Training Materials for Teaching NRC Personnel about Safety Culture

This is a companion piece to our Aug. 24, 2015 post on how the NRC effectively regulates licensee safety culture (SC) in the absence of any formal SC regulations.  This post summarizes a set of NRC slides* for training inspectors on SC basics and how to integrate SC information and observations into inspection reports.

The slides begin with an overview of SC, material you’ve seen countless times.  It includes the Chernobyl and Davis-Besse events, the Schein tri-level model and a timeline of SC-related activities at the NRC.

The bulk of the presentation shows how SC is related to and incorporated in the Reactor Oversight Process (ROP).  The starting point is the NRC SC Policy Statement, followed by the Common Language Initiative** which defined 10 SC traits.  The traits are connected to the ROP using 23 SC aspects.  Aspects are “the important characteristics of safety culture which are observable to the NRC staff during inspection and assessment of licensee performance” (p. 13)  Each SC aspect is associated with one of the ROP’s 3 cross-cutting areas: Human Performance (14 aspects), Problem Identification and Resolution (6 aspects) and Safety Conscious Work Environment (3 aspects).  During supplemental and reactive inspections there are an additional 12 SC aspects to be considered.  Each aspect has associated artifacts that indicate the aspect’s presence or absence.  SC aspects can contribute to a cross-cutting theme or, in more serious cases, a substantive cross-cutting issue (SCCI).***

The integration of SC findings into inspection reports is covered in NRC Inspection Manual Chapter 0612 and NINE different NRC Inspection Procedures (IPs). (p. 30)  In practice, the logic chain between a SC aspect and an inspection report is the reverse of the description in the preceding paragraph.  The creation of an inspection report starts with a finding followed by a search for a related SC cross-cutting aspect.  Each finding has one most significant cause and the inspectors should “find the aspect that describes licensee performance that would have prevented or precluded the performance deficiency represented by that cause.” (p. 33)

Our Perspective

This is important stuff.  When NRC inspectors are huddled in their bunker evaluating their data and observations after reviewing your documentation, crawling around your plant and talking with your people, the information in these slides provides the road map for their determination of how one or more alleged SC deficiencies contributed to a performance problem which resulted in an inspection finding.

Think of the SC aspects as pegs on which the inspectors can hang their observations to beef up their theory of why a problem occurred. Under routine conditions, there are 23 pegs; under more stringent inspections, there are 35 pegs.  That’s a lot of pegs and none of them is trivial which means your organization’s response may consume sizable resources.

We’ll finish with a more cheery thought:  If you get to the point where the NRC is going to conduct an independent assessment of your SC, their team will follow the guidance in IP 95003.  But don’t worry about their competence, “IP 95003 inspection teams will receive "just-in-time" training before performing the inspection.” (p. 43)

Bottom line: If it looks like controlling oversight behavior and quacks like a bureaucrat, then it probably is de facto regulation.


*  NRC Training Slides, “Safety Culture Reactor Oversight Process Training” (July 10, 2015).  ADAMS ML15191A253.  The slides include other material, e.g., a summary of the conditions under which the NRC can “request” a licensee to perform a SC assessment, a set of case studies and sample test questions for trainees.

**  The Common Language Initiative led to NUREG-2165, “Safety Culture Common Language” which was published in early 2014 and we reviewed on April 6, 2014.

***  There are some complicated decision rules for determining when a problem is a substantive cross-cutting issue and these are worth reviewing on pp. 27-28.

Notes on Regulatory Capture

NRC Public Meeting

A couple of recent local news items discuss a too-cozy relationship between regulators and the supposedly regulated, to the detriment of ratepayers and ordinary citizens.  Neither is nuclear-related but they may give us some ideas on how regulatory capture might (or does) manifest in the nuclear industry.

PG&E and the CPUC

First up is an article* about Pacific Gas and Electric Co. (PG&E) and the California Public Utilities Commission (CPUC).  PG&E is responsible for the deadly 2010 gas main explosion in San Bruno, CA.  It was later revealed that PG&E was involved in private, i.e., secret, lobbying to get the CPUC judge it wanted to handle the case.  An as investigation later concluded, such ex parte discussions gives the utilities an advantage over other participants in the regulatory process.

