2012 NRC Safety Culture Survey Results

ADAMS ML13087A326

Originally published 4-4-13.  This version updated with data from the associated staff briefing slide presentation.

The 2012 NRC Safety Culture and Climate Survey results are available in an Inspector General report* and a consultants' slide briefing.**  The top-level findings are (1) the 2012 results are not as favorable as the previous 2009 survey results and (2) the NRC compares favorably with national norms but lags when compared to a group of high performing companies (with strong financial results and high employee survey scores).  Let's look at some of the details.  All page references are to the report except where noted otherwise. 

The survey's 132 items were aimed at evaluating employee perceptions in 20 categories.  Many of these categories primarily addressed personnel practices—communication, supervision, diversity, training, development and the like.  However, it should come as no surprise to our regular readers that the categories of interest to us address, at least in part, the key business processes of decision making, priority setting and conflict resolution, i.e., areas where the goal of safety often competes with other goals.

Four categories appear to satisfy our criteria:

DPO/Non-Concurrence (DPO): “. . . employee awareness and perceived effectiveness of the Differing Professional Opinions program and the Non-concurrence process.”  This is one type of conflict resolution.  This category had the lowest number of favorable responses (although still over 50%) in the survey. (p. 13)  Three specific DPO items were among those that showed the most slippage, i.e., had fewer favorable responses, in 2012 compared to 2009. (Slides, p. 16)  Region IV had significantly*** fewer favorable 2012 scores on DPO compared to 2009. (p. 26) 

The consultants' cover letter identified this as an area for NRC management attention, saying the agency was “Losing significant ground on negative reactions when raising views different from senior management, supervisor, and peers.” 

NRC Mission and Strategic Plan: “. . . whether employees believe management decisions are consistent with the mission and strategic plan. . . .”    Compared with the high performing companies, the NRC scored 1 point lower on NRC Mission and Strategic Plan. (p. 17)  The Office of New Reactors and Region IV had significantly fewer favorable 2012 scores on NRC Mission and Strategic Plan compared to 2009. (pp. 25-26) 

The NRC Mission and Strategic Plan was identified as one of three key drivers of employee Engagement, also a survey category**** but treated as a dependent variable in a supporting multiple regression analysis.  In responding to specific questions, employees said they believed they were “sufficiently informed about NRC's performance of its mission” and that “management decisions are consistent with the mission” but both items scored significantly lower than in 2009 and compared to the high performing companies. (Slides, p. 33)

Quality focus: “. . . employee views on . . . the sacrifice of quality work due to the need to meet a deadline or the need to satisfy a personal or political agenda.”  This category had the third lowest number of favorable responses in the survey. (p. 13)  This category was also mentioned in the consultants' cover letter: “Reinforcing a key point raised in the focus groups [but one that did not stand out in the survey results], there is a clear opportunity to impact the perception that people sacrifice quality in order to meet metrics.”

Senior Management: “. . . confidence in management’s decisions.”  Compared with the high performing companies, the NRC scored 7 points lower on Senior Management, in a 3-way tie for second lowest. (p. 17)  This result may have been affected by this item: Only 41 percent of the respondents “. . . feel significant actions have been taken as a result of the previous Safety Culture and Climate survey.” (Slides, p. 23)  This issue was included in the list of conclusions to the consultants' report.  On the other hand, at least 75% favorable responses were recorded for senior management providing a clear sense of direction and employee confidence in senior management decisions. (Slides, p. 23)  That may look good but both items scored significantly lower than in 2009 and compared to the high performing companies.

The Office of New Reactors and Region IV had significantly less favorable 2012 scores on Senior Management compared to 2009. (pp. 25-26)  Region IV also had a significantly less favorable 2012 score on Senior Management than the overall NRC score. (p. 23)

Our Perspective

The report consists of mostly charts and graphs, with a lot of superficial data slicing and dicing and some authoritative-sounding conclusions.  The slide presentation shows additional data to illustrate some problem areas.  Both documents reinforce our belief in the limited usefulness of surveys and the problems associated with over-reliance on outside experts.  My “analysis” above is obviously limited but it's difficult to dig deeply because only a few of the 132 specific items are detailed in the report and slides. 

But the available data suggest that raising views inconsistent with the party line can lead to negative reactions.  NRC employees have some confidence the agency makes decisions consistent with its mission but less confidence in their senior management to take action on survey results.   

NRC senior management has a much more favorable view of the agency's situation than the overall organization.  Senior managers' survey responses were significantly more favorable than the overall NRC response in ALL 20 categories and an average of 18 percent more favorable in the 4 categories included in this post. (Slides, p. 37)  This suggests a possible disconnect between the bosses and everyone else.

And speaking of disconnections, it appears neither the group responsible for the Nuclear Renaissance nor Region IV is fully on the same page as the rest of the agency.

Finally, the documents' omission of safety as a goal or priority is notable.  “Nuclear safety” as a goal is only mentioned in the definition of SC.  Safety is mentioned as “safety concepts” in the Training category and the “NRC’s commitment to public safety” in the Continuous Improvement Commitment category.  One might expect safety to be more front and center in the SC survey. 


*  NRC Office of the Inspector General, “2012 NRC Safety Culture and Climate Survey,” OIG-13-A-15 (March 28, 2013)  ADAMS ML13087A326.  Although this was mostly a survey, the consultants (Towers Watson) did conduct some individual interviews and focus groups to help shape the survey content. Interestingly, the definition of safety culture used in the 2012 survey was not the same as the definition in the current NRC policy statement.  Instead, an earlier definition was used to permit comparisons between current survey results and prior years.

**  Towers Watson, “Nuclear Regulatory Commission 2012 Safety Culture and Climate Survey Briefing for NRC Staff” (Nov. 8, 2012).

***  “Significant” means statistically significant.

****  Engagement “Probes employees’ willingness to recommend the NRC as a good place to work, whether they feel they are a part of the agency, their pride in working for the NRC and their belief in NRC goals, objectives, and values.” (p. 10)

Safety Culture at the Pantex Plant

Pantex Plant

On January 25, 2013 we posted about DOE's report to the Defense Nuclear Facilities Safety Board (DNFSB) on the results of safety culture (SC) assessments at several DOE facilities, including the Pantex Plant.  Pantex was assessed because two Pantex employees had reported retaliation for raising a safety concern but the plant also had a history of potentially SC-significant issues.*

The Pantex SC assessment was performed in November 2012.  The report included several significant findings:

“Efforts to communicate and implement the principles of a High Reliability Organization (HRO) have been ongoing for several years. . . . [However,] The realization of the HRO principles has not yet been internalized by the Plant, . . .”

