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

Entergy Headquarters

TVA Headquarters

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

Entergy

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

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

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

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

TVA

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

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

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

Our Perspective

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

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

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

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


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

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

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

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

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

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

Nuclear Safety Culture: Catching up with the NRC

NRC Building

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

New Leadership Model for NRC*

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

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

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

NRC Lessons-Learned Program (LLP)**

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

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

Continued NSC Pressure on Problem Plants

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

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

Our Perspective

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

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


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

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

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

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

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

Watts Bar

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

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

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

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

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

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

Our Perspective

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

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

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

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

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

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


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

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

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

Nuclear Safety Culture 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.

New Safety Culture Assessment at the Hanford Waste Treatment Plant

Hanford WTP

The Department of Energy (DOE) recently released the latest safety culture (SC) assessment report* for the Hanford Waste Treatment Plant (WTP or “vit plant”) project.  The 2015 report follows similar SC assessments conducted in 2011 and 2014, all of which were inspired by the Defense Nuclear Facilities Safety Board’s scathing 2011 report on SC at the WTP.  This post provides a brief overview of the report’s findings then focuses on the critical success factors for a healthy SC.

Assessment Overview

The 2011, 2014 and 2015 assessments used the same methodology, with multiple data collection methods, including interviews, Behavioral Anchored Rating Scales (BARS)** and a SC survey.  Following are selected highlights from the 2015 report.

DOE’s Office of River Protection (ORP) has management responsibility for the WTP project.  In general, ORP personnel feel more positive about the organization’s SC than they did during the 2014 assessment.  Feelings of confusion about ORP’s more collaborative relationship with Bechtel (the prime contractor) have lessened.  ORP management is perceived to be more open to constructive criticism.  Concerns remain with lack of transparency, trust issues and the effectiveness of the problem resolution process.

Bechtel personnel were more positive than in either previous SC assessment.  Bechtel has undertaken many SC-related initiatives including the promotion of a shared mental model of the project by senior Bechtel managers.  In 2014, Bechtel Corporate’s role in project decision making was perceived to skew against SC concerns.  The creation of a new Bechtel nuclear business unit has highlighted the special needs of nuclear work. (pp. 2, 39)  On the negative side, craft workers remain somewhat suspicious and wary of soft retributions, e.g., being blamed for their own industrial mishaps or having their promotion or layoff chances affected by reporting safety issues.

See this newspaper article*** for additional details on the report’s findings. 

Critical Success Factors for a Healthy SC

We always look at the following areas for evidence of SC strength or weakness: management’s decision making process, recognition and handling of goal conflicts, the corrective action program and financial incentives.

Decision Making

Both ORP and Bechtel interviewees complained of a lack of basis or rationale for different types of decisions. (pp. 9, 16)  Some ORP and Bechtel interviewees did note that efforts to clarify decision making are in process. (pp. 13, 32)  Although the need to explain the basis for decisions was recognized, there was no discussion of the decision making process itself.  This is especially disappointing because decision making is one of the possible behaviors that can be included in a BARS analysis, but was not chosen for this assessment.

Goal Conflicts

Conflicts among cost, schedule and safety goals did not rise to the level of a reportable problem.  ORP interviewees reported that cost and schedule do not conflict with safety in their individual work. (p. 6)  Most Bechtel interviewees do not perceive schedule pressures to be the determining factor while completing various tasks. (p. 23)  Overall, this is satisfactory performance.

Corrective Action Program

We believe how well an organization recognizes and permanently resolves its problems is important.  Problem Identification and Resolution was one of the traits evaluated in the assessment.  ORP interviewees said that current safety concerns are being addressed.  The historical lack of management feedback on problem resolution is still a disincentive for reporting problems. (pp. 8-9)  Some Bechtel interviewees said “issue resolution with management engagement was the single most positive improvement in problem resolution, . . .” (p. 24)  This performance is minimally acceptable but needs ongoing attention.

Financial Incentives

DOE’s contract with Bechtel now includes incentives for Bechtel if it self-identifies problems (rather than waiting for DOE or some other party to identify them).  ORP believes the incentives are a positive influence on contractor performance. (p. 8)  Bechtel interviewees also believe the new contract has had a positive impact on the project.  However, Bechtel has a goal to reduce legacy issues and some believe the contract’s emphasis on new issues distracts from addressing legacy problems. (pp. 24-25)  The assessment had no discussion of either ORP or Bechtel senior management financial incentives.  The new contract conditions are good; ignoring senior management incentives is unacceptable.

