On January 25, 2013 we posted about DOE's report to the Defense Nuclear Facilities Safety Board (DNFSB) on the results of safety culture (SC) assessments at several DOE facilities, including the Pantex Plant. Pantex was assessed because two Pantex employees had reported retaliation for raising a safety concern but the plant also had a history of potentially SC-significant issues.*
The Pantex SC assessment was performed in November 2012. The report included several significant findings:
“Efforts to communicate and implement the principles of a High Reliability Organization (HRO) have been ongoing for several years. . . . [However,] The realization of the HRO principles has not yet been internalized by the Plant, . . .”
“The belief that the organization places a priority on safety is undermined by employee observations of poor facility conditions, lack of focus on meeting personal needs (work quality of life), and a sense of cronyism. . . . [This] has created the perception among many employees that the financial bottom line is the only focus that matters.
“There is a strong perception that retaliation exists for ‘rocking the boat.’ . . . The perception has created an environment where the raising of questions or identification of problems is not the consistently accepted way of doing business.
“The Pantex Plant has not been successful in understanding the organizational and programmatic behaviors that are necessary for a healthy safety culture. . . . organizational barriers have been created that will prevent successful implementation of the initiatives needed to enhance safe and reliable performance. . . . The barriers are also evident in the lack of respect, difficulty in effective communication, the non-alignment between the perceptions around the unions and management relationships and the notion of ‘need to know’ being extended to almost everything.”**
Sounds serious. So what's happened since the report was published? Well, DNFSB held a public meeting on March 14, 2013 to discuss SC problems at Pantex and management's approach to addressing them. As one might expect, the DOE opening statement declared the SC problems were intolerable and DOE had taken immediate action—by firing off a letter to the contractor.
“NNSA issued a letter to B&W Pantex directing immediate focus at all management and working levels to a safety conscious work environment (SCWE) for all on-going activities and operations. . . . Other immediate actions included the development of a single stop/pause work process which was provided to all employees and discussed at daily work planning meetings. The Employee Concerns Program and Equal Opportunity Office reporting chain was immediately elevated to a direct report to the General Manager’s Office, providing the highest level accesses for any employee concerns in these areas. Additionally, the differing professional opinion process was reinstated providing a formal mechanism for recognition and resolution of differing views on technical matters.
“Further, this letter directed B&W Pantex to prepare a comprehensive long-term corrective action plan mentioned previously, taking into account the Institute of Nuclear Power Operations (INPO) paper on the principles of a strong nuclear safety culture.”***
DOE listed actions being implemented, including an SC focus team, a seminar on HRO attributes, SCWE training, the issuance of a plant-specific SC policy and an alignment of performance incentives with SC objectives.
Babcock & Wilcox (B&W) B&W, the entity that actually has to do the work, did not file any written testimony for the public meeting so we have to go to the meeting video for their comments.****
B&W appears to be on board with the need for change. The B&W plant general manager and his safety manager were appropriately deferential to the DNFSB members and seemingly well-informed about the plant's remedial actions and SC improvement initiatives. The GM said he “fully accepts” the assessment findings (which were consistent with the plant's own SC survey conducted just prior to the DOE HSS assessment) and acknowledged that specific problems, e.g., communication issues with respect to safety vs production, existed. Improving SC/SCWE is the GM's “top priority.” B&W reiterated its commitment to building an HRO at Pantex, an initiative that overlaps with actions to strengthen SC and SCWE. Perhaps the most significant change the GM described was that 30% of managers' performance evaluations would be based on their modeling of appropriate SC/SCWE traits. Our perspective
Problem solved? Not yet and not for awhile. Pantex had some serious vertical communication and organizational structure issues. Their attempt to build an HRO has been ongoing for years. Their SCWE has had some cold spots.
In addition, the actions Pantex has initiated may be necessary but there is no guarantee they will be sufficient to achieve the plant's SC/SCWE/HRO goals. For example, there is no real discussion of how decision making processes will be affected other than resolving Nuclear Explosive Safety issues and the usual commitment to conservative decision making. There is no mention of a corrective action program (or some functional equivalent); an integrated process for identifying, evaluating and fixing problems is essential for ensuring safety, priorities and resource allocation are treated consistently throughout the plant.
We'll watch for progress (or lack thereof) and keep you posted.
* Pantex is the sole US site that assembles and disassembles nuclear weapons. Within DOE, the National Nuclear Security Administration (NNSA) has line management responsibility for Pantex. Babcock & Wilcox is responsible for managing and operating the plant under contract with DOE.