“The belief that the organization places a priority on safety is undermined by employee observations of poor facility conditions, lack of focus on meeting personal needs (work quality of life), and a sense of cronyism. . . . [This] has created the perception among many employees that the financial bottom line is the only focus that matters.

“There is a strong perception that retaliation exists for ‘rocking the boat.’ . . . The perception has created an environment where the raising of questions or identification of problems is not the consistently accepted way of doing business.

“The Pantex Plant has not been successful in understanding the organizational and programmatic behaviors that are necessary for a healthy safety culture. . . . organizational barriers have been created that will prevent successful implementation of the initiatives needed to enhance safe and reliable performance. . . . The barriers are also evident in the lack of respect, difficulty in effective communication, the non-alignment between the perceptions around the unions and management relationships and the notion of ‘need to know’ being extended to almost everything.”**

Sounds serious.  So what's happened since the report was published?  Well, DNFSB held a public meeting on March 14, 2013 to discuss SC problems at Pantex and management's approach to addressing them.  As one might expect, the DOE opening statement declared the SC problems were intolerable and DOE had taken immediate action—by firing off a letter to the contractor. 

“NNSA issued a letter to B&W Pantex directing immediate focus at all management and working levels to a safety conscious work environment (SCWE) for all on-going activities and operations. . . . Other immediate actions included the development of a single stop/pause work process which was provided to all employees and discussed at daily work planning meetings. The Employee Concerns Program and Equal Opportunity Office reporting chain was immediately elevated to a direct report to the General Manager’s Office, providing the highest level accesses for any employee concerns in these areas. Additionally, the differing professional opinion process was reinstated providing a formal mechanism for recognition and resolution of differing views on technical matters.

“Further, this letter directed B&W Pantex to prepare a comprehensive long-term corrective action plan mentioned previously, taking into account the Institute of Nuclear Power Operations (INPO) paper on the principles of a strong nuclear safety culture.”***

DOE listed actions being implemented, including an SC focus team, a seminar on HRO attributes, SCWE training, the issuance of a plant-specific SC policy and an alignment of performance incentives with SC objectives. 

Babcock & Wilcox (B&W)

B&W, the entity that actually has to do the work, did not file any written testimony for the public meeting so we have to go to the meeting video for their comments.****

B&W appears to be on board with the need for change.  The B&W plant general manager and his safety manager were appropriately deferential to the DNFSB members and seemingly well-informed about the plant's remedial actions and SC improvement initiatives.  The GM said he “fully accepts” the assessment findings (which were consistent with the plant's own SC survey conducted just prior to the DOE HSS assessment) and acknowledged that specific problems, e.g., communication issues with respect to safety vs production, existed.  Improving SC/SCWE is the GM's “top priority.”  B&W reiterated its commitment to building an HRO at Pantex, an initiative that overlaps with actions to strengthen SC and SCWE.  Perhaps the most significant change the GM described was that 30% of managers' performance evaluations would be based on their modeling of appropriate SC/SCWE traits.

Our perspective    

Problem solved?  Not yet and not for awhile.  Pantex had some serious vertical communication and organizational structure issues.  Their attempt to build an HRO has been ongoing for years.  Their SCWE has had some cold spots. 

In addition, the actions Pantex has initiated may be necessary but there is no guarantee they will be sufficient to achieve the plant's SC/SCWE/HRO goals.  For example, there is no real discussion of how decision making processes will be affected other than resolving Nuclear Explosive Safety issues and the usual commitment to conservative decision making.  There is no mention of a corrective action program (or some functional equivalent); an integrated process for identifying, evaluating and fixing problems is essential for ensuring safety, priorities and resource allocation are treated consistently throughout the plant.

We'll watch for progress (or lack thereof) and keep you posted.


*  Pantex is the sole US site that assembles and disassembles nuclear weapons.  Within DOE, the National Nuclear Security Administration (NNSA) has line management responsibility for Pantex.  Babcock & Wilcox is responsible for managing and operating the plant under contract with DOE.

The SC issues identified in the November 2012 assessment did not pop out of nowhere.  The DNFSB identified SC-related concerns at the plant during the previous year.  See statement of D.G. Ogg, Group Lead for Nuclear Weapons Programs, DNFSB, at the Pantex public meeting (March14, 2013).
   
**  DOE Office of Enforcement and Oversight, “Independent Oversight Assessment of Nuclear Safety Culture at the Pantex Plant” (Nov. 2012) p. 3.  The report is attached to the letter from G.S. Podansky (DOE) to P.S. Winokur (DNFSB) transmitting five independent safety culture assessments (Dec. 12, 2012).

***  Written testimony of Neile Miller, Acting Administrator, NNSA before the Defense Nuclear Facilities Safety Board Pantex Plant Public Meeting (March 14, 2013), p. 4. 

****  The meeting video is available on the DNFSB website.  The NNSA panel on Pantex SC runs from about 1:25 to 2:30, the B&W panel runs from about 2:35 to 3:20.

NRC Regulatory Information Conference (RIC) - Safety Culture (cont.)

Last week we previewed the safety culture (SC) content of the then-upcoming NRC RIC.  The Idaho National Lab speaker's slides were not available at that time but they are now and his presentation is reviewed below.  The focus is on the Advanced Test Reactor Programs but I think it's fair to infer that the thinking is representative of a wider swath of the DOE complex.

The presentation opens with five lengthy quotes from Admiral Rickover's November 1983 assessment of GPU and its competence to operate TMI-1.  The apparent intent is to illustrate that the principles for safe nuclear operations have been known (or at least available) for a long time.  Coincidentally, we posted on the Rickover assessment two months ago, and focused on one of the same quotes.  If you aren't acquainted with Rickover's seven principles, you really should read the introduction to the assessment, which is available from the Dickinson College library.

