Pick Any Two

Last week principal findings of the BP Oil Spill Presidential Commission were released.   Not surprisingly it cited root causes that were “systemic”, decisions without adequate consideration of risks, and failures of regulatory oversight.  It also cited a lack of a culture of safety at the companies involved in the Deepwater Horizon.  We came across an interesting entry in a blog tied to an article in the New York Times by John Broder on January 5, 2011, “Blunders Abounded Before Gulf Oil Spill, Panel Says”.  We thought it was worth passing on. 

Comment No. 7 of 66 submitted by:
Jim S.
Cleveland
January 5th, 2011
7:23 pm

“A fundamental law of engineering (or maybe of the world in general) is "Cheaper, Faster, Better: Pick Any Two".  

Clearly those involved, whether deliberately or by culture, chose Cheaper and Faster.”

Nuclear Safety Culture Assessment Manual

July 9, 2012 update: How to Get the NEI Nuclear Safety Culture Assessment Manual

The manual is available in the NRC ADAMS database, Accession Numbers ML091810801, ML091810803, ML091810805, ML091810807, ML091810808 and ML091810809.

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As recently reported at TheDay.com,* NEI has published a “Nuclear Safety Culture Assessment Manual,” a document that provides guidance for conducting a safety culture (SC) assessment at a nuclear power plant.  The industry has issued the manual and conducted some pilot program assessments in an effort to influence and stay ahead of the NRC’s initiative to finalize a SC policy statement this year.  The NRC is formulating a policy (as opposed to a regulatory requirement) in this area because it apparently believes that SC cannot be directly regulated and/or any attempt to assess SC comes too close to evaluating (or interfering with) plant management, a task the agency has sought to avoid. 

Basically, the manual describes an assessment methodology based on the eight INPO principles for creating/maintaining a strong nuclear safety culture.  It is a comprehensive how-to document including assessment team organization, schedules, interview guidance and questions, sample communication memos, and report templates.  The manual has a strongly prescriptive approach, i.e., it seeks to create a standardized approach which should facilitate comparisons between different facilities and the same facility over time. 

The best news from our perspective is that the NEI assessment approach relies heavily on interviews; it uses a site survey instrument only to identify pre-assessment areas of interest.  It’s no secret that we are skeptical about over-inference with respect to the health of a plant’s safety culture from the snapshot a survey provides.  The assessment also uses direct observations of behavior of employees at all levels during scheduled activities, such and meetings and briefings, and ad-hoc observation opportunities.

A big question is: In a week-long self assessment, can a team discern the degree to which an organization satisfies key principles, e.g., the level of trust in the organization or whether leaders demonstrate a commitment to safety?  I think we have to answer that with “Maybe.”  Skilled and experienced interviewers can probably determine the general status of these variables but may not develop a complete picture of all the nuances.  BUT, their evaluation will likely be more useful than any survey.

There is one obvious criticism with the NEI approach which industry critics have quickly identified.  As David Collins puts it in TheDay.com article, “[T]he industry is monitoring itself - this is the fox monitoring the henhouse."  While the manual is proposed for use by anyone performing a safety culture assessment, including a truly independent third party, the reality is the industry expects the primary users to be utilities performing self assessments or “independent” assessments, which include non-utility people on the team. 


*  P. Daddona, “Nuclear group puts methods into use to foster 'a safety culture',” TheDay.com
(Dec 21, 2010).

Cross Cutting Duke Energy vs. Indiana

The starting point of this post is not the nuclear industry per se and some may think it odd that we extrapolate from another part of the utility business to nuclear safety culture.  But the news of late regarding Duke Energy and its relationships with public utility regulators in Indiana raise some caution flags as to the nature of how corporate culture might influence the nuclear side of the business.  We believe it also raises fundamental issues about the NRC’s scope of culture assessment and may suggest the need for renewed approaches to so-called cross cutting issues.  With that let’s look at recent reports of what Duke executives and Indiana public servants have been up to.

In brief the situation involves Duke’s coal fired plant under construction in Indiana (the Edwardsport plant) and Duke Energy executives’ interactions with the Indiana Public Utilities Commission personnel, up to and including the head of the IPUC.  During the pendancy of the regulatory consideration of the plant costs, Duke engaged in hiring a key IPUC staff member (their General Counsel no less) and engaged in ongoing email exchanges indicating close personal relationships between Duke and IPUC personnel, the offering of favors, and the exchange of closely held information.  The upshot of the scandal has been the firings of the IPUC Chairman (by Indiana Governor Mitch Daniels), the former IPUC General Counsel hired by Duke, the head of Duke’s Indiana business unit (also a former IPUC staffer) and the Chief Operating Officer of Duke Energy, the second highest Duke Energy executive.  Phew.

