WANO Publicizes Projects That Promote Safety But Short-Changes Nuclear Safety Culture

NOT WANO's world headquarters

The World Association of Nuclear Operators (WANO) recently announced* the completion and delivery of 12 post-Fukushima projects intended to enhance safety in the world’s commercial nuclear power plants.  It appears the projects were accomplished by a combination of WANO and member personnel.  An addendum to the press release describes how WANO has revised its own practices to more effectively deliver its services in the 12 project areas to members.  The projects address emergency preparedness, emergency support plan, severe accident management, early event notification, onsite fuel storage, design safety fundamentals, peer review frequency and equivalency, corporate peer reviews, WANO assessment, transparency and visibility, and WANO internal assessment. 

Our Perspective

We usually don’t waste time with WANO because it has never developed or promoted any insight into the systemic interactions of the management and cultural variables that create ongoing nuclear organizational performance.  And the results they are touting are based on their familiar, inadequate worldview, viz. promoting more development for leaders and more detail to functional areas.

That said, we recognize that incremental improvements in the project areas might add some modest value and hopefully do not hurt performance.  (Performance may be “hurt” when personnel punctiliously and mindlessly follow policies, rules and procedures without considering if they are actually appropriate for the situation at hand.)

Most of WANO’s claims for improving its own services are typical chest-thumping but a few items perpetuate long-standing industry shortcomings, especially excessive secrecy.  For example, under design safety fundamentals WANO peer reviews assess whether safety-related design features are appropriately managed but “WANO does not make design-change recommendations or evaluate the design of the plant itself.”  WANO assessments of utility/plant performance are confidential to the subject CEOs.  And WANO’s concept of improving transparency means “effectively sharing information and best practices within the membership.”  Looks like WANO’s prime directive is to shield the dues-paying members from any hard questions or external criticism.

Our biggest gripe is WANO’s treatment, or lack thereof, of nuclear safety culture (NSC).  In the press release, culture is mentioned once: Mid-to-senior level “managers at nuclear power plants play a vital part in delivering excellence and a strong nuclear safety culture, due to their positional influence throughout the organisation.”  That’s true, but culture is much more pervasive, systemic and important than that.

We find it surreal that WANO has been busy organizing worldwide resources to polish the bowling ball** and then claim they have made the industry safer post-Fukushima.  Linking their putative progress to Fukushima ignores a fundamental truth: while weaknesses in various functional areas were causal factors that made a bad situation worse, the root cause of the Fukushima disaster was the deep-seated, value-driven unwillingness of people who knew to speak truth to power about the tsunami design inadequacies.  It was culture that killed the plant.


*  WANO press release, “WANO calls on industry to build on progress after post-Fukushima improvements” (June 26, 2018).  Retrieved July 5, 2018.

**  “polish a bowling ball” - A phrase we use to describe activities that make an existing construct shinier but have no impact on its fundamental nature or effectiveness.

Learning About Nuclear Safety Culture from the Web, Maybe

The Internet  Source:Wikipedia

We’ve come across some Internet content (one website, one article) that purports to inform the reader about nuclear safety culture (NSC).  This post reviews the content and provides our perspective on its value.

NSC Website

It appears the title of this site is “Nuclear Safety Culture”* and the primary target is journalists who want an introduction to NSC concepts, history and issues.  It is a product of a group of European entities.  It is a professional looking site that covers four major topics; we’ll summarize them in some detail to show their wide scope and shallow depth. 

Nuclear Safety Culture covers five sub-topics:

History traces the shift in attitudes toward and protection from ionizing radiation as the possible consequences became better known but the story ends in the 1950s.  Key actions describe the roles of internal and external stakeholders during routine operations and emergency situations.  The focus is on power production although medicine, industrial uses and weapons are also mentioned.  Definition of NSC starts with INSAG (esp. INSAG-4), then adds INPO’s directive to emphasize safety over competing goals, and a familiar list of attributes from the Nuclear Safety Journal.  As usual, there is nothing in the attributes about executive compensation or the importance of a systems view.  IAEA safety principles are self explanatory.  Key scientific concepts cover the units of radiation for dose, intake and exposure.  Some values are shown for typical activities but only one legal limit, for US airport X-rays, is included.**  There is no information in this sub-topic on how much radiation a person can tolerate or the regulatory limits for industrial exposure.

From Events to Accidents has two sub-topics:

From events to accidents describes the 7-level International Nuclear Event Scale (from a minor anomaly to major accident) but the scale itself is not shown.  This is a major omission.  Defence in depth discusses this important concept but provides only one example, the levels of physical protection between a fuel rod in a reactor and the environment outside the containment.

Controversies has two sub-topics:

Strengths and Weaknesses discuss some of the nuclear industry’s issues and characteristics: industry transparency is a double-edge sword, where increased information on events may be used to criticize a plant owner; general radiation protection standards for the industry; uncertainties surrounding the health effects of low radiation doses; the usual nuclear waste issues; technology evolution through generations of reactors; stress tests for European reactors; supply chain realities where a problem anywhere is used against the entire industry; the political climate, focusing on Germany and France; and energy economics that have diminished nuclear’s competitiveness.  Overall, this is a hodgepodge of topics and a B- discussion.  The human factor provides a brief discussion of the “blame culture” and the need for a systemic view, followed by summaries of the Korean and French document falsification events.

Stories summarizes three events: the Brazilian theft of a radioactive source, Chernobyl and Fukushima.  They are all reported in an overly dramatic style although the basic facts are probably correct.

The authors describe what they call the “safety culture breach” for each event.  The problem is they comingle overarching cultural issues, e.g., TEPCO’s overconfident management, with far more specific failures, e.g., violations of safety and security rules, and consequences of weak NSC, e.g., plant design inadequacies.  It makes one wonder if the author(s) of this section have a clear notion of what NSC is.

