Catching Up with Nuclear Safety Culture’s Bad Boys: Entergy and TVA

Entergy Headquarters

TVA Headquarters

We haven’t reported for awhile on the activities of the two plant operators who dominate the negative news in the Nuclear Safety Culture (NSC) space, viz., Entergy and TVA.  Spoiler alert: there is nothing novel or unexpected to report, only the latest chapters in their respective ongoing sagas.

Entergy

On March 12, 2018 the NRC issued a Confirmatory Order* (CO) to Entergy for violations at the Grand Gulf plant: (1) an examination proctor provided assistance to trainees and (2) nonlicensed operators did not tour all required watch station areas and entered inaccurate information into the operator logs.  The NRC characterized these as willful violations.  As has become customary, Entergy requested Alternative Dispute Resolution (ADR).  Entergy agreed to communicate fleet-wide the company’s intolerance for willful misconduct, evaluate why prior CO-driven corrective actions failed to prevent the current violations, conduct periodic effectiveness reviews of corrective actions, and conduct periodic “organizational health surveys” to identify NSC concerns that could contribute to willful misconduct.

On March 29, 2018 the NRC reported** on Arkansas Nuclear One’s (ANO’s) progress in implementing actions required by a June 17, 2016 Confirmatory Action Letter (CAL).  (We reported at length on ANO’s problems on June 25, 2015 and June 16, 2016.)  A weak NSC has been a major contributor to ANO’s woes.  The NRC inspection team concluded that all but one corrective actions were implemented and effective and closed those items.  The NRC also concluded that actions taken to address two inspection focus areas and two Yellow findings were also satisfactory.

On April 20, 2018 the NRC reported*** on ANO’s actions to address a White inspection finding.  They concluded the actions were satisfactory and noted that ANO’s root cause evaluation had identified nine NSC aspects with weaknesses.  Is that good news because they identified the weaknesses or bad news because they found so many?  You be the judge.

On June 18, 2018 the NRC closed**** ANO's CAL and moved the plant into column 1 of the Reactor Oversight Process Action Matrix.

TVA

The International Atomic Energy Agency (IAEA) conducted an Operational Safety Review Team (OSART) review***** of Sequoyah during August 14-31, 2017.  The team reviewed plant operational safety performance vis-à-vis IAEA safety standards and made appropriate recommendations and suggestions.  Two of the three significant recommendations have an NSC component: (1) “improve the performance of management and staff in challenging inappropriate behaviours” and “improve the effectiveness of event investigation and corrective action implementation . . .” (p. 2)

Focusing on NSC, the team observed: “The procedure for nuclear safety culture self-assessments does not include a sufficiently diverse range of tools necessary to gather all the information required for effective analysis. The previous periodic safety culture self-assessment results were based on surveys but other tools, such as interviews, focus groups and observations, were only used if the survey revealed any gaps.” (p. 60)

On March 14, 2018 the NRC reported^ on Watts Bar’s progress in addressing NRC CO EA-17-022 and Chilling Effect Letter (CEL) EA-16-061, and licensee action to establish and maintain a safety-conscious work environment (SCWE).  (We discussed the CEL on March 25, 2016 and NSC/SCWE problems on Nov. 14, 2016.)  Licensee actions with NSC-related components were noted throughout the report including the discussions on plant communications, training, work processes and independent oversight.  The sections on assessing NSC/SCWE and “Safety Over Production” included inspection team observations (aka opportunities for improvement) which were shared with the licensee. (pp. 10-11, 17, 24-27)  One TVA corrective action was to establish a Fleet Safety Culture Peer Team, which has been done.  The overall good news is the report had no significant NSC-related negative findings.  Focus group participants were generally positive about NSC and SCWE but expressed concern about “falling back into old patterns” and “declaring success too soon.” (p. 27)

Our Perspective

For Entergy, it looks like business as usual, i.e., NSC Whac-A-Mole.  They get caught or self-report an infraction, go to ADR, and promise to do better at the affected site and fleet-wide.  Eventually a new problem arises somewhere else.  The strength of their overall NSC appears to be floating in a performance band below satisfactory but above intolerable.

We are a bit more optimistic with respect to TVA.  It would be good if TVA could replicate some of Sequoyah’s (which has managed to keep its nose generally clean) values and practices at Browns Ferry and Watts Bar.  Perhaps their fleet wide initiative will be a mechanism for making that happen.

We applaud the NRC inspection team for providing specific information to Watts Bar on actions the plant could take to strengthen its NSC.

Bottom line: The Sequoyah OSART report is worth reviewing for its detailed reporting of the team’s observations of unsafe (or at least questionable) employee work behaviors.


*  K.M. Kennedy (NRC) to J.A. Ventosa (Entergy), “Confirmatory Order, NRC Inspection Report 05000416/2017014, and NRC Investigation Reports 4-2016-004 AND 4-2017-021” (Mar. 12, 2018).  ADAMS ML18072A191.

**  N.F. O’Keefe (NRC) to R.L. Anderson (Entergy), “Arkansas Nuclear One – NRC Confirmatory Action Letter (EA-16-124) Follow-up Inspection Report 05000313/2018012 AND 05000368/2018012” (Mar. 29, 2018).  ADAMS ML18092A005.

***  N.F. O’Keefe (NRC) to R.L. Anderson (Entergy), “Arkansas Nuclear One, Unit 2 – NRC Supplemental Inspection Report 05000368/2018040” (Apr. 20, 2018).  ADAMS ML18110A304.

****  K.M. Kennedy (NRC) to R.L. Anderson (Entergy), "Arkansas Nuclear One – NRC Confirmatory Action Letter (EA-16-124) Follow-up Inspection Report 05000313/2018013 AND 05000368/2018013 and Assessment Follow-up Letter" (Jun. 18, 2018)  ADAMS ML18165A206.

 *****  IAEA Operational Safety Review Team (OSART), Report of the Mission to the Sequoyah Nuclear Power Plant Aug. 14-31, 2017, IAEA-NSNI/OSART/195/2017.  ADAMS ML18061A036. The document date in the NRC library is Mar. 2, 2018.

^  A.D. Masters (NRC) to J.W. Shea “Watts Bar Nuclear Plant – Follow-up for NRC Confirmatory Order EA-17-022 and Chilled Work Environment Letter EA-16-061; NRC INSPECTION REPORT 05000390/2017009, 05000391/2017009” (Mar. 14, 2018).  ADAMS ML18073A202.

Nuclear Safety Culture Update at Pilgrim and Watts Bar

Pilgrim

Watts Bar

A couple of recent reports address the nuclear safety culture (NSC) problems at Pilgrim and Watts Bar.  This post summarizes the reports and provides our perspective on their content.  Spoiler alert: there is not much new in this news.

Pilgrim

The NRC issued their report* on phase C of their IP 95003 inspection at Pilgrim.  This is the phase where the NRC conducts its own assessment of the plant’s NSC.  The overall finding in the cover letter is: “The NRC determined that programs and processes at PNPS [Pilgrim] adequately support nuclear safety and that PNPS should remain in Column 4.”  However, the letter goes on to detail a host of deficiencies.  The relative good news is that Pilgrim’s NSC shortcomings weren’t sufficiently serious or interesting to merit mention in the cover letter.

