125A374.

The NRC Does Not Regulate Safety Culture, Right?

Last March, the NRC approved its safety culture policy statement.*  At the time, a majority of commissioners issued supplemental comments expressing their concern that the policy statement could be used as a back door to regulation.  The policy was issued in June, 2011.  Enough time has lapsed to ask: What, if anything has happened, i.e., how is the NRC treating safety culture as it exercises its authority to regulate licensees?

We examined selected NRC documents for some plants where safety culture has been raised as a possible issue and see a few themes emerging.  One is the requirement to examine the causes of specific incidents to ascertain if safety culture was a contributing factor.  It appears some (perhaps most or all) special inspection notices to licensees include some language about "an assessment of whether any safety culture component caused or significantly contributed to these findings."  

The obvious push is to get the licensee to do the work and explicitly address safety culture in their mea culpa to the agency.  Then the agency can say, for example, that "The inspection team confirmed that the licensee established appropriate corrective actions to address safety culture."**  A variant on this theme is now occurring at Browns Ferry, where the “NRC is reviewing results from safety culture surveys performed by the plant in 2011.”*** 

The NRC is also showing the stick, at least at one plant.  At Fort Calhoun, the marching orders are: “Assess the licensee’s third party evaluation of their safety culture. . . . If necessary, perform an independent assessment of the licensee’s safety culture using the guidance contained in Inspection Procedure 95003."****  I think that means: If you can't/won't/don't perform an adequate safety culture evaluation, then we will.  To back up this threat, it appears the NRC is developing procedures and materials for qualifying its inspectors to evaluate safety culture.

The Alternative Dispute Resolution (ADR) process is another way to get safety culture addressed.  For example, Entergy got in 10 CFR 50.7 (employee protection) trouble for lowering a River Bend employee’s rating in part because of questions he raised.  One of Entergy's commitments following ADR was to perform a site-wide safety culture survey.  It probably didn’t help that, in a separate incident, River Bend operators were found accessing the internet when they were supposed to be watching the control board.  Entergy also has to look at safety culture at FitzPatrick and Palisades because of incidents at those locations.***** 

What does the recent experience imply?

The NRC’s current perspective on safety culture is summed up in an NRC project manager’s post in an internet Nuclear Safety Culture forum: “You seem to [sic] hung up on how NRC is going to enforce safety culture.  We aren't.  Safety culture isn't required. It won't be the basis for denying a license application.  It won't be the basis for citing a violation during an inspection.  However, if an incident investigation identifies safety culture as one of the root causes, we will require corrective action to address it.”  (Note this is NOT an official agency statement.)

However, our Bob Cudlin made a more expansive prediction in his January 19, 2011 post: “. . . it appears that the NRC will “expect” licensees to meet the intent and the particulars of its policy statement.  It seems safe to assume the NRC staff will apply the policy in its assessments of licensee performance. . . . The greatest difficulty is to square the rhetoric of NRC Commissioners and staff regarding the absolute importance of safety culture to safety, the “nothing else matters” perspective, with the inherently limited and non-binding nature of a policy statement.”

While the record to date may support the NRC PM’s view, I think Bob’s observations are also part of the mix.  It’s pretty clear the NRC is turning the screw on licensee safety culture effectiveness, even if it’s not officially “regulating” safety culture.


*  NRC Commission Voting Record, SECY-11-005, “Proposed Final Safety Culture Policy Statement” (March 7, 2011).  I could not locate this document in ADAMS.

**  IR 05000482-11-006, 02/07-03/31/2011, Wolf Creek Generating Station - NRC Inspection Procedure 95002 Supplemental Inspection Report and Assessment Followup Letter (May 20, 2011) ADAMS ML111400351. 

***  Public Meeting Summary for Browns Ferry Nuclear Plant, Docket No. 50-259 (Feb. 26, 2012) ADAMS ML12037A092.

****  Fort Calhoun Station Manual Chapter 0350 Oversight Panel Charter (Jan. 12, 2012) ADAMS ML120120661.

*****  EN-11-026, Confirmatory Order, Entergy Operations Inc.  (Aug. 19, 2011)  ADAMS ML11227A133; NRC Press Release-I-12-002: “NRC Confirms Actions to be Taken at FitzPatrick Nuclear Plant to Address Violations Involving Radiation Protection Program” (Jan. 26, 2012) ADAMS ML120270073; NRC Press Release-III-12-003: “NRC Issues Confirmatory Orders to Palisades Plant Owner Entergy and Plant Operator” (Jan. 26, 2012) ADAMS ML120270071.

