NRC Non-Regulation of Safety Culture: Second Quarter Update

NRC SC poster, ADAMS ML120810464.

On March 17th we published a post on NRC safety culture (SC) related activities with individual licensees since the SC policy statement was issued in June, 2011.  This post is an update, highlighting selected NRC actions from mid-March through June. 

Our earlier post mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking SC related activities.  It looks like none of those plants has resolved its SC issues. 

For Browns Ferry we reported that the NRC was reviewing the plant’s 2011 SC surveys.  Turns out that was just the tip of the iceberg.  A recent PI&R inspection report indicates that the plant’s SC problems have existed for years and are deep-rooted.  Over time, Browns Ferry has reported SC issues including production and schedule taking priority over safety (2008), “struggling” with SC issues (2010) and a decline in SC (2011).  All of this occurred in spite of multiple licensee interventions and corrective actions.  The NRC’s current view is “Despite efforts to address SC issues at the site, the inspectors concluded that the lack of full confidence in the CAP has contributed to a decline in the SC since the last PI&R inspection.”*  We don’t expect this one to go away anytime soon.

Fort Calhoun management had said that SC deficiencies had contributed to problems in their CAP.  During the quarter, they presented actions planned or taken to remediate their SC deficiencies.  On June 11th, the NRC issued a Confirmatory Action Letter with a lengthy list of actions to be completed prior to plant restart.  One item is “OPPD will conduct a third-party safety culture assessment . . . and implement actions to address the results . . . .”**  It looks like Fort Calhoun is making acceptable progress on the SC front and we’d be surprised if SC ends up being an item that prevents restart.  Last April we provided some additional information on Fort Calhoun here.

In Palisades’ case, the NRC is asking for an extensive set of information on the actions being taken to improve SC at the site.  The last item on the long list requests the latest SC assessment for Entergy’s corporate office.  (This is not simply a fishing expedition.  Entergy is in trouble at other nuclear sites for problems that also appear related to SC deficiencies.)  After the information is provided and reviewed, the NRC “believe[s] that a public meeting on the safety culture assessment and your subsequent actions would be beneficial to ensure a full understanding by the NRC, your staff, and the public.”***  Back in January, we provided our perspective on Palisades here and here.

New NRC SC activity occurred at Susquehanna as part of a supplemental inspection related to a White finding and a White performance indicator.  The NRC conducted an “assessment of whether any safety culture component caused or significantly contributed to the white finding and PI.”  The assessment was triggered by PPL’s report that SC issues may have contributed to the plant’s performance problems.  The NRC inspectors reviewed documents and interviewed focus groups, individual managers and groups involved in plant assessments.  They concluded “components of safety culture identified by PPL did not contribute to the White PI or finding, and that the recently implemented corrective actions appear to being well received by the work force.”****  We report this item because it illustrates the NRC’s willingness and ability to conduct its own SC assessments where the agency believes they are warranted.

Our March post concluded: “It’s pretty clear the NRC is turning the screw on licensee safety culture effectiveness, even if it’s not officially “regulating” safety culture.”  That still appears to be the case.


*  V.M. McCree (NRC) to J.W. Shea (TVA), Browns Ferry Nuclear Plant - NRC Problem Identification and Resolution Inspection Report 05000259/2012007, 05000260/2012007 and 05000296/2012007 and Exercise of Enforcement Discretion (May 28, 2012) ADAMS ML12150A219.

**  E.E. Collins (NRC) to D.J. Bannister (OPPD), Confirmatory Action Letter – Fort Calhoun Station (June 11, 2012)  ADAMS ML12163A287.

***  G.L. Shear (NRC) to A. Vitale (Entergy), Request for Information on SC Issues at Palisades Nuclear Plant (June 26, 2012) ADAMS ML12179A155.

**** D.J. Roberts (NRC) to T.S. Rausch (PPL Susquehanna), Susquehanna Steam Electric Station – Assessment Follow-Up Letter and Interim NRC 95002 Supplemental Inspection Report 05000387/2012008 (May 7, 2012) ADAMS ML12125A374.

NEA 2008-2011 Construction Experience Report: Not Much There for Safety Culture Aficionados.

This month the Nuclear Energy Agency, a part of the Organization for Economic Co-Operation and Development, published a report on problems identified and lessons learned at nuclear plants during the construction phase.  The report focuses on three plants currently under construction and also includes incidents from a larger population of plants and brief reviews of other related studies. 