It isn’t apparent how helpful this site will be for newbie journalists, it is certainly not a complete “toolkit.”  Some topics are presented in an over-simplified manner and others are missing key figures.  In terms of examples, the site emphasizes major accidents (the ultimate trailing indicators) and ignores the small events, normalization of deviance, organizational drift and other dynamics that make up the bulk of daily life in an organization.  Overall, the toolkit looks a bit like a rush job or unedited committee work, e.g., the section on the major accidents is satisfactory but others are incomplete.  Importantly (or perhaps thankfully) the authors offer no original observations or insights with respect to NSC.  It’s worrisome that what the site creators call NSC is often just the safety practices that evolved as the hazards of radiation became better known. 

NSC Article

There is an article on NSC in the online version of Power magazine.  We are not publishing a link to the article because it isn’t very good; it looks more like a high schooler’s Internet-sourced term paper than a thoughtful reference or essay on NSC.

However, like the stopped clock that shows the correct time twice per day, there can be a worthwhile nugget in such an article.  After summarizing a research paper that correlated plants’ performance indicators with assessments of their NSC attributes (which paper we reviewed on Oct. 5, 2014), the author says “There are no established thresholds for determining whether a safety culture is “healthy” or “unhealthy.””  That’s correct.  After NSC assessors consolidate their interviews, focus groups, observations, surveys and document reviews, they always identify some improvement opportunities but the usual overall grade is “pass.”***  There’s no point score, meter or gauge.  Perhaps there should be.

Our Perspective

Don’t waste your time with pap.  Go to primary sources; an excellent starting point is the survey of NSC literature performed by a U.S. National Laboratory (which we reviewed on Feb. 10, 2013.)  Click on our References label to get other possibilities and follow folks who actually know something about NSC, like Safetymatters.


*  Nuclear Safety Culture was developed as part of the NUSHARE project under the aegis of the European Nuclear Education Network.   Retrieved June 19, 2017.

**  The airport X-ray limit happens to be the same as the amount of radiation emitted by an ordinary banana.

***  A violation of the Safety Conscious Work Environment (SCWE) regulations is quite different.  There it’s zero tolerance and if there’s a credible complaint about actual retaliation for raising a safety issue, the licensee is in deep doo-doo until they convince the regulator they have made the necessary adjustments in the work environment.

Is TEPCO’s Nuclear Safety Culture Still Weak?

Cover of TEPCO Self-Assessment

Tokyo Electric Power Co. (TEPCO) recently conducted a self-assessment* (SA) to ascertain progress vis-à-vis the goals in their Nuclear Safety Reform Plan.  The SA covered both Fukushima Daiichi and the undamaged plants.  It was approved by TEPCO’s president and reported to the Nuclear Reform Monitoring Committee (NRMC), an independent group of experts that advises TEPCO’s board of directors.  The committee reviewed the SA and communicated their evaluation to the board.  This post reviews both the SA and committee documents focusing on findings and observations related to safety culture (SC).

The TEPCO Self-Assessment

Comments with actual or potential relevance for culture appear throughout the 20-page SA report and are summarized below.  It appears about half of the SA findings and concrete action plans could have some connection to organizational culture.

Scores of employees have received awards for achieving goals related to stronger nuclear safety culture (NSC) and senior managers have been emphasizing nuclear safety but weaknesses still exist in implementing all the traits of a strong NSC.  Unsafe behaviors with respect to industrial safety are being corrected and the need for stronger nuclear safety is being established.  However, communications to the worker level with respect to nuclear safety may be insufficient.  The importance of nuclear safety is emphasized in new employee training and in meetings with contractor representatives. (pp. 4-5)  This is a mixed bag in the part of the SA most likely to be concerned with SC, viz., “Management Reforms Prioritizing Nuclear Safety.”

The company is working on strengthening work processes to improve risk management but employees report processes are unchanged and no clear priorities are established, factors that may increase fatigue and decrease motivation, both of which challenge the development of NSC. (p. 6)

Stricter safety regulations are being implemented and are no longer resisted based on their cost or operating impact. At Fukushima, the emphasis when performing work has shifted from speed to risk reduction to proceed safely. (pp. 8-9)  All good news.

Daily meetings share information on operating experience and near-misses but the overall information set is not leveraged because it is not managed to lead to long-term improvements. (p. 10)  In other words, continuous improvement is still a goal, not a reality.

Training is good for teaching employees how to complete tasks but the curriculum is insufficient to cultivate and inculcate a high level of safety performance.  The need for a more systematic approach to training is recognized but has not been realized. (pp. 12-13)

Overall findings of the SA emphasize the need to enhance a questioning attitude, strengthen supervision, and upgrade education and training. (p. 20)

NRMC Report and Cover Letter

The NRMC reviewed the SA in a 7-page report.**  One improvement noted by the NRMC was “Safety culture awareness has permeated throughout the organization and has improved significantly.”  However, the first three items on the list of nine Recommendations deal with NSC:

“Consistent efforts should be made to build a strong nuclear safety culture and instill the nuclear safety culture in an organizational culture.  The need for formal training and/or professional facilitation for the managers should be evaluated to instill a strong safety culture in the organization. . . . a safety culture program should be developed to the same standards” for contractors. (p. 5) 

There is also a one-page cover letter to the report.  Its primary focus is SC:

“TEPCO has made significant progress but must not become complacent . . . . TEPCO should instill . . . a strong safety culture throughout the organization, . . . TEPCO is encouraged to take further actions for the safety culture alignment at all levels of the organization . . .”

Our Perspective

SC and NSC occupy much of the space in all these documents.  What should we make of that, if anything?  One possibility is SC is acceptable but can always be improved or strengthened.  After all, as the NRMC notes “any self-assessment process must be critical by nature and therefore should identify areas for future improvement.”

