DNFSB Hearings on Safety Culture, Round Two

DNFSB Headquarters

On August 27, 2014 the Defense Nuclear Facilities Safety Board (DNFSB) convened the second of three hearings “to address safety culture at Department of Energy defense nuclear facilities and the Board’s Recommendation 2011–1, Safety Culture at the Waste Treatment and Immobilization Plant.”*  The first hearing was held on May 28, 2014 and heard from industry and federal government safety culture (SC) experts; we reviewed that hearing on June 9, 2014.  The second hearing received SC expert testimony from the U.S. Navy, the U.S. Chemical Safety and Hazard Investigation Board and academia.  The following discussion reviews the presentations in the order they were made to the board. 


Adm. Norton's (Naval Safety Center) presentation** on the Navy’s SC programs was certainly comprehensive with 32 slides for a half-hour talk (plus 22 backup slides).  It appears the major safety focus has been on aviation but the Center’s programs also address the afloat communities (surface, submarine and diving) and Marines.  The programs make heavy use of surveys and unit visits in addition to developing and presenting training and workshops.  Not surprisingly, the Navy stresses the importance of leadership, especially personal involvement and commitment, in creating a strong SC.  They recognize that implementing a strong SC faces a direct challenge from other organizational values such as the warfighter mentality*** and softer challenges in areas such as IT (where there are issues with multiple systems and data problems).

Program strengths include the focus on leadership (leadership drives climate, climate drives cultural change) and the importance of determining why mishaps occurred.  The positive influence of a strong SC on decision making is implied.

Program weaknesses can be inferred from what was not mentioned.  For example, there was no discussion of the importance of fixing problems or identifying hard-to-see technical problems.  More significantly, there was no mention of High Reliability Organization (HRO) attributes, a real head-scratcher given that some of the seminal work on HROs was conducted on aircraft carriers. 

Adm. Eccles' (Navy ret.) presentation**** basically reviews the Navy’s SUBSAFE program and its focus on compliance with program requirements from design through operations.  Eccles notes that ignorance, arrogance and complacency are challenges to maintaining an effective program.

Mr. Griffon's (Chemical Safety Board Member) presentation***** illustrates the CSB’s straightforward approach to investigating incidents, as reflected in the following quotes:

“Intent of CSB investigations are to get to root cause(s) and make recommendations toward prevention.” (p. 3)

While searching for root causes the CSB asks: “Why conditions or decisions leading to accident were seen as normal, rational, or acceptable prior to the accident.” (p. 4)

CSB review of incident-related artifacts includes two of our hot button issues, Process Safety Management action item closure (akin to a CAP) and the repair backlog. (p. 5)  Griffon reviews major incidents, e.g., Texas City and Deepwater Horizon.  For Deepwater, he notes how certain decisions were (deliberately) incompletely informed, i.e., did not utilize readily available relevant information, and thus are indicative of an inadequate SC. (p. 16)  Toward the end Griffon observes that “Safety culture study/change must consider inequalities of power and authority.” (p. 19)  That seems obvious but it doesn’t often get said so clearly.

We like the CSB’s approach.  There is no new information here but it’s a quick read of what basic SC should and shouldn’t be.

Prof. Meshkati's (Univ. of S. Cal.) presentation^ compares the cultures at TEPCO’s Fukushima Daiichi plant and Tohoku Electric’s Onagawa plant.  It is mainly a rehash of the op-ed Meshkati co-authored back in March 2014 (and we reviewed on March 19, 2014.)  The presentation adds something we pointed out as an omission in that op-ed, viz., that TEPCO’s Fukushima Daini plant eventually managed to shut down safely after the earthquake and tsunami.  Meshkati notes approvingly that Daini personnel exhibited impromptu, but prudent, decision-making and improvisation, e.g., by flexibly applying emergency operation procedures. (p. 37)

Prof. Sutcliffe (John Hopkins Univ.) co-authored an important book on High Reliability Organizations (which we reviewed on May 3, 2013) and this academically-oriented presentation^^ draws on her earlier work.  It begins with a familiar description of culture and how its evolution can be influenced.  Importantly it shows rewards (including money) as a key input affecting the link between leaders’ philosophy and employees’ behavior. (p. 6) 

Sutcliffe discusses how failure to redirect action (in a situation where a change is needed) can result from failure of foresight or sensemaking, or being overcome by dysfunctional momentum.  She includes a lengthy example featuring wildland firefighters that illustrates the linkages between cues, voiced concerns, search for disparate perspectives, situational reevaluation and redirected actions.  It’s worth a few minutes of your time to flip through these slides.

Our Perspective

For starters, the Naval Safety Center's activities may be too bureaucratic, with too many initiatives and programs, and focused mainly on compliance with procedures, rules, designs, etc.  It’s not clear what SC lessons can be learned from the Navy experience beyond the vital role of leadership in creating a cultural vision and attempting to influence behavior toward that vision.

The other presenters added nothing that was not already available to you, either through Safetymatters or from observing SC tidbits in the information soup that flows by everyone these days.

Subsequent to the first hearing we reported that Safety Conscious Work Environment (SCWE) issues exist at multiple DOE sites (see our July 8, 2014 post).  This should increase the sense of urgency associated with strengthening SC throughout DOE.  However, our bottom line remains the same as after the first hearing: “The DNFSB is still trying to figure out the correct balance between prescription and flexibility in its effort to bring DOE to heel on the SC issue.  SC is a vital part of the puzzle of how to increase DOE line management effectiveness in ensuring adequate safety performance at DOE facilities.” 


*  DNFSB Aug. 27, 2014 Public Hearing on Safety Culture and Board Recommendation 2011-1.  There is a video of the hearing available.

**  K.J. Norton (U.S. Navy), “The Naval Safety Center and Naval Safety Culture,“ presentation to DNFSB (Aug. 27, 2014).

***  “Anything, anywhere, anytime…at any cost”—desirable warfighter mentality perceived to conflict with safety.” (p. 11)

****  T. J. Eccles (U.S. Navy ret.), “A Culture of Safety: Submarine Safety in the U. S. Navy,” presentation to DNFSB (Aug. 27, 2014).

*****  M.A. Griffon (Chem. Safety Bd.), “CSB Investigations and Safety Culture,” presentation to DNFSB (Aug. 27, 2014).

^  Najm Meshkati, “Leadership and Safety Culture: Personal Reflections on Lessons Learned,” presentation to DNFSB (Aug. 27, 2014).  Prof. Meshkati was also the technical advisor to the National Research Council’s safety culture lessons learned from Fukushima report which we reviewed on July 30, 2014.

^^  K.M. Sutcliffe, “Leadership and Safety Culture,” presentation to DNFSB (Aug. 27, 2014).

Vit Plant Safety Culture Update

Hanford Waste Treatment Plant

DOE released a June 2014 follow-up assessment* on safety culture (SC) at the Hanford Waste Treatment Plant (WTP or the Vit Plant).  This post provides our perspective on the assessment.  We will not review every facet of the report but will focus on aspects that we think are important to understanding the current state of SC at the WTP project.

