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.

Declining Safety Culture at the Waste Isolation Pilot Plant?

DOE WIPP

Here’s another nuclear-related facility you may or may not know about: The Department of Energy’s (DOE) Waste Isolation Pilot Plant (WIPP) located near Carlsbad, NM.  WIPP’s mission is to safely dispose of defense-related transuranic radioactive waste.  “Transuranic” refers to man-made elements that are heavier than uranium; in DOE’s waste the most prominent of these elements is plutonium but waste also includes others, e.g., americium.*

Recently there have been two incidents at WIPP.  On Feb. 5, 2014 a truck hauling salt underground caught fire.  There was no radiation exposure associated with this incident.  But on Feb. 14, 2014 a radiation alert activated in the area where newly arrived waste was being stored.  Preliminary tests showed thirteen workers suffered some radiation exposure.

It will come as no surprise to folks associated with nuclear power plants that WIPP opponents have amped up after these incidents.  For our purposes, the most interesting quote comes from Don Hancock of the Southwest Research and Information Center: “I’d say the push for expansion is part of the declining safety culture that has resulted in the fire and the radiation release.”  Not surprisingly, WIPP management disputes that view.**

Our Perspective

So, are these incidents an early signal of a nascent safety culture (SC) problem?  After all, SC issues are hardly unknown at DOE facilities.  Or is the SC claim simply the musing of an opportunistic anti?  Who knows.  At this point, there is insufficient information available to say anything about WIPP’s SC.  However, we’ll keep an eye on this situation.  A bellwether event would be if the Defense Nuclear Facilities Safety Board decides to get involved.


*  See the WIPP and Environmental Protection Agency (EPA) websites for project information.  If the WIPP site is judged suitable, the underground storage area is expected to expand to 100 acres.

The EPA and the New Mexico Environmental Department have regulatory authority over WIPP.  The NRC has regulatory authority over the containers used to ship waste.  See National Research Council, “Improving the Characterization Program for Contact-Handled Transuranic Waste Bound for the Waste Isolation Pilot Plant” (Washington, DC: The National Academies Press, 2004), p. 27.

**  J. Clausing, “Nuclear dump leak raises questions about cleanup,” Las Vegas Review-Journal (Mar. 1, 2014).  Retrieved Mar. 3, 2014.

Four Years of Safetymatters

Aztec Calendar

Over the four plus years we have been publishing this blog, regular readers will have noticed some recurring themes in our posts.  The purpose of this post is to summarize our perspective on these key themes.  We have attempted to build a body of work that is useful and insightful for you.

Systems View

We have consistently considered safety culture (SC) in the nuclear industry to be one component of a complicated socio-technical system.  A systems view provides a powerful mental model for analyzing and understanding organizational behavior. 

Our design and explicative efforts began with system dynamics as described by authors such as Peter Senge, focusing on characteristics such as feedback loops and time delays that can affect system behavior and lead to unexpected, non-linear changes in system performance.  Later, we expanded our discussion to incorporate the ways systems adapt and evolve over time in response to internal and external pressures.  Because they evolve, socio-technical organizations are learning organizations but continuous improvement is not guaranteed; in fact, evolution in response to pressure can lead to poorer performance.

The systems view, system dynamics and their application through computer simulation techniques are incorporated in the NuclearSafetySim management training tool.

Decision Making

A critical, defining activity of any organization is decision making.  Decision making determines what will (or will not) be done, by whom, and with what priority and resources.  Decision making is  directed and constrained by factors including laws, regulations, policies, goals, procedures and resource availability.  In addition, decision making is imbued with and reflective of the organization's values, mental models and aspirations, i.e., its culture, including safety culture.

Decision making is intimately related to an organization's financial compensation and incentive program.  We've commented on these programs in nuclear and non-nuclear organizations and identified the performance goals for which executives received the largest rewards; often, these were not safety goals.

Decision making is part of the behavior exhibited by senior managers.  We expect leaders to model desired behavior and are disappointed when they don't.  We have provided examples of good and bad decisions and leader behavior. 

