VIT Plant Glop (Part 2)

(Ed. note: We're pleased to present an interesting take on the Vit Plant from Bill Mullins as a guest contributor.  We welcome contributions from others who would like to contribute leading edge thinking on nuclear safety culture.)

Bob Cudlin’s Jan. 24 post concludes, "Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting might be the better emphasis."

From where I sit, in this simple piece of seemingly practical advice hides much of the iceberg the WTP Titanic keeps circling around to repeatedly encounter amidst the fog of Nuclear Safety Culture (NSC) and such.

The key word is "expectations” – this is because for DOE the definition of Quality is “performance that meets or exceeds requirements and expectations.” Importantly the DOE Quality standard embraces a “continuous improvement” criterion. This definition of Quality and its attendant context are considerably more expansive than the one found at 10 CFR 50 Appendix B – and there is a very necessary reason for that.

At the Program level all the DOE Mission portfolios are of the Discover and Develop type. DOE programs and projects are chartered to go where none has gone before (i.e. nor generally can afford the capital risks to go such places first).

Not every project in DOE is of comparable difficulty, but many (e.g., the Environmental Management Program) of the sub-portfolios (e.g., Hanford Cleanup) take decades of trial and error practice to create reliable Acquisition Strategies.

Even now the Hanford Cleanup work is pretty well partitioned between 1) things we now do reliably and with a modicum of efficiency (cf. River Corridor Cleanup contract), and 2) that Goop/Gorp unconventional uncertainty. Today the former goes well and the latter goes poorly.

The WTP is a full-blooded Discover and Develop enterprise - the high-level tank waste is vastly more subtle in its physical chemistry than DOE and its prime contractor have been willing to acknowledge to their stakeholders in the Tri-Party Agreement with EPA and WA State. The stakeholders seem reluctant to puncture the veil of schedule illusion as well.

Generally I conclude the River Protection Program (RPP), which governs the WTP development, is not sufficiently aware of its vulnerability to unconventional uncertainty. It is the more unpredictable behavior of the tank waste that should be the center of attention; not unrealistic schedules and life cycle budget estimates into the far future.

It is this (some would say “studied”) blindness that the DNFSB is ultimately getting at via its nuclear safety oversight charter – I’m inclined to doubt that the Board recognizes the blind spot any better than most in DOE leadership. Like the carpenter with only a hammer on his tool belt, the Board’s way of framing issues with progress at the RPP tends to make every unanticipated or unwelcome outcome seem like a “nuclear safety nail.”

At the end of most days this over-dramatization of nuclear safety significance has been a deliberate strategy of the Board since it began its Safety in Design “action-forcing” campaign about four years ago.

In broad reality, the situation of the RPP can be viewed as a matter of inadequate safety consciousness or poorly chosen Acquisition Strategy – the latter perspective has more traction precisely because in encompasses protection concerns without being dragged into the “good vs. bad” attitude debates – which tend to be the heart of NSC conversations - that are presently fogging the air of the Hanford 200 Area.

Later in Bob’s post he observes: “In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.”

This conclusion is not without its supporting evidence: From the time that the Walt Thomasitus pushback on Bechtel Management began, DOE Office of River Protection project management has responded from a position that reeks annoyance and resentment. This has not helped with sorting out the key issues at the WTP, in fact when the Recommendation 2011-1 appeared the knee-jerk defensive response of the Deputy Secretary actually made things worse for a time.

There are now three prominent whistle-blowers feeding the maw of both GAO and the national press.*  Unfortunately, Thomasitus, Alexander, and Busche each raise concerns about whether the plant will work as advertised – not as matters of Acquisition Strategy, but as safety issues. That is unfortunate because it leads to this: “The treatment plant "is not a project that can be stopped and restarted," said Rep. Doc Hastings, R-Wash.”**

Just lately, we have a memorandum from the Secretary and Deputy Secretary that I believe finally puts a suitable Line Management framework around the 2011-1 IP and the WTP issue.  It will take a further post to elaborate the basis for my belief that this particular memorandum “answers the mail” about NSC in the DOE nuclear programs. At that point I can also suggest what I see as the barriers to this missive gaining the policy high ground against the wave of other “over-commitments” throughout the remainder of the 2012-1 IP.

(Mr. Mullins is a Principal at Better Choices Consulting.)

*  P. Eisler, “Problems plague cleanup at Hanford nuclear waste site,” USA Today (Jan. 25, 2012).

