Palisades: Back in the NRC’s Safety Culture Dog House

Our last Palisades post was on January 30, 2013 where we described the tortuous logic the NRC employed to conclude Palisades’ safety culture (SC) had become “adequate and improving.”  Or was it?  The NRC has recently parlayed an isolated Palisades incident into multiple requirements, one fleet-wide, to strengthen SC.  Details follow, taken from the resulting Confirmatory Order.*

The Incident

A Palisades security manager asked a security supervisor to cover a 2-hour partial shift because another supervisor had requested time off on Christmas Eve 2012.  Neither the manager nor the supervisor verified the supervisor had the necessary qualifications for the assignment.  He didn’t, which violated NRC regulations and the site security plan.  The problem came to light when two condition reports were written questioning the manager’s decision. (pp. 2-3)

How the Incident was Handled and Settled

Entergy requested Alternative Dispute Resolution (ADR), a process whereby the NRC and the licensee meet with a third party mediator to work out a resolution acceptable to both parties.

The Consequences

Entergy’s required corrective actions include what we’d expect, viz., action to improve and ensure adherence to security procedures.  In addition, Entergy is required to take multiple actions to strengthen SC.  These actions are spelled out in the Confirmatory Order and focus on several SC traits: (1) Leadership, Safety Values and Actions; (2) Problem Identification and Resolution; (3) Personal Accountability; (4) Work Processes; (5) Environment for Raising Concerns; and (6) Questioning Attitude and Proceeding In the Face of Uncertainty. (p. 4)

Specific requirements relate to (1) actions already implemented or to be implemented via Palisades’ Security Safety Conscious Work Environment Action Plan, (2) revising a Condition Review Group procedure to ensure the chairman considers whether the person assigned to a condition report is sufficiently independent, (3) developing and presenting a case study throughout the Entergy fleet that highlights the SC aspects of the event and (4) discussing the SC aspects of the issue with Palisades staff at three monthly tailgate meetings. (pp. 4-6, 11-12)

Our Perspective

The incident appears localized and the NRC said it had very low security significance.  Maybe Entergy thought they’d avoid any sort of penalty if they requested ADR.  Looks to us like they gambled and lost.  The NRC must think so, they are fairly gloating over the outcome.  In the associated press release, the Region III Administrator says: “Using the ADR process allowed us to achieve not only compliance with NRC requirements, but a wide range of corrective actions that go beyond those the agency may get through the traditional enforcement process”.**

Is the NRC using an elephant gun to shoot a mouse?  Or is there some unstated belief that Palisades’ SC is not as good as it should be and/or Entergy as a whole doesn’t properly value SC*** and this is a warning shot?  Or is something else going on?  You be the judge.


*  C.D. Pederson (NRC) to A. Vitale (Entergy), “Confirmatory Order Related to NRC Report No. 05000255/2014406 and OI Report 3-2013-018; Palisades Nuclear Plant” (July 21, 2014).  ADAMS ML14203A082.

**  NRC Press Release “NRC Issues Confirmatory Order to Entergy Regarding Palisades Nuclear Plant,” No. III-14-031 (July 22, 2014).

***  Entergy has had SC issues at other plants.  Click on the Entergy label for our related commentary.

Willful Violations at Indian Point

We report in this post on a situation that developed at Indian Point more than two years ago and was just recently closed out via NRC notices of violation to an individual (a Chemistry Manager for Entergy Nuclear Operations) and to Entergy Nuclear Operations itself. 

What should we make of another willful misconduct episode?  A misguided individual who made some bad choices but where the actual impact on safety (per Entergy and the NRC) was not significant?  The individual resigned (and plead to a felony conviction and probation), corrective actions to reinforce proper behaviors have been taken, and violations issued...what difference does it make?

The Events Surrounding the Misconduct

We are attaching a series of references as they contain more detail than we can recount in a blog post.  In particular Reference 4 provides the most comprehensive rendition of the relevant events.  Very briefly this is what occurred: During 2011 routine testing of diesel fuel oil at Indian Point (IP), as required by Tech Specs, indicated that the limits on particulate concentration were exceeded.  The Chemistry Manager with responsibility for this testing did not report (initiate Condition Reports) the anomalous results which would have resulted in the reserve fuel oil storage tank (RFOST) being declared inoperable.  The LCO is 30 days and if operability was not restored, shutdown of both IP units would have been required. [Ref 2, Cover Letter]  In early 2012 as part of a systems engineering self-assessment, the anomalous results and lack of reporting were identified.  The Chemistry Manager falsely indicated that re-sampling and testing had been performed which were acceptable.  He subsequently made false data entries to support this story.