Overview

Back in 2011, the Defense Nuclear Facilities Safety Board (DNFSB) called the WTP safety culture (SC) “flawed.”  Following the DNFSB report, DOE conducted an assessment of the WTP SC and concluded “that a significant number of staff within ORP [DOE’s Office of River Protection] and BNI [Bechtel National Inc.] expressed reluctance to raise safety or quality concerns for various reasons.” (p. 1) 

Like DOE’s 2011 report, the current one is based on multiple data sources: structured interviews, focus groups, observations and a culture survey.  The report identifies many SC-related interventions that have been initiated, and lists positive and negative findings from the data collected.  Detailed assessment results are reported separately for ORP and BNI.**
 
WTP’s Safety Conscious Work Environment (SCWE)—Voicing Concerns, Challenging Decisions, Fear of Retaliation

The 2011 DNFSB critique focused on the treatment of project personnel who raised technical issues.  Some of these personnel complained about retaliation for bringing up such issues.  These issues can be raised in the Employee Concerns Program (ECP), the Differing Professional Opinions (DPO) process and challenging management decisions.  In what is arguably the report’s most significant finding, perceptions of conditions in these areas are worse than they were in 2011 for ORP and unchanged for BNI. (pp. 4-5)

Supporting Details

Although ORP senior management pointed to recent reductions in ECP concerns, “[s]ome interviewees indicated that they perceived a chilled environment at ORP and they did not believe that ECP concerns and DPO issues were always addressed or resolved in a timely manner.  Additionally, some interviewees described being told by supervision not to write a DPO because it would be a career limiting decision.” (p. B-21)  Interviewees from both ORP and BNI said they lacked trust in the ECP. (pp. B-22/23)

Most ORP employees believe that constructive criticism is not encouraged. (p. 4)  Within ORP, only 30% of all ORP survey respondents (and 65% of managers) feel that they can openly challenge decisions made by management. (p. B-21)  In BNI/URS, the numbers are 45% of all respondents and 75% of managers. (p. B-22)

“The statement that management does not tolerate retaliation of any kind for raising concerns was agreed to by approximately 80% of the ORP, . . . 72% of the BNI and 80% of the URS survey respondents.” (pp. B-21-22)  In addition, “Anonymous PIERs [Project Issues Evaluation Reports] are used a lot because of fear of retaliation.” (p. B-23)  

All in all, hardly a ringing endorsement of the WTP SCWE.

Decision Making, Corrective Action and Compensation

Safetymatters readers know of our long-standing interest in how SC is reflected in these key artifacts.

Decision Making

“Interviewees provided some examples of where decision making was not perceived to reflect the highest commitment to safety”  Examples included downgrading or elimination of assessment findings, the margin of safety in corrective action plans and the acceptable level of risk for the project.  (p. B-9)  Looks like there's some room for improvement in this area.

Corrective Action

Within BNI, there are positive comments about the corrective action process but the assessment team “observed a lack of accountability for a backlog of corrective actions at a PIRB [Performance Improvement Review Board] meeting.  There is a perceived lack of accountability for corrective actions in timeliness, ownership, and quality, ...” (p. B-16)

“[O]nly about 18% of all ORP interviewee respondents believed that employees are encouraged to notify management of problems they observe and that there is a system that evaluates the problem and makes a determination regarding future action.” (p. 13)

Plenty of room for improvement here.

Compensation

In the area of compensation, it appears some rewards for Bechtel are based on SC behaviors. (p. B-8)  We consider that a very positive development.

Concerns Over ORP Working More Collaboratively with Bechtel

On the surface this looks like a positive change: two entities working together to achieve a common goal.  However, this has led to at least two concerns.  First, as described in the report, some ORP personnel believe ORP is abdicating or compromising its responsibility to perform oversight of Bechtel, in other words, ORP is more of a teammate and less of an umpire. (pp. B-4, -9, -14)  Second, and this reflects our perspective, changing the relationship between the entities can result in revised system dynamics, with old performance-oversight feedback loops replaced by new ones.  The rules of engagement have changed and while safety may still be the number one priority, the cultural milieu in which safety is achieved has also changed.

Another complication is caused by the role of Bechtel Corporate.  The report says corporate’s values and goals may not be well-aligned with BNI’s need to prioritize SC attributes and behavior.  This can lead to a lack of transparency in BNI decisions. (pp. 5, 7)  That may be a bit of weasel wording in the report; in more direct terms, corporate’s number one priority is for the money train to keep running.

Bottom Line on SC at WTP 

A strong SC is, in some ways, about respect for the individual.  The concerns that WTP personnel  express about using the ECP or DPO process, or challenging management decisions suggest that the WTP project has a ways to go to inculcate an adequate level of such respect.  More importantly, it doesn’t appear they have made any significant process toward that goal in the last few years.

Morale is an aspect of the overall culture and at the WTP, morale is arguably low because of lack of progress and missed schedules. (pp. 6, B-10)  There is undoubtedly plenty of work to do but on a day to day basis, we wouldn’t be surprised if some people feel their work is not meaningful.


*  DOE Office of Environment, Safety and Health Assessments (now the Office of Independent Enterprise Assessments), “Independent Oversight Follow-up Assessment of Safety Culture at the Waste Treatment and Immobilization Plant” (June, 2014).

**  ORP has line management responsibility for the WTP, BNI is the primary contractor and URS Corporation (URS) is a major subcontractor.

Catching Up on DOE’s SCWE Extent of Condition Review

Hanford Waste Treatment Plant

On May 29, 2014 DOE submitted its partial response to the Defense Nuclear Facilities Safety Board (DNFSB) Recommendation 2011-1 in a report* on DOE’s Safety Conscious Work Environment (SCWE) extent of condition review and recommended actions for ongoing safety culture (SC) improvement at DOE facilities.

(Quick history: The June 9, 2011 DNFSB report on DOE’s Hanford Waste Treatment Plant (WTP or the Vit Plant) said the WTP SC was “flawed.”  The report’s recommendations included that DOE should conduct an extent of condition review to determine whether WTP SC weaknesses existed at other DOE facilities.  DOE agreed to perform the review but focused on SCWE because, in DOE’s view, the issues at WTP were primarily SCWE related.)

This post summarizes the report’s findings then parses the details and provides our perspective.

 Report Findings and Recommendations

The report was based on data from eleven independent SC assessments and thirty-one SCWE self-assessments conducted by individual organizations.  The DOE review team processed the data through their analyzer and homogenizer to identify four primary SC attributes** to focus on for continuous improvement in DOE:

• Demonstrated safety leadership
• Open communication and fostering an environment free from retribution
• Teamwork and mutual respect
• Credibility, trust and reporting errors and problems

Further processing through the bureaucratizer yielded three recommended actions to improve the SC attributes:

• Form a DOE SC Improvement Panel to ensure leadership and focus on DOE's SC initiatives
• Incorporate SC and SCWE concepts and practices into DOE training
• Evaluate contract language to incorporate clear references to SC  (pp. 3-4)

Our Perspective

We reviewed the DOE independent assessments on January 25, 2013 and the self-assessments on March 31, 2014.  From the former we concluded that issues similar to those found at the WTP existed at other DOE facilities, but to a lesser degree than WTP.  The self-assessments were of such varying quality and credibility that we basically couldn’t infer anything.***

The Analyzer

The DOE team reviewed all the assessments to identify specific issues (problems).  The team binned issues under the SC attributes in DOE's Integrated Safety Management System Guide and then counted the number of issues under each attribute; a higher count meant a more serious problem.  They performed a similar exercise to identify positive organizational trends (strengths) mentioned in the assessments. 

