Vermont Yankee (part 5) - Muddy Water

In our April 5, 2010 post re Vermont Yankee we provided some initial thoughts on the report of the independent investigator regarding misleading statements provided by Entergy personnel to Vermont regulators, as contained in Entergy’s March 31, 2010 response to a March 1, 2010 NRC Demand for Information.* The Entergy filing also provides more detail on follow-up actions including an assessment of current site safety culture. In this post, we offer some additional observations and questions.
First, in our initial March 3, 2010 post regarding the VY situation, we disputed a prediction made by a third party that the administrative actions taken by Entergy for certain employees might have a detrimental effect on the safety culture at the plant - due to the way Entergy is treating its employees. In reality it appeared to us that any detrimental impact on safety culture would be more likely if Entergy had not taken appropriate actions. In Entergy’s report to the NRC, they provide the results of a follow-up assessment confirming that after the personnel actions employees were even more likely to raise concerns.

Also in our initial post we speculated that the Vermont Yankee events could have consequences for Entergy’s proposed spinout of six nuclear plants into a separate subsidiary. Since then Entergy has announced the cancellation of the spinout after a decision by New York re the extension of permits for their Indian Point plants.

However, after a careful review of the March 31 Entergy response, we are still left with water that is more than a little bit muddy. Entergy says a Synergy assessment a few months before the reporting event found safety culture at Vermont Yankee to be strong. After the event, Entergy states safety culture is strong or stronger, and with regard to the replaced staff, Entergy “continues to have confidence in the integrity of the affected employees.” Strong safety culture and organizational integrity are not supposed to add up to this kind of outcome. How then did things go wrong? How did the misleading statements to Vermont regulators come about and what was the cause?

A fundamental element of all nuclear plant problem resolution/corrective action programs is a determination of not just what happened, but why. Cause in other words, and in significant situations, the root cause. The root cause that led to eleven employees, including managers and site executives, being relieved of duties and disciplined is not contained in the Entergy materials. In fact, most of the focus appears to be on the safety culture of the plant staff both before and after the incident came to light and the personnel actions taken. Those actions and information appear to be reassuring in regards to the plant staff - but the plant staff was not where the problem occurred. There is also considerable emphasis on the fact that the managers have been replaced with competent substitutes. But haven’t those new managers been placed in exactly the same situation as the former managers were in? If it is not clear why the former managers failed to meet performance standards, then how is one confident that the replacements will do so?

As we have pointed out in other posts, the response to safety culture failures too often stresses the “values and beliefs” of personnel as the beginning and end of safety culture. We have argued that the situational parameters, including competing goals and interests, are at least as important if not paramount in trying to understand such issues.

What was the situation at Vermont Yankee and to what extent, if any, did it have an effect? The VY management team was operating in an environment where significant business decisions were in play. One was the extension of the operating license for VY which required approval by both the NRC and by the Vermont Senate. A second was the pending proposed spinout of nuclear units, including VY, into a separate subsidiary, a spinout that was expected to be worth billions of dollars to Entergy. SEC and other regulatory filings had been made by Entergy for the spinout and approvals were being sought from state regulators and the NRC.

Entergy’s March 31 NRC submittal also states, “Finally, neither the underlying report of investigation which led to the discipline, nor the interviews of the AFEs, identified any credible evidence to suggest that any weakness in the work environment or site safety culture contributed to a reluctance by anyone to provide clarifying or supplemental information to the relevant state officials. Indeed, there is no credible evidence that any of the AFEs are -- or were -- reluctant to report safety concerns or any other matter of potential regulatory significance or legal non-compliance.”

Does this mean that situational factors such as business priorities were evaluated and found not to be a contributor? If so, how was this done and what is the basis for such a conclusion? Or were such competing priorities acknowledged as potential influences and able to be dealt with as part of the management system? What other situational factors might have been present and to what effect?

On April 9, 2010 the NRC notified Entergy that the NRC was going to “initiate a detailed review and independent assessment of the acceptability of Entergy’s conclusions. . . .” ** We will keep you posted.

*ADAMS Accession Number ML100910420

**ADAMS Accession Number ML100990409

“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?