DNFSB Hearings on Safety Culture, Round Three

DNFSB Headquarters

On October 7, 2014 the Defense Nuclear Facilities Safety Board (DNFSB) held its third and final hearing* on safety culture (SC) at Department of Energy (DOE) nuclear facilities.  The original focus was on the Hanford Waste Treatment Plant (WTP) but this hearing also discussed the Waste Isolation Pilot Plant (WIPP), the Pantex plant and other facilities.  There were three presenters: DOE Secretary Moniz and two of his top lieutenants.  A newspaper article** published the same day reported key points made during the hearing and you should read that article along with this post.  This post focuses on items not included in the newspaper article, including the tone of the hearing and other nuances.  The presenters used no slides and the hearing transcript has not yet been released.  The only current record of the hearing is a DNFSB video.

Secretary Moniz

Moniz has been Secretary for about a year-and-a-half.  In his view, the keys to improving SC are training, consistent senior management attention, and procurement modifications, i.e., DOE’s intent to revise RFP and contracting processes to include SC expectations.  He also said fostering the consideration of SC in all decisions, including resource allocation, is important.  Board member Sullivan asked about the SC issues at Pantex and Moniz provided a generic answer about improving self-assessments and sharing lessons learned but ultimately punted to the next presenter, Ms. Creedon.

Principal Deputy Administrator Creedon, National Nuclear Security Administration (NNSA)

Creedon has been in her position for two months.  She believes NNSA employees get the job done in spite of bureaucracy but they need greater trust in senior management who, in turn, must work harder to engage the workforce.  Returning to the Pantex*** issues, Sullivan asked why the recommendations of the plant’s outside technical advisors had been ignored for years.  Creedon said she would work to improve communications up and down the organization.  In a separate exchange, she provided an example of positive reinforcement where NNSA employees can receive cash awards ($500) for good work. 

Creedon’s  prior position was in the Department of Defense.  To the extent she has the warfighter mentality (“Anything, anywhere, anytime…at any cost”)**** then balancing mission and safety may not be natural for her.  Her response to a question on this topic was not encouraging; she claimed the motto du jour for NNSA (“Mission First, People Always”) adequately addresses safety's prioity but it obviously doesn’t even mention safety.

Acting Assistant Secretary for Environmental Management Whitney

Whitney is also new in his job but not to DOE, coming from DOE Oak Ridge.  He laid out his goals of establishing trust, a questioning attitude and mutual respect.  He was asked about a SC assessment finding that DOE senior managers don’t feel responsible for safety, rather it belongs to the site leads or one of the EM mission support units.  Whitney said that was unacceptable and described the intent to add SC factors to senior management evaluations.  He also repeated the plan to upgrade the WTP contractor evaluation to include SC factors.  He noted that most employees stay at one site for their entire career, making it hard to transfer SC from site to site.

Our Perspective

The overall tone of the hearing was collegial.  The Board expressed support and encouragement for the presenters, all of whom are relatively new in their jobs.  The presenters all stayed on message and reinforced each other.  For example, for WTP one message is “We know there are still significant SC issues at WTP but we have the right team in place and are taking action and making progress.  Changing a decades-old culture takes time.”  Whitney received more of a (polite) grilling probably because the WTP and the WIPP are under his purview.

We are totally supportive of DOE’s stated intent to add SC factors to contracts and senior management evaluations.  When players have skin in the game, the chances of seeing desired behavioral changes are greatly increased.  We are equally supportive of Secretary Moniz’ desire to create a culture that incorporates safety considerations in all decisions.

DOE is trying to make its employees more conscious of safety’s importance; two thousand mangers have gone through SC training and there’s more to come.  Now we’re starting to worry about the drumbeat of SC creating a Weltanschauung where a strong SC is sine quo non for good outcomes and a weak SC is always present when bad outcomes occur.  Organizational reality is more complicated.  An organization with a mediocre SC can achieve satisfactory results if other effective controls and incentives are in place; an organization with a strong SC can still make poor decisions.  And luck can run good or bad for anyone.

*  DNFSB Oct. 7, 2014 Safety Culture Public Meeting and Hearing.  We posted on the first hearing on June 9, 2014 and the second hearing on Sept. 4, 2014.

**  A. Cary, “Moniz says safety culture at Hanford vit plant led to problems,” Tri-City Herald (Oct. 7, 2014).

***  NNSA's responsibilities include Pantex which has recognized SC issues.

****  See the third footnote in our Sept. 4, 2014 post.

Safety Culture at the Pantex Plant

Pantex Plant

On January 25, 2013 we posted about DOE's report to the Defense Nuclear Facilities Safety Board (DNFSB) on the results of safety culture (SC) assessments at several DOE facilities, including the Pantex Plant.  Pantex was assessed because two Pantex employees had reported retaliation for raising a safety concern but the plant also had a history of potentially SC-significant issues.*

The Pantex SC assessment was performed in November 2012.  The report included several significant findings:

“Efforts to communicate and implement the principles of a High Reliability Organization (HRO) have been ongoing for several years. . . . [However,] The realization of the HRO principles has not yet been internalized by the Plant, . . .”