But the NRC had plenty to say about NSC in the main report.  Highlights include the finding that NSC is a “fundamental problem” at Pilgrim.  NSC gradually deteriorated over time and “actions to balance competing priorities, manage problems, and prioritize workload resulted in reduced safety margins.”  Staffing reduction initiatives exacerbated plant performance problems.  Personnel were challenged to exhibit standards and expectations in conservative decision-making, work practices, and procedure use and adherence.  Contributing factors to performance shortcomings include lack of effective benchmarking of industry standards and the plant’s planned 2019 permanent shutdown.  The NRC also noted weaknesses in the Executive Review Board, Employee Concerns Program and the Nuclear Safety Culture Monitoring Panel. (pp. 8-10)

Watts Bar

In April the TVA inspector general (IG) issued a report** castigating TVA management for allowing a chilled work environment (CWE) to continue to exist at Watts Bar.  The IG report’s findings included: TVA's analyses and its response to the NRC’s CWE letter were incomplete and inadequate; TVA's planned corrective actions are unlikely to have long-term effectiveness; precursors of the CWE went unrecognized by management; and management has inappropriately influenced the outcome of analyses and investigations pertaining to Watts Bar NSC/SCWE issues.  Staff stress, fear and trust issues also exist.

In response, TVA management pointed out the corrective actions that were taken or are underway since the first draft of the IG report was issued.  Additionally, TVA management “has expressly acknowledged management's role in creating the condition and its responsibility for correcting it."

Our Perspective

This is merely a continuation of a couple of sad stories we’ve been reporting on for a long time.  Click on the Entergy, Pilgrim, TVA or Watts Bar labels to get our earlier reports. 

The finding that Pilgrim did not adequately benchmark against industry standards is appalling.  Entergy operates a fleet of nuclear plants and they don’t know what industry standards are?  Whatever.  Entergy is closing all the plants they purchased outside their service territory, hopefully to increase their attention on their utility-owned plants (where Arkansas Nuclear One remains a work in progress). 

We applaud the TVA IG for shining a light on the agency’s NSC issues.  In response to the IG report, TVA management put out a typical mea culpa accompanied by claims that their current corrective actions will fix the CWE and other NSC problems.  Well, their prior actions were ineffective and these actions will also probably fall short.  It doesn’t really matter.  TVA is too big to fail, both politically and economically, and their nuclear program will likely continue to plod along forever.


*  D.H. Dorman (NRC) to J. Dent (TVA), “Pilgrim Nuclear Power Station – Supplemental Inspection Report (Inspection Procedure 95003 Phase ‘C’) 05000293/2016011 and Preliminary Greater-than-Green Finding” (May 10, 2017).  ADAMS ML17129A217.

**  TVA Inspector General, “NTD Consulting Group, LLC's Assessment of TVA's Evaluation of the Chilled Work Environment at Watts Bar Nuclear Plant - 2016-16702” (April 19, 2017).  Also see D. Flessner, “TVA inspector general says safety culture problems remain at Watts Bar,” Chattanooga Times Free Press (April 21, 2017).  Retrieved May 25, 2017.

Nuclear Safety Culture at the 2017 NRC Regulatory Information Conference

NRC 2017 RIC

Nuclear Safety Culture (NSC) was assigned one technical session at the 2017 NRC Regulatory Information Conference (RIC).  The topic was maintaining a strong NSC during plant decommissioning.  This post reviews the session presentations and provides our perspective on the topic.

Nuclear Regulatory Commission (NRC)*

The presenter discussed the agency’s expectations that the requirements of the SC Policy Statement will continue to be met during decommissioning, recognizing that plant old-timers may experience issues with trust, commitment and morale while newcomers, often contractors, will need to be trained and managed to meet NSC standards going forward.  The presentation was on-target but contained no new information or insights.

International Atomic Energy Agency (IAEA)**

This presentation covered the IAEA documents that discuss NSC, viz., the General Safety Requirement “Leadership and Management for Safety,” and the Safety Guides “Application of the Management System for Facilities and Activities,” which covers NSC characteristics, and “The Management System for Nuclear Installations,” which covers NSC assessments, plus supporting IAEA Safety Reports and Technical Documents.  There was one slide covering decommissioning issues, none of which was new.

The slides were dense with turgid text; this presentation must have been excruciating to sit through.  The best part was IAEA did not attempt to add any value through some new approach or analysis, which always manages to muck up the delivery of any potentially useful information. 

Kewaunee***

The Kewaunee plant was shut down on May 7, 2013.  The shutdown announcement on Oct. 22, 2012 was traumatic for the staff and they went through several stages of grieving.  Management has worked to maintain transparency and an effective corrective action program, and retain people who can accept changing conditions.  It is a challenge for management to maintain a strong NSC as the plant transitions to long-term SAFSTOR.

It’s not surprising that Kewaunee is making the best of what is undoubtedly an unhappy situation for many of those involved.  The owner, Dominion Resources, has a good reputation in NSC space.

Vermont Yankee****

This plant was shut down on Dec. 29, 2014.  The site continued applying its process to monitor for NSC issues but some concerns still arose (problems in radiation practices, decline in industrial safety performance) that indicated an erosion in standards.  Corrective actions were developed and implemented.  A Site Review Committee provides oversight of NSC.

The going appears a little rougher at Vermont Yankee than Kewaunee.  This is not a surprise given both the plant and its owner (Entergy) have had challenges in maintaining a strong NSC. 

Our Perspective

The session topic reflects a natural life cycle: industrial facilities are built, operate and then close down.  But that doesn’t mean it’s painless to manage through the phase changes. 

In an operating plant, complacency is a major threat.  Complacency opens the door to normalization of deviation and other gremlins that move performance toward the edge of the envelope.  In the decommissioning phase, we believe loss of fear is a major threat.  Loss of fear of dramatic, even catastrophic radiological consequences (because the fuel has been off-loaded and the plant will never operate again) can lead to losing focus, lack of attention to procedural details, short cuts and other behaviors that can have significant negative consequences such as industrial accidents or mishandling of radioactive materials.

In a “Will the last person out please turn off the lights” environment, maintaining everyone’s focus on safety is challenging for people who operated the plant, often spending a large part of their careers there.  The lack of local history is a major reason to transfer work to specialty decommissioning contractors as quickly as possible. 

In 2016, NSC didn’t merit a technical session at the RIC; it was relegated to a tabletop presentation.  As the industry shrinks, we hope NSC doesn’t get downgraded to a wall poster.


*  D. Sieracki, “Safety Culture and Decommissioning,” 2017 RIC (Mar. 15, 2017).

**  A. Orrell, “Safety Culture and the IAEA International Perspectives,” 2017 RIC (Mar. 15, 2017).

***  S. Yeun, “Maintaining a Strong Safety Culture after Shutdown,” 2017 RIC (Mar. 15, 2017).

****  C. Chappell, “Safety Culture in Decommissioning: Vermont Yankee Experience,” 2017 RIC (Mar. 15, 2017).

Nuclear Safety Culture: Catching up with the NRC

NRC Building

No big nuclear safety culture (NSC) news has come out of the Nuclear Regulatory Commission (NRC) so far in 2017 but there have been a few minor items worth mentioning.

New Leadership Model for NRC*

In 2015, the NRC staff proposed developing an explicit NRC leadership model that would complement the agency’s existing Principles of Good Regulation and Organizational Values (Principles).  The model’s attributes would include “empowering employees . . . creative thinking, innovation, and informed risk-taking . . . .”  The Commission disagreed, saying staff should focus on the characteristics of the Principles that support the identified organizational attributes.

Subsequent staff research identified performance improvement opportunities in the areas of employee decision-making, empowerment and consensus, employee creativity, informed risk-taking and innovation.  They are re-proposing an explicit leadership model that focuses on “Empowerment & Shared Leadership, Innovation & Risk Tolerance, Participative Decision-Making, Diversity in Thought, Receptivity to New Ideas and Thinking, and Collaboration & Teamwork . . . .”

This was a significant social science project to rationalize development of a highly specified management model.  Could it contribute to improving the agency’s “effectiveness, efficiency, and agility”?  Or is it, in essence, a regulation that would suck energy away from what NRC leaders need to do to succeed in a changing environment?  You be the judge.

