IAEA OSART in USA

The International Atomic Energy Agency (IAEA) offers an Operational Safety Review Team (OSART) program where international teams of experts conduct in-depth reviews of nuclear power plant operational safety performance.  Performance is reviewed in various areas such as management, training, operations, maintenance, etc.  The reports also include comments about plant safety culture (SC).  IAEA has conducted scores of OSART reviews, including U.S. power plants.  This post covers SC-related findings for the U.S. plants; we are interested in what kinds of SC strengths and weaknesses the teams identify during their approximately two-week visits.

North Anna (2000)

This is the earliest OSART report available in the NRC ADAMS database.  There are two versions of the report, one distributed to NRC Commissioners on Nov. 30, 2000* and another released by IAEA on Feb. 12, 2001.**  Both versions include generally complimentary language related to SC saying management is committed to safety and continuous improvement is nurtured. (p. 7 in 2000 report)  In the Operations area the report notes “Policies and management verbal communication are consistent and emphasize the importance of safety first.  Safety culture is referred to at several hierarchical levels of the plant.” (p. 31 in 2000 report)

There is an interesting discrepancy between the two versions.  The first report says “The emphasis the plant is making on self-assessment and improving human performance to bring about a sustaining safety culture is presently balancing the perception of increased cost drivers and short term budgeting.” (p. 13)  This hints at a cost vs. safety goal conflict, a serious challenge to maintaining a strong SC.  However, the second report does not include that statement, instead noting elsewhere that “In the teams opinion, however, there is presently little resource margin to absorb increased demands and although the highly motivated staff continue to look for ways to improve, the potential for complacency and demotivation from the prospect of long term challenges with aging facilities and equipment and tightening budget poses a risk to maintaining that performance.” (p. 9)  Is this just a more politic way of saying the same thing or does it reflect an actual watering down of the report?

Brunswick (2005)

The report*** covers the initial visit and the follow-up visit 19 months later.  SC is treated more thoroughly than in earlier reviews: “An important element of the OSART review is the identification of those findings that exhibit positive and negative attributes of safety culture.” (p. 7)  At Brunswick positive SC attributes included a questioning attitude of all personnel, a strong self-assessment program, and adherence to established procedures.  Improvement opportunities included the need for increased attention for continuous improvement, greater use of self criticism when observing safety systems and components, and further expanding external operating experience activities. (p. 10) 

The team’s in-depth review of the corrective action program (CAP) provides a look at the SC in practice.  “The corrective action programme is very strong and closely monitored.” (p. 97)  Aging mechanisms, especially corrosion, are a challenge for the corrective action program (p. 69) but the plant’s response led to this issue being closed during the follow-up visit.  Rework is analyzed by a committee to address effective corrective actions (p. 57) but maintenance backlogs require constant attention. (p. 59)  After the team’s initial visit the plant developed a new system for classifying condition reports; at follow-up the team observed “Based on the new graded system, the plant is improving opportunities to focus analyses and resources in accordance with the significance of the events.” (p. 100)  Overall, this seems reflective of a SC that supports both the CAP and efforts to improve it.

Another finding reflecting SC was that the plant Management Succession Planning and Development Program did not include safety performance in talent assessment, ranking or as a specified core skill.  Brunswick claimed these factors were implicitly considered but strengthened the program to explicitly include nuclear safety, radiation safety and industrial safety goals for each plant staff member.  The review team found this action sufficient to close the issue. (pp. 21-22)  This is also indicative of a culture that encourages improvement efforts.

Arkansas Nuclear One (2008) 

The positive SC attributes in this report**** include a strong Human Performance program with a focus on continuous improvement, a rigorous and conservative approach when planning and performing tasks, and a willingness of staff to correct each other’s behavior without waiting to be corrected by management.  In addition, conservative decision making is a core value within the management team.  Problem areas include long standing defects throughout the plant (and first attempts to fix problems that do not always work), policies such as overtime and time pressure on outage schedule that suggest the plant is “cost” driven, and the benchmarking program does not work from a broad international base. (pp. 4-5, 34).  Both an ineffective CAP and a cost-driven plant (i.e, goal conflict between cost and safety) reflect a weak SC.

