Nuclear Safety Culture at the 2017 NRC Regulatory Information Conference

NRC 2017 RIC

Nuclear Safety Culture (NSC) was assigned one technical session at the 2017 NRC Regulatory Information Conference (RIC).  The topic was maintaining a strong NSC during plant decommissioning.  This post reviews the session presentations and provides our perspective on the topic.

Nuclear Regulatory Commission (NRC)*

The presenter discussed the agency’s expectations that the requirements of the SC Policy Statement will continue to be met during decommissioning, recognizing that plant old-timers may experience issues with trust, commitment and morale while newcomers, often contractors, will need to be trained and managed to meet NSC standards going forward.  The presentation was on-target but contained no new information or insights.

International Atomic Energy Agency (IAEA)**

This presentation covered the IAEA documents that discuss NSC, viz., the General Safety Requirement “Leadership and Management for Safety,” and the Safety Guides “Application of the Management System for Facilities and Activities,” which covers NSC characteristics, and “The Management System for Nuclear Installations,” which covers NSC assessments, plus supporting IAEA Safety Reports and Technical Documents.  There was one slide covering decommissioning issues, none of which was new.

The slides were dense with turgid text; this presentation must have been excruciating to sit through.  The best part was IAEA did not attempt to add any value through some new approach or analysis, which always manages to muck up the delivery of any potentially useful information. 

Kewaunee***

The Kewaunee plant was shut down on May 7, 2013.  The shutdown announcement on Oct. 22, 2012 was traumatic for the staff and they went through several stages of grieving.  Management has worked to maintain transparency and an effective corrective action program, and retain people who can accept changing conditions.  It is a challenge for management to maintain a strong NSC as the plant transitions to long-term SAFSTOR.

It’s not surprising that Kewaunee is making the best of what is undoubtedly an unhappy situation for many of those involved.  The owner, Dominion Resources, has a good reputation in NSC space.

Vermont Yankee****

This plant was shut down on Dec. 29, 2014.  The site continued applying its process to monitor for NSC issues but some concerns still arose (problems in radiation practices, decline in industrial safety performance) that indicated an erosion in standards.  Corrective actions were developed and implemented.  A Site Review Committee provides oversight of NSC.

The going appears a little rougher at Vermont Yankee than Kewaunee.  This is not a surprise given both the plant and its owner (Entergy) have had challenges in maintaining a strong NSC. 

Our Perspective

The session topic reflects a natural life cycle: industrial facilities are built, operate and then close down.  But that doesn’t mean it’s painless to manage through the phase changes. 

In an operating plant, complacency is a major threat.  Complacency opens the door to normalization of deviation and other gremlins that move performance toward the edge of the envelope.  In the decommissioning phase, we believe loss of fear is a major threat.  Loss of fear of dramatic, even catastrophic radiological consequences (because the fuel has been off-loaded and the plant will never operate again) can lead to losing focus, lack of attention to procedural details, short cuts and other behaviors that can have significant negative consequences such as industrial accidents or mishandling of radioactive materials.

In a “Will the last person out please turn off the lights” environment, maintaining everyone’s focus on safety is challenging for people who operated the plant, often spending a large part of their careers there.  The lack of local history is a major reason to transfer work to specialty decommissioning contractors as quickly as possible. 

In 2016, NSC didn’t merit a technical session at the RIC; it was relegated to a tabletop presentation.  As the industry shrinks, we hope NSC doesn’t get downgraded to a wall poster.


*  D. Sieracki, “Safety Culture and Decommissioning,” 2017 RIC (Mar. 15, 2017).

**  A. Orrell, “Safety Culture and the IAEA International Perspectives,” 2017 RIC (Mar. 15, 2017).

***  S. Yeun, “Maintaining a Strong Safety Culture after Shutdown,” 2017 RIC (Mar. 15, 2017).

****  C. Chappell, “Safety Culture in Decommissioning: Vermont Yankee Experience,” 2017 RIC (Mar. 15, 2017).

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.

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

Entergy Headquarters  Source: Nola.com

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

Utility-Owned Plants

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

Arkansas Nuclear One (ANO)

ANO is currently in Column 4 of the NRC Action Matrix and subject to an intrusive IP 95003 inspection.  ANO completed an independent SC assessment.  We reviewed their problems on June 25, 2015 and concluded “. . . the ANO culture endorses a “blame the contractor” attitude, accepts incomplete investigations into actual events and potential problems, and is content to let the NRC point out problems for them.”