Safety Culture Assessment

We have cited NRC Commissioner Apostolakis' observation that “we really care about what people do and maybe not why they do it . . .”  We sympathize with that view.  If organizations are making correct decisions and getting acceptable performance, the “why” is not immediately important.  However, in the longer run, trying to identify the why is essential, both to preserve organizational effectiveness and to provide a management (and mental) model that can be transported elsewhere in a fleet or industry.

What is not useful, and possibly even a disservice, is a feckless organizational SC “analysis” that focuses on a laundry list of attributes or limits remedial actions to retraining, closer oversight and selective punishment.  Such approaches ignore systemic factors and cannot provide long-term successful solutions.

We have always been skeptical of the value of SC surveys.  Over time, we saw that others shared our view.  Currently, broad-scope, in-depth interviews and focus groups are recognized as preferred ways to attempt to gauge an organization's SC and we generally support such approaches.

On a related topic, we were skeptical of the NRC's SC initiatives, which culminated in the SC Policy Statement.  As we have seen, this “policy” has led to back door de facto regulation of SC.

References and Examples

We've identified a library of references related to SC.  We review the work of leading organizational thinkers, social scientists and management writers, attempt to accurately summarize their work and add value by relating it to our views on SC.  We've reported on the contributions of Dekker, Dörner, Hollnagel, Kahneman, Perin, Perrow, Reason, Schein, Taleb, Vaughan, Weick and others.

We've also posted on the travails of organizations that dug themselves into holes that brought their SC into question.  Some of these were relatively small potatoes, e.g., Vermont Yankee and EdF, but others were actual disasters, e.g., Massey Energy and BP.  We've also covered DOE, especially the Hanford Waste Treatment and Immobilization Plant (aka the Vit plant).

Conclusion

We believe the nuclear industry is generally well-managed by well-intentioned personnel but can be affected by the natural organizational ailments of complacency, normalization of deviation, drift, hubris, incompetence and occasional criminality.  Our perspective has evolved as we have learned more about organizations in general and SC in particular.  Channeling John Maynard Keynes, we adapt our models when we become aware of new facts or better ways of looking at the data.  We hope you continue to follow Safetymatters.  

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.

NRC Regulatory Information Conference (RIC) - Safety Culture (cont.)

Last week we previewed the safety culture (SC) content of the then-upcoming NRC RIC.  The Idaho National Lab speaker's slides were not available at that time but they are now and his presentation is reviewed below.  The focus is on the Advanced Test Reactor Programs but I think it's fair to infer that the thinking is representative of a wider swath of the DOE complex.

The presentation opens with five lengthy quotes from Admiral Rickover's November 1983 assessment of GPU and its competence to operate TMI-1.  The apparent intent is to illustrate that the principles for safe nuclear operations have been known (or at least available) for a long time.  Coincidentally, we posted on the Rickover assessment two months ago, and focused on one of the same quotes.  If you aren't acquainted with Rickover's seven principles, you really should read the introduction to the assessment, which is available from the Dickinson College library.

The presentation describes components of the new DOE Cross Cutting Performance Areas for category 1, 2 and 3 nuclear facilities:  Evaluating the effectiveness of operations, maintenance, engineering and training programs; developing, monitoring and evaluating SC; and evaluating issue identification and resolution activities, including the significance determination process and the evaluation and resolution process for high significance issues.

The presentation concluded with a list of areas being emphasized at the Idaho lab: What is the right (as opposed to allowable) thing to do, educating leaders, communications, and decision making that reflects a learning organization and doesn't result in safety drift.

The presentation hit most of the right notes, a major exception being no mention of management or contractor financial incentive plans.  However, the unmistakable tone is there is really nothing new required of the lab, just a refinement of past and current practices.  Perhaps that's true for them but I have limited confidence in DOE entities' ability to self-evaluate.  We're pretty sure SC issues exist or have existed at other DOE facilities, especially the Vit Plant (click the label in the top right-hand column to pull up our posts).

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).

Nuclear Safety Culture Research

This is a subject that has been on our minds for some time.  Many readers may have eagerly jumped to this post to learn about the latest on research into nuclear safety culture (NSC) issues.  Sorry, you will be disappointed just as we were.  The painful and frankly inexplicable conclusion is that there is virtually no research in this area.  How come?

