Nuclear Safety Culture Under Assault: DNFSB Chairman Proposes Eliminating the Board

DNFSB headquarters

The Center for Public Integrity (CPI) recently published a report* that disclosed a private letter** from Sean Sullivan, the Chairman of the Defense Nuclear Facilities Safety Board (DNFSB) to the Director of the Office of Management and Budget in which the chairman proposed abolishing or downsizing the DNFSB.  The CPI is highly critical of the chairman’s proposals; support for their position includes a list of the safety improvements in the Department of Energy (DOE) complex that have resulted from DNFSB recommendations and the safety challenges that DOE facilities continue to face.

The CPI also cites a 2014 National Nuclear Security Administration (NNSA, the DOE sub-organization that oversees the nuclear weapons facilities) internal report that describes NNSA’s own safety culture weaknesses, e.g., lack of a questioning attitude toward contractor management’s performance claims, with respect to its oversight of the Los Alamos National Laboratory.

The CPI believes the chairman is responding to pressure from the private contractors who actually manage DOE facilities to reduce outside interference in, and oversight of, contractor activities.  That’s certainly plausible.  The contractors get paid regardless of their level of performance, and very little of that pay is tied to safety performance.  DNFSB recommendations and reports can be thorns in the sides of contractor management.

The Sullivan Letter

The primary proposal in the Sullivan letter is to abolish the DNFSB because the DOE has developed its own “robust regulatory structure” and oversight capabilities via the Office of Enterprise Assessments.  That’s a hollow rationale; the CPI report discusses the insufficiency of DOE’s own assessments.  If outright elimination is not politically doable then DNFSB personnel could be transferred to DOE, sustaining the appearance of independent oversight, and then be slowly absorbed into the larger DOE organization.  That is not a path to increased public confidence and looks like being assimilated by the Borg.***  The savings that could be realized from abolishing the DNFSB is estimated at $31 million, a number lost in the decimal dust of DOE’s $30+ billion budget.

Sullivan mentions but opposes transferring the DNFSB’s oversight responsibilities to the Nuclear Regulatory Commission.  Why?  Because the NRC is not only independent, it has enforcement powers which would be inappropriate for defense nuclear facilities and might compromise national security.  That’s a red herring but we’ll let it go; we don’t think oversight of defense facilities really meshes with the NRC’s mission.

His secondary proposal is to downsize the DNFSB workforce, especially its management structure, and transfer most of the survivors to specific defense facilities.  While we think DNFSB needs more resources, not fewer, it would be better if more DNFSB personnel were located in the field, keeping track of and reporting on DOE and contractor activities.

Our Perspective

Safetymatters first became interested in the DNFSB when we saw the growing mess at the Waste Treatment Plant (WTP, aka the Vit Plant) in Hanford, WA.  It was the DNFSB who forced the DOE and its WTP contractors to confront and remediate serious nuclear safety culture (NSC) problems.  We have published multiple reports on the resultant foot-dragging by DOE in its responses to DNFSB Recommendation 2011-1 which addressed safety conscious work environment (SCWE) problems at Hanford and other DOE facilities.  Click on the DOE label to see our offerings on WTP, other DOE facilities and the overall DOE complex.
 
We have reported on the NSC problems at the Waste Isolation Pilot Plant (WIPP) in New Mexico.  The DNFSB has played an important role in attempting to get DOE and the WIPP contractor to strengthen their safety practices.  Click the WIPP label to see our WIPP-related posts. 

We have also covered a report on the DNFSB’s own organizational issues, including board members’ meddling in day-to-day activities, weak leadership and too-frequent organizational changes.  See our Feb. 6, 2015 post for details.

DNFSB’s internal issues notwithstanding, the board plays an indispensible role in strengthening NSC and safety practices throughout the DOE complex.  They should be given greater authority (which won’t happen), stronger leadership and additional resources.

Bottom line: Sullivan’s proposal is just plain nuts.  He’s a Republican appointee so maybe he’s simply offering homage to his ultimate overlord.
  

*  P. Malone and R.J. Smith, “GOP chair of nuclear safety agency secretly urges Trump to abolish it,” The Center for Public Integrity (Oct. 19, 2017).  Retrieved Oct. 26, 2017.

**  S. Sullivan (DNFSB) to J.M Mulvaney (Management and Budget), no subject specified but described as an “initial high-level draft of [an] Agency Reform Plan” (June 29, 2019).  Available from the CPI in html and pdf format.  Retrieved Oct. 26, 2017.

***  The Borg is an alien group entity in Star Trek that forcibly assimilates other beings.  See Wikipedia for more information.

Nuclear Safety Culture at the Department of Energy—An Update

We haven’t reported on the U.S. Department of Energy’s (DOE) safety culture (SC) in awhile.  Although there hasn’t been any big news lately, we can look at some individual facts and then connect the dots to say something about SC.

Let’s start with some high-level good news.  In late 2016 DOE announced it had conducted its 100th SC training class for senior leaders of both federal and contractor entities across the DOE complex.*  The class focuses on teaching leaders the why and how of maintaining a collaborative workplace and Safety Conscious Work Environment (SCWE), and fostering trust in the work environment. 