Safety Conscious Work Environment (SCWE)

We usually don’t pay much attention to SCWE at nuclear power plants because it is part of the larger cultural milieu.  But SCWE has been a long-standing issue at various DOE facilities, as well as the impetus for the series of WTP SC assessments, so we’ll look at a few highlights from the SC survey data.

For ORP, mean responses to five of the six SCWE questions were higher (better) in 2015 vs 2014, and 2014 vs 2011.  However, for one question “Concerns raised are addressed” the mean is lower (worse) in 2015 vs 2014, and significantly lower in 2015 vs 2011.  This may indicate an issue with problem resolution. (p. B-2) 

For Bechtel, mean responses to all six SCWE questions were significantly higher (better) in 2015 vs 2014.  However, the 2011 data were not included so we cannot make any inference about possible longer-term trends. (p. B-5)  What is shown is good news because it appears people feel freer to raise safety concerns.  Interestingly, Bechtel’s mean 2015 responses were 5-13% higher (better) than ORP’s for all questions.

Both ORP and Bechtel are showing acceptable performance but continued improvement efforts are warranted.

Our Perspective

The Executive Summary and Conclusions suggest ORP and especially Bechtel have turned the corner since 2014. (pp. v, 37)  This is arguably true for SCWE but we’d say the jury is still out on improvement in the broader SC, based on our look at the BARS data.

For ORP, the BARS data mean scores are higher for 4 (out of 10) behaviors in 2015 vs 2014, but only higher for 1 behavior in 2015 vs 2011. (p. B-1)  The least charitable interpretation is ORP’s view of itself has not yet re-achieved 2011 levels.  For Bechtel the BARS data shows a bit brighter picture.  Mean scores are higher for 6 (out of 10) behaviors in 2015 vs 2014, and higher for 4 behaviors for 2015 vs 2011. (p. B-4)

The format of the report is probably intended to be reader-friendly but it mixes qualitative interview data and selected quantitative data from BARS and the survey.  The use of modifiers like “many” and “some” creates a sense of relative frequency or importance but no real specificity.  It’s impossible to say how much (if any) cherry picking of the interview data occurred.****

We also wonder about the evaluation team’s level of independence and optimism.  This is the first time DOE has performed a WTP SC assessment without the extensive use of outside consultants.  Put bluntly, how independent was the team’s effort given DOE Headquarters’ desire to see improvements at WTP?  And it’s not just HQ; DOE is under the gun from Congress, the DNFSB, the Government Accountability Office, and environmental activists and regulators to clean up their act at Hanford.

We want to see a stronger SC at Hanford but we’ll go with Ronald Reagan on this report: “Trust, but verify.”


*  DOE Office of Enterprise Assessments, “Follow-up Assessment of Safety Culture at the Hanford Site Waste Treatment and Immobilization Plant” (June, 2015).  We have followed the WTP saga for years; please click on the Vit Plant label to see our related posts.

**  Behavioral Anchored Rating Scales (BARS) quantitatively summarize interviewees’ perceptions of their organization using specific examples of good, moderate, and poor performance.   There are 17 possible organizational behaviors in a BARS analysis, but only 10 were used in this assessment:  Attention to Safety, Coordination of Work, Formalization, Interdepartmental Communication, Organizational Learning, Performance Quality, Problem Identification and Resolution, Resource Allocation, Roles and Responsibilities and Time Urgency. (p. C-2)

***  A. Cary, “DOE: Hanford vit plant safety culture shows improvement,” Tri-City Herald (June 26, 2015).

****  The report also includes multiple references to the two organizations’ behavioral norms that were inferred from the survey data.  It’s not exactly consultant mumbo-jumbo but it’s too complicated to attempt to explain in this space.

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.

Vit Plant Safety Culture Update

Hanford Waste Treatment Plant

DOE released a June 2014 follow-up assessment* on safety culture (SC) at the Hanford Waste Treatment Plant (WTP or the Vit Plant).  This post provides our perspective on the assessment.  We will not review every facet of the report but will focus on aspects that we think are important to understanding the current state of SC at the WTP project.