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

Grand Gulf

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

River Bend

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

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

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

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

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

Waterford 3

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

Entergy Wholesale Plants

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

FitzPatrick

Entergy purchased FitzPatrick in 2000.

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

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

Indian Point

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

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

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

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

Palisades

Entergy purchased Palisades in 2007.

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

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

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

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

Pilgrim

Entergy purchased Pilgrim in 1999.

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

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

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

Vermont Yankee

Entergy purchased Vermont Yankee in 2002.

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

Vermont Yankee ceased operations on Dec. 29, 2014.

Our Perspective

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

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

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

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


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

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

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

Safety Culture: Cause or Context (part 1)

As we have mentioned before, we are perplexed that people are still spending time working on safety culture definitions. After all, it’s not because of some definitional issue that problems associated with safety culture arise at nuclear plants. Perhaps one contributing factor to the ongoing discussion is that people hold different views of what the essence of safety culture is, views that are influenced by individuals’ backgrounds, experiences and expectations. Consultants, lawyers, engineers, managers, workers and social scientists can and do have different perceptions of safety culture. Using a term from system dynamics, they have different “mental models.”

Examining these mental models is not an empty semantic exercise; one’s mental model of safety culture determines (a) the degree to which one believes it is measurable, manageable or independent, i.e. separate from other organizational features, (b) whether safety culture is causally related to actions or simply a context for actions, and (c) most importantly, what specific strategies for improving safety performance might work.

To help identify different mental models, we will refer to a 2009 academic article by Susan Silbey,* a sociology professor at MIT. Her article does a good job of reviewing the voluminous safety culture literature and assigning authors and concepts into three main categories: Culture as (a) Causal Attitude, (b) Engineered Organization, and (c) Emergent and Indeterminate. To fit into our blog format, we will greatly summarize her paper, focusing on points that illustrate our notion of different mental models, and publish this analysis in two parts.

Safety Culture as Causal Attitude

In this model, safety culture is a general concept that refers to an organization’s collective values, beliefs, assumptions, and norms, often assessed using survey instruments. Explanations of accidents and incidents that focus on or blame an organization’s safety culture are really saying that the then-existing safety culture somehow caused the negative events to occur or can be linked to the events by some causal chain. (For an example of this approach, refer to the Baker Report on the 2005 BP Texas City refinery accident.)

Adopting this mental model, it follows logically that the corrective action should be to fix the safety culture. We’ve all seen, or been a part of, this – a new management team, more training, different procedures, meetings, closer supervision – all intended to fix something that cannot be seen but is explicitly or implicitly believed to be changeable and to some extent measurable.

This approach can and does work in the short run. Problems can arise in the longer-term as non-safety performance goals demand attention; apparent success in the safety area breeds complacency; or repetitive, monotonous reinforcement becomes less effective, leading to safety culture decay. See our post of March 22, 2010 for a discussion of the decay phenomenon.

Perhaps because this model reinforces the notion that safety culture is an independent organizational characteristic, the model encourages involved parties (plant owners, regulators, the public) to view safety culture with a relatively narrow field of view. Periodic surveys and regulatory observations conclude a plant’s safety culture is satisfactory and everyone who counts accepts that conclusion. But then an event occurs like the recent situation at Vermont Yankee and suddenly people (or at least we) are asking: How can eleven employees at a plant with a good safety culture (as indicated by survey) produce or endorse a report that can mislead reviewers on a topic that can affect public health and safety?

Safety Culture as Engineered Organization

The model is evidenced in the work of the High Reliability Organization (HRO) writers. Their general concept of safety culture appears similar to the Causal Attitude camp but HRO differs in “its explicit articulation of the organizational configuration and practices that should make organizations more reliably safe.” (Silbey, p. 353) It focuses on an organization’s learning culture where “organizational learning takes place through trial and error, supplemented by anticipatory simulations.” Believers are basically optimistic that effective organizational prescriptions for achieving safety goals can be identified, specified and implemented.

This model appears to work best in a command and control organization, i.e., the military. Why? Primarily because a specific military service is characterized by a homogeneous organizational culture, i.e., norms are shared both hierarchically (up and down) and across the service. Frequent personnel transfers at all organizational levels remove people from one situation and reinsert them into another, similar situation. Many of the physical settings are similar – one ship of a certain type and class looks pretty much like another; military bases have a common set of facilities.