The SC issues identified in the November 2012 assessment did not pop out of nowhere. The DNFSB identified SC-related concerns at the plant during the previous year. See statement of D.G. Ogg, Group Lead for Nuclear Weapons Programs, DNFSB, at the Pantex public meeting (March14, 2013).
** DOE Office of Enforcement and Oversight, “Independent Oversight Assessment of Nuclear Safety Culture at the Pantex Plant” (Nov. 2012) p. 3. The report is attached to the letter from G.S. Podansky (DOE) to P.S. Winokur (DNFSB) transmitting five independent safety culture assessments (Dec. 12, 2012).
*** Written testimony of Neile Miller, Acting Administrator, NNSA before the Defense Nuclear Facilities Safety Board Pantex Plant Public Meeting (March 14, 2013), p. 4.
**** The meeting video is available on the DNFSB website. The NNSA panel on Pantex SC runs from about 1:25 to 2:30, the B&W panel runs from about 2:35 to 3:20.
Last week we previewed the safety culture (SC) content of the then-upcoming NRC RIC. The Idaho National Lab speaker's slides were not available at that time but they are now and his presentation is reviewed below. The focus is on the Advanced Test Reactor Programs but I think it's fair to infer that the thinking is representative of a wider swath of the DOE complex.
The presentation opens with five lengthy quotes from Admiral Rickover's November 1983 assessment of GPU and its competence to operate TMI-1. The apparent intent is to illustrate that the principles for safe nuclear operations have been known (or at least available) for a long time. Coincidentally, we posted on the Rickover assessment two months ago, and focused on one of the same quotes. If you aren't acquainted with Rickover's seven principles, you really should read the introduction to the assessment, which is available from the Dickinson College library.
The presentation describes components of the new DOE Cross Cutting Performance Areas for category 1, 2 and 3 nuclear facilities: Evaluating the effectiveness of operations, maintenance, engineering and training programs; developing, monitoring and evaluating SC; and evaluating issue identification and resolution activities, including the significance determination process and the evaluation and resolution process for high significance issues.
The presentation concluded with a list of areas being emphasized at the Idaho lab: What is the right (as opposed to allowable) thing to do, educating leaders, communications, and decision making that reflects a learning organization and doesn't result in safety drift.
The presentation hit most of the right notes, a major exception being no mention of management or contractor financial incentive plans. However, the unmistakable tone is there is really nothing new required of the lab, just a refinement of past and current practices. Perhaps that's true for them but I have limited confidence in DOE entities' ability to self-evaluate. We're pretty sure SC issues exist or have existed at other DOE facilities, especially the Vit Plant (click the label in the top right-hand column to pull up our posts).
The RIC is this week, March 12-14. The teaser on the NRC blog says the technical sessions will include safety culture (SC) policies. Let's look at the program agenda and see what's in store for SC.
There will be 36 technical sessions. I reviewed all the titles and drilled down into sessions that might make some mention of SC, e.g., T4 - Construction Inspection Experience–The First Year and T7 - Human Impacts. However, I could find no mention of SC in any of the currently available slide presentations.
The introductory remarks summarize the development of the SC policy statement and its implementation. There is no news here.
The SC common language presentation reviews the history of this initiative (which we have previously reviewed here and here). The presentation has one quotable statement: “NRR will work to incorporate language into the ROP guidance documents and inspection procedures, as appropriate.” Does that sound like back door regulation of SC to you?
A presentation on domestic and international cooperation reviews the relationship between NRC and INPO, NRC and IAEA, and others. As an example of cooperation, the authors summarize the INPO SC survey data that were collected from operating plants and then analyzed by INPO (and later NRC) to show “statistically significant relationships between safety culture survey results and measures of plant performance.” We commented on this work when it first appeared in 2010, congratulating INPO for making the effort and agreeing with some of the findings but finally concluding that the analysis was incomplete and potentially misleading.
Anindustry presentation by Nuclear Fuel Services Inc. (NFS) describing their SC improvement program is worth a look. It lists almost two dozen program components, none of which is a trivial undertaking, which suggest how much work is involved in changing an existing SC. (I have no idea if NFS is actually pursuing the listed activities or how well they're doing.)
All in all, it's probably not worth traveling to Bethesda if you're seeking enlightenment about SC.