Now let’s turn to a more localized situation.  In Feb 2014, a storage drum burst at the DOE’s Waste Isolation Pilot Plant (WIPP) in New Mexico, resulting in a small release of radioactive material.  The drum burst because a sorbent added to the waste had been changed without considering the difference in chemical properties.**  This has been an expensive incident.  The plant has been closed for over three years; it was authorized to reopen in Jan 2017 and shipments are scheduled to resume in April 2017.*** 

The drum that burst came from the Los Alamos National Laboratory (LANL).  The WIPP Recovery Plan envisions continuing the pre-incident practice of the waste generators being responsible for correctly packing their waste: “All waste generators will have rigorous characterization, treatment, and packaging processes and procedures in place to ensure compliance with WIPP Waste Acceptance Criteria [WAC].”****  As we said in our May 3, 2016 post: “For this approach to work, WAC compliance by the waste generators . . . must be completely effective and 100% reliable.”  In the same post, we reported the Defense Nuclear Facilities Safety Board (DNFSB) had recognized this weak link in the chain.  However, because DNFSB cannot force changes it could only recommend that DOE “explore defense-in-depth measures that enhance WIPP’s capability to detect and respond to problems caused by unexpected failures in the WAC compliance program.”

As described in the current WAC, WIPP’s “defense-in-depth” appears to be limited to the local DOE office and the WIPP contractor performing Generator Site Technical Reviews, which cover sites’ implementation of WIPP requirements.*****  These reviews are supposed to assure that deficiencies are detected and noncompliant shipments are avoided but it’s not clear if any physical surveillance is involved or if this is strictly a paperwork exercise.

The foregoing is important because it ties to SC.  Firstly, WIPP has had SC issues, in fact, a deficient SC was identified as contributing to shortcomings in the handling of the aftermath of the drum explosion.  (We reviewed this in detail on May 3 and May 5, 2014.)  WIPP SC is supposedly better now: “NWP [the WIPP contractor] has made continuous improvements in their safety culture and has really embraced the recommendations provided in the 2015 review, as well as subsequent reviews and surveys.”^  Secondly, other SC problems, too myriad to even list here, have arisen throughout the DOE complex over the years.  (Click on the DOE label to see our reports on such problems.)

Finally, we present a recent data point for LANL.  In DOE’s report on criticality safety infractions and program non-compliances for FY 2016, LANL had the most such incidents, by far, of the DOE’s 24 sites and projects.^^  Most of the non-compliances were self-identified.  Now does this evidence a strong SC that recognizes and reports its problems or a weak SC that allows the problems to occur in the first place?  You be the judge.

Our Perspective

Through initiatives such as SC training, it appears that at the macro level, DOE is (finally) communicating that minimally complying with basic regulations for how organizations should treat employees is not enough; establishing trust, mainly through showing respect for employees’ efforts to raise safety questions and point out safety problems, is essential.  That’s a good thing.

But we see signs of weakness at the operational level, viz., between WIPP and its constellation of waste generators.  Although we are not fans of “Normal Accident” theory which says accidents are inevitable in tightly coupled, low slack environments, e.g., a nuclear power plant, we can appreciate the application of that mental model in the case of WIPP.  Historically, one feature of the DOE complex that has limited problems to specific locations is the weak coupling between facilities.  When every facility with bomb-making waste is shipping it to WIPP, tighter coupling is created in the overall waste management system.  Every waste generator’s SC can have an impact on WIPP’s safety performance.  The system does need more defense-in-depth.  At a minimum, WIPP should station resident inspectors at every waste generator site to verify compliance with the WAC.

Bottom line: DOE is trying harder in the SC space but their history does not inspire huge confidence going forward. 


*  “DOE Conducts 100th Safety Culture Training Class” (Dec. 29, 2016).

**  Organic kitty litter had been substituted for inorganic kitty litter.  See this Jan. 10, 2017 Forbes article for a good summary of the WIPP incident.

***  “WIPP Road Show Early Stops Planned in Carlsbad & Hobbs,” WIPP website (Feb. 27, 2017).  Retrieved March 7, 2017. 

****  DOE, “Waste Isolation Pilot Plant Recovery Plan,” Rev 0 (Sept. 30, 2014), p. 24.

*****  DOE, “Transuranic Waste Acceptance Criteria for the Waste Isolation Pilot Plant,” Rev 8.0 (July 5, 2016), pp. 20-21.

^  DOE, “Department of Energy Operational Readiness Review for the Waste Isolation Pilot Plant” (Dec. 2016), p. 33.

^^   DOE, “2016 Annual Metrics Report to the Defense Nuclear Facilities Safety Board – Nuclear Criticality Safety Programs” (Jan. 2017), p. 3.

Nuclear Safety Culture is Improving at the Waste Isolation Pilot Plant—Maybe

The WIPP

On Feb. 14, 2014, a drum containing radioactive waste exploded at the Department of Energy (DOE) Waste Isolation Pilot Plant (WIPP) resulting in the release of americium and plutonium into the environment.  In our May 3, 2014 review of the DOE’s phase 1 accident report, a weak safety culture (SC) was deemed a significant contributing factor to the incident.  The plant has yet to resume normal operations.

Over the last two years, DOE and Nuclear Waste Partnership (NWP, the prime contractor) have made efforts to strengthen the SC at the WIPP.  Following are two data points we can use to infer how much progress they’ve made.

