NRC Chairman Macfarlane's Speech to the National Press Club

As you know, Chairman Allison Macfarlane will be leaving the NRC and starting a new academic job in January.  Today she made a relatively lengthy speech* reviewing her tenure at NRC.  Her remarks touched on all the NRC’s major work areas, including the following comments on safety culture (SC).

In the area of current plant performance, she expressed a concern that the lowest performing plants seem to stay in that category for extended periods rather than fixing their problems and moving on.  She says “Poor management is easy to spot from the lack of safety culture and other persistent problems at plants.  I believe that solid leadership from the top – and not just attention to the bottom line – is necessary to ensure consistent plant performance.” (p. 5)  While we believe leadership is a necessary (but not sufficient) condition for success, her general observation is similar to what we saw back in the “problem plant” era of the 1990s.  A significant difference is there are far fewer plants in trouble these days.

Under new plant construction she observed that “today’s component manufacturers have had to adjust their safety culture practices to accommodate the rigorous, often unique, requirements presented by nuclear construction.  Some parts of the industry continue to struggle with these issues.” (p. 5)

At the NRC’s Regulatory Information Conference (RIC) back in March, three entities (two plants, one contractor) that have been in trouble because of SC issues made presentations detailing their problems and corrective actions.  We reviewed their RIC presentations on April25, 2014.

Our Perspective

As a matter of course, speeches like this emphasize the positive and the progress but it is interesting to note all the activities in which the NRC has its fingers.  It’s worth flipping through the pages just to reinforce that perspective.


*  Prepared Remarks of Chairman Allison M. Macfarlane, National Press Club, Washington, DC (Nov. 17, 2014).

Update on INPO Safety Culture Study

On October 22, 2010 we reported on an INPO study that correlated safety culture (SC) survey data with safety performance measures.  A more complete version of the analysis was published in an academic journal* this year and this post expands on our previous comments.

Summary of the Paper

The new paper begins with a brief description of SC and related research.  Earlier research suggests that some modest relationship exists between SC and safety performance but the studies were limited in scope.  Longitudinal (time-based) studies have yielded mixed results.  Overall, this leaves plenty of room for new research efforts.

According to the authors, “The current study provides a unique contribution to the safety culture literature by examining the relationship between safety culture and a diverse set of performance measures [NRC industry trends, ROP data and allegations, and INPO plant data] that focus on the overall operational safety of a nuclear power plant.” (p. 39)  They hypothesized small to medium correlations between current SC survey data and eleven then-current (2010) and future (2011) safety performance measures.**

The 110-item survey instrument was distributed across the U.S. nuclear industry and 2876 useable responses were received from employees and contractors representing almost all U.S. plants.  Principal components analysis (PCA) was applied to the survey data and resulted in nine useful factors.***  Survey items that did not have a high factor loading (on a single factor) or presented analysis problems were eliminated, resulting in 60 useful survey items.  Additional statistical analysis showed that the survey responses from each individual site were similar and the various sites had different responses on the nine factors.

Statistically significant correlations were observed between both overall SC and individual SC factors and the safety performance measures.****  A follow-on regression analysis suggested “that the factors collectively accounted for 23–52% of the variance in concurrent safety performance.” (p. 45)

“The significant correlations between overall safety culture and measures of safety performance ranged from -.26 to -.45, suggesting a medium effect and that safety culture accounts for 7–21% of the variance in most of the measures of safety performance examined in this study.” (p. 45)

Here is an example of a specific finding: “The most consistent relationship across both the correlation and regression analyses seemed to be between the safety culture factor questioning attitude, and the outcome variable NRC allegations. . . .Questioning attitude was also a significant predictor of concurrent counts of inspection findings associated with ROP cross-cutting aspects, the cross-cutting area of human performance, and total number of SCCIs. Fostering a questioning attitude may be a particularly important component of the overall safety culture of an organization.” (p. 45)

And another: “It is particularly interesting that the only measure of safety performance that was not significantly correlated with safety culture was industrial safety accident rate.” (p. 46)

The authors caution that “The single administration of the survey, combined with the correlational analyses, does not permit conclusions to be drawn regarding a causal relationship between safety culture and safety performance.  In particular, the findings presented here are exploratory, mainly because the correlational analyses cannot be used to verify causality and the data used represent snapshots of safety culture and safety performance.” (p. 46)

The relationships between SC and current performance were stronger than between SC and future performance.  This should give pause to those who would rush to use SC data as a leading indicator. 