A darker possibility is that TEPCO’s SC is still weak.  The NRMC’s report doesn’t have the language we usually see in the typical U.S. NSC report which says or implies “The plant is operating safely (indicating the NSC is at least minimally acceptable) but has improvement opportunities.”  We have to ask the NRMC: Is TEPCO’s current NSC acceptable or not?  Everyone understands Fukushima Daiichi is not operating, in fact, it’s still a mess where finding a lost fuel rod is world-wide news, but are current clean-up efforts occurring in an adequately safety-conscious environment?  The disaster occurred in 2011; some of the shortcomings noted in the SA should have been squared away by now.

On a different note, how does the SA address some topics dear to us?  Goal conflict is addressed when safety is mentioned as the primary goal and improvements are being made without cost being a major consideration.  The corrective action program (CAP) is mentioned but only as a tool for implementing improvement in the operating experience program.  Decision making is not mentioned at all so we don’t know how safety is being integrated into the decision making process at any level.  Another mixed bag.

Bottom line: Is SC front and center in all these documents because it is not yet acceptable?


*  “Report on TEPCO’s Self-Assessment of Progress” (Jan. 2017).

**  Nuclear Reform Monitoring Committee, “Review of the TEPCO’s Self-Assessment Effort on Nuclear Safety Reform,” (Jan. 30, 2017).

***  Nuclear Reform Monitoring Committee, Cover letter to "Review of the TEPCO's Self-Assessment Effort on Nuclear Safety Reform," (Jan. 30, 2017).  The public versions of all these TEPCO documents are copy protected so quotes have been retyped.

The Criminalization of Safety (Part 2)

Risky Business 

As we illustrated in Part 1 of this post a new aspect of safety management risk is possible criminal liability for actions, or inactions, associated with events that did, or could have, safety consequences.  While there has always been the potential for criminal liability it has generally been directed at the corporate level versus individual employees.  Heretofore, “few executives have been on the hook, partly because it is tough for prosecutors to prove an individual had criminal intent in a corporate setting where decision-making is spread among many.” ^1,2

The Justice Department has been making a new push to target individuals more frequently to hold them accountable for corporate malfeasance. Much of the criminal liability in recent years has been cropping up in industries other than nuclear, as illustrated in the summary table in Part 1.  The Deepwater Horizon drill rig explosion and the Massey Coal explosion at the Upper Big Branch mine have been leading examples.  More recently the series of scandals involving automobile manufacturers are adding to the record.  And the Flint water contamination situation is also evolving rapidly.  We’ll discuss the significance of these cases and how it could impact the conduct of individuals responsible for safe nuclear operations and the role of regulation.  In particular, under what circumstances criminal liability may attach and whether the potential to be held criminally liable is an effective force in assuring compliant behaviors and ultimately safety. 

Who’s a Criminal?

The various cases are a mix of corporate and individual liability.  All three corporations involved in Deepwater pleaded guilty to various charges and paid very large fines.  In BP’s case, it pleaded guilty to felony manslaughter.  Manslaughter charges against individuals employed by BP were dropped prior to trial.  Individual liability was limited to violations of the Clean Water Act and obstruction of justice (misdemeanors).³

David Uhlmann, a professor at the University of Michigan Law School and former environmental-crimes prosecutor stated, “The Justice Department always seeks to hold individuals accountable for corporate crime, but doing so in the Gulf oil spill meant charging individuals who had no control over the corporate culture that caused the spill.” ⁴

Other cases followed a similar pattern until Upper Big Branch.  Mostly lower level individuals were being targeted; higher ups were insulated from knowledge or direct involvement in the specific event.  With Massey prosecutors worked their way up the management chain all the way to the CEO.⁵  However even where there were significant indications of the CEO driving a “production first” culture, the felonies he faced were based on securities fraud and making false statements.  Ultimately he was convicted of violating safety standards and will serve jail time.⁶  Fukushima will be another attempt to hold senior management accountable (for something termed, “professional negligence”) but, as previously noted, the case is thought to be difficult.  The Attorney General in the Flint water cases promises more indictments and implies higher ups will be charged.  It remains to be seen whether this targeting of individuals will prove to be a truer preventive measure than other remedies.

Proof of Criminal Behavior is Difficult

Ultimately the prospect of criminal prosecution is fraught with legal and practical obstacles.⁷  Current law does not provide a realistic platform for prosecution or sentencing.  Statutory provisions are often limited to misdemeanors.  Making applicable statutes “tougher”, as already proposed by a presidential candidate, is also problematic as it risks over-criminalizing management actions which occur in a complex environment and involve many individuals.  Simple negligence is a problematic ground for criminal liability which generally requires a showing of intent or recklessness.⁸  As noted in regard to the VW scandal, “…investigations are ongoing. Whether criminal prosecutions result may be a matter of balancing suspicion of criminal wrongdoing against the standards of proof required - and the track record of recent prosecutions.⁹

All of the recent experience involving corporations were guilty pleas - the cases did not go to trial and so the standard of proof was not tested. In the BP cases, the DOJ made quite a splash with its indictments of individuals but clearly overreached in charging as the courts and juries quickly dismissed most cases and all felony charges.

Fukushima may be a bit of an oddity as the charges have been mandated by a citizen’s panel.   The charge is “professional negligence” which probably does not have a direct analog in U.S. law.  It does suggest that there will be scrutiny of the actual decisions made by executives which resulted in safety consequences.  In the Flint cases, there will another attempt to review an actual safety decision.  An engineer of the Michigan Department of Water Quality is charged with “misconduct” in authorizing use of the Flint water plant “knowing” it was deficient.  Bears watching.

Competing Priorities and Culture Are Being Cited More Frequently 

Personnel are already in a difficult position when it comes to assuring safety. Corporations inherently, and often quite intentionally, place significant emphasis on achieving operational and business goals.  These goals at certain junctures may conflict with assuring safety.  The de facto reality is that it is up to the operating personnel to constantly rationalize those conflicts in a way that achieves acceptable safely.  Those decisions are rarely obvious, may imply significant benefits or costs, and are subject to ex post critical review with all the benefits of time, hindsight, and no direct decision making responsibility.  Thus the focus may shift from decisions to the culture that may have produced or rationalized those decisions.