In November 2003 Professor Edgar Schein gave a speech at the INPO CEO conference.* It was not a lengthy academic lecture but his focus on managing culture, as opposed to changing or creating it, was interesting. At the time Schein was doing some work for ConEd and had a notion of nuclear plant culture, which he divided into four sub-cultures: engineering, hourly, operator and executive, each with its own underlying assumptions and values.
The engineering culture emphasizes elegant, possibly expensive designs that minimize the role of error-prone humans. Engineers want and value respect from other engineers, including those outside the plant (an external orientation).
The hourly culture (which I think means maintenance) values teamwork and has an experience-based perspective on safety. They want job security, fair wages, good equipment, adequate training and respect from their peers and supervisors.
The operator culture values teamwork and open communications. They see the invaluable contributions they make to keeping the plant running safely and efficiently. They want the best equipment, training and to be recognized for their contributions.
The executive culture is about money. They want productivity, cost control, safety and good relations with their boards of directors (another external orientation).
These sub-cultures are in conflict because they all can't have everything they want. The executive needs to acknowledge that cultural differences exist and each sub-culture brings certain strengths to the table. The executive's role is to create a climate of mutual respect and to work toward aligning the sub-cultures to achieve common goals, e.g., safety. The executive should not be trying to impose the values of a single sub-culture on everyone else. In other words, the executive should be a culture manager, not a culture changer.
This was a brief speech and I don't want to read too much into it. There are dysfunctional or no longer appropriate cultures and they have to be reworked, i.e., changed. But if many things are working OK, then build on the existing strengths.**
This was not a speech about cultural interventions. At the beginning, Schein briefly described his tri-level cultural model and noted if the observed artifacts match the espoused values, then there's no need to analyze the underlying assumptions. This is reminiscent of Commissioner Apostolakis' comment that “. . . we really care about what people do and maybe not why they do it . . . .”
** Focusing on strengths (and not wasting resources trying to shore up weaknesses unless they constitute a strategic threat) is a management prescription first promoted by Peter Drucker.
Another domino has fallen in the ongoing determination of culpability at Massey Energy in the Big Branch mine disaster. The February 28, 2013 Wall Street Journal* reports that the former head of a Massey subsidiary, Green Valley Coal, warned miners when federal inspectors were on their way into mines and to conceal safety hazards. The former executive specifically stated that the order to do this came from Massey’s CEO.
Thus it appears prosecutors are following the trail of bread crumbs in an inexorable climb to the CEO level. So often situations like this are simply attributed to weaknesses in the organization’s safety culture, particularly at the working levels. It is assumed that senior management’s policies and direction to make safety the first priority aren’t permeating the organization. More training, more indoctrination in safety priorities is required to get workers aligned with their corporate leadership. But what is becoming very apparent in the case of Massey, it is the intentional decisions by senior management prioritizing production over safety that drove the behavior of subordinates - and it was those working levels that suffered the immediate consequences. Now perhaps the consequences are being more fairly distributed.
The intent of the NRC's Safety Culture Common Language Path Forward initiative is to describe safety culture (SC) attributes at a more detailed level than the NRC’s SC policy statement. On January 29-30, 2013 the NRC held a public workshop to finalize the draft SC common language.* The document they issued after the workshop** contains attribute definitions and examples of behavior and artifacts that support or embody each attribute. This document will be used by the NRC to develop a NUREG containing the final common language.
Last March we posted on a draft produced by previous workshops, focusing on areas we consider critical for a strong SC: decision making, corrective action, management incentives and work backlogs. In that post, our opinion was that decision making and corrective action were addressed in a satisfactory manner, the treatment of incentives was minimally acceptable and backlogs were all but ignored.
So, how does the “final” language treat the same subject areas? Is it better than the draft comments we reviewed last March? The arrows indicate whether the final version is better ↑, the same → or worse ↓.
Decision making – Good↑. Decision making incorporates “. . . a consistent, systematic approach to make decisions” (p. 51) and a conservative bias, i.e., “. . . decision-making practices that emphasize prudent choices over those that are simply allowable. A proposed action is determined to be safe in order to proceed, rather than unsafe in order to stop.” (p. 52) In addition, communicating, explaining and justifying individual decisions is mentioned throughout the document.
