The Safety Culture Common Language Path Forward—and the Broken Window at the Nuclear Power Plant

The NRC has an initiative, the Safety Culture Common Language Path Forward, to describe safety culture (SC) elements at a more detailed level than the NRC’s SC policy statement.  There was a workshop for agency and industry representatives, and a conference call was scheduled for today to discuss next steps.  The draft “elements” from the workshop are a mélange of polished bureaucratese, company policy proclamations and management homilies.*

I was curious to see how they treated the areas I have been harping on as critical for effective SC: decision making, corrective action, management incentives and work backlogs.  Following is my very subjective rating of how well the draft elements cover the key subject areas.

Decision making – Mostly Satisfactory.  “The licensee makes safety-significant or risk-significant decisions using a systematic process.” (Shoop, p. 18)   We agree; in fact, we think ALL significant decisions should be made using a systematic process.  Why “systematic”?  To evidence transparency and robustness, i.e., to maximize the odds that a different decision-maker, if faced with a similar situation, will reach the same or similar answer.  However, one important type of decision, the resolution of goal conflict needs improvement.  Goal conflict appears focused on personal or professional disagreements; the big picture potential conflict of safety vs production, cost or schedule gets slight mention.

Corrective action – Satisfactory.  There are a lot of words about corrective action and the CAP and they cover the important points.  A minor gripe is the term “safety” may be overused when referring to identifying, evaluating or correcting problems.  A couple of possible unintended consequences of such overuse are to create the impression that (1) only safety-related problems need such thorough treatment or (2) anything someone wants done needs some relation, no matter how tenuous, to safety.

Management incentives – Minimally acceptable.  “Senior management incentive program [sic] reflect a bias toward long-term plant performance and safety.” (Shoop, p. 12)  One could say more about this topic (and we have, including here and here) but the statement gets over the bar. 

Backlogs – Unsatisfactory.  The single mention of backlogs is “Maintaining long term plant safety by . . . ensuring maintenance and engineering backlogs which are low enough [to] support safety” (Shoop, p. 32) and even that was the tail end of a list of contributing factors to plant safety.  Backlogs are much more important than that.  Excessive backlogs are demoralizing; they tell the workforce that accomplishing work to keep the plant, its procedures and its support processes in good repair or up-to-date is not important.  Every “problem plant” we worked on in the late 1990s had backlog issues.  This is where the title reference to the broken window comes in. 

“. . . if a window in a building is broken and is left unrepaired, all the rest of the windows will soon be broken. . . . one unrepaired broken window is a signal that no one cares, and so breaking more windows costs nothing.”**

Excessive backlogs are a broken window. 


*  NRC memo from U.S. Shoop to J. Giitter, “Safety Culture Common Language Path Forward” (Mar. 19, 2012) ADAMS ML12072A415.

**  J.Q. Wilson and G.L. Kelling, “Broken Windows: The police and neighborhood safety,” The Atlantic Monthly (Mar. 1982).

Going Beyond SCART: A More Useful Guidebook for Evaluating Safety Culture

Our March 11 post reviewed the IAEA SCART guidelines.  We found its safety culture characteristics and attributes comprehensive but its “guiding questions” for evaluators were thin gruel, especially in the areas we consider critical for safety culture: decision making, corrective action, work backlogs and management incentives.

This post reviews another document that combines the SCART guidelines, other IAEA documents and the author’s insights to yield a much more robust guidebook for evaluating a facility’s safety culture.  It’s called “Guidelines for Regulatory Assessment of Safety Culture in Licensees’ Organisations.”*  It starts with the SCART characteristics and attributes but gives more guidance to an evaluator: recommendations for documents to review, what to look for during the evaluation, additional (and more critical) guiding questions, and warning signs that can indicate safety culture weaknesses or problems.

Specific guidance in the areas we consider critical is generally more complete.  For example, in the area of decision making, evaluators are told to look for a documented process applicable to all matters that affect safety, attend meetings to observe the decision-making process, note the formalization of the decision making process and how/if long-term consequences of decisions are considered.  Goal conflict is explicitly addressed, including how differing opinions, conflict based on different experiences, and questioning attitudes are dealt with, and the evidence of fair and impartial methods to resolve conflicts.  Interestingly, example conflicts are not limited to the usual safety vs. cost or production but include safety vs. safety, e.g., a proposed change that would increase plant safety but cause additional personnel rad exposure to implement.  Evidence of unresolved conflicts is a definite warning flag for the evaluator. 

Corrective action (CA) also gets more attention, with questions and flags covering CA prioritization based on safety significance, the timely implementation of fixes, lack of CA after procedure violations or regulatory findings, verification that fixes are implemented and effective, and overall support or lack thereof for the CAP. 

Additional questions and flags cover backlogs in maintenance, corrective actions, procedure changes, unanalyzed physical or procedural problems, and training.