**  P. Eisler, “Safety at Wash. nuclear-waste site scrutinized,” USA Today (Jan. 27, 2012).

***  Letter from D.B. Poneman to P.S. Winokur transmitting DOE Memorandum dated Dec. 5, 2011 from S. Chu and D.B. Poneman to Heads of All Departmental Elements re: Nuclear Safety at the Department of Energy (Jan. 24, 2012).

Vit Plant Glop

Hanford WTP

DOE’s Waste Treatment Plant at Hanford, the “Vit Plant”, is being built to process a complex mixture of radioactive waste products from 1950s nuclear weapons production.  The wastes, currently in liquid form and stored in tanks at the site, was labeled “gorp” by William Mullins in one of his posts on the LinkedIn Nuclear Safety thread.*  Actually we think the better reference is to “glop”.  Glop is defined at merriam-webster.com as “a thick semiliquid substance (as food) that is usually unattractive in appearance”.  Readers should disregard the reference to food.  We would like to call attention to another source of “glop” accumulating at the Vit Plant.  It is the various reports by DOE and Hanford regarding safety culture at the site, most recently in response to the Defense Nuclear Facilities Safety Board’s (DNFSB, Board) findings in June 2011.  These forms of glop correspond more closely to the secondary definition in m-w, that is, “tasteless or worthless material”.

The specific reports are the DOE’s Implementation Plan (IP)** for the DFNSB’s review of safety culture at the WTP and the DOE's Office of Health, Safety and Security (HSS) current assessment of safety culture at the site.  Neither is very satisfying but we’ll focus on the IP in this post.

What may be most interesting in the DOE IP package are the reference documents including the DNFSB review and subsequent exchanges of letters between the Secretary of Energy and the DNFSB Chairman.  It takes several exchanges for the DNFSB to wrestle DOE into accepting the findings of the Board.  Recall in the Board’s original report it concluded:

“Taken as a whole, the investigative record convinces the Board that the safety culture at WTP is in need of prompt, major improvement and that corrective actions will only be successful and enduring if championed by the Secretary of Energy.” (IP, p. 33)***

In DOE’s initial (June 30, 2011) response they stated:

“Even while DOE fully embraces the objectives of the Board’s specific recommendations, it is important to note that DOE does not agree with all of the findings included in the Board’s report.”  (IP, p. 42)****

It goes on to state that “specifically” DOE does not agree with the conclusions regarding the overall quality of the safety culture.  Not surprisingly this brought the following response in the DNFSB’s August 12, 2011 letter, “...the disparity between the [DOE’s] stated acceptance and disagreement with the findings makes it difficult for the Board to assess the response….”  (IP, p. 46)*****  Note that in the body of the IP (p. 4) DOE does not acknowledge this difference of opinion either in the summary of its June 30 response or the Board’s August 12 rejoinder. 

We note that neither the DNFSB report nor the DOE IP is currently included among the references on Bechtel's Vit Plant website.  One can only wonder what the take away is for Vit Plant personnel — isn’t there a direct analogy between how DOE reacts to issues raised by the DNFSB and how Vit Plant management respond to issues raised at the plant?  Here’s an idea: provide a link to the safetymatters blog on the Vit Plant website.  Plant personnel will be able to access the IP, the DNFSB report and all of our informative materials and analysis.

In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.  Their cause analysis focuses on inadequate expectation setting, more knowledge and awareness and (closer to the mark) the conflicting goals emerging in the construction phase (IP, pp. 5-8).  While endlessly citing all the initiatives previously taken or underway, never does the DOE reflect on why these initiatives have not been effective to date.  What is DOE’s answer?  More assessments and surveys, more training, more “guidance”, more expectations, etc.

We do find Actions 1-5 and 1-6 interesting (IP, p. 16).  These will revise the BNI contract to achieve “balanced priorities”.  This is important and a good thing.  We have blogged about the prevalence of large financial incentives for nuclear executives in the commercial nuclear industry and assessments of most, if not all, other significant safety events (BP gulf disaster, BP refinery fire, Upper Big Branch coal mine explosion, etc.) highlight the presence of goal conflicts.  How one balances priorities is another thing and a challenge.  We have blogged extensively on this subject - search on “incentives” to identify all relevant posts.  In particular we have noted that where safety goals are included in incentives they tend to be based on industrial safety which is not very helpful to the issues at hand.  Our favorite quote comes from our April 7, 2011 post re the gulf oil rig disaster and is taken from Transocean’s annual report:

“...notwithstanding the tragic loss of life in the Gulf of Mexico, we [Transocean] achieved an exemplary statistical safety record as measured by our total recordable incident rate (‘‘TRIR’’) and total potential severity rate (‘‘TPSR’’).”

Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting, might be the better emphasis.  Then monitoring and independently assessing how specific technical and safety issues are reviewed and decided.  Training, expectations setting, reinforcement, policies, etc. are useful in “setting the table” but the test of whether the organization is embracing and implementing a strong safety culture can only be found in its actions.  Note that the Board’s June 2011 report focused on two specific examples of deficient decision processes and outcomes.  (One, the determination of the appropriate deposition velocity for analysis of the transport of radioactivity, the other the conservatism of a criticality analysis.)

There are two aspects of decisions: the process and the result.  The process includes the ability to freely raise safety concerns, the prioritization and time required to evaluate such issues, and the treatment of individuals who raise such concerns.  The result is the strength of the decision reached; i.e., do the decisions reinforce a strong safety culture?  We have posted and provided examples on the blog website of decision assessment using some methods for quantitative scoring.

*  The link to the thread is here.  Search for "gorp" to see Mr. Mullins' comment.

**  U.S. Dept. of Energy, “Implementation Plan for Defense Nuclear Facilities Safety Board Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant”  (Dec. 2011).

***  IP Att. 1, DNFSB Recommendation 2011-1, “Safety Culture at the Waste Treatment and Immobilization Plant” (June 9, 2011).

****  IP Att. 2, Letter from S. Chu to P.S. Winokur responding to DNFSB Recommendation 2011-1 (June 30, 2011) p. 4.

*****  IP Att. 4, Letter from P.S. Winokur  to S. Chu responding to Secretary Chu’s June 30, 2011 letter (Aug. 12, 2011) p. 1.

Lawyering Up

When concerns are raised about the safety culture of an organization with very significant safety responsibilities what’s one to do?  How about, bring in the lawyers.  That appears to be the news out of the Vit Plant* in Hanford, WA.  With considerable fanfare Bechtel unveiled a new website committed to their management of the vit plant.  The site provides an array of policies, articles, reports, and messages regarding safety and quality.

One of the major pieces of information on the site is a recent assessment of the state of safety culture at the vit plant.**  The conclusion of the assessment is quite positive: “Overall, we view the results from this assessment as quite strong, and similar to prior assessments conduct [sic] by the Project.” (p. 16)  The prior assessments were the 2008 and 2009 Vit Plant Opinion Surveys.

However our readers may also recall that earlier this year the Defense Nuclear Facilities Safety Board (DNFSB) issued its report that at the safety culture at the WTP plant is “flawed”.  In a previous post we quoted from the DNFSB report as follows:

“The HSS [DOE's Office of Health, Safety and Security] review of the safety culture on the WTP project 'indicates that BNI [Bechtel National Inc.] has established and implemented generally effective, formal processes for identifying, documenting, and resolving nuclear safety, quality, and technical concerns and issues raised by employees and for managing complex technical issues.'  However, the Board finds that these processes are infrequently used, not universally trusted by the WTP project staff, vulnerable to pressures caused by budget or schedule [emphasis added], and are therefore not effective.”

Thus the DNFSB clearly has a much different view of the state of safety culture at the vit plant than does DOE or Bechtel.  We note that the DNFSB report does not appear to be one of the numerous references available at the new website.  Links to the original DOE report and the recent assessment are provided.  There is also a November 17, 2011 message to all employees from Frank Russo, Project Director*** which introduces and summarizes the 2011 Opinion Survey on the project’s nuclear safety and quality culture (NSQC).  Neither the recent assessment nor the opinion survey addresses the issues raised by the DNFSB; it is as if the DNFSB review never happened.

What really caught our attention in the recent assessment is who wrote the report - a law firm.  Their assessment was based on in-depth interviews of 121 randomly selected employees using a 19 question protocol (the report states that the protocol is attached however it is not part of the web link).  But the law firm did not actually conduct the interviews - “investigators” from the BSII internal audit department did so and took notes that were then provided to the lawyers.  This may give new meaning to the concept of “defense in depth”.

The same law firm also analyzed the results from the 2011 Opinion Survey.  In the message to employees from , Russo asserts that the law firm has “substantial experience in interpreting [emphasis added] NSQC assessments”.  He goes on to say that the questions for the survey were developed by the WTP Independent Safety and Quality Culture Assessment (ISQCA) Team.  In our view, this executive level team has without question “substantial experience” in safety culture.  Supposedly the ISQCA team was tasked with assessing the site’s culture - why then did they only develop the questions and a law firm interpret the answers?  Strikes us as very odd. 

We don’t know the true state of safety culture at the vit plant and unfortunately, the work sponsored by vit plant management does little to provide such insight or to fully vet and respond to the serious deficiencies cited in the DNFSB assessment.  If we were employees at the plant we would be anxious to hear directly from the ISQCA team. 