Overview

Back in 2011, the Defense Nuclear Facilities Safety Board (DNFSB) called the WTP safety culture (SC) “flawed.”  Following the DNFSB report, DOE conducted an assessment of the WTP SC and concluded “that a significant number of staff within ORP [DOE’s Office of River Protection] and BNI [Bechtel National Inc.] expressed reluctance to raise safety or quality concerns for various reasons.” (p. 1) 

Like DOE’s 2011 report, the current one is based on multiple data sources: structured interviews, focus groups, observations and a culture survey.  The report identifies many SC-related interventions that have been initiated, and lists positive and negative findings from the data collected.  Detailed assessment results are reported separately for ORP and BNI.**
 
WTP’s Safety Conscious Work Environment (SCWE)—Voicing Concerns, Challenging Decisions, Fear of Retaliation

The 2011 DNFSB critique focused on the treatment of project personnel who raised technical issues.  Some of these personnel complained about retaliation for bringing up such issues.  These issues can be raised in the Employee Concerns Program (ECP), the Differing Professional Opinions (DPO) process and challenging management decisions.  In what is arguably the report’s most significant finding, perceptions of conditions in these areas are worse than they were in 2011 for ORP and unchanged for BNI. (pp. 4-5)

Supporting Details

Although ORP senior management pointed to recent reductions in ECP concerns, “[s]ome interviewees indicated that they perceived a chilled environment at ORP and they did not believe that ECP concerns and DPO issues were always addressed or resolved in a timely manner.  Additionally, some interviewees described being told by supervision not to write a DPO because it would be a career limiting decision.” (p. B-21)  Interviewees from both ORP and BNI said they lacked trust in the ECP. (pp. B-22/23)

Most ORP employees believe that constructive criticism is not encouraged. (p. 4)  Within ORP, only 30% of all ORP survey respondents (and 65% of managers) feel that they can openly challenge decisions made by management. (p. B-21)  In BNI/URS, the numbers are 45% of all respondents and 75% of managers. (p. B-22)

“The statement that management does not tolerate retaliation of any kind for raising concerns was agreed to by approximately 80% of the ORP, . . . 72% of the BNI and 80% of the URS survey respondents.” (pp. B-21-22)  In addition, “Anonymous PIERs [Project Issues Evaluation Reports] are used a lot because of fear of retaliation.” (p. B-23)  

All in all, hardly a ringing endorsement of the WTP SCWE.

Decision Making, Corrective Action and Compensation

Safetymatters readers know of our long-standing interest in how SC is reflected in these key artifacts.

Decision Making

“Interviewees provided some examples of where decision making was not perceived to reflect the highest commitment to safety”  Examples included downgrading or elimination of assessment findings, the margin of safety in corrective action plans and the acceptable level of risk for the project.  (p. B-9)  Looks like there's some room for improvement in this area.

Corrective Action

Within BNI, there are positive comments about the corrective action process but the assessment team “observed a lack of accountability for a backlog of corrective actions at a PIRB [Performance Improvement Review Board] meeting.  There is a perceived lack of accountability for corrective actions in timeliness, ownership, and quality, ...” (p. B-16)

“[O]nly about 18% of all ORP interviewee respondents believed that employees are encouraged to notify management of problems they observe and that there is a system that evaluates the problem and makes a determination regarding future action.” (p. 13)

Plenty of room for improvement here.

Compensation

In the area of compensation, it appears some rewards for Bechtel are based on SC behaviors. (p. B-8)  We consider that a very positive development.

Concerns Over ORP Working More Collaboratively with Bechtel

On the surface this looks like a positive change: two entities working together to achieve a common goal.  However, this has led to at least two concerns.  First, as described in the report, some ORP personnel believe ORP is abdicating or compromising its responsibility to perform oversight of Bechtel, in other words, ORP is more of a teammate and less of an umpire. (pp. B-4, -9, -14)  Second, and this reflects our perspective, changing the relationship between the entities can result in revised system dynamics, with old performance-oversight feedback loops replaced by new ones.  The rules of engagement have changed and while safety may still be the number one priority, the cultural milieu in which safety is achieved has also changed.

Another complication is caused by the role of Bechtel Corporate.  The report says corporate’s values and goals may not be well-aligned with BNI’s need to prioritize SC attributes and behavior.  This can lead to a lack of transparency in BNI decisions. (pp. 5, 7)  That may be a bit of weasel wording in the report; in more direct terms, corporate’s number one priority is for the money train to keep running.

Bottom Line on SC at WTP 

A strong SC is, in some ways, about respect for the individual.  The concerns that WTP personnel  express about using the ECP or DPO process, or challenging management decisions suggest that the WTP project has a ways to go to inculcate an adequate level of such respect.  More importantly, it doesn’t appear they have made any significant process toward that goal in the last few years.

Morale is an aspect of the overall culture and at the WTP, morale is arguably low because of lack of progress and missed schedules. (pp. 6, B-10)  There is undoubtedly plenty of work to do but on a day to day basis, we wouldn’t be surprised if some people feel their work is not meaningful.