However, the treatment of management incentives is still weak, basically the same as the SCART guidelines.  We recommend a more detailed evaluation of the senior managers’ compensation scheme or, in more direct language, how much do they get paid for production, and how much for safety?

The intended audience for this document is a regulator charged with assessing a licensee’s safety culture.  As we have previously discussed, some regulatory agencies are evaluating this approach.  For now, that’s a no-go in the U.S.  In any case, these guidelines provide a good checklist for self-assessors, internal auditors and external consultants.


*  M. Tronea, “Guidelines for Regulatory Oversight of Safety Culture in Licensees’ Organisations” Draft, rev. 8 (Bucharest, Romania:  National Commission for Nuclear Activities Control [CNCAN], April 2011).  In addition to being on the staff of CNCAN, the nuclear regulatory authority of Romania, Dr. Tronea is the founder/manager of the LinkedIn Nuclear Safety group.  

The NRC Does Not Regulate Safety Culture, Right?

Last March, the NRC approved its safety culture policy statement.*  At the time, a majority of commissioners issued supplemental comments expressing their concern that the policy statement could be used as a back door to regulation.  The policy was issued in June, 2011.  Enough time has lapsed to ask: What, if anything has happened, i.e., how is the NRC treating safety culture as it exercises its authority to regulate licensees?

We examined selected NRC documents for some plants where safety culture has been raised as a possible issue and see a few themes emerging.  One is the requirement to examine the causes of specific incidents to ascertain if safety culture was a contributing factor.  It appears some (perhaps most or all) special inspection notices to licensees include some language about "an assessment of whether any safety culture component caused or significantly contributed to these findings."  

The obvious push is to get the licensee to do the work and explicitly address safety culture in their mea culpa to the agency.  Then the agency can say, for example, that "The inspection team confirmed that the licensee established appropriate corrective actions to address safety culture."**  A variant on this theme is now occurring at Browns Ferry, where the “NRC is reviewing results from safety culture surveys performed by the plant in 2011.”*** 

The NRC is also showing the stick, at least at one plant.  At Fort Calhoun, the marching orders are: “Assess the licensee’s third party evaluation of their safety culture. . . . If necessary, perform an independent assessment of the licensee’s safety culture using the guidance contained in Inspection Procedure 95003."****  I think that means: If you can't/won't/don't perform an adequate safety culture evaluation, then we will.  To back up this threat, it appears the NRC is developing procedures and materials for qualifying its inspectors to evaluate safety culture.

The Alternative Dispute Resolution (ADR) process is another way to get safety culture addressed.  For example, Entergy got in 10 CFR 50.7 (employee protection) trouble for lowering a River Bend employee’s rating in part because of questions he raised.  One of Entergy's commitments following ADR was to perform a site-wide safety culture survey.  It probably didn’t help that, in a separate incident, River Bend operators were found accessing the internet when they were supposed to be watching the control board.  Entergy also has to look at safety culture at FitzPatrick and Palisades because of incidents at those locations.***** 

What does the recent experience imply?

The NRC’s current perspective on safety culture is summed up in an NRC project manager’s post in an internet Nuclear Safety Culture forum: “You seem to [sic] hung up on how NRC is going to enforce safety culture.  We aren't.  Safety culture isn't required. It won't be the basis for denying a license application.  It won't be the basis for citing a violation during an inspection.  However, if an incident investigation identifies safety culture as one of the root causes, we will require corrective action to address it.”  (Note this is NOT an official agency statement.)

However, our Bob Cudlin made a more expansive prediction in his January 19, 2011 post: “. . . 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. . . . 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.”

While the record to date may support the NRC PM’s view, I think Bob’s observations are also part of the mix.  It’s pretty clear the NRC is turning the screw on licensee safety culture effectiveness, even if it’s not officially “regulating” safety culture.


*  NRC Commission Voting Record, SECY-11-005, “Proposed Final Safety Culture Policy Statement” (March 7, 2011).  I could not locate this document in ADAMS.

**  IR 05000482-11-006, 02/07-03/31/2011, Wolf Creek Generating Station - NRC Inspection Procedure 95002 Supplemental Inspection Report and Assessment Followup Letter (May 20, 2011) ADAMS ML111400351. 

***  Public Meeting Summary for Browns Ferry Nuclear Plant, Docket No. 50-259 (Feb. 26, 2012) ADAMS ML12037A092.

****  Fort Calhoun Station Manual Chapter 0350 Oversight Panel Charter (Jan. 12, 2012) ADAMS ML120120661.

*****  EN-11-026, Confirmatory Order, Entergy Operations Inc.  (Aug. 19, 2011)  ADAMS ML11227A133; NRC Press Release-I-12-002: “NRC Confirms Actions to be Taken at FitzPatrick Nuclear Plant to Address Violations Involving Radiation Protection Program” (Jan. 26, 2012) ADAMS ML120270073; NRC Press Release-III-12-003: “NRC Issues Confirmatory Orders to Palisades Plant Owner Entergy and Plant Operator” (Jan. 26, 2012) ADAMS ML120270071.