The article concentrates on remedial legislation working its way through the system.  One bill would close the loophole that allows secret meetings between the CPUC and a regulated entity under certain conditions.  Another would create an independent inspector general for the agency.

Berkeley Zoning Adjustment Board 

This editorial** focuses on a city zoning board that is stuffed with members whose background is in the development industry.  It quotes at length local resident James McFadden who has some excellent observations about the nature of regulatory capture in this situation.

“Although many people are quick to assume that capture means corruption, they really are different things.

“Capture is more of an aligning of economic world views, not necessarily to any monetary advantage, often just to make one's job easier or more pleasant in dealing with people on a day to day basis . . . .

“Captured individuals . . . don't see their behavior as incorrect.  They have forgotten that their role is to provide oversight and protection to the public . . . Their public meetings evolve into patronizing facades of democracy.

“. . . For the most part, capture is about creating a pleasant working environment with those in industry who they deal with on a daily basis.  It is a slow and insidious process that strikes at the heart of human psychology which allows us to work in groups. . . . When we-the-public show up and complain, we become the opponent to be ignored.

“. . . The [public] meeting becomes a dance of false empowerment where getting through the meeting on time is more important than focusing on important issues or input from the public.”

Our Perspective

Do you see any of the above behavior in the nuclear industry?  Here’s a clue to get you started: the mental model for all federally regulated or controlled activities, viz., the infamous “iron triangle” of special interests, Congress and federal bureaucrats.  In the nuclear space, utility lobbyists and industry organizations encourage/pressure Congress for favorable treatment in exchange for support at election time.  Congress leans on the NRC when job losses are threatened because of a lengthy plant shutdown or costly “over regulation.”  The NRC listens to or cooperates with industry “experts” when it is considering new policies, regulations or interpretations.  We believe the iron triangle is alive and well in the nuclear industry but is nowhere near as scurrilous as, say, the welfare system.

(Now the anti-nukes also lobby Congress and certain members of Congress are relentless critics of the NRC.  Do the scales balance?  And where does the clash of lobbying titans leave Joe Citizen?)

Expanding on one side of the triangle, nuclear utilities make efforts to build organizational, professional and personal relationships with the NRC because it’s in their direct economic interest to do so.  In the other direction, don’t NRC personnel try to get along with utility people they see on a regular basis?  Who wants to alienate everybody all the time?  The NRC tries to avoid being too cozy with the utilities but they can’t completely avoid it.  They are in the same business and speak the same language.  However, it’s far from scandalous, like the relationship between the former Minerals Management Service and the offshore drilling industry.  And there is no overactive revolving door between the NRC and industry.

What about outsiders who try to influence policy?  At the top, gadflies who address agency-wide issues or work with HQ personnel may eventually get a seat at the table.  But in the field, Jane Citizen making a statement at a meeting concerning the local plant probably doesn’t have as much leverage.  Consider how difficult it is for the average whistleblower to have an impact.

The Wikipedia entry on regulatory capture cites Princeton professor Frank von Hippel, Barack Obama, Joe Biden, Greenpeace, the Union of Concerned Scientists and the Associated Press to support the position that the NRC has been “captured.”  Has the NRC been too accommodating to the industry?  You be the judge.

There is an old saying: “Familiarity breeds contempt.”  That’s true in some cases.  In other situations, familiarity breeds—greater familiarity.


*  J. Van Derbeken, “CPUC reform bills on governor’s desk,” San Francisco Chronicle (Sept. 15, 2015).  Questionable conduct flowed both ways.  It also came to light that the then-President of the CPUC appeared to offer his support for PG&E’s (and other utilities’) positions on regulatory cases in return for their contributions to his favorite political causes.  That’s called influence peddling.

**  B. O'Malley, “Berkeley's Zoning Board Slouches Toward Birthing Its Monster,” Berkeley Daily Planet (Sept. 13, 2015).  The Daily Planet is an online progressive (lefty) newspaper in Berkeley, CA.

