Conduct of the Science Enterprise and Effective Nuclear Safety Culture – A Reflection (Part 1)

(Ed. note: We have asked Bill Mullins to develop occasional posts for Safetymatters.  His posts will focus on, but not be limited to, the Hanford Waste Treatment Plant aka the Vit Plant.)

In a recent post the question was posed: “Can reality in the nuclear operating environment be similar (to the challenges of production pressures on scientists), or is nuclear somehow unique and different?”
 
In a prior post a Chief Nuclear Officer is quoted: “ . . the one issue is our corrective action program culture, our -- and it’s a culture that evolved over time. We looked at it more of a work driver, more of a -- you know, it’s a way to manage the system rather than . . . finding and correcting our performance deficiency.”

Another recent post describes the inherently multi-factor and non-linear character of what we’ve come to refer to as “Nuclear Safety Culture.”  Bob Cudlin observed: “We think there are a number of potential causes that are important to ensuring strong safety culture but are not receiving the explicit attention they deserve.  Whatever the true causes we believe that there will be multiple causes acting in a systematic manner - i.e., causes that interact and feedback in complex combinations to either reinforce or erode the safety culture state.”

I’d like to suggest a framework in which these questions and observations can be brought into useful relationship for thinking about the future of the US National Nuclear Energy Enterprise (NNEE).

This week I read yet another report on the Black Swan at Fukushima – this one representing views of US Nuclear industry heavy weights. It is just one of perhaps a dozen reviews, complete or on-going, that are adding to the stew pot of observations, findings, and recommendations about lessons to be learned from those “wreck the plant” events. I was wondering how all this “stuff” comes together in a manner that gives confidence that the net reliability of the US NNEE is increased rather than encumbered.

Were all these various “nuclear safety” reports scientific papers of the type referred to in the recent news story, then we would understand how they are “received” into the shared body of knowledge. Contributions would be examined, validations pursued, implications assessed, and yes, rewards or sanctions for work quality distributed. This system for the conduct of scientific research is very mature and has seemingly responded well to the extraordinary growth in volume and variety of research during the past half-century.

In the case of the Fukushima reports (and I’d suggest as validated by the corresponding pile of Deepwater Horizon reviews) there is no process akin to the publishing standards commonly employed in science or other academic research. In form, industrial catastrophes are typically investigated with some variation of causal analysis; also typically a distinguished panel of “experts” is assembled to conduct the review.

The credentials of those selected experts are relied upon to lend gravity to report results; this is generally in lieu of any peer or independent stakeholder review. An exception to this occurs when legislative hearings are convened to receive testimony from panel members and/or the responsible officials implicated in the events – but these second tier reviews are more often political theater than exercises in “seeking to understand.”

Since the TMI accident this trial by Blue Ribbon Panel methodology has proliferated; often firms such a BP hire such reviews (e.g. the Baker Panel on Texas City) to be done for official stakeholders that are below the level of regulatory or legislative responsibility. In the case of Deepwater Horizon and Fukushima it has been virtually open season for interested parties with any sort of credentialed authority (i.e. academic, professional society, watchdog group, etc.) to offer up a formal assessment of these major events.

And today of course we have the 24 hour news cycle with its voracious maw and indiscriminate headline writers; and let’s not forget the opinionated individuals like me – blogging furiously away with no authentic credentials but personal experience! How, I ask myself, does “sense-making” occur across the NNEE in this flurry of bits and bytes – unencumbered by the benefit of a reasoning tradition such as the world of scientific research? Not very well would be my conclusion.

There would appear to be an unexamined assumption that some mechanisms do exist to vet all the material generated in these investigation reports, but that seems to be susceptible to the kind of “forest lost for the trees” misperception cited in the Chief Nuclear Officer’s quote regarding corrective action systems becoming “the way we think about managing work.”
 
I can understand how, for a line manager at a single nuclear plant site that is operating in the main course of its life cycle, a scarce resource pot would lead to focusing on every improvement opportunity you’d like to address appearing as a “corrective action.” I would go a step further and say that given the domination of 10 CFR 50 Appendix B on the hierarchical norms for “quality” and “safety” that managing to a single “list” makes sense – if only to ensure that each potential action is evaluated for its nuclear licensing implications.

At the site level, the CNO has a substantial and carefully groomed basis for establishing the relative significance of each material condition in the plant; in most instances administrative matters are brightly color-coded “nuclear” or “other.” As we move up the risk-reckoning ladder through corporate decision-making and then branching into a covey of regulatory bodies, stockholder perspectives, and public perceptions, the purity of issue descriptions degrades – benchmarks become fuzzy.

The overlap of stakeholder jurisdictions presents multiple perspectives (via diverse lexicons) for what “safety,” “risk,” and “culture” weights are to be assigned to any particular issue. Often the issue as first identified is a muddle of actual facts and supposition which may or may not be pruned upon further study. The potential for dilemmas, predicaments, and double-binding stakeholder expectations goes up dramatically.
 
I would suggest that responses to the recent spate of high-profile nuclear facility events, beginning with the Davis-Besse Reactor Pressure Vessel Head near-miss, has provoked a serious cleavage in our collective ability to reason prudently about the policy, industrial strategy, and regulatory levels of risk. The consequences of this cleavage are to increase the degree of chaotic programmatic action and to obscure the longer term significance of these large-scale, unanticipated/unwelcome events, i.e., Black Swan vulnerabilities.

In the case of the NNEE I hypothesize that we are victims of our own history – and the presumption of exceptional success in performance improvement that followed the TMI event. With the promulgation of the Reactor Oversight Process in 1999, NRC and the industry appeared to believe that a mature understanding of oversight and self-governance practice existed and that going forward clarity would only increase regarding what factors were important to sustained high reliability across the entire NNEE.
 