IAEA’s Safety Culture Assessment Review Team (SCART) Program

The International Atomic Energy Agency (IAEA) offers the SCART service to Member States.  A SCART’s goal is to assess the safety culture in a nuclear facility and provide recommendations for enhancing safety culture going forward.  In this post, we provide an overview of the program and our evaluation of it.

What is SCART?

“SCART is an assessment of safety culture based on IAEA standards and guidelines by a team of international and independent safety culture experts.”*  A SCART mission can take up to a year start-to-finish, including a pre-SCART visit to finalize the scope of the  assessment.  The SCART on-site assessment takes two full weeks, including the review team’s on-site organizational activities.  The assessment uses document reviews, interviews and observations to gather data, and a fairly prescribed methodology for drawing inferences from the data. 

The review team utilizes an evaluation framework consisting of five key safety culture characteristics, which are assessed using 37 attributes.  The attributes describe “specific organizational performance or attitude . . . which, if fulfilled, would characterize this performance or attitude as belonging to a strong safety culture.”**

The review team’s findings describe the current state of safety culture at the host facility; the team’s recommendations and suggestions describe ways the safety culture could be improved.

Is it any good?

At first blush, SCART appears overly bureaucratic and time-consuming.  However, the assessment team is likely to be comprised of IAEA staff and outside experts from different countries, and the target facility is likely in yet another country.  In addition, much of prescribed methodology is aimed at ensuring the team covers all important topics and reaches robust, i.e., repeatable, conclusions.  All this takes time and a detailed game plan.

But what about the game plan itself?  

The review team forms opinions on five safety culture characteristics by assessing 37 attributes.  The characteristics are non-controversial and the set of attributes appears comprehensive. (SCART Guidelines, pp. 25-26)  Supporting them is a set of over 300 suggested “guiding questions” for the interviews.  For us, the most important aspects are the attributes and questions that address topics we consider essential for an effective safety culture: a successful corrective action program, acceptable work backlogs, a decision making process that appropriately values safety, and management incentives.

Corrective Action Program

Attribute E.5: Learning is facilitated through the ability to recognize and diagnose deviations, to formulate and implement solutions and to monitor the effects of corrective actions” (Guidelines, p. 47)

The relevant*** guiding questions are: “Can staff members or contractors point to examples of problems they have reported which have been fixed?”  “How high is the rate of repeat events or errors?”

There’s a lot more than can be asked about the CAP.  For example, Who can initiate an action request?  How are requests evaluated and prioritized; does safety receive consistent attention and appropriate priority?  What are the backlogs and trends?  What items are subject to root cause analysis?  Does root cause analysis find the real causes of problems, i.e., do the subject problems cease to occur after they have been fixed?  

Work Backlogs

“Attribute A.2: Safety is a primary consideration in the allocation of resources:” (Guidelines, p. 28)

The relevant guiding questions are: “Can staff members and contractors describe examples when the allocation of resources affected the backlog of maintenance tasks and nuclear facility modifications? What was the process to resolve the conflict?”

How about: What are the backlogs and trends in every major department?  Are backlogs at an acceptable level?  Why or why not?  If not, then is there a plan to clear the backlogs?  Are resources available to implement the plan?

Decision Making Process

Two attributes refer to decision making.  “Attribute A.1: The high priority given to safety is shown in documentation, communications and decision making:” (Guidelines, p. 27)   “Attribute A.5.: A proactive and long term approach to safety issues is shown in decision-making:” (Guidelines, p. 29)

The relevant guiding questions for A.1 are: “During periods of heavy work-load, in what way do managers ensure that staff members and contractors are reminded that unnecessary haste and shortcuts are inappropriate?  Can staff members and contractors describe situations when the rationale for significant decisions related to safety was communicated to a large group of individuals in the nuclear facility?  Can staff members and contractors describe situations when assumptions and conclusions of earlier safety decisions were challenged in the light of new information, operating experience or changes in context?”

The relevant guiding questions for A.5 are: “What is the approach of managers at all levels when they have to cope with an unforeseen event requiring more staff at short notice?  What happens if, for any reason, production requirements are permitted to interfere with scheduled training modules? What kind of a system for prioritizing maintenance work along safety requirements is established?

We would add:   How does the decision-making process handle competing goals, set priorities, treat devil’s advocates who raise concerns about possible unfavorable outcomes, and assign resources?  Are the most qualified people involved in key decisions, regardless of their position or rank?  How are safety concerns handled in making real-time decisions?

Management Incentives

Incentives are discussed under Attribute A.5 (see preceding section).