DNFSB Hearing on Safety Culture Progress at the Waste Treatment and Immobilization Plant (WTP)

The WTP aka the Vit Plant

On August 26, 2015 the Defense Nuclear Facilities Safety Board (DNFSB) held a hearing in the Hanford area to receive testimony from senior DOE officials representing DOE Headquarters, the Office of River Protection (ORP) and the WTP project regarding the current status of DOE efforts to improve safety culture (SC) at the WTP.  A senior DNFSB staff member also testified on DOE’s SC improvement efforts.

There is a video of the meeting but no transcript is yet available.* 

The panel of DOE managers enumerated the work that has been undertaken to improve SC at the WTP.**  Based on their written submittals, it is predictable and not especially interesting material.  Selected excerpts follow:

G. Podonsky (DOE HQ) – “. . . positive turn in the safety culture.  However, much work remains . . . . As our assessments of safety culture indicate, management often has a more positive outlook on the state of the safety culture than do the workers.”

K. Smith (ORP Mgr) – This is mostly a laundry list of actions, initiatives and putative progress.  “. . . ORP’s safety culture today . . .  is improving and headed in the right direction. . . . But there are areas that still need work . . .”

W.F. Hamel Jr. (Federal Project Director WTP) – This focuses on more specific, project-level actions.  “We believe we have made significant strides. . . . sustaining a healthy safety culture requires persistence and consistency at all levels of the organization . . .”  He gave a shout out to Bechtel for progress in improving their SC and the Safety Conscious Work Environment (SCWE).

After the panel completed their presentation, the DNFSB staff member responsible for overseeing WTP (and other DOE) SC efforts had ten minutes to provide the staff perspective on DOE’s efforts.  He summarized the SC assessments that have taken place at the WTP and other facilities in the DOE complex.***  His testimony had more “howevers” than a Consumer Reports review of a mediocre automobile.  For example, DOE’s original plan was developed prior to the 2012 SC assessment and did not include the latter’s findings.  DOE modified their plan for Hanford but it was not applied to other DOE facilities.  The DOE themes did not address the root causes the DNFSB identified in their 2011 Recommendation.  He was also critical of the DOE’s extent of condition review.

He was asked one question by the meeting chair: “Is the bad (i.e., not supportive of SC) management behavior identified in 2011 still occurring?”  The answer was “It’s mixed. Some yes and some no.”  The chair was clearly not happy with that answer after four years of effort.

Our Perspective

The DOE bureaucrats identified a passel of SC-related improvement activities and claim progress is being made but there is still work to accomplish.  The testimony of the DNFSB staffer was less optimistic.  A statement contributed for the record by an anonymous “concerned engineer” includes examples that look like they came straight from the bad old days.****  We have reviewed most the DOE/WTP assessments, action plans and progress reviews on Safetymatters; click on the DOE or WTP label to see related posts.  Call us harsh, but we don’t believe there will be any substantive changes in the way business is conducted at Hanford until the bad stuff starts leaching into the Columbia River.

On a slightly brighter note, the DNFSB is back to full strength with five members, including a new chairman.  From looking at the press releases, it appears they have added folks with federal/military backgrounds and middling technical exposure.  The new chair is a career technical functionary whose last stint was at the White House.  It’s hard to get All-Stars for a toothless agency.  What they can contribute to oversight of DOE remains to be seen.  We wish them well.


*  The video is here.  Testimony and statements are available here but most are scanned copies which means quotes have to be retyped and may not totally accurate.  For an overview of the meeting see A. Cary, "National board hears safety culture is improving at Hanford vit plant," Tri-City Herald (Aug. 26, 2015).

**  Statement for the Record and Additional Information of G. Podonsky, Office of Enterprise Assessments (Aug. 26, 2015).  Testimony of K. Smith, Manager, Office of River Protection (Aug. 26, 2015).  Testimony of W.F. Hamel Jr., Federal Project Director, Waste Treatment and Immobilization Plant (Aug. 26, 2015).

***  Testimony of D.B. Bullen, Group Lead, Nuclear Programs and Analysis, DNFSB.  The question and answer are not verbatim but paraphrased from the exchange between Bullen and the chair that occurs from about 1:52 to 1:55 in the video.

****  Statement from concerned engineer (Aug. 26, 2015).

NRC Regulation of Safety Culture: How They Do It

We have griped many times about how the NRC does, in fact, regulate (i.e., control or direct) licensee safety culture (SC) even though the agency claims it doesn’t because there is no applicable regulation.