We could be picky and ask if all the issues (or strengths) were of essentially the same importance or magnitude but the team had a lot of data to review so we’ll let that slide.  Concurrently identifying strengths was a good idea; it harkens back to Peter Drucker who advised managers to build on strengths.****

The Homogenizer

Here’s where we begin to have problems.  The team focused on identifying SC attributes and developing recommendations that applied to or affected the entire Department, essentially boiling their results down to a one-size-fits-all approach.  However, their own data belies that approach.  For example, the Leadership attribute “Open communication and fostering an environment free from retribution” was identified as both an issue AND a strength. 

In plain English, some organizations don’t exhibit the desired communication attribute and others do.  One proper fix is to identify who is doing it right, define what exactly they’re doing, and develop a method for transferring that approach to the problem organizations.  The report even says this attribute “is an area in which management can learn lessons from those sites where it was deemed a strength so that best practices can become commonplace” but this statement is buried at the end of the report. (p. 22)

The DOE entities exhibit a wide variety of scale, scope, mission and organizational and technical complexity.  The Department’s goal should be to recognize that reality, develop it as an overall strength and then build on it to create site- or organization-specific interventions.

The Bureaucratizer

The proposed fixes would basically create a top-level coordinating and oversight group, enhance SC and SCWE training and modify contracts.  The recommendations reflect a concerted search for the lowest common denominator and a minimum amount of real change.

If the SC Improvement Panel is established, it should focus on setting or refining SC policy and ensuring those policies are implemented by line management, especially field management.  They should also be involved in evaluating major SC issues.  If things aren’t going well, this group should be the first to ask the hard “Why?” questions.  But most of the panel’s proposed tasks, viz., maintaining SC visibility, providing a forum for evaluating SC status and overseeing training improvements, are low-value make work.

“[S]afety culture training for all personnel, up and down the management chain, will be updated and/ or developed to ensure that roles and responsibilities are understood and personnel have the capabilities needed to play their part in continuously improving DOE's safety culture; . . .” (p. 24)  This is a standard fix for almost any perceived organizational problem.  It doesn’t require managers to do anything different.

Modifying contracts to incorporate clear references to SC is only a beginning.  What are the carrots and the sticks to incent the contractors to actually develop, measure and maintain an effective SCWE and strong SC?

Bottom Line

This report comports completely with an organization that resembles a fifty foot sponge.  You can kick it as hard as you like, your foot goes in deep and you think you’ve had an effect, but when you withdraw your foot, the organization fills in the hole like your kick never happened.  I thought I heard a loud pop on May 29.  I now realize it was likely DNFSB Chairman Winokur’s head exploding when he read this report.

But Wait, There’s More

Remember the question the DNFSB initially asked in 2011: Do WTP SC issues exist elsewhere in DOE?  Well, the answer is: “Review of assessment results from both [independent and self assessments] indicated there is a SCWE extent of condition that requires additional and ongoing actions to improve performance.” (p. 28, the penultimate page of the report)


*  J. Hutton (DOE) to P.S. Winokur (DNFSB) May 29, 2014 letter transmitting DOE Consolidated Report for DNFSB Recommendation 2011-1, Actions 2-8 and 2-9 (May 2014).

** DOE considers SC in three focus areas: Leadership, Employee Engagement and Organizational Learning.  Each focus area has a set of associated attributes that describe what a positive SC should look like. (pp. 4-5)

***  The report puts the self-assessments in the best possible light by describing them as learning experiences for the organizations involved. (p.9)

****  Drucker was referring to individuals but, in this case, we’ll stretch the blanket to cover organizations.  For individuals, weaknesses should not be ignored but the energy required to fix them, if it’s even possible, is often too great.  However, one should keep an eye on such weaknesses and not allow them to lead to performance failure.

DNFSB Observations on Safety Culture

DNFSB Headquarters

The Defense Nuclear Facilities Safety Board (DNFSB) has been busy in the safety culture (SC) space.  First, their Chairman’s May 7, 2014 presentation on preventing major accidents provides a window into how the DNFSB views safety management and SC in the DOE complex.  Second, the DNFSB’s meeting on May 28, 2014 heard presentations on SC concepts from industry and government experts.  This post reviews and provides our perspective on both events. 

Chairman’s Presentation

This presentation was made at a DOE workshop.*  Chairman Winokur opened with some examples of production losses that followed incidents at DOE facilities and concluded the cost of safety is small compared to the cost of an accident.  He went on to discuss organizational factors that can set the stage for accidents or promote improved safety performance.  Some of these factors are tied to SC and will be familiar to Safetymatters readers.  They include the following:

Leadership

The presentation quotes Schein: “The only thing of real importance that leaders do is to create and manage culture.” (p. 13)  This quote is used by many in the nuclear industry to support a direct and complete connection between leadership and an organization’s culture.   While effective leadership is certainly necessary, we have long argued for a more nuanced view, viz., that leaders influence but do not unilaterally define culture.  In fact, on the same page in Organizational Culture, Schein says “Culture is the result of a complex group learning process that is only partially influenced by leader behavior.” **

Budget and production pressures and
Rewards that favor mission over safety 

As Winokur pointed out, it is unfortunately true that poor safety performance (accidents and incidents) can attract resources while good safety performance can lead to resources being redirected.  Good safety performance becomes taken for granted and is largely invisible.  “Always focus on balancing mission and safety.  There will always be trade-offs, but safety should not get penalized for success.” (p. 19) 

On our part, we feel like we’ve been talking about goal conflicts forever.  The first step in addressing goal conflicts is to admit they exist, always have and probably always will.  The key to resolving them is not by issuing a safety policy, it is to assure that an entity’s decision making process and its reward and compensation system treat safety with the priority it warrants. 

Decision making

Winokur says “Understand the nature of low-probability, high-consequence accidents driven by inadequate control of uncertainty, not cause-effect relationships . . .” (p. 14) and “Risk-informed decision making can be deceptive; focus on consequences, as well as probabilities.” (p. 16)  These observations are directly compatible with Nicholas Taleb: “This idea that in order to make a decision you need to focus on the consequences (which you can know) rather than the probability (which you can’t know) is the central idea of uncertainty.”***  See our June 18, 2013 post for a discussion of decisions that led to high-consequence (i.e., really bad) outcomes at Crystal River, Kewaunee and San Onofre.

There is no additional material in the presentation for a few important factors, so we will repeat earlier Safetymatters commentary on these topics.    