Our Perspective 

This is a dense paper and important details may be missing from this summary.  If you are interested in this topic then you should definitely read the original and our October 22, 2010 post.

That recognizable factors dropped out of the PCA should not be a surprise.  In fact, the opposite would have been the real surprise.  After all, the survey was constructed to include previously identified SC traits.  The nine factors mapped well against previously identified SC traits and INPO principles. 

However, there was no explanation, in either the original presentation or this paper, of why the 11 safety performance measures were chosen out of a large universe.  After all, the NRC and INPO collect innumerable types of performance data.  Was there some cherry picking here?  I have no idea but it creates an opportunity for a statistical aside, presented in a footnote below.*****

The authors attempt to explain some correlations by inventing a logic that connects the SC factor to the performance measure.  But it just speculation because, as the authors note, correlation is not causality.  You should look at the correlation tables and see if they make sense to you, or if some different processes are at work here. 

One aspect of this paper bothers me a little.  In the October 22, 2010 NRC public meeting, the INPO presenter said the analysis was INPO’s while an NRC presenter said NRC staff had reviewed and accepted the INPO analysis, which had been verified by an outside NRC contractor.  For this paper, those two presenters are joined by another NRC staffer as co-authors.  This is a difference.  It passes the smell test but does evidence a close working relationship between an independent public agency and a secretive private entity.


*  S.L. Morrow, G.K. Koves and V.E. Barnes, “Exploring the relationship between safety culture and safety performance in U.S. nuclear power operations,” Safety Science 69 (2014), pp. 37–47.  ADAMS ML14224A131.

**  The eleven performance measures included seven NRC measures (Unplanned scrams, NRC allegations,  ROP cross-cutting aspects,  Human performance cross-cutting inspection findings, Problem identification and resolution cross-cutting inspection findings, Substantive cross-cutting issues in the human performance or problem identification and resolution area and ROP action matrix oversight, i.e., which column a plant is in) and four INPO measures (Chemistry performance, Human performance error rate, Forced loss rate and Industrial safety accident rate.

***  The nine SC factors were management commitment to safety, willingness to raise safety concerns, decision making, supervisor responsibility for safety, questioning attitude, safety communication, personal responsibility for safety, prioritizing safety and training quality.

****  Specifically, 13 (out of 22) overall SC correlations with the current and future performance measures were significant as were 84 (out of 198) individual SC factor correlations.

*****  It would be nice to know if any background statistical testing was performed to pick the performance measures.  This is important because if one calculates enough correlations, or any other statistic, one will eventually get some false positives (Type I errors).  One way to counteract this problem is to establish a more restrictive threshold for significance, e.g., 0.01 vs 0.05 or 0.005 vs. 0.01. This note is simply my cautionary view.  I am not suggesting there are any methodological problem areas in the subject paper.

NAS Safety Culture Lessons Learned from Fukushima—Presentation to NRC

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

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

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

Our Perspective

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

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

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

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


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

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

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

The Incident

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

How the Incident was Handled and Settled

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

The Consequences

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

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

Our Perspective

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

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


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

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

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

NRC Non-Concurrence Process Assessment: Tempest in a Teapot?

On June 4, 2014 the NRC announced a revised agency-wide non-concurrence process (NCP) on their blog.*  A key objective of the NCP is “to ensure that a non-concurrence is heard, understood, and considered by employees included in the concurrence process so that the non-concurrence informs and supports the decisionmaking process.”**

The NRC performed an assessment*** of the prior NCP using multiple data sources, including the NRC’s 2012 Safety Culture and Climate Survey (SCCS) and an April 2013 survey targeted at employees who had been involved with the NCP as submitters or participants (employees who have responded to non-concurrences).

The assessment identified both strengths and weaknesses with the then-existing NCP.  In general, participants were aware of the NCP and were willing to use it.  However, “some users of the process felt they faced negative consequences, or that their views were not reflected in final decisions.” (blog post)  The assessment also included a bevy of planned actions to address NCP weaknesses.

For us, the interesting question is what does the assessment say or what can be inferred, if anything, with respect to the NRC’s safety culture (SC).  This post focuses on SC-related topics mentioned in the assessment that help us answer that question.

