NRC Staff Review of National Research Council Safety Culture Recommendations Arising from Fukushima

On July 30, 2014 we reviewed the safety culture (SC) aspects of the National Research Council report on lessons learned from the Fukushima nuclear accident.  We said the report’s SC recommendations were pretty limited: the NRC and industry must maintain and monitor a strong SC in all safety-related activities, the NRC must maintain its independence from outside influences, and the NRC and industry should increase their transparency about their SC-related efforts.

The NRC staff reviewed the report’s recommendations, assessed whether the agency was addressing them and documented their results.*  Given the low bar, it’s no surprise the staff concluded “that all NAS’s recommendations are being adequately addressed.” (p.1)  Following is the evidence the staff assembled to show the NRC is addressing the SC recommendations.

Emphasis on Safety Culture (pp. 25-26) 

In 1989, after Peach Bottom plant operators were caught sleeping on the job, the NRC issued a “Policy Statement on the Conduct of Nuclear Power Plant Operations.”   The policy statement focused on personal dedication and accountability but also underscored management’s responsibility for fostering a healthy SC.

In 1996, after Millstone whistleblowers faced retaliation, the NRC issued another policy statement, “Freedom of Employees in the Nuclear Industry to Raise Safety Concerns without Fear of Retaliation.”  This policy statement focused on the NRC’s expectation that all licensees will establish and maintain a safety-conscious work environment (SCWE).

In 2002, after discovery of the Davis-Besse reactor pressure vessel’s degradation, the Reactor Oversight Process (ROP) was strengthened to detect potential SC weaknesses during inspections and performance assessments.  ROP changes were described in Regulatory Issue
Summary 2006-13, “Information on the Changes Made to the Reactor Oversight Process to More Fully Address Safety Culture.”

In 2004, INPO published “Principles for a Strong Nuclear Safety Culture.”  In 2009, an industry/NEI/INPO effort produced a process for monitoring and improving SC, documented in NEI 09-07 “Fostering a Strong Nuclear Safety Culture.”  We reviewed NEI 09-07 on Jan. 6, 2011.

In 2008, the NRC initiated an effort to define and expand SC policy.  The final Safety Culture Policy Statement (SCPS) was published on June 14, 2011.  We posted eight times on the SCPS effort before the policy was issued.  Click on the SC Policy Statement label to see both those posts and subsequent ones that refer to the SCPS. 

An Independent Regulator (pp. 26-27)

The Energy Reorganization Act of 1974 established the NRC.  Principal Congressional oversight of the agency is performed by the Senate Subcommittee on Clean Air and Nuclear Safety, and the House Subcommittee on Energy and the Environment.  It’s not clear how the NRC performing obeisance before these committees contributes to the agency’s independence.

The NRC receives independent oversight from the NRC’s Office of the Inspector General and the U.S. Government Accountability Office.

Perhaps most relevant, the U.S. is a contracting party to the international Convention on Nuclear Safety.  The NRC prepares a periodic report describing how the U.S. fulfills its obligations under the CNS, including maintaining the independence of the regulatory body.  On March 26, 2014 we posted on the NRC’s most recent report.

Industry Transparency (pp. 27-28)

For starters, the NRC touts its SC website which includes the SCPS and SC-related educational and outreach materials.

In March 2014, the NRC published NUREG-2165, “Safety Culture Common Language,” which
documents a common language to describe SC in the nuclear industry.  We reviewed the NUREG on April 6, 2014.

That’s all.

Our Perspective 

We’ll give the NRC a passing grade on its emphasis on SC.  The “evidence” on agency independence is slim.  Some folks believe that regulatory capture has occurred, to a greater or lesser degree.  For what it’s worth, we think the agency is fairly independent.

The support for industry transparency is a joke.  As we said in our July 30, 2014 post, “the nuclear industry’s penchant for secrecy is a major contributor to the industry being its own worst enemy in the court of public opinion.”     


*  NRC Staff Review of National Academy of Sciences Report, “Lessons Learned from theFukushima Dai-ichi Nuclear Accident for Improving Safety of U.S. Nuclear Plants” (Apr. 9, 2015).  ADAMS ML15069A600.  The National Research Council is part of the National Academy of Sciences.