The relevant guiding questions are: “What is the major focus of incentives and priorities for senior management?  How are management incentive strategies discussed on the corporate level?”

We would add: How is safety incorporated into management incentives, if at all?  If safety is addressed, is it limited to industrial safety?  Is there any disincentive, e.g., loss of bonus, if safety-related incidents occur or recur?   


With over 300 guiding questions, I may have missed some that address our key issues.  But the ones identified above seem a little thin in their treatment of the most important issues related to safety culture.  We are not saying the other attributes and questions are not important—but they do not address the core of safety culture’s impact on organizational behavior. 

Has SCART Been Applied?

Yes.  Since 2006, IAEA has conducted three SCART evaluations, two of which occurred at nuclear power plants.  (A request to IAEA asking if additional evaluations have taken place went unanswered.)  I think we can safely say it is not wildly popular.

Conclusion

The SCART materials provide a good reference for anyone trying to figure out how to evaluate their facility’s safety culture.  The comprehensive, step-by-step approach ensures that all attributes are covered and individual expert opinions are melded into team opinions for each attribute and characteristic.  However, we doubt anyone would ever use it as a template for self-assessment.  It is too resource-intensive, treats key areas  lightly and basically creates a static, as opposed to dynamic, snapshot of safety culture.  The overall impression reminds me of the apocryphal tale of the man who wrote a book titled 1000 Ways to Make Love; unfortunately, he didn’t know any women.


*  C. Viktorsson, IAEA, “Understanding and Assessing Safety Culture,” Symposium on Nuclear Safety Culture: Fostering Safety Culture in Japan’s Nuclear Industry: How To Make It Robust?  (Mar 22-23, 2006) p. 18.

**  SCART Guidelines: Reference Report for IAEA Safety Culture Assessment Review Team (SCART), IAEA, Vienna (July 2008) p. 4.

***  Each attribute is followed by many guiding questions.  I have selected the questions that appear most related to our key topics.

Reflections on the Vit Plant's New Safety Culture Manager: Full Steam Ahead or Time for DOE to Consider a New Plan B?

(Ed. note: Here's a new essay on the Vit Plant by Bill Mullins.  In an era of sound bites and tweets, we provide a forum where complete ideas can be aired.  Please contact us if you would like to contribute.)

“Hanford Contractor Hires New Safety Culture Manager” Oregon Public Broadcasting News 2/8/12

Strange Circumstance: The Safetymatters readership may already have checked out the above item with its announcement of the latest move by the Bechtel National (BNI) management team for the “fast-track, design-build” contract at the Hanford Waste Treatment Plant (WTP).

Reviewing the announcement of Ward Sproat’s assignment to a newly created position “Safety Culture Manager” it seemed appropriate to make a few comments on what a strange turn of affairs this seems to be in what is already a very strange circumstance.

In its Recommendation 2011-1, the Defense Nuclear Facilities Safety Board (DNFSB) “determined that the prevailing safety culture at the Waste Treatment and Immobilization Plant (WTP) is flawed and effectively defeats [DOE Nuclear Safety Policy].”

No previous DNFSB Recommendation has addressed the issue of Nuclear Safety Culture (NSC) and its raising in the far-from-typical circumstance of the WTP contract represents a significant oversight policy challenge for DOE. DOE’s Implementation Plan makes substantial enterprise-wide commitments on the basis of this single exemplar.

Testing Nuclear Safety Culture: The 2011-1 finding arose in the midst of an already contentious WTP setting involving formal nuclear safety “whistle-blower” complaints and a DNFSB formal investigation of the surrounding circumstances. Equally significant is the fact that the WTP project is significantly troubled by questions of technology readiness levels in the key Pretreatment processes. BNI’s contract contains a $100M incentive for early start of waste treatment in the WTP.

One might conclude that the notion of NSC, for all the advocacy of its importance across the global nuclear energy enterprise, is receiving a significant baptism of fire at the WTP. The selection of Mr. Sproat, and the position created for him, allows some reflection upon a key attribute – Leadership – of NSC conventional wisdom.

There appears to be broad consensus that Leadership is important to effective NSC. From the US Nuclear Regulatory Commission (NRC) we have this statement of NSC trait:

“Leadership Safety Values and Actions – Leaders demonstrate a commitment to safety in their decisions and behaviors.”

Similar statements are found in INPO, IAEA and NEI standards on NSC; of interest here is: To what extent does the Leadership norm inform the selection criteria for Mr. Sproat?

Competence Commensurate: At this juncture in the River Protection Program there is a large body of opinion pointing to “Nuclear Safety Culture” as a normative factor that is implicated in difficulties managing the acquisition of the Waste Treatment Plant under DOE’s contract with Bechtel National. On the record, views range from “defective until demonstrated otherwise” (DNFSB); to sanguine (DOE Safety Oversight); to confident about improvement (Bechtel sponsored Independent Safety and Quality Culture Team).