James Rogers, chairman and chief executive officer of Duke, said Monday that former COO James Turner had not exercised undue influence with Indiana regulators but resigned because "he felt like it put the company in a bad place."  He went on to say, "He [Turner] made a decision on his own that he felt like those e-mails were embarrassing and inappropriate... If you read through them, it showed a very close relationship between the two of them.”*

But if one visits the Duke Energy website and reads through their Code of Business Ethics it would appear that the activities in Indiana routinely and broadly violated the espoused ethics.  So, did a very senior executive resign because he had bad email habits or was it the underlying actions and behaviors that were inappropriate? 

Our purpose here is not to delve into the details of the scandal since we think the actions taken in response speak for themselves.  Rather we want to examine the potential for such behaviors to spill over or create an influence on other parts of Duke’s business, namely their extensive nuclear plant fleet.  To us it raises the question of what is a cross cutting issue for nuclear safety?  The essence of cross cutting is to account for issues that have broad and potentially overlapping significance to achieving desired safety results.  With regard to safety culture, can such issues be limited to the scope of nuclear operations, or do they necessarily involve issues that span corporate governance and ethics?  A good question.

In prior posts (here and here) we reported some of our research on compensation structures within nuclear owner companies and the extent to which such compensation included incentives other than safety.  We found that corporate level executives including Chief Nuclear Officers were eligible for substantial amounts of compensation, large percentages of which were based on performance against business objectives such as profits and capacity factors.  We raised the concern that such large amounts of incentive-based compensation could exacerbate the influence of business priorities that compete with safety objectives.  The Duke-Indiana experience brings into focus other aspects of the corporate environment, such as business ethics and relationships with regulators, that could also bear on the ability of the organization to maintain its nuclear safety culture.  It is clear that certain corporate level decisions such as budgets and business goals directly impact the management of nuclear facilities.  It also seems likely that “softer” issues such as compensation, promotional opportunities and business ethics will be sending “environmental” messages to nuclear personnel as well.  

There is also something of an interesting parallel in the way that the current issues involving the Indiana PUC were handled.  Duke fired (or allowed to resign) both of its recent hires from IPUC and the COO of Duke Energy.  Similarly the governor of Indiana replaced the Chairman of the IPUC.  Sound familiar?  Seems like the approach taken within nuclear organizations when safety culture issues become problematic.  Get rid of some individuals and move on.  Such a response presumes that “bad people” are the root cause of these problems.  But one wonders, as do many of the news media reporting on this, whether at both Duke and IPUC this was just the way business was being done until it became public via the email exchanges.  If so doesn’t it suggest that cultural issues are involved?  And that the causes and extent of the cultural issues warrant further consideration?

What Duke decides to do or not do with regard to its corporate culture is probably an internal matter, but any spill over of corporate culture into nuclear safety culture is of more direct concern.  Should the NRC be aware of and interested in corporate culture, particularly when fundamental ethics and values are concerned?  How confident is the NRC that some safety culture breakdowns (think of Davis Besse and Millstone) had their genesis in a defective corporate culture?  Does corporate culture cross cut nuclear safety culture?  If not, why not?

*  J. Russell, “E-mail Scandal Topples Duke Energy's James Turner,” IndyStar.Com (Dec 7, 2010).

Ian Richardson, Safety Culturist

Ian Richardson, the British actor, may not be the first person who leaps to mind as someone with insight into the art of assessing safety culture.  But in an episode in the second volume of the BBC series "House of Cards," Ian’s character, the UK Prime Minister, observes:

“You can get people to say anything you want them to say, but getting them to do what they say is another thing.”

And with that thought, we wish you Happy Holidays.

SONGS Is Getting Better (Maybe)

On December 14, 2010 the NRC held a public meeting with Southern California Edison to discuss recent safety-related performance at the San Onofre Nuclear Generating Station (SONGS).  As you know, SONGS has been plagued for years by incidents, including willful violations, and employees claiming they fear retaliation if they report or discuss such incidents.  The newspaper item* on the meeting had an upbeat tone, and quoted NRC deputy director Troy Pruett, as saying:

"The trick now is for you guys to continue some of the successes you've had in the last two, three, four months."

That sounds good, and we hope SONGS continues to perform at a satisfactory level.  But the reality is a few months of symptom-free behavior is not enough to declare the patient cured.  To get a feel for the plant’s history of problems, check out this earlier article** by the same reporter.  In addition, please refer to our September, 2010 posts (here and here) for our perspective on what the underlying issues might be.