Leadership Commitment

Leadership commitment is an area of concern and planned actions. (p. 4)  “Data from several sources indicates that many of the responding employees are still uncertain about management’s support of the NCP. . . . management was just going through the motions. . . .[some employees] thought the process was biased . . .supervisors using the process indicated that they were concerned management would view it as a negative reflection on them [the supervisors].” (p. 11)  In the targeted survey, “more than half of submitters are concerned about management’s support of the NCP.” (p. 7)

Planned actions include “support managers in emphasizing their personal commitment to the welcoming of sharing differing views and the value of using the NCP in support of sound regulatory decisionmaking. . . . Management should demonstrate this [NCP is a positive] clearly and frequently through their actions and communications. . . . Staff will continue to support a variety of outreach activities and communication tools, such as EDO Updates, monthly senior management meetings, all-supervisor meetings, senior leadership meetings, Yellow Announcements, all-hands meetings, brown bag lunches, seminars, and articles in the NRC Reporter and office-level newsletters.” (p. 18)  Whew!

Potential Negative Consequences of Submitting a NCP

From the SCCS report the assessment highlights that “Forty-nine percent of employees believe that the NCP is effective (37 percent don’t have an opinion on the effectiveness of the NCP and 14 percent believe that the NCP is not effective).” (p. 6)  That 14 percent looks low but because there are only about a dozen NCP filings per year, it might actually reflect that a lot of people who use the process end up disappointed.  That view is supported by the targeted survey where “the majority of submitters believed that the rationale for the outcome was not clearly documented and that they experienced negative consequences as a result of submitting a non-concurrence.” (p. 7)

We reviewed the SCCS on April 6, 2013.  We noted that “The consultants' cover letter identified this [DPO/NCP] as an area for NRC management attention, saying the agency was “Losing significant ground on negative reactions when raising views different from senior management, supervisor, and peers.””

Planned actions include “proactively fostering an environment that encourages and supports differing views . . . evaluating the merits of infusing NCP key messages into existing training, including reinforcing that supervisors and managers will be held accountable for their actions. . . . consider training for all supervisors to address concerns of retaliation and chilling effect for engaging in the NCP. . . . hosting panel discussions including previous NCP submitters and participants . . . promote NCP success stories . . . evaluating the merits of establishing an anti-retaliation policy and procedures to address concerns of retaliation and chilling effect for engaging in the NCP. (p. 20)  Note these are all staff activities, management doesn’t have to do anything except go along with the program.

Goal Conflict

Goal conflict is another problem area.  The assessment notes “many responding employees commented they felt pressure to meet schedules at the expense of quality.” (p. 17)  That issue was also highlighted in the 2012 SCCS and could well be the source for the comment in the assessment.

Our Perspective

An effective NCP is important.  We believe NCP or some functionally equivalent practice should be more widely utilized in the world of formal organizations.

But it is easy to read too much into the NCP assessment.  The primary data input was the 2012 SCCS and that is relatively old news.  Another key input was the targeted survey.  However, the number of survey respondents was small because only a handful of people use the NCP.****  Based on the negative responses of the submitters, it appears that NRC needs to do a better job of administering the NCP, especially in the areas of (1) convincing submitters that their concerns were actually considered (even if ultimately rejected) and (2) ensuring there are no negative consequences associated with using the NCP.  These are real process implementation challenges but the NCP-related issues do not reflect some major, new problem in the agency’s SC.

On the other hand, perceptions of negative responses to rocking the boat in general or senior management’s lack of commitment to inclusive programs and “safety first” are SC signals to which attention must be paid.  If Staff trains their 10 gauge shotgun of interventions on these possibly systemic issues then some actual good could come out of this.


*  NRC blog “Improving NRC’s Internal Processes” (June 4, 2014).  Retrieved June 12, 2014.

**  NRC Non-Concurrence Process, Management Directive 10.158 (Mar. 14, 2014).  ADAMS ML13176A371.

“Non-concurrence” means an employee has a problem with a document the employee had a role in creating or reviewing.  For example, the employee might hold a different view on a technical matter or disagree with a proposed decision.

The NCP appears to be more formal and documented than the NRC Open Door policy and less restrictive than the Differing Professional Opinions (DPO) program which is reserved for concerns on established NRC positions.

***  NRC Office of Enforcement, “2014 Non-Concurrence Process Assessment”  (June 4, 2014).  ADAMS ML14056A294.

****  The survey was issued to 39 submitters (24 responded [62%]) and 62 participants (17 responded [27%]).

A Systems View of Two Industries: Nuclear and Air Transport

We have long promoted a systems view of nuclear facilities and the overall industry.  One consequence of that view is an openness to possible systemic problems as the root causes of incidents in addition to searching for malfunctioning components, both physical and human.

