Nuclear Safety Culture: The Threat of Bureaucratization

We recently read Sidney Dekker’s 2014 paper* on the bureaucratization of safety in organizations.  It’s interesting because it describes a very common evolution of organizational practices, including those that affect safety, as an organization or industry becomes more complicated and formal over time.  Such evolution can affect many types of organizations, including nuclear ones.  Dekker’s paper is summarized below, followed by our perspective on it. 

The process of bureaucratization is straightforward; it involves hierarchy (creating additional layers of organizational structure), specialized roles focusing on “safety related” activities, and the application of rules for defining safety requirements and the programs to meet them.  In the safety space, the process has been driven by multiple factors, including legislation and regulation, contracting and the need for a uniform approach to managing large groups of organizations, and increased technological capabilities for collection and analysis of data.

In a nutshell, bureaucracy means greater control over the context and content of work by people who don’t actually have to perform it.  The risk is that as bureaucracy grows, technical expertise and operational experience may be held in less value.

This doesn’t mean bureaucracy is a bad thing.  In many environments, bureaucratization has led to visible benefits, primarily a reduction in harmful incidents.  But it can lead to unintended, negative consequences including:

• Myopic focus on formal performance measures (often quantitative) and “numbers games” to achieve the metrics and, in some cases, earn financial bonuses,
• An increasing inability to imagine, much less plan for, truly novel events because of the assumption that everything bad that might happen has already been considered in the PRA or the emergency plan.  (Of course, these analyses/documents are created by siloed specialists who may lack a complete understanding of how the socio-technical system works or what might actually be required in an emergency.  Fukushima anyone?),
• Constraints on organizational members’ creativity and innovation, and a lack of freedom that can erode problem ownership, and
• Interest, effort and investment in sustaining, growing and protecting the bureaucracy itself.
  

Our Perspective

We realize reading about bureaucracy is about as exciting as watching a frog get boiled.  However, Dekker does a good job of explaining how the process of bureaucratization takes root and grows and the benefits that can result.  He also spells out the shortcomings and unintended consequences that can accompany it.

The commercial nuclear world is not immune to this process.  Consider all the actors who have their fingers in the safety pot and realize how few of them are actually responsible for designing, maintaining or operating a plant.  Think about the NRC’s Reactor Oversight Process (ROP) and the licensees’ myopic focus on keeping a green scorecard.  Importantly, the Safety Culture Policy Statement (SCPS) being an “expectation” resists the bureaucratic imperative to over-specify.  Instead, the SCPS is an adjustable cudgel the NRC uses to tap or bludgeon wayward licensees into compliance.  Foreign interest in regulating nuclear safety culture will almost certainly lead to its increased bureaucratization.  

Bureaucratization is clearly evident in the public nuclear sector (looking at you, Department of Energy) where contractors perform the work and government overseers attempt to steer the contractors toward meeting production goals and safety standards.  As Dekker points out, managing, monitoring and controlling operations across an organizational network of contractors and sub-contractors tends to be so difficult that bureaucratized accountability becomes the accepted means to do so.

We have presented Dekker’s work before, primarily his discussion of a “just culture” (reviewed Aug. 3, 2009) that tries to learn from mishaps rather than simply isolating and perhaps punishing the human actor(s) and “drift into failure” (reviewed Dec. 5, 2012) where a socio-technical system can experience unacceptable performance caused by systemic interactions while functioning normally.  Stakeholders can mistakenly believe the system is completely safe because no errors have occurred while in reality the system can be slipping toward an incident.  Both of these attributes should be considered in your mental model of how your organization operates.

Bottom line: This is an academic paper in a somewhat scholarly journal, in other words, not a quick and easy read.  But it’s worth a look to get a sense of how the tentacles of formality can wrap themselves around an organization.  In the worse case, they can stifle the capabilities the organization needs to successfully react to unexpected events and environmental changes.


*  S.W.A. Dekker, “The bureaucratization of safety,” Safety Science 70 (2014), pp. 348–357.  We saw this paper on Safety Differently, a website that publishes essays on safety.  Most of the site’s content appears related to industries with major industrial safety challenges, e.g., mining.

Learning About Nuclear Safety Culture from the Web, Maybe

The Internet  Source:Wikipedia

We’ve come across some Internet content (one website, one article) that purports to inform the reader about nuclear safety culture (NSC).  This post reviews the content and provides our perspective on its value.

NSC Website

It appears the title of this site is “Nuclear Safety Culture”* and the primary target is journalists who want an introduction to NSC concepts, history and issues.  It is a product of a group of European entities.  It is a professional looking site that covers four major topics; we’ll summarize them in some detail to show their wide scope and shallow depth. 

Nuclear Safety Culture covers five sub-topics:

History traces the shift in attitudes toward and protection from ionizing radiation as the possible consequences became better known but the story ends in the 1950s.  Key actions describe the roles of internal and external stakeholders during routine operations and emergency situations.  The focus is on power production although medicine, industrial uses and weapons are also mentioned.  Definition of NSC starts with INSAG (esp. INSAG-4), then adds INPO’s directive to emphasize safety over competing goals, and a familiar list of attributes from the Nuclear Safety Journal.  As usual, there is nothing in the attributes about executive compensation or the importance of a systems view.  IAEA safety principles are self explanatory.  Key scientific concepts cover the units of radiation for dose, intake and exposure.  Some values are shown for typical activities but only one legal limit, for US airport X-rays, is included.**  There is no information in this sub-topic on how much radiation a person can tolerate or the regulatory limits for industrial exposure.

From Events to Accidents has two sub-topics:

From events to accidents describes the 7-level International Nuclear Event Scale (from a minor anomaly to major accident) but the scale itself is not shown.  This is a major omission.  Defence in depth discusses this important concept but provides only one example, the levels of physical protection between a fuel rod in a reactor and the environment outside the containment.

Controversies has two sub-topics:

Strengths and Weaknesses discuss some of the nuclear industry’s issues and characteristics: industry transparency is a double-edge sword, where increased information on events may be used to criticize a plant owner; general radiation protection standards for the industry; uncertainties surrounding the health effects of low radiation doses; the usual nuclear waste issues; technology evolution through generations of reactors; stress tests for European reactors; supply chain realities where a problem anywhere is used against the entire industry; the political climate, focusing on Germany and France; and energy economics that have diminished nuclear’s competitiveness.  Overall, this is a hodgepodge of topics and a B- discussion.  The human factor provides a brief discussion of the “blame culture” and the need for a systemic view, followed by summaries of the Korean and French document falsification events.

