Vit Plant Safety Culture Update

Hanford Waste Treatment Plant

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

Overview

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

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

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

Supporting Details

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

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

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

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

Decision Making, Corrective Action and Compensation

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

Decision Making

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

Corrective Action

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

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

Plenty of room for improvement here.

Compensation

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

Concerns Over ORP Working More Collaboratively with Bechtel

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

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

Bottom Line on SC at WTP 

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

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


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

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

Catching Up on DOE’s SCWE Extent of Condition Review

Hanford Waste Treatment Plant

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

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

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

 Report Findings and Recommendations

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

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

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

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

Our Perspective

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

The Analyzer

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

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

The Homogenizer

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

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

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

The Bureaucratizer

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

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

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

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

Bottom Line

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

But Wait, There’s More

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


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

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

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

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

Our Gaze Returns to DOE and its Safety Culture

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

Background

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

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

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

Report on SCWE Self-Assessments

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

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

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

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

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

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

Our Perspective

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

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

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


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

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

***  Defense Nuclear Facilities Safety Board, Recommendation 2011-1 to the Secretary of Energy "Safety Culture at the Waste Treatment and Immobilization Plant" (Jun 9, 2011).

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

Meanwhile, Back at the Vit Plant

Previous posts* have chronicled the safety culture (SC) issues raised at the Waste Treatment and Immobilization Plant (WTP aka the Vit plant) at the Department of Energy's (DOE's) Hanford site.  Both the DOE Office of River Protection (ORP) and the WTP contractor (Bechtel) have been under the gun to strengthen their SC.  On May 30, 2013 DOE submitted a progress report** to the Defense Nuclear Facilities Safety Board covering both DOE and Bechtel activities.

DOE ORP

Based on an assessment by an internal SC Integrated Project Team (IPT), ORP reported its progress on nine near-term SC improvement actions contained in the ORP SC Improvement Plan.  For each action, the IPT assessed degree of implementation (full, partial or none) and effectiveness (full, partial, or indeterminate).  The following table summarizes the actions and current status.

ORP has a lot of activities going on but only two are fully implemented and none is yet claimed to be fully effective.  In ORP's own words, “ORP made a substantial start toward improving its safety culture, but much remains to be done to demonstrate effective change. . . . Four of the nine actions were judged to be partially effective, and the other five were judged to be of indeterminate effectiveness at the time of evaluation due to the recent completion of some of the actions, and because of the difficulty in measuring safety culture change over a one-year time period.” (Smith, p. 1)

The top-level ORP actions look substantive but digging into the implementation details reveals many familiar tactics for addressing SC problems: lots of training (some yet to be implemented), new or updated processes and procedures, (incomplete) distribution of INPO booklets, and the creation of a new behavioral expectations poster (which is largely ignored).

SC elements have been added to senior management and supervisor performance plans.  That appears to mean these folks are supposed to periodically discuss SC with their people.  There's no indication whether such behavior will be included in performance review or compensation considerations.

ORP did attempt to address concerns with the Differing Professional Opinion (DPO) process.  DPO and Employee Concerns Program (ECP) training was conducted but some employees reported reservations about both programs.

A new issues management system has been well received by employees but needs greater promotion by senior managers to increase employees' willingness to raise issues and ask questions.  The revised ECP also needs increased senior management support.

The team pointed out that ORP does not have a SC management statement or policy.

Bechtel

There is much less detail available here.  The report says Bechtel's plan “contains 50 actions broken into six strategic improvement areas:

A. Realignment and Maintenance of Design and Safety Basis
B. Management Processes of the WTP NSQC
C. Timeliness of Issues Identification
D. Resolution. Roles. Responsibilities. Authorities, and Accountabilities
E. Management and Supervisory Behaviors
F.  Construction Site-Unique Issues

“The scheduled completion date for the last actions is December 2013. Twenty-seven actions were complete as of March 31, 2013, with an additional 12 planned to be complete by June 30, 2013.” (p. 19)

“ORP has completed surveillances on 19 of the 27 completed actions identifying 7 opportunities for improvement.  Because changing an organization's culture takes time, the current oversight efforts are focused on verifying actions have been completed.” (ibid.)  In other words, there has been no evaluation of the effectiveness of Bechtel's actions.