The presentation describes components of the new DOE Cross Cutting Performance Areas for category 1, 2 and 3 nuclear facilities:  Evaluating the effectiveness of operations, maintenance, engineering and training programs; developing, monitoring and evaluating SC; and evaluating issue identification and resolution activities, including the significance determination process and the evaluation and resolution process for high significance issues.

The presentation concluded with a list of areas being emphasized at the Idaho lab: What is the right (as opposed to allowable) thing to do, educating leaders, communications, and decision making that reflects a learning organization and doesn't result in safety drift.

The presentation hit most of the right notes, a major exception being no mention of management or contractor financial incentive plans.  However, the unmistakable tone is there is really nothing new required of the lab, just a refinement of past and current practices.  Perhaps that's true for them but I have limited confidence in DOE entities' ability to self-evaluate.  We're pretty sure SC issues exist or have existed at other DOE facilities, especially the Vit Plant (click the label in the top right-hand column to pull up our posts).

NRC Regulatory Information Conference (RIC) - Safety Culture Preview

The RIC is this week, March 12-14.  The teaser on the NRC blog says the technical sessions will include safety culture (SC) policies.  Let's look at the program agenda and see what's in store for SC.

There will be 36 technical sessions.  I reviewed all the titles and drilled down into sessions that might make some mention of SC, e.g.,  T4 - Construction Inspection Experience–The First Year and T7 - Human Impacts.  However, I could find no mention of SC in any of the currently available slide presentations.

That left the last technical session on the agenda: TH36 - The NRC’s Safety Culture Policy Statement–Domestic and International Initiatives.  Following is a summary of the available presentations for this session.

The introductory remarks summarize the development of the SC policy statement and its implementation.  There is no news here.

The SC common language presentation reviews the history of this initiative (which we have previously reviewed here and here).  The presentation has one quotable statement: “NRR will work to incorporate language into the ROP guidance documents and inspection procedures, as appropriate.”  Does that sound like back door regulation of SC to you?

A presentation on domestic and international cooperation reviews the relationship between NRC and INPO, NRC and IAEA, and others.  As an example of cooperation, the authors summarize the INPO SC survey data that were collected from operating plants and then analyzed by INPO (and later NRC) to show “statistically significant relationships between safety culture survey results and measures of plant performance.”  We commented on this work when it first appeared in 2010, congratulating INPO for making the effort and agreeing with some of the findings but finally concluding that the analysis was incomplete and potentially misleading.   

An industry presentation by Nuclear Fuel Services Inc. (NFS) describing their SC improvement program is worth a look.  It lists almost two dozen program components, none of which is a trivial undertaking, which suggest how much work is involved in changing an existing SC.  (I have no idea if NFS is actually pursuing the listed activities or how well they're doing.)

All in all, it's probably not worth traveling to Bethesda if you're seeking enlightenment about SC. 

Schein at INPO in 2003

In November 2003 Professor Edgar Schein gave a speech at the INPO CEO conference.*  It was not a lengthy academic lecture but his focus on managing culture, as opposed to changing or creating it, was interesting.  At the time Schein was doing some work for ConEd and had a notion of nuclear plant culture, which he divided into four sub-cultures: engineering, hourly, operator and executive, each with its own underlying assumptions and values.

The engineering culture emphasizes elegant, possibly expensive designs that minimize the role of error-prone humans.  Engineers want and value respect from other engineers, including those outside the plant (an external orientation). 

The hourly culture (which I think means maintenance) values teamwork and has an experience-based perspective on safety.  They want job security, fair wages, good equipment, adequate training and respect from their peers and supervisors.

The operator culture values teamwork and open communications.  They see the invaluable contributions they make to keeping the plant running safely and efficiently.  They want the best equipment, training and to be recognized for their contributions.

The executive culture is about money.  They want productivity, cost control, safety and good relations with their boards of directors (another external orientation).

These sub-cultures are in conflict because they all can't have everything they want.  The executive needs to acknowledge that cultural differences exist and each sub-culture brings certain strengths to the table.  The executive's role is to create a climate of mutual respect and to work toward aligning the sub-cultures to achieve common goals, e.g., safety.  The executive should not be trying to impose the values of a single sub-culture on everyone else.  In other words, the executive should be a culture manager, not a culture changer.

This was a brief speech and I don't want to read too much into it.  There are dysfunctional or no longer appropriate cultures and they have to be reworked, i.e., changed.  But if many things are working OK, then build on the existing strengths.**

This was not a speech about cultural interventions.  At the beginning, Schein briefly described his tri-level cultural model and noted if the observed artifacts match the espoused values, then there's no need to analyze the underlying assumptions.  This is reminiscent of Commissioner Apostolakis' comment that “. . . we really care about what people do and maybe not why they do it . . . .”


*  E.H. Schein, “Keeping the Edge: Enhancing Performance Through Managing Culture,” speech at INPO CEO Conference (Nov. 7, 2003).  I came across this speech while reviewing the resources listed for a more contemporary DOE conference.

**  Focusing on strengths (and not wasting resources trying to shore up weaknesses unless they constitute a strategic threat) is a management prescription first promoted by Peter Drucker.

Massey Energy

Another domino has fallen in the ongoing determination of culpability at Massey Energy in the Big Branch mine disaster.  The February 28, 2013 Wall Street Journal* reports that the former head of a Massey subsidiary, Green Valley Coal, warned miners when federal inspectors were on their way into mines and to conceal safety hazards.  The former executive specifically stated that the order to do this came from Massey’s CEO.

Thus it appears prosecutors are following the trail of bread crumbs in an inexorable climb to the CEO level.  So often situations like this are simply attributed to weaknesses in the organization’s safety culture, particularly at the working levels.  It is assumed that senior management’s policies and direction to make safety the first priority aren’t permeating the organization.  More training, more indoctrination in safety priorities is required to get workers aligned with their corporate leadership.  But what is becoming very apparent in the case of Massey, it is the intentional decisions by senior management prioritizing production over safety that drove the behavior of subordinates - and it was those working levels that suffered the immediate consequences.  Now perhaps the consequences are being more fairly distributed.


*  "Guilty Plea in Case Tied to Massey Mine Blast," Wall Street Journal online (Feb. 28, 2013).