Stories summarizes three events: the Brazilian theft of a radioactive source, Chernobyl and Fukushima.  They are all reported in an overly dramatic style although the basic facts are probably correct.

The authors describe what they call the “safety culture breach” for each event.  The problem is they comingle overarching cultural issues, e.g., TEPCO’s overconfident management, with far more specific failures, e.g., violations of safety and security rules, and consequences of weak NSC, e.g., plant design inadequacies.  It makes one wonder if the author(s) of this section have a clear notion of what NSC is.

It isn’t apparent how helpful this site will be for newbie journalists, it is certainly not a complete “toolkit.”  Some topics are presented in an over-simplified manner and others are missing key figures.  In terms of examples, the site emphasizes major accidents (the ultimate trailing indicators) and ignores the small events, normalization of deviance, organizational drift and other dynamics that make up the bulk of daily life in an organization.  Overall, the toolkit looks a bit like a rush job or unedited committee work, e.g., the section on the major accidents is satisfactory but others are incomplete.  Importantly (or perhaps thankfully) the authors offer no original observations or insights with respect to NSC.  It’s worrisome that what the site creators call NSC is often just the safety practices that evolved as the hazards of radiation became better known. 

NSC Article

There is an article on NSC in the online version of Power magazine.  We are not publishing a link to the article because it isn’t very good; it looks more like a high schooler’s Internet-sourced term paper than a thoughtful reference or essay on NSC.

However, like the stopped clock that shows the correct time twice per day, there can be a worthwhile nugget in such an article.  After summarizing a research paper that correlated plants’ performance indicators with assessments of their NSC attributes (which paper we reviewed on Oct. 5, 2014), the author says “There are no established thresholds for determining whether a safety culture is “healthy” or “unhealthy.””  That’s correct.  After NSC assessors consolidate their interviews, focus groups, observations, surveys and document reviews, they always identify some improvement opportunities but the usual overall grade is “pass.”***  There’s no point score, meter or gauge.  Perhaps there should be.

Our Perspective

Don’t waste your time with pap.  Go to primary sources; an excellent starting point is the survey of NSC literature performed by a U.S. National Laboratory (which we reviewed on Feb. 10, 2013.)  Click on our References label to get other possibilities and follow folks who actually know something about NSC, like Safetymatters.


*  Nuclear Safety Culture was developed as part of the NUSHARE project under the aegis of the European Nuclear Education Network.   Retrieved June 19, 2017.

**  The airport X-ray limit happens to be the same as the amount of radiation emitted by an ordinary banana.

***  A violation of the Safety Conscious Work Environment (SCWE) regulations is quite different.  There it’s zero tolerance and if there’s a credible complaint about actual retaliation for raising a safety issue, the licensee is in deep doo-doo until they convince the regulator they have made the necessary adjustments in the work environment.

A Nordic Compendium on Nuclear Safety Culture

A new research paper* covers the challenges of establishing and improving nuclear safety culture (NSC) in a dynamic, i.e., project, environment.  The authors are Finnish and Swedish and it appears the problems of the Olkiluoto 3 plant inform their research interests.  Their summary and review of current NSC literature is of interest to us. 

They begin with an overall description of how organizational (and cultural) changes can occur in terms of direction, rate and scale.

Direction

Top-down (or planned) change relies on the familiar unfreeze-change-refreeze models of Kurt Lewin and Ed Schein.  Bottom-up (or emergent) change emphasizes self-organization and organizational learning.  Truly free form, unguided change leads to NSC being an emergent property of the organization.  As we know, the top-down approach is seldom, if ever, 100% effective because of frictional losses, unintended consequences or the impact of competing, emergent cultural currents.  In a nod to a systems perspective, the authors note organizational structures and behavior influence (and are influenced by) culture.

Rate

“Organizational change can also be distinguished by the rate of its occurrence, i.e, whether the change occurs abruptly or smoothly [italics added].” (p. 8)  We observe that most nuclear plants try to build on past success, hence they promote “continuous improvement” programs that don’t rattle the organization.  In contrast, a plant with major NSC problems sometimes receives shock treatment, often in the form of a new senior manager who is expected to clean things up.  New management systems and organizational structures can also cause abrupt change.

Scale

The authors identify four levels of change.  Most operating plants exhibit the least disruptive changes, called fine tuning and incremental adjustment.  Modular transformation attempts to change culture at the department level; corporate transformation is self-explanatory. 

The authors sound a cautionary note: “the more radical types of changes might not be easily initiated – or might not even be feasible, considering that safety culture is by nature a slowly and progressively changing phenomenon. The obvious condition where a safety-critical organization requires radical changes to its safety culture is when it is unacceptably unhealthy.” (p. 9)

Culture Change Strategies

The authors list seven specific strategies for improving NSC:

• Change organizational structures,
• Modify the behavior of a target group through, e.g. incentives and positive reinforcement,
• Improve interaction and communication to build a shared culture,
• Ensure all organizational members are committed to safety and jointly participate in its improvement,
• Training,
• Promote the concept and importance of NSC,
• Recruit and select employees who will support a strong NSC.

This section includes a literature review for examples of the specific strategies.

Project Organizations

The nature of project organizations is discussed in detail including their time pressures, wide use of teams, complex tasks and a context of a temporary organization in a relatively permanent environment.  The authors observe that “in temporary organisations, the threat of prioritizing “production” over safety may occur more naturally than in permanent organizations.” (pp. 16-17)  Projects are not limited to building new plants; as we have seen, large projects (Crystal River containment penetration, SONGS steam generator replacement) can kill operating plants.

The balance of the paper covers the authors’ empirical work.

Our Perspective 

This is a useful paper because it provides a good summary of the host of approaches and methods that have been (and are being) applied in the NSC space.  That said, the authors offer no new insights into NSC practice.

Although the paper’s focus is on projects, basically new plant construction, people responsible for fixing NSC at problem plants, e.g., Watts Bar, should peruse this report for lessons they can apply that might help achieve the step function NSC improvements such plants need.


*  K.Viitanen, N. Gotcheva and C. Rollenhagen, “Safety Culture Assurance and Improvement Methods in Complex Projects – Intermediate Report from the NKS-R SC AIM” (Feb. 2017).  Thanks to Aili Hunt of the LinkedIn Nuclear Safety Culture group for publicizing this paper.

Totally Nude, Naked Nuclear Safety Culture

I admit it.  The title is a cheap April Fools trick to draw new, perhaps less conventional, visitors to Safetymatters.  The only thing you’ll see here is the naked truth about nuclear safety culture (NSC), which we have been preaching about for years.