The report identifies a litany of problems that have occurred during plant construction; it is of interest to us because it frequently mentions safety culture as something that needs to be emphasized to prevent such problems.  Unfortunately, there is not much usable guidance beyond platitudinous statements such as “Safety culture needs to be established prior to the start of authorized activities such as the construction phase, and it is applied to all participants (licensee, vendor, architect engineer, constructors, etc.)”, “Safety culture should be maintained at very high level from the beginning of the project” and, from an U.K. report, “. . . an understanding of nuclear safety culture during construction must be emphasized.”*

These should not be world-shaking insights for regulators (the intended audience for the report) or licensees.  On the other hand, the industry continues to have problems that should have been eliminated after the fiascos that occurred during the initial build-out of the nuclear fleet in the 1960s through 1980s; maybe it does need regular reminding of George Santayana’s aphorism: “Those who cannot remember the past are condemned to repeat it.” 


*  Committee on Nuclear Regulatory Activities, Nuclear Energy Agency, “First Construction Experience Synthesis Report 2008-2011,” NEA/CNRA/R(2012)2 (May 3, 2012), pp. 8, 16 and 41.

Going Beyond SCART: A More Useful Guidebook for Evaluating Safety Culture

Our March 11 post reviewed the IAEA SCART guidelines.  We found its safety culture characteristics and attributes comprehensive but its “guiding questions” for evaluators were thin gruel, especially in the areas we consider critical for safety culture: decision making, corrective action, work backlogs and management incentives.

This post reviews another document that combines the SCART guidelines, other IAEA documents and the author’s insights to yield a much more robust guidebook for evaluating a facility’s safety culture.  It’s called “Guidelines for Regulatory Assessment of Safety Culture in Licensees’ Organisations.”*  It starts with the SCART characteristics and attributes but gives more guidance to an evaluator: recommendations for documents to review, what to look for during the evaluation, additional (and more critical) guiding questions, and warning signs that can indicate safety culture weaknesses or problems.

Specific guidance in the areas we consider critical is generally more complete.  For example, in the area of decision making, evaluators are told to look for a documented process applicable to all matters that affect safety, attend meetings to observe the decision-making process, note the formalization of the decision making process and how/if long-term consequences of decisions are considered.  Goal conflict is explicitly addressed, including how differing opinions, conflict based on different experiences, and questioning attitudes are dealt with, and the evidence of fair and impartial methods to resolve conflicts.  Interestingly, example conflicts are not limited to the usual safety vs. cost or production but include safety vs. safety, e.g., a proposed change that would increase plant safety but cause additional personnel rad exposure to implement.  Evidence of unresolved conflicts is a definite warning flag for the evaluator. 

Corrective action (CA) also gets more attention, with questions and flags covering CA prioritization based on safety significance, the timely implementation of fixes, lack of CA after procedure violations or regulatory findings, verification that fixes are implemented and effective, and overall support or lack thereof for the CAP. 

Additional questions and flags cover backlogs in maintenance, corrective actions, procedure changes, unanalyzed physical or procedural problems, and training.

However, the treatment of management incentives is still weak, basically the same as the SCART guidelines.  We recommend a more detailed evaluation of the senior managers’ compensation scheme or, in more direct language, how much do they get paid for production, and how much for safety?

The intended audience for this document is a regulator charged with assessing a licensee’s safety culture.  As we have previously discussed, some regulatory agencies are evaluating this approach.  For now, that’s a no-go in the U.S.  In any case, these guidelines provide a good checklist for self-assessors, internal auditors and external consultants.


*  M. Tronea, “Guidelines for Regulatory Oversight of Safety Culture in Licensees’ Organisations” Draft, rev. 8 (Bucharest, Romania:  National Commission for Nuclear Activities Control [CNCAN], April 2011).  In addition to being on the staff of CNCAN, the nuclear regulatory authority of Romania, Dr. Tronea is the founder/manager of the LinkedIn Nuclear Safety group.  

The NRC Does Not Regulate Safety Culture, Right?

Last March, the NRC approved its safety culture policy statement.*  At the time, a majority of commissioners issued supplemental comments expressing their concern that the policy statement could be used as a back door to regulation.  The policy was issued in June, 2011.  Enough time has lapsed to ask: What, if anything has happened, i.e., how is the NRC treating safety culture as it exercises its authority to regulate licensees?

