NRC Office of Investigations 2014 Annual Report: From Cases to Culture

The Nuclear Regulatory Commission (NRC) Office of Investigations (OI) recently released its FY2014 annual report.*  The OI investigates alleged wrongdoing by entities regulated by the NRC; OI’s focus is on willful and deliberate actions that violate NRC regulations and/or criminal statutes.

The OI report showed a definite downward trend in the number of new cases being opened, overall a 41% drop between FY2010 and FY2014.  Only one of the four categories of cases increased over that time frame, viz., material false statements, which held fairly steady through FY2013 but popped in FY2014 to 67% over FY2010.  We find this disappointing because false statements can often be linked to cultural attributes that prioritize getting a job done over compliance with regulations.

The report includes a chapter on “Significant Investigations.”  There were eight such investigations, four involving nuclear power plants.  We have previously reported on two of these cases, the Indian Point chemistry manager who falsified test results (see our May 12, 2014 post) and the Palisades security manager who assigned a supervisor to an armed responder role for which he was not currently qualified (see our July 24, 2014 post).  The other two, summarized below, occurred at River Bend and Salem.

In the River Bend case, a security officer deliberately falsified training records by taking a plant access authorization test for her son, a contractor employed by a plant supplier.  Similar to the Palisades case, Entergy elected alternative dispute resolution (ADR) and ended up with multiple corrective actions including revising its security procedures, establishing new controls for security-related information (SRI), evaluating SRI storage, developing a document highlighting the special responsibilities of nuclear security personnel, establishing decorum protocols for certain security posts, preparing and delivering a lessons learned presentation, conducting an independent third party safety culture (SC) assessment of the River Bend security organization [emphasis added], and delivering refresher training on 10 CFR 50.5 and 50.9.  Most of these requirements are to be implemented fleet-wide, i.e., at all Entergy nuclear plants, not just River Bend.**

The Salem case involved a senior reactor operator who used an illegal substance then performed duties while under its influence.  The NRC issued a Level III Notice of Violation (NOV) to the operator.  The operator’s NRC license was terminated at PSE&G’s request.***  PSE&G was not cited in this case.

Our Perspective

You probably noticed that three of the “significant” cases involved Entergy plants.  Entergy is no stranger to issues with a possible cultural component including the following:****

In 2013, Arkansas Nuclear One received a NOV after an employee deliberately falsified documents regarding the performance of Emergency Preparedness drills and communication surveillances.

In 2012, Fitzpatrick received a Confirmatory Order (Order) after the NRC discovered violations, the majority of which were willful, related to adherence to site radiation protection procedures.

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

In 2012, Palisades received an Order after an operator left the control room without permission and without performing a turnover to another operator.  Entergy went to ADR and ended up with multiple corrective actions, some fleet-wide.  We have posted many times about the long-running SC saga at Palisades—click on the Palisades label to pull up the posts. 

In 2005, Pilgrim received a NOV after an on-duty supervisor was observed sleeping in the control room.  In 2013, Pilgrim received a NOV for submitting false medical documentation on operators.

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

These cases involve behavior that was (at least in hindsight) obviously wrong.  It’s not a stretch to suggest that a weak SC may have been a contributing factor.  So has Entergy received the message?  You be the judge.

“Think of how stupid the average person is, and realize half of them are stupider than that.” ― George Carlin (1937–2008)


*  NRC Office of Investigations, “2014 OI Annual Report,” NUREG-1830, Vol. 11 (Feb. 2015).  ADAMS ML15034A064.

**  M.L. Dapas (NRC) to E.W. Olson (River Bend), “Confirmatory Order, Notice of Violation, and Civil Penalty – NRC Special Inspection Report 05000458/2014407 and NRC Investigation Report 4-2012-022- River Bend Station” (Dec. 3, 2014).  ADAMS ML14339A167.

***  W.M. Dean (NRC) to G. Meekins (an individual), “Notice of Violation (Investigation Report No. 1-2014-013)” (July 9, 2014).  ADAMS ML14190A471.

****  All Entergy-related NRC enforcement actions were obtained from the NRC website.

Congressional Panel Slices and Dices Culture in Report on DOE/NNSA

A U.S. congressional panel recently released a report* detailing its recommendations for improving the performance of the National Nuclear Security Administration (NNSA).  NNSA is an agency within the Department of Energy responsible for maintaining the U.S. nuclear weapons stockpile, reducing danger from weapons of mass destruction, providing the Navy with nuclear propulsion, and responding to nuclear and radiological emergencies.**

The panel’s report has a host of recommendations and action items for making NNSA more effective, including changing the agency’s management culture to be more mission performance oriented.  The report’s key points would fit on one page but of course they aren’t presented that way; this is a 188 page government report with a 16 page executive summary.