As a framework for assessing the BNI appointment I’m using the DOE’s Integrated Safety Management (ISM) Doctrine (cf. DOE P 450.4A). The ISM Doctrine encompasses NSC.

ISM Guiding Principle #3 states:

“COMPETENCE COMMENSURATE WITH RESPONSIBILITIES.  Personnel possess the experience, knowledge, skills, and abilities that are necessary to discharge their responsibilities."

Given the BNI action to bring Mr. Sproat’s relevant experience to bear on the WTP challenges it seems reasonable to assess his “Competence commensurate with responsibilities” for NSC leadership, and how that relates to the identified needs for WTP project improvement. Stated differently, does the appointment of Mr. Sproat indicate BNI understands what is expected by way of WTP performance improvement?

Determination of Competence: Mr. Sproat has clearly held positions of substantial responsibility; in the near past he was the Presidential Appointee in DOE responsible for development of the Yucca Mountain Repository license application to the NRC – this too was work DOE contracted to Bechtel. Now, one must ask: How does executive experience with preparing a highly structured NRC license application for a geological repository relate to the development of a DOE Authorization Basis for a High Level Liquid Waste treatment facility of very uncertain feasibility?

Mr. Sproat’s experience with DOE projects has been outside the domain of the Environmental Management Program to which the Hanford Tank Waste belongs. Similarly, he appears to have limited experience with Federal Facilities Compliance Agreements which govern major RCRA actions such as the WTP; likewise his knowledge of the DOE practice of nuclear facility “regulation by contract” would appear to be indirect at best. These shortfalls of direct experience will likely make for a steep learning curve.

Mr. Sprout undoubtedly has leadership capacity, but is it relevant to the WTP acquisition? Can DOE rely upon his judgment regarding his fitness for leadership in this very troubled circumstance? As I understand the sense of the several authoritative NSC standards, the importance of “nuclear safety as an over-riding priority” would seem to create a considerable premium on direct experience when the project involved is well outside the “typical” nuclear facility setting – as is the WTP.

The significantly atypical character of the WTP would thus suggest that the assessment of Mr. Sproat’s fit to the challenge should be made by someone who is intimate with the project. Reporting at such a high level, this person would seem to be the BNI Project Manager Mr. Russo, perhaps with the aid of some key reports.

BNI’s Judgment of Fitness: For an assessment of the BNI judgment of Competence Commensurate with Responsibilities, consider Mr. Russo’s announcement of Mr. Sproat’s assignment. Therein, Mr. Russo portrays the January 2012 report of the DOE Office of Health, Security and Safety’s follow up review of safety culture for the WTP project. He observes: “The HSS report is particularly important because it is from the perspective of DOE. As such, it represents the knowledge and experience of the entire weapons complex.” This would not appear to be the case.

At the HSS Report Section 2.2 Scope and Methods we find:

“The applied framework was the one recently described by the NRC. The evaluation was conducted using the same methodology that aligns with the current NRC procedures for independent safety culture assessment.

“The safety culture components important for the existence of a healthy safety culture within a nuclear facility have been identified (INSAG-15, 2002; Institute of Nuclear Power Operations Principles for a Strong Nuclear Safety Culture, 2004; NRC Inspection Manual 0305, 2006). The NRC and its stakeholders have recently agreed upon nine traits that are viewed as necessary in promoting a positive safety culture…

“While the methodology used in this evaluation was based upon work originally developed with the support of the NRC to assess the influence of organization and management on safety performance, the methodology has also been effectively implemented in non-nuclear organizations, such as mining, health care, research, engineering, and transportation.”

Several observations are in order at this point:

•    The analytical framework of this evaluation is taken from a commercial vendor’s standard process. This framework was developed in 1991 at Brookhaven National Laboratory for the US NRC. The principals of the contractor Human Performance Analysis Corporation (HPAC)  were developers of the methodology which is used in a variety of high consequence circumstances and is not particularly tailored to any of the NRC, IAEA, INPO, or other safety culture developments since the inception of the current Reactor Oversight Process in 1999.

•    While the work in 1991 was advanced for its time, there is a case to be made that the “enterprise culture construct” employed then has become obsolescent – at least as far as the civilian nuclear power enterprise is concerned. HPAC cites as reference a culture model developed by Edgar Schein many years before 1991. As recently as 2003 Dr. Schein, in an address to the INPO CEOs on the subject of managing culture change employed a very different construct – he did not use the term “safety culture” in that talk; rather he characterized enterprise culture as emergent of all performance aspects (i.e. production and protection) at the interface of the various distinct professional cultures (executives, engineers, operators, maintainers) where work is planned.