INPO’s View on Fukushima Safety Culture Lessons Learned

In November 2011 the Institute of Nuclear Power Operations (INPO) published a special report* on the March 2011 Fukushima accident.  The report provided an overview and timeline for the accident, focusing on the evolution of the situation during the first several days after the earthquake and tsunami.  Safety culture (SC) was not mentioned in the report.

In August 2012 INPO issued an addendum** to the report covering Fukushima lessons learned in eight areas, including SC.  Each area contains a lengthy discussion of relevant plant activities and experiences, followed by specific lessons learned.  According to INPO, some lessons learned may be new or different from those published elsewhere.  Several caught our attention as we paged through the addendum: Invest resources to assess low-probability, high-consequence events (Black Swans).  Beef up available plant staffing to support regular staff in case a severe, long duration event inconveniently occurs on a weekend.  Evaluate the robustness of off-site event management facilities (TEPCO’s was inaccessible, lost power and did not have filtered ventilation).  Be aware that assigning most decision making authority to the control room crew (as TEPCO did) meant other plant groups could not challenge or check ops’ decisions—efficiency at the cost of thoroughness.  Conduct additional training for a high-dose environment when normal dosage limits are replaced with emergency ones.  Ensure that key personnel have in-depth reactor and power plant knowledge to respond effectively if situations evolve beyond established procedures and flexibility is required.

Focusing on SC, the introduction to this section is clear and unexpectedly strong: “History has shown that accidents and their precursors at commercial nuclear electric generating stations result from a series of decisions and actions that reflect flaws in the shared assumptions, values, and beliefs of the operating organization.” (p. 33)

The SC lessons learned are helpful.  INPO observed that while TEPCO had taken several steps over the years to strengthen its SC, it missed big picture issues including cultivating a questioning attitude, challenging assumptions, practicing safety-first decision making and promoting organizational learning.  In each of these areas, the report covers specific deficiencies or challenges faced at Fukushima followed by questions aimed at readers asking them to consider if similar conditions exist or could exist at their own facilities.

Our Perspective

The addendum has a significant scope limitation: it does not address public policy (e.g., regulatory or governmental) factors that contributed to the Fukushima accident and yielded their own lessons learned.***  However, given the specified scope, a quick read of the entire addendum suggests it’s reasonably thorough, the SC section certainly is.  The questions aimed at report readers are the kind we ask all the time on Safetymatters but we award INPO full marks for addressing these general, qualitative, open-ended subjects.  One question INPO raised that we have not specifically asked is “To what extent are the safety implications considered during enterprise business planning and budgeting?” (italics added)  Another, inferred from the report text, is “How do operators create complex, realistic scenarios (e.g., with insufficient information and/or personnel under stress) during emergency training?”  These are legitimate additions to the repertoire.  

The addendum is not perfect.  For example, INPO trots out the “special and unique” mantra when discussing the essential requirements to maintain core cooling capability and containment integrity (esp. with respect to venting at Fukushima).  This mantra, coupled with INPO’s usual penchant for secrecy, undermines public support for commercial nuclear power.  INPO can be a force for good when its work products, like this report and addendum, are publicly available.  It would be better for the industry if INPO were more transparent and if commercial nuclear power were characterized as a safety-intense industrial process run by ordinary, albeit highly trained, people.

Bottom line, you should read the addendum looking for bits that apply to your own situation.


*  INPO, “Special Report on the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station,” INPO 11-005 Rev. 0 (Nov. 2011).

**  INPO, “Lessons Learned from the Nuclear Accident at the Fukushima Daiichi Nuclear Power Station,” INPO 11-005 Rev. 0 Addendum (Aug. 2012).  Thanks to Madalina Tronea for publicizing this document.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety discussion group.

***  Regulatory, government and corporate governance lessons learned have been publicized by other Fukushima reviewers and the findings widely distributed, including on Safetymatters.  Click on the Fukushima label to see our related posts. 

More Safety Culture “Trait Talk” from the NRC

Typical NRC Trait Talk brochure

The NRC introduced a series of educational brochures, the Safety Culture Trait Talk, at the March 2014 Regulatory Information Conference.  Each brochure covers one of the nine safety culture (SC) traits in the NRC SC Policy Statement (SCPS), describing why the trait is important and providing examples of related attributes and an illustrative scenario.