One system where we see this openness is the air transport industry—the air carriers and the Federal Aviation Administration (FAA).  The FAA has two programs for self-reporting of incidents and problems: the Voluntary Disclosure Reporting Program (VDRP) and the Aviation Safety Action Program (ASAP).  These programs are discussed in a recent report* by the FAA’s Office of Inspector General (OIG) and are at least superficially similar to the NRC’s Licensee Event Reporting and Employee Concerns Program.

What’s interesting is that VDRP is receptive to the reporting of both individual and systemic issues.  The OIG report says the difference between individual and systemic is “important because if the issue is systemic, the carrier will have to develop a detailed fix to address the system as a whole—whereas if the issue is more isolated or individual, the fix will be focused more at the employee level, such as providing counseling or training.” (p. 7)  In addition, it appears both FAA programs  are imbued with the concept of a “just culture,” another topic we have posted about on several occasions and which is often associated with a systems view.  A just culture is one where people are encouraged to provide essential safety-related information, the blame game is aggressively avoided, and a clear line exists between acceptable and unacceptable behavior.

Now the implementation of the FAA programs is far from perfect.  As the OIG points out, the FAA doesn't ensure root causes are identified or corrective actions are sufficient and long-lived, and safety data is not analyzed to identify trends that represent risks.  Systemic issues may not always be reported by the carriers or recognized by the FAA.  But overall, there appears to be an effort at open, comprehensive communication between the regulator and the regulated.

So why does the FAA encourage a just culture while the nuclear industry seems fixated on a culture of blame?  One factor might be the NRC’s focus on hardware-centric performance measures.  If these are improving over time, one might infer that any incidents are more likely caused by non-hardware, i.e., humans. 

But perhaps we can gain greater insight into why one industry is more accepting of systemic issues by looking at system-level factors, specifically the operational (or actual) coupling among industry participants versus their coupling as perceived by external observers.**

As a practical matter, the nuclear industry is loosely coupled, i.e., each plant operates more or less independently of the others (even though plants with a common owner are subject to the same policies as other members of the fleet).  There is seldom any direct competition between plants.  However, the industry is viewed by many external observers, especially anti-nukes, as a singular whole, i.e, tightly coupled.  Insiders reinforce this view when they say things like “an accident at one plant is an accident for all.”  And, in fact, one incident (e.g., Davis-Besse) can have industry-wide implications although the physical risk may be entirely local.  In such a socio-political environment, there is implicit pressure to limit or encapsulate the causes of any incidents or irregularities to purely local sources and avoid the mention of possible systemic issues.  The leads to a search for the faulty component, the bad employee, a failure to update a specific procedure or some other local problem that can be fixed by improved leadership and oversight, clearer expectations, more attention to detail, training etc.  The result of this approach (plus other industry-wide factors, e.g., the lack of transparency in certain oversight practices*** and the “special and unique” mantra) is basically a closed system whose client, i.e., the beneficiary of system efforts, is itself.

In contrast, the FAA’s world has two parts, the set of air carriers whose relationship with each another is loosely coupled, similar to the nuclear industry, and the air traffic control (ATC) sub-system, which is more tightly coupled because all the carriers share the same airspace and ATC.  Because of loose coupling, a systemic problem at a single carrier affects only that carrier and does not infect the rest of the industry.  What is most interesting is that a single airline accident (in the tightly coupled portion of the system) does not lead to calls to shut down the industry.  Air transport has no organized opposition to its existence.  Air travel is such an integral part of so many people’s lives that pressure exists to keep the system running even in the face of possible hazards.  As a consequence, the FAA has to occasionally reassert its interest in keeping safety risks from creeping into the system.  Overall, we can say the air transport industry is relatively open, able to admit the existence of problems, even systemic ones, without taking an inadvertent existential risk. 

The foregoing is not intended to be a comprehensive comparison of the two industries.  Rather it is meant to illustrate how one can apply a simple systems concept to gain some insights into why participants in different industries behave differently.  While both the FAA and NRC are responsible for identifying systemic issues in their respective industries, it appears FAA has an easier time of it.  This is not likely to change given the top-level factors described above. 


