“Safety is Job One” at Massey

“Massey Energy's members are the best trained, most productive and safest miners in the world. They embrace the company's commitment to safety - including ongoing comprehensive training and use of state-of-the-art technology and equipment.”

The above quote is taken from Massey Energy’s website where safety is touted as a company ethic. Sadly, even if true there are 25 fewer of them today.

Non-fatal days lost (NFDL) rates are the benchmark used by the coal industry to measure safety. And the industry average is 3.31. (Imagine the NRC's ROP including an indicator like NFDL.) Violations (cited by the Mine Safety and Health Administration) are also an indicator for mine safety. But according to Massey CEO Blankenship, “Violations are unfortunately a normal part of the mining process.”* And “We don’t pay much attention to the violation count.”**

Massey’s commitment to safety came under scrutiny back in 2005 after Mr. Blankenship sent a memorandum to his deep mine superintendents stating:

“If any of you have been asked by your group presidents, your supervisors, engineers or anyone else to do anything other than run coal (i.e., build overcasts, do construction jobs, or whatever), you need to ignore them and run coal. . . . This memo is necessary only because we seem not to understand that coal pays the bills.

In a follow-up memo a week later, Mr. Blankenship said some superintendents might have interpreted his first memo as implying that safety was a secondary consideration; in the second memo he called safety the company’s ‘first responsibility.’” *[emphasis added]

What do you think was the takeaway by the organization as a result of the two memos?

Massey is an easy target at the moment and we are not using these quotes to pile onto the outrage associated with the recent mine explosion. What is obvious is that the avowals by Massey that “Safety is Job One” are meaningless in the face of the actual behavior of the corporation. This was the point in our March 12, 2010 post re BP and their refinery safety issues. A very real problem is that virtually everyone engaged in complex and risky industrial activities makes the same safety pronouncements whether or not they live by them. Thus, the pronouncements are robbed of any real significance or value - not just to those who disregard them, but to all. It sounds a lot like stuff that politicians say and which no one believes, because they all say it and none of them means it.

So our takeaway is a caution to nuclear organizations not to reflexively broadcast and re-emphasize their commitment to safety as a response or correction to an identified safety culture problem. Or at least any such emphasis needs to be in a context coupled to specific actions that actually sustain and reflect that commitment. As we comment regularly in this blog, we view safety culture as a dynamic system and one aspect of that system is the interplay of management reinforcement and organizational trust. Reinforcement of safety priority tends to be the focus of a lot of communications and training, reasserting values and beliefs, etc. while trust tends to be determined by people’s perceptions of actual decisions and actions. When reinforcement and actions are congruent, trust is elevated. When management says one thing but acts in ways that are inconsistent, or appear inconsistent, trust evaporates and the attempt at reinforcement may make things worse.


* “Deaths at West Virginia Mine Raise Issues About Safety,” NY Times (April 6, 2010).
** “Massey’s Long History of Coal Mine Violations," The Energy Source blog at forbes.com (April 6, 2010).

Safety Culture as Competitive Capability

A recent McKinsey survey describes companies' desire to use training to build competitive capabilities however, most training actually goes toward lower-priority areas more aligned with the organizations' culture. For example, a company should be focusing its training on developing project management but instead focuses on pricing because price leadership is viewed as an important component of company culture.

This caused us to wonder: How many nuclear managers believe their plant's safety culture is a competitive capability and where is safety culture on the training priority list? We believe that safety culture is actually a competitive asset of nuclear organizations in that safety performance is inextricably linked to overall performance. But how many resources are allocated to safety culture training? How is training effectiveness measured? We fear the traditional tools for such training may not be that effective in actually moving the culture dial, thus not yield measurable competitive benefit.

Hope exists. One unsurprising survey conclusion is "When senior leaders set the agenda for building capabilities, those agendas are more often aligned with the capability most important to performance." (p. 7) The challenge is to get senior nuclear managers to recognize and act on the importance of safety culture training.