At that time, only one Trait Talk was available, viz., Leadership Safety Values and Actions.  We thought the content was pretty good.  The “Why is this trait important?” portion was derived from an extensive review of SC-related social science literature, which we liked a lot and posted about Feb. 10, 2013.  The “What does this trait look like?” section (aka attributes) comes from the SC Common Language initiative, which we have reviewed multiple times, most recently on April 6, 2014.  The illustrative scenario is new content developed for each brochure.

During 2014 and early 2015, NRC published additional Trait Talk brochures and now has one for each trait in the SCPS.*  We reviewed them all and still believe they provide a useful introduction and overview for each trait.  Following is our take on each trait’s essence (based on the brochure contents), and each brochure’s strengths and weaknesses.  

Leadership Safety Values and Actions

This trait focuses on the responsibilities of leaders to set the tone for SC through their own visible actions.  There is a good discussion of how employees at all levels can face goal conflicts, e.g., safety vs. production.  The focus of the reward system is on the staff; unfortunately, there is no mention of management’s financial incentives.  Although leaders’ decisions set the priority for safety, there is no mention of the decision making process, arguably management’s most fundamental and important function.**

Work Processes

This trait focuses on controlling work.  It emphasizes limiting temporary modifications, minimizing backlogs and adhering to procedures, which is all good.  It also says “organizations may require strict adherence to normal and emergency operating procedures.   However, flexibility may be necessary when responding to off-normal conditions.”  This may give the purists heartburn but it reflects reality and is a major observation of the Fukushima disaster.

Questioning Attitude

This trait is about avoiding complacency, watching for abnormalities while going about one’s duties and stopping work if unexpected conditions or results are encountered.  The key is ensuring safety has its appropriate priority at all times, which is not easy if a plant is under significant financial or political pressure.

Problem Identification and Resolution

This trait is about identifying and permanently resolving current problems, and anticipating potential future challenges and dealing with them before they manifest.  In our view, this is one of the two most important areas (the other being decision making) where everyone sees what a plant’s real priorities are.  This Trait Talk covers the topic well.

Environment for Raising Concerns

The trait is about establishing and maintaining a safety conscious work environment (SCWE).  The Trait Talk lays out the theory but the truth is whistle-blowers in many industries, including nuclear, become pariahs.

Effective Safety Communication

This trait is about transparency (although the term does not appear in the brochure.)  All business communication should be clear, complete, understandable and respectful.  The Trait Talk’s discussion on the importance of first-level supervisors being a primary source of information for their employees is very good.

Respectful Work Environment

The title says it all about this trait which overlaps with others, including questioning attitude, SCWE and transparent communications.  The Trait Talk has a good discussion of trust, at both the individual and organizational level.  One aspect we would add to the trust “equation” is the perception of self-interest vs. concern for others.

Continuous Learning

This trait is about identifying, obtaining, sharing, applying and retaining new knowledge that can lead to improved individual or organizational performance.  This trait overlaps with others, including questioning attitude and a respectful work environment.

Personal Accountability

This trait is mostly about everyone’s willingness to accept responsibility for safety but it also encompasses assigned individuals’ obligation for specific safety responsibilities.  For the latter case, the brochure’s statement that “Personal accountability is not finger pointing, blame, or punishment” is simply not true. 

Our Perspective 

The brochures provide a useful introduction and overview for each trait in the SCPS.  The content is generally good, with some weak spots and missing items.  These are, after all, four-page brochures and roughly 45 percent of the content is the same in every brochure.


*  All the Trait Talk brochures can be downloaded from the SC education materials page on the NRC website.

**  Interestingly, Decision Making is included as a tenth trait in NRC NUREG-2165, “Safety Culture Common Language” (Mar. 2014).  ADAMS ML14083A200.

NAS Safety Culture Lessons Learned from Fukushima—Presentation to NRC

We reviewed the National Academy of Sciences’ (NAS) Fukushima Lessons Learned report on July 30, 2014.  As you recall, we were underwhelmed by the recommendations related to nuclear safety culture (SC).  Basically, the report said the NRC should maintain a strong SC at the facilities it regulates and maintain the agency’s independence.  In addition, the NRC and industry should increase the transparency of their efforts to assess and improve SC.