Our perspective

The ORP program is a traditional approach aimed at incremental organizational performance improvement.  There is no or scant mention of what we'd call strategic concerns, e.g., recognizing and addressing schedule/budget/safety goal conflicts; decision making in a complex, dynamic environment with many external pressures; riding herd on Bechtel; or creating a sense of urgency with respect to SC.

The most surprising thing to us was how unexpectedly candid the assessment was (for one produced by an employee team) in describing the program's impact to date.  For example, as the IPT performed its assessment, it tried to determine if employees were aware of the SC actions or their effects.  The results were mixed: some employees see changes but many don't, or they sense a general change but are unaware of specifics, e.g., new or changed procedures.  In general, organizational emphasis on SC declined over the year and was not very visible to the average employee.

The team's most poignant item was a direct appeal for personal involvement by the ORP manager in the SC program.  That tells you everything you need to know about SC's priority at ORP.


*  Click on Vit Plant under Labels to see previous posts.

**  M. Moury (DOE) to P.S. Winokur (DNFSB), DOE completes Action 1-9 of the Department's Implementation Plan for DNFSB Recommendation 2011-1, Safety Culture at the Waste Treatment and Immobilization Plant (May 30, 2013).  A status summary memo from ORP's K.W. Smith and the IPT report are attached to the Moury letter.  Our thanks to Bill Mullins for bringing these documents to our attention.

A New Sheriff Coming to DOE?

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

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


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

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

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

The Vit Plant

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

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

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

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

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

So, do Vit Plant SC concerns exist elsewhere?

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

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

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

A chilled atmosphere adverse to safety exists

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

Technical dissent is suppressed

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

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

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

Conclusion

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

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


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

Drift Into Failure by Sydney Dekker

Sydney Dekker's Drift Into Failure* is a noteworthy effort to provide new insights into how accidents and other bad outcomes occur in large organizations. He begins by describing two competing world views, the essentially mechanical view of the world spawned by Newton and Descartes (among others), and a view based on complexity in socio-technical organizations and a systems approach. He shows how each world view biases the search for the “truth” behind how accidents and incidents occur.

Newtonian-Cartesian (N-C) Vision

Issac Newton and Rene Descartes were leading thinkers during the dawn of the Age of Reason. Newton used the language of mathematics to describe the world while Descartes relied on the inner process of reason. Both believed there was a single reality that could be investigated, understood and explained through careful analysis and thought—complete knowledge was possible if investigators looked long and hard enough. The assumptions and rules that started with them, and were extended by others over time, have been passed on and most of us accept them, uncritically, as common sense, the most effective way to look at the world.

The N-C world is ruled by invariant cause-and-effect; it is, in fact, a machine. If something bad happens, then there was a unique cause or set of causes. Investigators search for these broken components, which could be physical or human. It is assumed that a clear line exists between the broken part(s) and the overall behavior of the system. The explicit assumption of determinism leads to an implicit assumption of time reversibility—because system performance can be predicted from time A if we know the starting conditions and the functional relationships of all components, then we can start from a later time B (the bad outcome) and work back to the true causes. (p. 84) Root cause analysis and criminal investigations are steeped in this world view.

In this view, decision makers are expected to be rational people who “make decisions by systematically and consciously weighing all possible outcomes along all relevant criteria.” (p. 3) Bad outcomes are caused by incompetent or worse, corrupt decision makers. Fixes include more communications, training, procedures, supervision, exhortations to try harder and criminal charges.

Dekker credits Newton et al for giving man the wherewithal to probe Nature's secrets and build amazing machines. However, Newtonian-Cartesian vision is not the only way to view the world, especially the world of complex, socio-technical systems. For that a new model, with different concepts and operating principles, is required.