“The belief that the organization places a priority on safety is undermined by employee observations of poor facility conditions, lack of focus on meeting personal needs (work quality of life), and a sense of cronyism. . . . [This] has created the perception among many employees that the financial bottom line is the only focus that matters.

“There is a strong perception that retaliation exists for ‘rocking the boat.’ . . . The perception has created an environment where the raising of questions or identification of problems is not the consistently accepted way of doing business.

“The Pantex Plant has not been successful in understanding the organizational and programmatic behaviors that are necessary for a healthy safety culture. . . . organizational barriers have been created that will prevent successful implementation of the initiatives needed to enhance safe and reliable performance. . . . The barriers are also evident in the lack of respect, difficulty in effective communication, the non-alignment between the perceptions around the unions and management relationships and the notion of ‘need to know’ being extended to almost everything.”**

Sounds serious.  So what's happened since the report was published?  Well, DNFSB held a public meeting on March 14, 2013 to discuss SC problems at Pantex and management's approach to addressing them.  As one might expect, the DOE opening statement declared the SC problems were intolerable and DOE had taken immediate action—by firing off a letter to the contractor. 

“NNSA issued a letter to B&W Pantex directing immediate focus at all management and working levels to a safety conscious work environment (SCWE) for all on-going activities and operations. . . . Other immediate actions included the development of a single stop/pause work process which was provided to all employees and discussed at daily work planning meetings. The Employee Concerns Program and Equal Opportunity Office reporting chain was immediately elevated to a direct report to the General Manager’s Office, providing the highest level accesses for any employee concerns in these areas. Additionally, the differing professional opinion process was reinstated providing a formal mechanism for recognition and resolution of differing views on technical matters.

“Further, this letter directed B&W Pantex to prepare a comprehensive long-term corrective action plan mentioned previously, taking into account the Institute of Nuclear Power Operations (INPO) paper on the principles of a strong nuclear safety culture.”***

DOE listed actions being implemented, including an SC focus team, a seminar on HRO attributes, SCWE training, the issuance of a plant-specific SC policy and an alignment of performance incentives with SC objectives. 

Babcock & Wilcox (B&W)

B&W, the entity that actually has to do the work, did not file any written testimony for the public meeting so we have to go to the meeting video for their comments.****

B&W appears to be on board with the need for change.  The B&W plant general manager and his safety manager were appropriately deferential to the DNFSB members and seemingly well-informed about the plant's remedial actions and SC improvement initiatives.  The GM said he “fully accepts” the assessment findings (which were consistent with the plant's own SC survey conducted just prior to the DOE HSS assessment) and acknowledged that specific problems, e.g., communication issues with respect to safety vs production, existed.  Improving SC/SCWE is the GM's “top priority.”  B&W reiterated its commitment to building an HRO at Pantex, an initiative that overlaps with actions to strengthen SC and SCWE.  Perhaps the most significant change the GM described was that 30% of managers' performance evaluations would be based on their modeling of appropriate SC/SCWE traits.

Our perspective    

Problem solved?  Not yet and not for awhile.  Pantex had some serious vertical communication and organizational structure issues.  Their attempt to build an HRO has been ongoing for years.  Their SCWE has had some cold spots. 

In addition, the actions Pantex has initiated may be necessary but there is no guarantee they will be sufficient to achieve the plant's SC/SCWE/HRO goals.  For example, there is no real discussion of how decision making processes will be affected other than resolving Nuclear Explosive Safety issues and the usual commitment to conservative decision making.  There is no mention of a corrective action program (or some functional equivalent); an integrated process for identifying, evaluating and fixing problems is essential for ensuring safety, priorities and resource allocation are treated consistently throughout the plant.

We'll watch for progress (or lack thereof) and keep you posted.


*  Pantex is the sole US site that assembles and disassembles nuclear weapons.  Within DOE, the National Nuclear Security Administration (NNSA) has line management responsibility for Pantex.  Babcock & Wilcox is responsible for managing and operating the plant under contract with DOE.

The SC issues identified in the November 2012 assessment did not pop out of nowhere.  The DNFSB identified SC-related concerns at the plant during the previous year.  See statement of D.G. Ogg, Group Lead for Nuclear Weapons Programs, DNFSB, at the Pantex public meeting (March14, 2013).
   
**  DOE Office of Enforcement and Oversight, “Independent Oversight Assessment of Nuclear Safety Culture at the Pantex Plant” (Nov. 2012) p. 3.  The report is attached to the letter from G.S. Podansky (DOE) to P.S. Winokur (DNFSB) transmitting five independent safety culture assessments (Dec. 12, 2012).

***  Written testimony of Neile Miller, Acting Administrator, NNSA before the Defense Nuclear Facilities Safety Board Pantex Plant Public Meeting (March 14, 2013), p. 4. 