Complacency and
Accumulated residual risks that erode the safety margin

We have pointed out how organizations, especially high reliability organizations, strive to maintain mindfulness and combat complacency.  Complacency leads to hubris (“It can’t happen here”) and opens the door for the drift toward failure that occurs with normalization of deviance, constant environmental adaptations, “normal” system performance excursions, group think and an irreducible tendency for SC to decay over time.

Lack of oversight

This refers to everyone who has the responsibility to provide competent, timely, incisive assessment of an entity’s activities but fails to do so.  Their inaction or incompetence neither reinforces a strong SC nor prods a weak SC to improve. 

DNFSB Hearing with SC Expert Presentations

This was "the first of two hearings the Board will convene to address safety culture at Department of Energy defense nuclear facilities and the Board’s Recommendation 2011–1, Safety Culture at the Waste Treatment and Immobilization Plant."****  This hearing focused on presentations by SC experts: Sonya Haber (an SC consultant to DOE), NRC and NASA.  The experts’ slide presentations and a video of the hearing are available here.

Haber hit the right buttons in her presentation but neither she nor anyone else mentioned her DOE client's failure to date to integrate the SC assessments and self-assessments DOE initiated at various facilities in response to Recommendation 2011-1.  We still don’t know whether WTP SC problems exist elsewhere in the DOE complex.  We commented on the DOE’s response to 2011-1 on January 25, 2013 and March 31, 2014.

Winokur asked Haber about the NRC's "safety first" view vs. the DOE's "mission/safety balance."  The question suggests he may be thinking the "balance" perspective gives the DOE entities too much wiggle room to short change safety in the name of mission.

The NRC presenter was Stephanie Morrow.  Her slides recited the familiar story of the evolution of the SC Policy Statement and its integration into the Reactor Oversight Process.  She showed a new figure that summarized NRC’s SC interests in different columns of the ROP action matrix.  Chairman Winokur asked multiple questions about how much direction the NRC gives the licensees in how to perform SC assessments.  The answer was clear: In the NRC’s world, SC is the licensee's responsibility; the NRC looks for adequacy in the consideration of SC factors in problem resolution and SC assessments.  Morrow basically said if DNFSB is too prescriptive, it risks ending up "owning" the facility SC instead of the DOE and facility contractor.

Our Perspective

The Chairman’s presentation addressed SC in a general sense.  However, the reality of the DOE complex is a formidable array of entities that vary widely in scope, scale and missions.  A strong SC is important across the complex but one-size-fits-all approaches probably won’t work.  On the other hand, the custom fit approach, where each entity has flexibility to build its SC on a common DOE policy foundation doesn’t appear to lead to uniformly good results either.  The formal hearing to receive presentations from SC industry experts evidences that the DNFSB is gathering information on what works in other fields.  

Bottom line: The DNFSB is still trying to figure out the correct balance between prescription and flexibility in its effort to bring DOE to heel on the SC issue.  SC is an vital part of the puzzle of how to increase DOE line management effectiveness in ensuring adequate safety performance at DOE facilities.


*  P.S. Winokur, “A User’s Guide to Preventing Major Accidents,” presentation at the 2014 Nuclear Facility Safety Programs Annual Workshop (May 7, 2014).  The workshop was sponsored by the DOE Office of Environment, Health, Safety, and Security.  Thanks to Bill Mullins for bring this presentation to our attention.

**  E. Schein, Organizational Culture and Leadership (San Francisco, CA: Jossey-Bass, 2004), p. 11.

***  N. Taleb, The Black Swan (New York: Random House, 2007), p. 211.

****  DNFSB May 28, 2014 Public Hearing on Safety Culture and Board Recommendation 2011-1.

Our Gaze Returns to DOE and its Safety Culture

The Department of Energy (DOE) recently submitted a report* to the Defense Nuclear Facilities Safety Board (DNFSB) covering DOE’s evaluation of Safety Conscious Work Environment (SCWE) self-assessments at various DOE facilities.  This evaluation was included in the DOE’s Implementation Plan** (IP) developed in response to the DNFSB report, Safety Culture at the Waste Treatment and Immobilization Plant.*** (WTP, or the Vit Plant).  This post provides some background on how WTP safety culture (SC) problems led to a wider assessment of SC in DOE facilities and then reviews the current report.

Background

The DNFSB report on the WTP was issued June 9, 2011; it said the WTP SC was “flawed.”  Issues included discouraging technical dissent, goal conflicts between schedule/budget and safety, and intimidation of personnel.  We posted on the DNFSB report June 15, 2011.  The report’s recommendations included this one: that the Secretary of Energy “conduct an Extent of Condition Review to determine whether these safety culture weaknesses are limited to the WTP Project, . . .” (DNFSB, p. 6) 

After some back-and-forth between DOE and DNFSB, DOE published their IP in December 2011.  We reviewed the IP on Jan. 24, 2012.  Although the IP contained multiple action items, our overall impression was “that DOE believes there is no fundamental safety culture issue. . . . 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.”  So we were not exactly optimistic but DOE did say it would “conduct an Extent of Condition Review to find out whether similar safety culture weaknesses exist at other sites in addition to the WTP and whether there are barriers to strong safety culture at Headquarters and the Department as a whole (e.g., policies or implementation issues). The review will focus on the Safety Conscious Work Environment (SCWE) at each site examined.” (IP, p. 17)  In other words, SC was reduced to SCWE from the get-go.****

Part of the DOE review was to assess SCWE at a group of selected DOE facilities.  DOE submitted SC assessments covering five facilities to DNFSB on Dec. 12, 2012.  We reviewed the package in our post Jan. 25, 2013 and observed “The DOE submittal contained no meta-analysis of the five assessments, and no comparison to Vit Plant concerns.  As far as [we] can tell, the individual assessments made no attempt to focus on whether or not Vit Plant concerns existed at the reviewed facilities.”  We called the submittal “foot dragging” by DOE.

Report on SCWE Self-Assessments

A related DOE commitment was to perform SCWE self-assessments at numerous DOE facilities and then evaluate the results to determine if SCWE issues similar to WTP’s existed elsewhere.  It is important to understand that this latest report is really only the starting point for evaluating the self-assessments because it focuses on the processes used during the self-assessments and not the results obtained. 

The evaluation of the self-assessments was a large undertaking.  The evaluation team visited 22 DOE and contractor organizations and performed document reviews for 9 additional organizations, including the DOE Office of River Protection and Bechtel National, major players in the WTP drama. 

Problems abounded.  Self-assessment guidance was prepared but not distributed to all sites in a timely manner and there was no associated training.  Each self-assessment team had a “subject matter expert” but the qualifications for that role were not specified.  Data collection methods were not consistently applied and data analyses were of variable quality.  As a consequence, the self-assessment approaches used varied widely and the results obtained had variable reliability.