We’re Still Here

As you may have noticed, we haven’t been posting recently.  It’s not for lack of interest; we just haven’t come across much news or other items worthy of comment or passing on to you.  We will not waste your time (or ours) with fluff simply to fill the space.  If you have any safety culture news, articles, publications, etc. that you’d like us to review and comment on, please let us know about them via email.

*  P. Sisson, “San Onofre: Federal regulators report progress at nuclear plant,” North Country Times (Dec 14, 2010).

**  P. Sisson, “San Onofre: Latest progress report on nuke plant set for Tuesday,” North Country Times (Dec 9, 2010).

Another Brick in the Wall for BP et al

Yesterday the National Academy of Engineering released their report* on the Deepwater Horizon blowout.  The report includes a critical appraisal of many decisions made during the period when the well was being prepared for temporary abandonment, decisions that in the aggregate decreased safety margins and increased risks.  This Washington Post article** provides a good summary of the report.

The report was written by engineers and scientists and has a certain “Just the facts, ma’am” tone.  It does not specifically address safety culture.  But we have to ask: What can one infer about a culture where the business practices don’t include “any standard practice . . . to guide the tradeoffs between cost and schedule and the safety implications of the many decisions (that is, a risk management approach).”  (p. 15)

We have had plenty to say about BP and the Deepwater Horizon accident.  Click on the BP label below to see all of our related blog entries.

*  Committee for the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future; National Academy of Engineering; National Research Council, “Interim Report on Causes of the Deepwater Horizon Oil Rig Blowout and Ways to Prevent Such Events” (2010).

**  D. Cappiello, “Experts: BP ignored warning signs on doomed well,” The Washington Post (Nov 17, 2010).  Given our blog’s focus on the nuclear industry, it’s worth noting that, in an interview, the committee chairman said, “the behavior leading up to the oil spill would be considered unacceptable in companies that work with nuclear power or aviation.”

Human Beings . . . Conscious Decisions

In a  New York Times article* dated November 8, 2010, there was a headline to the effect that Fred Bartlit, the independent investigator for the presidential panel on the BP oil rig disaster earlier this year had not found that “cost trumped safety” in decisions leading up to the accident.  The article noted that this finding contradicted determinations by other investigators including those sponsored by Congress.  We had previously posted on this subject, including taking notice of the earlier findings of cost trade-offs, and wanted to weigh in based on this new information.

First we should acknowledge that we have no independent knowledge of the facts associated with the blowout and are simply reacting to the published findings of current investigations.  In our prior posts we had posited that cost pressures could be part of the equation in the leadup to the spill.  On June 8, 2010 we observed:

“...it is clear that the environment leading up to the blowout included fairly significant schedule and cost pressures. What is not clear at this time is to what extent those business pressures contributed to the outcome. There are numerous cited instances where best practices were not followed and concerns or recommendations for prudent actions were brushed aside. One wishes the reporters had pursued this issue in more depth to find out ‘Why?’ ”

And we recall one of the initial observations made by an OSHA official shortly after the accident as detailed in our April 26, 2010 post:

“In the words of an OSHA official BP still has a ‘serious, systemic safety problem’ across the company.”

So it appears we have been cautious in reaching any conclusions about BP’s safety management.  That said, we do want to put into context the finding by Mr. Bartlit.  First we would note that he is, by profession, a trial lawyer and may be both approaching the issue and articulating his finding with a decidedly legal focus.  The specific quotes attributed to him are as follows:

“. . . we have not found a situation where we can say a man had a choice between safety and dollars and put his money on dollars” and “To date we have not seen a single instance where a human being made a conscious decision to favor dollars over safety,...”

It is not surprising that a lawyer would focus on culpability in terms of individual actions.  When things go wrong, most industries, nuclear included, look to assign blame to individuals and move on.  It is also worth noting that the investigator emphasized that no one had made a “conscious” decision to favor cost over safety.  We think it is important to keep in mind that safety management and failures of safety decision making may or may not involve conscious decisions.  As we have stated many times in other posts, safety can be undermined through very subtle mechanisms such that even those involved may not appreciate the effects, e.g., the normalization of deviance.  Finally we think the OSHA investigator may have been closer to the truth with his observation about “systemic” safety problems.  It may be that Mr. Bartlit, and other investigators, will be found to have suffered from what is termed “attribution error” where simple explanations and causes are favored and the more complex system-based dynamics are not fully assessed or understood in the effort to answer “Why?”  

* J.M. Broder, "Investigator Finds No Evidence That BP Took Shortcuts to Save Money," New York Times (Nov 8, 2010).