The Safety Culture Common Language Path Forward (Update)

The intent of the NRC's Safety Culture Common Language Path Forward initiative is to describe safety culture (SC) attributes at a more detailed level than the NRC’s SC policy statement.  On January 29-30, 2013 the NRC held a public workshop to finalize the draft SC common language.*  The document they issued after the workshop** contains attribute definitions and examples of behavior and artifacts that support or embody each attribute.  This document will be used by the NRC to develop a NUREG containing the final common language.

Last March we posted on a draft produced by previous workshops, focusing on areas we consider critical for a strong SC: decision making, corrective action, management incentives and work backlogs.  In that post, our opinion was that decision making and corrective action were addressed in a satisfactory manner, the treatment of incentives was minimally acceptable and backlogs were all but ignored.

So, how does the “final” language treat the same subject areas?  Is it better than the draft comments we reviewed last March?  The arrows indicate whether the final version is better ↑, the same → or worse ↓.

Decision making – Good↑.  Decision making incorporates “. . . a consistent, systematic approach to make decisions” (p. 51) and a conservative bias, i.e., “. . . decision-making practices that emphasize prudent choices over those that are simply allowable. A proposed action is determined to be safe in order to proceed, rather than unsafe in order to stop.” (p. 52)  In addition, communicating, explaining and justifying individual decisions is mentioned throughout the document. 

Goal conflict is addressed under leader behavior “. . . when resolving apparent conflicts between nuclear safety and production” (p. 12) and leaders “avoid unintended or conflicting messages that may be conveyed by operational decisions” (p. 37); work process “activities are coordinated to address conflicting or changing priorities.” (p. 23) 

Corrective action – Satisfactory→.  The section on problem identification and resolution (pp. 13-17) is suffused with desirable characteristics of corrective actions and the CAP.  A good CAP has a low threshold for identifying issues and problems are thoroughly evaluated.  Corrective actions are timely, effective and prevent recurrence of problems.  Periodic analysis of CAP and other data is used to identify any programmatic or common cause issues.

Management incentives – Unsatisfactory↓.  The section on incentives appears to focus on workers, not managers: “Leaders ensure incentives, sanctions, and rewards are aligned with nuclear safety policies and reinforce behaviors and outcomes which reflect safety as the overriding priority.” (p. 7)  This is even less complete than the single sentence that appeared in last year's draft: “Senior management incentive program [sic] reflect a bias toward long-term plant performance and safety.”*** The failure to mention the senior management incentive program is a serious shortcoming.

Backlogs – Minimally Acceptable↑.  Backlogs are specifically mentioned in maintenance and engineering (p. 24) and document changes (p. 25).  In addition, problem evaluation, corrective actions, CAP trending analyses, operating experience lessons and many administrative activities are supposed to be addressed in a “timely” manner.  I hope that implies that backlogs in these areas should not be too large.     

But attention to backlogs is still important.  Repeating what we said last year, “Excessive backlogs are demoralizing; they tell the workforce that accomplishing work to keep the plant, its procedures and its support processes in good repair or up-to-date is not important.  Every “problem plant” we worked on in the late 1990s had backlog issues.”

Conclusion

Overall, this latest document is an improvement over the March 2012 version but still short of what we'd like to see.


*  M.J. Keefe (NRC) to U.S. Shoop (NRC), “Summary of the January 29-30, Workshop to Develop Common Language for Safety Culture” (Feb. 7, 2013)  ADAMS ML13038A059.

**  Nuclear Safety Culture Common Language 4th Public Workshop January 29-31, 2013  ADAMS ML13031A343.

***  U.S. Shoop (NRC) to J. Giitter (NRC), “Safety Culture Common Language Path Forward” (Mar. 19, 2012) p. 12.  ADAMS ML12072A415.

Personal and Organizational Habits: A Threat to Safety Culture?

A book I received as a gift got me thinking about habits: The Power of Habit: Why We Do What We Do in Life and Business by Charles Duhigg.*  Following is a summary of selected points that we can relate to safety culture (SC) and our assessment of the book's usefulness for SC aficionados. 

Habits are automatic activity sequences people exhibit when they perceive specific triggering cues in the environment.  Habit behavior is learned, and directed toward achieving some reward, which may be physical or psychological.  The brain creates habits to conserve energy and operate more efficiently; without habits people would be overwhelmed by the countless decisions they would have to make to complete the most mundane tasks, e.g., driving to work.

People use habits at work to increase their productivity and get things done.  Unfortunately, habits can allow potential safety threats to slip through the cracks.  How?  Because while Rational Man considers all available alternatives before making a decision, and Satisficing Man consciously picks the first alternative that looks good enough, Habit Man is carrying out his behavior more or less unconsciously.  If the work environment contains weak signals of nascent problems or external environmental threats, then people following their work habits are not likely to pick up such signals.  Bad work habits may be the handmaiden of complacency.

Organizations also have habits (sometimes called routines).  Routines are important because, without them, it would be much more difficult to get work accomplished.  Routines reduce uncertainty throughout the organization and create truces between competing groups and individuals.  Some routines are the result of decisions made long ago, others evolve organically.  They are so embedded in the organization that no one questions them.**

Duhigg includes many case studies involving individuals and organizations.  One organizational case study is worth repeating because it focuses on changing safety habits.

When Paul O'Neill*** became Alcoa CEO in 1987 he made improving worker safety his first initiative.  He believed the habits that led to safety were keystone habits and if they could be changed (improved) then other business routines would follow.  In this case, he was correct.  Proper work routines are also the safest ones; over time quality and productivity improved and the stock price rose.  The new routines resulted in new values, e.g., intolerance for unsafe practices,  becoming ingrained in the culture.

The bottom line

I'd put this book in the self-help category—the strongest sections focus on individuals, how they can be crippled by bad habits, and how they can change those habits.  With the exception of the Alcoa case, this book is not really about SC so I'm not recommending it for our readers but it does stimulate thought about the role of unconscious habits and routines in reinforcing a strong SC, or facilitating its decay.  If work habits or routines become frozen and cannot (or will not) adjust to changes in the external or task environment, then performance problems will almost surely arise.      