The Complex System

Characteristics

The sheer number of parts does not make a system complex, only complicated. A truly complex system is open (it interacts with its environment), has components that act locally and don't know the full effects of their actions, is constantly making decisions to maintain performance and adapt to changing circumstances, and has non-linear interactions (small events can cause large results) because of multipliers and feedback loops. Complexity is a result of the ever-changing relationships between components. (pp.138-144)

Adding to the myriad information confronting a manager or observer, system performance is often optimized at the edge of chaos, where competitors are perpetually vying for relative advantage at an affordable cost.** The system is constantly balancing its efforts between exploration (which will definitely incur costs but may lead to new advantages) and exploitation (which reaps benefits of current advantages but will likely dissipate over time). (pp. 164-165)

The most important feature of a complex system is that it adapts to its environment over time in order to survive. And its environment is characterized by resource scarcity and competition. There is continuous pressure to maintain production and increase efficiency (and their visible artifacts: output, costs, profits, market share, etc) and less visible outputs, e.g., safety, will receive less attention. After all, “Though safety is a (stated) priority, operational systems do not exist to be safe. They exist to provide a service or product . . . .” (p. 99) And the cumulative effect of multiple adaptive decisions can be an erosion of safety margins and a changed response of the entire system. Such responses may be beneficial or harmful—a drift into failure.

Drift by a complex system exhibits several characteristics. First, as mentioned above, it is driven by environmental factors. Second, drift occurs in small steps so changes can be hardly noticed, and even applauded if they result in local performance improvement; “. . . successful outcomes keep giving the impression that risk is under control” (p. 106) as a series of small decisions whittle away at safety margins. Third, these complex systems contain unruly technology (think deepwater drilling) where uncertainties exist about how the technology may be ultimately deployed and how it may fail. Fourth, there is significant interaction with a key environmental player, the regulator, and regulatory capture can occur, resulting in toothless oversight.

“Drifting into failure is not so much about breakdowns or malfunctioning of components, as it is about an organization not adapting effectively to cope with the complexity of its own structure and environment.” (p. 121) Drift and occasionally accidents occur because of ordinary system functioning, normal people going about their regular activities making ordinary decisions “against a background of uncertain technology and imperfect information.” Accidents, like safety, can be viewed as an emergent system property, i.e., they are the result of system relationships but cannot be predicted by examining any particular system component.

Managers' roles

Managers should not try to transform complex organizations into merely complicated ones, even if it's possible. Complexity is necessary for long-term survival as it maximizes organizational adaptability. The question is how to manage in a complex system. One key is increasing the diversity of personnel in the organization. More diversity means less group think and more creativity and greater capacity for adaptation. In practice, this means validation of minority opinions and encouragement of dissent, reflecting on the small decisions as they are made, stopping to ponder why some technical feature or process is not working exactly as expected and creating slack to reduce the chances of small events snowballing into large failures. With proper guidance, organizations can drift their way to success.

Accountability

Amoral and criminal behavior certainly exist in large organizations but bad outcomes can also result from normal system functioning. That's why the search for culprits (bad actors or broken parts) may not always be appropriate or adequate. This is a point Dekker has explored before, in Just Culture (briefly reviewed here) where he suggests using accountability as a means to understand the system-based contributors to failure and resolve those contributors in a manner that will avoid recurrence.

Application to Nuclear Safety Culture

A commercial nuclear power plant or fleet is probably not a complete complex system. It interacts with environmental factors but in limited ways; it's certainly not directly exposed to the Wild West competition of say, the cell phone industry. Group think and normalization of deviance*** is a constant threat. The technology is reasonably well-understood but changes, e.g., uprates based on more software-intensive instrumentation and control, may be invisibly sanding away safety margin. Both the industry and the regulator would deny regulatory capture has occurred but an outside observer may think the relationship is a little too cozy. Overall, the fit is sufficiently good that students of safety culture should pay close attention to Dekker's observations.

In contrast, the Hanford Waste Treatment Plant (Vit Plant) is almost certainly a complex system and this book should be required reading for all managers in that program.

Conclusion

Drift Into Failure is not a quick read. Dekker spends a lot of time developing his theory, then circling back to further explain it or emphasize individual pieces. He reviews incidents (airplane crashes, a medical error resulting in patient death, software problems, public water supply contamination) and descriptions of organization evolution (NASA, international drug smuggling, “conflict minerals” in Africa, drilling for oil, terrorist tactics, Enron) to illustrate how his approach results in broader and arguably more meaningful insights than the reports of official investigations. Standing on the shoulders of others, especially Diane Vaughan, Dekker gives us a rich model for what might be called the “banality of normalization of deviance.” 

* S. Dekker, Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems (Burlington VT: Ashgate 2011).

** See our Sept. 4, 2012 post onCynefin for another description of how the decisions an organization faces can suddenly slip from the Simple space to the Chaotic space.