We’ve repeatedly listed the ingredients for a strong NSC: decision-making that recognizes goal conflicts and establishes clear, consistent safety priorities; an effective corrective action program; a mental model of organizational functioning that considers interrelationships and feedback loops among key variables; a compensation plan that rewards safety performance; and leadership that walks the talk on NSC.

We’ve also said that, absent constant maintenance, NSC will invariably decay over time because of complacency and system dynamics.  Complacency leads to hubris (“It can’t happen here”) and opens the door for the drift toward failure that occurs with normalization of deviance and group think.  System dynamics include constant environmental adaptations, goal conflicts, shifting priorities, management incentives tilted toward production and cost achievements, and changing levels of intra-organizational trust. 

NSC in practice appears to have approached an asymptote to the ideal.  Problems still occur; currently Entergy, TVA and AREVA are in the hot seat.  We have to ask: Is the industry’s steady-state NSC a low-intensity war of Whac-a-Mole?  You be the judge.

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.

Nuclear Safety Culture at the Department of Energy—An Update

We haven’t reported on the U.S. Department of Energy’s (DOE) safety culture (SC) in awhile.  Although there hasn’t been any big news lately, we can look at some individual facts and then connect the dots to say something about SC.

Let’s start with some high-level good news.  In late 2016 DOE announced it had conducted its 100th SC training class for senior leaders of both federal and contractor entities across the DOE complex.*  The class focuses on teaching leaders the why and how of maintaining a collaborative workplace and Safety Conscious Work Environment (SCWE), and fostering trust in the work environment. 

Now let’s turn to a more localized situation.  In Feb 2014, a storage drum burst at the DOE’s Waste Isolation Pilot Plant (WIPP) in New Mexico, resulting in a small release of radioactive material.  The drum burst because a sorbent added to the waste had been changed without considering the difference in chemical properties.**  This has been an expensive incident.  The plant has been closed for over three years; it was authorized to reopen in Jan 2017 and shipments are scheduled to resume in April 2017.*** 

The drum that burst came from the Los Alamos National Laboratory (LANL).  The WIPP Recovery Plan envisions continuing the pre-incident practice of the waste generators being responsible for correctly packing their waste: “All waste generators will have rigorous characterization, treatment, and packaging processes and procedures in place to ensure compliance with WIPP Waste Acceptance Criteria [WAC].”****  As we said in our May 3, 2016 post: “For this approach to work, WAC compliance by the waste generators . . . must be completely effective and 100% reliable.”  In the same post, we reported the Defense Nuclear Facilities Safety Board (DNFSB) had recognized this weak link in the chain.  However, because DNFSB cannot force changes it could only recommend that DOE “explore defense-in-depth measures that enhance WIPP’s capability to detect and respond to problems caused by unexpected failures in the WAC compliance program.”

As described in the current WAC, WIPP’s “defense-in-depth” appears to be limited to the local DOE office and the WIPP contractor performing Generator Site Technical Reviews, which cover sites’ implementation of WIPP requirements.*****  These reviews are supposed to assure that deficiencies are detected and noncompliant shipments are avoided but it’s not clear if any physical surveillance is involved or if this is strictly a paperwork exercise.

The foregoing is important because it ties to SC.  Firstly, WIPP has had SC issues, in fact, a deficient SC was identified as contributing to shortcomings in the handling of the aftermath of the drum explosion.  (We reviewed this in detail on May 3 and May 5, 2014.)  WIPP SC is supposedly better now: “NWP [the WIPP contractor] has made continuous improvements in their safety culture and has really embraced the recommendations provided in the 2015 review, as well as subsequent reviews and surveys.”^  Secondly, other SC problems, too myriad to even list here, have arisen throughout the DOE complex over the years.  (Click on the DOE label to see our reports on such problems.)

Finally, we present a recent data point for LANL.  In DOE’s report on criticality safety infractions and program non-compliances for FY 2016, LANL had the most such incidents, by far, of the DOE’s 24 sites and projects.^^  Most of the non-compliances were self-identified.  Now does this evidence a strong SC that recognizes and reports its problems or a weak SC that allows the problems to occur in the first place?  You be the judge.

Our Perspective

Through initiatives such as SC training, it appears that at the macro level, DOE is (finally) communicating that minimally complying with basic regulations for how organizations should treat employees is not enough; establishing trust, mainly through showing respect for employees’ efforts to raise safety questions and point out safety problems, is essential.  That’s a good thing.

But we see signs of weakness at the operational level, viz., between WIPP and its constellation of waste generators.  Although we are not fans of “Normal Accident” theory which says accidents are inevitable in tightly coupled, low slack environments, e.g., a nuclear power plant, we can appreciate the application of that mental model in the case of WIPP.  Historically, one feature of the DOE complex that has limited problems to specific locations is the weak coupling between facilities.  When every facility with bomb-making waste is shipping it to WIPP, tighter coupling is created in the overall waste management system.  Every waste generator’s SC can have an impact on WIPP’s safety performance.  The system does need more defense-in-depth.  At a minimum, WIPP should station resident inspectors at every waste generator site to verify compliance with the WAC.

Bottom line: DOE is trying harder in the SC space but their history does not inspire huge confidence going forward. 


*  “DOE Conducts 100th Safety Culture Training Class” (Dec. 29, 2016).

**  Organic kitty litter had been substituted for inorganic kitty litter.  See this Jan. 10, 2017 Forbes article for a good summary of the WIPP incident.

***  “WIPP Road Show Early Stops Planned in Carlsbad & Hobbs,” WIPP website (Feb. 27, 2017).  Retrieved March 7, 2017. 

****  DOE, “Waste Isolation Pilot Plant Recovery Plan,” Rev 0 (Sept. 30, 2014), p. 24.

*****  DOE, “Transuranic Waste Acceptance Criteria for the Waste Isolation Pilot Plant,” Rev 8.0 (July 5, 2016), pp. 20-21.

^  DOE, “Department of Energy Operational Readiness Review for the Waste Isolation Pilot Plant” (Dec. 2016), p. 33.

^^   DOE, “2016 Annual Metrics Report to the Defense Nuclear Facilities Safety Board – Nuclear Criticality Safety Programs” (Jan. 2017), p. 3.

Is TEPCO’s Nuclear Safety Culture Still Weak?

Cover of TEPCO Self-Assessment

Tokyo Electric Power Co. (TEPCO) recently conducted a self-assessment* (SA) to ascertain progress vis-à-vis the goals in their Nuclear Safety Reform Plan.  The SA covered both Fukushima Daiichi and the undamaged plants.  It was approved by TEPCO’s president and reported to the Nuclear Reform Monitoring Committee (NRMC), an independent group of experts that advises TEPCO’s board of directors.  The committee reviewed the SA and communicated their evaluation to the board.  This post reviews both the SA and committee documents focusing on findings and observations related to safety culture (SC).