*  FAA Office of Inspector General, “Further Actions are Needed to Improve FAA’s Oversight of the Voluntary Disclosure Reporting Program” Report No. AV-2014-036 (April 10, 2014).  Thanks to Bill Mullins for pointing out this report to us.

“VDRP provides air carriers the opportunity to voluntarily report and correct areas of non-compliance without civil penalty. The program also provides FAA important safety information that might not otherwise come to its attention.“ (p. 1)  ASAP “allows individual aviation employees to disclose possible safety violations to air carriers and FAA without fear that the information will be used to take enforcement or disciplinary action against them.” (p. 2)

**  “Coupling” refers to the amount of slack, buffer or give between two items in a system.

***  For example, INPO’s board of directors is comprised of nuclear industry CEOs, INPO evaluation reports are delivered in confidence to its members and INPO has basically unfettered access to the NRC.  This is not exactly a recipe for gaining public trust.  See J.O. Ellis Jr. (INPO CEO), Testimony before the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling (Aug. 25, 2010).  Retrieved from NEI website May 27, 2014.

Willful Violations at Indian Point

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

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

The Events Surrounding the Misconduct

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

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

Further Observations

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

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

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

Why?

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

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

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

Safety and Safety Culture

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

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

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

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

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


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

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

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

References

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

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

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

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

Safety Culture at the NRC Regulatory Information Conference

NRC Public Meeting

The NRC held their annual Regulatory Information Conference (RIC) March 11-13, 2014.  It included a session on safety culture (SC), summarized below.*

NRC Presentation

The NRC presentation reviewed their education and outreach activities on the SC Policy Statement (SCPS) and their participation in IAEA meetings to develop an implementation strategy for the IAEA Nuclear Safety Action Plan. 

The only new item was Safety Culture Trait Talk, an educational brochure.  Each brochure covers one of the nine SC traits in the SCPS, describing why the trait is important and providing examples of associated behaviors and attitudes, and an illustrative scenario. 

It appears only one brochure, Leadership Safety Values and Actions, is currently available.**  A quick read suggests the brochure content is pretty good.  The “Why is this trait important?” content was derived from an extensive review of SC-related social science literature, which we liked a lot and posted about Feb. 10, 2013.  The “What does this trait look like?” section comes from the SC Common Language initiative, which we have reviewed multiple times, most recently on April 6, 2014.  The illustrative scenario is new content developed for the brochure and provides a believable story of how normalization of deviance can creep into an organization under the skirt of an employee bonus program based on plant production.

Licensee Presentations

There were three licensee presentations, all from entities that the NRC has taken to the woodshed over SC deficiencies.  Presenting at the RIC may be part of their penance but it’s interesting to see what folks who are under the gun to change their SC have to say.

Chicago Bridge & Iron, which is involved in U.S. nuclear units currently under construction, got in trouble for creating a chilled work environment at one of its facilities.  The fixes focus on their Safety Conscious Work Environment and Corrective Action Program.   Detailed activities come from the familiar menu: policy updates, a new VP role, training, oversight, monitoring, etc.  Rapping CB&I’s knuckles certainly creates an example for other companies trying to cash in on the “Nuclear Renaissance” in the U.S.  Whatever CB&I does, they are motivated to make it work because there is probably a lot of money at stake.  The associated NRC Confirmatory Order*** summarizes the history of the precipitating incident and CB&I’s required corrective actions.

Browns Ferry has had SC-related problems for a long time and has been taken to task by both NRC and INPO.  The presentation includes one list of prior plant actions that DIDN’T work while a different list displays current actions that are supposedly working.  Another slide shows improvement in SC metrics based on survey data—regular readers know how we feel about SC surveys.  The most promising initiative they are undertaking is to align with the rest of the TVA fleet on NEI 09-07 “Fostering a Strong Nuclear Safety Culture.”  Click on the Browns Ferry label to see our posts that mention the plant.

Fort Calhoun’s problems started with the 2011 Missouri River floods and just got worse, moving them further down the ROP Action Matrix and forcing them to (among many other things) complete an independent SC assessment.  They took the familiar steps, creating policies, changing out leadership, conducting training, etc.  They also instituted SC “pulse” surveys and use the data to populate their SC performance indicators.  Probably the most important action plant owner OPPD took was to hire Exelon to manage the plant.  Fort Calhoun’s SC-related NRC Confirmatory Action Letter was closed in March 2013 so they are out of the penalty box.

Bottom line: The session presentations are worth a look.