*  C. Duhigg,  The Power of Habit: Why We Do What We Do in Life and Business (New York: Random House 2012).  To simplify this post and focus on a linkage to SC, many of the book's concepts are not mentioned in the main text above.  For example, when the brain links the reward back to the cue, it creates a neurological craving; the stronger the craving, the more likely the cue will trigger the activities that lead to the reward.  Bad habits can be changed by inserting a new activity routine between the cue and the reward.  A belief that change is possible is needed before people will attempt to change their habits; willpower and self-discipline are necessary for changes to stick.  A real (or manufactured) crisis can make organizational routines amenable to change.

**  The result can be the worst kind of machine bureaucracy: rigid hierarchies, organizational silos, narrow employee responsibilities, and no information shared or questions asked.

***  O'Neill later served as U.S. Treasury Secretary during 2001-2002.

Safety Culture - Lessons from the Social Science Literature

In 2011 the NRC contracted with the Pacific Northwest National Laboratory to conduct a review of social science literature related to safety culture (SC) and methods for evaluating interventions proposed to address issues identified during SC assessments.  The resultant report* describes how traits such as leadership, trust, respect, accountability, and continuous learning are discussed in the literature. 

The report is heavily academic but not impenetrable and a good reference work on organizational culture theory and research.  I stumbled on this report in ADAMS and don't know why it hasn't had wider distribution.  Perhaps it's seen as too complicated or, more importantly, doesn't exactly square with the NRC/NEI/industry Weltanschauung when the authors say things like:  

“There is no simple recipe for developing safety culture interventions or for assessing the likelihood that these interventions will have the desired effects.” (p. 2)

“The literature consistently emphasizes that effecting directed behavioral, cognitive, or cultural change in adults and within established organizations is challenging and difficult, requires persistence and energy, and is frequently unsuccessful.” (p. 7)

This report contains an extensive review of the literature and it is impossible to summarize in a blog post.  We'll provide an overview of the content, focusing on interesting quotes and highlights, then revisit Schein's model and close with our two cents worth.

Concept of safety culture

This section begins with the definition of SC and the nine associated traits in the NRC SC policy statement, and compares them with other organizations' (IAEA, NEI, DOE et al) efforts. 

The Schein model is proposed as a way to understand “why things are as they are” as a starting point upon which to build change strategies aimed at improving organizational performance.  An alternative approach is to define the characteristics of an ideal SC, then evaluate how much the target organization differs from the ideal, and use closing the gap as the objective for corrective strategies.  The NEI approach to SC assessment reflects the second conceptual model.  A third approach, said to bridge the difference between the first two, is proposed by holistic thinkers such as Reason who focus on overall organizational culture. 

This is not the usual “distinction without a difference” argument that academics often wage.  Schein's objective is to improve organizational performance; the idealists' objective is to make an organization correspond to the ideal model with an assumption that desired performance will follow. 

The authors eventually settle on the high reliability organization (HRO) literature as providing the best basis for linking individual and organizational assumptions with traits and mechanisms for affecting safety performance.  Why?  The authors say the HRO approach identifies some of the specific mechanisms that link elements of a culture to safety outcomes and identifies important relationships among the cultural elements. (p. 15)  A contrary explanation is that the authors wanted to finesse their observation that Schein (beloved by NRC) and NEI have different views of the the basis that should be used for designing SC improvement initiatives.

Building blocks of culture 

The authors review the “building blocks” of culture, highlighting areas that correspond to the NRC safety culture traits.  If an organization wants to change its culture, it needs to decide which building blocks to address and how to make and sustain changes.

Organizational characteristics that correspond to NRC SC traits include leadership, communication, work processes, and problem identification and resolution.  Leadership and communication are recognized as important in the literature and are discussed at length.  However, the literature review offered thin gruel in the areas of work processes, and problem identification and resolution; in other words, the connections between these traits and SC are not well-defined. (pp. 20-25)

There is an extensive discussion of other building blocks including perceptions, values, attitudes, norms**, beliefs, motivations, trust, accountability and respect.  Implications for SC assessment and interventions are described, where available.  Adaptive processes such as sense making and double-loop learning are also mentioned.

Change and change management

The authors review theories of individual and organizational change and change management.  They note that planned interventions need to consider other changes that may be occurring because of dynamic processes between the organization and its environment and within the organization itself.

Many different models for understanding and effecting organizational change are described.  As the authors summarize: “. . . change is variously seen as either pushed by problems or pulled by visions or goals; as purposive and volitional or inadvertent and emergent; as a one-time event or a continuous process. It is never seen as easy or simple.” (p. 43)

The authors favor Montaño and Kaspryzk’s Integrated Behavioral Model, shown in the figure below, as a template for designing and evaluating SC interventions.  It's may be hard to read here but suffice to say a lot of factors go into an individual's decision to perform a new behavior and most or all of these factors should be considered by architects of SC interventions.  Leadership can provide input to many of these factors (through communication, modeling desired behavior, including decision making) and thus facilitate (or impede) desired behavioral changes.

From Montaño and Kaspryzk

Resistance to change can be wide-spread.  Effective leadership is critical to overcoming resistance and implementing successful cultural changes.  “. . . leaders in formal organizations have the power and responsibility to set strategy and direction, align people and resources, motivate and inspire people, and ensure that problems are identified and solved in a timely manner.” (p. 54)

Lessons from initiatives to create other specific organizational cultures

The authors review the literature on learning organizations, total quality management and quality organizations, and sustainable organizations for lessons applicable to SC initiatives.  They observe that this literature “is quite consistent in emphasizing the importance of recognizing that organizations are multi-level, dynamic systems whose elements are related in complex and multi-faceted ways, and that culture mirrors this dynamic complexity, despite its role in socializing individuals, maintaining stability, and resisting change.” (p. 61)

“The studies conducted on learning, quality, and sustainable organizations and their corresponding cultures contain some badly needed information about the relationship among various traits, organizational characteristics, and behaviors that could help inform the assessment of safety cultures and the design and evaluation of interventions.” (p. 65)  Topics mentioned include management leadership and commitment, trust, respect, shared vision and goals, and a supportive learning environment.