*  DOE Office of Environment, Safety and Health Assessments (now the Office of Independent Enterprise Assessments), “Independent Oversight Follow-up Assessment of Safety Culture at the Waste Treatment and Immobilization Plant” (June, 2014).

**  ORP has line management responsibility for the WTP, BNI is the primary contractor and URS Corporation (URS) is a major subcontractor.

Catching Up on DOE’s SCWE Extent of Condition Review

Hanford Waste Treatment Plant

On May 29, 2014 DOE submitted its partial response to the Defense Nuclear Facilities Safety Board (DNFSB) Recommendation 2011-1 in a report* on DOE’s Safety Conscious Work Environment (SCWE) extent of condition review and recommended actions for ongoing safety culture (SC) improvement at DOE facilities.

(Quick history: The June 9, 2011 DNFSB report on DOE’s Hanford Waste Treatment Plant (WTP or the Vit Plant) said the WTP SC was “flawed.”  The report’s recommendations included that DOE should conduct an extent of condition review to determine whether WTP SC weaknesses existed at other DOE facilities.  DOE agreed to perform the review but focused on SCWE because, in DOE’s view, the issues at WTP were primarily SCWE related.)

This post summarizes the report’s findings then parses the details and provides our perspective.

 Report Findings and Recommendations

The report was based on data from eleven independent SC assessments and thirty-one SCWE self-assessments conducted by individual organizations.  The DOE review team processed the data through their analyzer and homogenizer to identify four primary SC attributes** to focus on for continuous improvement in DOE:

• Demonstrated safety leadership
• Open communication and fostering an environment free from retribution
• Teamwork and mutual respect
• Credibility, trust and reporting errors and problems

Further processing through the bureaucratizer yielded three recommended actions to improve the SC attributes:

• Form a DOE SC Improvement Panel to ensure leadership and focus on DOE's SC initiatives
• Incorporate SC and SCWE concepts and practices into DOE training
• Evaluate contract language to incorporate clear references to SC  (pp. 3-4)

Our Perspective

We reviewed the DOE independent assessments on January 25, 2013 and the self-assessments on March 31, 2014.  From the former we concluded that issues similar to those found at the WTP existed at other DOE facilities, but to a lesser degree than WTP.  The self-assessments were of such varying quality and credibility that we basically couldn’t infer anything.***

The Analyzer

The DOE team reviewed all the assessments to identify specific issues (problems).  The team binned issues under the SC attributes in DOE's Integrated Safety Management System Guide and then counted the number of issues under each attribute; a higher count meant a more serious problem.  They performed a similar exercise to identify positive organizational trends (strengths) mentioned in the assessments. 

We could be picky and ask if all the issues (or strengths) were of essentially the same importance or magnitude but the team had a lot of data to review so we’ll let that slide.  Concurrently identifying strengths was a good idea; it harkens back to Peter Drucker who advised managers to build on strengths.****

The Homogenizer

Here’s where we begin to have problems.  The team focused on identifying SC attributes and developing recommendations that applied to or affected the entire Department, essentially boiling their results down to a one-size-fits-all approach.  However, their own data belies that approach.  For example, the Leadership attribute “Open communication and fostering an environment free from retribution” was identified as both an issue AND a strength. 

In plain English, some organizations don’t exhibit the desired communication attribute and others do.  One proper fix is to identify who is doing it right, define what exactly they’re doing, and develop a method for transferring that approach to the problem organizations.  The report even says this attribute “is an area in which management can learn lessons from those sites where it was deemed a strength so that best practices can become commonplace” but this statement is buried at the end of the report. (p. 22)

The DOE entities exhibit a wide variety of scale, scope, mission and organizational and technical complexity.  The Department’s goal should be to recognize that reality, develop it as an overall strength and then build on it to create site- or organization-specific interventions.

The Bureaucratizer

The proposed fixes would basically create a top-level coordinating and oversight group, enhance SC and SCWE training and modify contracts.  The recommendations reflect a concerted search for the lowest common denominator and a minimum amount of real change.

If the SC Improvement Panel is established, it should focus on setting or refining SC policy and ensuring those policies are implemented by line management, especially field management.  They should also be involved in evaluating major SC issues.  If things aren’t going well, this group should be the first to ask the hard “Why?” questions.  But most of the panel’s proposed tasks, viz., maintaining SC visibility, providing a forum for evaluating SC status and overseeing training improvements, are low-value make work.