The self-assessment reports exhibited varying quality.  Some were satisfactory but “In many of the self-assessment reports, the overall conclusions did not accurately reflect the information in the data and analysis sections. In some cases, negative results were presented with a statement rationalizing or minimizing the issue, rather than indicating a need to find out more about the issue and resolve it.  In other cases, although data and/or analysis reflected potential problems, those problems were not mentioned in the conclusions or executive summaries, which senior management is most likely to read.” (p. 7)

The evaluation team summarized as follows: “The overall approach ultimately used to self-assess SCWE across the complex did not provide for consistent application of assessment methodologies and was not designed to ensure validity and credibility. . . . The wide variation in the quality of methodologies and analysis of results significantly reduces the confidence in the conclusions of many of the self-assessments.  Consequently, caution should be used in drawing firm conclusions about the state of SCWE or safety culture across the entire DOE complex based on a compilation of results from all the site self-assessments.” (p. iii)

“The Independent Oversight team concluded that DOE needs to take additional actions to ensure that future self-assessments provide a valid and accurate assessment of the status of the safety culture at DOE sites and organizations, . . .” (p. 8)  This is followed by a series of totally predictable recommendations for process improvements: “enhance guidance and communications,” increase management “involvement in, support for, and monitoring of site self-assessments,” and “DOE sites . . . should increase their capabilities to perform self-assessments . . .” (pp. 9-10)

Our Perspective

The steps taken to date do not inspire confidence in the DOE’s interest in determining if and what SCWE (much less more general SC) issues exist in the DOE complex.  For the facilities that were directly evaluated, we have some clues to the existence similar problems.  For the facilities that conducted self-assessments, so far we have—almost nothing.

There is one big step remaining: DOE also said it would “develop a consolidated report from the results of the self-assessments and HSS independent reviews.” (IP, p. 20)  We await that report with bated breath.

For our U.S. readers: This is your tax dollars at work. 


*  DOE Office of Enforcement and Oversight, “Independent Oversight Evaluation of Line Self-Assessments of Safety Conscious Work Environment” (Feb. 2014).

**  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).

***  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).

****  DOE rationalized reducing the scope of investigation from SC to SCWE by saying “The safety culture issues identified at WTP are primarily SCWE issues. . .” (p. 17)  We posted a lecturette about SC being much more than SCWE here.

Meanwhile, Back at the Vit Plant

Previous posts* have chronicled the safety culture (SC) issues raised at the Waste Treatment and Immobilization Plant (WTP aka the Vit plant) at the Department of Energy's (DOE's) Hanford site.  Both the DOE Office of River Protection (ORP) and the WTP contractor (Bechtel) have been under the gun to strengthen their SC.  On May 30, 2013 DOE submitted a progress report** to the Defense Nuclear Facilities Safety Board covering both DOE and Bechtel activities.

DOE ORP

Based on an assessment by an internal SC Integrated Project Team (IPT), ORP reported its progress on nine near-term SC improvement actions contained in the ORP SC Improvement Plan.  For each action, the IPT assessed degree of implementation (full, partial or none) and effectiveness (full, partial, or indeterminate).  The following table summarizes the actions and current status.

ORP has a lot of activities going on but only two are fully implemented and none is yet claimed to be fully effective.  In ORP's own words, “ORP made a substantial start toward improving its safety culture, but much remains to be done to demonstrate effective change. . . . Four of the nine actions were judged to be partially effective, and the other five were judged to be of indeterminate effectiveness at the time of evaluation due to the recent completion of some of the actions, and because of the difficulty in measuring safety culture change over a one-year time period.” (Smith, p. 1)

The top-level ORP actions look substantive but digging into the implementation details reveals many familiar tactics for addressing SC problems: lots of training (some yet to be implemented), new or updated processes and procedures, (incomplete) distribution of INPO booklets, and the creation of a new behavioral expectations poster (which is largely ignored).

SC elements have been added to senior management and supervisor performance plans.  That appears to mean these folks are supposed to periodically discuss SC with their people.  There's no indication whether such behavior will be included in performance review or compensation considerations.

ORP did attempt to address concerns with the Differing Professional Opinion (DPO) process.  DPO and Employee Concerns Program (ECP) training was conducted but some employees reported reservations about both programs.

A new issues management system has been well received by employees but needs greater promotion by senior managers to increase employees' willingness to raise issues and ask questions.  The revised ECP also needs increased senior management support.

The team pointed out that ORP does not have a SC management statement or policy.

Bechtel

There is much less detail available here.  The report says Bechtel's plan “contains 50 actions broken into six strategic improvement areas:

A. Realignment and Maintenance of Design and Safety Basis
B. Management Processes of the WTP NSQC
C. Timeliness of Issues Identification
D. Resolution. Roles. Responsibilities. Authorities, and Accountabilities
E. Management and Supervisory Behaviors
F.  Construction Site-Unique Issues

“The scheduled completion date for the last actions is December 2013. Twenty-seven actions were complete as of March 31, 2013, with an additional 12 planned to be complete by June 30, 2013.” (p. 19)

“ORP has completed surveillances on 19 of the 27 completed actions identifying 7 opportunities for improvement.  Because changing an organization's culture takes time, the current oversight efforts are focused on verifying actions have been completed.” (ibid.)  In other words, there has been no evaluation of the effectiveness of Bechtel's actions.

Our perspective

The ORP program is a traditional approach aimed at incremental organizational performance improvement.  There is no or scant mention of what we'd call strategic concerns, e.g., recognizing and addressing schedule/budget/safety goal conflicts; decision making in a complex, dynamic environment with many external pressures; riding herd on Bechtel; or creating a sense of urgency with respect to SC.

The most surprising thing to us was how unexpectedly candid the assessment was (for one produced by an employee team) in describing the program's impact to date.  For example, as the IPT performed its assessment, it tried to determine if employees were aware of the SC actions or their effects.  The results were mixed: some employees see changes but many don't, or they sense a general change but are unaware of specifics, e.g., new or changed procedures.  In general, organizational emphasis on SC declined over the year and was not very visible to the average employee.

The team's most poignant item was a direct appeal for personal involvement by the ORP manager in the SC program.  That tells you everything you need to know about SC's priority at ORP.


*  Click on Vit Plant under Labels to see previous posts.

**  M. Moury (DOE) to P.S. Winokur (DNFSB), DOE completes Action 1-9 of the Department's Implementation Plan for DNFSB Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant (May 30, 2013).  A status summary memo from ORP's K.W. Smith and the IPT report are attached to the Moury letter.  Our thanks to Bill Mullins for bringing these documents to our attention.

A New Sheriff Coming to DOE?

On April 9th, the nominee for Secretary of Energy, Dr. Ernest Moniz, appeared before the Senate Committee on Energy and Natural Resources.  Most of the three hour hearing was in a Q&A format, with the committee chairman showing special interest in the major problems at Hanford, viz., leaking waste storage tanks and explosive hydrogen accumulation in same, the Waste Treatment Plant (aka Vit Plant) project and the site safety culture (SC).*

With respect to the SC issue, the nominee said it was “unacceptable” for SC to not be where it needs to be.  In response to a question from the committee chairman, Dr. Moniz said he was willing to meet with Vit Plant whistleblowers.  Depending on the outcome of such a meeting, if it occurs, the new Secretary could send a powerful signal to the Hanford site and beyond about his views on SC, Differing Professional Opinion (and related) practices, a Safety Conscious Work Environment and retaliation against employees who question organizational decisions.