•    While giving lip-service to its definition, neither the HSS Report nor the HPAC Appendix (a separate report from the same assessment data sets) reflects the DOE Safety Culture standard developed jointly in 2009/10 by DOE and Energy Facility Contractors Group (EFCOG). This is significant because the definition of Safety Culture in that work takes shape from the DOE’s Integrated Safety Management Policy and Doctrine – if differs markedly from virtually all NRC and other definitions in that it is not a “safety first” framework (i.e. “overriding priority given to nuclear safety).

•    There is no indication that any of the various Safety Culture assessment and improvement approaches draw upon experience with one-of-a-kind technology development, a multi-facility complex design, process challenged dominated by physical chemistry not radiological concerns, and systematization on a scale unprecedented since the Manhattan project – if even then.

On these bases, Mr. Russo’s contention that the HSS review is indicative of DOE complex-wide expectations for Safety Culture is misplaced.

Finding the Glitch: What can be expected from Mr. Sproat would seem to follow from how valuable his NSC relevant experience will be in curing the misalignment of two professional organizations “facility design” and “safety analysis.” These organizations – one headed by a senior management whistle-blower on this project – have been working for some years to conflicted objectives.

“For the WTP project, DOE decided to implement a “design-build” approach in which significant construction efforts are undertaken in parallel with the design efforts. The goal of this approach was to complete the WTP sooner, thus allowing DOE to meet milestones for addressing tank waste hazards and reducing the environmental and safety risks associated with the hazardous wastes in the tank.”

This statement fails to fully illuminate that fact that it is universally understood in the world of large project acquisition, that “design-build” efforts are only prudently employed in circumstances of high certainty from past precedent both in terms of design, construction methods, resource availability, and other such uncertainty-stabilizing factors. None of these conditions ever pertained in the instance of the WTP.

The over-arching conclusion of the HSS review seems to be this:

“While there is no fear of retaliation in the ORP (including DOE-WTP) work environment, there is a definite unwillingness and uncertainty among employees about the ability to openly challenge management decisions. There are definite perceptions that there is not an environment conducive to raising concerns or where management wants or willingly listens to concerns. Most employees also believe that constructive criticism is not encouraged.”

Like the several other reports on the record this conclusion tells the “What” of the challenge, but not the “Why.”

Conclusion: In the latest HSS Report’s many pages of recommendations it seems clear that conditions observed have not improved much from those of 12 -24 months earlier. While there is plenty of room for improvement on the DOE side of the ledger, it is difficult to avoid a conclusion that the appointment of Mr. Sproat, and his arrival’s announcement by Mr. Russo, suggest that BNI still sees the unresolved design and technology development challenges as “punch-list items.”

For BNI, even in the midst of the prolonged “safety culture” uproar, it appears the many disparate review results still comprise a “Full Steam Ahead” matter to be resolved by top-down command and control management methods.  I wish them luck with that – to DOE I suggest looking toward a radical Plan B.

(Mr. Mullins is a Principal at Better Choices Consulting.)

More BP

We have posted numerous times on the travails of BP following the Deepwater Horizon disaster and the contribution of safety culture to these performance results.  BP is back in the news since the trial date for a variety of suits and countersuits is coming up shortly.  We thought we would take the opportunity for a quick update.

The good news is the absence of any more significant events at BP facilities.  In its presentation to investors on 4Q11 and 2012 Strategy, BP highlighted its 10 point moving forward plan, including at the top of the list, “relentless focus on safety and managing risk”.* 

It is impossible for us to assess how substantive and effective this focus has been or will be, but we’ve now heard from BP’s Board member Frank Bowman.  Bowman is head of the Board’s Safety, Ethics and Environment Assurance Committee.  He served on the panel that investigated BP’s US refineries after the Texas City explosion in 2005 and then became a member of BP’s US advisory council; and in November 2010, he joined the main board as a non-executive director.  Basically Bowman’s mission is to help transfer his U.S. nuclear navy safety philosophy to BP’s energy business.

Bowman reports that he has been impressed by the way the safety and operational risk and upstream organizations have taken decisions to suspend operations when necessary. “We’ve recently walked away from several jobs where our standards were not being met by our partners or a contractor. That sends a message heard around the world, and we should continue to do that.”**

Looking for more specifics in the 4Q11 investor presentation, we came across the following “safety performance record”. (BP 4Q11, p. 12)

The charts plot “loss of containment” issues (these are basically releases of hydrocarbons) and personnel injury frequency.  The presentation notes that “Aside from the exceptional activities of the Deepwater Horizon response, steady progress has been made over the last decade.”  Perhaps but we are skeptical that these data are useful for measuring progress in the area of safety culture and management.  For one they both show positive trends over a time period where BP had two major disasters - the Texas City oil refinery fire in 2005 and Deepwater Horizon in 2010.  At a minimum these charts confirm that the tracked parameters do nothing to proactively predict safety health.  As Mr. Bowman notes, “Culture is set by the collective behaviour of an organisation’s leaders… The collective behaviour of BP’s leaders must consistently endorse safety as central to our very being.” (BP Magazine, p. 10)

On the subject of management behavior, the investigations and analyses of Deepwater Horizon consistently noted the contribution of business pressures and competing priorities that lead to poor decisions.  In our September 30, 2010 blog post we included a quote from the then-new BP CEO:

“Mr. Dudley said he also plans a review of how BP creates incentives for business performance, to find out how it can encourage staff to improve safety and risk management.”