The Mine Safety and Health Administration report concluded that the [Upper Big Branch] disaster was "entirely preventable," and was caused in part by a pattern of major safety problems and Massey's efforts to conceal hazards from government inspectors, all of which "reflected a pervasive culture that valued production over safety.”  The Governor of West Virginia’s independent review also found that Massey had “made life difficult” for miners who tried to address safety and built “a culture in which wrongdoing became acceptable.”

As noted in the media, “the automotive industry is caught up in an emissions rigging scandal that exposes systematic cheating and an apparent culture of corrupt ethics."  At VW nine executives so far have been suspended but blame has been focused on a small group of engineers for the misconduct, and VW contends that members of its management board did not know of the decade-long deception.  The idea that a few engineers are responsible “just doesn’t pass the laugh test,’ said John German, a former official at the Environmental Protection Agency…its management culture — confident, cutthroat and insular — is coming under scrutiny as potentially enabling the lawbreaking behavior.¹⁰  Mitsubishi Motors is also implicated and investigations are being launched into their peers – including Daimler and Peugeot – to assess the extent of the problem around the world.

Ineffective Regulation is Becoming a Focus 

Last but perhaps the most intriguing evolution in these cases is a new emphasis on the responsibility of the regulator when safety is compromised. There was an extensive and ongoing history of violations at Big Branch Mine, many unresolved, but which did not lead to more stringent enforcement measures by the Mine Safety and Health Administration (MSHA) - such as a shutdown of mine operations.  State of West Virginia investigators claimed that the U.S Department of Labor and its MSHA were equally at fault for failing to act decisively after Massey was issued 515 citations for safety violations at the UBBM in 2009.  “…officials with the MSHA repeatedly defended their agency’s performance. They were quick to point to the fact that the Mine Safety Act places the duty for providing a safe workplace squarely on the shoulders of the employer, insisting that the operator is ultimately responsible for operating a safe mine.” ¹¹

Similar concerns have arisen with regard to Fukushima where safety regulators have been perceived to lack independence from nuclear plant operators. And thinking back to Davis Besse, it seems that the NRC’s actions could have been more intrusive and proactive in determining the condition of the RPV head prior to allowing the inspections to be delayed.

With regard to Flint we noted above that criminal (felony) charges have been brought against a state engineer for “misconduct in office” for authorizing use of the Flint plant.  In addition, he and a supervisor are also charged with misconduct in office for “willfully and knowingly misleading the federal Environmental Protection Agency…”   An expert in environmental crimes notes ”It’s extremely unusual and maybe unprecedented for state and local officials to be charged with criminal drinking water violations, . . .” ¹²

Whether these pending actions lead to a robust effort to hold regulators and their staff accountable is hard to know.  It bears watching, particularly the contention by MSHA and other regulatory agencies including the NRC, that operators are primarily and ultimately responsible. In Part 3 we’ll share some thoughts on what might other approaches might be effective.

¹ P. Loftus, "Criminal Trials of Former Health-Care Executives Set to Begin," The Wall Street Journal (May 22, 2016).

² The Davis Besse case is prototypical of the way cases were handled in the past.  The corporation pleaded guilty to making false statements and paid a big fine.  Lower level individuals were found guilty of similar charges.  In the Siemaszko trial the court was quite ready to attribute to the defendant knowledge of the content of NRC communications, whether directly prepared by him or not, or acquiescence in materials drafted by others that misrepresented conditions for the RPV.  They also dismissed his contention that he lacked proper expertise.  The court found that he knew and had a motive - keeping the plant running.  There was testimony that higher management was the source of the operational pressure but culpability did not extend beyond the individuals making the actual statements and submittals to the NRC.

³ Transocean Deepwater Inc. also admitted that members of its crew onboard the Deepwater Horizon, acting at the direction of BP’s Well Site Leaders were negligent in failing fully to investigate clear indications that the well was not secure and that oil and gas were flowing into the well.  Halliburton was the supplier of drilling cement to seal the outside of the drilling pipe.  Its guilty plea admitted destroying evidence of instructions to employees to “get rid of” simulation analyses of the event that failed to show that Halliburton’s recommendations to BP would have lowered the risk of a blowout.  [S. Mufson, "Halliburton to Plead Guilty to Destroying Evidence in BP Spill," The Washington Post (July 25, 2013).]  This was an attempt to show that a decision by BP to use fewer pipe centralizers was a serious error contributing to the accident.

⁴ A. Viswanatha, "U.S. Bid to Prosecute BP Staff in Gulf Oil Spill Falls Flat," The Wall Street Journal (Feb. 27, 2016).

⁵ Notably the lower level managers pleaded to charges and did not go to trial.  The acquittal of the CEO on felony level charges illustrates the challenges of proving these cases.

⁶ “Large punitive or compensating settlements, so the argument goes, act as an effective deterrent for mining companies, forcing them to improve their safety systems or face potentially debilitating fines. However, given the revelations about Massey and the several major US mining disasters that have taken place in the last ten years, it's impossible to argue that financial punishment has been a wholly effective scarecrow, especially when companies feel they can game the MSHA system.”  [C. Lo, "Upper Big Branch: the search for justice," Mining-technology.com (June 20, 2013).]

⁷ "To this point, research on corporate crime has been, for the most part, overlooked by mainstream criminology. In particular, corporate violations of safety regulations in the coal mining industry have yet to be studied within the field of criminology.”  [C. N. Stickeler,  "A Deadly Way of Doing Business: A Case Study of Corporate Crime in the Coal Mining Industry," University of South Florida (Jan. 2012).]

⁸ “carelessness which is in reckless disregard for the safety or lives of others, and is so great it appears to be a conscious violation of other people's rights to safety. It is more than simple inadvertence, but it is just shy of being intentionally evil.”  Read more: http://dictionary.law.com/Default.aspx?selected=838#ixzz41W5CGRf0.