NRC Lessons-Learned Program (LLP)**

This program was established after the Davis-Bessie fiasco to review agency, nuclear industry and outside incidents for lessons-learned that verify or could strengthen NRC processes.  Because a recognized lesson-learned leads to an NRC corrective action plan (i.e., resource usage) there is a high threshold for accepting proposed lessons-learned.  In the past year, six incidents ranging from the government response to the Flint, MI water crisis to two gripe papers published by the Union of Concerned Scientists passed a preliminary screen.  Ultimately, none of the items met the LLP minimum criteria although all were addressed by other NRC groups or processes.  

The LLP Oversight Board is considering whether the LLP should be discontinued, the threshold should be lowered, or the status quo approach should be continued.  Our concern is that the hard-headedness which characterizes the nuclear industry has also infected the LLP and prevents them from being open to actually learning anything from the experience of others.

Continued NSC Pressure on Problem Plants

Finally, NRC continues to (rightfully) squeeze plants with recognized NSC problems to fix such problems.  Arkansas Nuclear One (ANO) has a Confirmatory Action Letter (CAL) that requires the plant to implement specific improvement steps, including establishing a NSC Observer function to monitor leader behavior and enhancing decision making to ensure NSC aspects are considered.***  We discussed ANO’s NSC problems at length on June 16, 2016.

Watts Bar received part 2 of an inspection report on plant performance in the areas of NSC and Safety Conscious Work Environment (SCWE).****  It was a continuation of the beat down they received in part 1 (which we reviewed on Nov. 14, 2016).  The major findings were site-wide challenges to Watts Bar’s SCWE and weaknesses in the criteria used to evaluate NSC standards.  The inspection team’s detailed findings were too numerous to list here but included disagreeing with the site’s interpretation of safety “pulsing” data, management relaxing the standards for evaluating NSC data, overly limited assessment of NSC survey results and weaknesses in the training for NSC monitors.  The report is worth reading to show what a diligent inspector sees when looking at the same plant-produced NSC data that management has been cherry-picking for positive results and trends.

Our Perspective

The first calendar quarter of 2017 looks like business as usual at the NRC, at least when it comes to NSC.  That’s probably as it should be; we really don’t want them to be too distracted by the downsizing and problems occurring in the U.S. commercial nuclear industry.  The agency is trying to figure out how to be more agile and, without saying so, looking forward to having to do the same work with fewer resources.  (While some costs, e.g., plant inspection activities, are variable and can scale down with the industry, our guess is much of their work/cost structure is more-or-less fixed.)

There was a safety culture session at the recent Regulatory Information Conference, which we will separately review.


*  Memo from V.M. McCree to NRC Commissioners, “Re-Examination of the Need for a U.S. Nuclear Regulatory Commission Leadership Model” (Feb. 6, 2017).  ADAMS ML16348A323.

**  Memo from V.M. McCree to NRC Commissioners, “Annual Report on the Lessons-Learned Program” (Feb. 17, 2017).  ADAMS ML16231A323.

***  Letter from T.R. Farnholtz (NRC) to R. Anderson (ANO), “Arkansas Nuclear One – NRC Component Design Bases Inspection and Confirmatory Action Letter Follow-up Inspection Report 05000313/2016008 AND 05000368/2016008” (Feb. 28, 2017), pp. A3-5/-6.  ADAMS ML17059D000.

****  Letter from J.T. Munday (NRC) to J.W. Shea (TVA), “Watts Bar Nuclear Plant – NRC Problem Identification and Resolution Inspection (Part 2); and Safety Conscious Work Environment Issue of Concern Follow-up; NRC Inspection Report 05000390/2016013, 05000391/2016013” (March 10, 2017), pp. 2, 13-16.  ADAMS ML17069A133.

Reflections on Nuclear Safety Culture for the New Year

©iStockphoto.com

The start of a new year is an opportunity to take stock of the current situation in the U.S. nuclear industry and reiterate what we believe with respect to nuclear safety culture (NSC).

For us, the big news at the end of 2016 was Entergy’s announcement that Palisades will be shutting down on Oct. 1, 2018.*  Palisades has been our poster child for a couple of things: (1) Entergy’s unwillingness or inability to keep its nose clean on NSC issues and (2) the NRC’s inscrutable decision making on when the plant’s NSC was either unsatisfactory or apparently “good enough.”

We will have to find someone else to pick on but don’t worry, there’s always some new issue popping up in NSC space.  Perhaps we will go to France and focus on the current AREVA and Électricité de France imbroglio which was cogently summarized in a Power magazine editorial: “At the heart of France’s nuclear crisis are two problems.  One concerns the carbon content of critical steel parts . . . manufactured or supplied by AREVA . . . The second problem concerns forged, falsified, or incomplete quality control reports about the critical components themselves.”**  Anytime the adjectives “forged” or “falsified” appear alongside nuclear records, the NSC police will soon be on the scene.  

Why do NSC issues keep arising in the nuclear industry?  If NSC is so important, why do organizations still fail to fix known problems or create new problems for themselves?  One possible answer is that such issues are the occasional result of the natural functioning of a low-tolerance, complex socio-technical system.  In other words, performance may drift out of bounds in the normal course of events.  We may not be able to predict where such issues will arise (although the missed warning signals will be obvious in retrospect) but we cannot reasonably expect they can be permanently eliminated from the system.  In this view, an NSC can be acceptably strong but not 100% effective.

If they are intellectually honest, this is the implicit mental model that most NSC practitioners and “experts” utilize even though they continue to espouse the dogma that more engineering, management, leadership, oversight, training and sanctions can and will create an actual NSC that matches some ideal NSC.  But we’ve known for years what an ideal NSC should look like, i.e., its attributes, and how responsibilities for creating and maintaining such a culture should be spread across a nuclear organization.***  And we’re still playing Whac-A-Mole.

At Safetymatters, we have promoted a systems view of NSC, a view that we believe provides a more nuanced and realistic view of how NSC actually works.  Where does NSC live in our nuclear socio-technical system?  Well, it doesn’t “live” anywhere.  NSC is, to some degree, an emergent property of the system, i.e., it is visible because of the ongoing functioning of other system components.  But that does not mean that NSC is only an effect or consequence.  NSC is both a consequence and a cause of system behavior.  NSC is a cause through the way it affects the processes that create hard artifacts, such as management decisions or the corrective action program (CAP), softer artifacts like the leadership exhibited throughout an organization, and squishy organizational attributes like the quality of hierarchical and interpersonal trust that permeates the organization like an ether or miasma. 

Interrelationships and feedback loops tie NSC to other organizational variables.  For example, if an organization fixes its problems, its NSC will appear stronger and the perception of a strong NSC will influence other organizational dynamics.  This particular feedback loop is generally reinforcing but it’s not some superpower, as can be seen in a couple of problems nuclear organizations may face: 

Why is a CAP ineffective?  The NSC establishes the boundaries between the desirable, acceptable, tolerable and unacceptable in terms of problem recognition, analysis and resolution.  But the strongest SC cannot compensate for inadequate resources from a plant owner, a systemic bias in favor of continued production****, a myopic focus on programmatic aspects (following the rules instead of searching for a true answer) or incompetence in plant staff. 

Why are plant records falsified?  An organization’s party line usually pledges that the staff will always be truthful with customers, regulators and each other.  The local culture, including its NSC, should reinforce that view.  But fear is always trying to slip in through the cracks—fear of angering the boss, fear of missing performance targets, fear of appearing weak or incompetent, or fear of endangering a plant’s future in an environment that includes the plant’s perceived enemies.  Fear can overcome even a strong NSC.