Incentive Payment to NWP

In FY2015 NWP earned a performance fee* based on both objective and subjective criteria.  Overall, NWP received 85.7% of the total potential fee ($11,714K out of $13,665K.)
 
The objective portion comprised 75% of the total potential fee and NWP was awarded 89.7% of that amount ($9,194K).  Only one objective criterion appears related to SC, viz., “reducing preventive and corrective maintenance backlogs” and NWP received the full fee possible, $550K out of $550K.

The subjective portion comprised 25% of the total potential fee and NWP was awarded 73.7% of that amount ($2,520K).  There is more information about SC in this portion of the award fee determination document.  DOE said NWP’s performance on improving its safety programs reflected “a maturing nuclear safety culture with continuous improvements.”  However, there were signs of SC weakness in the Areas for Improvement including “The contractor did not provide sufficient objective evidence of closure of all of the corrective actions it submitted as complete in FY2015”; “The small number of self-assessments by the contractor in FY2015 was inadequate to measure performance” and “Recent improvements in the nuclear safety culture are slowly being realized in the safe execution of work . . .”

DNFSB Critique of WIPP's Upgraded Documented Safety Analysis 

A recent Defense Nuclear Facilities Safety Board (DNFSB) staff report** reviews the WIPP Documented Safety Analysis (DSA) currently being updated by NWP under the oversight of DOE.  The DNFSB report identifies one significant issue for DOE management attention, summarized below:

The Feb. 2014 explosion occurred because Los Alamos National Laboratory (LANL) shipped ignitable waste to WIPP even though the existing Waste Acceptance Criteria (WAC) prohibited such action.  Currently, other LANL-generated drums containing potentially ignitable waste are securely stored at WIPP.

The draft DSA does not analyze the possibility that some similar accident could occur involving a container arriving at WIPP in the future.  Instead, DOE and NWP argue that improvements to the WIPP WAC and/or WAC compliance program will reliably prevent problems in future waste receipts.  In other words, something that happened before will not happen again because WIPP will be watching for it.  For this approach to work, WAC compliance by the waste generators and WIPP inspectors must be completely effective and 100% reliable.  DNFSB recommends that DOE and NWP management “explore defense-in-depth measures that enhance WIPP’s capability to detect and respond to problems caused by unexpected failures in the WAC compliance program.”

Our Perspective

The performance fee awards indicate that NWP needs to keep working to strengthen its SC to an acceptable level.

The DSA issue is more troublesome.  What kind of effective SC would blow off (pun intended) its responsibility to consider the possibility of recurrence of exactly the kind of problem that occurred before and caused the WIPP to be shut down for over two years?  We criticize other organizations for over-analyzing the specifics of individual accidents while ignoring other possibilities, especially systemic issues, but in this case, NWP and DOE are not even reaching the lowest perceptible bar of repeat incident prevention.

We’ll give the DNFSB points for raising the DSA issue but take away some points because they didn’t make a straightforward recommendation that NWP and DOE complete a more thorough analysis of the specific hazard of another drum of prohibited waste slipping through the system and into the underground.

At best, we can say the SC at the WIPP is incrementally improved.  DOE has always taken a half-hearted approach to SC and their lack of commitment is visible here.


*  T. Shrader (DOE) to P. Breidenbach (NWP), "Contract DE-EM0001971 Nuclear Waste Partnership LLC - Award Fee Determination for the Period October 1, 2014 through September 30, 2015, and FY2015 Fee Determination Scorecard for Total Earned Award Fee and Performance Based Incentives" (April 12, 2016).

**  J.L. Connery (DNFSB) to E.J. Moniz (DOE), letter with DNFSB Staff Issue Report “Waste Isolation Pilot Plant Documented Safety Analysis” dated Jan. 13, 2016 attached (Mar. 28, 2016).

NRC IG Reviews DNFSB Organizational Culture and Climate

The Nuclear Regulatory Commission Inspector General (IG) provides IG services to the Defense Nuclear Facilities Safety Board (DNFSB), an independent government agency.  The DNFSB organizational culture and climate study* reviewed here was performed for the NRC IG by an outside consultant.

Summary of Methods and Results

The study’s methodology is familiar: Review relevant past reports, develop a survey instrument based on employee interviews and focus groups, administer the survey to all employees and interpret the results.

Themes (issues, shortcomings) brought up during the interviews included DNFSB’s handling of change management, communication, personnel development, leadership, internal procedures and performance management (aka personal recognition). (pp. 6-7)

The report compared the DNFSB survey results with three external norms: a cross-section of U.S. industry, U.S. employees working in Research and Development, and industries that have experienced significant changes with widespread employee impact.  The last group consists of organizations under stress because of reorganization, bankruptcy, layoffs, etc. (p. 14)

The report’s summary is not encouraging: “the general trend shows an unfavorable comparison for the DNFSB on all three external benchmarks, . . . Also, many employees feel they do not have the right tools and resources.  Along with that, 38 percent of employees say they plan to leave DNFSB in the next year.” (p. 4)

The employee survey had 14 categories, higher scores mean greater respondent agreement with positive traits.  Analyzing the survey responses in three different dimensions yielded one typical and two unusual results.  In our opinion, they suggest uneven DNFSB management effectiveness across the organization.