Two of the report’s authors presented the NAS findings to the NRC on July 31, 2014 as part of a panel of external stakeholders presenting Fukushima lessons learned.  This post, based on the meeting transcript*, reviews the SC-related comments at that meeting.  The NAS presenter repeated the report’s SC recommendations then added some comments about the differences between Japanese and American culture. (pp. 18-19)  He also noted that the SC chapter in the report exhibits a range of views of SC held by different members of the 21-person NAS committee. (p. 24)

The NAS presentation was one of six made by the external panel.  A five-member NRC staff panel reported separately on the agency’s Fukushima-related investigations and activities.  Only the NAS presentation mentioned SC; the other presentations focused on plant hardware, off-site equipment, and state and foreign regulatory activities.

Our Perspective

Although this was a busy meeting with a tight schedule, SC did warrant comments from the Commissioners:

Commissioner Magwood said “. . . I also agree with many of the points the Committee raised about safety culture. I think that the cultural and training issues may actually be more important than some of the hardware issues that we spend a lot of time talking about.  And that is something that has not got enough emphasis.” (p. 57)

Commissioner Svinicki said “I liked the simple statement that was made of nuclear safety culture is a big issue.”  She also appreciated that the committee had a “vibrant” discussion on SC. (pp. 73-74)

Bottom line: Given the number of presentations SC did not get short shrift from the Commission. The Commissioners acknowledged SC’s importance but there was no real discussion of the topic.


*  NRC, “Briefing on the Status of Lessons Learned from the Fukushima Dai-ichi Accident,” meeting transcript (July 31, 2014).  ADAMS ML14217A208.

DNFSB Hearings on Safety Culture, Round Two

DNFSB Headquarters

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


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

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

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

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

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

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

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

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

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

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

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

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

Our Perspective

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

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

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


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

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

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

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

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

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

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

1995 ANS Safety Culture Conference: A Portal to the Past

In April 1995 the American Nuclear Society (ANS) sponsored a nuclear safety culture (SC) conference in Vienna.  This was a large undertaking, with over 80 presentations; the proceedings are almost 900 pages in length.*  Presenters included industry participants, regulators, academics and consultants.  1995 was early in the post-Soviet era and the new openness (and concerns about Soviet reactors) led to a large number of presenters from Russia, Ukraine and Eastern Europe.  This post presents some conference highlights on topics we emphasize on Safetymatters.

Decision Making

For us, decision making should be systemic, i.e., consider all relevant inputs and the myriad ways a decision can affect consequences.  The same rigor should be applied to all kinds of decisions—finance, design, operations, resource allocation, personnel, etc.  Safety should always have the highest priority and decisions should accord safety its appropriate consideration.  Some presenters echoed this view.

“Safety was (and still is) seen as being vital to the success of the industry and hence the analysis and assessment of safety became an integral part of management decision making” (p. 41); “. . . in daily practice: overriding priority to safety is the principle, to be taken into account before making any decision” (p. 66); and “The complexity of operations implies a systemic decision process.” (p. 227)

The relationship between leadership and decisions was mentioned.  “The line management are a very important area, as they must . . . realise how their own actions and decisions affect Safety Culture.  The wrong actions, or perceived messages could undermine the work of the team leaders” (p. 186); “. . . statements alone do not constitute support; in the intermediate and long-term, true support is demonstrated by behavior and decision and not by what is said.” (p. 732)

Risk was recognized as a factor in decision making.  “Risk culture yields insights that permit balanced safety vs.cost decisions to be made” (p. 325); “Rational decision making is based on facts, experience, cognitive (mental) models and expected outcomes giving due consideration to uncertainties in the foregoing and the generally probabilistic nature of technical and human matters.  Conservative decision making is rational decision making that is risk-averse.  A conservative decision is weighted in favor of risk control at the expense of cost.” (p. 435)

In sum, nuclear thought leaders knew what good decision making should look like—but we still see cases that do not live up to that standard.

