BP Exec Quit Over Safety Before Deepwater Disaster

Today’s Wall Street Journal has an interesting news item about a BP Vice President who quit prior to the Deepwater Horizon disaster because he felt BP "was not adequately committed to improving its safety protocols in offshore drilling to the level of its industry peers." The full article is available here.

“what people do, not why they do it…”

Our perseverance through over three hours of the web video of the Commission meeting on the proposed safety culture policy statement was finally rewarded in the very last minute of discussion.  Commissioner Apostolakis reiterated some of his concerns with the direction of the policy statement, observing that the NRC is a performance-based agency and:

“...we really care about what people do and maybe not why they do it….”

Commissioner Apostolakis was amplifying his discomfort with the inclusion of values along with behaviors in the policy as values are inherently fuzzy, not measurable, and may or may not be a prerequisite to the right behaviors.  Perhaps most of all, he believed omitting the reference to core values would not detract from the definition of safety culture. 

Earlier in the meeting Commissioner Apostolakis had tried to draw out the staff on whether the definition of safety culture needed values in addition to behaviors [at time 2:34:58], and would it be a fatal flaw to omit “core values”.  The staff response was illuminating.  The justification offered for retaining values was “stakeholder consensus”, and extensive outreach efforts that supported inclusion.  (But why was it so important to stakeholders?)  The staff went on to clarify: “culture does not lend itself to be inspectable”, but “having values with behaviors is what culture is all about”.   Frankly we’re not sure what that means, but we do know that safety culture behaviors are inspectable because they are observable and measurable.

That much of the staff’s justification for including values in the policy statement seemed to reside in the fact that all the stakeholders had agreed received positive endorsement by Chairman Jaczko when he observed:  “...Commissioner Magwood I think made a profound point that there was value in this process here that may be tremendously more important than the actual policy statement was the fact that people got together and started talking about this and realized that across this wide variety of stakeholders, there was pretty good agreement about the kinds of things that we were talking about.”

Chairman Jaczko also weighed in on the values-behaviors contrast, coming down firmly on the inclusion of values and offering the following justification:

“...not all entities with a good safety culture will have necessarily the right values…”

Respectfully, we believe at a minimum this will further confuse the NRC’s policy on safety culture, and in all likelihood places emphasis in exactly the wrong place.  Is the Chairman agreeing all that matters is what people do?  Or is he suggesting that the NRC would find fault with a licensee that was acting consistent with safety but did not manifest the “right” values.  And how would the NRC reach such a finding?  More fundamentally, isn’t Commissioner Apostolakis correct in his blunt statement - that we [NRC] don’t care why they [licensees] do it?

More Hope

Our prior post highlighted a comment early in the January 24, 2011 Commission meeting to review the proposed policy statement on nuclear safety culture. 

In the context of her advocacy for regulations in addition to a policy statement, attorney Billie Garde stated she “hoped” that proceeding with just a policy statement was the right decision.  We thought her warning of the fallout from a possible future nuclear event would get some attention.  It did, at least with Commissioner Svinicki who sought some clarification of Garde’s concern.  Just prior to this clip, Svinicki had observed that in her mind a policy statement can’t supplant an appropriate regulatory framework in terms of compelling certain behaviors.  No matter what you think about the appropriateness of a policy statement versus other regulatory actions, Garde is certainly correct that the question will be asked in the future: Did the NRC do enough?

“I Hope For All Our Sakes This is Right”

On January 24, 2011 the NRC Commissioners met to review the proposed policy statement on nuclear safety culture developed by the NRC staff. This most recent effort was chartered by the Commission more than 3 years ago and represents the next step in the process to publish the proposed statement for public comment.

“25 years is long enough to build a policy statement…” for nuclear safety culture. This observation by Billie Garde* in her opening remarks to the Commissioners, with her timeline referring to the Chernobyl and space shuttle Challenger accidents in 1986. She also emphasized that the need was to now focus on implementation of the policy statement. She maintained her position that a policy statement alone would not be sufficient and that regulation would be necessary to assure consistent and reliable implementation.

