Is Entergy’s Nuclear Safety Culture Hurting the Company or the Industry?

Entergy Headquarters  Source: Nola.com

A recent NRC press release* announced a Confirmatory Order (CO) issued to Entergy Operations, Inc. following an investigation that determined workers at Waterford 3 failed to perform fire inspections and falsified records.  Regulatory action directed at an Entergy plant has a familiar ring and spurs us to look at various problems that have arisen in Entergy’s fleet over the years.  The NRC has connected the dots to safety culture (SC) in some cases while other problems suggest underlying cultural issues. 

Utility-Owned Plants

These plants were part of the utility mergers that created Entergy.

Arkansas Nuclear One (ANO)

ANO is currently in Column 4 of the NRC Action Matrix and subject to an intrusive IP 95003 inspection.  ANO completed an independent SC assessment.  We reviewed their problems on June 25, 2015 and 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.”

In 2013 ANO received a Notice of Violation (NOV) after an employee deliberately falsified documents regarding the performance of Emergency Preparedness drills and communication surveillances.**

Grand Gulf

We are not aware of any SC issues at Grand Gulf.

River Bend

In 2014 Entergy received a CO to document commitments made because of the willful actions of an unidentified River Bend security officer in March 2012.

(In 2014 the NRC Office of Investigations charged that a River Bend security officer had deliberately falsified training records in Oct. 2013.  It appears a subsequent NRC investigation did not substantiate that charge.***)

In 2012 River Bend received a NOV for operators in the control room accessing the internet in violation of an Entergy procedure.

In 2011 River Bend received a CO to document commitments made because an employee apparently experienced retaliatory action after asking questions related to job qualifications.  Corrective actions included Entergy reinforcing its commitment to a safety conscious work environment, reviewing Employee Concerns Program enhancements and conducting a plant wide SC survey.

In 1999 River Bend received a NOV for deliberately providing an NRC inspector with information that was incomplete and inaccurate.

Waterford 3

As noted in the introduction to this post, Waterford 3 recently received a CO because of failure to perform fire inspections and falsifying records.

Entergy Wholesale Plants

These plants were purchased by Entergy and are located outside Entergy’s utility service territory.

FitzPatrick

Entergy purchased FitzPatrick in 2000.

In 2012, FitzPatrick received a CO after the NRC discovered violations, the majority of which were willful, related to adherence to site radiation protection procedures.  Corrective actions included maintaining the SC processes described in NEI 09-07 “Fostering a Strong Nuclear Safety Culture.”

Entergy plans on closing the plant Jan. 27, 2017.

Indian Point

Entergy purchased Indian Point 3 in 2000 and IP2 in 2001.

In 2015 Indian Point received a NOV because it provided information to the NRC related to a licensed operator's medical condition that was not complete and accurate in all material respects.

In 2014 Indian Point received a NOV because a chemistry manager falsified test results.  The manager subsequently resigned and then Entergy tried to downplay the incident.  Our May 12, 2014 post on this event is a reader favorite.

During 2006-08 Indian Point received two COs and three NOVs for its failure to install backup power for the plant’s emergency notification system.

Palisades

Entergy purchased Palisades in 2007.

In 2015 Entergy received a NOV because it provided information to the NRC related to Palisades’ compliance with ASME Code acceptance criteria that was not complete and accurate in all material respects.

In 2014 Entergy received a CO because a Palisades security manager assigned a supervisor to an armed responder role for which he was not currently qualified (see our July 24, 2014 post).

Over 2011-12 a virtual SC saga played out at Palisades.  It is too complicated to summarize here but see our Jan. 30, 2013 post.

In 2012 Palisades received a CO after an operator left the control room without permission and without performing a turnover to another operator.  Corrective actions included conducting a SC assessment of the Palisades Operations department.

Pilgrim

Entergy purchased Pilgrim in 1999.

Like ANO, Pilgrim is also in column 4 of the Action Matrix.  They are in the midst of a three-phase IP 95003 inspection currently focused on corrective action program weaknesses (always a hot button issue for us); a plant SC assessment will be performed in the third phase.

In 2013, Pilgrim received a NOV because it provided information to the NRC related to medical documentation on operators that was not complete and accurate in all material respects.

In 2005 Pilgrim received a NOV after an on-duty supervisor was observed sleeping in the control room. 

Vermont Yankee

Entergy purchased Vermont Yankee in 2002.

During 2009, Vermont Yankee employees made “incomplete and misleading” statements to state regulators about tritium leakage from plant piping.  Eleven employees, including the VP for operations, were subsequently put on leave or reprimanded.  Click the Vermont Yankee label to see our multiple posts on this incident. 

Vermont Yankee ceased operations on Dec. 29, 2014.

Our Perspective

These cases involved behavior that was wrong or, at a minimum, lackadaisical.  It’s not a stretch to infer that a weak SC may have been a contributing factor even where it was not specifically cited.

Only three U.S. nuclear units are in column 4 of the NRC’s Action Matrix—and all three are Entergy plants.  Only TVA comes close to Entergy when it comes to being SC-challenged.

We can’t predict the future but it doesn’t take a rocket scientist to plot Entergy’s nuclear trajectory.  One plant is dead and the demise of another has been scheduled.  It will be no surprise if Indian Point goes next; it’s in a densely populated region, occasionally radioactively leaky and a punching bag for New York politicians.