Huh? aka Vermont Yankee (part 4)

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

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

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


*ADAMS Accession Number ML100910420

NRC Briefing on Safety Culture - March 30, 2010

It would be difficult to come up with an attention-grabbing headline for the March 30 Commission briefing on safety culture. Not much happened. There were a lot of high fives for the perceived success of the staff’s February workshop and its main product, a strawman definition of nuclear safety culture. The only provocative remarks came from a couple of outside the mainstream “stakeholders”, the union rep for the NRC employees (and this was really limited to perceptions of internal NRC safety culture) and long time nuclear gadfly, Bille Garde (commended by Commissioner Svinicki for her consistency of position on safety culture spanning the last 20 years). Otherwise the discussions were heavily process oriented with very light questioning by the two currently seated Commissioners.

The main thrust of the briefing was on the definition of safety culture that was produced in the workshop. That strawman is different than that proposed by the NRC staff, or for that matter those used by other nuclear organizations such as INPO and INSAG. The workshop process sounded much more open and collegial than recent legislative processes on Capitol Hill.

Perhaps the one quote of the session that yields some insight as to where the Commission may be headed was from Chairman Jaczko; his comments can be viewed in the video below. Later in the briefing the staff demurred on endorsing the workshop product (versus the original staff proposal) pending additional input from internal and external sources.

Can Blogging Be Good for Safety Culture?

I came across a very interesting idea in some of my recent web browsing - an idea that I like for several reasons. First, it centers on an approach of using a blog or blogging, to enhance safety culture in large, high risk organizations. Hard for someone writing a safety culture blog not to find the idea intriguing. Second, the idea emanated from an engineer at NASA, Dale Huls, at the Johnson Space Center in Houston. NASA has been directly and significantly challenged in safety issues multiple times, including the Challenger and Columbia shuttle accidents. Third, the idea was presented in a PAPER written five years ago when blogging was still a shadow of what it has become - now of course it occupies its own world, the blogosphere.

The thesis of Dale’s paper is “...to explore an innovative approach to culture change at NASA that goes beyond reorganizations, management training, and a renewed emphasis on safety.” (p.1) Whatever you may conclude about blogging as an approach, I do think it is time to look beyond the standard recipe of “fixes” that Dale enumerates and which the nuclear industry also follows almost as black letter law.

One of the benefits that Dale sees is that “Blogs could be a key component to overcoming NASA’s ‘silent safety culture.’ As a communications tool, blogs are used to establish trust...(p.1)....and to create and promote a workplace climate in which dissent can be constructively addressed and resolved.” (p.2) It seems to me that almost any mechanism that promotes safety dialogue could be beneficial. Blogs encourage participation and communication. Even if many visitors to the blog only read posts and do not post themselves, they are part of the discussion. To the extent that managers and even senior executives participate, it can provide a direct, unfiltered path to connect with people in the organization. All of this promotes trust, understanding, and openness. While these are things that management can preach, bringing about the reality can be more difficult.

“Note that blogs are not expected to replace formal lines of communication, but rather enhance those communication lines with an informal process that encourages participation without peer pressure or fear of retribution.” (p.2) In any event, much of a useful safety dialogue is broader than raising a particular safety issue or concern.

So you might be wondering, did NASA implement blogging to facilitate its safety culture change? Dale wrote me in an email, “While NASA did not formally take up a specific use of blogging for safety matters, it seems that NASA is beginning to embrace the blogging culture. Several prominent NASA members utilize blogging to address NASA culture, e.g., Wayne Hale, manager of the Space Shuttle Program.

What should the nuclear industry take away from this? It might start with a question or two. Are there informal communication media such as blogs active at individual nuclear plants and how are they viewed by employees? Are they supported in any way by management, or the organization, or the industry? Are there any nuclear industry blogs that fulfill a comparable role? There is the Nuclear Safety Culture Group on LinkedIn that has seen sporadic discussion and commenting on a few issues. It currently has 257 members. This would be a good topic for some input from those who know of other forums.

Well Done by NRC Staffer

To support the discussion items on this blog we spend time ferreting out interesting pieces of information that bear on the issue of nuclear safety culture and promote further thought within the nuclear community. This week brought us to the NRC website and its Key Topics area.

As probably most of you are aware, the NRC hosted a workshop in February of this year for further discussions of safety culture definitions. In general we believe that the amount of time and attention being given to definitional issues currently seems to be at the point of diminishing returns. When we examine safety culture performance issues that arise around the industry, it is not apparent that confusion over the definition of safety culture is a serious causal issue, i.e., that someone was thinking of the INPO definition of safety culture instead of the INSAG one or the Schein perspective. Perhaps it must be a step in the process but to us what is interesting, and of paramount importance, is what causes disconnects between safety beliefs and actions taken and what can be done about them?