Rewards

Rewards or compensation were mentioned by people from nuclear operating organizations.  Incentive-based compensation was included as a key aspect of the TEPCO management approach (p. 551) and a nuclear lab manager recommended using monetary compensation to encourage cooperation between organizational departments. (p. 643)  A presenter from a power plant said “A recognition scheme is in place . . . to recognise and reward individuals and teams for their contribution towards quality improvement and nuclear safety enhancement.” (p. 805)

Rewards were also mentioned by several presenters who did not come from power plants.  For example, the reward system should stress safety (p. 322); rewards should be given for exhibiting a “caring attitude” about SC (p. 348) and to people who call attention to safety problems. (p. 527)  On the flip side, a regulator complained about plants that rewarded behavior that might cause safety to erode. (pp. 651, 656) 

Even in 1995 the presentations could have been stronger since INSAG-4** is so clear on the topic: “Importantly, at operating plants, systems of reward do not encourage high plant output levels if this prejudices safety.  Incentives are therefore not based on production levels alone but are also related to safety performance.” (INSAG-4, p. 11)  Today, our own research has shown that nuclear executives’ compensation often favors production.   

Systems Approach

We have always favored nuclear organizational mental models that consider feedback loops, time delays, adaptation, evolution and learning—a systems approach.  Presenters’ references to a system include “commercial, public, and military operators of complex high reliability socio-technical systems” (p. 260); “. . . assess the organisational, managerial and socio-technical influences on the Safety Culture of socio-technical systems such as nuclear power plants” (p. 308); “Within the complex system such as . . . [a] nuclear power plant there is a vast number of opportunities for failures to stay hidden in the system” (p. 541); and “It is proposed that the plant should be viewed as an integrated sociotechnical system . . .” (p. 541)

There are three system-related presentations that we suggest you read in their entirety; they have too many good points to summarize here.  One is by Electricité de France (EdF) personnel (pp. 193-201), another by Constance Perin (pp. 330-336) and a third by John Carroll (pp. 338-345). 

Here’s a sample, from Perin: “Through self-analysis, nuclear organizations can understand how they currently respond socially, culturally, and technically to such system characteristics of complexity, density, obscured signals, and delayed feedback in order to assure their capacities for anticipating, preventing, and recovering from threats to safety.” (p. 330)  It could have been written yesterday.

The Role of the Regulator

By 1995 INSAG-4 had been published and generally accepted by the nuclear community but countries were still trying to define the appropriate role for the regulator; the topic merited a half-dozen presentations.  Key points included the regulator (1) requiring that an effective SC be established, (2) establishing safety as a top-level goal and (3) performing some assessment of a licensee’ safety management system (either directly or part of ordinary inspection duties).  There was some uncertainty about how to proceed with compliance focus vs. qualitative assessment.

Today, at least two European countries are looking at detailed SC assessment, in effect, regulating SC.  In the U.S., the NRC issued a SC policy statement and performs back-door, de facto SC regulation through the “bring me another rock” approach.

So conditions have changed in regulatory space, arguably for the better when the regulator limits its focus to truly safety-significant activities.

Our Perspective

In 1995, some (but not all) people held what we’d call a contemporary view of SC.  For example, “Safety culture constitutes a state of mind with regard to safety: the value we attribute to it, the priority we give it, the interest we show in it.  This state of mind determines attitudes and behavior.” (p. 495)

But some things have changed.  For example, several presentations mentioned SC surveys—their design, administration, analysis and implications.  We now (correctly) understand that SC surveys are a snapshot of safety climate and only one input into a competent SC assessment.

And some things did not turn out well.  For example, a TEPCO presentation said “the decision making process is governed by the philosophy of valuing harmony highly so that a conclusion preferred by all the members is chosen as far as possible when there are divided opinions.” (p. 583)  Apparently harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards. 


*  A. Carnino and G. Weimann, ed., “Proceedings of the International Topical Meeting on Safety Culture in Nuclear Installations,” April 24-28, 1995 (Vienna: ANS Austria Local Section, 1995).  Thanks to Bill Mullins for unearthing this document.

**  International Nuclear Safety Advisory Group, “Safety Culture,” Safety Series No. 75-INSAG-4, (Vienna: IAEA, 1991). INSAG-4 included a definition of SC, a description of SC components, and illustrative evidence that the components exist in a specific organization.

National Research Council: Safety Culture Lessons Learned from Fukushima

The National Research Council has released a report* on lessons learned from the Fukushima nuclear accident that may be applicable to U.S. nuclear plants.  The report begins with a recitation of various Fukushima aspects including site history, BWR technology, and plant failure causes and consequences.  Lessons learned were identified in the areas of Plant Operations and Safety Regulations, Offsite Emergency Management, and Nuclear Safety Culture (SC).  This review focuses on the SC aspects of the report.