Does Entergy’s SC performance inspire public trust and confidence in the company?  Does their performance affect people's perception of other plants in the industry?  You be the judge.


*  NRC press release, “NRC Issues Confirmatory Order to Entergy Operations, Inc.” (April 8, 2016).  ADAMS ML16099A090.

**  COs and NOVs are summarized from Escalated Enforcement Actions Issued to Reactor Licensees on the NRC website.

***  J.M. Rollins (NRC) to J. McCann (Entergy), Closure of Investigation 014-2014-046 (Jan. 25, 2016.)  ADAMS ML16025A141.

Safety Culture at the 2016 NRC Regulatory Information Conference

RIC program cover

The official evidence of the NRC’s interest in safety culture (SC) at the 2016 Regulatory Information Conference (RIC) consisted of a tabletop presentation on SC training initiatives and support materials.  The tabletop was available during the entire conference and the intent was to engage with participants and make them aware of the SC learning resources that the NRC published this past year.

At past RICs, SC merited a technical session slot in the program, one of thirty-to-forty such sessions at the conference.

Our Perspective

SC has never been an A-list topic at the RIC but we’ll allow that a constant human presence at a tabletop may provide greater opportunities for interacting with conference participants than a single technical session.

We believe SC should get more exposure and promotion at the RIC.  For example, the 2014 RIC had a very good SC panel with three companies that had been (or were still) on the NRC’s SC s___ list making presentations on their get-well efforts.  We reviewed that RIC on April 25, 2014.

Perhaps the NRC could dragoon a few Chief Nuclear Officers to come in and talk about their pay packages and how they are incentivized and rewarded for establishing and maintaining a strong SC.  Now that would be interesting.

Nuclear Safety Culture Problem at TVA: NRC Issues Chilling Effect Letter to Watts Bar

Watts Bar  Source: Wikipedia

The U.S. Nuclear Regulatory Commission (NRC) recently sent a “chilling effect letter”* (CEL) to the Tennessee Valley Authority (TVA) over NRC’s belief that reactor operators at TVA’s Watts Bar plant do not feel free to raise safety concerns because they fear retaliation and do not feel their concerns are being addressed.  The NRC questions whether the plant’s corrective action program (CAP) and Employee Concerns Program have been effective at identifying and resolving the operators’ concerns.  In addition, NRC is concerned that plant management is exercising undue influence over operators’ activities thereby compromising a safety-first environment in the control room.

TVA officials must respond to the NRC within 30 days with a plan describing how they will address the issues identified in the CEL.

What’s a Chilling Effect Letter?

“CELs are issued when the NRC has concluded that the work environment is “chilled,” (i.e., workers perceive that the licensee is suppressing or discouraging the raising of safety concerns or is not addressing such concerns when they are raised).”**

Our Perspective

The absence of fear of retaliation is the principal attribute of an effective safety conscious work environment (SCWE) which in turn is an important component of a strong safety culture (SC).  Almost all commercial nuclear plants in the U.S. have figured out how to create and maintain an acceptable SCWE.

TVA appears to be an exception and a slow learner.  This is not a new situation for them.  As the CEL states, “a Confirmatory Order (EA-09-009, EA-09-203) remains in effect to confirm commitments made by TVA for all three [emphasis added] nuclear stations to address past SCWE issues.”

We have reported multiple times on long-standing SC problems at another TVA plant, Browns Ferry.  And, as we posted on Apr. 25, 2014, Browns Ferry management even made a presentation on their SC improvement actions at the 2014 NRC Regulatory Information Conference.

NRC raised questions about the Watts Bar CAP.  As we have long maintained, CAP effectiveness (promptly responding to identified issues, accurately characterizing them and permanently fixing them) is a key artifact of SC and a visible indicator of SC strength.

As regular readers know, we believe executive compensation is another indicator of SC.  The recipient of the CEL is TVA’s Chief Nuclear Officer (CNO).  According to TVA’s most recent SEC 10-K,*** the CNO made about $2.1 million in FY 2015.  Almost $1 million of the total was short-term (annual) and long-term incentive pay.  The components of the CNO’s annual incentive plan included capability factor, forced outage rate, equipment reliability and budget performance—safety is not mentioned.****  The long-term plan included the wholesale rate excluding fuel, load not served and external measures that included an undefined “nuclear performance index.”  To the surprise of no one who follows these things, the CNO is not being specifically incentivized to create a SCWE or a strong SC.

Bottom line: This CEL is just another brick in the wall for TVA.   


*  C. Haney (NRC) to J.P. Grimes (TVA), “Chilled Work Environment for Raising and Addressing Safety Concerns at the Watts Bar Nuclear Plant” (Mar. 23, 2016) ADAMS ML16083A479.

**  D.J. Sieracki, “U.S. Nuclear Regulatory Commission Safety Culture Oversight,” IAEA  International Conference on Human and Organizational Aspects of Assuring Nuclear Safety (Feb. 24, 2016), p. 115 of “Programme and Abstracts.”

***  Tennessee Valley Authority SEC Form 10-K (annual report) for the fiscal year ended Sept. 30, 2015.  Executive compensation is discussed on pp. 152-77.

****  The calculation of the annual incentive plan payouts for named executives included a corporate multiplier based on six performance measures, one of which was safety performance based on the number of recordable injuries per hours worked, i.e., industrial safety.  The weights of the six components are not shown.