⁹ J. Ewing and G. Bowley, "The Engineering of Volkswagen’s Aggressive Ambition," The New York Times (Dec. 13, 2015).

¹⁰ Ibid.

¹¹ The quote is from the case study and references the Governor’s investigation - McAteer, J. D., Beall, K., Beck, J. A., Jr., McGinley, P. C., Monforton, C., Roberts, D. C., Spence, B., & Weise, S. (2011). Upper Big Branch: The April 5, 2010, explosion: A Failure of Basic Coal Mine Safety Practices (Report to the Governor).

¹² M. Davey and R. Perez-Pena "Flint Water Crisis Yields First Criminal Charges," New York Times (April 20, 2016). 

The Criminalization of Safety (Part 1)

US DOJ logo

Nuclear safety management and culture relies on nuclear personnel conducting themselves in accordance with espoused values and making safety the highest priority.  When failures occur individual workers may be (and often are) blamed but broader implications are generally portrayed as an organizational culture deficiency and addressed in that context.  

Only rarely does the specter of criminality enter the picture, requiring a level of malfeasance - intentional conduct or recklessness - that is beyond the boundaries of conventional safety culture. 

The potential for criminal liability raises several issues.  What is the nexus between safety culture and criminal behavior?  What is the significance of the increased frequency of criminal prosecutions following major accidents or scandals in nuclear and other industries?  And where does culpability really lie - with individuals? culture? the corporation? or the complex socio-technical systems within which individuals act?

If one has been paying close attention to the news fairly numerous examples of criminal prosecutions involving safety management issues across a variety of industries and regulatory bodies is occurring.  It is becoming quite a list of late.  We thought this would be an appropriate time to take stock of these trends and their implications for nuclear safety management.

Recent Experience

We have prepared a table* summarizing relevant experience from the nuclear and other high risk industries.  (The link is to a pdf file as it is impractical to display the complete table within this blog post.)  Below is a table snippet showing a key event: the criminal prosecutions associated with the Davis Besse reactor vessel head corrosion in 2001/2002. First Energy, the owner/operator, pleaded guilty to criminal charges and two lower level employees were found guilty at trial.  A third individual, a contractor working for First Energy, was acquitted at trial.

More currently high level executives of TEPCO, the owner/operator of the Fukushima plant in Japan, were charged, though the circumstances are a bit odd.  Prosecutors had twice declined to bring criminal charges but were ultimately overruled by a citizens panel.  The case is expected to be difficult to prove.  Nonetheless this is an attempt to hold the former TEPCO Chairman and heads of the nuclear division criminally accountable.

The only other recent examples in the U.S. nuclear industry that we could identify involved falsification of documents, in one instance by a chemistry manager at Indian Point and the other a security officer at River Bend.**  One has pleaded guilty and sentenced to probation; the other case has been referred to the U.S. Department of Justice (DOJ).

Looking beyond nuclear, the picture is dominated by several major operational accidents - the Deepwater Horizon drill rig explosion and the explosion of the Upper Big Branch coal mine owned by Massey Energy.  Deepwater resulted in guilty pleas by the three corporations involved in the drilling operation - BP, Transocean and Halliburton - with massive criminal and civil fines.  BP’s plea included felony manslaughter.  Several employees also faced criminal charges.  Two faced involuntary manslaughter charges in addition to violations of the Clean Water Act.  The manslaughter charges were later dropped by prosecutors.  One employee pleaded guilty to the Clean Water Act violations and was sentenced to probation, the other went to trial and was acquitted.

The Massey case is noteworthy in that criminal charges ultimately climbed the corporate ladder all the way to the CEO.  Ultimately he was acquitted of felony charges of securities fraud and making false statements, but he “was convicted of a single count of conspiring to violate federal safety standards; he was not convicted of any count holding him responsible for the 2010 accident at the Upper Big Branch mine.”***  It “is widely believed to be the first CEO of a major U.S. corporation to be convicted of workplace safety related charges following an industrial accident.”****  Three other individuals also pleaded or were found guilty of misdemeanor charges.

Next up are the auto companies, GM, Volkswagen and Mitsubishi.  The GM scandal involved the installation of faulty ignition switches in cars that subsequently resulted in a number of deaths.  GM entered into a plea agreement with DOJ admitting criminal wrongdoing and paid large monetary fines.  As of this time no criminal charges have been brought against GM employees.  VW and Mitsubishi have both admitted to manipulating fuel economy and emissions testing and there is speculation that other auto manufacturers could be in the same boat.  The investigations are ongoing at this time but criminal pleas at the corporate level are all but certain.

Last in this pantheon is the city of Flint water quality scandal.  The Attorney General of Michigan recently filed criminal charges against three individuals and promised “more charges soon”.  The interesting aspect here is that the three charged are all government workers - one for the city and two for the Michigan Department of Environmental Quality.  And the two state officials have been charged with misconduct in office, a felony.  Essentially regulators are being held accountable for their oversight.  As David Ullmann, a former chief of DOJ’s environmental crimes section, stated, “It’s extremely unusual and maybe unprecedented for state and local officials to be charged with criminal drinking water violations.”  This bears watching.

In Part 2 we will analyze the trends in these cases and draw some insights into the possible significance of efforts to criminalize safety performance.  In Part 3 we will offer our observations regarding implications for nuclear safety management and some thoughts on approaches to mitigate the need for criminalization.


*  Criminal Prosecutions of Safety Related Events (May 22, 2016).

**  We posted on the Indian Point incident on May 12, 2014 and the River Bend case on Feb. 20, 2015.

***  A. Blinder, "Mixed Verdict for Donald Blankenship, Ex-Chief of Massey Energy, After Coal Mine Blast," New York Times (Dec. 3, 2015 corrected Dec. 5, 2015).

****  K. Maher, "Former Massey Energy CEO Sentenced to 12 Months in Prison," Wall Street Journal (April 6, 2016).  The full article may only be accessible to WSJ subscribers.