A short time later employee concerns were filed via the Entergy Ethics Line and the Employee Concerns Program (ECP).  Entergy initiated an investigation using outside attorneys (Morgan Lewis).  At the same time the NRC initiated an Office of Investigations (OI) investigation.  The Chemistry Manager refused to cooperate in the investigation and resigned.  Subsequent testing of the fuel oil indicated limits were being exceeded and compensatory actions were taken.  Pursuant to the investigations the Chemistry Manager admitted willful misconduct.  The US Attorney issued a criminal complaint and ultimately the manager plead to a felony and received probation.  Entergy was cited for a Severity Level III violation, civil penalty waived.

Further Observations

Plowing through the documentation of this issue left us with a few lingering questions.  One is with regard to the sanitized LER that Entergy submitted to the NRC in August 2012.  The LER makes no mention of the filing of employee concerns, investigation by outside attorneys or the NRC OI investigation.  For that matter the LER never mentions that the cause of the event was willful misconduct by a department manager.  Rather it characterizes the situation in the abstract - as a failure to use the corrective action program.  In other words a whole lot was happening in the background which would cast the event in a different light, including its potential significance.*

While the cited violations are linked to the misconduct of the Chemistry Manager, it appears there had been ongoing issues within the Chemistry Department for some time: entering test data diligently, understanding the significance of the data, and initiating CRs.  “The circumstances surrounding the violations are of concern to the NRC because they indicate a lack of consideration for (and/or knowledge of) TS requirements by ENO Chemistry staff.  The NRC also noted that the Chemistry Manager would not have had the opportunity to commit the violations had ENO staff exhibited the proper regard for the site TS.”  [Ref 4, p. 4]  But in its chronology of events, Entergy contends that in March 2102 there was “no reason to question the integrity of former Chemistry Manager…” [Ref 4, Encl 2, slide 15].  Perhaps not the integrity, but what about management effectiveness? 

Further context.  Entergy gives itself credit for how it responded to the evolving situation.  They highlight that a self-assessment team identified the anomalies (true), that employees raised concerns through established programs (true), that Entergy conducted an investigation (true).  [Ref 4, Encl 2, slide 35]  But what is missing is that normal business processes (management oversight, QA audits, or Chemistry Department personnel) did not identify the anomalies prior to the self-assessment; that employees felt the need to use the Ethics Line and the ECP rather than directly raising within the management chain; that upon discovery of the anomalies, it appears that Entergy went to great lengths to avoid declaring that the fuel oil did not meet specs.**  The net result is that the RFOST was able to be maintained as operable for almost three months before definitive action was taken to filter the oil. [Ref 4, Encl 2, slides 17-21]

Why?

The most interesting and relevant question posed by these events is why did the Chemistry Manager take the actions he did?  “The Manager said that he falsified the data because he needed more time to prove his theory [that the IP Chemistry Department’s sampling practices were poor] and incorporate new test methods, and he had not wanted the plant to unnecessarily shut down.”  [Ref 2, Encl 1] That is the extent of what the NRC reports on its investigation of the motive of the Chemistry Manager.  An employee for 29 years undertakes a series of deliberate violations of his professional responsibilities “to prove his theory”.  Perhaps. 

One of the final corrective actions implemented for this event occurred in December 2013 when the General Manager for Plant Operations briefed the Department Managers on deliberate misconduct.  Included was a statement, "If we have to shutdown the plant we will do so". [Ref 4, Encl 2, slide 32] Without reading too much into a single bullet point, one wonders if this is a tacit acknowledgment by Entergy that the Chemistry Manager may have been influenced to do what he did because he did not want to be the cause of a plant shutdown.

We would be very interested to see how much probing was done by the NRC investigators, or Entergy’s attorneys, of this individual’s motive, particularly in terms of any perceived pressure to keep the plant operating.  Such pressure needn’t come from Entergy, it seems self-evident that Indian Point’s licensing situation and the long standing political opposition within New York State poses an existential threat to the plant.  If his motive was just a matter of a revised test “theory”, were these the first out-of-spec fuel oil test results on his watch?  If there had been others, how were they handled?  How long had he been in the position?  Had he initiated any other actions prior to this time to investigate the testing protocol?  As we noted in our post dated September 12, 2013 regarding the NRC’s Information Notice on willful violations, in none of the cited examples did the NRC provide any perspective on the motives of the individuals or the potential effects of the environment within which they were working.

Safety and Safety Culture

How does all of this shed any light on safety and safety culture? 