In that regard she lays claim to one of the more disconcerting observations made at the meeting, the gist of which can be summed up as, “I hope for all our sakes this is right…”

Here’s the video clip with the exchange between Garde and Commissioner Apostolakis.

We will be following up with additional posts with highlights from the Commission session.

*  Billie Garde is an attorney in Washington, D.C.  Her NRC website bio is here.

Culture de la Sécurité

If you are paying attention you noticed we’re using French words.  And the reason is the current news regarding Air France and its safety practices and safety culture.

The principal finding of an independent study of the airline’s operations was a lack of “strong safety leadership at all levels of management" as reported in a January 26 Wall Street Journal (WSJ) article.*

While Air France has refused to make the report public, a review by the WSJ stated that the study was “sharply critical of broad aspects of the safety culture”.

Over the previous several days there have been articles in the WSJ preceding and attending the completion of the independent study.  The first of the articles** previewed some of the findings and provided favorable commentary based on an understanding that Air France would be making the report public (“Air France to Disclose…”).  This was characterized as a move toward greater openness on the part of the airline and commented, “safety experts said it was unusual for a large company, especially an airline, to give outsiders such latitude publicly to expose gaps in safety systems.”  And quoting Bill Voss, president of the Flight Safety Foundation, a global air-safety advocacy organization based in Alexandria, Va., "It's extraordinary that they are willing to release the results," said Mr. Voss. The process "gives me confidence there will be follow-through."

Well, in a follow-up article the next day, when receipt of the study results was announced by Air France, the reaction was disappointment as the airline indicated it would not release the report or its recommendations.  Nonetheless the airline trumpeted its actions:

“According to an Air France news release, the report said that creating the outside review team ‘in a public manner and providing it a broad charter’ to examine flight safety ‘was a courageous act’ and an example of safety leadership ‘rarely seen in today's international aviation industry.’” ***

In deciding on whether Air France should be awarded the Légion d'honneur, one might also consider that the current safety study was undertaken in the wake of four serious crashes between 1999 and 2009 (the most recent being the flight from Rio to Paris that went down mid-Atlantic).  In addition, it follows a prior safety study,

“Finished in 2006, that report was distributed to more than 4,000 company pilots and was widely praised for its frankness about shortcomings within the carrier. Although Air France has said its executive committee made formal decisions to implement the report's recommendations, critics of the airline continue to maintain management didn't aggressively pursue the changes.” (Jan 24, 2011)

I think we’ve seen this before.  Think about the safety studies after the Challenger crash, but not really implemented and then the disintegration on reentry of the Columbia.  Or BP and the Texas oil refinery fire followed by the Deepwater Horizon last summer.  Obviously safety assessments, no matter how strong and how independent, ultimately require the subject organization to implement changes.  We think the current Air France report correctly fingers safety leadership by management “starting at the top”.  And it never fails in these situations that top management describes as its highest priority…...can anybody guess……that’s right, it’s “safety first”.  (Jan 26, 2011)

Perhaps if it was safety first Air France might be releasing the study and its recommendations.  Wouldn’t that help make real its safety priority and wouldn’t such transparency help ensure that the recommendations are actually implemented?   We have commented in prior posts on transparency and we will continue to emphasize its importance to safety culture across all industries.


*  A. Pasztor, D. Michaels and D. Gauthier-Villars, “Air France Panel Cites Wide Safety Deficiencies,” WSJ.com (Jan 26, 2011).

** A. Pasztor and D. Michaels, “Air France to Disclose Review's Criticisms,” WSJ.com (Jan 24, 2011).

***  A. Pasztor, “Air France Enhances Safety Efforts,” later re-headlined “Air France Withholds Key Report,” WSJ.com (Jan 25, 2011).

A Nuclear Model for Oil and Gas

The President’s Commission has issued its report on the Deepwater Horizon disaster.* The report reviews the history of the tragedy and makes recommendations based on lessons learned.  This post focuses on the report’s use of the nuclear industry, in particular the role played by INPO, as a model for an oil and gas industry safety institute and auditor.