Designing and evaluating targeted interventions 

This section emphasizes the potential value of the evaluation science*** approach (used primarily in health care) for the nuclear industry.  The authors go through the specific steps for implementing the evaluation science model, drilling down in spots to describe additional tools, such as logic modeling (to organize and visualize issues, interventions and expected outcomes), that can be used.  There is a lot of detail here including suggestions for how the NRC might use backward mapping and a review of licensee logic models to evaluate SC assessment and intervention efforts.  Before anyone runs off to implement this approach, there is a major caveat:

“The literature on the design, implementation, and evaluation of interventions to address identified shortcomings in an organization’s safety culture is sparse; there is more focus on creating a safety culture than on intervening to correct identified problems.” (p. 67)

Relation to Schein

Schein's model of culture (shown on p. 8) and prescriptions for interventions are the construct most widely known to the nuclear industry and its SC practitioners.  His work is mentioned throughout the PNNL report.  Schein assumes that cultural change is a top-down effort (so leadership plays a key role) focused on individuals.  Change is implemented using an unfreeze—replace/move—refreeze strategy.  Schein's model is recommended in the program theory-driven evaluation science approach.  The authors believe Schein's “description of organizational culture and change does one of the best jobs of conveying the “cultural” dimensions in a way that conveys its embeddedness and complexity.” (p. 108)  The authors note that Schein's cultural levels interact in complex ways, requiring a systems approach that relates the levels to each other, SC to the larger organizational culture, and culture to overall organizational functioning.

So if you're acquainted with Schein you've got solid underpinnings for reading this report even if you've never heard of any of the over 300 principal authors (plus public agencies and private entities) mentioned therein.  If you want an introduction to Schein, we have posted on his work here and here.

Conclusion

This is a comprehensive and generally readable reference work.  SC practitioners should read the executive summary and skim the rest to get a feel for the incredible number of theorists, researchers and institutions who are interested in organizational culture in general and/or SC in particular.  The report will tell you what a culture consists of and how you might go about changing it.

We have a few quibbles.  For example, there are many references to systems but very little to what we call systems thinking (an exception is Senge's mention of systems thinking on p. 58 and systems approach on p. 59).  There is no recognition of the importance of feedback loops.

The report refers multiple times to the dynamic interaction of the factors that comprise a SC but does not provide any model of those interactions.  There is limited connectivity between potentially successful interventions and desired changes in observable artifacts.  In other words, this literature review will not tell you how to improve your plant's decision making process or corrective action program, resolve goal conflicts or competing priorities, align management incentives with safety performance, or reduce your backlogs.


*  K.M. Branch and J.L. Olson, “Review of the Literature Pertinent to the Evaluation of Safety Culture Interventions” (Richland, WA: Pacific Northwest National Laboratory, Dec. 2011).  ADAMS ML13023A054

**  The authors note “The NRC safety culture traits could also be characterized as social norms.” (p. 28)

***  “. . . evaluation science focuses on helping stakeholders diagnose organization and social needs, design interventions, monitor intervention implementation, and design and implement an evaluation process to measure and assess the intended and unintended consequences that result as the intervention is implemented.” (p. 69)

Talking Sheep at Palisades

In Lewis Carroll’s Through the Looking Glass, Alice and the White Queen advance into the chessboard's fifth rank by crossing over a brook together, but at the very moment of the crossing, the Queen transforms into a talking sheep.  Alice soon finds herself struggling to handle the oars of a small rowboat, where the Sheep annoys her with nonsensical shouting.  Now consider the NRC’s Nov. 9, 2012 followup inspection report* at Palisades related to the DC panel event and the Service Water pump coupling failure.  It brings to mind a similar picture - in this case inspectors struggling to propel a small rowboat of substance on a river of nonsensical jargon and bureaucratese.

Reading this inspection report (IR) reveals endless repetition of process details and findings of other reports, and astonishingly little substance or basis for the inspectors' current findings and conclusions.  The IR “assesses” the findings of the Palisades root cause analysis and associated extent of condition and corrective actions.  The discussion is deeply ingrained with yellow findings, white findings, crosscutting this and cornerstone that, a liberal dose of safety culture traits and lots of significance determinations.  Frankly it’s hard to even remember what started the whole thing.  Perhaps of most interest, the IR notes  that much of the Palisades management team was replaced in the period since these two events. (p. 23)  Why?  Were they deemed incompetent? Unwilling to implement appropriate risk and safety priorities?  Or just sacrificial lambs? (more sheep).  It appears that these changes carried significant weight with the NRC inspectors although it is not specifically stated. 

Then there is this set of observations:

“During interviews the inspectors heard that there were concerns about staffing levels in multiple departments, but the site was aware and was actively working with Entergy corporate management to post and fill positions. . . Entergy Corporate was perceived by many on the site to be stifling progress in filling positions.  The many issues at Palisades and staffing problems have contributed to the organization becoming more reactive to addressing maintenance and equipment reliability issues versus being proactive in addressing possible problems.” (p. 23)

Which is it?  The site was actively working with Entergy or Entergy was stifling progress in filling positions?  Without further amplification or justification the IR delivers its conclusion: “The inspection team concluded the safety culture was adequate and improving.” (p. 24, emphasis added)  There is no discussion of how or on what basis the inspectors reached this conclusion.  In particular the finding of “improving” is hard to understand as it does not appear that this inspection team had previously assessed the safety culture at the site.

At one point the IR stumbles into a revealing and substantive issue that could provide significant insight into the problems at Palisades.  It describes another event at the plant with a lot of similarities to the DC panel. 

“The inspection team focused inspection efforts on ... an occurrence when, on May 14, 2012, workers erroneously placed a wire jumper between 115 Volt AC and 125 Volt DC circuits ...many of the actions and behaviors exhibited by the workers involved were similar in nature to the loss of DC bus event that occurred in September 2011...Those similar behaviors included the lack of a pre-job brief and discussion regarding the limitations of the work scope, workers taking action outside of the scope allowed by ‘toolpouch maintenance,’ supervisors failing to adequately challenge the workers, and workers proceeding in the face of uncertainty when unexpected conditions arose.” (p. 21)

So far so good.

“Many of the supervisors and managers the inspection team interviewed stated that the May 2012 near-miss was not a repeat event of the September 2011 event because the May 2012 near-miss involved only a handful of individuals, whereas the September 2011 occurrence involved multiple individuals across multiple organizations at Palisades. The inspectors agreed that the May 2012 near-miss involved fewer individuals, but there were individuals from several organizations involved in the near-miss. The inspectors concluded that the RCE assessment was narrow in that it stated only the field work team failed to internalize the cause and corrective actions from the September 2011 DC bus event. The inspectors concluded that other individuals, including the WCC SRO, CRS, and a non-licensed plant operator also exhibited behaviors similar to those of the September 2011 DC bus event.” (p. 21)

Still good but starting to wonder if the Palisades supervisors and managers really got the lessons learned from September 2011.