Our Perspective

NSC is real and complicated but it is not mysterious.  Most importantly, NSC is not some red herring that keeps us from seeing the true causes of underlying organizational performance problems.  Safetymatters will continue to offer you the information and insights you need to be more successful in your efforts to understand NSC and use it as a force for better performance in your organization.

Your organization will not increase its performance in the safety dimension if it continues to apply and reprocess the same thinking that the nuclear industry has been promoting for years.  NSC is not something that can be directly managed or even influenced independent of other organizational variables.  “Leadership” alone will not fix your organization’s problems.  You may protect your career by parroting the industry’s adages but you will not move the ball down the field without exercising some critical and independent thought.

We wish you a safe and prosperous 2017.


*  “Palisades Power Purchase Agreement to End Early,” Entergy press release (Dec. 8,2016).

**  L. Buchsbaum, “France’s Nuclear Storm: Many Power Plants Down Due to Quality Concerns,” Power (Dec. 1, 2016).  Retrieved Jan. 4, 2017.

***  For example, take a look back at INSAG-4 and NUREG-1756 (which we reviewed on May 26, 2015).

****  We can call that the Nuclear Production Culture (NPC).

Here We Go Again: NRC to Inspect Nuclear Safety Culture at Entergy’s Pilgrim Plant

Pilgrim

Entergy’s Pilgrim station has been in Column 4 of the Nuclear Regulatory Commission’s (NRC) Action Matrix since September 2015.  Column 4 plants receive more numerous, extensive and intrusive NRC inspections than plants that receive baseline inspections.  Pilgrim is in Column 4 primarily because its Corrective Action Program (CAP) is not effective, i.e., the CAP is not permanently fixing significant plant problems.  Pilgrim’s latest inspection follows NRC Inspection Procedure (IP) 95003.  As part of IP 95003 the NRC will assess the plant’s nuclear safety culture (NSC) to ascertain if a weak NSC is contributing to the plant’s inability or unwillingness to identify, specify, investigate and permanently fix problems.*

Our Perspective

Those are the facts.  Now let’s pull on our really tight crankypants.  Entergy is in a race with the Tennessee Valley Authority (TVA) to see which fleet operator can get into the most trouble with the NRC over NSC issues.  We reviewed Entergy’s NSC problems at its different plants in our April 13, 2016 post.  Subsequently, the NRC published its report on NSC issues at Entergy’s Arkansas Nuclear One (ANO) plant, which also was subject to an IP 95003 inspection.  We reviewed the ANO inspection report on June 16, 2016.  That’s all basically bad news.  However, there is one bit of good news: Entergy recently offloaded one of its plants, FitzPatrick, to Exelon, a proven nuclear enterprise with a good track record. 

Did we mention that Pilgrim is on the industrial equivalent of Death Row?  Entergy has announced its plan to shut down the plant on May 31, 2019.**  Local anti-nuclear activists want it shut down immediately.***  Pilgrim will certainly be under increased NRC scrutiny for the rest of its operating life.  The agency says “Should there be indications of degrading performance, we will take additional regulatory actions as needed, . . . up to and including a plant shutdown order.”****  As readers know, the Safetymatters  founders worked in the commercial nuclear industry and are generally supportive of it.  But maybe it’s time to pull the plug at Pilgrim. 

"Can't anybody here play this game?" — Casey Stengel (1890-1975)

*  “NRC to Perform Wide-Ranging Team Inspection at Pilgrim Nuclear Power Plant; Review Supports Agency’s Increased Oversight,” NRC press release No. I-16-030 (Nov.  28, 2016).  A.L. Burritt (NRC) to J. Dent (Entergy), “Pilgrim Nuclear Power Station – Notification of Inspection Procedure 95003 Phase ‘C’ Inspection” (Oct. 13, 2016).  ADAMS ML16286A592.

**  “Entergy Intends to Refuel Pilgrim in 2017; Cease Operations on May 31, 2019” (April 14, 2016).  Retrieved Nov. 29, 2016.

***  “Protesters Demand Pilgrim Nuclear Power Plant Be Shut Down Now,” CapeCod.com (Nov. 28, 2016).  Retrieved Nov. 29, 2016.

****  “Additional NRC Oversight at Pilgrim Nuclear Power Plant,” an NRC webpage.  The quote is under the Assessment Results tab.  Retrieved Nov. 29, 2016.

NRC Identifies Nuclear Safety Culture Problems at Watts Bar. What a Surprise.

Watts Bar

A recent NRC inspection report* was very critical of both the Safety Conscious Work Environment (SCWE) and the larger Nuclear Safety Culture (NSC) at the Tennessee Valley Authority’s (TVA’s) Watts Bar plant.  This post presents highlights from the report and provides our perspective on the situation. 

The inspection was a follow-up to a Chilling Effect Letter (CEL)** the NRC issued to Watts Bar in March, 2016.  We reviewed the CEL on March 25, 2016.

The inspection team conducted focus groups and interviews with staff and management.  “. . . the inspection team identified deficiencies in the safety conscious work environment across multiple departments.  Although nearly all employees indicated that they were personally willing to raise nuclear safety concerns, many [nearly half] stated they did not feel free to raise concerns without fear of retaliation.  In addition, most employees did not believe that concerns were promptly reviewed or appropriately resolved, either by their management or via the Corrective Action Program [CAP].” (p. 5) 

While discussing management’s response to the CEL, employees were cautiously optimistic that their work environment would improve although they could not cite any specific examples of improvements.  Management putting their “spin” on the CEL and prior instances of retaliation against employees contribute to a lack of trust between employees and management. (p. 6)

In general, “. . . most employees also noted that there was a strong sense of production over safety throughout the organization. . . . Focus group participants provided examples of disrespectful behavior [by management], intimidation and shopping around work to other employees or contractors who would be less likely to raise issues. . . . all focus groups stated that they could enter issues into the CAP; however, most believed the CAP was ineffective at resolving issues.  The CAP was characterized as a problem identification, but not a problem resolution tool.” (p. 7)

Employees also expressed a lack of confidence in the plant’s Employee Concerns Program. (pp. 7-8)

Our Perspective

The chilled work environment and other NSC issues described in the inspection report did not arise out of thin air.  TVA has a long history of deficient SC at its plants.  Our March 25, 2016 post included a reference to a 2009 NRC Confirmatory Order, still in effect, covering TVA commitments to address past SCWE issues at all three of their nuclear sites.

Browns Ferry, another TVA plant, was a regular character in our 2012 series on the NRC’s de facto regulation of NSC.  As we noted on July 3, 2012 “Browns Ferry has reported SC issues including production and schedule taking priority over safety (2008), “struggling” with SC issues (2010) and a decline in SC (2011).  All of this occurred in spite of multiple licensee interventions and corrective actions.”  As part of their penance, Browns Ferry management made a presentation on their SC improvement actions at the 2014 NRC Regulatory Information Conference.  See our April 25, 2014 post for details.

For a little icing on the nuclear cake, our March 25, 2016 post also summarized the TVA Chief Nuclear Officer’s compensation plan, which doesn’t appear to include any financial incentives for establishing or maintaining a strong NSC.  .

TVA’s less-than-laser focus on safety is also reflected in their non-nuclear activities.  For example, the Dec. 22, 2008 Kingston Fossil Plant coal fly ash slurry spill was the largest such spill in U.S. history.  It was not some “act of God”; neighbors had noticed minor leaks for years and TVA confirmed there had been prior instances of seepage.***  

Bottom line: This unambiguous and complete inspection report includes multiple, significant deficiencies but it’s not new news.