Reading the law firm report provides little comfort.  We have commented many times about the inherent limitations of surveys and interviews to solicit attitudes and perceptions.  When the raw materials are interview notes of a small fraction of the employees, and assessed by lawyers who were not present in the interviews, we become more skeptical.  Several quotes from the report related to the Employee Concerns Program illustrate our concern.

“The overwhelming majority of interviewees have never used ECP. Only 6.5% of the interviewees surveyed had ever used the program.  [Note: this means a total of nine interviewees.] There is a major difference between the views of interviewees with no personal experience with ECP and those who have used the program: the majority of the interviewees who have not used the program have a positive impression of the program, while more than half of the interviewees who have used the program have a negative impression of it.” (p. 5, emphasis added)

Our favorite quote out of the report is the following.  “Two interviewees who commented on the [ECP] program appear to have confused it with Human Resources.” (p. 6)  One only wonders if the comments were favorable.

Eventually the report gets around to a conclusion that we probably could not say any better.  “We recognize that an interview population of nine employees who have used the ECP in the past is insufficient to draw any meaningful conclusions about the program.” (p. 17)

We’re left with the following question: Why go about an assessment of safety culture in such an obtuse manner, one that is superficial in its “interpretation” of very limited data,  laden with anecdotal material, and ultimately over reaching in its conclusions?

*  The "Vit Plant" is the common name for the Hanford Waste Treatment Plant (WTP).

**  Pillsbury Winthrop Shaw Pittman, LLP, "Assessment of a Safety Conscious Work Environment at the Hanford Waste Treatment Plant" (undated).  The report contains no information on when the interviews or analysis were performed.  Because a footnote refers to the 2009 Opinion Survey and a report addendum refers to an October, 2010 DOE report, we assume the assessment was performed in early-to-mid 2010.

*** WTP Comm, "Message from Frank: 2011 NSQC Employee Survey Results" (Nov. 17, 2011).  

DNFSB Goes Critical

Hanford WTP

The Defense Nuclear Facilities Safety Board (DNFSB)issued a “strongly worded” report* this week on safety culture at the Hanford Waste Treatment and Immobilization Plant (WTP).  The DNFSB determined that the safety culture at the WTP is “flawed” and “that both DOE and contractor project management behaviors reinforce a subculture at WTP that deters the timely reporting, acknowledgement, and ultimate resolution of technical safety concerns.”

For example, the Board found that “expressions of technical dissent affecting safety at WTP, especially those affecting schedule or budget, were discouraged, if not opposed or rejected without review” and heard testimony from several witnesses that “raising safety issues that can add to project cost or delay schedule will hurt one's career and reduce one's participation on project teams.”

Only several months ago we blogged about initiatives by DOE regarding safety culture at its facilities.  In our critique we observed, “Goal conflict, often expressed as safety vs mission, should obviously be avoided but its insidiousness is not adequately recognized [in the DOE initiatives]."  Seems like the DNFSB put their finger on this at WTP.  In fact the DNFSB report states:

“The HSS [DOE's Office of Health, Safety and Security] review of the safety culture on the WTP project 'indicates that BNI [Bechtel National Inc.] has established and implemented generally effective, formal processes for identifying, documenting, and resolving nuclear safety, quality, and technical concerns and issues raised by employees and for managing complex technical issues.'  However, the Board finds that these processes are infrequently used, not universally trusted by the WTP project staff, vulnerable to pressures caused by budget or schedule [emphasis added], and are therefore not effective.” 

The Board was not done with goal conflict. It went on to cite the experience of a DOE expert witness:

“The testimony of several witnesses confirms that the expert witness was verbally admonished by the highest level of DOE line management at DOE's debriefing meeting following this session of the hearing.  Although testimony varies on the exact details of the verbal interchange, it is clear that strong hostility was expressed toward the expert witness whose testimony strayed from DOE management's policy while that individual was attempting to adhere to accepted professional standards.”

This type of intimidation need not be, and generally is not, so explicit. The same message can be sent through many subtle and insidious channels which are equally effective.  It is goal conflict of another stripe - we refer to it as “organizational stress” - where the organizational interests of individuals - promotions, performance appraisals, work assignments, performance incentives, etc. - create another dimension of tension in achieving safety priority.  It is just as real and a lot more personal than the larger goal conflicts of cost and schedule pressures.

*  Defense Nuclear Facilities Safety Board, Recommendation 2011-1 to the Secretary of Energy "Safety Culture at the Waste Treatment and Immobilization Plant" (Jun 9, 2011).