“The inspectors determined that, while the May 2012 near-miss shared some commonalities with the September 2011 event, the two conditions were not the result of the same basic causes. The inspectors reached this conclusion because the May 2012 near-miss did not result in a significant plant transient [emphasis added] and also did not exhibit the same site wide, organizational breakdowns in risk recognition and management that led to the September 2011 event.” (pp. 21-22)

Whoops.  First, what is the relevance of the outcome of the May 2012 event?  Why is it being alluded to as a cause?  Are the inspectors saying that if in September 2011 the Palisades personnel took exactly the actions they took but had the good fortune not to let the breaker stab slip it would not be a significant safety event?  

With regard to the extent of organizational breakdown, in the prior paragraph the inspectors had pushed back on this rationale - but now conclude the May 2012 event is different because it was not “site-wide”.  It is not clear how you square these arguments particularly if one goes back to the original root cause of  the DC panel event: 

“...senior leaders had not established a sufficiently sensitive culture of risk recognition and management, which resulted in the plant’s managers, supervisors, and workers not recognizing, accounting for, or preparing for the industrial safety risk and plant operational nuclear risk…” (p. 1) and, quoting from the licensee root cause analysis “site leadership at all levels was not sufficiently intrusive into work on panel ED-11-2.” (p. 13)

It is hard to see how the May 2012 event didn’t exhibit these same causes.  In addition, the “Why Staircase” in the Palisades root cause analysis (p. 21) does not identify or allude to the extent of involvement of multiple organizations - at all.  While we do not believe that such linear, “why” thinking is adequate for a complex system, it is the basis for what Palisades found and what the NRC inspectors accepted.

We’re not really sure what to make of this inspection effort.  On its face it doesn’t provide much of a basis for its conclusion that the safety culture is adequate and improving.  Perhaps the real basis is the new management team?  Or perhaps the NRC doesn’t really have many options in this situation.  If the current inspection found the weaknesses not to have been resolved, what could the NRC do?  Is there such a thing as an “inadequate” safety culture?  Or just safety culture that need improvement?  It seems the NRC’s safety culture construct has created a Looking Glass-like inversion of reality - maybe a convenient trope within the agency but increasingly a baffling and unsatisfying distraction to achieving competent nuclear safety management. 

Bottom line:  The NRC close out inspection is a baaaad report.


*  S. West (NRC) to A. Vitale (Entergy), “Palisades Nuclear Plant - NRC Supplemental Inspection Report 05000255/2012011; and Assessment Follow-up Letter” (Nov. 9, 2012) ADAMS ML12314A304.

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).

May Day

This is another in our series of posts following up the Upper Big Branch coal mine disaster in April 2010. As reported in the Wall Street Journal* a former superintendent in the Massey Energy mine, Gary May, was sentenced to 21 months in prison for his part in the accident. Specifically May “warned miners that inspectors were coming and ordered subordinates to falsify a record book and disable a methane monitor so workers could keep mining coal.”

The U.S. attorney in charge of the case is basing criminal indictments on a conspiracy that he believes “certainly went beyond Upper Big Branch.” In other words the government is working its way up the food chain at Massey with lower level managers such as May pleading guilty and cooperating with prosecutors. The developments here are worth keeping an eye on as it is relatively rare to see the string pulled so extensively in cases of safety failures at the operating level. The role and influence of senior executives will ultimately come under scrutiny and their culpability determined not on the slogans they promulgated but on their actions.

* K. Maher, “Former Mine OfficialSentenced to 21 Months,” Wall Street Journal (Jan. 17, 2013).

Adm. Hyman Rickover – Systems Thinker

The TMI-2 accident occurred in 1979. In 1983 the plant owner, General Public Utilities Corp. (GPU), received a report* from Adm. Hyman Rickover (the “Father of the Nuclear Navy”) recommending that GPU be permitted by the NRC to restart the undamaged TMI Unit 1 reactor. We are not concerned with the report's details or conclusions but one part caught our attention.

The report begins by describing Rickover's seven principles for successful nuclear operation. One of these principles is the “Concept of Total Responsibility” which he explains as follows: “Operating nuclear plants safely requires adherence to a total concept wherein all elements are recognized as important and each is constantly reinforced. Training, equipment maintenance, technical support, radiological control, and quality control are essential elements but safety is achieved through integrating them effectively in operating decisions.” (p. 9, emphasis added)

We think the foregoing sounds like version 1.0 of points we have been emphasizing in this blog, namely:

• Performance over time is the result of relationships and interactions among organizational components, in other words, the system is what's important.

• Decisions are where the rubber meets the road in terms of goals, priorities and resource allocation; the extant safety culture provides a context for decision-making.

• Safety performance is an emergent organizational property, a result of system activities, and cannot be predicted by examining individual system components.

We salute Adm. Rickover for his prescient insights.

* Adm. H.G. Rickover, “An Assessment of the GPU Nuclear Corporation Organization and Senior Management and Its Competence to Operate TMI-1” (Nov. 19, 1983). Available from Dickinson College library here.

NRC Non-Regulation of Safety Culture: Fourth Quarter Update

NRC SC Brochure ML113490097

On March 17, July 3 and October 17, 2012 we posted on NRC safety culture (SC) related activities with individual licensees. This post highlights selected NRC actions during the fourth quarter, October through December 2012. We report on this topic to illustrate how the NRC squeezes plants on SC even if the agency is not officially regulating SC.

Prior posts mentioned Browns Ferry, Fort Calhoun and Palisades as plants where the NRC was undertaking significant SC-related activities. It appears none of those plants has resolved its SC issues.

Browns Ferry

An NRC supplemental inspection report* contained the following comment on a licensee root cause analysis: “Inadequate emphasis on the importance of regulatory compliance has contributed to a culture which lacks urgency in the identification and timely resolution of issues associated with non-compliant and potentially non-conforming conditions.” Later, the NRC observes “This culture change initiative [to address the regulatory compliance issue] was reviewed and found to still be in progress. It is a major corrective action associated with the upcoming 95003 inspection and will be evaluated during that inspection.” (Two other inspection reports, both issued November 30, 2012, noted the root cause analyses had appropriately considered SC contributors.)