We examined selected NRC documents for some plants where safety culture has been raised as a possible issue and see a few themes emerging.  One is the requirement to examine the causes of specific incidents to ascertain if safety culture was a contributing factor.  It appears some (perhaps most or all) special inspection notices to licensees include some language about "an assessment of whether any safety culture component caused or significantly contributed to these findings."  

The obvious push is to get the licensee to do the work and explicitly address safety culture in their mea culpa to the agency.  Then the agency can say, for example, that "The inspection team confirmed that the licensee established appropriate corrective actions to address safety culture."**  A variant on this theme is now occurring at Browns Ferry, where the “NRC is reviewing results from safety culture surveys performed by the plant in 2011.”*** 

The NRC is also showing the stick, at least at one plant.  At Fort Calhoun, the marching orders are: “Assess the licensee’s third party evaluation of their safety culture. . . . If necessary, perform an independent assessment of the licensee’s safety culture using the guidance contained in Inspection Procedure 95003."****  I think that means: If you can't/won't/don't perform an adequate safety culture evaluation, then we will.  To back up this threat, it appears the NRC is developing procedures and materials for qualifying its inspectors to evaluate safety culture.

The Alternative Dispute Resolution (ADR) process is another way to get safety culture addressed.  For example, Entergy got in 10 CFR 50.7 (employee protection) trouble for lowering a River Bend employee’s rating in part because of questions he raised.  One of Entergy's commitments following ADR was to perform a site-wide safety culture survey.  It probably didn’t help that, in a separate incident, River Bend operators were found accessing the internet when they were supposed to be watching the control board.  Entergy also has to look at safety culture at FitzPatrick and Palisades because of incidents at those locations.***** 

What does the recent experience imply?

The NRC’s current perspective on safety culture is summed up in an NRC project manager’s post in an internet Nuclear Safety Culture forum: “You seem to [sic] hung up on how NRC is going to enforce safety culture.  We aren't.  Safety culture isn't required. It won't be the basis for denying a license application.  It won't be the basis for citing a violation during an inspection.  However, if an incident investigation identifies safety culture as one of the root causes, we will require corrective action to address it.”  (Note this is NOT an official agency statement.)

However, our Bob Cudlin made a more expansive prediction in his January 19, 2011 post: “. . . it appears that the NRC will “expect” licensees to meet the intent and the particulars of its policy statement.  It seems safe to assume the NRC staff will apply the policy in its assessments of licensee performance. . . . The greatest difficulty is to square the rhetoric of NRC Commissioners and staff regarding the absolute importance of safety culture to safety, the “nothing else matters” perspective, with the inherently limited and non-binding nature of a policy statement.”

While the record to date may support the NRC PM’s view, I think Bob’s observations are also part of the mix.  It’s pretty clear the NRC is turning the screw on licensee safety culture effectiveness, even if it’s not officially “regulating” safety culture.


*  NRC Commission Voting Record, SECY-11-005, “Proposed Final Safety Culture Policy Statement” (March 7, 2011).  I could not locate this document in ADAMS.

**  IR 05000482-11-006, 02/07-03/31/2011, Wolf Creek Generating Station - NRC Inspection Procedure 95002 Supplemental Inspection Report and Assessment Followup Letter (May 20, 2011) ADAMS ML111400351. 

***  Public Meeting Summary for Browns Ferry Nuclear Plant, Docket No. 50-259 (Feb. 26, 2012) ADAMS ML12037A092.

****  Fort Calhoun Station Manual Chapter 0350 Oversight Panel Charter (Jan. 12, 2012) ADAMS ML120120661.

*****  EN-11-026, Confirmatory Order, Entergy Operations Inc.  (Aug. 19, 2011)  ADAMS ML11227A133; NRC Press Release-I-12-002: “NRC Confirms Actions to be Taken at FitzPatrick Nuclear Plant to Address Violations Involving Radiation Protection Program” (Jan. 26, 2012) ADAMS ML120270073; NRC Press Release-III-12-003: “NRC Issues Confirmatory Orders to Palisades Plant Owner Entergy and Plant Operator” (Jan. 26, 2012) ADAMS ML120270071.