What caught our eye was how many different types of culture were mentioned in the report.  While the report’s focus was putatively on management culture, the authors also referred to DOE, civilian, enterprise, risk management, risk aversion, safety, entitlement, non-inclusion, governance, corporate, compliance, security, professional, organizational, reliability and generic “culture.”  I am not making this up.

With so many types of culture, one might think there must have been a significant effort to define culture.  Well, no.  I saw only one definition of culture: “A common definition of management culture is, “This is how things are done here.”” (p. 39)  Could they have done better?  You be the judge.

Lots of insight into culture?  Not really.  I saw one systemic observation about culture: “In a healthy organization, management practices and culture are mutually reinforcing in creating productive behaviors: management practices shape the culture; the culture shapes behaviors and reinforces the management practices.” (ibid.)  We’ll award E for Effort here because this can be true although not always.

So it’s culture this and culture that but it’s left as an exercise for the reader to determine what exactly culture is and how the various sub-cultures contribute to an understanding of the larger picture.

Our Perspective

Every member of the panel has an opinion of what organizational culture is.  However, without a precise definition and a representation of how culture relates to other organizational factors (including hard ones like practices and soft ones like leadership and trust) there is no shared mental model.  And without that, there is no clear appreciation of how their proposed interventions might leverage (or antagonize) the existing culture or even work at all.  This lack of effort on culture is especially disappointing given that one member of the panel was the NRC Chairman back when that agency was agonizing endlessly over the proper definition of safety culture.

But let’s look at the larger reality here.  Most people (myself included) will never take the time to wade through a report like this and that’s probably the way the serious stakeholders (DOD, DOE and their contractors) want it; they are willing to play along with Congress rearranging the lounge car chairs as long as the money train keeps running.


*  Congressional Advisory Panel on the Governance of the Nuclear Security Enterprise, “A New Foundation for the Nuclear Enterprise” (Dec. 2014).  Thanks to Bill Mullins for recommending this report. 

**  National Nuclear Security Administration website.

Corrosion in the Culture of the DNFSB?

We have posted many times on the Defense Nuclear Facilities Safety Board’s (DNFSB) efforts to get the Department of Defense (DOE) to confront and resolve its safety culture (SC) issues.  Now it appears the DNFSB has management and cultural issues of its own.  In a stinging report* by an outside consultant, DNFSB board members are said to have a “divisive and dysfunctional relationship” and the organizational culture is called “toxic.” (p. iii)  This post highlights the cultural aspects of selected issues and the proposed fixes.

Major issues that can affect culture are the board itself, the negative tone of oral and written communications, and the performance recognition system.

DNFSB is a small agency (100+ people) and most work in the same office.  There is no place to hide from the effects of troubles at the top.  The Board’s basic problem is that the members don’t have a shared mental model of the DNFSB’s mission and strategies.  And, because the members are political appointees representing both major parties, creating some kind of unity is a major challenge.  The report contains many recommendations related to improving board functioning but the reality is it’s mainly a political issue.  Board dysfunctionality is a cultural issue because hydra-headed leadership distracts, confuses and ultimately demoralizes the agency staff.  Most alarming to us, to the extent investigations are driven by board members’ interests rather than by science and safety considerations (a perception reported by some staff), the board’s shortcomings can impinge on the agency’s SC. 

Communications problems start at the board level and permeate the agency. Negative communications, e.g., condescending language and personal attacks, lead to a culture of disrespect.  The recommendations for communications include “Immediately ensure a professional tone in all communications, both among board members and throughout the Agency.  Consider use of an internal communication code of conduct.” (p. 3-2)  In our view, business communications should focus on the issues, be respectful and exhibit a modicum of integrity.

Performance recognition recommendations include “Assess staff sentiment with regard to priorities for nonmonetary incentives, and develop offerings accordingly.” (p. 3-5)  Nonmonetary recognition was mentioned by an employee committee tasked with identifying underlying causes for DNFSB’s declining scores on the periodic federal employee viewpoint survey.  We’re not sure why monetary recognition is off the table, perhaps because of perceived budget problems.  Our feeling is if some type of above-and-beyond behavior is worth recognizing, then an organization should be willing to pay something for it.

There are also a couple of more straightforward management issues: frequent disruptive organizational changes, and the lack of management and leadership competence.  If not addressed, such issues can certainly weaken culture but they are not as important as the ones described previously.