NRC IG Reviews DNFSB Organizational Culture and Climate

The Nuclear Regulatory Commission Inspector General (IG) provides IG services to the Defense Nuclear Facilities Safety Board (DNFSB), an independent government agency.  The DNFSB organizational culture and climate study* reviewed here was performed for the NRC IG by an outside consultant.

Summary of Methods and Results

The study’s methodology is familiar: Review relevant past reports, develop a survey instrument based on employee interviews and focus groups, administer the survey to all employees and interpret the results.

Themes (issues, shortcomings) brought up during the interviews included DNFSB’s handling of change management, communication, personnel development, leadership, internal procedures and performance management (aka personal recognition). (pp. 6-7)

The report compared the DNFSB survey results with three external norms: a cross-section of U.S. industry, U.S. employees working in Research and Development, and industries that have experienced significant changes with widespread employee impact.  The last group consists of organizations under stress because of reorganization, bankruptcy, layoffs, etc. (p. 14)

The report’s summary is not encouraging: “the general trend shows an unfavorable comparison for the DNFSB on all three external benchmarks, . . . Also, many employees feel they do not have the right tools and resources.  Along with that, 38 percent of employees say they plan to leave DNFSB in the next year.” (p. 4)

The employee survey had 14 categories, higher scores mean greater respondent agreement with positive traits.  Analyzing the survey responses in three different dimensions yielded one typical and two unusual results.  In our opinion, they suggest uneven DNFSB management effectiveness across the organization.

Across organizational groups, the General Manager and Admin/ Support groups scored above DNFSB averages on most categories; the Technical Director and Engineering groups scored below DNFSB averages on most categories. (p. 13)  In our experience, this is no surprise; bosses and admin people are usually more satisfied (or less dissatisfied) than the folks who have to get the work done.

Looking at employee tenure, employees with the shortest tenure scored the highest (this is typical) then the scores go downhill.  The longest tenured employees have the lowest scores, which is unusual; most organizations have a U-shaped curve, with newcomers and old timers the most satisfied. (p. 14)

By pay (GS or DN) level, “what is atypical is that the lowest-scoring group is not the lowest-level group, but instead the mid-level group, . . .” (p. 15)

The report identifies Sustainable Engagement (SE)** as a key category.  Using regression analysis, the authors identified five drivers (other survey categories) of SE, two that had acceptable survey scores and three that are candidates for organizational improvement interventions: communication, leadership and performance management. (p.17)  This is as close the report comes to suggesting what the DNFSB might actually do about their problems.

Our Perspective 

This report recognizes that DNFSB has significant challenges but it contains zero surprises.  It’s not even news.  The same or similar ground was covered by a Dec. 2014 organizational study performed for the DNFSB which we reviewed on Feb. 6, 2015.

Problems mentioned in the 2014 report include board dysfunctionality, communications, performance recognition, change management, frequent disruptive organizational changes, and the lack of management and leadership competence.  The 2014 report  included extensive discussion of possible organizational interventions and other corrective actions.

The NRC IG already knew change management was a serious challenge facing the DNFSB; it was mentioned in an Oct. 2014 IG report.***  That report was likely the impetus for this 2015 study.

The DNFSB has been in apparent disarray for over a year.  New members have been appointed to the Board this year, including a new chairman.  It remains to be seen whether they can address the internal challenges and, more importantly, provide meaningful recommendations to their single client, the U.S. Department of Defense.

Bottom line: This NRC IG consultant’s report adds little value to understanding the DNFSB’s organizational issues or developing effective corrective actions. 


*  Towers Watson, “DNFSB 2015 Culture and Climate Survey: Executive Overview of Key Findings” (Aug. 2015).  ADAMS ML15245A515.  Thanks to John Hockert for publicizing this report on the LinkedIn Nuclear Safety Culture forum.

**  Sustainable Engagement is defined as follows: “Assesses the level of DNFSB employees’ connection to the organization, marked by being proud to work at DNFSB, committing effort to achieve the goals (being engaged) having an environment that support productivity (being enabled) and maintaining personal well-being (feeling energized).” (p. 9)

**  H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.

Training Materials for Teaching NRC Personnel about Safety Culture

This is a companion piece to our Aug. 24, 2015 post on how the NRC effectively regulates licensee safety culture (SC) in the absence of any formal SC regulations.  This post summarizes a set of NRC slides* for training inspectors on SC basics and how to integrate SC information and observations into inspection reports.

The slides begin with an overview of SC, material you’ve seen countless times.  It includes the Chernobyl and Davis-Besse events, the Schein tri-level model and a timeline of SC-related activities at the NRC.