Across organizational groups, the General Manager and Admin/ Support groups scored above DNFSB averages on most categories; the Technical Director and Engineering groups scored below DNFSB averages on most categories. (p. 13)  In our experience, this is no surprise; bosses and admin people are usually more satisfied (or less dissatisfied) than the folks who have to get the work done.

Looking at employee tenure, employees with the shortest tenure scored the highest (this is typical) then the scores go downhill.  The longest tenured employees have the lowest scores, which is unusual; most organizations have a U-shaped curve, with newcomers and old timers the most satisfied. (p. 14)

By pay (GS or DN) level, “what is atypical is that the lowest-scoring group is not the lowest-level group, but instead the mid-level group, . . .” (p. 15)

The report identifies Sustainable Engagement (SE)** as a key category.  Using regression analysis, the authors identified five drivers (other survey categories) of SE, two that had acceptable survey scores and three that are candidates for organizational improvement interventions: communication, leadership and performance management. (p.17)  This is as close the report comes to suggesting what the DNFSB might actually do about their problems.

Our Perspective 

This report recognizes that DNFSB has significant challenges but it contains zero surprises.  It’s not even news.  The same or similar ground was covered by a Dec. 2014 organizational study performed for the DNFSB which we reviewed on Feb. 6, 2015.

Problems mentioned in the 2014 report include board dysfunctionality, communications, performance recognition, change management, frequent disruptive organizational changes, and the lack of management and leadership competence.  The 2014 report  included extensive discussion of possible organizational interventions and other corrective actions.

The NRC IG already knew change management was a serious challenge facing the DNFSB; it was mentioned in an Oct. 2014 IG report.***  That report was likely the impetus for this 2015 study.

The DNFSB has been in apparent disarray for over a year.  New members have been appointed to the Board this year, including a new chairman.  It remains to be seen whether they can address the internal challenges and, more importantly, provide meaningful recommendations to their single client, the U.S. Department of Defense.

Bottom line: This NRC IG consultant’s report adds little value to understanding the DNFSB’s organizational issues or developing effective corrective actions. 


*  Towers Watson, “DNFSB 2015 Culture and Climate Survey: Executive Overview of Key Findings” (Aug. 2015).  ADAMS ML15245A515.  Thanks to John Hockert for publicizing this report on the LinkedIn Nuclear Safety Culture forum.

**  Sustainable Engagement is defined as follows: “Assesses the level of DNFSB employees’ connection to the organization, marked by being proud to work at DNFSB, committing effort to achieve the goals (being engaged) having an environment that support productivity (being enabled) and maintaining personal well-being (feeling energized).” (p. 9)

**  H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.

DNFSB Hearing on Safety Culture Progress at the Waste Treatment and Immobilization Plant (WTP)

The WTP aka the Vit Plant

On August 26, 2015 the Defense Nuclear Facilities Safety Board (DNFSB) held a hearing in the Hanford area to receive testimony from senior DOE officials representing DOE Headquarters, the Office of River Protection (ORP) and the WTP project regarding the current status of DOE efforts to improve safety culture (SC) at the WTP.  A senior DNFSB staff member also testified on DOE’s SC improvement efforts.

There is a video of the meeting but no transcript is yet available.* 

The panel of DOE managers enumerated the work that has been undertaken to improve SC at the WTP.**  Based on their written submittals, it is predictable and not especially interesting material.  Selected excerpts follow:

G. Podonsky (DOE HQ) – “. . . positive turn in the safety culture.  However, much work remains . . . . As our assessments of safety culture indicate, management often has a more positive outlook on the state of the safety culture than do the workers.”

K. Smith (ORP Mgr) – This is mostly a laundry list of actions, initiatives and putative progress.  “. . . ORP’s safety culture today . . .  is improving and headed in the right direction. . . . But there are areas that still need work . . .”

W.F. Hamel Jr. (Federal Project Director WTP) – This focuses on more specific, project-level actions.  “We believe we have made significant strides. . . . sustaining a healthy safety culture requires persistence and consistency at all levels of the organization . . .”  He gave a shout out to Bechtel for progress in improving their SC and the Safety Conscious Work Environment (SCWE).

After the panel completed their presentation, the DNFSB staff member responsible for overseeing WTP (and other DOE) SC efforts had ten minutes to provide the staff perspective on DOE’s efforts.  He summarized the SC assessments that have taken place at the WTP and other facilities in the DOE complex.***  His testimony had more “howevers” than a Consumer Reports review of a mediocre automobile.  For example, DOE’s original plan was developed prior to the 2012 SC assessment and did not include the latter’s findings.  DOE modified their plan for Hanford but it was not applied to other DOE facilities.  The DOE themes did not address the root causes the DNFSB identified in their 2011 Recommendation.  He was also critical of the DOE’s extent of condition review.

He was asked one question by the meeting chair: “Is the bad (i.e., not supportive of SC) management behavior identified in 2011 still occurring?”  The answer was “It’s mixed. Some yes and some no.”  The chair was clearly not happy with that answer after four years of effort.