“[S]afety culture training for all personnel, up and down the management chain, will be updated and/ or developed to ensure that roles and responsibilities are understood and personnel have the capabilities needed to play their part in continuously improving DOE's safety culture; . . .” (p. 24)  This is a standard fix for almost any perceived organizational problem.  It doesn’t require managers to do anything different.

Modifying contracts to incorporate clear references to SC is only a beginning.  What are the carrots and the sticks to incent the contractors to actually develop, measure and maintain an effective SCWE and strong SC?

Bottom Line

This report comports completely with an organization that resembles a fifty foot sponge.  You can kick it as hard as you like, your foot goes in deep and you think you’ve had an effect, but when you withdraw your foot, the organization fills in the hole like your kick never happened.  I thought I heard a loud pop on May 29.  I now realize it was likely DNFSB Chairman Winokur’s head exploding when he read this report.

But Wait, There’s More

Remember the question the DNFSB initially asked in 2011: Do WTP SC issues exist elsewhere in DOE?  Well, the answer is: “Review of assessment results from both [independent and self assessments] indicated there is a SCWE extent of condition that requires additional and ongoing actions to improve performance.” (p. 28, the penultimate page of the report)


*  J. Hutton (DOE) to P.S. Winokur (DNFSB) May 29, 2014 letter transmitting DOE Consolidated Report for DNFSB Recommendation 2011-1, Actions 2-8 and 2-9 (May 2014).

** DOE considers SC in three focus areas: Leadership, Employee Engagement and Organizational Learning.  Each focus area has a set of associated attributes that describe what a positive SC should look like. (pp. 4-5)

***  The report puts the self-assessments in the best possible light by describing them as learning experiences for the organizations involved. (p.9)

****  Drucker was referring to individuals but, in this case, we’ll stretch the blanket to cover organizations.  For individuals, weaknesses should not be ignored but the energy required to fix them, if it’s even possible, is often too great.  However, one should keep an eye on such weaknesses and not allow them to lead to performance failure.

DOE Report on WIPP's Safety Culture

On Feb. 14, 2014, an incident at the Department of Energy (DOE) Waste Isolation Pilot Plant (WIPP) resulted in the release of radioactive americium and plutonium into the environment.  This post reviews DOE’s Phase 1 incident report*, with an emphasis on safety culture (SC) concerns.

From the Executive Summary

The Accident Investigation Board (the Board) concluded that a more thorough hazard analysis, coupled with a better filter system could have prevented the unfiltered above ground release. (p. ES-1)

The root cause of the incident was Nuclear Waste Partnership’s (NWP**, the site contractor) and the DOE Carlsbad Field Office’s (CBFO) failure to manage the radiological hazard. “The cumulative effect of inadequacies in ventilation system design and operability compounded by degradation of key safety management programs and safety culture [emphasis added] resulted in the release of radioactive material . . . and the delayed/ineffective recognition and response to the release.” (pp. ES 6-7)

The report presents eight contributing causes, most of which point to NWP deficiencies.  SC was included as a site-wide concern, specifically the SC does not fully implement DOE safety management policy, “[t]here is a lack of a questioning attitude, reluctance to bring up and document issues, and an acceptance and normalization of degraded equipment and conditions.”  A recent Safety Conscious Work Environment (SCWE) survey suggests a chilled work environment. (p. ES-8)

The report includes 31 conclusions, 4 related to SC.  “NWP and CBFO have allowed the safety culture at the WIPP project to deteriorate . . . Questioning attitudes are not welcomed by management . . . DOE has exacerbated the safety culture problem by referring to numbers of [problem] reports . . . as a measure of [contractor] performance . . . . [NWP and CBFO] failed to identify weaknesses in . . . safety culture.” (pp. ES 14-15, 19-20)

The report includes 47 recommendations (called Judgments of Need) with 4 related to SC.  They cover leadership (including the CBFO site manager) behavior, organizational learning, questioning attitude, more extensive use of existing processes to raise issues, engaging outside SC expertise and improving contractor SC-related processes. (ibid.)

Report Details

The body of the report presents the details behind the conclusions and recommendations.  Following are some of the more interesting SC items, starting with our hot button issues: decision making (esp. the handling of goal conflict), corrective action, compensation and backlogs. 