The TEPCO Self-Assessment

Comments with actual or potential relevance for culture appear throughout the 20-page SA report and are summarized below.  It appears about half of the SA findings and concrete action plans could have some connection to organizational culture.

Scores of employees have received awards for achieving goals related to stronger nuclear safety culture (NSC) and senior managers have been emphasizing nuclear safety but weaknesses still exist in implementing all the traits of a strong NSC.  Unsafe behaviors with respect to industrial safety are being corrected and the need for stronger nuclear safety is being established.  However, communications to the worker level with respect to nuclear safety may be insufficient.  The importance of nuclear safety is emphasized in new employee training and in meetings with contractor representatives. (pp. 4-5)  This is a mixed bag in the part of the SA most likely to be concerned with SC, viz., “Management Reforms Prioritizing Nuclear Safety.”

The company is working on strengthening work processes to improve risk management but employees report processes are unchanged and no clear priorities are established, factors that may increase fatigue and decrease motivation, both of which challenge the development of NSC. (p. 6)

Stricter safety regulations are being implemented and are no longer resisted based on their cost or operating impact. At Fukushima, the emphasis when performing work has shifted from speed to risk reduction to proceed safely. (pp. 8-9)  All good news.

Daily meetings share information on operating experience and near-misses but the overall information set is not leveraged because it is not managed to lead to long-term improvements. (p. 10)  In other words, continuous improvement is still a goal, not a reality.

Training is good for teaching employees how to complete tasks but the curriculum is insufficient to cultivate and inculcate a high level of safety performance.  The need for a more systematic approach to training is recognized but has not been realized. (pp. 12-13)

Overall findings of the SA emphasize the need to enhance a questioning attitude, strengthen supervision, and upgrade education and training. (p. 20)

NRMC Report and Cover Letter

The NRMC reviewed the SA in a 7-page report.**  One improvement noted by the NRMC was “Safety culture awareness has permeated throughout the organization and has improved significantly.”  However, the first three items on the list of nine Recommendations deal with NSC:

“Consistent efforts should be made to build a strong nuclear safety culture and instill the nuclear safety culture in an organizational culture.  The need for formal training and/or professional facilitation for the managers should be evaluated to instill a strong safety culture in the organization. . . . a safety culture program should be developed to the same standards” for contractors. (p. 5) 

There is also a one-page cover letter to the report.  Its primary focus is SC:

“TEPCO has made significant progress but must not become complacent . . . . TEPCO should instill . . . a strong safety culture throughout the organization, . . . TEPCO is encouraged to take further actions for the safety culture alignment at all levels of the organization . . .”

Our Perspective

SC and NSC occupy much of the space in all these documents.  What should we make of that, if anything?  One possibility is SC is acceptable but can always be improved or strengthened.  After all, as the NRMC notes “any self-assessment process must be critical by nature and therefore should identify areas for future improvement.”

A darker possibility is that TEPCO’s SC is still weak.  The NRMC’s report doesn’t have the language we usually see in the typical U.S. NSC report which says or implies “The plant is operating safely (indicating the NSC is at least minimally acceptable) but has improvement opportunities.”  We have to ask the NRMC: Is TEPCO’s current NSC acceptable or not?  Everyone understands Fukushima Daiichi is not operating, in fact, it’s still a mess where finding a lost fuel rod is world-wide news, but are current clean-up efforts occurring in an adequately safety-conscious environment?  The disaster occurred in 2011; some of the shortcomings noted in the SA should have been squared away by now.

On a different note, how does the SA address some topics dear to us?  Goal conflict is addressed when safety is mentioned as the primary goal and improvements are being made without cost being a major consideration.  The corrective action program (CAP) is mentioned but only as a tool for implementing improvement in the operating experience program.  Decision making is not mentioned at all so we don’t know how safety is being integrated into the decision making process at any level.  Another mixed bag.

Bottom line: Is SC front and center in all these documents because it is not yet acceptable?


*  “Report on TEPCO’s Self-Assessment of Progress” (Jan. 2017).

**  Nuclear Reform Monitoring Committee, “Review of the TEPCO’s Self-Assessment Effort on Nuclear Safety Reform,” (Jan. 30, 2017).

***  Nuclear Reform Monitoring Committee, Cover letter to "Review of the TEPCO's Self-Assessment Effort on Nuclear Safety Reform," (Jan. 30, 2017).  The public versions of all these TEPCO documents are copy protected so quotes have been retyped.

Nuclear Safety Culture and the Shrinking U.S. Nuclear Plant Population

In the last few years, nuclear plant owners have shut down or scheduled for shutdown 17 units totaling over 14,000 MW.  Over half of these units had (or have) nuclear safety culture (NSC) issues sufficiently noteworthy to warrant mention here on Safetymatters.  We are not saying that NSC issues alone have led to the permanent shutdown of any plant, but such issues often accompany poor decision-making that can hasten a plant’s demise.  Following is a roll call of the deceased or endangered plants.

Plants with NSC issues

NSC issues provide windows into organizational behavior; the sizes of issues range from isolated problems to systemic weaknesses.

FitzPatrick

This one doesn’t exactly belong on the list.  Entergy scheduled it for shutdown in Jan. 2017 but instead it will likely be purchased by a white knight, Exelon, in a transaction brokered by the governor of New York.  With respect to NSC, in 2012 FitzPatrick received a Confirmatory Order (CO) after the NRC discovered violations, the majority of which were willful, related to adherence to site radiation protection procedures. 

Fort Calhoun

This plant shut down on Oct. 24, 2016.  According to the owner, the reason was “market conditions.”  It’s hard for a plant to be economically viable when it was shut down for over two years because of scheduled maintenance, flooding, a fire and various safety violations.  The plant kept moving down the NRC Action Matrix which meant more inspections and a third-party NSC assessment.  A serious cultural issue was how the plant staff’s perception of the Corrective Action Program (CAP) had evolved to view the CAP as a work management system rather than the principal way for the plant to identify and fix its problems.  Click on the Fort Calhoun label to pull up our related posts.

Indian Point 2 and 3

Units 2 and 3 are scheduled to shut down in 2020 and 2021, respectively.  As the surrounding population grew, the political pressure to shut them down also increased.  A long history of technical and regulatory issues did not inspire confidence.  In NSC space, they had problems with making incomplete or false statements to the NRC, a cardinal sin for a regulated entity.  The plant received a Notice of Violation (NOV) in 2015 for providing information about a licensed operator's medical condition that was not complete and accurate; they received a NOV in 2014 because a chemistry manager falsified test results.  Our May 12, 2014 post on the latter event is a reader favorite. 