Change management recommendations include “Develop a change management organizational competency . . .  [and] a change management plan, . . .” (p. 3-3)  As an aside, the NRC Inspector General (IG) provides IG services to the DNFSB; an October 2014 IG report** identified change management as a serious challenge facing the agency.

Increasing competence corrective actions include “Institute tailored management and supervisory training for technical staff management and supervisors. . . .” (p. 3-3)  This is not controversial; it simply needs to be accomplished.

Our Perspective 

If the report accurately describes DNFSB’s reality, it looks like a bit of a mess.  The board’s chairman recently retired so the President has an opportunity to nominate someone who is willing and able to clean it up.  Absent competent leadership from the top, the report’s recommendations may make a dent in the problems but will not be a cure-all.

We wish them well.  If the DNFSB’s focus wanes, it bodes ill for efforts to spur DOE to increase its management competence and strengthen its SC.


*  J. O'Hara and P.M. Darmory, “Assessment of the Defense Nuclear Facilities Safety Board Workforce and Culture,” Report DNF40T1 (Dec. 2014).  Thanks to Bill Mullins for recommending this report.

**H.T. Bell (NRC) to Chairman Winokur (DNFSB), “Inspector General’s Assessment of the Most Serious Management and Performance Challenges Facing the Defense Nuclear Facilities Safety Board,” DNFSB-OIG-15-A-01 (Oct. 1, 2014).  ADAMS ML14274A247.

Safety Culture at Chevron’s Richmond, CA Refinery

The U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report* on the August 2012 fire at the Chevron refinery in Richmond, CA caused by a leaking pipe.  In the discussion around the CSB’s interim incident report (see our April 16, 2013 post) the agency’s chairman said Chevron’s safety culture (SC) appeared to be a factor in the incident.  This post focuses on the final report findings related to the refinery’s SC.

During their investigation, the CSB learned that some personnel were uncomfortable working around the leaking pipe because of potential exposure to the flammable fluid.  “Some individuals even recommended that the Crude Unit be shut down, but they left the final decision to the management personnel present.  No one formally invoked their Stop Work Authority.  In addition, Chevron safety culture surveys indicate that between 2008 and 2010, personnel had become less willing to use their Stop Work Authority. . . . there are a number of reasons why such a program may fail related to the ‘human factors’ issue of decision-making; these reasons include belief that the Stop Work decision should be made by someone else higher in the organizational hierarchy, reluctance to speak up and delay work progress, and fear of reprisal for stopping the job.” (pp. 12-13) 

The report also mentioned decision making that favored continued production over safety. (p. 13)  In the report’s details, the CSB described the refinery organization’s decisions to keep operating under questionable safety conditions as “normalization of deviance,” a term popularized by Diane Vaughn and familiar to Safetymatters readers. (p. 105) 

The report included a detailed comparison of the refinery’s 2008 and 2010 SC surveys.  In addition to the decrease in employees’ willingness to use their Stop Work Authority, surveyed operators and mechanics reported an increased belief that using such authority could get them into trouble (p. 108) and that equipment was not properly cared for. (p. 109) 

Our Perspective

We like the CSB.  They’re straight shooters and don’t mince words.  While we are not big fans of SC surveys, the CSB’s analysis of Chevron’s SC surveys appears to show a deteriorating SC between 2008 and 2010. 

Chevron says they agree with some CSB findings however Chevron believes “the CSB has presented an inaccurate depiction of the Richmond Refinery’s current process safety culture.”  Chevron says “In a third-party survey commissioned by Contra Costa County, when asked whether they feel free to use Stop Work Authority during any work activity, 93 percent of Chevron refinery workers responded favorably.  The overall results for the process safety survey exceeded the survey taker’s benchmark for North American refineries.”**  Who owns the truth here?  The CSB?  Chevron?  Both?    

In 2013, the city of Richmond adopted an Industrial Safety Ordinance (RISO) that requires Chevron to conduct SC assessments, preserve records and develop corrective actions.  The CSB recommendations including beefing up the RISO to evaluate the quality of Chevron’s action items and their actual impact on SC. (p. 116)

Chevron continues to receive blowback from the incident.  The refinery is the largest employer and taxpayer in Richmond.  It’s not a company town but Chevron has historically had a lot of political sway in the city.  That’s changed, at least for now.  In the recent city council election, none of the candidates backed by Chevron was elected.***

As an aside, the CSB report referenced a 2010 study**** that found a sample of oil and gas workers directly intervened in only about 2 out of 5 of the unsafe acts they observed on the job.  How diligent are you and your colleagues about calling out safety problems?

*  CSB, “Final Investigation Report Chevron Richmond Refinery Pipe Rupture and Fire,” Report No. 2012-03-I-CA (Jan. 2015).