*  The meeting video is available here, Hanford is discussed from about 3:05 to 3:20. 

A letter from the DNFSB chairman provides a good summary of the key issues at Hanford.  See P.S. Winokur (DNFSB) to R.L. Wyden (chairman of the Senate Committee on Energy and Natural Resources), letter providing the DNFSB's perspective on the state of nuclear safety at the Hanford Site (April 1, 2013).

Safety Culture at the Pantex Plant

Pantex Plant

On January 25, 2013 we posted about DOE's report to the Defense Nuclear Facilities Safety Board (DNFSB) on the results of safety culture (SC) assessments at several DOE facilities, including the Pantex Plant.  Pantex was assessed because two Pantex employees had reported retaliation for raising a safety concern but the plant also had a history of potentially SC-significant issues.*

The Pantex SC assessment was performed in November 2012.  The report included several significant findings:

“Efforts to communicate and implement the principles of a High Reliability Organization (HRO) have been ongoing for several years. . . . [However,] The realization of the HRO principles has not yet been internalized by the Plant, . . .”

“The belief that the organization places a priority on safety is undermined by employee observations of poor facility conditions, lack of focus on meeting personal needs (work quality of life), and a sense of cronyism. . . . [This] has created the perception among many employees that the financial bottom line is the only focus that matters.

“There is a strong perception that retaliation exists for ‘rocking the boat.’ . . . The perception has created an environment where the raising of questions or identification of problems is not the consistently accepted way of doing business.

“The Pantex Plant has not been successful in understanding the organizational and programmatic behaviors that are necessary for a healthy safety culture. . . . organizational barriers have been created that will prevent successful implementation of the initiatives needed to enhance safe and reliable performance. . . . The barriers are also evident in the lack of respect, difficulty in effective communication, the non-alignment between the perceptions around the unions and management relationships and the notion of ‘need to know’ being extended to almost everything.”**

Sounds serious.  So what's happened since the report was published?  Well, DNFSB held a public meeting on March 14, 2013 to discuss SC problems at Pantex and management's approach to addressing them.  As one might expect, the DOE opening statement declared the SC problems were intolerable and DOE had taken immediate action—by firing off a letter to the contractor. 

“NNSA issued a letter to B&W Pantex directing immediate focus at all management and working levels to a safety conscious work environment (SCWE) for all on-going activities and operations. . . . Other immediate actions included the development of a single stop/pause work process which was provided to all employees and discussed at daily work planning meetings. The Employee Concerns Program and Equal Opportunity Office reporting chain was immediately elevated to a direct report to the General Manager’s Office, providing the highest level accesses for any employee concerns in these areas. Additionally, the differing professional opinion process was reinstated providing a formal mechanism for recognition and resolution of differing views on technical matters.

“Further, this letter directed B&W Pantex to prepare a comprehensive long-term corrective action plan mentioned previously, taking into account the Institute of Nuclear Power Operations (INPO) paper on the principles of a strong nuclear safety culture.”***

DOE listed actions being implemented, including an SC focus team, a seminar on HRO attributes, SCWE training, the issuance of a plant-specific SC policy and an alignment of performance incentives with SC objectives. 

Babcock & Wilcox (B&W)

B&W, the entity that actually has to do the work, did not file any written testimony for the public meeting so we have to go to the meeting video for their comments.****

B&W appears to be on board with the need for change.  The B&W plant general manager and his safety manager were appropriately deferential to the DNFSB members and seemingly well-informed about the plant's remedial actions and SC improvement initiatives.  The GM said he “fully accepts” the assessment findings (which were consistent with the plant's own SC survey conducted just prior to the DOE HSS assessment) and acknowledged that specific problems, e.g., communication issues with respect to safety vs production, existed.  Improving SC/SCWE is the GM's “top priority.”  B&W reiterated its commitment to building an HRO at Pantex, an initiative that overlaps with actions to strengthen SC and SCWE.  Perhaps the most significant change the GM described was that 30% of managers' performance evaluations would be based on their modeling of appropriate SC/SCWE traits.

Our perspective    

Problem solved?  Not yet and not for awhile.  Pantex had some serious vertical communication and organizational structure issues.  Their attempt to build an HRO has been ongoing for years.  Their SCWE has had some cold spots. 

In addition, the actions Pantex has initiated may be necessary but there is no guarantee they will be sufficient to achieve the plant's SC/SCWE/HRO goals.  For example, there is no real discussion of how decision making processes will be affected other than resolving Nuclear Explosive Safety issues and the usual commitment to conservative decision making.  There is no mention of a corrective action program (or some functional equivalent); an integrated process for identifying, evaluating and fixing problems is essential for ensuring safety, priorities and resource allocation are treated consistently throughout the plant.

We'll watch for progress (or lack thereof) and keep you posted.


*  Pantex is the sole US site that assembles and disassembles nuclear weapons.  Within DOE, the National Nuclear Security Administration (NNSA) has line management responsibility for Pantex.  Babcock & Wilcox is responsible for managing and operating the plant under contract with DOE.

The SC issues identified in the November 2012 assessment did not pop out of nowhere.  The DNFSB identified SC-related concerns at the plant during the previous year.  See statement of D.G. Ogg, Group Lead for Nuclear Weapons Programs, DNFSB, at the Pantex public meeting (March14, 2013).
   
**  DOE Office of Enforcement and Oversight, “Independent Oversight Assessment of Nuclear Safety Culture at the Pantex Plant” (Nov. 2012) p. 3.  The report is attached to the letter from G.S. Podansky (DOE) to P.S. Winokur (DNFSB) transmitting five independent safety culture assessments (Dec. 12, 2012).

***  Written testimony of Neile Miller, Acting Administrator, NNSA before the Defense Nuclear Facilities Safety Board Pantex Plant Public Meeting (March 14, 2013), p. 4. 

****  The meeting video is available on the DNFSB website.  The NNSA panel on Pantex SC runs from about 1:25 to 2:30, the B&W panel runs from about 2:35 to 3:20.

Safety Culture Assessments: the Vit Plant vs. Other DOE Facilities

The Vit Plant

 As you recall, the Defense Nuclear Facilities Safety Board (DNFSB) set off a little war with DOE when DNFSB published its blistering June 2011 critique* of the Hanford Waste Treatment Plant's (Vit Plant) safety culture (SC).  Memos were fired back and forth but eventually things settled down.  One of DOE's resultant commitments was to assess SC at other DOE facilities to see if  SC concerns identified at the Vit Plant were also evident elsewhere.  Last month DOE transmitted the results of five assessments to DNFSB.**  The following facilities were evaluated:

• Los Alamos National Laboratory Chemistry and Metallurgy Research Replacement Project (Los Alamos)
• Y-12 National Security Complex Uranium Processing Facility Project (UPF)
• Idaho Cleanup Project Sodium Bearing Waste Treatment Project (Idaho)
• Office of Environmental Management Headquarters (EM)
• Pantex Plant 

The same protocol was used for each of the assessments: DOE's Health, Safety and Security organization formed a team of its own assessors and two outside experts from the Human Performance Analysis Corporation (HPA).  Multiple data collection tools, including functional analysis, semi-structured focus group and individual interviews, observations and behavioral anchored rating scales, were used to assess organizational behaviors.  The external experts also conducted a SC survey at each site.