Decision Making

The introduction to section 5 on SC includes an interesting statement:  “In normal human behavior, production behaviors naturally take precedence over prevention behaviors unless there is a strong safety culture - nurtured by strong leadership.” (p. 61)

The report suggests nature has taken its course: WIPP values production first and most.  “Eighteen emergency management drills and exercises were cancelled in 2013 due to an impact on operations. . . .Management assessments conducted by the contractor have a primary focus on cost and schedule performance.” (p. 62)  “The functional checks on CAMs [continuous air monitors] were often delayed to allow waste-handling activities to continue.” (p. 64)  “[D]ue consideration for prioritization of maintenance of equipment is not given unless there is an immediate impact on the waste emplacement processes.” (p. ES-17)  These observations evidence an imbalance between the goals of production and prevention (against accidents and incidents) and, following the logic of the introductory statement, a weak SC.

Corrective Action

The corrective action program has problems.  “The [Jan. 2013] SCWE Self-Assessment . . . identified weaknesses in teamwork and mutual respect . . . Other than completing the [SCWE] National Training Center course, . . . no other effective corrective actions have been implemented. . . . [The Self-Assessment also ]“identified weaknesses in effective resolution of reported problems.” (p. 63)  For problems that were reported, “The Board noted several instances of reported deficiencies that were either not issued, or for which corrective action plans were not developed or acted on for months.” (p. 65)

Compensation

Here is the complete text of Conclusion 14, which was excerpted above: “DOE has exacerbated the safety culture problem by referring to numbers of ORPS [incident and problem] reports and other deficiency reporting documents, rather than the significance of the events, as a measure of performance by Source Evaluation Boards during contract bid evaluations, and poor scoring on award fee determinations.  Directly tying performance to the number of occurrence reports drives the contractor to non-disclosure of events in order to avoid the poor score. [emphasis added]  This practice is contrary to the Department’s goals of the development and implementation of a strong safety culture across our projects.” (p. ES-15)  ‘Nuff said. 

Backlogs

Maintenance was deferred if it interfered with production.  Equipment and systems were  allowed to degrade (pp. ES-7, ES-17, C-7)  There is no indication that maintenance backlogs were a problem; the work simply wasn’t done.

Other SC Issues

In addition to our Big Four and the issues cited from the Executive Summary, the report mentions the following concerns.  (A listing of all SC deficiencies is presented on p. D-3.)

• Delay in recognizing and responding to events,
• Bias for negative conclusions on Unreviewed Safety Question Determinations, and
• Infrequent presence of NWP management in the underground and surface.

Our Perspective

For starters, the Board appears to have a limited view of what SC is.  They see it as a cause for many of WIPP's problems but it can be fixed if it is “nurtured by strong leadership” and the report's recommendations are implemented.  The recommendations are familiar and can be summed up as “Row harder!”***  In reality, SC is both cause (it creates the context for decision making) and consequence (it is influenced by the observed actions of all organization members, not just senior management).  SC is an organizational property that cannot be managed directly.  

The report is a textbook example of linear, deterministic thinking, especially Appendix E (46 pgs.) on events and causal factors related to the incident.  The report is strong on what happened but weak on why things happened.  Going through Appendix E, SC is a top-level blanket cause of nuclear safety program and radiological event shortcomings (and, to a lesser degree, ventilation, CAMs and ground control problems) but there is no insight into how SC interacts with other organizational variables or with WIPP’s external (political, regulatory, DOE policy) environment. 

Here’s an example of what we’re talking about, viz., how one might gain some greater insight into a problem by casting a wider net and applying a bit of systems thinking.  The report faults DOE HQ for ineffective oversight, providing inadequate resources and not holding CBFO accountable for performance.  The recommended fix is for DOE HQ “to better define and execute their roles and responsibilities” for oversight and other functions. (p. ES-21)  That’s all what and no why.  Is there some basic flaw in the control loop involving DOE HQ, CBFO and NWP?  DOE HQ probably believes it transmits unambiguous orders and expectations through its official documents—why weren’t they being implemented in the field and why didn’t DOE know it?  Is the information flow from DOE to CBFO to NWP clear and adequate (policies, goals); how about the flow in the opposite direction (performance feedback, problems)?  Is something being lost in the translation from one entity to another?  Does this control problem exist between DOE HQ and other sites, i.e., is it a systemic problem?  Who knows.****

Are there other unexamined factors that make WIPP's problems more likely?  For example, has WIPP escaped the scrutiny and centralized controls that DOE applies to other entities?  As a consequence, has WIPP had too much autonomy to adjust its behavior to match its perception of the task environment?  Are DOE’s and WIPP’s mental models of the task environment similar or even adequate?  Perhaps WIPP (and possibly DOE) see the task environment as simpler than it actually is, and therefore the strategies for handling the environment lack requisite variety.  Was there an assumption that NWP would continue the apparently satisfactory performance of the previous contractor?  It's obvious these questions do not specifically address SC but they seek to ascertain how the organizations involved are actually functioning, and SC is an important variable in the overall system.