****  The meeting video is available on the DNFSB website.  The NNSA panel on Pantex SC runs from about 1:25 to 2:30, the B&W panel runs from about 2:35 to 3:20.

Safety Culture Assessments: the Vit Plant vs. Other DOE Facilities

The Vit Plant

 As you recall, the Defense Nuclear Facilities Safety Board (DNFSB) set off a little war with DOE when DNFSB published its blistering June 2011 critique* of the Hanford Waste Treatment Plant's (Vit Plant) safety culture (SC).  Memos were fired back and forth but eventually things settled down.  One of DOE's resultant commitments was to assess SC at other DOE facilities to see if  SC concerns identified at the Vit Plant were also evident elsewhere.  Last month DOE transmitted the results of five assessments to DNFSB.**  The following facilities were evaluated:

• Los Alamos National Laboratory Chemistry and Metallurgy Research Replacement Project (Los Alamos)
• Y-12 National Security Complex Uranium Processing Facility Project (UPF)
• Idaho Cleanup Project Sodium Bearing Waste Treatment Project (Idaho)
• Office of Environmental Management Headquarters (EM)
• Pantex Plant 

The same protocol was used for each of the assessments: DOE's Health, Safety and Security organization formed a team of its own assessors and two outside experts from the Human Performance Analysis Corporation (HPA).  Multiple data collection tools, including functional analysis, semi-structured focus group and individual interviews, observations and behavioral anchored rating scales, were used to assess organizational behaviors.  The external experts also conducted a SC survey at each site.

A stand-alone report was prepared for each facility, consisting of a summary and recommendation (ca. 5 pages) and the outside experts' report (ca. 25 pages).  The outside experts organized their observations and findings along the nine SC traits identified by the NRC, viz.,

• Leadership Safety Values and Actions
• Problem Identification and Resolution
• Personal Accountability
• Work Processes
• Continuous Learning
• Environment for Raising Concerns
• Effective Safety Communication
• Respectful Work Environment
• Questioning Attitude.

So, do Vit Plant SC concerns exist elsewhere?

That's up to the reader to determine.  The DOE submittal contained no meta-analysis of the five assessments, and no comparison to Vit Plant concerns.  As far as I can tell, the individual assessments made no attempt to focus on whether or not Vit Plant concerns existed at the reviewed facilities.

However, my back-of-the-envelope analysis (no statistics, lots of inference) of the reports suggests there are some Vit Plant issues that exist elsewhere but not to the degree that riled the DNFSB when it looked at the Vit Plant.  I made no effort to distinguish between issues mentioned by federal versus contractor employees, or by different contractors.  Following are the major Vit Plant concerns, distilled from the June 2011 DNFSB letter, and their significance at other facilities.

Schedule and/or budget pressure that can lead to suppressed issues or safety short-cuts
 
This is the most widespread and frequently mentioned concern.  It appears to be a significant issue at the UPF where the experts say “the project is being driven . . . by a production mentality.”  Excessive focus on financial incentives was also raised at UPF.  Some Los Alamos interviewees reported schedule pressure.  So did some folks at Idaho but others said safety was not compromised to make schedule; financial incentives were also mentioned there.  At EM, there were fewer comments on schedule pressure and at Pantex, interviewees opined that management shielded employees from pressure and tried to balance the message that both safety and production are important.

A chilled atmosphere adverse to safety exists

The atmosphere is cool at some other facilities, but it's hard to say the temperature is actually chilly.  There were some examples of perceived retaliation at Los Alamos and Pantex.  (Two Pantex employees reported retaliation for raising a safety concern; that's why Pantex, which was not on the original list of facilities for SC evaluation, was included.)  Fear of retaliation, but not actual examples, was reported at UPF and EM.  Fear of retaliation was also reported at Pantex. 

Technical dissent is suppressed

This is a minor issue.  There were some negative perceptions of the differing professional opinion (DPO) process at Los Alamos.  Some interviewees thought the DPO process at EM could be better utilized.  The experts said DPO needed to be better promoted at Pantex. 

Processes for raising and resolving SC-related questions exist but are neither trusted nor used

Another minor issue.  The experts said the procedures at Los Alamos should be reevaluated and enforced.

Conclusion

I did not read every word of this 155 page report but it appears some facilities have issues akin to those identified at the Vit Plant but their scope and/or intensity generally appear to be less.

The DOE submittal is technically responsive to the DNFSB commitment but is not useful without further analysis.  The submittal evidences more foot dragging by DOE to cover up the likely fact that the Vit Plant's SC problems are more significant than other facilities' and buy time to attempt to correct those problems.


* Defense Nuclear Facilities Safety Board, Recommendation 2011-1 to the Secretary of Energy "Safety Culture at the Waste Treatment and Immobilization Plant" (Jun 9, 2011).  We have posted on the DOE-DNFS imbroglio here, here and here.
   
**  G.S. Podansky (DOE) to P.S. Winokur (DNFSB), letter transmitting five independent safety culture assessments (Dec. 12, 2012).