Our Perspective

The DOE bureaucrats identified a passel of SC-related improvement activities and claim progress is being made but there is still work to accomplish.  The testimony of the DNFSB staffer was less optimistic.  A statement contributed for the record by an anonymous “concerned engineer” includes examples that look like they came straight from the bad old days.****  We have reviewed most the DOE/WTP assessments, action plans and progress reviews on Safetymatters; click on the DOE or WTP label to see related posts.  Call us harsh, but we don’t believe there will be any substantive changes in the way business is conducted at Hanford until the bad stuff starts leaching into the Columbia River.

On a slightly brighter note, the DNFSB is back to full strength with five members, including a new chairman.  From looking at the press releases, it appears they have added folks with federal/military backgrounds and middling technical exposure.  The new chair is a career technical functionary whose last stint was at the White House.  It’s hard to get All-Stars for a toothless agency.  What they can contribute to oversight of DOE remains to be seen.  We wish them well.


*  The video is here.  Testimony and statements are available here but most are scanned copies which means quotes have to be retyped and may not totally accurate.  For an overview of the meeting see A. Cary, "National board hears safety culture is improving at Hanford vit plant," Tri-City Herald (Aug. 26, 2015).

**  Statement for the Record and Additional Information of G. Podonsky, Office of Enterprise Assessments (Aug. 26, 2015).  Testimony of K. Smith, Manager, Office of River Protection (Aug. 26, 2015).  Testimony of W.F. Hamel Jr., Federal Project Director, Waste Treatment and Immobilization Plant (Aug. 26, 2015).

***  Testimony of D.B. Bullen, Group Lead, Nuclear Programs and Analysis, DNFSB.  The question and answer are not verbatim but paraphrased from the exchange between Bullen and the chair that occurs from about 1:52 to 1:55 in the video.

****  Statement from concerned engineer (Aug. 26, 2015).

New Safety Culture Assessment at the Hanford Waste Treatment Plant

Hanford WTP

The Department of Energy (DOE) recently released the latest safety culture (SC) assessment report* for the Hanford Waste Treatment Plant (WTP or “vit plant”) project.  The 2015 report follows similar SC assessments conducted in 2011 and 2014, all of which were inspired by the Defense Nuclear Facilities Safety Board’s scathing 2011 report on SC at the WTP.  This post provides a brief overview of the report’s findings then focuses on the critical success factors for a healthy SC.

Assessment Overview

The 2011, 2014 and 2015 assessments used the same methodology, with multiple data collection methods, including interviews, Behavioral Anchored Rating Scales (BARS)** and a SC survey.  Following are selected highlights from the 2015 report.

DOE’s Office of River Protection (ORP) has management responsibility for the WTP project.  In general, ORP personnel feel more positive about the organization’s SC than they did during the 2014 assessment.  Feelings of confusion about ORP’s more collaborative relationship with Bechtel (the prime contractor) have lessened.  ORP management is perceived to be more open to constructive criticism.  Concerns remain with lack of transparency, trust issues and the effectiveness of the problem resolution process.

Bechtel personnel were more positive than in either previous SC assessment.  Bechtel has undertaken many SC-related initiatives including the promotion of a shared mental model of the project by senior Bechtel managers.  In 2014, Bechtel Corporate’s role in project decision making was perceived to skew against SC concerns.  The creation of a new Bechtel nuclear business unit has highlighted the special needs of nuclear work. (pp. 2, 39)  On the negative side, craft workers remain somewhat suspicious and wary of soft retributions, e.g., being blamed for their own industrial mishaps or having their promotion or layoff chances affected by reporting safety issues.

See this newspaper article*** for additional details on the report’s findings. 

Critical Success Factors for a Healthy SC

We always look at the following areas for evidence of SC strength or weakness: management’s decision making process, recognition and handling of goal conflicts, the corrective action program and financial incentives.

Decision Making

Both ORP and Bechtel interviewees complained of a lack of basis or rationale for different types of decisions. (pp. 9, 16)  Some ORP and Bechtel interviewees did note that efforts to clarify decision making are in process. (pp. 13, 32)  Although the need to explain the basis for decisions was recognized, there was no discussion of the decision making process itself.  This is especially disappointing because decision making is one of the possible behaviors that can be included in a BARS analysis, but was not chosen for this assessment.

Goal Conflicts

Conflicts among cost, schedule and safety goals did not rise to the level of a reportable problem.  ORP interviewees reported that cost and schedule do not conflict with safety in their individual work. (p. 6)  Most Bechtel interviewees do not perceive schedule pressures to be the determining factor while completing various tasks. (p. 23)  Overall, this is satisfactory performance.

Corrective Action Program

We believe how well an organization recognizes and permanently resolves its problems is important.  Problem Identification and Resolution was one of the traits evaluated in the assessment.  ORP interviewees said that current safety concerns are being addressed.  The historical lack of management feedback on problem resolution is still a disincentive for reporting problems. (pp. 8-9)  Some Bechtel interviewees said “issue resolution with management engagement was the single most positive improvement in problem resolution, . . .” (p. 24)  This performance is minimally acceptable but needs ongoing attention.

Financial Incentives

DOE’s contract with Bechtel now includes incentives for Bechtel if it self-identifies problems (rather than waiting for DOE or some other party to identify them).  ORP believes the incentives are a positive influence on contractor performance. (p. 8)  Bechtel interviewees also believe the new contract has had a positive impact on the project.  However, Bechtel has a goal to reduce legacy issues and some believe the contract’s emphasis on new issues distracts from addressing legacy problems. (pp. 24-25)  The assessment had no discussion of either ORP or Bechtel senior management financial incentives.  The new contract conditions are good; ignoring senior management incentives is unacceptable.