A stand-alone report was prepared for each facility, consisting of a summary and recommendation (ca. 5 pages) and the outside experts' report (ca. 25 pages).  The outside experts organized their observations and findings along the nine SC traits identified by the NRC, viz.,

• Leadership Safety Values and Actions
• Problem Identification and Resolution
• Personal Accountability
• Work Processes
• Continuous Learning
• Environment for Raising Concerns
• Effective Safety Communication
• Respectful Work Environment
• Questioning Attitude.

So, do Vit Plant SC concerns exist elsewhere?

That's up to the reader to determine.  The DOE submittal contained no meta-analysis of the five assessments, and no comparison to Vit Plant concerns.  As far as I can tell, the individual assessments made no attempt to focus on whether or not Vit Plant concerns existed at the reviewed facilities.

However, my back-of-the-envelope analysis (no statistics, lots of inference) of the reports suggests there are some Vit Plant issues that exist elsewhere but not to the degree that riled the DNFSB when it looked at the Vit Plant.  I made no effort to distinguish between issues mentioned by federal versus contractor employees, or by different contractors.  Following are the major Vit Plant concerns, distilled from the June 2011 DNFSB letter, and their significance at other facilities.

Schedule and/or budget pressure that can lead to suppressed issues or safety short-cuts
 
This is the most widespread and frequently mentioned concern.  It appears to be a significant issue at the UPF where the experts say “the project is being driven . . . by a production mentality.”  Excessive focus on financial incentives was also raised at UPF.  Some Los Alamos interviewees reported schedule pressure.  So did some folks at Idaho but others said safety was not compromised to make schedule; financial incentives were also mentioned there.  At EM, there were fewer comments on schedule pressure and at Pantex, interviewees opined that management shielded employees from pressure and tried to balance the message that both safety and production are important.

A chilled atmosphere adverse to safety exists

The atmosphere is cool at some other facilities, but it's hard to say the temperature is actually chilly.  There were some examples of perceived retaliation at Los Alamos and Pantex.  (Two Pantex employees reported retaliation for raising a safety concern; that's why Pantex, which was not on the original list of facilities for SC evaluation, was included.)  Fear of retaliation, but not actual examples, was reported at UPF and EM.  Fear of retaliation was also reported at Pantex. 

Technical dissent is suppressed

This is a minor issue.  There were some negative perceptions of the differing professional opinion (DPO) process at Los Alamos.  Some interviewees thought the DPO process at EM could be better utilized.  The experts said DPO needed to be better promoted at Pantex. 

Processes for raising and resolving SC-related questions exist but are neither trusted nor used

Another minor issue.  The experts said the procedures at Los Alamos should be reevaluated and enforced.

Conclusion

I did not read every word of this 155 page report but it appears some facilities have issues akin to those identified at the Vit Plant but their scope and/or intensity generally appear to be less.

The DOE submittal is technically responsive to the DNFSB commitment but is not useful without further analysis.  The submittal evidences more foot dragging by DOE to cover up the likely fact that the Vit Plant's SC problems are more significant than other facilities' and buy time to attempt to correct those problems.


* 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).  We have posted on the DOE-DNFS imbroglio here, here and here.
   
**  G.S. Podansky (DOE) to P.S. Winokur (DNFSB), letter transmitting five independent safety culture assessments (Dec. 12, 2012).

Reflections on the Vit Plant's New Safety Culture Manager: Full Steam Ahead or Time for DOE to Consider a New Plan B?

(Ed. note: Here's a new essay on the Vit Plant by Bill Mullins.  In an era of sound bites and tweets, we provide a forum where complete ideas can be aired.  Please contact us if you would like to contribute.)

“Hanford Contractor Hires New Safety Culture Manager” Oregon Public Broadcasting News 2/8/12

Strange Circumstance: The Safetymatters readership may already have checked out the above item with its announcement of the latest move by the Bechtel National (BNI) management team for the “fast-track, design-build” contract at the Hanford Waste Treatment Plant (WTP).

Reviewing the announcement of Ward Sproat’s assignment to a newly created position “Safety Culture Manager” it seemed appropriate to make a few comments on what a strange turn of affairs this seems to be in what is already a very strange circumstance.

In its Recommendation 2011-1, the Defense Nuclear Facilities Safety Board (DNFSB) “determined that the prevailing safety culture at the Waste Treatment and Immobilization Plant (WTP) is flawed and effectively defeats [DOE Nuclear Safety Policy].”

No previous DNFSB Recommendation has addressed the issue of Nuclear Safety Culture (NSC) and its raising in the far-from-typical circumstance of the WTP contract represents a significant oversight policy challenge for DOE. DOE’s Implementation Plan makes substantial enterprise-wide commitments on the basis of this single exemplar.

Testing Nuclear Safety Culture: The 2011-1 finding arose in the midst of an already contentious WTP setting involving formal nuclear safety “whistle-blower” complaints and a DNFSB formal investigation of the surrounding circumstances. Equally significant is the fact that the WTP project is significantly troubled by questions of technology readiness levels in the key Pretreatment processes. BNI’s contract contains a $100M incentive for early start of waste treatment in the WTP.

One might conclude that the notion of NSC, for all the advocacy of its importance across the global nuclear energy enterprise, is receiving a significant baptism of fire at the WTP. The selection of Mr. Sproat, and the position created for him, allows some reflection upon a key attribute – Leadership – of NSC conventional wisdom.

There appears to be broad consensus that Leadership is important to effective NSC. From the US Nuclear Regulatory Commission (NRC) we have this statement of NSC trait:

“Leadership Safety Values and Actions – Leaders demonstrate a commitment to safety in their decisions and behaviors.”

Similar statements are found in INPO, IAEA and NEI standards on NSC; of interest here is: To what extent does the Leadership norm inform the selection criteria for Mr. Sproat?

Competence Commensurate: At this juncture in the River Protection Program there is a large body of opinion pointing to “Nuclear Safety Culture” as a normative factor that is implicated in difficulties managing the acquisition of the Waste Treatment Plant under DOE’s contract with Bechtel National. On the record, views range from “defective until demonstrated otherwise” (DNFSB); to sanguine (DOE Safety Oversight); to confident about improvement (Bechtel sponsored Independent Safety and Quality Culture Team).

As a framework for assessing the BNI appointment I’m using the DOE’s Integrated Safety Management (ISM) Doctrine (cf. DOE P 450.4A). The ISM Doctrine encompasses NSC.

ISM Guiding Principle #3 states:

“COMPETENCE COMMENSURATE WITH RESPONSIBILITIES.  Personnel possess the experience, knowledge, skills, and abilities that are necessary to discharge their responsibilities."