In contrast, commercial nuclear plants represent a somewhat different population. Many staff members work more or less permanently at a specific plant and the industry could not have come up with more unique physical plant configurations if it had tried. Perhaps it is not surprising that HRO research, including reviews of nuclear plants, has shown strong cultural homogeneity within individual organizations but lack of a shared culture across organizations.

At its best, the model can instill “processes of collective mindfulness” or “interpretive work directed at weak signals.” At its worst, if everyone sees things alike, an organization can “[drift] toward[s] inertia without consideration that things could be different.” (Weick 1999, quoted in Silbey, p.354) Because HRO is highly dependent on cultural homogeneity, it may be less conscious of growing problems if the organization starts to slowly go off the rails, a la the space shuttle Challenger.

We have seen efforts to implement this model at individual nuclear plants, usually by trying to get everything done “the Navy way.” We have even promoted this view when we talked back in the late 1990s about the benefits of industry consolidation and the best practices that were being implemented by Advanced Nuclear Enterprises (a term Bob coined in 1996). Today, we can see that this model provides a temporary, partial answer but can face challenges in the longer run if it does not constantly adjust to the dynamic nature of safety culture.

Stay tuned for Safety Culture: Cause or Context (part 2).

* Susan S. Silbey, "Taming Prometheus: Talk of Safety and Culture," Annual Review of Sociology, Volume 35, September 2009, pp. 341-369.

Safety Culture Assessments and Surveys

It appears that the safety culture at Vermont Yankee continues to interest the NRC, given the discussion during the recent public meeting related to VY's safety culture survey. We will soon be posting our additional thoughts on the nature of safety culture but for some background material, we suggest our posts of August 17, 2009 (Safety Culture Assessment), August 24, 2009 (Assessment Results) and August 26, 2009 (Can Assessments Identify/Breed Complacency). You might want to check these out in light of the attention safety culture surveys are receiving.

Vermont Yankee (part 5) - Muddy Water

In our April 5, 2010 post re Vermont Yankee we provided some initial thoughts on the report of the independent investigator regarding misleading statements provided by Entergy personnel to Vermont regulators, as contained in Entergy’s March 31, 2010 response to a March 1, 2010 NRC Demand for Information.* The Entergy filing also provides more detail on follow-up actions including an assessment of current site safety culture. In this post, we offer some additional observations and questions.
First, in our initial March 3, 2010 post regarding the VY situation, we disputed a prediction made by a third party that the administrative actions taken by Entergy for certain employees might have a detrimental effect on the safety culture at the plant - due to the way Entergy is treating its employees. In reality it appeared to us that any detrimental impact on safety culture would be more likely if Entergy had not taken appropriate actions. In Entergy’s report to the NRC, they provide the results of a follow-up assessment confirming that after the personnel actions employees were even more likely to raise concerns.

Also in our initial post we speculated that the Vermont Yankee events could have consequences for Entergy’s proposed spinout of six nuclear plants into a separate subsidiary. Since then Entergy has announced the cancellation of the spinout after a decision by New York re the extension of permits for their Indian Point plants.

However, after a careful review of the March 31 Entergy response, we are still left with water that is more than a little bit muddy. Entergy says a Synergy assessment a few months before the reporting event found safety culture at Vermont Yankee to be strong. After the event, Entergy states safety culture is strong or stronger, and with regard to the replaced staff, Entergy “continues to have confidence in the integrity of the affected employees.” Strong safety culture and organizational integrity are not supposed to add up to this kind of outcome. How then did things go wrong? How did the misleading statements to Vermont regulators come about and what was the cause?

A fundamental element of all nuclear plant problem resolution/corrective action programs is a determination of not just what happened, but why. Cause in other words, and in significant situations, the root cause. The root cause that led to eleven employees, including managers and site executives, being relieved of duties and disciplined is not contained in the Entergy materials. In fact, most of the focus appears to be on the safety culture of the plant staff both before and after the incident came to light and the personnel actions taken. Those actions and information appear to be reassuring in regards to the plant staff - but the plant staff was not where the problem occurred. There is also considerable emphasis on the fact that the managers have been replaced with competent substitutes. But haven’t those new managers been placed in exactly the same situation as the former managers were in? If it is not clear why the former managers failed to meet performance standards, then how is one confident that the replacements will do so?