The bulk of the presentation shows how SC is related to and incorporated in the Reactor Oversight Process (ROP).  The starting point is the NRC SC Policy Statement, followed by the Common Language Initiative** which defined 10 SC traits.  The traits are connected to the ROP using 23 SC aspects.  Aspects are “the important characteristics of safety culture which are observable to the NRC staff during inspection and assessment of licensee performance” (p. 13)  Each SC aspect is associated with one of the ROP’s 3 cross-cutting areas: Human Performance (14 aspects), Problem Identification and Resolution (6 aspects) and Safety Conscious Work Environment (3 aspects).  During supplemental and reactive inspections there are an additional 12 SC aspects to be considered.  Each aspect has associated artifacts that indicate the aspect’s presence or absence.  SC aspects can contribute to a cross-cutting theme or, in more serious cases, a substantive cross-cutting issue (SCCI).***

The integration of SC findings into inspection reports is covered in NRC Inspection Manual Chapter 0612 and NINE different NRC Inspection Procedures (IPs). (p. 30)  In practice, the logic chain between a SC aspect and an inspection report is the reverse of the description in the preceding paragraph.  The creation of an inspection report starts with a finding followed by a search for a related SC cross-cutting aspect.  Each finding has one most significant cause and the inspectors should “find the aspect that describes licensee performance that would have prevented or precluded the performance deficiency represented by that cause.” (p. 33)

Our Perspective

This is important stuff.  When NRC inspectors are huddled in their bunker evaluating their data and observations after reviewing your documentation, crawling around your plant and talking with your people, the information in these slides provides the road map for their determination of how one or more alleged SC deficiencies contributed to a performance problem which resulted in an inspection finding.

Think of the SC aspects as pegs on which the inspectors can hang their observations to beef up their theory of why a problem occurred. Under routine conditions, there are 23 pegs; under more stringent inspections, there are 35 pegs.  That’s a lot of pegs and none of them is trivial which means your organization’s response may consume sizable resources.

We’ll finish with a more cheery thought:  If you get to the point where the NRC is going to conduct an independent assessment of your SC, their team will follow the guidance in IP 95003.  But don’t worry about their competence, “IP 95003 inspection teams will receive "just-in-time" training before performing the inspection.” (p. 43)

Bottom line: If it looks like controlling oversight behavior and quacks like a bureaucrat, then it probably is de facto regulation.


*  NRC Training Slides, “Safety Culture Reactor Oversight Process Training” (July 10, 2015).  ADAMS ML15191A253.  The slides include other material, e.g., a summary of the conditions under which the NRC can “request” a licensee to perform a SC assessment, a set of case studies and sample test questions for trainees.

**  The Common Language Initiative led to NUREG-2165, “Safety Culture Common Language” which was published in early 2014 and we reviewed on April 6, 2014.

***  There are some complicated decision rules for determining when a problem is a substantive cross-cutting issue and these are worth reviewing on pp. 27-28.

Notes on Regulatory Capture

NRC Public Meeting

A couple of recent local news items discuss a too-cozy relationship between regulators and the supposedly regulated, to the detriment of ratepayers and ordinary citizens.  Neither is nuclear-related but they may give us some ideas on how regulatory capture might (or does) manifest in the nuclear industry.

PG&E and the CPUC

First up is an article* about Pacific Gas and Electric Co. (PG&E) and the California Public Utilities Commission (CPUC).  PG&E is responsible for the deadly 2010 gas main explosion in San Bruno, CA.  It was later revealed that PG&E was involved in private, i.e., secret, lobbying to get the CPUC judge it wanted to handle the case.  An as investigation later concluded, such ex parte discussions gives the utilities an advantage over other participants in the regulatory process.

The article concentrates on remedial legislation working its way through the system.  One bill would close the loophole that allows secret meetings between the CPUC and a regulated entity under certain conditions.  Another would create an independent inspector general for the agency.

Berkeley Zoning Adjustment Board 

This editorial** focuses on a city zoning board that is stuffed with members whose background is in the development industry.  It quotes at length local resident James McFadden who has some excellent observations about the nature of regulatory capture in this situation.

“Although many people are quick to assume that capture means corruption, they really are different things.

“Capture is more of an aligning of economic world views, not necessarily to any monetary advantage, often just to make one's job easier or more pleasant in dealing with people on a day to day basis . . . .

“Captured individuals . . . don't see their behavior as incorrect.  They have forgotten that their role is to provide oversight and protection to the public . . . Their public meetings evolve into patronizing facades of democracy.

“. . . For the most part, capture is about creating a pleasant working environment with those in industry who they deal with on a daily basis.  It is a slow and insidious process that strikes at the heart of human psychology which allows us to work in groups. . . . When we-the-public show up and complain, we become the opponent to be ignored.

“. . . The [public] meeting becomes a dance of false empowerment where getting through the meeting on time is more important than focusing on important issues or input from the public.”

Our Perspective

Do you see any of the above behavior in the nuclear industry?  Here’s a clue to get you started: the mental model for all federally regulated or controlled activities, viz., the infamous “iron triangle” of special interests, Congress and federal bureaucrats.  In the nuclear space, utility lobbyists and industry organizations encourage/pressure Congress for favorable treatment in exchange for support at election time.  Congress leans on the NRC when job losses are threatened because of a lengthy plant shutdown or costly “over regulation.”  The NRC listens to or cooperates with industry “experts” when it is considering new policies, regulations or interpretations.  We believe the iron triangle is alive and well in the nuclear industry but is nowhere near as scurrilous as, say, the welfare system.

(Now the anti-nukes also lobby Congress and certain members of Congress are relentless critics of the NRC.  Do the scales balance?  And where does the clash of lobbying titans leave Joe Citizen?)

Expanding on one side of the triangle, nuclear utilities make efforts to build organizational, professional and personal relationships with the NRC because it’s in their direct economic interest to do so.  In the other direction, don’t NRC personnel try to get along with utility people they see on a regular basis?  Who wants to alienate everybody all the time?  The NRC tries to avoid being too cozy with the utilities but they can’t completely avoid it.  They are in the same business and speak the same language.  However, it’s far from scandalous, like the relationship between the former Minerals Management Service and the offshore drilling industry.  And there is no overactive revolving door between the NRC and industry.