*** We have posted many times about normalization of deviance, the corrosive organizational process by which the yesterday's “unacceptable” becomes today's “good enough.”

Reflections on the Vit Plant's New Safety Culture Manager: Full Steam Ahead or Time for DOE to Consider a New Plan B?

(Ed. note: Here's a new essay on the Vit Plant by Bill Mullins.  In an era of sound bites and tweets, we provide a forum where complete ideas can be aired.  Please contact us if you would like to contribute.)

“Hanford Contractor Hires New Safety Culture Manager” Oregon Public Broadcasting News 2/8/12

Strange Circumstance: The Safetymatters readership may already have checked out the above item with its announcement of the latest move by the Bechtel National (BNI) management team for the “fast-track, design-build” contract at the Hanford Waste Treatment Plant (WTP).

Reviewing the announcement of Ward Sproat’s assignment to a newly created position “Safety Culture Manager” it seemed appropriate to make a few comments on what a strange turn of affairs this seems to be in what is already a very strange circumstance.

In its Recommendation 2011-1, the Defense Nuclear Facilities Safety Board (DNFSB) “determined that the prevailing safety culture at the Waste Treatment and Immobilization Plant (WTP) is flawed and effectively defeats [DOE Nuclear Safety Policy].”

No previous DNFSB Recommendation has addressed the issue of Nuclear Safety Culture (NSC) and its raising in the far-from-typical circumstance of the WTP contract represents a significant oversight policy challenge for DOE. DOE’s Implementation Plan makes substantial enterprise-wide commitments on the basis of this single exemplar.

Testing Nuclear Safety Culture: The 2011-1 finding arose in the midst of an already contentious WTP setting involving formal nuclear safety “whistle-blower” complaints and a DNFSB formal investigation of the surrounding circumstances. Equally significant is the fact that the WTP project is significantly troubled by questions of technology readiness levels in the key Pretreatment processes. BNI’s contract contains a $100M incentive for early start of waste treatment in the WTP.

One might conclude that the notion of NSC, for all the advocacy of its importance across the global nuclear energy enterprise, is receiving a significant baptism of fire at the WTP. The selection of Mr. Sproat, and the position created for him, allows some reflection upon a key attribute – Leadership – of NSC conventional wisdom.

There appears to be broad consensus that Leadership is important to effective NSC. From the US Nuclear Regulatory Commission (NRC) we have this statement of NSC trait:

“Leadership Safety Values and Actions – Leaders demonstrate a commitment to safety in their decisions and behaviors.”

Similar statements are found in INPO, IAEA and NEI standards on NSC; of interest here is: To what extent does the Leadership norm inform the selection criteria for Mr. Sproat?

Competence Commensurate: At this juncture in the River Protection Program there is a large body of opinion pointing to “Nuclear Safety Culture” as a normative factor that is implicated in difficulties managing the acquisition of the Waste Treatment Plant under DOE’s contract with Bechtel National. On the record, views range from “defective until demonstrated otherwise” (DNFSB); to sanguine (DOE Safety Oversight); to confident about improvement (Bechtel sponsored Independent Safety and Quality Culture Team).

As a framework for assessing the BNI appointment I’m using the DOE’s Integrated Safety Management (ISM) Doctrine (cf. DOE P 450.4A). The ISM Doctrine encompasses NSC.

ISM Guiding Principle #3 states:

“COMPETENCE COMMENSURATE WITH RESPONSIBILITIES.  Personnel possess the experience, knowledge, skills, and abilities that are necessary to discharge their responsibilities."

Given the BNI action to bring Mr. Sproat’s relevant experience to bear on the WTP challenges it seems reasonable to assess his “Competence commensurate with responsibilities” for NSC leadership, and how that relates to the identified needs for WTP project improvement. Stated differently, does the appointment of Mr. Sproat indicate BNI understands what is expected by way of WTP performance improvement?

Determination of Competence: Mr. Sproat has clearly held positions of substantial responsibility; in the near past he was the Presidential Appointee in DOE responsible for development of the Yucca Mountain Repository license application to the NRC – this too was work DOE contracted to Bechtel. Now, one must ask: How does executive experience with preparing a highly structured NRC license application for a geological repository relate to the development of a DOE Authorization Basis for a High Level Liquid Waste treatment facility of very uncertain feasibility?