A Professor's Essay on Nuclear Safety Culture

Prof. Najmedin Meshkati recently published an article* that reviews how the Chernobyl and Fukushima disasters demonstrated the essential need for a strong safety culture (SC) in the nuclear industry.  The article is summarized below.

He begins by reminding us the root cause of the Chernobyl accident was a deficient SC, a problem that affected not only the Chernobyl plant but also permeated the entire Soviet nuclear ecosystem. 

Fukushima is characterized as an anthropogenic accident, i.e, caused by human action or inaction.  He contrasts the fate of TEPCO’s Fukushima Daiichi plant with the Tohoku Electric Power Company’s Onagawa plant.  Onagawa was closer to the earthquake epicenter than Fukushima and faced a taller tsunami but shut down safely and with limited damage.  The author concludes Tohoku had a stronger SC than TEPCO.  We reviewed Meshkati’s earlier paper comparing TEPCO and Tohoku on March 19, 2014.

He also mentions the 1961 SL-1 reactor accident** and the 1979 TMI accident.  Both presented the opportunity for SC lessons learned but they were obviously not taken to heart by all industry participants.

The author concludes with a cautionary note to newly expanding nuclear countries: human factors and SC are critical success factors “and operators’ individual mindfulness and improvisation potential need to be nurtured and cultivated by the organizations that operate such systems; and regulatory regimes should envision, encourage, and enforce them.”

Our Perspective

There is nothing new here.  The article reads like a reasonably well-researched paper prepared for a college senior seminar, with multiple linked references.***  Meshkati does have the advantage of having been “on the ground” at both Chernobyl and Fukushima but that experience does not inform this article beyond adding a bit of color to his description of the Chernobyl sarcophagus (a “temple of eternal doom”).  Overall, the article does not provide new information or insights for Safetymatters readers who have examined the accidents in any level of detail.

What’s interesting is the platform on which the article appeared.  The WorldPost is produced by The Huffington Post, a politically liberal news and opinion website, and the Berggruen Institute, a political and social think tank.  We would not have expected the HuffPost to be associated with an article that exhibits any faint pro-nuclear flavor, even one as vanilla as this.

We don’t celebrate the anniversaries of Chernobyl and Fukushima but we should certainly remember the events, especially when we see the nuclear industry hubris meter trending toward the red zone.


*  N. Meshkati, “Chernobyl’s 30th Anniversary (and Fukushima’s 5th): A Tale of Preventable Nuclear Accidents and the Vital Role of Safety Culture,” The WorldPost (April 22, 2016).

**  Stationary Low-Power Reactor Number One (SL-1) was a U.S. Army prototype small power reactor.  A Jan. 3, 1961 accident killed its three operators.

***  I looked at all the links but didn’t see anything new for the “must read” list.  However, you might quickly check them out if you are interested in these significant historical events.

IAEA Nuclear Safety Culture Conference

The International Atomic Energy Agency (IAEA) recently sponsored a week-long conference* to celebrate 30 years of interest and work in safety culture (SC).  By our reckoning, there were about 75 individual presentations in plenary sessions and smaller groups; dialog sessions with presenters and subject matter experts; speeches and panels; and over 30 posters.  It must have been quite a circus.

We cannot justly summarize the entire conference in this space but we can highlight material related to SC factors we’ve emphasized or people we’ve discussed on Safetymatters, or interesting items that merit your consideration.

Topics We Care About

A Systems Viewpoint

Given that the IAEA has promoted a systemic approach to safety and it was a major conference topic it’s no surprise that many participants addressed it.  But we were still pleased to see over 30 presentations, posters and dialogues that included mention of systems, system dynamics, and systemic and/or holistic viewpoints or analyses.  Specific topics covered a broad range including complexity, coupling, Fukushima, the Interaction between Human, Technical and Organizational Factors (HTOF), error/incident analysis, regulator-licensee relationships, SC assessment, situational adaptability and system dynamics.

Role of Leadership

Leadership and Management for Safety was another major conference topic.  Leadership in a substantive context was mentioned in about 20 presentations and posters, usually as one of multiple success factors in creating and maintaining a strong SC.  Topics included leader/leadership commitment, skills, specific competences, attributes, obligations and responsibilities; leadership’s general importance, relationship to performance and role in accidents; and the importance of leadership in nuclear regulatory agencies. 

Decision Making

This was mentioned about 10 times, with multiple discussions of decisions made during the early stages of the Fukushima disaster.  Other presenters described how specific techniques, such as Probabilistic Risk Assessment and Human Reliability Analysis, or general approaches, such risk control and risk informed, can contribute to decision making, which was seen as an important component of SC.

Compensation and Rewards

We’ve always been clear: If SC and safety performance are important then people from top executives to individual workers should be rewarded (by which we mean paid money) for doing it well.  But, as usual, there was zero mention of compensation in the conference materials.  Rewards were mentioned a few times, mostly by regulators, but with no hint they were referring to monetary rewards.  Overall, a continuing disappointment.   

Participants Who Have Been Featured in Safetymatters

Over the years we have presented the work of many conference participants to Safetymatters readers.  Following are some familiar names that caught our eye.  Page numbers refer to the conference “Programme and Abstracts” document.
 
We have to begin with Edgar Schein, the architect of the cultural construct used by almost everyone in the SC space.  His discussion paper (p. 47) argued that the SC components in a nuclear plant depend on whether the executives actually create the climate of trust and openness that the other attributes hinge on.  We’ve referred to Schein so often he has his own label on Safetymatters.

Mats Alvesson’s presentation (p. 46) discussed “hyper culture,” the vague and idealistic terms executives often promote that look good in policy documents but seldom work well in practice.  This presentation is consistent with his article on Functional Stupidity which we reviewed on Feb. 23, 2016.

Sonja Haber’s paper (p. 55) outlined a road map for the nuclear community to move forward in the way it thinks about SC.  Dr. Haber has conducted many SC assessments for the Department of Energy that we have reviewed on Safetymatters. 