As we have pointed out in other posts, the response to safety culture failures too often stresses the “values and beliefs” of personnel as the beginning and end of safety culture. We have argued that the situational parameters, including competing goals and interests, are at least as important if not paramount in trying to understand such issues.

What was the situation at Vermont Yankee and to what extent, if any, did it have an effect? The VY management team was operating in an environment where significant business decisions were in play. One was the extension of the operating license for VY which required approval by both the NRC and by the Vermont Senate. A second was the pending proposed spinout of nuclear units, including VY, into a separate subsidiary, a spinout that was expected to be worth billions of dollars to Entergy. SEC and other regulatory filings had been made by Entergy for the spinout and approvals were being sought from state regulators and the NRC.

Entergy’s March 31 NRC submittal also states, “Finally, neither the underlying report of investigation which led to the discipline, nor the interviews of the AFEs, identified any credible evidence to suggest that any weakness in the work environment or site safety culture contributed to a reluctance by anyone to provide clarifying or supplemental information to the relevant state officials. Indeed, there is no credible evidence that any of the AFEs are -- or were -- reluctant to report safety concerns or any other matter of potential regulatory significance or legal non-compliance.”

Does this mean that situational factors such as business priorities were evaluated and found not to be a contributor? If so, how was this done and what is the basis for such a conclusion? Or were such competing priorities acknowledged as potential influences and able to be dealt with as part of the management system? What other situational factors might have been present and to what effect?

On April 9, 2010 the NRC notified Entergy that the NRC was going to “initiate a detailed review and independent assessment of the acceptability of Entergy’s conclusions. . . .” ** We will keep you posted.

*ADAMS Accession Number ML100910420

**ADAMS Accession Number ML100990409

Huh? aka Vermont Yankee (part 4)

On March 31, 2010, Entergy transmitted to the NRC key findings of the Morgan, Lewis & Bockius LLP investigation of misstatements by Entergy employees at Vermont Yankee.* The investigation concluded that no Entergy employees "intentionally misled" Vermont regulators and "The investigation also concluded that no one made any intentionally false statements in state regulatory proceedings." That’s all fairly clear.

But then the same paragraph continues: “The report found, however, that certain ENVY [Entergy Nuclear Vermont Yankee ] personnel did not clarify certain understandings and assumptions, which resulted in misunderstandings, when viewed in a context different from the one understood to be relevant to the CRA [Comprehensive Reliability Assessment]."

I was fine up to the “however”. I just don’t understand the law firm’s tortured phrasing of what did happen. Will anyone else?


*ADAMS Accession Number ML100910420

Vermont Yankee (part 3)

There was an interesting article in the March 22, 2010 Hartford Courant regarding Paul Blanch, the former Northeast Utilities engineer who was in the middle of safety issues at Millstone in the 1990s. Specifically he was in the news due to his recent testimony against the extension of the operating license for Vermont Yankee. But what caught my eye was some of his broader observations regarding safety and the nuclear industry. Regarding the industry, Blanch states, "Safety is not their No. 1 concern," he said. "Making money is their No. 1 concern." He goes on to say he has no faith in the NRC, or utilities’ commitment to safety.

Bringing attention to these comments is important not because one may agree or disagree with them. They are significant because they represent a perception of the industry, and the NRC for that matter, that can and does get attention. One problem is that everyone says safety is their highest priority but then certain events suggest otherwise - as an example, let’s look at another company and industry recently in the news:

From the BP website:

Safe and reliable operations are BP’s number one priority....

This is from a company that was recently fined over $3 million by OSHA for safety violations at its Ohio refinery (see our March 12, 2010 post) and had previously been fined almost $90 million for the explosion at its Texas refinery.

Supporting this commitment is the following description of safety management at BP:

“...members of the executive team undertook site visits, in which safety was a focus, to reinforce the importance of their commitment to safe and reliable operations. The executives also regularly included safety and operations issues in video broadcasts and communications to employees, townhall meetings and messages to senior leaders.“

It is hardly unreasonable that someone could have a perception that BP’s highest priority was not safety. Unfortunately almost those identical words can also be found in the statements and pronouncements of many nuclear utilities. (By the way the narrow emphasis by BP management on “reinforcement” might be considered in the context of our post dated March 22, 2010 on Safety Culture Dynamics.)