Postscript:  On April 13, 2016 we asked “Is Entergy’s Nuclear Safety Culture Hurting the Company or the Industry?”  We could ask the same question about TVA.  The answer in TVA’s case is “Probably not” primarily because it is a federal corporation and thus is perceived differently from investor-owned nuclear enterprises.  For political reasons, public entities, including TVA and the Department of Energy’s nuclear facilities, are deemed too important to fail.  As a consequence, the bar for tolerable performance is lower and their shortcomings do not appear to infect the perception of private entities that conduct similar activities.


A. Blamey (NRC) to J.W. Shea (TVA), “Watts Bar Nuclear Plant - NRC Problem Identification and Resolution Inspection (Part 1); and Safety Conscious Work Environment Issues of Concern Follow-up; NRC Inspection Report 05000390/2016007 and 05000391/2016007,” (Oct. 26, 2016).  ADAMS ML16300A409.

“Chilled Work Environment for Raising and Addressing Safety Concerns at the Watts Bar Nuclear Plant,” (March 23, 2016).  ADAMS ML16083A479.

Wikipedia, “Kingston Fossil Plant coal fly ash slurry spill.”  Retrieved Nov. 11, 2016.

Nuclear Safety Culture in the Latest U.S. Report for the Convention on Nuclear Safety

NUREG-1650 cover

The Nuclear Regulatory Commission (NRC) recently published NUREG-1650, rev. 6, the seventh national report for the Convention on Nuclear Safety.*  The report is prepared for the triennial meeting of the Convention and describes the policies, laws, practices and other activities utilized by the U.S. to meet its international obligations and ensure the safety of its commercial nuclear power plants.  Nuclear Safety Culture (NSC) is one of the topics discussed in the report.  This post highlights NSC changes (new items and updates) from the sixth report (NUREG-1650, rev. 5) which we reviewed on March 26, 2014.  The numbers shown below are section numbers in the current report.

8.1.5  International Responsibilities and Activities 

The NRC’s International Regulatory Development Partnership (IRDP) program supports the safe introduction of nuclear power in “new entrant” countries.  IRDP training addresses many topics including safety culture. (p. 99)

8.1.6.2  Human Resources 

This section was updated to include a reference to the 2015 NRC Safety Culture and Climate Survey.

10.1  Background [for article 10, “Priority to Safety”] 

The report notes “All U.S. nuclear power plants have committed to conducting a safety culture self-assessment every 2 years and have committed to conducting monitoring panels as described in Nuclear Energy Institute (NEI) 09-07, “Fostering a Healthy Nuclear Safety Culture,” dated March 2014.” (p. 120)  We reviewed NEI 09-07 on Jan. 6, 2011.

10.4  Safety Culture

The bulk of the report addressing NSC is in this section and exhibits a significant rewrite from the previous report.  Some of the changes reorganized existing material but there are also new items, discussed below, and additional background information.  Overall, section 10.4 is more complete and lucid than its predecessor.

10.4.1  Safety Culture Policy Statement

This contains material that formerly appeared under 10.4 and has been expanded to include two new safety culture traits, “questioning attitude” and “decisionmaking.”  The NRC worked with licensees and other stakeholders to develop a common language for discussing and assessing NSC; this effort resulted in NUREG-2165, “Safety Culture Common Language.”  We reviewed NUREG-2165 on April 6, 2014.

10.4.2  NRC Monitoring of Licensee Safety Culture 

This section has been edited to improve clarity and completeness, and provide more specific references to applicable procedures.  For example, IP 95003 now includes detailed guidance for NRC inspectors who conduct an independent assessment of licensee NSC.**

New language specifies interventions the NRC may take with respect to licensee NSC: “These activities range from requesting the licensee perform a safety culture self-assessment to a meeting between senior NRC managers and a licensee’s Board of Directors to discuss licensee performance issues and actions to address persistent and continuing safety culture cross-cutting issues.” (p. 128)

10.4.3 The NRC Safety Culture

This section covers the NRC’s efforts to maintain and enhance its own SC.  The section has been rewritten and strengthened throughout.  It discusses the need for continuous improvement and says “Complacency lends itself to a degradation in safety culture when new information and historical lessons are not processed and used to enhance the NRC and its regulatory products.” (p. 130)  That’s true; SC that is not actively maintained will invariably decay.

12.3.5  Human Factors Information System 

This system handles human performance information extracted from NRC inspection and licensee event reports.  The report notes “the database is being updated to include data with a safety culture perspective.” (p. 146)

Institute of Nuclear Power Operations (INPO)

INPO also provides content for the report, basically a description of INPO’s activities to ensure plant safety.  Their discussion includes a section on SC, which is not materially different from their contribution to the previous version of the report.

Our Perspective

Like the sixth national report, this seventh report appears to cover every aspect of the NRC’s operations but does not present any new information.  In other words, it’s a good reference document.

The NSC changes are incremental but move toward increased bureaucratization and intrusive oversight of NSC.  The NRC is certainly showing the hilt of the sword of regulation if not the blade.  We still believe if it reads like a set of requirements, results in enforceable interventions and quacks like the NRC, it’s de facto regulation.


*  NRC NUREG-1650 Rev. 6, “The United States of America Seventh National Report for the Convention on Nuclear Safety” (Oct. 2016).  ADAMS ML16293A104.  The Convention on Nuclear Safety is a legally binding commitment to maintain a level of safety that meets international benchmarks.

**  This detailed guidance is also mentioned in 12.3.6 Support to Event Investigations and For-Cause Inspections and Training (p. 148).

Korean Perspective on Nuclear Safety Culture

Republic of Korea flag

We recently read two journal articles that present the Korean perspective on nuclear safety culture (NSC), one from a nuclear research institute and the other from the Korean nuclear regulator.  Selected highlights from each article are presented below, followed by our perspective on the articles’ value.

Warning:  Although the articles are in English, they were obviously translated from Korean, probably by a computer, and the translation is uneven.  However, the topics and references (including IAEA, NRC, J. Reason and Schein) will be familiar to you so with a little effort you can usually figure out what the authors are saying.

Korean NSC Situation and Issues*

The author is with the Korea Atomic Energy Research Institute.  He begins by describing a challenge facing the nuclear industry: avoiding complacency (because plant performance has been good) when the actual diffusion of NSC attributes among management and workers is unknown and major incidents, e.g., Fukushima, point to deficient NSC has a major contributor.  One consequence of this situation is that increased regulatory intervention in licensee NSC is a clear trend. (pp. 249, 254)

However, different countries have differing positions on how to intervene in or support NSC because (1) the objectification of an essentially qualitative factor is necessarily limited and (2) they fear diluting the licensee’s NSC responsibilities and/or causing unintended consequences. 

The U.S. NRC’s NSC history is summarized, including how NSC is addressed in the Reactor Oversight Process and relevant supplemental inspection procedures.  The author’s perception is “If safety culture vulnerability is judged to seriously affect the safety of a nuclear power plant, NRC orders the suspension of its operation, based on the judgment.” (p. 254)  In addition, the NRC has “developed and has been applying a licensee safety culture oversight program, based on site-stationed inspector's observation and assessment . . .” (ibid.)

The perception that the NRC would shut down a plant over NSC issues is a bit of a stretch.  While the agency is happy to pile on over NSC shortcomings when a plant has technical problems (see our June 16, 2016 post on ANO) it has also wrapped itself in knots to rationalize the acceptability of plant NSC in other cases (see our Jan. 30, 2013 post on Palisades).   

There is a passable discussion of the methods available for assessing NSC, ranging from observing top management leadership behavior to taking advantage of “Big data” approaches.  However, the author cautions against reliance on numeric indicators; they can have undesirable consequences.  He observes that Europe has a minimal number of NSC regulations while the U.S. has none.  He closes with recommendations for the Korean nuclear industry.