Mr. Sproat’s experience with DOE projects has been outside the domain of the Environmental Management Program to which the Hanford Tank Waste belongs. Similarly, he appears to have limited experience with Federal Facilities Compliance Agreements which govern major RCRA actions such as the WTP; likewise his knowledge of the DOE practice of nuclear facility “regulation by contract” would appear to be indirect at best. These shortfalls of direct experience will likely make for a steep learning curve.

Mr. Sprout undoubtedly has leadership capacity, but is it relevant to the WTP acquisition? Can DOE rely upon his judgment regarding his fitness for leadership in this very troubled circumstance? As I understand the sense of the several authoritative NSC standards, the importance of “nuclear safety as an over-riding priority” would seem to create a considerable premium on direct experience when the project involved is well outside the “typical” nuclear facility setting – as is the WTP.

The significantly atypical character of the WTP would thus suggest that the assessment of Mr. Sproat’s fit to the challenge should be made by someone who is intimate with the project. Reporting at such a high level, this person would seem to be the BNI Project Manager Mr. Russo, perhaps with the aid of some key reports.

BNI’s Judgment of Fitness: For an assessment of the BNI judgment of Competence Commensurate with Responsibilities, consider Mr. Russo’s announcement of Mr. Sproat’s assignment. Therein, Mr. Russo portrays the January 2012 report of the DOE Office of Health, Security and Safety’s follow up review of safety culture for the WTP project. He observes: “The HSS report is particularly important because it is from the perspective of DOE. As such, it represents the knowledge and experience of the entire weapons complex.” This would not appear to be the case.

At the HSS Report Section 2.2 Scope and Methods we find:

“The applied framework was the one recently described by the NRC. The evaluation was conducted using the same methodology that aligns with the current NRC procedures for independent safety culture assessment.

“The safety culture components important for the existence of a healthy safety culture within a nuclear facility have been identified (INSAG-15, 2002; Institute of Nuclear Power Operations Principles for a Strong Nuclear Safety Culture, 2004; NRC Inspection Manual 0305, 2006). The NRC and its stakeholders have recently agreed upon nine traits that are viewed as necessary in promoting a positive safety culture…

“While the methodology used in this evaluation was based upon work originally developed with the support of the NRC to assess the influence of organization and management on safety performance, the methodology has also been effectively implemented in non-nuclear organizations, such as mining, health care, research, engineering, and transportation.”

Several observations are in order at this point:

•    The analytical framework of this evaluation is taken from a commercial vendor’s standard process. This framework was developed in 1991 at Brookhaven National Laboratory for the US NRC. The principals of the contractor Human Performance Analysis Corporation (HPAC)  were developers of the methodology which is used in a variety of high consequence circumstances and is not particularly tailored to any of the NRC, IAEA, INPO, or other safety culture developments since the inception of the current Reactor Oversight Process in 1999.

•    While the work in 1991 was advanced for its time, there is a case to be made that the “enterprise culture construct” employed then has become obsolescent – at least as far as the civilian nuclear power enterprise is concerned. HPAC cites as reference a culture model developed by Edgar Schein many years before 1991. As recently as 2003 Dr. Schein, in an address to the INPO CEOs on the subject of managing culture change employed a very different construct – he did not use the term “safety culture” in that talk; rather he characterized enterprise culture as emergent of all performance aspects (i.e. production and protection) at the interface of the various distinct professional cultures (executives, engineers, operators, maintainers) where work is planned.

•    While giving lip-service to its definition, neither the HSS Report nor the HPAC Appendix (a separate report from the same assessment data sets) reflects the DOE Safety Culture standard developed jointly in 2009/10 by DOE and Energy Facility Contractors Group (EFCOG). This is significant because the definition of Safety Culture in that work takes shape from the DOE’s Integrated Safety Management Policy and Doctrine – if differs markedly from virtually all NRC and other definitions in that it is not a “safety first” framework (i.e. “overriding priority given to nuclear safety).

•    There is no indication that any of the various Safety Culture assessment and improvement approaches draw upon experience with one-of-a-kind technology development, a multi-facility complex design, process challenged dominated by physical chemistry not radiological concerns, and systematization on a scale unprecedented since the Manhattan project – if even then.