That presumption has proven a premature one, but it does not appear from the Fukushima responses that many in leadership positions recognize this fact. Today, the US NNEE finds itself trapped in a “limits to growth system.” That risk-reckoning system institutionalizes a series of related conclusions about the overall significance of nuclear energy health hazards and their relationship to other forms of risk common to all large industrial sectors.

The NNEE elements of thought leadership appear to act (on the evidence of the many Fukushima reports) as if the rationale of 10 CFR 50 Appendix B regarding “conditions adverse to quality” and the preeminence of “nuclear safety corrective actions” is beyond question. It’s time to do an obsolescence check on what I’ve come to call the Nuclear Fear Cycle.

Quoting Bob Cudlin again: “Whatever the true causes we believe that there will be multiple causes acting in a systematic manner - i.e., causes that interact and feedback in complex combinations to either reinforce or erode the safety culture state.” You are invited to ponder the following system.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ISM Guiding Principle #3 states:

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

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

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

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

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

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

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

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

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

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

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

Several observations are in order at this point:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

VIT Plant Glop (Part 2)

(Ed. note: We're pleased to present an interesting take on the Vit Plant from Bill Mullins as a guest contributor.  We welcome contributions from others who would like to contribute leading edge thinking on nuclear safety culture.)

Bob Cudlin’s Jan. 24 post concludes, "Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting might be the better emphasis."

From where I sit, in this simple piece of seemingly practical advice hides much of the iceberg the WTP Titanic keeps circling around to repeatedly encounter amidst the fog of Nuclear Safety Culture (NSC) and such.

The key word is "expectations” – this is because for DOE the definition of Quality is “performance that meets or exceeds requirements and expectations.” Importantly the DOE Quality standard embraces a “continuous improvement” criterion. This definition of Quality and its attendant context are considerably more expansive than the one found at 10 CFR 50 Appendix B – and there is a very necessary reason for that.

At the Program level all the DOE Mission portfolios are of the Discover and Develop type. DOE programs and projects are chartered to go where none has gone before (i.e. nor generally can afford the capital risks to go such places first).

Not every project in DOE is of comparable difficulty, but many (e.g., the Environmental Management Program) of the sub-portfolios (e.g., Hanford Cleanup) take decades of trial and error practice to create reliable Acquisition Strategies.

Even now the Hanford Cleanup work is pretty well partitioned between 1) things we now do reliably and with a modicum of efficiency (cf. River Corridor Cleanup contract), and 2) that Goop/Gorp unconventional uncertainty. Today the former goes well and the latter goes poorly.

The WTP is a full-blooded Discover and Develop enterprise - the high-level tank waste is vastly more subtle in its physical chemistry than DOE and its prime contractor have been willing to acknowledge to their stakeholders in the Tri-Party Agreement with EPA and WA State. The stakeholders seem reluctant to puncture the veil of schedule illusion as well.

Generally I conclude the River Protection Program (RPP), which governs the WTP development, is not sufficiently aware of its vulnerability to unconventional uncertainty. It is the more unpredictable behavior of the tank waste that should be the center of attention; not unrealistic schedules and life cycle budget estimates into the far future.

It is this (some would say “studied”) blindness that the DNFSB is ultimately getting at via its nuclear safety oversight charter – I’m inclined to doubt that the Board recognizes the blind spot any better than most in DOE leadership. Like the carpenter with only a hammer on his tool belt, the Board’s way of framing issues with progress at the RPP tends to make every unanticipated or unwelcome outcome seem like a “nuclear safety nail.”

At the end of most days this over-dramatization of nuclear safety significance has been a deliberate strategy of the Board since it began its Safety in Design “action-forcing” campaign about four years ago.

In broad reality, the situation of the RPP can be viewed as a matter of inadequate safety consciousness or poorly chosen Acquisition Strategy – the latter perspective has more traction precisely because in encompasses protection concerns without being dragged into the “good vs. bad” attitude debates – which tend to be the heart of NSC conversations - that are presently fogging the air of the Hanford 200 Area.

Later in Bob’s post he observes: “In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.”

This conclusion is not without its supporting evidence: From the time that the Walt Thomasitus pushback on Bechtel Management began, DOE Office of River Protection project management has responded from a position that reeks annoyance and resentment. This has not helped with sorting out the key issues at the WTP, in fact when the Recommendation 2011-1 appeared the knee-jerk defensive response of the Deputy Secretary actually made things worse for a time.

There are now three prominent whistle-blowers feeding the maw of both GAO and the national press.*  Unfortunately, Thomasitus, Alexander, and Busche each raise concerns about whether the plant will work as advertised – not as matters of Acquisition Strategy, but as safety issues. That is unfortunate because it leads to this: “The treatment plant "is not a project that can be stopped and restarted," said Rep. Doc Hastings, R-Wash.”**

Just lately, we have a memorandum from the Secretary and Deputy Secretary that I believe finally puts a suitable Line Management framework around the 2011-1 IP and the WTP issue.  It will take a further post to elaborate the basis for my belief that this particular memorandum “answers the mail” about NSC in the DOE nuclear programs. At that point I can also suggest what I see as the barriers to this missive gaining the policy high ground against the wave of other “over-commitments” throughout the remainder of the 2012-1 IP.

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

*  P. Eisler, “Problems plague cleanup at Hanford nuclear waste site,” USA Today (Jan. 25, 2012).

**  P. Eisler, “Safety at Wash. nuclear-waste site scrutinized,” USA Today (Jan. 27, 2012).

***  Letter from D.B. Poneman to P.S. Winokur transmitting DOE Memorandum dated Dec. 5, 2011 from S. Chu and D.B. Poneman to Heads of All Departmental Elements re: Nuclear Safety at the Department of Energy (Jan. 24, 2012).