Regulatory Oversight of NSC**

The authors are with the Korea Institute of Nuclear Safety, the nuclear regulatory agency.  The article covers their philosophy and methods for regulating NSC.  It begins with a list of challenges associated with NSC regulatory oversight and a brief review of international efforts to date.  Regulatory approaches include monitoring onsite vulnerabilities (U.S.), performing standard reviews of licensee NSC evaluations (Canada, Korea) and using NSC indicators (Germany, Finland) although the authors note such indicators do not directly measure NSC. (pp. 267-68)

In the Korean view, the regulator should perform independent oversight but not directly intervene in licensee activities.  NSC assessment is separate and different from compliance-based inspection, requires effective two-way communications (i.e., a common language) and aims at creating long-term continuous improvement. (pp. 266-67)  Their NSC model uses a value-neutral definition of NSC (as opposed to strong vs. weak); incorporates Schein’s three levels; includes individuals, the organization and leaders; and emphasizes the characteristics shared by organization members.  It includes elements from IAEA GSR Part 2, the NRC, J. Reason's reporting culture, DOE, INPO, just culture and Korea-specific concerns about economics trumping safety. (pp. 268-69)***

In the detailed description of the model, we were pleased to see “Incentives, sanctions, and rewards correspond to safety competency of individuals.”  (p. 270)  An organization’s reward system has always been a hot-button issue for us; all nuclear organizations claim to value NSC, few are willing to pay for achieving or maintaining it.  Click the “Compensation” label to see all our posts on this topic.

The article presents a summary of an exercise to validate the model, i.e., link model components to actual plant safety performance.  The usual high-level mumbo-jumbo is not helped by the rough spots in the translation.  Inspection results, outage rates, scrams, incidents, unplanned shutdowns and radiation doses were claimed to be appropriately correlated with NSC model components.

There should be no surprise that the model was validated.  Getting a “right” answer is obviously good for the regulator.  We routinely express some skepticism over studies that validate models when we can’t see the actual data and we don’t know if the analysis was independently reviewed by anyone who actually understands or cares about the subject matter.

During the pilot study, several improvement areas in Korean NPP's safety culture were identified.  The approach has not been permanently installed.

Our Perspective

These articles are worth reading just to get a different, i.e., non-U.S., perspective on regulatory evaluation of (and possible intervention in) licensee SC.  It’s also worthwhile to get a non-U.S. perspective on what they think is going on in U.S. nuclear regulatory space.  Their information sources probably include a June 2015 NRC presentation to Korean regulators referenced in our Aug. 24, 2015 post.  

It’s interesting that Europe has some regulations that focus on ongoing communications with the licensees.  In contrast, the U.S. has no regulations but an approach that can stretch like a cheap blanket to cover all possible licensee situations.

Afterword

We haven’t posted for awhile.  It’s not because we’ve lost interest but there hasn’t been much worth reporting.  The big nuclear news in the U.S. is not about NSC, rather it’s about plants being scheduled for shutdown because of their economics.  International information sources have not been offering up much either.  For example, the LinkedIn NSC forum has pretty much dried up except for recycled observations and consultants’ self-serving white papers.


*  Y-H Lee, “Current Status and Issues of Nuclear Safety Culture,” Journal of the Ergonomics Society of Korea vol. 35 no. 4 (Aug 2016) 247-261.

**  YS Choi, SJ Jung and YH Chung, “Regulatory Oversight of Nuclear Safety Culture and the Validation Study on the Oversight Model Components,” Journal of the Ergonomics Society of Korea vol. 35 no. 4 (Aug 2016) 263-275.

***  Korea has had problems, mentioned in both articles, caused by deficient NSC.  Also see our Aug. 7, 2013 post for related information.

Nuclear Safety Culture at ANO—the NRC Weighs In

Arkansas Nuclear One (credit: Edibobb)

On June 25, 2015 we posted about Arkansas Nuclear One’s (ANO) performance problems (a stator drop, inadequate flood protection and unplanned scrams) and the Nuclear Regulatory Commission’s (NRC's) reaction.  The NRC assigned ANO to column 4 of the Action Matrix where it receives the highest level of oversight for an operating plant.  As part of this increased oversight, the NRC conducted a comprehensive inspection of ANO performance, programs and processes.  A lengthy inspection report* was recently issued.

According to the NRC press release** the inspection team identified the following major issues:

“Resource reductions and leadership behaviors were the most significant causes for ANO’s declining performance. . . . ANO management did not reduce workloads through efficiencies or the elimination of unnecessary work, . . . Leaders . . . did not address expanding work backlogs***. . . . An unexpected increase in employee attrition between 2012 and 2014 caused a loss in experienced personnel, . . . Since 2007, the reduced resources created a number of changes that slowly began to impact equipment reliability.  The Entergy fleet reduced preventive maintenance and extended the time between some maintenance activities.”

The press release goes on to list numerous ANO corrective actions and NRC observations that suggest the potential for improved plant performance.

What About ANO’s Safety Culture?

The press release also mentions that the inspection team evaluated the adequacy of a 2015 Third Party Nuclear Safety Culture Assessment (TPNSCA) conducted at ANO.  The press release gives short shrift to the key role a weak safety culture (SC) played in creating ANO’s problems in the first place and the extensive SC questions raised and diagnostics performed by the NRC inspection team.

Last June, based on NRC and ANO meeting presentations, we concluded “the ANO culture endorses a “blame the contractor” attitude, accepts incomplete investigations into actual events and potential problems, and is content to let the NRC point out problems for them.”  These are serious deficiencies.  Do the same or similar problems appear in the inspection report?  To answer that question, we need to dig into the details of the 243 page report.

The Cover Letter

Top-level SC problems are included in the NRC cover letter which says “The inspection team identified what it considered to be missed opportunities for ANO to have promptly initiated performance improvements since being placed in Column 4.  More specifically, ANO: 1) was slow to implement corrective actions to address the findings from the Corrective Action Program cause evaluation and the Third Party Nuclear Safety Culture Assessment; 2) did not perform an evaluation of the causes for safety culture problems; . . .” (letter, p. 2)

Executive Summary

The report's Executive Summary says “The Third Party Nuclear Safety Culture Assessment identified that ANO personnel tolerated, and at times normalized, degraded conditions.”  Expanding on the missed opportunities comment in the cover letter, “the NRC team’s independent safety culture evaluation noted limited improvement in safety culture since the completion of ANO’s independent Third Party Nuclear Safety Culture Assessment.” (report p. 5)  “ANO did not create a specific improvement plan to address the findings of the safety culture assessments, choosing to address selected safety culture attributes that were associated with root cause evaluations rather than treating the findings in the context of a separate problem area.  By not performing a cause evaluation for safety culture, ANO management missed the opportunity to address the full scope of safety culture weaknesses.” (pp. 5-6)

Review of ANO Recovery Plan 

The NRC’s critique of ANO’s Recovery Plan included “The NRC team questioned the recovery team’s decision not to perform casual evaluations of the PAs [Problem Areas].  In response, ANO performed apparent cause evaluations (ACEs) or gap analyses for each PA.  The NRC team questioned the recovery team’s decision not to perform causal evaluations for the safety culture attributes identified in [a 2014] . . . safety culture survey, the TPNSCA, and the RCEs [Root Cause Evaluations].  The team also questioned the recovery team’s decision not to treat safety culture as a separate problem area.” (p. 21)

This is an example where the NRC was still identifying ANO’s overarching problems for the plant staff.

Review of RCEs for Fundamental Problem Areas

“ANO’s Vendor Oversight RCE identified weak implementation of administrative controls and placing undue confidence in vendor services as common cause failures. However, ANO did not assess the underlying safety culture aspects.” (p. 110, emphasis added)

This is not “blame the vendor” but is a different serious problem, viz., an over-reliance on vendor activities to protect the customer.  (This problem is not unique to ANO; it also might exist at the Waste Isolation Pilot Plant.  See our May 3, 2016 post for details.)