As Dr. Reason has noted so simply, no organization is just in the business of being safe. What might be much more beneficial is some better acknowledgment of the tension between safety and production (and cost and schedule) and how nuclear organizations are able to address it. This awareness is a more credible posture for public perception, for regulators and for the organization itself. It would also highlight the insight that many have in the nuclear industry - that safety and reliable production are actually tightly coupled - that over the long term they must coexist. The irony may be that I recall 20 years ago Entergy was the leader in publicizing (and achieving) their goals to be upper quartile in safety, production and cost.

Vermont Yankee (part 2) - What Would Reason Say?

The "Reason" in the title refers to Dr. James Reason, Professor Emeritus, Department of Psychology, University of Manchester.

“It is clear from in-depth accident analyses that some of the most powerful pushes towards local traps [characteristics of the workplace that lead people to compromise safety priorities] come from an unsatisfactory resolution of the inevitable conflict that exists (at least in the short-term) between the goals of safety and production. The cultural accommodation between the pursuit of these goals must achieve a delicate balance. On the one hand, we have to face the fact that no organization is just in the business of being safe.  Every company must obey both the ' ALARP ' principle (keep the risks as low as reasonably practicable) and the 'ASSIB' principle (and still stay in business). On the other hand, it is now increasingly clear that few organizations can survive a catastrophic organizational accident (Reason 1997).”

"Achieving a Safe Culture: Theory and Practice." (1998), p. 301.
 
Dr. Reason has been a leading and influential thinker in the area of safety and risk management in the workplace and the creation of safety culture in high risk industries.  Get to know Dr. Reason through his own words in future blog posts featuring some of his key insights.

Vermont Yankee (part 1)

This week saw a very significant development in the nuclear industry and the potential consequences of safety culture issues on a specific plant, a large nuclear enterprise and the industry. As has been widely reported (see link below) the Vermont Senate voted against the extension of the Vermont Yankee nuclear plant’s operating license. In part it appears this action stemmed from the recent leakages of tritium at the plant site but perhaps more significantly, from how the matter was handled by the plant owner, Entergy. In response to allegations that Entergy may have supplied contradictory or misleading information, Entergy engaged the law firm of Morgan Lewis and Bockius LLP to undertake an independent review of the matter. Entergy subsequently has taken administrative actions on 11 employees.

The fallout of these events has not only put into question the future of the Vermont Yankee plant, triggered the interest of the NRC and a requirement that Entergy officials testify under oath, it may also have consequences for Entergy’s plans to spin-off six of its nuclear plants into an independent subsidiary. This restructuring has been a major part of Entergy’s plans for its nuclear business and Entergy has announced that it will be evaluating its options at an upcoming meeting.

There is much to be considered as a result of the Vermont Yankee situation and we will be posting several more times on this subject. In this post we wanted to focus on some initial reaction from other quarters that we found to be off the mark. The link below to the Energy Collective includes a post from Rod Adams who appears to have done a fair bit of analysis of the facts that are currently available. His major observation is as follows:

“That said, it has become clear to me that the corporate leaders at Entergy ....never learned that taking early actions to prevent problems works a hell of a lot better than massive overreaction once it finally becomes apparent to everyone that action is required. Panic at the top never works - it destroys the confidence of the people...”

In part the author relies on the Morgan Lewis law firm’s finding that Entergy employees did not intentionally mislead Vermont regulators. However, he apparently ignores the Morgan Lewis conclusion that Entergy personnel provided responses that were, ultimately, “incomplete and misleading”.

Given the findings of the independent investigator it is hard to see what choice Entergy had, and absent additional facts, it would appear to us that the employee actions were necessary and appropriate. Adams goes on to speculate that there may even be a detrimental effect on the safety culture at the plant - due to the way Entergy is treating its employees. In reality it appears to us that any detrimental impact on safety culture would have been more likely if Entergy had not taken appropriate actions. Still, the question of how safety culture played into the failure of Entergy staff to provide unambiguous information in the first place, and how safety culture will be impacted by subsequent events is a subject that merits more detailed consideration. We will provide our thoughts in future posts.
Link to 2-25-10 Wall Street Journal news item reporting Vermont's action.
Link to Rod Adams 2-26-10 blog post.
Link to 2-24-10 Entergy Press Release on Investigation Report.