Ken Koves of INPO led or participated in three dialogue sessions.  He was a principal researcher in a project that correlated SC survey data with safety performance measures which we reviewed on Oct. 22, 2010 and Oct. 5, 2014.

Najmedin Meshkati discussed (p. 60) how organizations react when their control systems start to run behind environmental demands using Fukushima as an illustrative case.  His presentation draws on an article he coauthored comparing the cultures at TEPCO’s Fukushima Daiichi plant and Tohoku Electric’s Onagawa plant which we reviewed on Mar. 19, 2014.

Jean-Marie Rousseau co-authored a paper (p. 139) on the transfer of lesson learned from accidents in one industry to another industry.  We reviewed his paper on the effects of competitive pressures on nuclear safety management issues on May 8, 2013.

Carlo Rusconi discussed (p. 167) how the over-specialization of knowledge required by decision makers can result in pools of knowledge rather than a stream accessible to all members of an organization.  A systemic approach to training can address this issue.  We reviewed Rusconi’s earlier papers on training on June 26, 2013 and Jan. 9, 2014.

Richard Taylor’s presentation (p. 68) covered major event precursors and organizations’ failure to learn from previous events.  We reviewed his keynote address at a previous IAEA conference where he discussed using system dynamics to model organizational archetypes on July 31, 2012.

Madalina Tronea talked about (p. 114) the active oversight of nuclear plant SC by the National Commission for Nuclear Activities Control (CNCAN), the Romanian regulatory authority.  CNCAN has developed its own model of organizational culture and uses multiple methods to collect information for SC assessment.  We reviewed her initial evaluation guidelines on Mar. 23, 2012. 

Our Perspective

Many of the presentations were program descriptions or status reports related to the presenter’s employer, usually a utility or regulatory agency.  Fukushima was analyzed or mentioned in 40 different papers or posters.  Overall, there were relatively few efforts to promote new ideas, insights or information.  Having said that, following are some materials you should consider reviewing.

From the conference participants mentioned above, Haber’s abstract (p. 55) and Rusconi’s abstract (p. 167) are worth reading.  Taylor’s abstract (p. 68) and slides are also worth reviewing.  He advocates using system dynamics to analyze complicated issues like the effectiveness of organizational learning and how events can percolate through a supply chain.

Benoît Bernard described the Belgian regulator’s five years of experience assessing nuclear plant SC.  Note that lessons learned are described in his abstract (p. 113) but are somewhat buried in his presentation slides.

If you’re interested in a systems view of SC, check out Francisco de Lemos’ presentation (p. 63) which gives a concise depiction of a complex system plus a Systems Theoretic Accident Models and Processes (STAMP) analysis.  His paper is based on Nancy Leveson’s work which we reviewed on Nov. 11, 2013.

Diana Engström argued that nuclear personnel can put more faith in reported numbers than justified by the underlying information, e.g., CAP trending data, and thus actually add risk to the overall system.  We’d call this practice an example of functional stupidity although she doesn’t use that term in her provocative paper.  Both her abstract (p. 126) and slides are worth reviewing.

Jean Paries gave a talk on the need for resilience in the management of nuclear operations.  The abstract (p. 228) is clear and concise; there is additional information in his slides but they are a bit messy.

And that’s it for this installment.  Be safe.  Please don’t drink and text.


*  International Atomic Energy Agency, International Conference on Human and Organizational Aspects of Assuring Nuclear Safety: Exploring 30 years of Safety Culture (Feb. 22–26, 2016).  This page shows the published conference materials.  Thanks to Madalina Tronea for publicizing them.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety Culture discussion group. 

2016 NEA Report on Fukushima Lessons Learned

Five years after the Fukushima disaster, the Nuclear Energy Agency (NEA) has released an updated report* on Fukushima lessons learned.  It summarizes NEA and member country safety improvements and corrective actions, including “efforts to understand and characterise the importance of strong nuclear safety cultures . . .” (p. 3)

Keep in mind that countries (not plant operators) comprise the NEA so safety culture (SC) discussion centers on government, i.e., regulatory, activities.  Selected SC-related excerpts from the report follow:

“Several NEA member countries have adopted a broad consideration of safety culture characteristics, including human and organisational factors, which include specific safety culture programmes that focus on attitudes towards safety, organisational capability, decision-making processes [including during emergencies] and the commitment to learn from experience.” (p. 11)

“Some [countries] have adopted a systematic consideration of safety culture characteristics in inspection and oversight processes. . . . These include periodic internal and external safety culture assessments.” (p. 29)

Desirable SC characteristics for a regulator (as opposed to a licensee) are discussed on pp. 40-42.  That may seem substantial but it’s all pulled from a different 2016 NEA publication, “The Safety Culture of an Effective Nuclear Regulatory Body,” which we reviewed on Feb. 10, 2016.  That publication had one point worth repeating here, viz., the regulator, in its efforts to promote and ensure safety, should think holistically about the overall regulator-licensee- socio-technical-legal-political system in terms of causes and effects, feedback loops and overall system performance. 

Our Perspective

This report may be a decent high-level summary of activities undertaken around the world but it is not sufficiently detailed to provide guidance and it certainly contains no original analysis.  The report does include a respectable list of Fukushima-related references.

Many of the actions, initiatives and activities described in the report are cited multiple times, creating the impression of more content than actually exists.  For example, the quote above from p. 11 is repeated, in whole or in part, in at least four other places.

If the NEA were a person, we’d characterize it as an “empty suit.”  While the summaries of and excerpts from the references, meetings, etc. are satisfactory, the NEA-authored top-level observations are often pro-nuclear cheerleading or just plain blather, e.g., “NEA member countries have continued to take appropriate actions to maintain and enhance the level of safety at their nuclear facilities, and thus nuclear power plants are safer now because of actions taken since the accident.  Ensuring safety is a continual process, . . .” (p. 11)**


*  Nuclear Energy Agency, “Five Years after the Fukushima Daiichi Accident: Nuclear Safety Improvements and Lessons Learnt,” NEA No. 7284 (2016).  The NEA is an arm of the Organisation for Economic Co-operation and Development (OECD).  This report builds on a 2013 report, “The Fukushima Daiichi Nuclear Power Plant Accident: OECD/NEA Nuclear Safety Response and Lessons Learnt.”