Inspection Report Chapter on SC

The NRC team conducted its own assessment of ANO’s SC. The NRC team interviewed personnel at all levels, conducted focus group discussions, performed behavioral observations, reviewed documents and relevant plant programs, and evaluated plant management meetings.  Overall, they assessed all ten SC traits using the full set of SC attributes contained in NRC documentation.  For each trait, the report includes its attributes, inspection team observations and findings, and relevant ANO corrective actions.

The team also reviewed seven RCEs and concluded ANO addressed the major SC attributes identified in each RCE.  However, “The NRC team noted that ANO identified that some safety culture attributes were contributors to several of the RCE problem statements, but ANO did not consider the collective significance.” (p. 184)

ANO took the hint.  “In response to the NRC team’s concerns, ANO performed a common cause analysis of all of the safety culture attributes that were identified in the recovery RCEs in order to assess the collective significance and causes.” (p. 185)  ANO developed a SC Area Action Plan (AAP) and the NRC concluded “The corrective actions identified in the NSC AAP were comprehensive and appropriate to address the causes for safety culture weaknesses.” (p. 186)

“The NRC team’s graded safety culture assessment independently confirmed the results from the TPNSCA.” (p. 188)

“The NRC team was concerned that the SCLT’s [Safety Culture Leadership Team, senior managers] conclusion that ANO’s safety culture was “adequate” in August 2015 did not appropriately reflect the data provided by, or the recommendations from, the NSCMP [Nuclear Safety Culture Monitoring Panel, mid-level personnel].  This SCLT conclusion did not reflect the declining condition with respect to safety culture and indicated a lack of awareness that improvements in safety culture at ANO were needed.”  The SCLT eventually came around and in December 2015 declared that ANO’s SC was not acceptable. (p. 192)

Our Perspective

The NRC is optimistic that ANO has correctly identified the root causes of its performance problems and has undertaken corrective actions that will ultimately prove effective.  We hope so but we’ll go with “trust but verify” on this one.  ANO still exhibits problems with incomplete analyses and leaning on the NRC to identify systemic deficiencies.

The NRC team took a good look at ANO's SC.  Quite frankly, their effort was more comprehensive than we expected.  They used an acceptable methodology for their SC assessment.  The fact that their assessment findings were consistent with the TPNSCA is not surprising.  SC evaluation is a robust social science activity and qualified SC evaluators using similar techniques should obtain generally comparable results.

We believe the NRC’s SC professionals are qualified and competent but probably encouraged to support the overall inspection findings.  The elephant in the room is that SC is a policy, not a regulation.  Would the NRC keep a plant in column 4 based solely on their belief that the plant SC is deficient?  Look at the contortions the agency performed at Palisades as that plant’s SC somehow went from weak, with constant problems, to “improving” and, we inferred, acceptable.  (See our Jan. 30, 2013 post for details.)

There may have been a bit of similar magical thinking at ANO.  In the inspection report, every SC trait had examples of shortcomings but also had “appropriate” corrective actions to improve performance.****  How can this be when ANO (and Entergy) have been so slow to grasp the systemic nature of their SC problems?

Let’s close on a different note.  Earlier this year ANO named a full-time SC manager, a person whose background is in plant security.  On the surface, this is an “unfiltered” choice.  (See our March 10, 2016 post for a discussion of filtering in personnel decisions.)  He may be exactly the type of person ANO needs to make SC improvements happen.  We wish him well.


*  M. L. Dapas (NRC) to J. Browning (ANO), “Arkansas Nuclear One – NRC Supplemental Inspection Report 05000313/2016007 and 05000368/2016007” (June 9, 2016).  ADAMS ML16161B279.

**  V. Dricks, Press Release, “NRC Issues Comprehensive Inspection Report on Arkansas Nuclear One” (June 13, 2015).

***  We have often noted that large backlogs, especially of safety-related work, are an artifact of a weak SC.

****  One trait was judged to have no significant issues so corrective action was not needed.

The Criminalization of Safety (Part 3)

Our Perspective

The facts and circumstances of the events described in Table 1 in Part 1 point to a common driver - the collision of business and safety priorities, with safety being compromised.  Culture is inferred as the “cause” in several of the events but with little amplification or specifics.^[1]  The compromises in some cases were intentional, others a product of a more complex rationalization.  The events have been accompanied by increased criminal prosecutions with varied success. 

We think it is fair to say that so far, criminalization of safety performance does not appear to be an effective remedy.  Statutory limitations and proof issues are significant limitations with no easy solution. The reality is that criminalization is at its core a “disincentive”.  To be effective it would have to deter actions or decisions that are not consistent with safety but not create a minefield of culpability.  It is also a blunt instrument requiring rather egregious behavior to rise to the level of criminality.  Its best use is probably as an ultimate boundary, to deter intentional misconduct but not be an unintended trap for bad judgment or inadequate performance.  In another vein, criminalization would also seem incompatible with the concept of a “just culture” other than for situations involving intentional misconduct or gross negligence.

Whether effective or not, criminalization reflects the urgency felt by government authorities to constrain excessive risk taking, intentional or not, and enhance oversight.  It is increasingly clear that current regulatory approaches are missing the mark.  All of the events catalogued in Table 1 occurred in industries that are subject to detailed safety and environmental regulation.  After the fact assessments highlight missed opportunities for more assertive regulatory intervention, and in the Flint cases there are actual criminal charges being applied to regulators.  The Fukushima event precipitated a complete overhaul of the nuclear regulatory structure in Japan, still a work in progress.  Post hoc punishments, no matter how severe, are not a substitute.

Nuclear Regulation Initiatives

Looking specifically at nuclear regulation in the U.S. we believe several specific reforms should be considered. It is always difficult to reform without the impetus of a major safety event, but we could see these actions as ones that could appear obvious in a post-event assessment if there was ever an “O-ring” moment in the nuclear industry.^[2]

1. The NRC should include the safety management system in its regulatory activities.

The NRC has effectively constructed a cordon sanitaire around safety management by decreeing that “management” is beyond the scope of regulation.  The NRC relies on the fact that licensees bear the primary responsibility for safety and the NRC should not intrude into that role.  If one contemplates the trend of recent events scrutinizing the performance of regulators following safety events, this legalistic “defense” may not fare well in a situation where more intrusive regulation could have made the difference.

The NRC does monitor “safety culture” and often requires licensees to address weaknesses in culture following performance issues.  In essence safety culture has become an anodyne for avoiding direct confrontation of safety management issues.  Cynically one could say it is the ultimate conspiracy - where regulators and “stakeholders” come together to accept something that is non-contentious and conveniently abstract to prevent a necessary but unwanted (apparently by both sides) intrusion into safety management.

As readers of this blog know, our unyielding focus has been on the role of the complex socio-technical system that functions within a nuclear organization to operate nuclear plants effectively and safely.  This management system includes many drivers, variables, feedbacks, culture, and time delays in its processes, not all of which are explicit or linear.  The outputs of the system are the actions and decisions that ultimately produce tangible outcomes for production and safety.  Thus it is a safety system and a legitimate and necessary area for regulation.

NRC review of safety management need not focus on traditional management issues which would remain the province of the licensee.  So organizational structure, personnel decisions, etc. need not be considered.^[3]  But here we should heed the view of Daniel Kahneman where he suggests we think of organizations as “factories for producing decisions” and therefore, think of decisions as a product.  (See our Nov. 4,2011 post, A Factory for Producing Decisions.)  Decisions are in fact the key product of the safety management system.  Regulatory focus on how the management system functions and the decisions it produces could be an effective and proactive approach.