Spoiler alert: the report reflects the work of a 24-person committee, with the draft reviewed by two dozen other individuals.**  We suggest you adjust your expectations accordingly.

The SC chapter of the report provides some background on SC and echoes the by-now familiar cultural issues at both Tokyo Electric Power Company (TEPCO) and Japan’s Nuclear Energy Agency.  Moving to the U.S., the committee summarizes the current situation in a finding: “The U.S. nuclear industry, acting through the Institute of Nuclear Power Operations, has voluntarily established nuclear safety culture programs and mechanisms for evaluating their implementation at nuclear plants. The U.S. Nuclear Regulatory Commission has published a policy statement on nuclear safety culture, but that statement does not contain implementation steps or specific requirements for industry adoption.” (p. 7-8)  This is accurate as far as it goes.

After additional discussion of the U.S. nuclear milieu, the chapter concludes with two recommendations, reproduced below along with associated commentary.

An Effective, Independent Regulator

“RECOMMENDATION 7.2A: The U.S. Nuclear Regulatory Commission and the U.S. nuclear power industry must maintain and continuously monitor a strong nuclear safety culture in all of their safety-related activities. Additionally, the leadership of the U.S. Nuclear Regulatory Commission must maintain the independence of the regulator. The agency must ensure that outside influences do not compromise its nuclear safety culture and/or hinder its discussions with and disclosures to the public about safety-related matters.” (pp. S-9, 7-17)

In the lead up to this recommendation, there was some lack of unanimity on the subject of whether the NRC was sufficiently independent and if some degree of regulatory capture has occurred.  The debate covered industry involvement in rule-making, Davis-Besse and other examples.

We saw one quote worth repeating here: “The president and Senate of the United States also play important roles in helping to maintain the USNRC’s regulatory independence by nominating and appointing highly qualified agency leaders (i.e., commissioners) and working to ensure that the agency is free from undue influences.” (pp. 7-14/15)  We’ll leave it to the reader to determine if the executive and legislative branches met that standard with the previous NRC chairman and the two current commissioner nominees, both lawyers—one an NRC lifer and the other a former staffer on the Hill.

Snarky comment notwithstanding, the first recommendation is a motherhood statement and borderline tautology (who can envision the effective negation of any of the three imperative statements?)  More importantly, it appears only remotely related to the concept of SC; even at its simplest, SC consists of values and artifacts and there’s not much of either in the recommendation.

Increased Industry Transparency

“RECOMMENDATION 7.2B: The U.S. nuclear industry and the U.S. Nuclear Regulatory Commission should examine opportunities to increase the transparency of and communication about their efforts to assess and improve their nuclear safety cultures.” (pp. S-9, 7-17)

The discussion includes a big kiss for INPO.  “INPO has taken the lead for promoting a strong nuclear safety culture in the U.S. nuclear industry through training and evaluation programs.” (p. 7-10)  The praise for INPO continues in an attachment to the SC chapter but it eventually gets to the elephant in the room: “The results of INPO’s inspection program are shared among INPO membership, but such information is not made available to the public. . . . Releases of summaries of these inspections by management to the public would help increase transparency.” (p. 7-21)

The committee recognizes that implementing the recommendation “would require that the industry and regulators disclose additional information to the public about their efforts to assess safety culture effectiveness, remediate deficiencies, and implement improvements.” (p. 7-17)

At least transparency is a cultural attribute.  We have long opined that the nuclear industry’s penchant for secrecy is a major contributor to the industry being its own worst enemy in the court of public opinion. 

Our Perspective

This report looks like what it is: a crowd sourced effort by a focus group of academics using the National Academy of Sciences’ established bureaucratic processes.  The report is 367 pages long, with over 350 references and a bunch of footnotes.  The committee’s mental model of SC focuses on organizational processes that influence SC. (p. 7-1)  I think it's fair to infer that their notion of improvement is to revise the rules that govern the processes, then maximize compliant behavior.  Because of the committee’s limited mental model, restricted mission*** and the real or perceived need to document every factoid, the report ultimately provides no new insights into how U.S. nuclear plants might actually realize stronger SC.