A key dimension of safety culture is the accurate assessment of safety significance.  The position of Entergy, and adopted by the NRC***, was that the actual impact of the violations on reactor safety was not significant. [Ref 4, Encl 2, slide 36]  Also note that NRC finds that all of this is in the ROP category for “green” significance. The argument is a familiar one.  TS limits are conservative and below what is actually “OK”.  And if particulates are a problem there are filters on the diesel generators, and these can be changed out during operation of the diesels if necessary.  This is a familiar characterization - safety significance is evaluated within the strict boundaries of the NRC’s safety construct of design basis assumptions, almost exclusively hardware based.  As we noted in our September 24, 2013 post, this ignores the larger environment and “system” within which people actually function. 

The Synergy Safety Culture Survey conducted from Feb to April 2012 is cited as finding a “healthy work environment in Chemistry Department” - yet this was at the very time test results were being falsified by the manager and employees were resorting to the ECP to raise issues.  Other assessments by the NRC and INPO also did not identify issues. [Ref 4, Encl 2, slide 29].  There is reference to an “independent investigation” of the employee concerns but the documentation does not reveal who did the investigation or its findings.  The investigation found “no one interviewed” had a reluctance to raise an issue.  Nowhere is the prior use of the Ethics Line and ECP by several individuals on an anonymous basis explained. 

Something that is hard to square is the NRC assertion that there is a strong link between willful violations and safety culture, and the results of these various assessments at Indian Point by Synergy, the NRC and INPO.  So if there is a link, and safety culture assessments don’t reveal its presence, are the assessments valid?  Or if the assessments are valid, is there really a link with willful misconduct? 

Here’s our take.  Willful misconduct is an indication of an issue with the safety culture.  But the issue arises out of a broader and more complex context than the NRC or industry is willing to address.  At Indian Point there is an overriding operating context where the extension of the plants’ operating licenses is being contested by powerful political forces in New York State.  If the licenses are not extended, the plants close and people lose their jobs.  This is not theoretical as the Entergy-owned plant, Vermont Yankee, is doing just that.  If you are an employee at Indian Point, you must feel that pressure every day.  When an issue comes up such as failed diesel fuel tests that could result in temporary shutdown of both units, it is an additional threat to the viability of the plant.  That pressure can create a powerful desire to rationalize the fuel tests are not valid and/or that slightly contaminated fuel isn’t a significant safety concern because…[see Entergy and NRC agreement that it is not a significant safety concern].  So there is a situation where there is an immediate and significant penalty (shutdown of both units) versus a test result that may or may not be valid or of real safety significance.  The result: deliberate misconduct in burying the test results but also very possibly (I am speculating) the individual and others in the organization can still believe that safety is not impacted.  As actions are consistent with “real” safety significance, it preserves the myth that safety culture is still healthy.


*  As stated in the NRC Enforcement Policy (on page 9, section 2.2.1.d): “Willful violations are of particular concern because the NRC’s regulatory program is based on licensees and their contractors, employees, and agents acting with integrity and communicating with candor. The Commission cannot tolerate willful violations. Therefore, a violation may be considered more significant than the underlying noncompliance if it includes indications of willfulness.” [NRC Information Notice 2013-15]

**  The sequence of events starting in March 2012 in response to RFOST sample (by off-site testing lab) being out of spec: the RFOST is declared inoperable but a supervisor declares that the sample test method was not appropriate, the department procedure is revised to allow on-site testing of a new sample (what was site review process? procedure revision appears to have occurred and become effective in one day), and the test results are now found acceptable.  This allows the RFOST to be declared operable. Without telling anyone, the former Chem Mgr sends a split sample for off-site testing and it comes back over spec.  Why wouldn’t plant management have required a split sample in the first place to verify on-site test?  Two employee concerns are filed, the ML investigation is initiated and the Chemistry Manager resigns.  At the next sampling in mid-April, once again the on-site analysis finds the sample to be within spec but management now requires outside testing in light of the resignation of the Chemistry Manager.  Outside test indicates out-of-spec but an “evaluation” concludes that the in-house results are valid and  RFOST remains “operable”.  Another month goes by and sample is taken in late May.  Sample sent outside, late June results indicate out-of-spec.  This time the RFOST is declared inoperable.  Not clear if late May sample was tested on-site (or why not) and why this time the outside test result is deemed valid.  A final footnote, one of the corrective actions for this event was to discontinue on-site oil analysis but no discussion of why, or why it had been approved in the first place.

***  “the underlying technical findings would have been evaluated as having very low safety significance (i.e. green) under the Reactor Oversight Process (ROP) because the higher fuel oil particulate concentration would not have impacted the ability of the EDGs to fulfill their safety function.” [Ref 4, p. 3]

References

1 - J.A. Ventosa (Entergy) to NRC, Licensee Event Report # 2012-007-00 (Aug. 20, 2012).  ADAMS ML12235A541.