What about outsiders who try to influence policy?  At the top, gadflies who address agency-wide issues or work with HQ personnel may eventually get a seat at the table.  But in the field, Jane Citizen making a statement at a meeting concerning the local plant probably doesn’t have as much leverage.  Consider how difficult it is for the average whistleblower to have an impact.

The Wikipedia entry on regulatory capture cites Princeton professor Frank von Hippel, Barack Obama, Joe Biden, Greenpeace, the Union of Concerned Scientists and the Associated Press to support the position that the NRC has been “captured.”  Has the NRC been too accommodating to the industry?  You be the judge.

There is an old saying: “Familiarity breeds contempt.”  That’s true in some cases.  In other situations, familiarity breeds—greater familiarity.


*  J. Van Derbeken, “CPUC reform bills on governor’s desk,” San Francisco Chronicle (Sept. 15, 2015).  Questionable conduct flowed both ways.  It also came to light that the then-President of the CPUC appeared to offer his support for PG&E’s (and other utilities’) positions on regulatory cases in return for their contributions to his favorite political causes.  That’s called influence peddling.

**  B. O'Malley, “Berkeley's Zoning Board Slouches Toward Birthing Its Monster,” Berkeley Daily Planet (Sept. 13, 2015).  The Daily Planet is an online progressive (lefty) newspaper in Berkeley, CA.

NRC Regulation of Safety Culture: How They Do It

We have griped many times about how the NRC does, in fact, regulate (i.e., control or direct) licensee safety culture (SC) even though the agency claims it doesn’t because there is no applicable regulation.

A complete description of the agency’s approach was provided in 2010 NRC staff testimony* before the Atomic Safety and Licensing Board.  Note this testimony was given before the Safety Culture Policy Statement was issued but we believe it depicts current practices.  The key point is that “Oversight of an operating reactor licensee’s safety culture is implemented by the ROP [Reactor Oversight Process].” (p. 17)  Following are some lengthy quotes from the testimony and you can decide whether or not they add up to “regulation.”

“The ROP provides for the oversight of a licensee’s safety culture in four ways.  First, the ROP provides for the review of a licensee’s safety culture in a graded manner when that licensee has significant performance issues.  The level of the staff’s oversight is determined by the safety significance of the performance issues.  This review and evaluation is described in the ROP’s supplemental inspection program . . . An IP 95002 inspection is usually performed when a licensee enters [column 3] . . . of the ROP Action Matrix. . . [In certain circumstances] the NRC will request the licensee to perform an independent safety culture assessment.  An IP 95003 inspection is performed when a licensee enters [column 4] . . . of the ROP Action Matrix.  When this occurs, the NRC expects [emphasis added] the licensees to perform a third-party safety culture assessment.  The staff will review the results of the assessment and perform sample evaluations to verify the results.

“Second, the ROP’s reactive inspection program evaluates a licensee’s response to an event, including consideration of contributing causes related to the safety culture components, to fully understand the circumstances surrounding an event and its probable causes.

“Third, the ROP provides continuous oversight of licensee performance as inspectors evaluate inspection findings for cross-cutting aspects.  Cross-cutting aspects are aspects of licensee performance that can potentially affect multiple facets of plant operations and usually manifest themselves as the root causes of performance problems. . . .**

“Fourth, the ROP provides for the review of a licensee’s safety culture if that licensee has difficulty correcting long-standing substantive cross-cutting issues.  In these cases, the NRC will request the licensee to perform a safety culture assessment, and the NRC Staff will evaluate the results and the licensee’s response to the results.” (pp. 18-19)  In addition, “The ROP assessment process looks at long-standing substantive cross-cutting issues to determine if safety culture assessments need to be performed and reviewed.” (p. 24)  Significantly, “Safety culture is addressed through the use of cross-cutting issues which do not relate to the Action Matrix column that a plant may be placed in.” (p. 32)

Our Perspective

In our opinion, SC is regulated via a linkage to ongoing NRC activities.  Outputs from NRC inspection activities performed under the aegis of regulation (i.e., law) are used to assess licensee SC and force licensees to perform activities, e.g., SC assessments or corrective actions***, that the licensees might not choose to perform of their own free will.

The reality is NRC “requests” or “expectations” are like a commanding officer’s “wishes”; the intelligent subordinate understands they have the force of orders.  Here’s how the agency describes the fist inside the glove: “If the NRC requests a licensee to take an action, and the licensee refuses, the Agency can perform that action (i.e., the safety culture assessment) for them.” (p. 29)  We assume the NRC would invoke its regulatory authority to justify such an assessment.  But what licensee would want an under-experienced posse of federal inspectors, who expect to find problems because why else would they be assigned to the task, running through their organization?

Occasionally, the NRC drops the veil long enough to reveal the truth.  An NRC staffer (one of the witnesses who sponsored the ASLB testimony described above) recently made a presentation to the Korean nuclear regulator.  It included a figure that summarizes the SC aspects of the ROP Action Matrix.  Under columns 3 and 4, the figure says “may request” and “request” the licensee to conduct a SC assessment.  However, on the next page, the presentation bullets are more forthcoming: “For Plants in Columns 3 . . . and 4 . . . NRC requires [emphasis added] Licensee to conduct third party safety culture assessment which is reviewed by NRC.”****

We’re not opposed to the NRC squeezing licensees to strengthen their SC.  We just don’t like hypocrisy and doublespeak.  Perhaps the agency takes this convoluted approach to controlling SC to support their claim they don’t interfere with licensee management.  We don’t believe that; do you?