Palisades

This plant had a long history of technical and NSC issues.  It is scheduled for shutdown on Oct. 1, 2018.  In 2015 Palisades received a NOV because it provided information to the NRC that was not complete and accurate; in 2014 it received a CO because a security manager assigned a person to a role for which he was not qualified; in 2012 it received a CO after an operator left the control room without permission and without performing a turnover to another operator.  Click on the Palisades label to pull up our related posts.

Pilgrim

This plant is scheduled for shutdown on May 31, 2019.  It worked its way to column 4 of the Action Matrix in Sept. 2015 and is currently undergoing an IP 95003 inspection, including an in-depth evaluation of the plant’s CAP and an independent assessment of the plant’s NSC.  In 2013, Pilgrim received a NOV because it provided information to the NRC that was not complete and accurate; in 2005 it received a NOV after an on-duty supervisor was observed sleeping in the control room.

San Onofre 2 and 3

These units ceased operations on Jan. 1, 2012.  The proximate cause of death was management incompetence: management opted to replace the old steam generators (S/Gs) with a large, complex design that the vendor had never fabricated before.  The new S/Gs were unacceptable in operation when tube leakage occurred due to excessive vibrations.  NSC was never anything to write home about either: the plant was plagued for years by incidents, including willful violations, and employees claiming they feared retaliation if they reported or discussed such incidents.

Vermont Yankee

This plant shut down on Dec. 29, 2014 ostensibly for “economic reasons” but it had a vociferous group of critics calling for it to go.  The plant evidenced a significant NSC issue in 2009 when plant staff parsed an information request to the point where they made statements that were “incomplete and misleading” to state regulators about tritium leakage from plant piping.  Eleven employees, including the VP for operations, were subsequently put on leave or reprimanded.  Click on the Vermont Yankee label to pull up our related posts.

Plant with no serious or interesting NSC issues 

The following plants have not appeared on our NSC radar in the eight years we’ve been publishing Safetymatters.  We have singled out a couple of them for extremely poor management decisions.

Crystal River basically committed suicide when they tried to create a major containment penetration on their own and ended up with a delaminating containment.  It ceased operations on Sept. 26, 2009.

Kewaunee shut down on May 7, 2013 for economic reasons, viz., the plant owner apparently believed their initial 8-year PPA would be followed by equal or even higher prices in the electricity market.  The owner was wrong.

Rounding out the list, Clinton is scheduled to shut down June 1, 2017; Diablo Canyon 1 and 2 will shut down in 2024 and 2025, respectively; Oyster Creek is scheduled to shut down on June 1, 2019; and Quad Cities 1 and 2 are scheduled to shut down on June 1, 2018 — all for business reasons.

Our Perspective

Bad economics (low natural gas prices, no economies of scale for small units) were the key drivers of these shutdown decisions but NSC issues and management incompetence played important supporting roles.  NSC problems provide ammunition to zealous plant critics but, more importantly, also create questions about plant safety and viability in the minds of the larger public.

Reflections on Nuclear Safety Culture for the New Year

©iStockphoto.com

The start of a new year is an opportunity to take stock of the current situation in the U.S. nuclear industry and reiterate what we believe with respect to nuclear safety culture (NSC).

For us, the big news at the end of 2016 was Entergy’s announcement that Palisades will be shutting down on Oct. 1, 2018.*  Palisades has been our poster child for a couple of things: (1) Entergy’s unwillingness or inability to keep its nose clean on NSC issues and (2) the NRC’s inscrutable decision making on when the plant’s NSC was either unsatisfactory or apparently “good enough.”

We will have to find someone else to pick on but don’t worry, there’s always some new issue popping up in NSC space.  Perhaps we will go to France and focus on the current AREVA and Électricité de France imbroglio which was cogently summarized in a Power magazine editorial: “At the heart of France’s nuclear crisis are two problems.  One concerns the carbon content of critical steel parts . . . manufactured or supplied by AREVA . . . The second problem concerns forged, falsified, or incomplete quality control reports about the critical components themselves.”**  Anytime the adjectives “forged” or “falsified” appear alongside nuclear records, the NSC police will soon be on the scene.  

Why do NSC issues keep arising in the nuclear industry?  If NSC is so important, why do organizations still fail to fix known problems or create new problems for themselves?  One possible answer is that such issues are the occasional result of the natural functioning of a low-tolerance, complex socio-technical system.  In other words, performance may drift out of bounds in the normal course of events.  We may not be able to predict where such issues will arise (although the missed warning signals will be obvious in retrospect) but we cannot reasonably expect they can be permanently eliminated from the system.  In this view, an NSC can be acceptably strong but not 100% effective.

If they are intellectually honest, this is the implicit mental model that most NSC practitioners and “experts” utilize even though they continue to espouse the dogma that more engineering, management, leadership, oversight, training and sanctions can and will create an actual NSC that matches some ideal NSC.  But we’ve known for years what an ideal NSC should look like, i.e., its attributes, and how responsibilities for creating and maintaining such a culture should be spread across a nuclear organization.***  And we’re still playing Whac-A-Mole.

At Safetymatters, we have promoted a systems view of NSC, a view that we believe provides a more nuanced and realistic view of how NSC actually works.  Where does NSC live in our nuclear socio-technical system?  Well, it doesn’t “live” anywhere.  NSC is, to some degree, an emergent property of the system, i.e., it is visible because of the ongoing functioning of other system components.  But that does not mean that NSC is only an effect or consequence.  NSC is both a consequence and a cause of system behavior.  NSC is a cause through the way it affects the processes that create hard artifacts, such as management decisions or the corrective action program (CAP), softer artifacts like the leadership exhibited throughout an organization, and squishy organizational attributes like the quality of hierarchical and interpersonal trust that permeates the organization like an ether or miasma. 

Interrelationships and feedback loops tie NSC to other organizational variables.  For example, if an organization fixes its problems, its NSC will appear stronger and the perception of a strong NSC will influence other organizational dynamics.  This particular feedback loop is generally reinforcing but it’s not some superpower, as can be seen in a couple of problems nuclear organizations may face: 

Why is a CAP ineffective?  The NSC establishes the boundaries between the desirable, acceptable, tolerable and unacceptable in terms of problem recognition, analysis and resolution.  But the strongest SC cannot compensate for inadequate resources from a plant owner, a systemic bias in favor of continued production****, a myopic focus on programmatic aspects (following the rules instead of searching for a true answer) or incompetence in plant staff. 