*  RIC Session T11: Safety Culture Journeys: Lessons Learned from Culture Change Efforts (Mar. 11, 2014).  Retrieved April 25, 2014.  Slides for all the presentations are available from this page.

**  “Leadership Safety Values and Actions,” NRC Safety Culture Trait Talk, no. 1 (Mar. 2014).  ADAMS ML14051A543.  Retrieved April 25, 2014.

***  NRC Confirmatory Order EA-12-189 re: Chicago Bridge and Iron (Sept. 16, 2013).  ADAMS ML13233A432.  Retrieved April 25, 2014.

NRC Issues Safety Culture Common Language NUREG

The NRC has issued NUREG-2165* which formalizes the safety culture (SC) common language that has been under development since the NRC SC Policy Statement (SCPS) was issued.  On topics important to us the NUREG repeats word-for-word the text of a document** prepared after a common language workshop held January 29-30, 2013.  Both documents contain a set of SC traits, attributes that define each trait and examples that would evidence each attribute.  Because the language is the same, our opinion on the treatment of our important topics remains the same, as described in detail in our Feb. 28, 2013 post.  Specifically, the treatment of

Decision making, including the treatment of goal conflicts, is Good;

Corrective action, part of problem identification and resolution, is Satisfactory;

Management Incentives is Unsatisfactory because the associated attributes focuses on workers, not managers, and any senior management incentive program is not mentioned; and

Work Backlogs are mentioned in a couple of specific areas so the overall grade is Minimally Acceptable.

But we have one overarching concern that transcends our opinion of common language specifics.

Our Perspective

Our biggest issue with the traits, attributes and examples approach is our fear it will lead to the complete bureaucratization of SC evaluation, either consciously or unconsciously.  The examples in particular can morph into soft requirements on a physical or mental checklist.  Such an approach leads to numerous questions.  How many of the 10 traits does a healthy or positive SC exhibit?***  How many of the 40 attributes?  Are the traits equally important?  How about the attributes?  Could the weighting factors vary across plant sites?  How many examples must be observed before an attribute is judged acceptably present?

We understand the value of effective communications among regulators, licensee personnel and other stakeholders.  But we worry about possible unintended consequences as people attempt to apply the guidance in NUREG-2165, especially in the NRC’s Reactor Oversight Process (ROP).****


*  NRC NUREG-2165, “Safety Culture Common Language” (Mar. 2014).  ADAMS ML14083A200.

**  Nuclear Safety Culture Common Language 4th Public Workshop January 29-31, 2013.  ADAMS ML13031A343.

***  The NUREG-2165 text describes a “healthy” SC while the SCPS (published as NUREG/BR-0500, Rev. 1, ADAMS ML12355A122) refers to a “positive” SC.  The correct answer to “how many traits?” may be “more than ten” because the authors note “There may also be traits not included in the SCPS that are important in a healthy safety culture.” (p. 2)

****  The common language “initiative is within the Commission-directed framework for enhancing the ROP treatment of cross-cutting areas to more fully address safety culture.” (p. 3)  This may require a little linguistic jujitsu since the SCPS says “traits were not developed for inspection purposes.”

NRC "National Report" to IAEA

A March 25, 2014 NRC press release* announced that Chairman Macfarlane presented the Sixth National Report for the Convention on Nuclear Safety** to International Atomic Energy Agency (IAEA) member countries.  The report mentions safety culture (SC) several times, as discussed below.  There is no breaking news in a report like this.  We’re posting about it only because it provides an encyclopedic review of NRC activities including a description of how SC fits into their grand scheme of things.  We also tie the report’s contents to related posts on Safetymatters.  The numbers shown below are section numbers in the report.

6.3.11 Public Participation 

This section describes how the NRC engages with stakeholders and the broader public.  As part of such engagement, the NRC says it expects employers to maintain an open environment where workers are free to raise safety concerns. “These expectations are communicated through the NRC’s Safety Culture Policy Statement” and other regulatory directives and tools. (p. 72)  This is pretty straightforward and we have no comment.

8.1.6.2 Human Resources

Section 8 describes the NRC, from its position in the federal government to how it runs its internal activities.  One such activity is the NRC Inspector General’s triennial General Safety Culture and Climate Survey for NRC employees.  Reporting on the most recent (2012) survey, “the NRC scored above both Federal and private sector benchmarks, although in 2012 the agency did not perform as strongly as it had in the past.” (p. 96)  We posted on the internal SC survey back on April 6, 2013; we felt the survey raised a few significant issues.