There is the oft-quoted 2002 comment by then ACRS Chairman, Dr. George Apostolakis:

"For the last 20 to 25 years this agency [the NRC] has started research projects on organizational-managerial issues that were abruptly and rudely stopped because, if you do that, the argument goes, regulations follow. So we don't understand these issues because we never really studied them."*

A principal focus of this blog has been to bring to the attention of our readers relevant information from academic and research sources.  We cover a wide range of topics where we see a connection to nuclear safety culture.  Thus we continually monitor additions to the science of NSC through papers, presentations, books, etc.  In doing so we have come to realize, there is and has been very little relevant research specifically addressing nuclear safety culture.  Even a search of secondary sources; i.e., the references contained in primary research documents, indicates a near vacuum of NSC-specific research.  This is in contrast to the oil and chemical industries and the U.S. manned space program.  In an August 2, 2010 post we described research by  Dr. Stian Antonsen of the Norwegian University of Science and Technology on “..whether it is possible to ‘predict’ if an organization is prone to having major accidents on the basis of safety culture assessments” [short answer: No].

Returning to the September 2012 DOE Nuclear Safety Workshop (see our Oct. 8, 2012 post), where nuclear safety culture was a major agenda item, we observe the only reference in all the presentations to actual research was from the results of an academic study of 17 offshore platform accidents to identify “cultural causal factors”. (See Mark Griffon’s presentation, slide 17.)

With regard to the manned space program, recall the ambitious MIT study to develop a safety culture simulation model for NASA and various independent studies, perhaps most notably Diane Vaughan's The Challenger Launch Decision.  We have posted on each of these.

One study we did locate that is on topic is an empirical analysis of the use of safety culture surveys in the Millstone engineering organization performed by Professor John Carroll of MIT.  He found that “their [surveys'] use for assessing and measuring safety culture...is problematic…”**  It strikes us as curious that the nuclear industry which has so strongly embraced culture surveys hasn’t followed that with basic research to establish the legitimacy and limits of their application.

To further test the waters for applicable research we reviewed the research plans for major nuclear organizations.  The NRC Strategic Plan Fiscal Years 2008-2013 (Updated 2012)*** cites two goals in this area, neither of which address substantive nuclear safety culture issues:

Promote awareness of the importance of a strong safety culture and individual accountability of those engaged in regulated activities. (p.9)

Ensure dissemination of the Safety Culture Policy Statement to all of the regulated community. [Supports Safety Implementation Strategy 7] (p.12)

DOE’s 2010 Nuclear Energy Research and Development Roadmap identifies the following “major challenges”:

- Aging and degradation of system structures and components, such as reactor core internals, reactor pressure vessels, concrete, buried pipes, and cables.
- Fuel reliability and performance issues.
- Obsolete analog instrumentation and control technologies.
- Design and safety analysis tools based on 1980s vintage knowledge bases and computational capabilities.****

The goals of these nuclear research programs speak for themselves.  Now compare to the following from the Chemical Safety Board Strategic Plan:

“Safety Culture continues to be cited in investigations across many industry sectors including the Presidential Commission Report on Deepwater Horizon, the Fukushima Daiichi incident, and the Defense Nuclear Facilities Safety Board’s recommendation for the Hanford Waste Treatment and Immobilization Plant. A potential study would consider issues such as how safety culture is defined, what makes an effective safety culture, and how to evaluate safety culture.”*****

And this from the VTT Technical Research Centre of Finland, the largest energy sector research unit in Northern Europe.

Man, Organisation and Society – in this area, safety management in a networked operating environment, and the practices for developing nuclear safety competence and safety culture have a key role in VTT's research. The nuclear specific know-how and the combination of competencies in behavioural sciences and fields of technology made possible by VTT's multidisciplinary expertise are crucial to supporting the safe use of nuclear power.#

We invite our readers to bring to our attention any NSC-specific research of which they may be aware.


*  J. Mangels and J. Funk, “Davis-Besse workers' repair job hardest yet,” Cleveland Plain Dealer (Dec. 29, 2002).  Retrieved Oct. 29, 2012.