We suggest two areas of the management system that could be addressed as a first priority: (1) Increased transparency of how the management system produces specific safety decisions including the capture of objective data on each such decision, and (2) review of management compensation plans to minimize the potential for incentives to promote excessive risk taking in operations.

2. The NRC should require greater transparency in licensee management decisions with potential safety impacts.

Managing nuclear operations involves a continuum of decisions balancing a variety of factors including production and safety.  These decisions may occur with individuals or with larger groups in meetings or other forums.  Some may involve multiple reviews and concurrences.  But in general the details of decision making, i.e., how the sausage is made, are rarely captured in detail during the process or preserved for later assessment.^[4]  Typically only decisions that happen to yield a bad outcome (e.g., prompt the issuance of an LER or similar) become subject to more intensive review and post mortem.  Or actions that require specific, advance regulatory approval and require an SER or equivalent.^[5]  

Transparency is key.  Some say the true test of ethics is what people do when no one is looking.  Well the converse of that may also be true - do people behave better when they know oversight is or could be occurring?  We think a lot of the NRC’s regulatory scheme is already built on this premise, relying as it does on auditing licensee activities and work products.

Thinking back to the Davis Besse example, the criminal prosecutions of both the corporate entity and individuals were limited to providing false or incomplete information to the NRC.  There was no attempt to charge on the basis of the actual decisions to propose, advocate for, and attempt to justify, that the plant could continue to operate beyond the NRC’s specified date for corrective actions.  The case made by First Energy was questionable as presented to the NRC and simply unjustified when accounting for the real facts behind their vessel head inspections.

Transparency would be served by documenting and preserving the decision process on safety significant issues.  These data might include the safety significance and applicable criteria, the potential impact on business performance (plant output, cost, schedule, etc), alternatives considered, and the participants and their inputs to the decision making process, and how a final decision was reached.   These are the specifics that are so hard or impossible to reproduce after the fact.^[6]  The not unexpected result: blaming someone or something but not gaining insight into how the management system failed.

This approach would provide an opportunity for the NRC to audit decisions on a routine basis.  Licensee self assessment would also be served through safety committee review and other oversight including INPO.  Knowing that decisions will be subject to such scrutiny also can promote careful balancing of factors in safety decisions and serve to articulate how those balances are achieved and safety is served.  Having such tangible information shared throughout the organization could be the strongest way to reinforce the desired safety culture.

3. As part of its regulation of the safety management system, the NRC should restrict incentive compensation for nuclear management that is based on meeting business goals.

We started this series of posts focusing on criminalization of safety.  One of the arguments for more aggressive criminalization is essentially to offset the powerful pull of business-based incentives with the fear of criminal sanctions.  This has proved to elusive.  Similarly attempting to balance business incentives with safety incentives also is problematic.  The Transocean experience illustrates that quite vividly.^[7]

Our survey several years ago of nuclear executive compensation indicated (1) the amounts of compensation are very significant for the top nuclear executives, (2) the compensation is heavily dependent on each year’s performance, and (3) business performance measured by EPS is the key to compensation, safety performance is a minor contributor.  A corollary to the third point might be that in no cases that we could identify was safety performance a condition precedent or qualification for earning the business-based incentives. (See our July 9, 2010 post, Nuclear Management Compensation (Part 2)).  With 60-70% of total compensation at risk, executives can see their compensation, and that of the entire management team, impacted by as much as several million dollars in a year.  Can this type of compensation structure impact safety?  Intuition says it creates both risk and a perception problems.  Virtually every significant safety event in Table 1 has reference to the undue influence of production priorities on safety.  The issue was directly raised in at least one nuclear organization^[8] which revised its compensation system to avoid undermining safety culture. 

We believe a more effective approach is to minimize the business pressures in the first place.  We believe there is a need for a regulatory policy that discourages or prohibits licensee organizations from utilizing significant incentives based on financial performance.  Such incentives invariably target production and budget goals as they are fundamental to business success.  To the extent safety goals are included they are a small factor or based on metrics that do not reflect fundamental safety.  Assuring safety is the highest priority is not subject to easily quantifiable and measurable metrics - it is judgmental and implicit in many actions and decisions taken on a day-to-day basis at all levels of the organization.  Organizations should pay nuclear management competitively and generously and make informed judgments about their overall performance.

Others have recognized the problem and taken similar steps to address it.  For example, in the aftermath of the financial crisis of 2008 the Federal Reserve Board has been doing some arm twisting with U.S. financial services companies to adjust their executive compensation plans - and those plans are in fact being modified to cap bonuses associated with achieving performance goals. (See our April 25, 2013 post, Inhibiting Excessive Risk Taking by Executives.)

Nick Taleb (of Black Swan fame) believes that bonuses provide an incentive to take risks.  He states, “The asymmetric nature of the bonus (an incentive for success without a corresponding disincentive for failure) causes hidden risks to accumulate in the financial system and become a catalyst for disaster.”  Now just substitute “nuclear operations” for “the financial system”.

Central to Taleb’s thesis is his belief that management has a large informational advantage over outside regulators and will always know more about risks being taken within their operation. (See our Nov. 9, 2011 post, Ultimate Bonuses.)  Eliminating the force of incentives and providing greater transparency to safety management decisions could reduce risk and improve everybody’s insight into those risks deemed acceptable.

Conclusion

In industries outside the commercial nuclear space, criminal charges have been brought for bad outcomes that resulted, at least in part, from decisions that did not appropriately consider overall system safety (or, in the worst cases, simply ignored it.)  Our suggestions are intended to reduce the probability of such events occurring in the nuclear industry.

---

^[1] It raises the question whether anytime business priorities trump safety it is a case of deficient culture.  We have argued in other blog posts that sufficiently high business or political pressure can compromise even a very strong safety culture.  So reflexive resort to safety culture may be easy but not be very helpful.

^[2] Credit to Adam Steltzner author of The Right Kind of Crazy recounting his and other engineers’ roles in the design of the Mars rovers.  His reference is to the failure of O-ring seals on the space shuttle Challenger.

^[3] We do recognize that there are regulatory criteria for general organizational matters such as for the training and qualification of personnel. 

^[4] In essence this creates a “safe harbor” for most safety judgments and to which the NRC is effectively blind.

^[5] In Davis Besse much of the “proof” that was relied on in the prosecutions of individuals was based on concurrence chains for key documents and NRC staff recollections of what was said in meetings.  There was no contemporaneous documentation of how First Energy made its threshold decision that postponing the outage was acceptable, who participated, and who made the ultimate decision.  Much was made of the fact that management was putting great pressure on maintaining schedule but there was no way to establish how that might have directly affected decision making.

^[6] Kahneman believes there is “hindsight bias”.  Hindsight is 20/20 and it supposedly shows what decision makers could (and should) have known and done instead of their actual decisions that led to an unfavorable outcome, incident, accident or worse.  We now know that when the past was the present, things may not have been so clear-cut.  See our Dec.18, 2013 post, Thinking, Fast and Slow by Daniel Kahneman.

^[7] Transocean, owner of the Deepwater Horizon oil rig, awarded millions of dollars in bonuses to its executives after “the best year in safety performance in our company’s history,” according to an annual report…’Notwithstanding the tragic loss of life in the Gulf of Mexico, we achieved an exemplary statistical safety record as measured by our total recordable incident rate and total potential severity rate.’”  See our April 7, 2011 post for the original citation in Transocean's annual report and further discussion.

^[8] “The reward and recognition system is perceived to be heavily weighted toward production over safety”.  The reward system was revised "to ensure consistent health of NSC”.  See our July 29, 2010 post, NRC Decision on FPL (Part 2).