The 4Q11 presentation and Mr. Bowman’s interview are noticeably silent on this subject.  The best we could come up with was the following rather cryptic statement in the 4Q11: “We’ve also evolved our approach to performance management and reward, requiring employees to set personal priorities for safety and risk management, focus more on the long term and working as one team.” (BP 4Q11, p. 15)  We’re not sure how “personal priorities” relate to the compensation incentives which were the real focus of the concerns expressed in the accident investigations.

Looking a bit further we uncovered the following in a statement by the chairwoman of BP’s Board Remuneration Committee: “For 2011 the overall policy for executive directors [compensation] will remain largely unchanged…”***  If you guessed that incentives would be based only on meeting business results, you would be right.

In closing we leave with one other comment from Mr. Bowman, one that we think has great salience in the instant situation of BP and for other high risk industries including nuclear generation: “In any business dealing with an unforgiving environment, complacency is your worst enemy. You have to be very careful about what conclusion to draw from the absence of an accident.” (BP Magazine, p. 9) [emphasis added]

*  BP 4Q11 & 2012 Strategy presentation, p. 8.

**  BP Magazine, Issue 4 2011, p. 9.

***  Letter from the chairman of the remuneration committee (Mar. 2, 2011).

Is Safety Culture An Inherently Stable System?

The short answer:  No.

“Stable” means that an organization’s safety culture effectiveness remains at about the same level* over time.  However, if a safety culture effectiveness meter existed and we attached it to an organization, we would see that, over time, the effectiveness level rises and falls, possibly even dropping to an unacceptable level.  Level changes occur because of shocks to the system and internal system dynamics.

Shocks

Sudden changes or challenges to safety culture stability can originate from external (exogenous) or internal (endogenous) sources.

Exogenous shocks include significant changes in regulatory requirements, such as occurred after TMI or the Browns Ferry fire, or “it’s not supposed to happen” events that do, in fact, occur, such as a large earthquake in Virginia or a devastating tsunami in Japan that give operators pause, even before any regulatory response.

Organizations have to react to such external events and their reaction is aimed at increasing plant safety.  However, while the organization’s focus is on its response to the external event, it may take its eye off the ball with respect to its pre-existing and ongoing responsibilities.  It is conceivable that the reaction to significant external events may distract the organization and actually lower overall safety culture effectiveness.

Endogenous shocks include the near-misses that occur at an organization’s own plant.  While it is unfortunate that such events occur, it is probably good for safety culture, at least for awhile.  Who hasn’t paid greater attention to their driving after almost crashing into another vehicle?

The insertion of new management, e.g., after a plant has experienced a series of performance or regulatory problems, is another type of internal shock.  This can also raise the level of safety culture—IF the new management exercises competent leadership and makes progress on solving the real problems. 

Internal Dynamics    

Absent any other influence, safety culture will not remain at a given level because of an irreducible tendency to decay.  Decay occurs because of rising complacency, over-confidence, goal conflicts, shifting priorities and management incentives.  Cultural corrosion, in the form of normalization of deviance, is always pressing against the door, waiting for the slightest crack to appear.  We have previously discussed these challenges here.

An organization may assert that its safety culture is a stability-seeking system, one that detects problems, corrects them and returns to the desired level.  However, performance with respect to the goal may not be knowable with accuracy because of measurement issues.  There is no safety culture effectiveness meter, surveys only provide snapshots of instant safety climate and even a lengthy interview-based investigation may not lead to repeatable results, i.e, a different team of evaluators might (or might not) reach different conclusions.  That’s why creeping decay is difficult to perceive. 

Conclusion

Many different forces can affect an organization’s safety culture effectiveness, some pushing it higher while others lower it.  Measurement problems make it difficult to know what the level is and the trend, if any.  The takeaway is there is no reason to assume that safety culture is a stable system whose effectiveness can be maintained at or above an acceptable level.


*  “Level” is a term borrowed from system dynamics, and refers to the quantity of a variable in a model.  We recognize that safety culture is an organizational property, not something stored in a tank, but we are using “level” to communicate the notion that safety culture effectiveness is something that can improve (go up) or degrade (go down).

VIT Plant Glop (Part 2)

(Ed. note: We're pleased to present an interesting take on the Vit Plant from Bill Mullins as a guest contributor.  We welcome contributions from others who would like to contribute leading edge thinking on nuclear safety culture.)