**  M. Aldax, “Survey finds Richmond Refinery safety culture strong,” Richmond Standard (Jan. 29, 2015).  Retrieved Jan. 29, 2015.  The Richmond Standard is a website published by Chevron Richmond.

***  C. Jones, “Chevron’s $3 million backfires in Richmond election,” SFGate (Nov. 5, 2014).  Retrieved Jan. 29, 2015.

****  R.D. Ragain, P. Ragain, Mike Allen and Michael Allen, “Study: Employees intervene in only 2 of 5 observed unsafe acts,” Drilling Contractor (Jan./Feb. 2011).  Retrieved Jan. 29, 2015.

Defense in Depth and Safety Culture from an IAEA Conference

A 2013 IAEA conference focused on the concept of Defense in Depth (DID) and its implementation at nuclear facilities.  It was a large-scale event with almost 50 presentations and papers.  The published proceedings* run over 350 pages.  This post focuses on the treatment of safety culture (SC) by the authors and presenters.  The proceedings started off well: SC was explicitly mentioned as a cross-cutting issue in the implementation of DID. (p. 1)  In addition, the conference itself was predicated on Fukushima lessons learned which, as everyone now knows, included SC shortcomings in both licensee and government organizations.

But on the whole the treatment of SC was something of a disappointment.  The presentations from Argentina, Pakistan and Vietnam mentioned SC in passing.  The presentation from Egypt discussed the regulator’s role in SC oversight at length. (pp. 302-304)  Only the following three presentations gave SC a featured role.

SC in WANO

The World Association of Nuclear Operators (WANO) presenter said this about SC: “Safety supposes that no operator feels isolated, or refuses openness and permanent self-questioning; it requests as well for WANO to ensure that cultural and sometimes political barriers do not hinder safety culture . . . . In WANO, we believe that management system and practices are at the centre of safety culture, and a full involvement of top management (CEOs) of our members is absolutely requested.”**

SC in Indonesia

Two papers discussed SC at different nuclear facilities in Indonesia.  Desirable SC characteristics at both facilities were based on INSAG-4.

The Experimental Fuel Element Installation (EFEI)

The abstract of this paper*** highlighted SC’s role at this facility.  “The application of safety culture in a nuclear facility is one way of DID implementation.  Safety culture aims at the performance of safe works, the prevention of deviation, and the accomplishment of quality operation.  It is in accordance with the first level of DID concept which is the prevention of abnormal operation and failures that is done through conservative design and high quality in construction and operation. . . The objective of safety culture implementation in the EFEI is to encourage workers to have a stronger sense of responsibility on safety and to contribute actively for its development”  The paper presented a laundry list of strategies used to strengthen SC including briefings, workshops, training, senior management visits, integration of safety into work processes, self-assessments, open reporting on safety incidents, open and timely reporting to the regulator, evaluation of safety performance indicators and an annual SC questionnaire.

The authors displayed a bit of realism when they said “Leaders cannot completely control safety culture, but they may influence it.” (p. 179)  They also said their questionnaire results indicated that EFEI SC is at Stage 2 (from IAEA-TECDOC-1329) where “Safety becomes an organizational goal.”  They want SC to evolve to Stage 3 where the organization believes “Safety can always be improved.” (pp. 187-188)

Kartini Research Reactor

This paper**** reported the findings of a SC self-assessment.  The method consisted of questionnaire responses reviewed by experts.  The assessment identified several good current practices in maintaining the safety status of Kartini reactor.  As supporting evidence, the authors noted the number of inspection/audit findings from the regulator went down while reactor utilization and operating hours increased over the past several years.  One opportunity for improvement was the need for more frequent dialogues between employees and managers.

Our Perspective

There is not much SC substance here.  The recitations on SC repeated familiar stuff you’ve seen in lots of places.  In other words, zero new information or insight.  The single page WANO presentation indicates their lowest common denominator audience is even lower than IAEA’s.  Perhaps there were technical issues discussed at the conference that are of interest to you.  Otherwise, don’t invest your coffee break in going through this lengthy document.

*  IAEA, International Conference on TopicalIssues in Nuclear Installation Safety: Defence in Depth — Advances andChallenges for Nuclear Installation Safety, Oct. 21-24, 2013 ConferenceProceedings, IAEA-TECDOC-CD-1749 (Vienna, 2014).  We are grateful to Madalina Tronea for publicizing this material.  Dr. Tronea is the founder and moderator of the LinkedIn Nuclear Safety Culture forum.