10.4 Safety Culture

Section 10 covers activities that ensure that safety receives its “due priority” from licensees and the NRC itself.  Sub-section 10.4 provides an in-depth description of the NRC’s SC-related policies and practices so we excerpt from it at length.

The discussion begins with the SC policy statement and the traits of a positive (sic) SC, including Leadership, Problem identification and resolution, Personal accountability, etc.

The most interesting part is 10.4.1 NRC Monitoring of Licensee Safety Culture which covers “the policies, programs, and practices that apply to licensee safety culture.” (p. 118)  It begins with the Reactor Oversight Process (ROP) and its SC-related enhancements.  NRC staff identified 13 components as important to SC, including decision making, resources, work control, etc.  “All 13 safety culture components are applied in selected baseline, event followup, and supplemental IPs [inspection procedures].” (p. 119)

“There are no regulatory requirements for licensees to perform safety culture assessments routinely. However, depending on the extent of deterioration of licensee performance, the NRC has a range of expectations [emphasis added] about regulatory actions and licensee safety culture assessments, . . .” (p. 119)

“In the routine or baseline inspection program, the inspector will develop an inspection finding and then identify whether an aspect of a safety culture component is a significant causal factor of the finding. The NRC communicates the inspection findings to the licensee along with the associated safety culture aspect. 

“When performing the IP that focuses on problem identification and resolution, inspectors have the option to review licensee self-assessments of safety culture. The problem identification and resolution IP also instructs inspectors to be aware of safety culture components when selecting samples.” (p. 119)

“If, over three consecutive assessment periods (i.e., 18 months), a licensee has the same safety culture issue with the same common theme, the NRC may ask [emphasis added] the licensee to conduct a safety culture self-assessment.” (p. 120)

If the licensee performance degrades to Column 3 of the ROP Action Matrix and “the NRC determines that the licensee did not recognize that safety culture components caused or significantly contributed to the risk-significant performance issues, the NRC may request [emphasis added] the licensee to complete an independent assessment of its safety culture.” (p. 120)

For licensees in Column 4 of the ROP “the NRC will expect [emphasis added] the licensee to conduct a third-party independent assessment of its safety culture. The NRC will review the licensee’s assessment and will conduct an independent assessment of the licensee’s safety culture . . .” (p. 120)

ROP SC considerations “provide the NRC staff with (1) better opportunities to consider safety culture weaknesses . . . (2) a process to determine the need to specifically evaluate a licensee’s safety culture . . . and (3) a structured process to evaluate the licensee’s safety culture assessment and to independently conduct a safety culture assessment for a licensee . . . .  By using the existing Reactor Oversight Process framework, the NRC’s safety culture oversight activities are based on a graded approach and remain transparent, understandable, objective, risk-informed, performance-based, and predictable.” (p. 120)

We described this hierarchy of NRC SC-related activities in a post on May 24, 2013.  We called it de facto regulation of SC.  Reading the above only confirms that conclusion.  When the NRC asks, requests or expects the licensee to do something, it’s akin to a military commander’s “wishes,” i.e., they’re the same as orders.

10.4.2 The NRC Safety Culture 

This section covers the NRC’s actions to strengthen its internal SC.  This actions include appointing an SC Program Manager; integrating SC into the NRC’s Strategic Plan; developing training; evaluating the NRC’s problem identification, evaluation and resolution processes; and establishing clear expectations and accountability for maintaining current policies and procedures. 

We would ask how SC affects (and is affected by) the NRC’s decision making and resource allocation processes, work practices, operating experience integration and establishing personal accountability for maintaining the agency’s SC.  What’s good for the goose (licensee) is good for the gander (regulator).

Institute of Nuclear Power Operations (INPO) 

INPO also provided content for the report.  Interestingly, it is a 39-page Part 3 in the body of the report, not an appendix.  Part 3 covers INPO’s mission, organization, etc. and includes a section on SC.