**    J.S. Carroll, "Safety Culture as an Ongoing Process: Culture Surveys as Opportunities for Inquiry and Change," work paper (undated) p.23, later published in Work and Stress 12 (1998), pp. 272-284.

***  NRC "Strategic Plan: Fiscal Years 2008–2013" (Feb. 2012) published as NUREG-1614, Vol. 5.

****  DOE, "Nuclear Energy Research and Development Roadmap" (April 2010) pp. 17-18. 

*****  CSB, "2012-2016 US Chemical Safety Board Strategic Plan" (June 2012) p. 17.
  
#  “Nuclear power plant safety research at VTT,” Public Service Review: European Science and Technology 15 (July 13, 2012).  Retrieved Oct. 29, 2012.

DOE Nuclear Safety Workshop

The DOE held a Nuclear Safety Workshop on September 19-20, 2012.  Safety culture (SC) was the topic at two of the technical breakout sessions, one with outside (non-DOE) presenters and the other with DOE-related presenters.  Here’s our take on the outsiders’ presentations.

Chemical Safety Board (CSB)

This presentation* introduced the CSB and its mission and methods.  The CSB investigates chemical accidents and makes recommendations to prevent recurrences.  It has no regulatory authority. 

Its investigations focus on improving safety, not assigning blame.  The CSB analyzes systemic factors that may have contributed to an accident and recognizes that “Addressing the immediate cause only prevents that exact accident from occurring again.” (p. 5) 

The agency analyzes how safety systems work in real life and “why conditions or decisions leading to an accident were seen as normal, rational, or acceptable prior to the accident.” (p. 6)  They consider organizational and social causes, including “safety culture, organizational structure, cost pressures, regulatory gaps and ineffective enforcement, and performance agreements or bonus structures.” (ibid.)

The presentation included examples of findings from CSB investigations into the BP Texas City and Deepwater Horizon incidents.  The CSB’s SC model is adapted from the Schein construct.  What’s interesting is their set of artifacts includes many “soft” items such as complacency, normalization of deviance, management commitment to safety, work pressure, and tolerance of inadequate systems.

This is a brief and informative presentation, and well worth a look.  Perhaps because the CSB is unencumbered by regulatory protocol, it seems freer to go where the evidence leads it when investigating incidents.  We are impressed by their approach.
 
NRC

The NRC presentation** reviewed the basics of the Reactor Oversight Process (ROP) and then drilled down into how potential SC issues are identified and addressed.  Within the ROP, “. . . a safety culture aspect is assigned if it is the most significant contributor to an inspection finding.” (p.12)  After such a finding, the NRC may perform an SC assessment (per IP 95002) or request the licensee to perform one, which the NRC then reviews (per IP 95003).

This presentation is bureaucratic but provides a useful road map.  Looking at the overall approach, it is even more disingenuous for the NRC to claim that it doesn’t regulate SC.

IAEA

There was nothing new here.  This infomercial for IAEA*** covered the basic history of SC and reviewed contents of related IAEA documents, including laundry lists of desired organizational attributes.  The three-factor IAEA SC figure presented is basically the Schein model, with different labels.  The components of a correct culture change initiative are equally recognizable: communication, continuous improvement, trust, respect, etc.

The presentation had one repeatable quote: “Culture can be seen as something we can influence, rather than something we can control” (p. 10)

Conclusion

SC conferences and workshops are often worthless but sometimes one does learn things.  In this case, the CSB presentation was refreshingly complete and the NRC presentation was perhaps more revealing than the presenter intended.


*  M.A. Griffon, U.S. Chemical Safety and Hazards Investigation Board, “CSB Investigations and Safety Culture,” presented at the DOE Nuclear Safety Workshop (Sept. 19, 2012). 

**  U. Shoop, NRC, “Safety Culture in the U.S. Nuclear Regulatory Commission’s Reactor Oversight Process,” presented at the DOE Nuclear Safety Workshop (Sept. 19, 2012).

***  M. Haage, IAEA, “What is Safety Culture & Why is it Important?” presented at the DOE Nuclear Safety Workshop (Sept. 19, 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.)

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.