*  NRC Staff Testimony of V.E. Barnes et al Concerning Safety Culture and NRC Safety Culture Policy Development and Implementation before the Atomic Safety and Licensing Board (July 30, 2010) revised Sept. 7, 2010.  ADAMS ML102500605.

**  The ROP framework includes three cross-cutting areas (human performance, problem identification and resolution, and safety conscious work environment) which contain nine safety culture components. (p. 23)

***  This is another leverage point for the agency.  They make sure SC assessment findings are entered in the licensee’s corrective action program (CAP).  Then they use their regulatory authority over the CAP to ensure it is useful and effective, i.e., that SC corrective actions are implemented. (p. 30)

****  M. Keefe, “Incorporating Safety Culture into the Reactor Oversight Process (ROP),” presentation to the Korea Institute of Nuclear Safety (June 2-3, 2015), pp. 5-6.  ADAMS ML15161A109.

Safety Culture at Arkansas Nuclear One

Arkansas Nuclear One (credit: Edibobb)

Everyone has heard about the March 31, 2013 stator drop at Arkansas Nuclear One (ANO).  But there was also unsatisfactory performance with respect to flood protection and unplanned scrams.  As a consequence, ANO has been assigned to column 4 of the NRC’s Action Matrix where it will receive the highest level of oversight for an operating plant.

When a plant is in column 4 the NRC takes a particular interest in its safety culture (SC) and ANO is no exception.  NRC required ANO to have an independent (i.e., outside third party) SC assessment, which was conducted starting in late 2014.  While the assessment report is not public, some highlights were discussed during the May 21, 2015 NRC staff briefing of the Commissioners on the results of the April 15, 2015 Agency Action Review Meeting.*

NRC Presentation

The bulk of the staff presentation was a soporific review of agency progress in a variety of areas.  But when the topic turned to ANO, the Regional Administrator responsible for ANO was quite specific and minced no words.  Following are the key problems he reviewed.  See if you can connect the dots on SC issues based on these artifacts.

Let’s start with the stator drop.  ANO’s initial root cause evaluation did not identify any root or contributing causes related to ANO’s own performance, but rather focused solely on the contractor.  After the NRC identified ANO’s failure to follow its load handling procedure, ANO conducted another root cause evaluation and identified their own organizational performance issues such as inadequate project oversight and non-conservative decision making. (pp. 28-29)

The stator drop damaged a fire main which caused localized flooding.  This led to an extended condition review which identified various equipment and structures that could be subject to flooding.  The NRC inspectors pointed out deficiencies in the condition review and identified corrective actions that likely would not work.  In addition, earlier flooding walkdowns completed as part of the NRC’s post-Fukushima requirements failed to identify the majority of the flood protection deficiencies.  These walkdowns were also performed by a contractor.  (pp. 29-31)

Finally, ANO did not report an April 2014 Unit 2 trip as an unplanned scram because the trip occurred during a planned down power evolution.  After prodding by the NRC inspectors, ANO reclassified this event as an unplanned scram. (pp. 31-32)

Overall, the NRC felt it was driving ANO to perform complete evaluations and develop effective corrective actions.  NRC believes that ANO’s “cause evaluations typically don't provide for a thorough assessment of organizational and programmatic contributors to events or issues.” (p. 35)  Later, in response to a question, the Regional Administrator said “I think the licensee clearly needs to own the performance gaps, ensure that their assessments in the various areas are comprehensive and then identify appropriate actions, and then engage and ensure those actions are effective. . . . I don't want to be in a position where our inspection activities are the means for identifying the performance gaps.” (p. 44)

Responding to a question about ANO’s independent SC assessment, he said “one of the key findings . . . was that there's an urgent need to internalize and communicate the seriousness of performance problems and engage the site in their strategy for improvement.” (p. 45)

Entergy Presentation

A team of Entergy (ANO’s owner) senior managers presented their action plan for ANO.  They said they would own their own problems, improve contractor oversight, identify their own issues, increase corporate oversight and improve their CAP.

With respect to culture, they said “We're going to change the culture to promote a healthy, continuous improvement and to not only achieve, but also to sustain excellence.” (pp. 70-71)  They are benchmarking other plants, analyzing ANO’s issues and adding resources including people with plant performance recovery experience. 

They took comfort from the SC assessment conclusion “That although weaknesses exist, the overall safety culture at ANO is sufficient to support safe operation." (p. 72)

In response to a question about important takeaways from the SC assessment, Entergy referred to the need for the plant to recognize that performance has got to improve, the CAP must be more effective and organizational programmatic elements are important.  In addition, they vowed to align the organization on the performance gaps (and their significance) and establish a sense of urgency in order to fix them. (pp. 80-81)

Our Perspective

Not to be too cynical, but what else could Entergy say?  When your plant is in column 4, a mega mea culpa is absolutely necessary.  But Entergy’s testimony read like generic management arm-waving invoking the usual set of fixes.

Basically, 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.  Where did those values come from?  Is “increased oversight” sufficient to create a long-term fix?