6. Priority to Safety (Safety Culture)

The industry and INPO have their own definition of SC: “An organization’s values and behaviors—modeled by its leaders and internalized by its members—that serve to make nuclear safety the overriding priority.” (p. 230)

“INPO activities reinforce the primary obligation of the operating organizations’ leadership to establish and foster a healthy safety culture, to periodically assess safety culture, to address shortfalls in an open and candid fashion, and to ensure that everyone from the board room to the shop floor understands his or her role in safety culture.” (p. 231)

We believe our view of SC is broader than INPO’s.  As we said in our July 24, 2013 post “We believe culture, including SC, is an emergent organizational property created by the integration of top-down activities with organizational history, long-serving employees, and strongly held beliefs and values, including the organization's “real” priorities.  In other words, SC is a result of the functioning over time of the socio-technical system.  In our view, a CNO can heavily influence, but not unilaterally define, organizational culture including SC.” 

Conclusion

This 341 page report appears to cover every aspect of the NRC’s operations but, as noted in our introduction, it does not present any new information.  It’s a good reference document to cite if someone asks you what the NRC is or what it does.

We found it a bit odd that the definition of SC in the report is not the definition promulgated in the NRC SC Policy Statement.  Specifically, the report says the NRC uses the 1991 INSAG definition of SC: “that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear safety issues receive the attention warranted by their significance.” (p. 118)

The Policy Statement says “Nuclear safety culture is the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment.”***

Of course, both definitions are different from the INPO definition provided above.  We’ll leave it as an exercise for the reader to figure out what this means.


*  NRC Press Release No: 14-021, “NRC Chairman Macfarlane Presents U.S. National Report to IAEA’s Convention on Nuclear Safety” (Mar. 25, 2014).  ADAMS ML14084A303.

**  NRC NUREG-1650 Rev. 5, “The United States of America Sixth National Report for the Convention on Nuclear Safety” (Oct. 2013).  ADAMS ML13303B021. 

***  NUREG/BR 0500 Rev 1, “Safety Culture Policy Statement” (Dec 2012).  ADAMS ML12355A122.  This definition comports with the one published in the Federal Register Vol. 76, No. 114 (June 14, 2011) p. 34777.

NRC Outreach on the Safety Culture Policy Statement

An NRC public meeting

Last August 7th, the NRC held a public meeting to discuss their outreach initiatives to inform stakeholders about the Safety Culture Policy Statement (SCPS).  A meeting summary was published in October.*  Much of the discussion covered what we'll call the bureaucratization of safety culture (SC)—development of communication materials (inc. a poster, brochure, case studies and website), presentations at conferences and meetings (some international), and training.  However, there were some interesting tidbits, discussed below.

One NRC presentation covered the SC Common Language Initiative.**  The presenter remarked that an additional SC trait, Decision Making (DM), was added during the development of the common language.  In our Feb. 28, 2013 review of the final common language document, we praised the treatment of DM; it is a principal creator of artifacts that reflect an organization's SC.

The INPO presentation noted that “After the common language effort was completed in January, 2013, INPO published Revision 1 of 12-012, which includes all of the examples developed during the common language workshop.” (p. 6)  We reviewed that INPO document here.

But here's the item that got our attention.  During a presentation on NRC outreach, an industry participant cautioned the NRC to not put policy statements into regulatory documents because policy statements are an expectation, not a regulation. The senior NRC person at the meeting agreed with the comment “and the importance of the NRC not overstepping the Commission’s direction that implementing the SCPS is not a regulatory requirement, but rather the Commission’s expectations.” (p. 4)

We find the last comment disingenuous.  We have previously posted on how the NRC has created de facto regulation of SC.***  In the absence of clear de jure regulation, licensees and the NRC end up playing “bring me another rock” until the NRC accepts a licensee's pronouncements, as verified by NRC inspectors.  For an example of this convoluted kabuki, read Bob Cudlin's Jan. 30, 2013 post on how Palisades' efforts to address a plant incident finally gained NRC acceptance, or at least an NRC opinion that Palisades' SC was “adequate and improving.”

We'll keep you posted on SCPS-related activities.


*  D.J. Sieracki to R.P. Zimmerman, “Summary of the August 7, 2013, Public Meeting between the U.S. Nuclear Regulatory Commission Staff  and Stakeholders to  Exchange Information and Discuss Ongoing Education and Outreach Associated with the Safety Culture Policy Statement” (Oct. 1, 2013).  ADAMS ML13267A385.  We continue to find it ironic that the SCPS is administered by the NRC's Office of Enforcement.  Isn't OE's primary focus on people and companies who violate the NRC's regulations?

**  “The common language initiative uses the traits from the SCPS as a basic foundation, and contains definitions and examples to describe each trait more fully.” (p. 3)

***  For related posts, please click the "Regulation of Safety Culture" label.