On these bases, Mr. Russo’s contention that the HSS review is indicative of DOE complex-wide expectations for Safety Culture is misplaced.

Finding the Glitch: What can be expected from Mr. Sproat would seem to follow from how valuable his NSC relevant experience will be in curing the misalignment of two professional organizations “facility design” and “safety analysis.” These organizations – one headed by a senior management whistle-blower on this project – have been working for some years to conflicted objectives.

“For the WTP project, DOE decided to implement a “design-build” approach in which significant construction efforts are undertaken in parallel with the design efforts. The goal of this approach was to complete the WTP sooner, thus allowing DOE to meet milestones for addressing tank waste hazards and reducing the environmental and safety risks associated with the hazardous wastes in the tank.”

This statement fails to fully illuminate that fact that it is universally understood in the world of large project acquisition, that “design-build” efforts are only prudently employed in circumstances of high certainty from past precedent both in terms of design, construction methods, resource availability, and other such uncertainty-stabilizing factors. None of these conditions ever pertained in the instance of the WTP.

The over-arching conclusion of the HSS review seems to be this:

“While there is no fear of retaliation in the ORP (including DOE-WTP) work environment, there is a definite unwillingness and uncertainty among employees about the ability to openly challenge management decisions. There are definite perceptions that there is not an environment conducive to raising concerns or where management wants or willingly listens to concerns. Most employees also believe that constructive criticism is not encouraged.”

Like the several other reports on the record this conclusion tells the “What” of the challenge, but not the “Why.”

Conclusion: In the latest HSS Report’s many pages of recommendations it seems clear that conditions observed have not improved much from those of 12 -24 months earlier. While there is plenty of room for improvement on the DOE side of the ledger, it is difficult to avoid a conclusion that the appointment of Mr. Sproat, and his arrival’s announcement by Mr. Russo, suggest that BNI still sees the unresolved design and technology development challenges as “punch-list items.”

For BNI, even in the midst of the prolonged “safety culture” uproar, it appears the many disparate review results still comprise a “Full Steam Ahead” matter to be resolved by top-down command and control management methods.  I wish them luck with that – to DOE I suggest looking toward a radical Plan B.

(Mr. Mullins is a Principal at Better Choices Consulting.)

VIT Plant Glop (Part 2)

(Ed. note: We're pleased to present an interesting take on the Vit Plant from Bill Mullins as a guest contributor.  We welcome contributions from others who would like to contribute leading edge thinking on nuclear safety culture.)

Bob Cudlin’s Jan. 24 post concludes, "Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting might be the better emphasis."

From where I sit, in this simple piece of seemingly practical advice hides much of the iceberg the WTP Titanic keeps circling around to repeatedly encounter amidst the fog of Nuclear Safety Culture (NSC) and such.

The key word is "expectations” – this is because for DOE the definition of Quality is “performance that meets or exceeds requirements and expectations.” Importantly the DOE Quality standard embraces a “continuous improvement” criterion. This definition of Quality and its attendant context are considerably more expansive than the one found at 10 CFR 50 Appendix B – and there is a very necessary reason for that.

At the Program level all the DOE Mission portfolios are of the Discover and Develop type. DOE programs and projects are chartered to go where none has gone before (i.e. nor generally can afford the capital risks to go such places first).

Not every project in DOE is of comparable difficulty, but many (e.g., the Environmental Management Program) of the sub-portfolios (e.g., Hanford Cleanup) take decades of trial and error practice to create reliable Acquisition Strategies.

Even now the Hanford Cleanup work is pretty well partitioned between 1) things we now do reliably and with a modicum of efficiency (cf. River Corridor Cleanup contract), and 2) that Goop/Gorp unconventional uncertainty. Today the former goes well and the latter goes poorly.

The WTP is a full-blooded Discover and Develop enterprise - the high-level tank waste is vastly more subtle in its physical chemistry than DOE and its prime contractor have been willing to acknowledge to their stakeholders in the Tri-Party Agreement with EPA and WA State. The stakeholders seem reluctant to puncture the veil of schedule illusion as well.

Generally I conclude the River Protection Program (RPP), which governs the WTP development, is not sufficiently aware of its vulnerability to unconventional uncertainty. It is the more unpredictable behavior of the tank waste that should be the center of attention; not unrealistic schedules and life cycle budget estimates into the far future.