Safety Conscious Work Environment (SCWE)

We usually don’t pay much attention to SCWE at nuclear power plants because it is part of the larger cultural milieu.  But SCWE has been a long-standing issue at various DOE facilities, as well as the impetus for the series of WTP SC assessments, so we’ll look at a few highlights from the SC survey data.

For ORP, mean responses to five of the six SCWE questions were higher (better) in 2015 vs 2014, and 2014 vs 2011.  However, for one question “Concerns raised are addressed” the mean is lower (worse) in 2015 vs 2014, and significantly lower in 2015 vs 2011.  This may indicate an issue with problem resolution. (p. B-2) 

For Bechtel, mean responses to all six SCWE questions were significantly higher (better) in 2015 vs 2014.  However, the 2011 data were not included so we cannot make any inference about possible longer-term trends. (p. B-5)  What is shown is good news because it appears people feel freer to raise safety concerns.  Interestingly, Bechtel’s mean 2015 responses were 5-13% higher (better) than ORP’s for all questions.

Both ORP and Bechtel are showing acceptable performance but continued improvement efforts are warranted.

Our Perspective

The Executive Summary and Conclusions suggest ORP and especially Bechtel have turned the corner since 2014. (pp. v, 37)  This is arguably true for SCWE but we’d say the jury is still out on improvement in the broader SC, based on our look at the BARS data.

For ORP, the BARS data mean scores are higher for 4 (out of 10) behaviors in 2015 vs 2014, but only higher for 1 behavior in 2015 vs 2011. (p. B-1)  The least charitable interpretation is ORP’s view of itself has not yet re-achieved 2011 levels.  For Bechtel the BARS data shows a bit brighter picture.  Mean scores are higher for 6 (out of 10) behaviors in 2015 vs 2014, and higher for 4 behaviors for 2015 vs 2011. (p. B-4)

The format of the report is probably intended to be reader-friendly but it mixes qualitative interview data and selected quantitative data from BARS and the survey.  The use of modifiers like “many” and “some” creates a sense of relative frequency or importance but no real specificity.  It’s impossible to say how much (if any) cherry picking of the interview data occurred.****

We also wonder about the evaluation team’s level of independence and optimism.  This is the first time DOE has performed a WTP SC assessment without the extensive use of outside consultants.  Put bluntly, how independent was the team’s effort given DOE Headquarters’ desire to see improvements at WTP?  And it’s not just HQ; DOE is under the gun from Congress, the DNFSB, the Government Accountability Office, and environmental activists and regulators to clean up their act at Hanford.

We want to see a stronger SC at Hanford but we’ll go with Ronald Reagan on this report: “Trust, but verify.”


*  DOE Office of Enterprise Assessments, “Follow-up Assessment of Safety Culture at the Hanford Site Waste Treatment and Immobilization Plant” (June, 2015).  We have followed the WTP saga for years; please click on the Vit Plant label to see our related posts.

**  Behavioral Anchored Rating Scales (BARS) quantitatively summarize interviewees’ perceptions of their organization using specific examples of good, moderate, and poor performance.   There are 17 possible organizational behaviors in a BARS analysis, but only 10 were used in this assessment:  Attention to Safety, Coordination of Work, Formalization, Interdepartmental Communication, Organizational Learning, Performance Quality, Problem Identification and Resolution, Resource Allocation, Roles and Responsibilities and Time Urgency. (p. C-2)

***  A. Cary, “DOE: Hanford vit plant safety culture shows improvement,” Tri-City Herald (June 26, 2015).

****  The report also includes multiple references to the two organizations’ behavioral norms that were inferred from the survey data.  It’s not exactly consultant mumbo-jumbo but it’s too complicated to attempt to explain in this space.

More Evidence of Weak Safety Culture in DOE

DNFSB Headquarters

We have posted many times about safety culture (SC) issues in the Department of Energy (DOE) empire.  Many of those issues have been raised by the Defense Nuclear Facilities Safety Board (DNFSB), an overseer of DOE activities.  Following is a recent example based on a DNFSB staff report.*

The Radcalc Imbroglio

Radcalc is a computer program used across the DOE complex (and beyond) to determine the transportation package classification for radioactive materials, including radioactive waste, based on the isotopic content.  Radcalc errors could lead to serious consequences, e.g., exposure to radiation or explosions, in the event of a transportation accident.  DOE classified Radcalc as safety software and assigned it the second highest level of rigor in DOE’s software quality assurance (SQA) procedures.

A DNFSB audit found multiple deficiencies with respect to Radcalc, most prominently DOE’s inability to provide any evidence of federal oversight of Radcalc during the software's lifetime (which dates back to the mid-1990s).  In addition, there was no evidence DOE contractors had any Radcalc-related QA plans or programs, or maintained software configuration management.  Neither DOE nor the contractors effectively used their corrective action program to identify and correct software problems.  DNFSB identified other problems but you get the idea.