ANO naturally gives a lot of weight to the SC assessment because its findings appear relatively simple and apparently actionable.   Somewhat surprisingly, the NRC also appears to give this assessment broad credibility.  We think that’s misplaced.  The chances are slim of such an assessment identifying deep, systemic cultural issues although we admit we don’t know the assessment details.  Did the assessment team perform document reviews, conduct focus groups or interviews?  If it was a survey, it only identified the most pressing issues in the plant’s safety climate.

Taking a more systemic view, we note that Entergy has a history of SC issues over many plants in its fleet.  Check out our Feb. 20, 2015 post for highlights on some of their problems.  Are ANO’s problems just the latest round of SC Whac-A-Mole at Entergy?

Entergy has always had a strong Operations focus at its plants.  The NRC’s confidence in ANO’s operators is the main reason that plant is not shut down.  But continuously glorifying the operators, particularly their ability to respond successfully to challenging conditions, is like honoring firefighters while ignoring the fire marshal.  The fire marshal role at a nuclear plant is played by Engineering and Maintenance, groups whose success is hidden (thus under-appreciated) in an ongoing series of dynamic, non-events, viz., continuous safe plant operation.  That’s a cultural issue.  By the way, who gets the lion’s share of praise and highest status at your plant?


*  “Briefing on Results of the Agency Action Review Plan Meeting,” public meeting transcript (May 21, 2015).  ADAMS ML15147A041.

The Agency Action Review Meeting (AARM) “is a meeting of the senior leadership of the agency, and its goals are to review the appropriateness of agency actions taken for reactor material licensees with significant performance issues.” (pp. 3-4)

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

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

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

Emphasis on Safety Culture (pp. 25-26) 

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

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

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

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

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

An Independent Regulator (pp. 26-27)

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

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

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

Industry Transparency (pp. 27-28)

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

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

That’s all.

Our Perspective 

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

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


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

More Safety Culture “Trait Talk” from the NRC

Typical NRC Trait Talk brochure

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

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

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

Leadership Safety Values and Actions

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

Work Processes

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

Questioning Attitude

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

Problem Identification and Resolution

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

Environment for Raising Concerns

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

Effective Safety Communication

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

Respectful Work Environment

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

Continuous Learning

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

Personal Accountability

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

Our Perspective 

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


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

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

NRC Office of Investigations 2014 Annual Report: From Cases to Culture

The Nuclear Regulatory Commission (NRC) Office of Investigations (OI) recently released its FY2014 annual report.*  The OI investigates alleged wrongdoing by entities regulated by the NRC; OI’s focus is on willful and deliberate actions that violate NRC regulations and/or criminal statutes.

The OI report showed a definite downward trend in the number of new cases being opened, overall a 41% drop between FY2010 and FY2014.  Only one of the four categories of cases increased over that time frame, viz., material false statements, which held fairly steady through FY2013 but popped in FY2014 to 67% over FY2010.  We find this disappointing because false statements can often be linked to cultural attributes that prioritize getting a job done over compliance with regulations.

The report includes a chapter on “Significant Investigations.”  There were eight such investigations, four involving nuclear power plants.  We have previously reported on two of these cases, the Indian Point chemistry manager who falsified test results (see our May 12, 2014 post) and the Palisades security manager who assigned a supervisor to an armed responder role for which he was not currently qualified (see our July 24, 2014 post).  The other two, summarized below, occurred at River Bend and Salem.

In the River Bend case, a security officer deliberately falsified training records by taking a plant access authorization test for her son, a contractor employed by a plant supplier.  Similar to the Palisades case, Entergy elected alternative dispute resolution (ADR) and ended up with multiple corrective actions including revising its security procedures, establishing new controls for security-related information (SRI), evaluating SRI storage, developing a document highlighting the special responsibilities of nuclear security personnel, establishing decorum protocols for certain security posts, preparing and delivering a lessons learned presentation, conducting an independent third party safety culture (SC) assessment of the River Bend security organization [emphasis added], and delivering refresher training on 10 CFR 50.5 and 50.9.  Most of these requirements are to be implemented fleet-wide, i.e., at all Entergy nuclear plants, not just River Bend.**

The Salem case involved a senior reactor operator who used an illegal substance then performed duties while under its influence.  The NRC issued a Level III Notice of Violation (NOV) to the operator.  The operator’s NRC license was terminated at PSE&G’s request.***  PSE&G was not cited in this case.

Our Perspective

You probably noticed that three of the “significant” cases involved Entergy plants.  Entergy is no stranger to issues with a possible cultural component including the following:****

In 2013, Arkansas Nuclear One received a NOV after an employee deliberately falsified documents regarding the performance of Emergency Preparedness drills and communication surveillances.

In 2012, Fitzpatrick received a Confirmatory Order (Order) after the NRC discovered violations, the majority of which were willful, related to adherence to site radiation protection procedures.

During 2006-08, Indian Point received two Orders and three NOVs for its failure to install backup power for the plant’s emergency notification system.

In 2012, Palisades received an Order after an operator left the control room without permission and without performing a turnover to another operator.  Entergy went to ADR and ended up with multiple corrective actions, some fleet-wide.  We have posted many times about the long-running SC saga at Palisades—click on the Palisades label to pull up the posts. 

In 2005, Pilgrim received a NOV after an on-duty supervisor was observed sleeping in the control room.  In 2013, Pilgrim received a NOV for submitting false medical documentation on operators.