Contrast with Other DOE SC Investigations 

This report presents a sharp contrast to the foot-dragging that takes place elsewhere in DOE.  Why can’t DOE bring a similar sense of urgency to the SC investigations it is supposed to be conducting at its other facilities?  Was the WIPP incident that big a deal (because it involved a radioactive release) or is it merely something that DOE can wrap its head around?  (After all, WIPP is basically an underground warehouse.)  In any event, something rang DOE’s bell because they quickly assembled a 5 member board with 16 advisor/consultants and produced a 300 page report in less than two months.*****

Bottom line: You don't need to pore over this report but it provides some perspective on how DOE views SC and demonstrates that a giant agency can get moving if it's motivated to do so.


*  DOE Office of Environmental Management, “Accident Investigation Report: Radiological Release Event at the Waste Isolation Pilot Plant on February 14, 2014, Phase 1” (April 2014).  Retrieved April 30, 2014.  Our thanks to Mark Lyons who posted this report on the LinkedIn Nuclear Safety group discussion board.

**  NWP LLC was formed by URS Energy and Construction, Inc. and Babcock & Wilcox Technical Services Group, Inc.  Their major subcontractor is AREVA Federal Services, LLC.  All three firms perform work at other, i.e., non-WIPP, DOE facilities.  NWP assumed management of WIPP on Oct. 1, 2012.  From NWP website.  Retrieved May 2, 2014.

***  To the Board's credit, they did not go looking for individual scapegoats to blame for WIPP's difficulties.

****  In fairness, the report has at least one example of a feedback loop in the CBFO-NWP sub-system: CBFO's use of the condition reports as an input to NWP’s compensation review and NWP's predictable reaction of creating fewer condition reports.

*****  The Accident Investigation Board was appointed on Feb. 27, 2014 and completed its Phase 1 investigation on March 28, 2014.  The Phase 1 report was released to the public on April 22, 2014.

Our Gaze Returns to DOE and its Safety Culture

The Department of Energy (DOE) recently submitted a report* to the Defense Nuclear Facilities Safety Board (DNFSB) covering DOE’s evaluation of Safety Conscious Work Environment (SCWE) self-assessments at various DOE facilities.  This evaluation was included in the DOE’s Implementation Plan** (IP) developed in response to the DNFSB report, Safety Culture at the Waste Treatment and Immobilization Plant.*** (WTP, or the Vit Plant).  This post provides some background on how WTP safety culture (SC) problems led to a wider assessment of SC in DOE facilities and then reviews the current report.

Background

The DNFSB report on the WTP was issued June 9, 2011; it said the WTP SC was “flawed.”  Issues included discouraging technical dissent, goal conflicts between schedule/budget and safety, and intimidation of personnel.  We posted on the DNFSB report June 15, 2011.  The report’s recommendations included this one: that the Secretary of Energy “conduct an Extent of Condition Review to determine whether these safety culture weaknesses are limited to the WTP Project, . . .” (DNFSB, p. 6) 

After some back-and-forth between DOE and DNFSB, DOE published their IP in December 2011.  We reviewed the IP on Jan. 24, 2012.  Although the IP contained multiple action items, our overall impression was “that DOE believes there is no fundamental safety culture issue. . . . While endlessly citing all the initiatives previously taken or underway, never does the DOE reflect on why these initiatives have not been effective to date.”  So we were not exactly optimistic but DOE did say it would “conduct an Extent of Condition Review to find out whether similar safety culture weaknesses exist at other sites in addition to the WTP and whether there are barriers to strong safety culture at Headquarters and the Department as a whole (e.g., policies or implementation issues). The review will focus on the Safety Conscious Work Environment (SCWE) at each site examined.” (IP, p. 17)  In other words, SC was reduced to SCWE from the get-go.****

Part of the DOE review was to assess SCWE at a group of selected DOE facilities.  DOE submitted SC assessments covering five facilities to DNFSB on Dec. 12, 2012.  We reviewed the package in our post Jan. 25, 2013 and observed “The DOE submittal contained no meta-analysis of the five assessments, and no comparison to Vit Plant concerns.  As far as [we] can tell, the individual assessments made no attempt to focus on whether or not Vit Plant concerns existed at the reviewed facilities.”  We called the submittal “foot dragging” by DOE.