The report provides an in-depth review of INPO’s role and methods and we will not repeat that review in this space.  We want to highlight the differences between the oil and gas and nuclear industries, some recognized in the report, that would challenge a new safety auditor. 

First, “The oil and gas industry is more fragmented and diversified in nature. . . .” (p. 240)  The industry includes vertically integrated giants, specialty niche firms and everything in-between.  Some are global in nature while others are regional firms.  In our view, it appears that oil and gas industry participants cooperate with each other in certain instances and compete with each other in different cases.  (In contrast, most [all?] U.S. nuclear plants are not in direct competition with other plants.)  Obtaining agreement to create a relatively powerful industry auditing entity will not be a simple matter.    

Second, “concerns about potential disclosure to business competitors of proprietary information might make it harder to establish an INPO-like entity in the oil and gas industry.” (p. 240)  Oil and gas firms regard technology as an important source of competitive advantage.  “[A]n INPO-like approach might run into problems if companies perceived the potential for inspections of offshore facilities to reveal ‘technical and proprietary and confidential information that companies may be reluctant to share with one another.’” (p. 241)  Not only will it be difficult to get a firm to share its proprietary technology if it may lose competitive advantage by doing so, but this will make it more difficult for the auditing organization to promote the industry-wide use of the most effective, safest technologies

Third, and this could be a potentially large problem, INPO operates in almost total secrecy.  “[INPO] assessment results are never revealed to anyone other than the utility CEOs and site managers, but INPO formally meets with the NRC four times a year to discuss trends and information of “mutual interest.” And if INPO has discovered serious problems associated with specific plants, it notifies the NRC.”  (p. 236)  INPO claims, probably realistically, that maintaining member confidentiality is key to obtaining full and willing cooperation in evaluations. 

However, this secrecy contributes zero to public understanding of and support for nuclear plant operations and owners.  At this point in its evolution, the oil and gas industry needs more transparency in its auditing and oversight functions, not less.  After all, and forgive the bluntness here, very few people have died at U.S. commercial nuclear power plants (and those were in non-nuclear incidents) while the oil and gas industry has suffered numerous fatalities.  We think a government auditor, whose evaluations of facilities and managements would be made public, is the better answer for the oil and gas industry at this time.


*  National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling, “Deep Water: The Gulf Oil Disaster and the Future of Offshore Drilling,” Report to the President (Jan 2011).

NRC Policy Statements

For some time we have been thinking about one of the underlying aspects of the NRC’s current safety culture initiative which is to establish a “policy statement” for nuclear safety culture.  As we know the use of a policy statement in this area dates back to 1989.  A subtext to this approach is whether the NRC should “regulate” nuclear safety culture, presumably through the issuance of regulatory rules and requirements.  We recognize that the “regulate” issue is very much a hot button and we are not addressing it at this time.  Instead we thought it might be worthwhile to consider in some detail just what is a Commission policy statement and what it might or might not accomplish.

On the NRC website we looked at what was available regarding policy statements.  There is a Commission Policy Statements page with a listing of the current set of policy statements, organized by topic.  However, most policy statements relate to the conduct of business by the NRC itself with fewer statements addressing substantive regulatory and safety criteria.  We could not locate on the website information regarding how policy statements are intended to be used in the regulatory process.  For that we turned to recent NRC Issuances,* which are adjudicatory decisions by Atomic Safety and Licensing Boards and the Commission itself, to obtain guidance on the applicability and weight accorded NRC Policy Statements. 

“Policy Statements are neither rules nor orders, and therefore do not establish requirements that bind either the agency or the public.”**

This comes from a Commission decision for a case involving the scope of environmental review for an early site permit.  The Commission references a D.C. Circuit Court case that found:

“A general statement of policy . . . does not establish a ‘‘binding norm.’’ It is not finally determinative of the issues or rights to which it is addressed. The agency cannot apply or rely upon a general statement of policy as law because a general statement of policy only announces what the agency seeks to establish as policy.” (p. 240)

In its decision, the Commission goes on to state:

“For the [Atomic Safety and Licensing] Board to suggest that the strictures of the Policy Statement may be enforced as law, or that it in some way creates a substantive mandate, accords too much weight to the Policy Statement.” (p. 240) 

So far so good.  But after finding that the staff’s review satisfied applicable statutory and regulatory requirements (but did not comport with the letter of the policy statement), the Commission ends its decision on a more confusing note.