Why are plant records falsified?  An organization’s party line usually pledges that the staff will always be truthful with customers, regulators and each other.  The local culture, including its NSC, should reinforce that view.  But fear is always trying to slip in through the cracks—fear of angering the boss, fear of missing performance targets, fear of appearing weak or incompetent, or fear of endangering a plant’s future in an environment that includes the plant’s perceived enemies.  Fear can overcome even a strong NSC.

Our Perspective

NSC is real and complicated but it is not mysterious.  Most importantly, NSC is not some red herring that keeps us from seeing the true causes of underlying organizational performance problems.  Safetymatters will continue to offer you the information and insights you need to be more successful in your efforts to understand NSC and use it as a force for better performance in your organization.

Your organization will not increase its performance in the safety dimension if it continues to apply and reprocess the same thinking that the nuclear industry has been promoting for years.  NSC is not something that can be directly managed or even influenced independent of other organizational variables.  “Leadership” alone will not fix your organization’s problems.  You may protect your career by parroting the industry’s adages but you will not move the ball down the field without exercising some critical and independent thought.

We wish you a safe and prosperous 2017.


*  “Palisades Power Purchase Agreement to End Early,” Entergy press release (Dec. 8,2016).

**  L. Buchsbaum, “France’s Nuclear Storm: Many Power Plants Down Due to Quality Concerns,” Power (Dec. 1, 2016).  Retrieved Jan. 4, 2017.

***  For example, take a look back at INSAG-4 and NUREG-1756 (which we reviewed on May 26, 2015).

****  We can call that the Nuclear Production Culture (NPC).

Canadian Draft Regulation on Nuclear Safety Culture

Draft REGDOC cover

The Canadian Nuclear Safety Commission (CNSC) has published a draft regulatory document REGDOC-2.1.2, “Safety Culture” for comment*  The REGDOC will be a requirement for nuclear power plants and provide guidance for other nuclear entities and activities.  

The REGDOC establishes “requirements and guidance for fostering and assessing safety culture.” (p. 1)  The CNSC’s purpose is to promote a healthy safety culture (SC) which they say “is a key factor in reducing the likelihood of safety-related events and mitigating their potential impact, and in continually improving safety performance.” (ibid.)

Section 2 specifies five characteristics of a healthy SC: Safety is a clearly recognized value, accountability for safety is clear, a learning organization is built around safety, safety is integrated into all activities in the organization, and a safety leadership process exists in the organization.  For each characteristic, the document lists observable indicators. 

Sections 3 and 4 describe how licensees should perform SC assessments.  Specifically, assessments should be empirical, valid, practical and functional.  Each of these three characteristics is fleshed out with relevant criteria.  The document goes on to discuss the mechanics of performing assessments: developing a communications strategy, defining the assessment framework, selecting team members, planning and conducting assessments, developing findings and recommendations, writing reports, etc.

Our Perspective

The REGDOC is clear and relatively brief.  None of the content is controversial or even new; the document is based on multiple International Atomic Energy Agency (IAEA) publications.  (14 of 15 references in the document are from IAEA.  The “Additional Information” page includes items from INPO, NEI and WANO.)

Here’s how the REGDOC addresses SC topics that are important to us:

Decision making - Satisfactory

The introduction to the SC characteristics says “The highest level of governing documentation should make safety the utmost priority – overriding the demands of production and project schedules . . .” (p. 4)  The specific SC indicators include “Timely decisions are made that reflect the value and relative priority placed on safety.” (ibid.)  “Workers are involved in risk assessment and decision-making processes.” (p. 5)  “A proactive and long-term approach to safety is demonstrated in decision making.” (p. 6)  We would have liked a more explicit treatment of safety-production-cost goal conflict but what the CNSC has included is OK.

Taking a systems view of SC - Unacceptable

This topic is only mentioned in a table of SC maturity model indicators that is in an appendix to the REGDOC.  The links between SC and other important organizational attributes must be inferred from the observable indicators.  There is no discussion of the interrelationship between SC and other important organizational attributes, e.g., the safety conscious work environment, management’s commitment to safety, or workers’ trust in management to do the right thing.

Rewards and compensation - Unacceptable 

The discussion is limited to workers.  What about senior management compensation and incentives?  How much are senior managers paid, if anything, for establishing and maintaining a healthy SC?

The discussion on performing assessments refers several times to a SC maturity model that is appended to the REGDOC.  The model has three stages of organizational maturity—requirement driven, goal driven and continually improving, along with specific observable behaviors associated with each stage.  The model can be used to “describe and interpret the organization’s safety culture, . . .” (p. 10)  Nowhere does the REGDOC explicitly state that stage 3 (a continually improving organization) is the desired configuration.  This is a glaring omission in the REGDOC.

Bottom line: If you keep up with IAEA’s SC-related publications, you don’t need to look at this draft REGDOC which adds zero value to our appreciation or understanding of SC.


*  Canadian Nuclear Safety Commission, draft regulatory document REGDOC-2.1.2, “Safety Culture” (Sept. 2016).  The CNSC is accepting public comments on the document until Jan. 31, 2017.

Here We Go Again: NRC to Inspect Nuclear Safety Culture at Entergy’s Pilgrim Plant

Pilgrim

Entergy’s Pilgrim station has been in Column 4 of the Nuclear Regulatory Commission’s (NRC) Action Matrix since September 2015.  Column 4 plants receive more numerous, extensive and intrusive NRC inspections than plants that receive baseline inspections.  Pilgrim is in Column 4 primarily because its Corrective Action Program (CAP) is not effective, i.e., the CAP is not permanently fixing significant plant problems.  Pilgrim’s latest inspection follows NRC Inspection Procedure (IP) 95003.  As part of IP 95003 the NRC will assess the plant’s nuclear safety culture (NSC) to ascertain if a weak NSC is contributing to the plant’s inability or unwillingness to identify, specify, investigate and permanently fix problems.*

Our Perspective

Those are the facts.  Now let’s pull on our really tight crankypants.  Entergy is in a race with the Tennessee Valley Authority (TVA) to see which fleet operator can get into the most trouble with the NRC over NSC issues.  We reviewed Entergy’s NSC problems at its different plants in our April 13, 2016 post.  Subsequently, the NRC published its report on NSC issues at Entergy’s Arkansas Nuclear One (ANO) plant, which also was subject to an IP 95003 inspection.  We reviewed the ANO inspection report on June 16, 2016.  That’s all basically bad news.  However, there is one bit of good news: Entergy recently offloaded one of its plants, FitzPatrick, to Exelon, a proven nuclear enterprise with a good track record. 