In 2012, River Bend received a NOV for operators in the control room accessing the internet in violation of an Entergy procedure. 

These cases involve behavior that was (at least in hindsight) obviously wrong.  It’s not a stretch to suggest that a weak SC may have been a contributing factor.  So has Entergy received the message?  You be the judge.

“Think of how stupid the average person is, and realize half of them are stupider than that.” ― George Carlin (1937–2008)


*  NRC Office of Investigations, “2014 OI Annual Report,” NUREG-1830, Vol. 11 (Feb. 2015).  ADAMS ML15034A064.

**  M.L. Dapas (NRC) to E.W. Olson (River Bend), “Confirmatory Order, Notice of Violation, and Civil Penalty – NRC Special Inspection Report 05000458/2014407 and NRC Investigation Report 4-2012-022- River Bend Station” (Dec. 3, 2014).  ADAMS ML14339A167.

***  W.M. Dean (NRC) to G. Meekins (an individual), “Notice of Violation (Investigation Report No. 1-2014-013)” (July 9, 2014).  ADAMS ML14190A471.

****  All Entergy-related NRC enforcement actions were obtained from the NRC website.

Back to the Past at Millstone?

Millstone

A recent article* in the Hartford Courant newspaper reported on a turbine-driven auxiliary feedwater (TDAFW) pump problem at Millstone 3 that took so long to resolve that the NRC issued a White finding to plant owner Dominion Resources.

The article included a quote from the Connecticut Nuclear Energy Advisory Council (NEAC) describing their unease over the pump problem.  We dug a little deeper on the NEAC, a state government entity that works with public agencies and plant operators to ensure public health and safety.  Their 2014 annual report** highlights the TDAFW pump problem and another significant event at Millstone, a loss of site power that caused a dual reactor trip.  NRC inspections following these two events resulted in one Severity Level III finding, the White finding previously mentioned and two Green findings.  The events and NRC findings led the NEAC to express “great concern regarding the downward performance trend” to Dominion and request a formal response from Millstone management on any root cause that linked the performance problems.

In his response to the NEAC, the Millstone site VP said there was no root cause linking events.  He also said two safety culture (SC) improvement areas had been identified, viz., problem identification and evaluation and establishing clarity around decision making, and that the site has implemented improvement actions to address those areas.  In the Courant article, a plant spokesman is quoted as saying "If it's not immediately obvious why it's not working, we put a team to work on it."

The article also referred to related behind-the-scenes NRC staff emails*** in which the time it took for Dominion to identify and address the TDAFW pump issue raised eyebrows at the NRC.

So what does the TDAFW pump event tell us about SC at Millstone?

Our Perspective

Is Millstone on the road to the bad old days, when SC was AWOL from the site?  We hope not.  And there is some evidence that suggests the TDAFW pump issue was an isolated problem exacerbated by a bit of bad luck (a vendor supplying the wrong part with the same part number as the correct part).

Positive data includes the following: Millstone 2 and 3 both had all green performance indicators on the 3QTR2014 NRC ROP and, more importantly, a mid-2014 baseline inspection of the Millstone CAP “concluded that Dominion was generally effective in identifying, evaluating, and resolving problems.”****  In addition, plant “staff expressed a willingness to use the corrective action program to identify plant issues and deficiencies and stated that they were willing to raise safety issues.” (p. 10)

Currently, M2 is subject to baseline inspection and M3 to baseline and a supplemental inspection because of the White finding.

To us, this doesn’t look like a plant on the road to SC hell although we agree with the NRC that the TDAFW pump problem took too long to evaluate and resolve.

We hope the Millstone organization learned more from the TDAFW pump problem than they displayed in their reply to the NRC.*****  In dealing with the regulator, Millstone naturally tried to bound the problem and their response: they pointed at the vendor for sending them the wrong part, implemented a TDAFW pump troubleshooting guide, revised a troubleshooting procedure, and produced and presented two case studies to applicable plant personnel. 

The site VP’s letter to NEAC suggests a broader application of the lessons learned.  We suggest the “trust but verify” principle for dealing with vendors be strengthened and that someone be assigned to read Constance Perin’s Shouldering Risk (see our Sept. 12, 2011 review) and report back on the ways factors such as accepted logics, organizational power relations and production pressure can prevent organizations from correctly perceiving problems that are right in front of them.

*  S. Singer, “Emails Show NRC's Concern Over How Millstone Nuclear Plant Reacted To Malfunction,” Hartford Courant (Jan. 12, 2015).

**  2014 Nuclear Energy Advisory Council (NEAC) Report (Dec. 11, 2014).  The Nov. 10, 2014 letter from Millstone site VP S.E. Scace to J.W. Sheehan (NEAC) is appended to NEAC’s 2014 annual report.

***  The Associated Press obtained the emails under a Freedom of Information Act request.  Most of the content relates to the evolution of technical issues but, as cited in the Courant article, there are mentions of Millstone’s slowness in dealing with the pump issue.  The emails are available at ADAMS ML14358A318 and ML14358A320.

****  “Millstone Power Station – NRC Problem Identification and Resolution Inspection Report 05000336/2014009 and 05000423/2014009” (Sept. 12, 2014), cover letter.  ADAMS ML14255A229.

*****  Dominion Nuclear Connecticut, Inc. Millstone Power Station Unit 3, Reply to a Notice of Violation (Nov. 19, 2014).  ADAMS ML14325A060.