2 - NRC to J. Ventosa, NRC Inspection Report Nos. 05000247/2013011 & 05000286/2013011 and NRC Office of Investigation Reports No. 1-2012-036 (Dec. 18, 2013)  ADAMS ML13354B806.

3 - NRC to D. Wilson (former Chemistry Mgr.), Notice of Violation and Order Prohibiting Involvement in NRC-Licensed Activities (April 29, 2014).  ADAMS ML14118A337.

4 - NRC to J. Ventosa, Notice of Violation (April 29, 2014).  ADAMS ML14118A124.

NRC Non-Regulation of Safety Culture: Fourth Quarter Update

NRC SC Brochure ML113490097

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

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

Browns Ferry

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

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

Fort Calhoun

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

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

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

Palisades

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

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

Other Plants

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

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

The NRC perspective and our reaction

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

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

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

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

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

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

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

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

^^  S. West (NRC) to A. Vitale (Entergy), “Palisades Nuclear Plant - NRC Supplemental Inspection Report 05000255/2012011; and Assessment Follow-up Letter” (Nov. 9, 2012) ADAMS ML12314A304.

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

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

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

NRC Non-Regulation of Safety Culture: Third Quarter Update

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

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

Browns Ferry

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

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

Fort Calhoun

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

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

Palisades

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

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

Other Plants

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

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

The Bottom Line

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

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


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

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

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

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

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

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

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

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

The NRC Does Not Regulate Safety Culture, Right?

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

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

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

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

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

What does the recent experience imply?

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

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

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


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

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

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

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

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

Vermont Yankee (part 5) - Muddy Water

In our April 5, 2010 post re Vermont Yankee we provided some initial thoughts on the report of the independent investigator regarding misleading statements provided by Entergy personnel to Vermont regulators, as contained in Entergy’s March 31, 2010 response to a March 1, 2010 NRC Demand for Information.* The Entergy filing also provides more detail on follow-up actions including an assessment of current site safety culture. In this post, we offer some additional observations and questions.
First, in our initial March 3, 2010 post regarding the VY situation, we disputed a prediction made by a third party that the administrative actions taken by Entergy for certain employees might have a detrimental effect on the safety culture at the plant - due to the way Entergy is treating its employees. In reality it appeared to us that any detrimental impact on safety culture would be more likely if Entergy had not taken appropriate actions. In Entergy’s report to the NRC, they provide the results of a follow-up assessment confirming that after the personnel actions employees were even more likely to raise concerns.

Also in our initial post we speculated that the Vermont Yankee events could have consequences for Entergy’s proposed spinout of six nuclear plants into a separate subsidiary. Since then Entergy has announced the cancellation of the spinout after a decision by New York re the extension of permits for their Indian Point plants.

However, after a careful review of the March 31 Entergy response, we are still left with water that is more than a little bit muddy. Entergy says a Synergy assessment a few months before the reporting event found safety culture at Vermont Yankee to be strong. After the event, Entergy states safety culture is strong or stronger, and with regard to the replaced staff, Entergy “continues to have confidence in the integrity of the affected employees.” Strong safety culture and organizational integrity are not supposed to add up to this kind of outcome. How then did things go wrong? How did the misleading statements to Vermont regulators come about and what was the cause?

A fundamental element of all nuclear plant problem resolution/corrective action programs is a determination of not just what happened, but why. Cause in other words, and in significant situations, the root cause. The root cause that led to eleven employees, including managers and site executives, being relieved of duties and disciplined is not contained in the Entergy materials. In fact, most of the focus appears to be on the safety culture of the plant staff both before and after the incident came to light and the personnel actions taken. Those actions and information appear to be reassuring in regards to the plant staff - but the plant staff was not where the problem occurred. There is also considerable emphasis on the fact that the managers have been replaced with competent substitutes. But haven’t those new managers been placed in exactly the same situation as the former managers were in? If it is not clear why the former managers failed to meet performance standards, then how is one confident that the replacements will do so?

As we have pointed out in other posts, the response to safety culture failures too often stresses the “values and beliefs” of personnel as the beginning and end of safety culture. We have argued that the situational parameters, including competing goals and interests, are at least as important if not paramount in trying to understand such issues.

What was the situation at Vermont Yankee and to what extent, if any, did it have an effect? The VY management team was operating in an environment where significant business decisions were in play. One was the extension of the operating license for VY which required approval by both the NRC and by the Vermont Senate. A second was the pending proposed spinout of nuclear units, including VY, into a separate subsidiary, a spinout that was expected to be worth billions of dollars to Entergy. SEC and other regulatory filings had been made by Entergy for the spinout and approvals were being sought from state regulators and the NRC.