Did we mention that Pilgrim is on the industrial equivalent of Death Row?  Entergy has announced its plan to shut down the plant on May 31, 2019.**  Local anti-nuclear activists want it shut down immediately.***  Pilgrim will certainly be under increased NRC scrutiny for the rest of its operating life.  The agency says “Should there be indications of degrading performance, we will take additional regulatory actions as needed, . . . up to and including a plant shutdown order.”****  As readers know, the Safetymatters  founders worked in the commercial nuclear industry and are generally supportive of it.  But maybe it’s time to pull the plug at Pilgrim. 

"Can't anybody here play this game?" — Casey Stengel (1890-1975)

*  “NRC to Perform Wide-Ranging Team Inspection at Pilgrim Nuclear Power Plant; Review Supports Agency’s Increased Oversight,” NRC press release No. I-16-030 (Nov.  28, 2016).  A.L. Burritt (NRC) to J. Dent (Entergy), “Pilgrim Nuclear Power Station – Notification of Inspection Procedure 95003 Phase ‘C’ Inspection” (Oct. 13, 2016).  ADAMS ML16286A592.

**  “Entergy Intends to Refuel Pilgrim in 2017; Cease Operations on May 31, 2019” (April 14, 2016).  Retrieved Nov. 29, 2016.

***  “Protesters Demand Pilgrim Nuclear Power Plant Be Shut Down Now,” CapeCod.com (Nov. 28, 2016).  Retrieved Nov. 29, 2016.

****  “Additional NRC Oversight at Pilgrim Nuclear Power Plant,” an NRC webpage.  The quote is under the Assessment Results tab.  Retrieved Nov. 29, 2016.

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.

Korean Perspective on Nuclear Safety Culture

Republic of Korea flag

We recently read two journal articles that present the Korean perspective on nuclear safety culture (NSC), one from a nuclear research institute and the other from the Korean nuclear regulator.  Selected highlights from each article are presented below, followed by our perspective on the articles’ value.

Warning:  Although the articles are in English, they were obviously translated from Korean, probably by a computer, and the translation is uneven.  However, the topics and references (including IAEA, NRC, J. Reason and Schein) will be familiar to you so with a little effort you can usually figure out what the authors are saying.

Korean NSC Situation and Issues*

The author is with the Korea Atomic Energy Research Institute.  He begins by describing a challenge facing the nuclear industry: avoiding complacency (because plant performance has been good) when the actual diffusion of NSC attributes among management and workers is unknown and major incidents, e.g., Fukushima, point to deficient NSC has a major contributor.  One consequence of this situation is that increased regulatory intervention in licensee NSC is a clear trend. (pp. 249, 254)

However, different countries have differing positions on how to intervene in or support NSC because (1) the objectification of an essentially qualitative factor is necessarily limited and (2) they fear diluting the licensee’s NSC responsibilities and/or causing unintended consequences. 

The U.S. NRC’s NSC history is summarized, including how NSC is addressed in the Reactor Oversight Process and relevant supplemental inspection procedures.  The author’s perception is “If safety culture vulnerability is judged to seriously affect the safety of a nuclear power plant, NRC orders the suspension of its operation, based on the judgment.” (p. 254)  In addition, the NRC has “developed and has been applying a licensee safety culture oversight program, based on site-stationed inspector's observation and assessment . . .” (ibid.)

The perception that the NRC would shut down a plant over NSC issues is a bit of a stretch.  While the agency is happy to pile on over NSC shortcomings when a plant has technical problems (see our June 16, 2016 post on ANO) it has also wrapped itself in knots to rationalize the acceptability of plant NSC in other cases (see our Jan. 30, 2013 post on Palisades).   

There is a passable discussion of the methods available for assessing NSC, ranging from observing top management leadership behavior to taking advantage of “Big data” approaches.  However, the author cautions against reliance on numeric indicators; they can have undesirable consequences.  He observes that Europe has a minimal number of NSC regulations while the U.S. has none.  He closes with recommendations for the Korean nuclear industry.

Regulatory Oversight of NSC**

The authors are with the Korea Institute of Nuclear Safety, the nuclear regulatory agency.  The article covers their philosophy and methods for regulating NSC.  It begins with a list of challenges associated with NSC regulatory oversight and a brief review of international efforts to date.  Regulatory approaches include monitoring onsite vulnerabilities (U.S.), performing standard reviews of licensee NSC evaluations (Canada, Korea) and using NSC indicators (Germany, Finland) although the authors note such indicators do not directly measure NSC. (pp. 267-68)

In the Korean view, the regulator should perform independent oversight but not directly intervene in licensee activities.  NSC assessment is separate and different from compliance-based inspection, requires effective two-way communications (i.e., a common language) and aims at creating long-term continuous improvement. (pp. 266-67)  Their NSC model uses a value-neutral definition of NSC (as opposed to strong vs. weak); incorporates Schein’s three levels; includes individuals, the organization and leaders; and emphasizes the characteristics shared by organization members.  It includes elements from IAEA GSR Part 2, the NRC, J. Reason's reporting culture, DOE, INPO, just culture and Korea-specific concerns about economics trumping safety. (pp. 268-69)***

In the detailed description of the model, we were pleased to see “Incentives, sanctions, and rewards correspond to safety competency of individuals.”  (p. 270)  An organization’s reward system has always been a hot-button issue for us; all nuclear organizations claim to value NSC, few are willing to pay for achieving or maintaining it.  Click the “Compensation” label to see all our posts on this topic.

The article presents a summary of an exercise to validate the model, i.e., link model components to actual plant safety performance.  The usual high-level mumbo-jumbo is not helped by the rough spots in the translation.  Inspection results, outage rates, scrams, incidents, unplanned shutdowns and radiation doses were claimed to be appropriately correlated with NSC model components.

There should be no surprise that the model was validated.  Getting a “right” answer is obviously good for the regulator.  We routinely express some skepticism over studies that validate models when we can’t see the actual data and we don’t know if the analysis was independently reviewed by anyone who actually understands or cares about the subject matter.

During the pilot study, several improvement areas in Korean NPP's safety culture were identified.  The approach has not been permanently installed.

Our Perspective

These articles are worth reading just to get a different, i.e., non-U.S., perspective on regulatory evaluation of (and possible intervention in) licensee SC.  It’s also worthwhile to get a non-U.S. perspective on what they think is going on in U.S. nuclear regulatory space.  Their information sources probably include a June 2015 NRC presentation to Korean regulators referenced in our Aug. 24, 2015 post.  