Goal conflict is addressed under leader behavior “. . . when resolving apparent conflicts between nuclear safety and production” (p. 12) and leaders “avoid unintended or conflicting messages that may be conveyed by operational decisions” (p. 37); work process “activities are coordinated to address conflicting or changing priorities.” (p. 23)
Corrective action – Satisfactory→. The section on problem identification and resolution (pp. 13-17) is suffused with desirable characteristics of corrective actions and the CAP. A good CAP has a low threshold for identifying issues and problems are thoroughly evaluated. Corrective actions are timely, effective and prevent recurrence of problems. Periodic analysis of CAP and other data is used to identify any programmatic or common cause issues.
Management incentives – Unsatisfactory↓. The section on incentives appears to focus on workers, not managers: “Leaders ensure incentives, sanctions, and rewards are aligned with nuclear safety policies and reinforce behaviors and outcomes which reflect safety as the overriding priority.” (p. 7) This is even less complete than the single sentence that appeared in last year's draft: “Senior management incentive program [sic] reflect a bias toward long-term plant performance and safety.”*** The failure to mention the senior management incentive program is a serious shortcoming.
Backlogs – Minimally Acceptable↑. Backlogs are specifically mentioned in maintenance and engineering (p. 24) and document changes (p. 25). In addition, problem evaluation, corrective actions, CAP trending analyses, operating experience lessons and many administrative activities are supposed to be addressed in a “timely” manner. I hope that implies that backlogs in these areas should not be too large.
But attention to backlogs is still important. Repeating what we said last year, “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.”
Conclusion
Overall, this latest document is an improvement over the March 2012 version but still short of what we'd like to see.
A book I received as a gift got me thinking about habits: The Power of Habit: Why We Do What We Do in Life and Business by Charles Duhigg.* Following is a summary of selected points that we can relate to safety culture (SC) and our assessment of the book's usefulness for SC aficionados.
Habits are automatic activity sequences people exhibit when they perceive specific triggering cues in the environment. Habit behavior is learned, and directed toward achieving some reward, which may be physical or psychological. The brain creates habits to conserve energy and operate more efficiently; without habits people would be overwhelmed by the countless decisions they would have to make to complete the most mundane tasks, e.g., driving to work.
People use habits at work to increase their productivity and get things done. Unfortunately, habits can allow potential safety threats to slip through the cracks. How? Because while Rational Man considers all available alternatives before making a decision, and Satisficing Man consciously picks the first alternative that looks good enough, Habit Man is carrying out his behavior more or less unconsciously. If the work environment contains weak signals of nascent problems or external environmental threats, then people following their work habits are not likely to pick up such signals. Bad work habits may be the handmaiden of complacency.
Organizations also have habits (sometimes called routines). Routines are important because, without them, it would be much more difficult to get work accomplished. Routines reduce uncertainty throughout the organization and create truces between competing groups and individuals. Some routines are the result of decisions made long ago, others evolve organically. They are so embedded in the organization that no one questions them.**
Duhigg includes many case studies involving individuals and organizations. One organizational case study is worth repeating because it focuses on changing safety habits.
When Paul O'Neill*** became Alcoa CEO in 1987 he made improving worker safety his first initiative. He believed the habits that led to safety were keystone habits and if they could be changed (improved) then other business routines would follow. In this case, he was correct. Proper work routines are also the safest ones; over time quality and productivity improved and the stock price rose. The new routines resulted in new values, e.g., intolerance for unsafe practices, becoming ingrained in the culture.
The bottom line
I'd put this book in the self-help category—the strongest sections focus on individuals, how they can be crippled by bad habits, and how they can change those habits. With the exception of the Alcoa case, this book is not really about SC so I'm not recommending it for our readers but it does stimulate thought about the role of unconscious habits and routines in reinforcing a strong SC, or facilitating its decay. If work habits or routines become frozen and cannot (or will not) adjust to changes in the external or task environment, then performance problems will almost surely arise.
* C. Duhigg, The Power of Habit: Why We Do What We Do in Life and Business (New York: Random House 2012). To simplify this post and focus on a linkage to SC, many of the book's concepts are not mentioned in the main text above. For example, when the brain links the reward back to the cue, it creates a neurological craving; the stronger the craving, the more likely the cue will trigger the activities that lead to the reward. Bad habits can be changed by inserting a new activity routine between the cue and the reward. A belief that change is possible is needed before people will attempt to change their habits; willpower and self-discipline are necessary for changes to stick. A real (or manufactured) crisis can make organizational routines amenable to change.
** The result can be the worst kind of machine bureaucracy: rigid hierarchies, organizational silos, narrow employee responsibilities, and no information shared or questions asked.
*** O'Neill later served as U.S. Treasury Secretary during 2001-2002.