DNFSB Analysis

As part of its analysis of problems and causes, the DNFSB identified multiple contributing factors including the following related to organization.  “There is an apparent lack of a systematic, structured, and documented approach to determine which organization within DOE is responsible to perform QA audits of contractor organizations.  During the review, different organizations within DOE stated that they thought another organization was responsible for performing Radcalc contractor QA audits.  DOE procedures do not clearly delineate which organization is responsible for QA/SQA audits and assessments.” (Report, p. 4)

Later, the report says “In addition, this review identified potentially significant systemic [emphasis added] concerns that could affect other safety software. These are: inadequate QA/SQA requirement specification in DOE contracts and the lack of policy identifying the DOE organizations in charge of performing QA assessments to ensure compliance; unqualified and/or inadequate numbers of qualified federal personnel to oversee contract work; . . . and additional instances of inadequate oversight of computer work within DOE (e.g., Radtran).” (Report, p. 5)

Our Perspective

Even without the DNFSB pointing out “systemic” concerns, this report practically shouts the question “What kind of SC would let this happen?”  We are talking about a large group of organizations where a significant, safety-related activity failed to take place and the primary reason (excuse) is “Not my group’s job.”  And no one took on the task to determine whose job it was.  This underlying cultural attitude could be as significant as the highly publicized SC problems at individual DOE facilities, e.g., the Hanford Waste Treatment Plant or the Waste Isolation Pilot Plant.

The DNFSB asked DOE to respond to the report within 90 days.  What will such a report say?  Let’s go out on a limb here and predict the report will call for “improved procedures, training and oversight.”  The probability of anyone facing discipline over this lapse: zero.  The probability of DOE investigating its own and/or contractor cultures for a possible systemic weakness: also zero.  Why?  Because there’s no money in it for DOE or the contractors and the DNFSB doesn’t have the organizational or moral authority to force it to happen.

We’ve always championed the DNFSB as the good guys, trying to do the right thing with few resources.  But the sad reality is they are a largely invisible backroom bureaucracy.  When a refinery catches fire, the Chemical Safety Board is front and center explaining what happened and what they’ll recommend to keep it from happening again.  When was the last time you saw the DNFSB on the news or testifying before Congress?  Their former chairman retired suddenly late last year, with zero fanfare; we think it’s highly likely the SC initiative he championed and attempted to promulgate throughout DOE went out the door with him.


*  J.H. Roberson (DNFSB) to D.M. Klaus (DOE), letter (Mar. 16, 2015) with enclosed Staff Issue Report “Review of Federal Oversight of Software Quality Assurance for Radcalc” (Dec. 17, 2014).  Thanks to Bill Mullins for bringing this document to our attention.

Corrosion in the Culture of the DNFSB?

We have posted many times on the Defense Nuclear Facilities Safety Board’s (DNFSB) efforts to get the Department of Defense (DOE) to confront and resolve its safety culture (SC) issues.  Now it appears the DNFSB has management and cultural issues of its own.  In a stinging report* by an outside consultant, DNFSB board members are said to have a “divisive and dysfunctional relationship” and the organizational culture is called “toxic.” (p. iii)  This post highlights the cultural aspects of selected issues and the proposed fixes.

Major issues that can affect culture are the board itself, the negative tone of oral and written communications, and the performance recognition system.

DNFSB is a small agency (100+ people) and most work in the same office.  There is no place to hide from the effects of troubles at the top.  The Board’s basic problem is that the members don’t have a shared mental model of the DNFSB’s mission and strategies.  And, because the members are political appointees representing both major parties, creating some kind of unity is a major challenge.  The report contains many recommendations related to improving board functioning but the reality is it’s mainly a political issue.  Board dysfunctionality is a cultural issue because hydra-headed leadership distracts, confuses and ultimately demoralizes the agency staff.  Most alarming to us, to the extent investigations are driven by board members’ interests rather than by science and safety considerations (a perception reported by some staff), the board’s shortcomings can impinge on the agency’s SC. 

Communications problems start at the board level and permeate the agency. Negative communications, e.g., condescending language and personal attacks, lead to a culture of disrespect.  The recommendations for communications include “Immediately ensure a professional tone in all communications, both among board members and throughout the Agency.  Consider use of an internal communication code of conduct.” (p. 3-2)  In our view, business communications should focus on the issues, be respectful and exhibit a modicum of integrity.

Performance recognition recommendations include “Assess staff sentiment with regard to priorities for nonmonetary incentives, and develop offerings accordingly.” (p. 3-5)  Nonmonetary recognition was mentioned by an employee committee tasked with identifying underlying causes for DNFSB’s declining scores on the periodic federal employee viewpoint survey.  We’re not sure why monetary recognition is off the table, perhaps because of perceived budget problems.  Our feeling is if some type of above-and-beyond behavior is worth recognizing, then an organization should be willing to pay something for it.

There are also a couple of more straightforward management issues: frequent disruptive organizational changes, and the lack of management and leadership competence.  If not addressed, such issues can certainly weaken culture but they are not as important as the ones described previously.

Change management recommendations include “Develop a change management organizational competency . . .  [and] a change management plan, . . .” (p. 3-3)  As an aside, the NRC Inspector General (IG) provides IG services to the DNFSB; an October 2014 IG report** identified change management as a serious challenge facing the agency.