Thus, it was heartening and refreshing to see a presentation that addressed the key issue of culture and actions head-on. Most definitions of safety culture are heavy on descriptions of commitment, values, beliefs and attributes and light on the actual behaviors and decisions people make everyday. However, the definition that caught our attention was:

“The values, attitudes, motivations and knowledge that affect the extent to which safety is emphasized over competing goals in decisions and behavior.”

(Dr. Valerie Barnes, USNRC, “What is Safety Culture”, Powerpoint presentation, NRC workshop on safety culture, February 2010, p. 13)

This definition acknowledges the existence of competing goals and the need to address the bottom line manifestation of culture: decisions and actual behavior. We would prefer “actions” to “behavior” as it appears that behavior is often used or meant in the context of process or state of mind. Actions, as with decisions, signify to us the conscious and intentional acts of individuals. The definition also focuses on result in another way - “the extent to which safety is emphasized . . . in decisions. . . .” [emphasis added] What counts is not just the act of emphasizing, i.e. stressing or highlighting, safety but the extent to which safety impacts decisions made, or actions taken.

For similar reasons we think Dr. Barnes' definition is superior to the definition that was the outcome of the workshop:

“Nuclear safety culture is the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment.”

(Workshop Summary, March 12, 2010, ADAMS ACCESSION NUMBER ML100700065, p.2)

As we previously argued in a 2008 white paper:

“. . . it is hard to avoid the trap that beliefs may be definitive but decisions and actions often are much more nuanced. . . .

"First, safety management requires balancing safety and other legitimate business goals, in an environment where there are few bright lines defining what is adequately safe, and where there are significant incentives and penalties associated with both types of goals. As a practical matter, ‘Safety culture is fragile.....a balance of people, problems and pressures.’

"Second, safety culture in practice is “situational”, and is continually being re-interpreted based on people’s actual behaviors and decisions in the safety management process. Safety culture beliefs can be reinforced or challenged through the perception of each action (or inaction), yielding an impact on culture that can be immediate or incubate gradually over time.”

(Robert Cudlin, "Practicing Nuclear Safety Management," March 2008, p. 3)

We hope the Barnes definition gets further attention and helps inform this aspect of safety culture policy.

Because They Don’t Understand...?

This post's title is part of a quote from the book Switch: How to Change Things When Change is Hard that we introduced in our March 7, 2010 post. The full quote is:

“It can sometimes be challenging.....to distinguish why people don’t support your change. Is it because they don’t understand or because they’re not enthused?....The answer isn’t always obvious, even to experts.” [p. 107]

So it appears that when people don’t comply with prescribed standards or regimens, the problem may not be knowledge or understanding, it may be something tied to emotion. Bringing about change in something as deeply embedded as culture is not simply a matter of clicking on the new, desired program. The authors provide a number of interesting examples of situations resistant to change and how they have been overcome through using emotion to galvanize action. There are teenagers with cancer who play video games that help them visualize beating the cancer. The accounting manager who changes his priorities after visiting his not-for-profit vendor organizations and experiencing for himself their limited resources and the dire consequences of late reimbursements.

The most common situation for generating emotion sufficient to support change is a crisis, often an organizational crisis that is existential. But crisis is associated with “negative emotions” that may yield specific but not necessarily long lasting actions. Positive emotions on the other hand can lead to being more open to new thoughts and values and a mindset that wants to adopt what is essentially a new identity. One of the more effective ways to generate the needed positive emotion is through experiencing (e.g., using a video game, or immersion in the environment of a stakeholder) the conditions associated with the needed changes.

In nuclear safety management, how often after events that are deemed to be indicative of safety culture weakness, are personnel provided with additional training on expectations and elements of safety culture. Does this appear to be a knowledge-based approach? If so is the problem that staff don’t understand what is expected? Or is positive emotion the missing ingredient - the addition of which might help personnel want to identify with and inhabit the cultural values?

Vermont Yankee (part 3)

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

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

From the BP website:

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

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

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

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

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

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