**  J. Regaldo, “WANO Actions to Reinforce the Operators’ Safety Culture Worldwide,” p. 147.

***  H. Hardiyanti, B. Herutomo and G. K. Suryaman, “Safety Culture as a Pillar of Defense-in-Depth Implementation at the Experimental Fuel Element Installation, Batan, Indonesia,” pp. 173-188.

****  S. Syarip, “Safety Management and Safety Culture Self Assessment of Kartini Research Reactor,” pp. 321-326.

Back to the Past at Millstone?

Millstone

A recent article* in the Hartford Courant newspaper reported on a turbine-driven auxiliary feedwater (TDAFW) pump problem at Millstone 3 that took so long to resolve that the NRC issued a White finding to plant owner Dominion Resources.

The article included a quote from the Connecticut Nuclear Energy Advisory Council (NEAC) describing their unease over the pump problem.  We dug a little deeper on the NEAC, a state government entity that works with public agencies and plant operators to ensure public health and safety.  Their 2014 annual report** highlights the TDAFW pump problem and another significant event at Millstone, a loss of site power that caused a dual reactor trip.  NRC inspections following these two events resulted in one Severity Level III finding, the White finding previously mentioned and two Green findings.  The events and NRC findings led the NEAC to express “great concern regarding the downward performance trend” to Dominion and request a formal response from Millstone management on any root cause that linked the performance problems.

In his response to the NEAC, the Millstone site VP said there was no root cause linking events.  He also said two safety culture (SC) improvement areas had been identified, viz., problem identification and evaluation and establishing clarity around decision making, and that the site has implemented improvement actions to address those areas.  In the Courant article, a plant spokesman is quoted as saying "If it's not immediately obvious why it's not working, we put a team to work on it."

The article also referred to related behind-the-scenes NRC staff emails*** in which the time it took for Dominion to identify and address the TDAFW pump issue raised eyebrows at the NRC.

So what does the TDAFW pump event tell us about SC at Millstone?

Our Perspective

Is Millstone on the road to the bad old days, when SC was AWOL from the site?  We hope not.  And there is some evidence that suggests the TDAFW pump issue was an isolated problem exacerbated by a bit of bad luck (a vendor supplying the wrong part with the same part number as the correct part).

Positive data includes the following: Millstone 2 and 3 both had all green performance indicators on the 3QTR2014 NRC ROP and, more importantly, a mid-2014 baseline inspection of the Millstone CAP “concluded that Dominion was generally effective in identifying, evaluating, and resolving problems.”****  In addition, plant “staff expressed a willingness to use the corrective action program to identify plant issues and deficiencies and stated that they were willing to raise safety issues.” (p. 10)

Currently, M2 is subject to baseline inspection and M3 to baseline and a supplemental inspection because of the White finding.

To us, this doesn’t look like a plant on the road to SC hell although we agree with the NRC that the TDAFW pump problem took too long to evaluate and resolve.

We hope the Millstone organization learned more from the TDAFW pump problem than they displayed in their reply to the NRC.*****  In dealing with the regulator, Millstone naturally tried to bound the problem and their response: they pointed at the vendor for sending them the wrong part, implemented a TDAFW pump troubleshooting guide, revised a troubleshooting procedure, and produced and presented two case studies to applicable plant personnel. 

The site VP’s letter to NEAC suggests a broader application of the lessons learned.  We suggest the “trust but verify” principle for dealing with vendors be strengthened and that someone be assigned to read Constance Perin’s Shouldering Risk (see our Sept. 12, 2011 review) and report back on the ways factors such as accepted logics, organizational power relations and production pressure can prevent organizations from correctly perceiving problems that are right in front of them.

*  S. Singer, “Emails Show NRC's Concern Over How Millstone Nuclear Plant Reacted To Malfunction,” Hartford Courant (Jan. 12, 2015).

**  2014 Nuclear Energy Advisory Council (NEAC) Report (Dec. 11, 2014).  The Nov. 10, 2014 letter from Millstone site VP S.E. Scace to J.W. Sheehan (NEAC) is appended to NEAC’s 2014 annual report.

***  The Associated Press obtained the emails under a Freedom of Information Act request.  Most of the content relates to the evolution of technical issues but, as cited in the Courant article, there are mentions of Millstone’s slowness in dealing with the pump issue.  The emails are available at ADAMS ML14358A318 and ML14358A320.

****  “Millstone Power Station – NRC Problem Identification and Resolution Inspection Report 05000336/2014009 and 05000423/2014009” (Sept. 12, 2014), cover letter.  ADAMS ML14255A229.

*****  Dominion Nuclear Connecticut, Inc. Millstone Power Station Unit 3, Reply to a Notice of Violation (Nov. 19, 2014).  ADAMS ML14325A060.