An NRC-TVA public meeting was held December 5, 2012 to discuss the results of the supplemental inspections.** Browns Ferry management made a presentation to review progress in implementing their Integrated Improvement Plan and indicated they expected to be prepared for the IP 95003 inspection (which will include a review of the plant's third party SC assessment) in the spring of 2013.

Fort Calhoun

SC must be addressed to the NRC’s satisfaction prior to plant restart. The NRC's Oct. 2, 2012 inspection report*** provided details on the problems identified by the Omaha Public Power District (OPPD) in the independent Fort Calhoun SC assessment, including management practices that resulted “. . . in a culture that valued harmony and loyalties over standards, accountability, and performance.”

Fort Calhoun's revision 4 of its improvement plan**** (the first revision issued since Exelon took over management of the plant in September, 2012) reiterates management's previous commitments to establishing a strong SC and, in a closely related area, notes that “The Corrective Action Program is already in place as the primary tool for problem identification and resolution. However, CAP was not fully effective as implemented. A new CAP process has been implemented and root cause analysis on topics such as Condition Report quality continue to create improvement actions.”

OPPD's progress report***** at a Nov. 15, 2012 public meeting with the NRC includes over two dozen specific items related to improving or monitoring SC. However, the NRC restart checklist SC items remain open and the agency will be performing an IP 95003 inspection of Fort Calhoun SC during January-February, 2013.^

Palisades

Palisades is running but still under NRC scrutiny, especially for SC. The Nov. 9, 2012 supplemental inspection report^^ is rife with mentions of SC but eventually says “The inspection team concluded the safety culture was adequate and improving.” However, the plant will be subject to additional inspection efforts in 2013 to “. . . ensure that you [Palisades] are implementing appropriate corrective actions to improve the organization and strengthen the safety culture on site, as well as assessing the sustainability of these actions.”

At an NRC-Entergy public meeting December 11, Entergy's presentation focused on two plant problems (DC bus incident and service water pump failure) and included references to SC as part of the plant's performance recovery plan. The NRC presentation described Palisades SC as “adequate” and “improving.”^^^

Other Plants

NRC supplemental inspections can require licensees to assess “whether any safety culture component caused or significantly contributed to” some performance issue. NRC inspection reports note the extent and adequacy of the licensee’s assessment, often performed as part of a root cause analysis. Plants that had such requirements laid on them or had SC contributions noted in inspection reports during the fourth quarter included Braidwood, North Anna, Perry, Pilgrim, and St. Lucie. Inspection reports that concluded there were no SC contributors to root causes included Kewaunee and Millstone.

Monticello got a shout-out for having a strong SC. On the other hand, the NRC fired a shot across the bow of Prairie Island when the NRC PI&R inspection report included an observation that “. . . while the safety culture was currently adequate, absent sustained long term improvement, workers may eventually lose confidence in the CAP and stop raising issues.”^^^^ In other words, CAP problems are linked to SC problems, a relationship we've been discussing for years.

The NRC perspective and our reaction

Chairman Macfarlane's speech to INPO mentioned SC: “Last, I would like to raise “safety culture” as a cross-cutting regulatory issue. . . . Strengthening and sustaining safety culture remains a top priority at the NRC. . . . Assurance of an effective safety culture must underlie every operational and regulatory consideration at nuclear facilities in the U.S. and worldwide.”^^^^^

The NRC claims it doesn't regulate SC but isn't “assurance” part of “regulation”? If NRC practices and procedures require licensees to take actions they might not take on their own, don't the NRC's activities pass the duck test (looks like a duck, etc.) and qualify as de facto regulation? To repeat what we've said elsewhere, we don't care if SC is regulated but the agency should do it officially, through the front door, and not by sneaking in the back door.

*  E.F. Guthrie (NRC) to J.W. Shea (TVA), “Browns Ferry Nuclear Plant NRC Supplemental Inspection Report 05000259/2012014, 05000260/2012014, 05000296/2012014” (Nov. 23, 2012) ADAMS ML12331A180.

**  E.F. Guthrie (NRC) to J.W. Shea (TVA), “Public Meeting Summary for Browns Ferry Nuclear Plant, Docket No. 50-259, 260, and 296” (Dec. 18, 2012) ADAMS ML12353A314.

***  M. Hay (NRC) to L.P. Cortopassi (OPPD), “Fort Calhoun - NRC Integrated Inspection Report Number 05000285/2012004” (Oct. 2, 2012) ADAMS ML12276A456.

****  T.W. Simpkin (OPPD) to NRC, “Fort Calhoun Station Integrated Performance Improvement Plan, Rev. 4” (Nov. 1, 2012) ADAMS ML12311A164.

*****  NRC, “Summary of November 15, 2012, Meeting with Omaha Public Power District” (Dec. 3, 2012) ADAMS ML12338A191.

^  M. Hay (NRC) to L.P. Cortopassi (OPPD), “Fort Calhoun Station – Notification of Inspection (NRC Inspection Report 05000285/2013008 ” (Dec. 28, 2012) ADAMS ML12363A175.

^^  S. West (NRC) to A. Vitale (Entergy), “Palisades Nuclear Plant - NRC Supplemental Inspection Report 05000255/2012011; and Assessment Follow-up Letter” (Nov. 9, 2012) ADAMS ML12314A304.

^^^  O.W. Gustafson (Entergy) to NRC, Entergy slides to be presented at the December 11, 2012 public meeting (Dec. 7, 2012) ADAMS ML12342A350. NRC slides for the same meeting ADAMS ML12338A107.

^^^^  K. Riemer (NRC) to J.P. Sorensen (NSP), “Prairie Island Nuclear Generating Plant, Units 1 and 2; NRC Biennial Problem Identification and Resolution Inspection Report 05000282/2012007; 05000306/2012007” (Sept. 25, 2012) ADAMS ML12269A253.

^^^^^  A.M. Macfarlane, “Focusing On The NRC Mission: Maintaining Our Commitment to Safety” speech presented at the INPO CEO Conference (Nov. 6, 2012) ADAMS ML12311A496.