A complete description of the agency’s approach was provided in 2010 NRC staff testimony* before the Atomic Safety and Licensing Board.  Note this testimony was given before the Safety Culture Policy Statement was issued but we believe it depicts current practices.  The key point is that “Oversight of an operating reactor licensee’s safety culture is implemented by the ROP [Reactor Oversight Process].” (p. 17)  Following are some lengthy quotes from the testimony and you can decide whether or not they add up to “regulation.”

“The ROP provides for the oversight of a licensee’s safety culture in four ways.  First, the ROP provides for the review of a licensee’s safety culture in a graded manner when that licensee has significant performance issues.  The level of the staff’s oversight is determined by the safety significance of the performance issues.  This review and evaluation is described in the ROP’s supplemental inspection program . . . An IP 95002 inspection is usually performed when a licensee enters [column 3] . . . of the ROP Action Matrix. . . [In certain circumstances] the NRC will request the licensee to perform an independent safety culture assessment.  An IP 95003 inspection is performed when a licensee enters [column 4] . . . of the ROP Action Matrix.  When this occurs, the NRC expects [emphasis added] the licensees to perform a third-party safety culture assessment.  The staff will review the results of the assessment and perform sample evaluations to verify the results.

“Second, the ROP’s reactive inspection program evaluates a licensee’s response to an event, including consideration of contributing causes related to the safety culture components, to fully understand the circumstances surrounding an event and its probable causes.

“Third, the ROP provides continuous oversight of licensee performance as inspectors evaluate inspection findings for cross-cutting aspects.  Cross-cutting aspects are aspects of licensee performance that can potentially affect multiple facets of plant operations and usually manifest themselves as the root causes of performance problems. . . .**

“Fourth, the ROP provides for the review of a licensee’s safety culture if that licensee has difficulty correcting long-standing substantive cross-cutting issues.  In these cases, the NRC will request the licensee to perform a safety culture assessment, and the NRC Staff will evaluate the results and the licensee’s response to the results.” (pp. 18-19)  In addition, “The ROP assessment process looks at long-standing substantive cross-cutting issues to determine if safety culture assessments need to be performed and reviewed.” (p. 24)  Significantly, “Safety culture is addressed through the use of cross-cutting issues which do not relate to the Action Matrix column that a plant may be placed in.” (p. 32)

Our Perspective

In our opinion, SC is regulated via a linkage to ongoing NRC activities.  Outputs from NRC inspection activities performed under the aegis of regulation (i.e., law) are used to assess licensee SC and force licensees to perform activities, e.g., SC assessments or corrective actions***, that the licensees might not choose to perform of their own free will.

The reality is NRC “requests” or “expectations” are like a commanding officer’s “wishes”; the intelligent subordinate understands they have the force of orders.  Here’s how the agency describes the fist inside the glove: “If the NRC requests a licensee to take an action, and the licensee refuses, the Agency can perform that action (i.e., the safety culture assessment) for them.” (p. 29)  We assume the NRC would invoke its regulatory authority to justify such an assessment.  But what licensee would want an under-experienced posse of federal inspectors, who expect to find problems because why else would they be assigned to the task, running through their organization?

Occasionally, the NRC drops the veil long enough to reveal the truth.  An NRC staffer (one of the witnesses who sponsored the ASLB testimony described above) recently made a presentation to the Korean nuclear regulator.  It included a figure that summarizes the SC aspects of the ROP Action Matrix.  Under columns 3 and 4, the figure says “may request” and “request” the licensee to conduct a SC assessment.  However, on the next page, the presentation bullets are more forthcoming: “For Plants in Columns 3 . . . and 4 . . . NRC requires [emphasis added] Licensee to conduct third party safety culture assessment which is reviewed by NRC.”****

We’re not opposed to the NRC squeezing licensees to strengthen their SC.  We just don’t like hypocrisy and doublespeak.  Perhaps the agency takes this convoluted approach to controlling SC to support their claim they don’t interfere with licensee management.  We don’t believe that; do you?