Report on SCWE Self-Assessments

A related DOE commitment was to perform SCWE self-assessments at numerous DOE facilities and then evaluate the results to determine if SCWE issues similar to WTP’s existed elsewhere.  It is important to understand that this latest report is really only the starting point for evaluating the self-assessments because it focuses on the processes used during the self-assessments and not the results obtained. 

The evaluation of the self-assessments was a large undertaking.  The evaluation team visited 22 DOE and contractor organizations and performed document reviews for 9 additional organizations, including the DOE Office of River Protection and Bechtel National, major players in the WTP drama. 

Problems abounded.  Self-assessment guidance was prepared but not distributed to all sites in a timely manner and there was no associated training.  Each self-assessment team had a “subject matter expert” but the qualifications for that role were not specified.  Data collection methods were not consistently applied and data analyses were of variable quality.  As a consequence, the self-assessment approaches used varied widely and the results obtained had variable reliability.

The self-assessment reports exhibited varying quality.  Some were satisfactory but “In many of the self-assessment reports, the overall conclusions did not accurately reflect the information in the data and analysis sections. In some cases, negative results were presented with a statement rationalizing or minimizing the issue, rather than indicating a need to find out more about the issue and resolve it.  In other cases, although data and/or analysis reflected potential problems, those problems were not mentioned in the conclusions or executive summaries, which senior management is most likely to read.” (p. 7)

The evaluation team summarized as follows: “The overall approach ultimately used to self-assess SCWE across the complex did not provide for consistent application of assessment methodologies and was not designed to ensure validity and credibility. . . . The wide variation in the quality of methodologies and analysis of results significantly reduces the confidence in the conclusions of many of the self-assessments.  Consequently, caution should be used in drawing firm conclusions about the state of SCWE or safety culture across the entire DOE complex based on a compilation of results from all the site self-assessments.” (p. iii)

“The Independent Oversight team concluded that DOE needs to take additional actions to ensure that future self-assessments provide a valid and accurate assessment of the status of the safety culture at DOE sites and organizations, . . .” (p. 8)  This is followed by a series of totally predictable recommendations for process improvements: “enhance guidance and communications,” increase management “involvement in, support for, and monitoring of site self-assessments,” and “DOE sites . . . should increase their capabilities to perform self-assessments . . .” (pp. 9-10)

Our Perspective

The steps taken to date do not inspire confidence in the DOE’s interest in determining if and what SCWE (much less more general SC) issues exist in the DOE complex.  For the facilities that were directly evaluated, we have some clues to the existence similar problems.  For the facilities that conducted self-assessments, so far we have—almost nothing.

There is one big step remaining: DOE also said it would “develop a consolidated report from the results of the self-assessments and HSS independent reviews.” (IP, p. 20)  We await that report with bated breath.

For our U.S. readers: This is your tax dollars at work. 


*  DOE Office of Enforcement and Oversight, “Independent Oversight Evaluation of Line Self-Assessments of Safety Conscious Work Environment” (Feb. 2014).

**  U.S. Dept. of Energy, “Implementation Plan for Defense Nuclear Facilities Safety Board Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant”  (Dec. 2011).

***  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).

****  DOE rationalized reducing the scope of investigation from SC to SCWE by saying “The safety culture issues identified at WTP are primarily SCWE issues. . .” (p. 17)  We posted a lecturette about SC being much more than SCWE here.

A New Sheriff Coming to DOE?

On April 9th, the nominee for Secretary of Energy, Dr. Ernest Moniz, appeared before the Senate Committee on Energy and Natural Resources.  Most of the three hour hearing was in a Q&A format, with the committee chairman showing special interest in the major problems at Hanford, viz., leaking waste storage tanks and explosive hydrogen accumulation in same, the Waste Treatment Plant (aka Vit Plant) project and the site safety culture (SC).*

With respect to the SC issue, the nominee said it was “unacceptable” for SC to not be where it needs to be.  In response to a question from the committee chairman, Dr. Moniz said he was willing to meet with Vit Plant whistleblowers.  Depending on the outcome of such a meeting, if it occurs, the new Secretary could send a powerful signal to the Hanford site and beyond about his views on SC, Differing Professional Opinion (and related) practices, a Safety Conscious Work Environment and retaliation against employees who question organizational decisions.


*  The meeting video is available here, Hanford is discussed from about 3:05 to 3:20. 

A letter from the DNFSB chairman provides a good summary of the key issues at Hanford.  See P.S. Winokur (DNFSB) to R.L. Wyden (chairman of the Senate Committee on Energy and Natural Resources), letter providing the DNFSB's perspective on the state of nuclear safety at the Hanford Site (April 1, 2013).