“We expect conformance with the Policy Statement, and relevant associated guidance, in future licensing actions of this magnitude.” (p. 248)

In another matter involving a policy statement governing the admissibility of contentions in license renewal proceedings, Commissioners Merrifield and McGaffigan joined in a concurring opinion to observe:

“If we are not willing to enforce our policy statements, the statements become meaningless.”***

Finally, an earlier ASLB decision seems to address policy statements on a practical level, where the Board feels “compelled” by Commission policy: 

Notwithstanding these clear inconsistencies, we find ourselves compelled by Commission rulings and policy statements to accept this approach by the Staff because the Commission has advised that their ‘‘longstanding practice . . . grounded in sound policy’’ is to ‘‘leave [ ] to the expert NRC technical staff prime responsibility for technical fact-finding on uncontested matters.’’****

Based on all of this what is the likely impact of the safety culture policy statement on NRC license holders?  On the one hand it appears that the NRC will “expect” licensees to meet the intent and the particulars of its policy statement.  It seems safe to assume the NRC staff will apply the policy in its assessments of licensee performance.  On the other hand, if a licensee does not meet some aspect of the policy it could find solid footing in a challenge to the enforceability of the policy statement.  The greatest difficulty is to square the rhetoric of NRC Commissioners and staff regarding the absolute importance of safety culture to safety, the “nothing else matters” perspective, with the inherently limited and non-binding nature of a policy statement.


*  NRC Issuances are published as NUREG-0750.  Individual volumes are available here. 

**  66 NRC 215 (2007) at 217, In the Matter of: DOMINION NUCLEAR NORTH ANNA, LLC (Early Site Permit for North Anna ESP Site) CLI-07-27 Nov 20, 2007.

***  65 NRC 1 (2007) at 8, In the Matter of: ENTERGY NUCLEAR VERMONT YANKEE, LLC, and ENTERGY NUCLEAR OPERATIONS, INC. (Vermont Yankee Nuclear Power Station) CLI-07-1 Commissioner Jeffrey S. Merrifield, with Whom Commissioner Edward McGaffigan, Jr. Joins, Concurring Jan 11, 2007.

****  64 NRC 460 (2006) at 492, ATOMIC SAFETY AND LICENSING BOARD In the Matter of EXELON GENERATION COMPANY, LLC (Early Site Permit for Clinton ESP Site) Dec 28, 2006.

ACRS and Safety Culture Policy (cont.)

Our previous post reported on the ACRS letter to the NRC endorsing the agency’s approach to developing a safety culture policy.*  We noted the concern of some ACRS members that the policy might be a back door method to impose regulatory requirements while avoiding the requirements of the regulatory process.

The dissenting ACRS members also raised some other interesting issues about the proposed policy.

First, they questioned whether the proposed traits were the most important ones in terms of their contribution to safety.  Why weren’t organizational and individual integrity, and technical competence included?  Good question.  After all, wasn’t an integrity shortfall at the heart of the misleading of the Vermont senate and the willful violations at San Onofre?

Second, they commented “[T]here is faint evidence that the listed traits (individually or collectively) are assured to produce measureable improvements in safety.” (p. 4)  We raised the same issue in our October 22, 2010 post on the NRC safety culture workshop.  What are the linkages, if any, between the traits and measurable or observable safety-related performance?

Our concern about the lack of demonstrated linkages leads to what may be a bedrock question underlying all of the safety culture policy discussion: If the ROP isn’t providing sufficient information to support the NRC’s confidence in a licensee’s safety culture, then how can the agency develop that information in a defined, disciplined and vetted manner?  Is a safety culture policy going to provide that assurance?


*  Letter dated Dec 15, 2010 from S. Abdel-Khalik (ACRS) to G. Jaczko (NRC), subject "Safety Culture Policy Statement," ADAMS Accession Number ML103410358.