*  NRC Staff Testimony of V.E. Barnes et al Concerning Safety Culture and NRC Safety Culture Policy Development and Implementation before the Atomic Safety and Licensing Board (July 30, 2010) revised Sept. 7, 2010.  ADAMS ML102500605.

**  The ROP framework includes three cross-cutting areas (human performance, problem identification and resolution, and safety conscious work environment) which contain nine safety culture components. (p. 23)

***  This is another leverage point for the agency.  They make sure SC assessment findings are entered in the licensee’s corrective action program (CAP).  Then they use their regulatory authority over the CAP to ensure it is useful and effective, i.e., that SC corrective actions are implemented. (p. 30)

****  M. Keefe, “Incorporating Safety Culture into the Reactor Oversight Process (ROP),” presentation to the Korea Institute of Nuclear Safety (June 2-3, 2015), pp. 5-6.  ADAMS ML15161A109.

CPUC Proposes to Probe PG&E’s Culture

CPUC Headquarters (Source: Coolcaesar on en.wikipedia)

Yesterday’s edition of a Bay Area newspaper included a report* on a California Public Utilities Commission (CPUC) proposal to undertake a deep review of Pacific Gas & Electric’s (PG&E) culture and governance.  This is part of the long tail of consequences, including fines and criminal charges, the company has experienced in the aftermath of the Sept. 9, 2010 gas main explosion in San Bruno, CA.

The author got a Georgetown law professor (Scott Hempling) to opine on the situation and he had a couple of interesting observations:

“. . . for any utility, perhaps the most significant potential root cause of subpar performance is a culture of a entitlement, arising from the fact that the utility does not have to compete to maintain its monopoly.”

As to whether the CPUC has the authority to order changes at PG&E, he said “If it's not the PUC, then perhaps the state Legislature.  That monopoly that PG&E has was not granted by God.  It's not in the U.S. Constitution.  It is granted either by the PUC or the state Legislature."

What would your state regulator find if they stuck a probe into your organization?  Would there be a significant reading on the entitlement meter?

Diablo Canyon

At Safetymatters our major concern is with nuclear safety culture (SC) so it’s natural to ask how or even if the proposed review could affect Diablo Canyon.  On the surface, the answer is no probable impact.  PG&E’s problems and accidents have been concentrated in its gas business.  And from the get-go, PG&E has worked to isolate Diablo Canyon from the rest of the company.  But the plant’s many implacable opponents constitute a wild card in this situation.  You can bet they will do everything they can to get the scope of any CPUC review to include Diablo Canyon’s SC and operations.


*  G. Avalos, “San Bruno aftermath: PUC eyes broad probe of PG&E,” Contra Costa Times online (Aug. 17, 2015).

For more details on the CPUC proposal, see their press release: “CPUC Set to Consider Investigation into PG&E’S Culture and Governance to Ensure Safety is a Priority” (Aug. 17, 2015).

A Quiet Conclusion to Millstone’s TDAFW Pump Problem

Millstone

On Jan. 15, 2015 we posted about the long time it took Millstone to correctly evaluate and fix a problem with a turbine-driven auxiliary feedwater (TDAFW) pump.  The lengthy problem resolution caught the attention of the plant’s state overseer and the NRC.  We wondered if the event was a harbinger of some slippage in Millstone’s safety culture (SC).

The NRC conducted a supplemental inspection into the pump issue and published their results in late July.*  Because this inspection was conducted using Inspection Procedure 95001, one NRC action was to verify that the licensee’s root cause evaluations appropriately considered SC.  The inspectors’ SC findings, summarized below, are on pp. 7-8 of the report details.

Dominion (Millstone’s owner) identified SC-related weaknesses in three cross-cutting areas:

Problem Identification and Resolution and Human Performance, Conservative Bias

The licensee identified several instances where evaluations of issues or events were not complete, evaluations were less than timely and/or thorough and corrective actions were not sustainable.  In addition, the licensee identified instances of inadequate decision making and bypassing the Corrective Action Program (CAP) program implementation.

The corrective action in both areas was to make changes in the organizational behavior through station leadership stand downs and by improving the scheduling of daily CAP related meetings to ensure adequate engagement in the processing and review of CAP products.