Entergy’s March 31 NRC submittal also states, “Finally, neither the underlying report of investigation which led to the discipline, nor the interviews of the AFEs, identified any credible evidence to suggest that any weakness in the work environment or site safety culture contributed to a reluctance by anyone to provide clarifying or supplemental information to the relevant state officials. Indeed, there is no credible evidence that any of the AFEs are -- or were -- reluctant to report safety concerns or any other matter of potential regulatory significance or legal non-compliance.”

Does this mean that situational factors such as business priorities were evaluated and found not to be a contributor? If so, how was this done and what is the basis for such a conclusion? Or were such competing priorities acknowledged as potential influences and able to be dealt with as part of the management system? What other situational factors might have been present and to what effect?

On April 9, 2010 the NRC notified Entergy that the NRC was going to “initiate a detailed review and independent assessment of the acceptability of Entergy’s conclusions. . . .” ** We will keep you posted.

*ADAMS Accession Number ML100910420

**ADAMS Accession Number ML100990409

Huh? aka Vermont Yankee (part 4)

On March 31, 2010, Entergy transmitted to the NRC key findings of the Morgan, Lewis & Bockius LLP investigation of misstatements by Entergy employees at Vermont Yankee.* The investigation concluded that no Entergy employees "intentionally misled" Vermont regulators and "The investigation also concluded that no one made any intentionally false statements in state regulatory proceedings." That’s all fairly clear.

But then the same paragraph continues: “The report found, however, that certain ENVY [Entergy Nuclear Vermont Yankee ] personnel did not clarify certain understandings and assumptions, which resulted in misunderstandings, when viewed in a context different from the one understood to be relevant to the CRA [Comprehensive Reliability Assessment]."

I was fine up to the “however”. I just don’t understand the law firm’s tortured phrasing of what did happen. Will anyone else?


*ADAMS Accession Number ML100910420

Vermont Yankee (part 1)

This week saw a very significant development in the nuclear industry and the potential consequences of safety culture issues on a specific plant, a large nuclear enterprise and the industry. As has been widely reported (see link below) the Vermont Senate voted against the extension of the Vermont Yankee nuclear plant’s operating license. In part it appears this action stemmed from the recent leakages of tritium at the plant site but perhaps more significantly, from how the matter was handled by the plant owner, Entergy. In response to allegations that Entergy may have supplied contradictory or misleading information, Entergy engaged the law firm of Morgan Lewis and Bockius LLP to undertake an independent review of the matter. Entergy subsequently has taken administrative actions on 11 employees.

The fallout of these events has not only put into question the future of the Vermont Yankee plant, triggered the interest of the NRC and a requirement that Entergy officials testify under oath, it may also have consequences for Entergy’s plans to spin-off six of its nuclear plants into an independent subsidiary. This restructuring has been a major part of Entergy’s plans for its nuclear business and Entergy has announced that it will be evaluating its options at an upcoming meeting.

There is much to be considered as a result of the Vermont Yankee situation and we will be posting several more times on this subject. In this post we wanted to focus on some initial reaction from other quarters that we found to be off the mark. The link below to the Energy Collective includes a post from Rod Adams who appears to have done a fair bit of analysis of the facts that are currently available. His major observation is as follows:

“That said, it has become clear to me that the corporate leaders at Entergy ....never learned that taking early actions to prevent problems works a hell of a lot better than massive overreaction once it finally becomes apparent to everyone that action is required. Panic at the top never works - it destroys the confidence of the people...”

In part the author relies on the Morgan Lewis law firm’s finding that Entergy employees did not intentionally mislead Vermont regulators. However, he apparently ignores the Morgan Lewis conclusion that Entergy personnel provided responses that were, ultimately, “incomplete and misleading”.

Given the findings of the independent investigator it is hard to see what choice Entergy had, and absent additional facts, it would appear to us that the employee actions were necessary and appropriate. Adams goes on to speculate that there may even be a detrimental effect on the safety culture at the plant - due to the way Entergy is treating its employees. In reality it appears to us that any detrimental impact on safety culture would have been more likely if Entergy had not taken appropriate actions. Still, the question of how safety culture played into the failure of Entergy staff to provide unambiguous information in the first place, and how safety culture will be impacted by subsequent events is a subject that merits more detailed consideration. We will provide our thoughts in future posts.
Link to 2-25-10 Wall Street Journal news item reporting Vermont's action.
Link to Rod Adams 2-26-10 blog post.
Link to 2-24-10 Entergy Press Release on Investigation Report.