*  National Research Council Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants, “Lessons Learned from the Fukushima Nuclear Accident for Improving Safety of U.S. Nuclear Plants” Prepublication Copy.  Downloaded July 26, 2014.  The National Research Council is part of the National Academy of Sciences (NAS).  Thanks to Bill Mullins for bringing this report to our attention.

**  The technical advisor to the committee was Najmedin Meshkati from the University of Southern California.  If that name rings a bell with Safetymatters readers, it may be because he and his student, Airi Ryu, published an op-ed last March contrasting the culture of Tohoru Electric with the culture of TEPCO.  We posted our review of the op-ed here.

***  The committee was tasked to consider causes of the Fukushima accident, conclusions from previous NAS studies and lessons that can be learned to improve nuclear plant safety in certain specified areas.  The committee was directed to not make any policy recommendations that involved non-technical value judgments. (p. S-10)

Safety Culture at Tohoku Electric vs. Tokyo Electric Power Co. (TEPCO)

Fukushima No. 1 (Daiichi)

An op-ed* in the Japan Times asserts that the root cause of the Fukushima No. 1 (Daiichi) plant’s failures following the March 11, 2011 earthquake and tsunami was TEPCO’s weak corporate safety culture (SC).  This post summarizes the op-ed then provides some background information and our perspective.

Op-Ed Summary 

According to the authors, Tohoku Electric had a stronger SC than TEPCO.  Tohoku had a senior manager who strongly advocated safety, company personnel participated in seminars and panel discussions about earthquake and tsunami disaster prevention, and the company had strict disaster response protocols in which all workers were trained.  Although their Onagawa plant was closer to the March 11, 2011 quake epicenter and experienced a higher tsunami, it managed to shut down safely.

SC-related initiatives like Tohoku’s were not part of TEPCO’s culture.  Fukushima No. 1’s problems date back to its original siting and early construction.  TEPCO removed 25 meters off the 35 meter natural seawall of the plant site and built its reactor buildings at a lower elevation of 10 meters (compared to 14.7m for Onagawa).  Over the plant’s life, as research showed that tsunami levels had been underestimated, TEPCO “resorted to delaying tactics, such as presenting alternative scientific studies and lobbying”** rather than implementing countermeasures.

Background and Our Perspective

The op-ed is a condensed version of the authors’ longer paper***, which was adapted from a research paper for an engineering class, presumably written by Ms. Ryu.  The op-ed is basically a student paper based on public materials.  You should read the longer paper, review the references and judge for yourself if the authors have offered conclusions that go beyond the data they present.

I suggest you pay particular attention to the figure that supposedly compares Tohoku and TEPCO using INPO’s ten healthy nuclear SC traits.  Not surprisingly, TEPCO doesn’t fare very well but note the ratings were based on “the author’s personal interpretations and assumptions” (p. 26)

Also note that the authors do not mention Fukushima No. 2 (Daini), a four-unit TEPCO plant about 15 km south of Fukushima No. 1.  Fukushima No. 2 also experienced damage and significant challenges after being hit by a 9m tsunami but managed to reach shutdown by March 18, 2011.  What could be inferred from that experience?  Same corporate culture but better luck?

Bottom line, by now it’s generally agreed that TEPCO SC was unacceptably weak so the authors plow no new ground in that area.  However, their description of Tohoku Electric’s behavior is illuminating and useful.


*  A. Ryu and N. Meshkati, “Culture of safety can make or break nuclear power plants,” Japan Times (Mar. 14, 2014).  Retrieved Mar. 19, 2014.

**  Quoted in the op-ed but taken from “The official report of the Fukushima Nuclear Accident Independent Investigation Commission [NAIIC] Executive Summary” (The National Diet of Japan, 2012), p. 28.  The NAIIC report has a longer Fukushima root cause explanation than the op-ed, viz, “the root causes were the organizational and regulatory systems that supported faulty rationales for decisions and actions, . . .” (p. 16) and “The underlying issue is the social structure that results in “regulatory capture,” and the organizational, institutional, and legal framework that allows individuals to justify their own actions, hide them when inconvenient, and leave no records in order to avoid responsibility.” (p. 21)  IMHO, if this were boiled down, there wouldn’t be much SC left in the bottom of the pot.

***  A. Ryu and N. Meshkati, “Why You Haven’t Heard About Onagawa Nuclear Power Station after the Earthquake and Tsunami of March 11, 2011” (Rev. Feb. 26, 2014).