Bob Cudlin’s Jan. 24 post concludes, "Our advice for the Vit Plant would be as follows.  In terms of expectations, enforcing rather than setting might be the better emphasis."

From where I sit, in this simple piece of seemingly practical advice hides much of the iceberg the WTP Titanic keeps circling around to repeatedly encounter amidst the fog of Nuclear Safety Culture (NSC) and such.

The key word is "expectations” – this is because for DOE the definition of Quality is “performance that meets or exceeds requirements and expectations.” Importantly the DOE Quality standard embraces a “continuous improvement” criterion. This definition of Quality and its attendant context are considerably more expansive than the one found at 10 CFR 50 Appendix B – and there is a very necessary reason for that.

At the Program level all the DOE Mission portfolios are of the Discover and Develop type. DOE programs and projects are chartered to go where none has gone before (i.e. nor generally can afford the capital risks to go such places first).

Not every project in DOE is of comparable difficulty, but many (e.g., the Environmental Management Program) of the sub-portfolios (e.g., Hanford Cleanup) take decades of trial and error practice to create reliable Acquisition Strategies.

Even now the Hanford Cleanup work is pretty well partitioned between 1) things we now do reliably and with a modicum of efficiency (cf. River Corridor Cleanup contract), and 2) that Goop/Gorp unconventional uncertainty. Today the former goes well and the latter goes poorly.

The WTP is a full-blooded Discover and Develop enterprise - the high-level tank waste is vastly more subtle in its physical chemistry than DOE and its prime contractor have been willing to acknowledge to their stakeholders in the Tri-Party Agreement with EPA and WA State. The stakeholders seem reluctant to puncture the veil of schedule illusion as well.

Generally I conclude the River Protection Program (RPP), which governs the WTP development, is not sufficiently aware of its vulnerability to unconventional uncertainty. It is the more unpredictable behavior of the tank waste that should be the center of attention; not unrealistic schedules and life cycle budget estimates into the far future.

It is this (some would say “studied”) blindness that the DNFSB is ultimately getting at via its nuclear safety oversight charter – I’m inclined to doubt that the Board recognizes the blind spot any better than most in DOE leadership. Like the carpenter with only a hammer on his tool belt, the Board’s way of framing issues with progress at the RPP tends to make every unanticipated or unwelcome outcome seem like a “nuclear safety nail.”

At the end of most days this over-dramatization of nuclear safety significance has been a deliberate strategy of the Board since it began its Safety in Design “action-forcing” campaign about four years ago.

In broad reality, the situation of the RPP can be viewed as a matter of inadequate safety consciousness or poorly chosen Acquisition Strategy – the latter perspective has more traction precisely because in encompasses protection concerns without being dragged into the “good vs. bad” attitude debates – which tend to be the heart of NSC conversations - that are presently fogging the air of the Hanford 200 Area.

Later in Bob’s post he observes: “In fact, reading all the references and the IP leave the impression that DOE believes there is no fundamental safety culture issue.”

This conclusion is not without its supporting evidence: From the time that the Walt Thomasitus pushback on Bechtel Management began, DOE Office of River Protection project management has responded from a position that reeks annoyance and resentment. This has not helped with sorting out the key issues at the WTP, in fact when the Recommendation 2011-1 appeared the knee-jerk defensive response of the Deputy Secretary actually made things worse for a time.

There are now three prominent whistle-blowers feeding the maw of both GAO and the national press.*  Unfortunately, Thomasitus, Alexander, and Busche each raise concerns about whether the plant will work as advertised – not as matters of Acquisition Strategy, but as safety issues. That is unfortunate because it leads to this: “The treatment plant "is not a project that can be stopped and restarted," said Rep. Doc Hastings, R-Wash.”**

Just lately, we have a memorandum from the Secretary and Deputy Secretary that I believe finally puts a suitable Line Management framework around the 2011-1 IP and the WTP issue.  It will take a further post to elaborate the basis for my belief that this particular memorandum “answers the mail” about NSC in the DOE nuclear programs. At that point I can also suggest what I see as the barriers to this missive gaining the policy high ground against the wave of other “over-commitments” throughout the remainder of the 2012-1 IP.

(Mr. Mullins is a Principal at Better Choices Consulting.)

*  P. Eisler, “Problems plague cleanup at Hanford nuclear waste site,” USA Today (Jan. 25, 2012).

**  P. Eisler, “Safety at Wash. nuclear-waste site scrutinized,” USA Today (Jan. 27, 2012).

***  Letter from D.B. Poneman to P.S. Winokur transmitting DOE Memorandum dated Dec. 5, 2011 from S. Chu and D.B. Poneman to Heads of All Departmental Elements re: Nuclear Safety at the Department of Energy (Jan. 24, 2012).