It’s interesting that Europe has some regulations that focus on ongoing communications with the licensees.  In contrast, the U.S. has no regulations but an approach that can stretch like a cheap blanket to cover all possible licensee situations.

Afterword

We haven’t posted for awhile.  It’s not because we’ve lost interest but there hasn’t been much worth reporting.  The big nuclear news in the U.S. is not about NSC, rather it’s about plants being scheduled for shutdown because of their economics.  International information sources have not been offering up much either.  For example, the LinkedIn NSC forum has pretty much dried up except for recycled observations and consultants’ self-serving white papers.


*  Y-H Lee, “Current Status and Issues of Nuclear Safety Culture,” Journal of the Ergonomics Society of Korea vol. 35 no. 4 (Aug 2016) 247-261.

**  YS Choi, SJ Jung and YH Chung, “Regulatory Oversight of Nuclear Safety Culture and the Validation Study on the Oversight Model Components,” Journal of the Ergonomics Society of Korea vol. 35 no. 4 (Aug 2016) 263-275.

***  Korea has had problems, mentioned in both articles, caused by deficient NSC.  Also see our Aug. 7, 2013 post for related information.

Nuclear Safety Culture Self-Assessment Guidance from IAEA

IAEA report cover

The International Atomic Energy Agency (IAEA) recently published guidance on performing safety culture (SC) self-assessments (SCSAs).  This post summarizes the report* and offers our perspective on its usefulness.

The Introduction presents some general background on SC and specific considerations to keep in mind when conducting an SCSA, including a “conscious effort to think in terms of the human system (the complex, dynamic interaction of individuals and teams within an organization) rather than the technological system.” (p. 2)  Importantly, an SCSA is not based on technical skills or nuclear technology, nor is it focused on immediate corrective actions for observed problems.

Section 2 provides additional information on SC, starting with the basics, e.g., culture is one way of explaining why things happen in organizations.  The familiar iceberg model is presented, with the observable artifacts above the surface and the national, ethnic and religious values that underlie culture way below the waterline.  Culture is robust (it cannot be changed rapidly) and complicated (subcultures exist).  So far, so good.

Then things start to go off the rails.  The report reminds us that the IAEA SC framework** has five SC characteristics but then the report introduces, with no transition, a four-element model for envisioning SC; naturally, the model elements are different from the five SC characteristics previously mentioned.  The report continues with a discussion of IAEA’s notion of “shared space,” the boundary area where working relationships develop between the individual and other organizational members.  We won’t mince words: the four-component model and “shared space” are a distraction and zero value-added.

Section 3 explores the characteristics of SCSAs.  Initially, an SCSA focuses on developing an accurate description of the current culture, the “what is.”  It then moves on to evaluating a SC’s strengths and weaknesses by comparing “what is” with “what should be.”  An SCSA is different from a typical audit in numerous ways, including the need for specialized training, a focus on organizational dynamics and an understanding of the complex interplay of multicultural dimensions of the organization.

SCSAs require recognition of the biases present when a culture examines itself.  Coupling this observation with an earlier statement that effective SCSAs require understanding of the relevant social sciences, the report recommends obtaining qualified external support personnel (at least for the initial efforts at conducting SCSAs).  In addition, there are many risks (the report comes up with 17) associated with performing an SCSA that have to be managed.  All of these aspects are important and need to be addressed.

Section 4 describes the steps in performing an SCSA.  The figure that purportedly shows all the steps is unapproachable and unintelligible.  However, the steps themselves—prepare the organization, the team and the SCSA plan; conduct the pre-launch and the SCSA; analyze the results; summarize the communicate the findings; develop actions; capture lessons learned; and conduct a follow-up—are reasonable.

The description of SCSA team composition, competences and responsibilities is also reasonable.  Having a team member with a behavioral science background is highly desirable but probably not available internally in other than the largest organizations. 

Section 5 covers SCSA methods: document review, questionnaires, observations, focus groups and interviews.  For each method, the intent, limitations and risks, and intended uses are discussed.  Each method requires specific skills.  The purpose is to develop an overall view of the culture.  Because of the limitations of individual methods, multiple (and preferably all) methods should be used.  Overall, this section is a pretty good high-level description of the different investigative methods.

Section 6 describes how to perform an integrated analysis of the information gathered.  This involves working iteratively with parallel information sets.  There is a lengthy discussion of how to develop cultural themes from the different data sources.  Themes are combined into an overall descriptive view of the culture which can then be compared to the IAEA SC framework (a normative view) to identify relative strengths and weaknesses, and improvement opportunities.

Section 7 describes approaches to communicating the findings and transitioning into action.  It covers preparing the SCSA report, communicating the results to management and the larger organization, possible barriers to implementing improvement initiatives and maintaining continuous improvement in an organization’s SC.

The report has an extensive set of appendices that illustrate how an SCSA can be conducted.  Appendix I is a laundry list of potential areas for inquiry.  Appendices II-VIII present a case study using all the SCSA methods in Section 5, followed by some example overall conclusions.  Appendix IX is an outline of an SCSA final report.  The guidance on using the SCSA methods is acceptably complete and clear.

A 28-page Annex (including 8 pages of references) describes the social science underlying the recommended methodology for performing SCSAs.  It covers too much ground to be summarized here.  The writing is uneven, with some topics presented in a fluid style (probably a single voice) while others, especially those referring to many different sources, are more ragged.  Because of the extensive use of in-line references, the reader can easily identify source materials.   

Our Perspective

There’s good news and bad news in this Safety Report.  The good news is that when IAEA collates and organizes the work of others, e.g., academics, SC practitioners or industry best practices, IAEA can create a readable, reasonably complete reference on a subject, in this case, SCSA.

The bad news is that when IAEA tries to add new content with their own concepts, constructs, figures and such, they fail to add any value.  In fact, they detract from the total package.  It seems to never have occurred to the IAEA apparatchiks to circulate their ideas for new content for substantive review and comment.


*  International Atomic Energy Agency, “Performing Safety Culture Self-assessments,” Safety Reports Series no. 83 (Vienna: IAEA, 2016).  Thanks to Madalina Tronea for publicizing this report.  Dr. Tronea is the founder/moderator of the LinkedIn Nuclear Safety Culture discussion group.

**  Interestingly, the IAEA SC framework (SC definition, key characteristics and attributes) is mentioned without much discussion; the reader is referred to other IAEA documents for more details.  That’s OK.  For purposes of SCSA, it’s only important that the organization, including the SCSA team, agree on a SC definition and its associated characteristics and attributes.  This will give everyone involved a shared normative view for linking the SCSA findings to a picture of what the SC should look like.