Lessons Learned from “Lessons Learned”: The Evolution of Nuclear Power Safety after Accidents and Near-Accidents by Blandford and May

This publication appeared on a nuclear safety online discussion board.*  It is a high-level review of significant commercial nuclear industry incidents and the subsequent development and implementation of related lessons learned.  This post summarizes and evaluates the document then focuses on its treatment of nuclear safety culture (SC). 

The authors cover Three Mile Island (1979), Chernobyl (1986), Le Blayais [France] plant flooding (1999), Davis-Besse (2002), U.S. Northeast Blackout (2003) and Fukushima-Daiichi (2011).  There is a summary of each incident followed by the major lessons learned, usually gleaned from official reports on the incident. 

Some lessons learned led to significant changes in the nuclear industry, other lessons learned were incompletely implemented or simply ignored.  In the first category, the creation of INPO (Institute of Nuclear Power Operations) after TMI was a major change.**  On the other hand, lessons learned from Chernobyl were incompletely implemented, e.g., WANO (World Association of Nuclear Operators, a putative “global INPO”) was created but it has no real authority over operators.  Fukushima lessons learned have focused on design, communication, accident response and regulatory deficiencies; implementation of any changes remains a work in progress.

The authors echo some concerns we have raised elsewhere on this blog.  For example, they note “the likelihood of a rare external event at some site at some time over the lifetime of a reactor is relatively high.” (p. 16)  And “the industry should look at a much higher probability of problems than is implied in the “once in a thousand years” viewpoint.” (p. 26)  Such cautions are consistent with Taleb's and Dédale's warnings that we have discussed here and here.

The authors also say “Lessons can also be learned from successes.” (p. 3)  We agree.  That's why our recommendation that managers conduct periodic in-depth analyses of plant decisions includes decisions that had good outcomes, in addition to those with poor outcomes.

Arguably the most interesting item in the report is a table that shows deaths attributable to different types of electricity generation.  Death rates range from 161 (per TWh) for coal to 0.04 for nuclear.  Data comes from multiple sources and we made no effort to verify the analysis.***

On Safety Culture

The authors say “. . . a culture of safety must be adopted by all operating entities. For this to occur, the tangible benefits of a safety culture must become clear to operators.” (p. 2, repeated on p. 25)  And “The nuclear power industry has from the start been aware of the need for a strong and continued emphasis on the safety culture, . . .” (p. 24)  That's it for the direct mention of SC.

Such treatment is inexcusably short shrift for SC.  There were obvious, major SC issues at many of the plants the authors discuss.  At Chernobyl, the culture permitted, among other things, testing that violated the station's own safety procedures.  At Davis-Besse, the culture prioritized production over safety—a fact the authors note without acknowledging its SC significance.  The combination of TEPCO's management culture which simply ignored inconvenient facts and their regulator's “see no evil” culture helped turn a significant plant event at Fukushima into an abject disaster.

Our Perspective

It's not clear who the intended audience is for this document.  It was written by two professors under the aegis of the American Academy of Arts and Sciences, an organization that, among other things, “provides authoritative and nonpartisan policy advice to decision-makers in government, academia, and the private sector.”****  While it is a nice little history paper, I can't see it moving the dial in any public policy discussion.  The scholarship in this article is minimal; it presents scant analysis and no new insights.  Its international public policy suggestions are shallow and do not adequately recognize disparate, even oppositional, national interests.  Perhaps you could give it to non-nuclear folks who express interest in the unfavorable events that have occurred in the nuclear industry. 


*  E.D. Blandford and M.M. May, “Lessons Learned from “Lessons Learned”: The Evolution of Nuclear Power Safety after Accidents and Near-Accidents” (Cambridge, MA: American Academy of Arts and Sciences, 2012).  Thanks to Madalina Tronea for publicizing this article on the LinkedIn Nuclear Safety group discussion board.  Dr. Tronea is the group's founder/moderator.

**  This publication is a valentine for INPO and, to a lesser extent, the U.S. nuclear navy.  INPO is hailed as “extraordinarily effective” (p. 12) and “a well-balanced combination of transparency and privacy; . . .” (p. 25)

***  It is the only content that demonstrates original analysis by the authors.

****  American Academy of Arts and Sciences website (retrieved Jan. 20, 2014).