Human Performance, Procedure Adherence

The licensee identified instances where corrective actions were not completed as written. Dominion’s corrective actions include CAP group reviews for specified corrective action assignments, implementing a Corrective Action Review Board coordinator and restricting manager level functions in the central reporting system to department managers.

Overall, the inspectors determined that Dominion’s root cause, extent of condition, and extent of cause evaluations appropriately considered SC components.

Our Perspective

The SC fixes are from the everyday menu: more management involvement, better oversight and improved organizational practices.  The report also mentioned additional traditional fixes (upgraded procedures, more training and the development of relevant case studies) applied to other aspects of how and how well the plant investigated its handling of the pump problem.  Taken together, they are concrete, if not exactly momentous, actions to improve a vital organizational process, i.e., the CAP.  In addition, the fixes are consistent with the plant's position that the TDAFW pump problem was a localized issue.

We would like to see a more systemic investigation of SC-related factors but the actions taken reflect an acceptable SC and reinforce our perception that Dominion (unlike Millstone’s former owner) takes safety seriously.


*  R.R. McKinley (NRC) to D.A. Heacock (Dominion), “Millstone Power Station Unit 3 – NRC Supplemental Inspection Report 05000423/2015010 and Assessment Follow-Up Letter” (July 22, 2015).  ADAMS ML15202A473.

Obtain Better Decisions by Asking Better Questions

We’re currently experiencing a reduced flow of quality feedstock into our safety culture mill.  But we did see a reference to a Harvard Business Review (HBR) article* that’s worth a quick read.

The authors’ thesis is the pressure on business to make decisions ever more quickly means important questions may never get asked, or even considered, which leads to poor decision-making.  Their proposed fix is to ask more, better questions to help frame decisions.  They suggest four types of questions, presented in the consultant’s favorite typology:  the two-by-two matrix.  In this case, one axis is the View of the Problem (wide or narrow) and the other is the Intent of the Question (to affirm or discover), as shown in the following figure.

Types of Questions to Improve Decision Making  (Source Mu Sigma)

Clarifying questions are focused on helping participants or managers understand what has happened so far, e.g., the data gathered or partial decisions already made.  People often don’t ask these questions because of cultural pressures to move forward, or they tend to make assumptions and fill in any missing parts themselves.**

Adjoining questions explore related aspects of the problem utilizing available information, e.g., how the results of this analysis could be applied elsewhere. 

Funneling questions are focused on learning more about the analysis to date.  How was an answer derived?  What were your assumptions?  What are the root causes of this problem?  The authors opine that most analytical teams usually do a good job of asking this type of question.

Elevating questions raise broader issues and create opportunities to make new connections between individual decisions, e.g., what are the larger issues or trends we should be concerned about?

There is a cultural dimension to question asking, particularly the unspoken rules about what types of questions can be asked, and by whom, in the decision making process.  Leaders need to encourage people to ask questions and co-workers need to be tolerant of the question askers rather than pushing to obtain and deliver an answer.

Our Perspective

The information in this article is hardly magical.  Most of us recognize that the best investigators and managers know What kind of questions they are asking and Why.  But we do have a few exercises for you to think about.   

For starters, look at the questions suggested or prescribed in your official problem-solving or problem analysis recipes.  Do they omit any types of questions that could add value to your immediate situation, bigger picture issues or the overall process?

What’s your problem solving culture like?  How are people treated who ask questions, especially devil’s advocate questions, that don’t add instant value to the search for an answer?

Finally, consider Millstone’s issue with a turbine-driven auxiliary feedwater pump (which we reviewed on Jan. 15, 2015).  Could more extensive questioning during the initial analysis phase have more quickly led the investigators to a correct understanding of the problem?    


*  T. Pohlmann and N.M. Thomas, “Relearning the Art of Asking Questions,” Harvard Business Review on-line (Mar. 27, 2015).  The authors are not famous professors.  They are two consultants with a Mu Sigma, a Big Data company, who are publishing under the HBR aegis.  That doesn’t disqualify their work, it’s just something to keep mind as they describe a construct their firm uses.

**  For an informative and entertaining essay on how people develop their own models of what’s going on in the world, even when they are wildly misinformed, check out “We Are All Confident Idiots.”