Regulatory Assessment of Safety Culture—Not Made in U.S.A.

Last February, the International Atomic Energy (IAEA) hosted a four-day meeting of regulators and licensees on safety culture.*  “The general objective of the meeting [was] to establish a common opinion on how regulatory oversight of safety culture can be developed to foster safety culture.”  In fewer words, how can the regulator oversee and assess safety culture?

While no groundbreaking new methods for evaluating a nuclear organization’s safety culture were presented, the mere fact there is a perception that oversight methods need to be developed is encouraging.  In addition, outside the U.S., it appears more likely that regulators are expected to engage in safety culture oversight if not formal regulation.

Representatives from several countries made presentations.  The NRC presentation discussed the then-current status of the effort that led to the NRC safety culture policy statement announced in June.  The presentations covering Belgium, Bulgaria, Indonesia, Romania, Switzerland and Ukraine described different efforts to include safety culture assessment into licensee evaluations.

Perhaps the most interesting material was a report on an attendee survey** administered at the start of the meeting.  The survey covered “national regulatory approaches used in the oversight of safety culture.” (p.3) 18 member states completed the survey.  Following are a few key findings:

The states were split about 50-50 between having and not having regulatory requirements related to safety culture. (p. 7)  The IAEA is encouraging regulators to get more involved in evaluating safety culture and some countries are responding to that push.

To minimize subjectivity in safety culture oversight, regulators try to use oversight practices that are transparent,  understandable, objective, predictable, and both risk-informed and performance-based. (p. 13)  This is not news but it is a good thing; it means regulators are trying to use the same standards for evaluating safety culture as they use for other licensee activities.

Licensee decision-making processes are assessed using observations of work groups, probabilistic risk analysis, and during the technical inspection. (p. 15)  This seems incomplete or even weak to us.  In-depth analysis of critical decisions is necessary to reveal the underlying assumptions (the hidden, true culture) that shape decision-making.

Challenges include the difficulty in giving an appropriate priority to safety in certain real-time decision making situations and the work pressure in achieving production targets/ keeping to the schedule of outages. (p. 16)  We have been pounding the drum about goal conflict for a long time and this survey finding simply confirms that the issue still exists.

Bottom Line

The meeting was generally consistent with our views.  Regulators and licensees need to focus on cultural artifacts, especially decisions and decision making, in the short run while trying to influence the underlying assumptions in the long run to reduce or eliminate the potential for unexpected negative outcomes.

*  IAEA Technical Meeting on Safety Culture Oversight and Assessment, Vienna, Feb. 15-18, 2011.

**  A. Kerhoas, "Synthesis of Questionnaire Survey."

You Want Safety Culture? Then Pass a Law.

On October 7, 2011 California governor Brown signed SB 705 authored by state senator Mark Leno. 

The Leno bill, among many others, was inspired by a major gas pipeline explosion that occurred September 9, 2010 in San Bruno, CA resulting in multiple fatalities.  The ensuing investigations have identified a familiar litany of contributing causes: defective welds, ineffective maintenance practices, missing and incomplete records, and lax corporate management.

SB 705 adds Sections 961 and 963 to the Public Utilities Code.  Section 961 requires each gas corporation to “develop a plan for the safe and reliable operation of its commission-regulated gas pipeline facility. . . .”* (§ 961(b)(1))

Section 963 states “It is the policy of the state that the commission and each gas corporation place safety of the public and gas corporation employees as the top priority. [emphasis added]  The commission shall take all reasonable and appropriate actions necessary to carry out the safety priority policy of this paragraph consistent with the principle of just and reasonable cost-based rates.”* (§ 963(b)(3))

I was surprised that an unambiguous statement about safety’s importance was apparently missing from the state’s code.  I give senator Leno full credit for this vital contribution.

Of course, he couldn’t leave well enough alone and was quoted as saying “It’s not going to fix the situation overnight, but it changes the culture immediately.”** [emphasis added]

Now this comment is typical political braggadocio, and the culture will not change “immediately.”  However, this law will make safety more prominent on the corporate radar and eventually there should be responsive changes in policies, practices, procedures and behaviors.

*  Bill Text: CA Senate Bill 705 - 2011-2012 Regular Session

**  W. Buchanan, “Governor signs bill forcing automatic pipe valves,” S.F. Chronicle (Oct. 8, 2011).