Given the BNI action to bring Mr. Sproat’s relevant experience to bear on the WTP challenges it seems reasonable to assess his “Competence commensurate with responsibilities” for NSC leadership, and how that relates to the identified needs for WTP project improvement. Stated differently, does the appointment of Mr. Sproat indicate BNI understands what is expected by way of WTP performance improvement?

Determination of Competence: Mr. Sproat has clearly held positions of substantial responsibility; in the near past he was the Presidential Appointee in DOE responsible for development of the Yucca Mountain Repository license application to the NRC – this too was work DOE contracted to Bechtel. Now, one must ask: How does executive experience with preparing a highly structured NRC license application for a geological repository relate to the development of a DOE Authorization Basis for a High Level Liquid Waste treatment facility of very uncertain feasibility?

Mr. Sproat’s experience with DOE projects has been outside the domain of the Environmental Management Program to which the Hanford Tank Waste belongs. Similarly, he appears to have limited experience with Federal Facilities Compliance Agreements which govern major RCRA actions such as the WTP; likewise his knowledge of the DOE practice of nuclear facility “regulation by contract” would appear to be indirect at best. These shortfalls of direct experience will likely make for a steep learning curve.

Mr. Sprout undoubtedly has leadership capacity, but is it relevant to the WTP acquisition? Can DOE rely upon his judgment regarding his fitness for leadership in this very troubled circumstance? As I understand the sense of the several authoritative NSC standards, the importance of “nuclear safety as an over-riding priority” would seem to create a considerable premium on direct experience when the project involved is well outside the “typical” nuclear facility setting – as is the WTP.

The significantly atypical character of the WTP would thus suggest that the assessment of Mr. Sproat’s fit to the challenge should be made by someone who is intimate with the project. Reporting at such a high level, this person would seem to be the BNI Project Manager Mr. Russo, perhaps with the aid of some key reports.

BNI’s Judgment of Fitness: For an assessment of the BNI judgment of Competence Commensurate with Responsibilities, consider Mr. Russo’s announcement of Mr. Sproat’s assignment. Therein, Mr. Russo portrays the January 2012 report of the DOE Office of Health, Security and Safety’s follow up review of safety culture for the WTP project. He observes: “The HSS report is particularly important because it is from the perspective of DOE. As such, it represents the knowledge and experience of the entire weapons complex.” This would not appear to be the case.

At the HSS Report Section 2.2 Scope and Methods we find:

“The applied framework was the one recently described by the NRC. The evaluation was conducted using the same methodology that aligns with the current NRC procedures for independent safety culture assessment.

“The safety culture components important for the existence of a healthy safety culture within a nuclear facility have been identified (INSAG-15, 2002; Institute of Nuclear Power Operations Principles for a Strong Nuclear Safety Culture, 2004; NRC Inspection Manual 0305, 2006). The NRC and its stakeholders have recently agreed upon nine traits that are viewed as necessary in promoting a positive safety culture…

“While the methodology used in this evaluation was based upon work originally developed with the support of the NRC to assess the influence of organization and management on safety performance, the methodology has also been effectively implemented in non-nuclear organizations, such as mining, health care, research, engineering, and transportation.”

Several observations are in order at this point:

•    The analytical framework of this evaluation is taken from a commercial vendor’s standard process. This framework was developed in 1991 at Brookhaven National Laboratory for the US NRC. The principals of the contractor Human Performance Analysis Corporation (HPAC)  were developers of the methodology which is used in a variety of high consequence circumstances and is not particularly tailored to any of the NRC, IAEA, INPO, or other safety culture developments since the inception of the current Reactor Oversight Process in 1999.

•    While the work in 1991 was advanced for its time, there is a case to be made that the “enterprise culture construct” employed then has become obsolescent – at least as far as the civilian nuclear power enterprise is concerned. HPAC cites as reference a culture model developed by Edgar Schein many years before 1991. As recently as 2003 Dr. Schein, in an address to the INPO CEOs on the subject of managing culture change employed a very different construct – he did not use the term “safety culture” in that talk; rather he characterized enterprise culture as emergent of all performance aspects (i.e. production and protection) at the interface of the various distinct professional cultures (executives, engineers, operators, maintainers) where work is planned.

•    While giving lip-service to its definition, neither the HSS Report nor the HPAC Appendix (a separate report from the same assessment data sets) reflects the DOE Safety Culture standard developed jointly in 2009/10 by DOE and Energy Facility Contractors Group (EFCOG). This is significant because the definition of Safety Culture in that work takes shape from the DOE’s Integrated Safety Management Policy and Doctrine – if differs markedly from virtually all NRC and other definitions in that it is not a “safety first” framework (i.e. “overriding priority given to nuclear safety).

•    There is no indication that any of the various Safety Culture assessment and improvement approaches draw upon experience with one-of-a-kind technology development, a multi-facility complex design, process challenged dominated by physical chemistry not radiological concerns, and systematization on a scale unprecedented since the Manhattan project – if even then.

On these bases, Mr. Russo’s contention that the HSS review is indicative of DOE complex-wide expectations for Safety Culture is misplaced.

Finding the Glitch: What can be expected from Mr. Sproat would seem to follow from how valuable his NSC relevant experience will be in curing the misalignment of two professional organizations “facility design” and “safety analysis.” These organizations – one headed by a senior management whistle-blower on this project – have been working for some years to conflicted objectives.

“For the WTP project, DOE decided to implement a “design-build” approach in which significant construction efforts are undertaken in parallel with the design efforts. The goal of this approach was to complete the WTP sooner, thus allowing DOE to meet milestones for addressing tank waste hazards and reducing the environmental and safety risks associated with the hazardous wastes in the tank.”

This statement fails to fully illuminate that fact that it is universally understood in the world of large project acquisition, that “design-build” efforts are only prudently employed in circumstances of high certainty from past precedent both in terms of design, construction methods, resource availability, and other such uncertainty-stabilizing factors. None of these conditions ever pertained in the instance of the WTP.

The over-arching conclusion of the HSS review seems to be this:

“While there is no fear of retaliation in the ORP (including DOE-WTP) work environment, there is a definite unwillingness and uncertainty among employees about the ability to openly challenge management decisions. There are definite perceptions that there is not an environment conducive to raising concerns or where management wants or willingly listens to concerns. Most employees also believe that constructive criticism is not encouraged.”

Like the several other reports on the record this conclusion tells the “What” of the challenge, but not the “Why.”

Conclusion: In the latest HSS Report’s many pages of recommendations it seems clear that conditions observed have not improved much from those of 12 -24 months earlier. While there is plenty of room for improvement on the DOE side of the ledger, it is difficult to avoid a conclusion that the appointment of Mr. Sproat, and his arrival’s announcement by Mr. Russo, suggest that BNI still sees the unresolved design and technology development challenges as “punch-list items.”

For BNI, even in the midst of the prolonged “safety culture” uproar, it appears the many disparate review results still comprise a “Full Steam Ahead” matter to be resolved by top-down command and control management methods.  I wish them luck with that – to DOE I suggest looking toward a radical Plan B.

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