A Factory for Producing Decisions

The subject of this post is the compelling insights of Daniel Kahneman into issues of behavioral economics and how we think and make decisions.  Kahneman is one of the most influential thinkers of our time and a Nobel laureate.  Two links are provided for our readers who would like additional information.  One is via the McKinsey Quarterly, a video interview* done several years ago.  It runs about 17 minutes.  The second is a current review in The Atlantic** of Kahneman’s just released book, Thinking Fast and Slow.

Kahneman begins the McKinsey interview by suggesting that we think of organizations as “factories for producing decisions” and therefore, think of decisions as a product.  This seems to make a lot of sense when applied to nuclear operating organizations - they are the veritable “River Rouge” of decision factories.  What may be unusual for nuclear organizations is the large percentage of decisions that directly or indirectly include safety dimensions, dimensions that can be uncertain and/or significantly judgmental, and which often conflict with other business goals.  So nuclear organizations have to deliver two products: competitively priced megawatts and decisions that preserve adequate safety.

To Kahneman decisions as product logically raises the issue of quality control as a means to ensure the quality of decisions.  At one level quality control might focus on mistakes and ensuring that decisions avoid recurrence of mistakes.  But Kahneman sees the quality function going further into the psychology of the decision process to ensure, e.g., that the best information is available to decision makers, that the talents of the group surrounding the ultimate decision maker are being used effectively, and the presence of an unbiased decision-making environment.

He notes that there is an enormous amount of resistance within organizations to improving decision processes. People naturally feel threatened if their decisions are questioned or second guessed.  So it may be very difficult or even impossible to improve the quality of decisions if the leadership is threatened too much.  But, are there ways to avoid this?  Kahneman suggests the “premortem” (think of it as the analog to a post mortem).  When a decision is being formulated (not yet made), convene a group meeting with the following premise: It is a year from now, we have implemented the decision under consideration, it has been a complete disaster.  Have each individual write down “what happened?”

The objective of the premortem is to legitimize dissent and minimize the innate “bias toward optimism” in decision analysis.  It is based on the observation that as organizations converge toward a decision, dissent becomes progressively more difficult and costly and people who warn or dissent can be viewed as disloyal.  The premortem essentially sets up a competitive situation to see who can come up with the flaw in the plan.  In essence everyone takes on the role of dissenter.  Kahneman’s belief is that the process will yield some new insights - that may not change the decision but will lead to adjustments to make the decision more robust. 

Kahneman’s ideas about decisions resonate with our thinking that the most useful focus for nuclear safety culture is the quality of organizational decisions.  It also contrasts with a recent instance of a nuclear plant run afoul of the NRC (Browns Ferry) and now tagged with a degraded cornerstone and increased inspections.  As usual in the nuclear industry, TVA has called on an outside contractor to come in and perform a safety culture survey, to “... find out if people feel empowered to raise safety concerns….”***  It may be interesting to see how people feel, but we believe it would be far more powerful and useful to analyze a significant sample of recent organizational decisions to determine if the decisions reflect an appropriate level of concern for safety.  Feelings (perceptions) are not a substitute for what is actually occurring in the decision process. 

We have been working to develop ways to grade whether decisions support strong safety culture, including offering opportunities on this blog for readers to “score” actual plant decisions.  In addition we have highlighted the work of Constance Perin including her book, Shouldering Risks, which reveals the value of dissecting decision mechanics.  Perin’s observations about group and individual status and credibility and their implications for dissent and information sharing directly parallel Kahneman’s focus on the need to legitimize dissent.  We hope some of this thinking ultimately overcomes the current bias in nuclear organizations to reflexively turn to surveys and the inevitable retraining in safety culture principles.

*  "Daniel Kahneman on behavioral economics," McKinsey Quarterly video interview (May 2008).

** M. Popova, "The Anti-Gladwell: Kahneman's New Way to Think About Thinking," The Atlantic website (Nov. 1, 2011).

*** A. Smith, "Nuke plant inspections proceeding as planned," Athens [Ala.] News Courier website (Nov. 2, 2011).