It is this (some would say “studied”) blindness that the DNFSB is ultimately getting at via its nuclear safety oversight charter – I’m inclined to doubt that the Board recognizes the blind spot any better than most in DOE leadership. Like the carpenter with only a hammer on his tool belt, the Board’s way of framing issues with progress at the RPP tends to make every unanticipated or unwelcome outcome seem like a “nuclear safety nail.”

At the end of most days this over-dramatization of nuclear safety significance has been a deliberate strategy of the Board since it began its Safety in Design “action-forcing” campaign about four years ago.

In broad reality, the situation of the RPP can be viewed as a matter of inadequate safety consciousness or poorly chosen Acquisition Strategy – the latter perspective has more traction precisely because in encompasses protection concerns without being dragged into the “good vs. bad” attitude debates – which tend to be the heart of NSC conversations - that are presently fogging the air of the Hanford 200 Area.

Later in Bob’s post he observes: “In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.”

This conclusion is not without its supporting evidence: From the time that the Walt Thomasitus pushback on Bechtel Management began, DOE Office of River Protection project management has responded from a position that reeks annoyance and resentment. This has not helped with sorting out the key issues at the WTP, in fact when the Recommendation 2011-1 appeared the knee-jerk defensive response of the Deputy Secretary actually made things worse for a time.

There are now three prominent whistle-blowers feeding the maw of both GAO and the national press.*  Unfortunately, Thomasitus, Alexander, and Busche each raise concerns about whether the plant will work as advertised – not as matters of Acquisition Strategy, but as safety issues. That is unfortunate because it leads to this: “The treatment plant "is not a project that can be stopped and restarted," said Rep. Doc Hastings, R-Wash.”**

Just lately, we have a memorandum from the Secretary and Deputy Secretary that I believe finally puts a suitable Line Management framework around the 2011-1 IP and the WTP issue.  It will take a further post to elaborate the basis for my belief that this particular memorandum “answers the mail” about NSC in the DOE nuclear programs. At that point I can also suggest what I see as the barriers to this missive gaining the policy high ground against the wave of other “over-commitments” throughout the remainder of the 2012-1 IP.

(Mr. Mullins is a Principal at Better Choices Consulting.)

*  P. Eisler, “Problems plague cleanup at Hanford nuclear waste site,” USA Today (Jan. 25, 2012).

**  P. Eisler, “Safety at Wash. nuclear-waste site scrutinized,” USA Today (Jan. 27, 2012).

***  Letter from D.B. Poneman to P.S. Winokur transmitting DOE Memorandum dated Dec. 5, 2011 from S. Chu and D.B. Poneman to Heads of All Departmental Elements re: Nuclear Safety at the Department of Energy (Jan. 24, 2012).

Vit Plant Glop

Hanford WTP

DOE’s Waste Treatment Plant at Hanford, the “Vit Plant”, is being built to process a complex mixture of radioactive waste products from 1950s nuclear weapons production.  The wastes, currently in liquid form and stored in tanks at the site, was labeled “gorp” by William Mullins in one of his posts on the LinkedIn Nuclear Safety thread.*  Actually we think the better reference is to “glop”.  Glop is defined at merriam-webster.com as “a thick semiliquid substance (as food) that is usually unattractive in appearance”.  Readers should disregard the reference to food.  We would like to call attention to another source of “glop” accumulating at the Vit Plant.  It is the various reports by DOE and Hanford regarding safety culture at the site, most recently in response to the Defense Nuclear Facilities Safety Board’s (DNFSB, Board) findings in June 2011.  These forms of glop correspond more closely to the secondary definition in m-w, that is, “tasteless or worthless material”.

The specific reports are the DOE’s Implementation Plan (IP)** for the DFNSB’s review of safety culture at the WTP and the DOE's Office of Health, Safety and Security (HSS) current assessment of safety culture at the site.  Neither is very satisfying but we’ll focus on the IP in this post.