Increasing competence corrective actions include “Institute tailored management and supervisory training for technical staff management and supervisors. . . .” (p. 3-3)  This is not controversial; it simply needs to be accomplished.

Our Perspective 

If the report accurately describes DNFSB’s reality, it looks like a bit of a mess.  The board’s chairman recently retired so the President has an opportunity to nominate someone who is willing and able to clean it up.  Absent competent leadership from the top, the report’s recommendations may make a dent in the problems but will not be a cure-all.

We wish them well.  If the DNFSB’s focus wanes, it bodes ill for efforts to spur DOE to increase its management competence and strengthen its SC.


*  J. O'Hara and P.M. Darmory, “Assessment of the Defense Nuclear Facilities Safety Board Workforce and Culture,” Report DNF40T1 (Dec. 2014).  Thanks to Bill Mullins for recommending this report.

**H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.

DNFSB Hearings on Safety Culture, Round Three

DNFSB Headquarters

On October 7, 2014 the Defense Nuclear Facilities Safety Board (DNFSB) held its third and final hearing* on safety culture (SC) at Department of Energy (DOE) nuclear facilities.  The original focus was on the Hanford Waste Treatment Plant (WTP) but this hearing also discussed the Waste Isolation Pilot Plant (WIPP), the Pantex plant and other facilities.  There were three presenters: DOE Secretary Moniz and two of his top lieutenants.  A newspaper article** published the same day reported key points made during the hearing and you should read that article along with this post.  This post focuses on items not included in the newspaper article, including the tone of the hearing and other nuances.  The presenters used no slides and the hearing transcript has not yet been released.  The only current record of the hearing is a DNFSB video.

Secretary Moniz

Moniz has been Secretary for about a year-and-a-half.  In his view, the keys to improving SC are training, consistent senior management attention, and procurement modifications, i.e., DOE’s intent to revise RFP and contracting processes to include SC expectations.  He also said fostering the consideration of SC in all decisions, including resource allocation, is important.  Board member Sullivan asked about the SC issues at Pantex and Moniz provided a generic answer about improving self-assessments and sharing lessons learned but ultimately punted to the next presenter, Ms. Creedon.

Principal Deputy Administrator Creedon, National Nuclear Security Administration (NNSA)

Creedon has been in her position for two months.  She believes NNSA employees get the job done in spite of bureaucracy but they need greater trust in senior management who, in turn, must work harder to engage the workforce.  Returning to the Pantex*** issues, Sullivan asked why the recommendations of the plant’s outside technical advisors had been ignored for years.  Creedon said she would work to improve communications up and down the organization.  In a separate exchange, she provided an example of positive reinforcement where NNSA employees can receive cash awards ($500) for good work. 

Creedon’s  prior position was in the Department of Defense.  To the extent she has the warfighter mentality (“Anything, anywhere, anytime…at any cost”)**** then balancing mission and safety may not be natural for her.  Her response to a question on this topic was not encouraging; she claimed the motto du jour for NNSA (“Mission First, People Always”) adequately addresses safety's prioity but it obviously doesn’t even mention safety.

Acting Assistant Secretary for Environmental Management Whitney

Whitney is also new in his job but not to DOE, coming from DOE Oak Ridge.  He laid out his goals of establishing trust, a questioning attitude and mutual respect.  He was asked about a SC assessment finding that DOE senior managers don’t feel responsible for safety, rather it belongs to the site leads or one of the EM mission support units.  Whitney said that was unacceptable and described the intent to add SC factors to senior management evaluations.  He also repeated the plan to upgrade the WTP contractor evaluation to include SC factors.  He noted that most employees stay at one site for their entire career, making it hard to transfer SC from site to site.

Our Perspective

The overall tone of the hearing was collegial.  The Board expressed support and encouragement for the presenters, all of whom are relatively new in their jobs.  The presenters all stayed on message and reinforced each other.  For example, for WTP one message is “We know there are still significant SC issues at WTP but we have the right team in place and are taking action and making progress.  Changing a decades-old culture takes time.”  Whitney received more of a (polite) grilling probably because the WTP and the WIPP are under his purview.

We are totally supportive of DOE’s stated intent to add SC factors to contracts and senior management evaluations.  When players have skin in the game, the chances of seeing desired behavioral changes are greatly increased.  We are equally supportive of Secretary Moniz’ desire to create a culture that incorporates safety considerations in all decisions.

DOE is trying to make its employees more conscious of safety’s importance; two thousand mangers have gone through SC training and there’s more to come.  Now we’re starting to worry about the drumbeat of SC creating a Weltanschauung where a strong SC is sine quo non for good outcomes and a weak SC is always present when bad outcomes occur.  Organizational reality is more complicated.  An organization with a mediocre SC can achieve satisfactory results if other effective controls and incentives are in place; an organization with a strong SC can still make poor decisions.  And luck can run good or bad for anyone.

*  DNFSB Oct. 7, 2014 Safety Culture Public Meeting and Hearing.  We posted on the first hearing on June 9, 2014 and the second hearing on Sept. 4, 2014.

**  A. Cary, “Moniz says safety culture at Hanford vit plant led to problems,” Tri-City Herald (Oct. 7, 2014).

***  NNSA's responsibilities include Pantex which has recognized SC issues.

****  See the third footnote in our Sept. 4, 2014 post.