**  As a catty aside, the reputation of the NEA’s relatively new Director-General doesn’t exactly contribute to the agency’s respectability, his having been called “a treacherous, miserable liar,” “first-class rat” and “a tool of the nuclear industry” by an influential U.S. Senator during a 2012 Huffington Post interview.  At that time, the Director-General was a U.S. Nuclear Regulatory Commissioner.

IAEA Urges Stronger Nuclear Safety Culture in Japan

Fukushima

The International Atomic Energy Agency (IAEA) recently completed a peer review of Japan's Nuclear Regulation Authority (NRA), a regulatory agency established in the aftermath of the 2011 Fukushima disaster.  Highlights of the review were discussed at an IAEA press conference.*

The IAEA review team praised the NRA’s progress in various areas, such as demonstrating independence and transparency, and made suggestions and recommendations for further improvement, primarily in the area of NRA staff recruiting and development.

The IAEA team also mentioned safety culture (SC), recommending “the NRA and nuclear licensees ‘continue to strengthen the promotion of safety culture, including by fostering a questioning attitude’.”

Our Perspective

We look forward to the IAEA’s final report which is due in about three months.  We are especially interested in seeing if there is comprehensive discussion and specific direction with respect to “fostering a questioning attitude.”  The Japanese nuclear industry in general and TEPCO (Fukushima’s owner) in particular certainly need to cultivate employees’ willingness to develop and consider open-ended questions such as “what if?” and “what can go wrong?”

More importantly, they also need to instill the necessary backbone to stand up in front of the bosses and ask tough questions and demand straight answers.  Lots of folks probably knew the Fukushima seawall wasn’t high enough and the emergency equipment in the basement was subject to flooding but everyone went along with the program.  That’s what has to change to create a stronger SC.


*  “IAEA praises reform of Japan's nuclear regulator,” World Nuclear News (Jan. 22, 2016).

Fukushima and Volkswagen: Systemic Similarities and Observations for the U.S. Nuclear Industry

Fukushima

VW Logo (Source: Wikipedia)

Recent New York Times articles* have described the activities, culture and context of Volkswagen, currently mired in scandal.  The series inspired a Yogi Berra moment: “It’s deja vu all over again.”  Let’s look at some of the circumstances that affected Fukushima and Volkswagen and see if they give us any additional insights into the risk profile of the U.S. commercial nuclear industry.

An Accommodating Regulator

The Japanese nuclear regulator did not provide effective oversight of Tokyo Electric Power Co.  One aspect of this was TEPCO’s relative power over the regulator because of TEPCO’s political influence at the national level.  This was a case of complete regulatory capture.

The German auto regulator doesn’t provide effective oversight either.  “[T]he regulatory agency for motor vehicles in Germany is deliberately starved for resources by political leaders eager to protect the country’s powerful automakers, . . .” (NYT 12-9-15)  This looks more like regulatory impotence than capture but the outcome is the same.

In the U.S., critics have accused the NRC of being captured by industry.  We disagree but have noted that the regulator and licensees working together over long periods of time, even across the table, can lead to familiarity, common language and indiscernible mutual adjustments. 

Deference to Senior Managers

Traditionally in Japan, people in senior positions are treated as if they have the right answers, no matter what the facts facing a lower-ranking employee might suggest.  Members of society go along to get along.  As we said in an Aug. 7, 2014 post, “harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards.” 

The Volkswagen culture was a different but had the same effect.  The CEO managed through fear.  At VW, “subordinates were fearful of contradicting their superiors and were afraid to admit failure.”  A former CEO “was known for publicly dressing down subordinates . . .”  (NYT 12-13-15)

In the U.S., INPO’s singled-minded focus on the unrivaled importance of leadership can, if practiced by the wrong kind of people, lead to a suppression of dissent, facts that contradict the party line and the questioning attitude that is vital to maintain safe facilities.

Companies Not Responsible to All Legitimate Stakeholders

In the Fukushima plant design, TEPCO gave short shrift to local communities, their citizens, governments and first responders, ultimately exposing them to profound hazards.  TEPCO’s behavior also impacted the international nuclear power community, where any significant incident at one operator is a problem for them all.

Volkswagen’s isolation from public responsibilities is facilitated by its structure.  Only 12% of the company is held by independent shareholders.  Like other large German companies, the labor unions hold half the seats on VW’s board.  Two more seats are held by the regional government (a minority owner) which in practice cannot vote against labor. So the union effectively controls the board. (NYT 12-13-15)

We have long complained about the obsessive secrecy practiced by the U.S. nuclear industry, particularly in its relations with its self-regulator, INPO.  It is not a recipe for building trust and confidence with the public, an affected and legitimate stakeholder.

Our Perspective

The TEPCO safety culture (SC) was unacceptably weak.  And its management culture simply ignored inconvenient facts.

Volkswagen’s culture has valued technical competence and ambition, and apparently has lower regard for regulations (esp. foreign, i.e., U.S. ones) and other rules of the game.

We are not saying the gross problems of either company infect the U.S. nuclear industry.  But the potential is there.  The industry has experienced events that suggest the presence of human, technical and systemic shortcomings.  For a general illustration of inadequate management effectiveness, look at Entergy’s series of SC problems.  For a specific case, remember Davis-Besse, where favoring production over safety took the plant to the brink of a significant failure.  Caveat nuclear.


*  See, for example: J. Ewing and G. Bowley, “The Engineering of Volkswagen’s Aggressive Ambition,” New York Times (Dec. 13, 2015).  J. Ewing, “Volkswagen Terms One Emissions Problem Smaller Than Expected,” New York Times (Dec. 9, 2015).