What may be most interesting in the DOE IP package are the reference documents including the DNFSB review and subsequent exchanges of letters between the Secretary of Energy and the DNFSB Chairman.  It takes several exchanges for the DNFSB to wrestle DOE into accepting the findings of the Board.  Recall in the Board’s original report it concluded:

“Taken as a whole, the investigative record convinces the Board that the safety culture at WTP is in need of prompt, major improvement and that corrective actions will only be successful and enduring if championed by the Secretary of Energy.” (IP, p. 33)***

In DOE’s initial (June 30, 2011) response they stated:

“Even while DOE fully embraces the objectives of the Board’s specific recommendations, it is important to note that DOE does not agree with all of the findings included in the Board’s report.”  (IP, p. 42)****

It goes on to state that “specifically” DOE does not agree with the conclusions regarding the overall quality of the safety culture.  Not surprisingly this brought the following response in the DNFSB’s August 12, 2011 letter, “...the disparity between the [DOE’s] stated acceptance and disagreement with the findings makes it difficult for the Board to assess the response….”  (IP, p. 46)*****  Note that in the body of the IP (p. 4) DOE does not acknowledge this difference of opinion either in the summary of its June 30 response or the Board’s August 12 rejoinder. 

We note that neither the DNFSB report nor the DOE IP is currently included among the references on Bechtel's Vit Plant website.  One can only wonder what the take away is for Vit Plant personnel — isn’t there a direct analogy between how DOE reacts to issues raised by the DNFSB and how Vit Plant management respond to issues raised at the plant?  Here’s an idea: provide a link to the safetymatters blog on the Vit Plant website.  Plant personnel will be able to access the IP, the DNFSB report and all of our informative materials and analysis.

In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.  Their cause analysis focuses on inadequate expectation setting, more knowledge and awareness and (closer to the mark) the conflicting goals emerging in the construction phase (IP, pp. 5-8).  While endlessly citing all the initiatives previously taken or underway, never does the DOE reflect on why these initiatives have not been effective to date.  What is DOE’s answer?  More assessments and surveys, more training, more “guidance”, more expectations, etc.

We do find Actions 1-5 and 1-6 interesting (IP, p. 16).  These will revise the BNI contract to achieve “balanced priorities”.  This is important and a good thing.  We have blogged about the prevalence of large financial incentives for nuclear executives in the commercial nuclear industry and assessments of most, if not all, other significant safety events (BP gulf disaster, BP refinery fire, Upper Big Branch coal mine explosion, etc.) highlight the presence of goal conflicts.  How one balances priorities is another thing and a challenge.  We have blogged extensively on this subject - search on “incentives” to identify all relevant posts.  In particular we have noted that where safety goals are included in incentives they tend to be based on industrial safety which is not very helpful to the issues at hand.  Our favorite quote comes from our April 7, 2011 post re the gulf oil rig disaster and is taken from Transocean’s annual report:

“...notwithstanding the tragic loss of life in the Gulf of Mexico, we [Transocean] achieved an exemplary statistical safety record as measured by our total recordable incident rate (‘‘TRIR’’) and total potential severity rate (‘‘TPSR’’).”

Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting, might be the better emphasis.  Then monitoring and independently assessing how specific technical and safety issues are reviewed and decided.  Training, expectations setting, reinforcement, policies, etc. are useful in “setting the table” but the test of whether the organization is embracing and implementing a strong safety culture can only be found in its actions.  Note that the Board’s June 2011 report focused on two specific examples of deficient decision processes and outcomes.  (One, the determination of the appropriate deposition velocity for analysis of the transport of radioactivity, the other the conservatism of a criticality analysis.)

There are two aspects of decisions: the process and the result.  The process includes the ability to freely raise safety concerns, the prioritization and time required to evaluate such issues, and the treatment of individuals who raise such concerns.  The result is the strength of the decision reached; i.e., do the decisions reinforce a strong safety culture?  We have posted and provided examples on the blog website of decision assessment using some methods for quantitative scoring.

*  The link to the thread is here.  Search for "gorp" to see Mr. Mullins' comment.

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

***  IP Att. 1, DNFSB Recommendation 2011-1, “Safety Culture at the Waste Treatment and Immobilization Plant” (June 9, 2011).

****  IP Att. 2, Letter from S. Chu to P.S. Winokur responding to DNFSB Recommendation 2011-1 (June 30, 2011) p. 4.

*****  IP Att. 4, Letter from P.S. Winokur  to S. Chu responding to Secretary Chu’s June 30, 2011 letter (Aug. 12, 2011) p. 1.