Seabrook (2011)

In the Seabrook report***** SC strengths include consistent reinforcement of key values by the management team and no evidence of production taking precedence over safety.  Opportunities for improvement include a more aggressive approach to addressing long term issues, thus reducing the potential for staff normalization to less than excellent conditions. (pp. 4, 45)

A positive observation is that plant communications stress safety as the no. 1 priority. (p. 7)  Another is that Seabrook has a problem reporting culture based on a low-threshold and high-volume reporting system. (pp. 2, 56)  Personnel who report problems outside their area of responsibility are recognized with a “Good Catch” award.  Personnel writing lots of condition reports is generally a good thing but some corrective actions are closed prematurely. (pp. 54-56, 59)

More significantly, plant problems include a lack of resolution of long term issues, plant material condition deterioration and degraded equipment conditions. (pp. 2, 44-45)  Significant backlogs exist in the CAP, work orders and procedure change requests. (p. 8)  Work backlogs are an indication of a culture that lives with issues rather than resolving them.

Seabrook SC standards are summarized as “very positive” (p. 4) and maybe they are, but the reality of backlogs and unresolved long-term issues is inconsistent with a strong SC. 

Our Perspective

It’s probably unrealistic to expect a group of foreigners to visit a U.S. plant for two weeks and come up with significant SC insights.^  The summaries of SC positives and negatives appear to be relatively superficial but findings in the functional areas can offer a look at the actual underlying SC.  Some of the OSART observations and findings on key artifacts provide information from which we can infer the strength of SC at a plant being reviewed. 

We would like to see greater attention to how important decisions are made at a plant.  Decision making was only mentioned in passing (North Anna, p. 31) or a simple statement like plant performance indicators are a key input to decision making. (ANO, p. 6)

Finally, compensation and reward systems appear to be outside the OSART scope but we know these are critical to reinforce safety-related behavior and overall SC.


*  J.D. Lee (NRC) to NRC Commissioners, “IAEA Report on OSART Mission at North Anna Power Station, January 22 to February 10, 2000” (Nov. 30, 2000).  ADAMS ML010160525.

**  IAEA, “Report of the OSART Mission to the USA North Anna Nuclear Power Plant 22 January to 10 February 2000” (Released Feb. 12, 2001).  ADAMS ML010470115.

***  IAEA, “Report of the OSART Mission to the Brunswick Nuclear Plant United States of America 9-25 May 2005 and Follow Up Visit 4-8 December 2006” no date.  ADAMS ML071100006.

****  IAEA, “Report of the OSART Mission to the Arkansas Nuclear One Nuclear Power Plant United States of America 15 June – 2 July 2008” no date.  ADAMS ML083440148.

*****  P. Freeman (Seabrook) to NRC, “IAEA Final Report OSART Mission to Seabrook Nuclear Power Plant USA 6-23 June 2011” (Mar. 16, 2012).  ADAMS ML12081A105.

^  A partial view is suggested in the Foreword to the Seabrook report where the authors note that an OSART review represents a “snapshot in time.”  In fairness, it would be equally unrealistic to expect a team of Americans to visit a foreign plant and develop a deep understanding of plant culture in a similar time period.

1995 ANS Safety Culture Conference: A Portal to the Past

In April 1995 the American Nuclear Society (ANS) sponsored a nuclear safety culture (SC) conference in Vienna.  This was a large undertaking, with over 80 presentations; the proceedings are almost 900 pages in length.*  Presenters included industry participants, regulators, academics and consultants.  1995 was early in the post-Soviet era and the new openness (and concerns about Soviet reactors) led to a large number of presenters from Russia, Ukraine and Eastern Europe.  This post presents some conference highlights on topics we emphasize on Safetymatters.

Decision Making

For us, decision making should be systemic, i.e., consider all relevant inputs and the myriad ways a decision can affect consequences.  The same rigor should be applied to all kinds of decisions—finance, design, operations, resource allocation, personnel, etc.  Safety should always have the highest priority and decisions should accord safety its appropriate consideration.  Some presenters echoed this view.

“Safety was (and still is) seen as being vital to the success of the industry and hence the analysis and assessment of safety became an integral part of management decision making” (p. 41); “. . . in daily practice: overriding priority to safety is the principle, to be taken into account before making any decision” (p. 66); and “The complexity of operations implies a systemic decision process.” (p. 227)

The relationship between leadership and decisions was mentioned.  “The line management are a very important area, as they must . . . realise how their own actions and decisions affect Safety Culture.  The wrong actions, or perceived messages could undermine the work of the team leaders” (p. 186); “. . . statements alone do not constitute support; in the intermediate and long-term, true support is demonstrated by behavior and decision and not by what is said.” (p. 732)

Risk was recognized as a factor in decision making.  “Risk culture yields insights that permit balanced safety vs.cost decisions to be made” (p. 325); “Rational decision making is based on facts, experience, cognitive (mental) models and expected outcomes giving due consideration to uncertainties in the foregoing and the generally probabilistic nature of technical and human matters.  Conservative decision making is rational decision making that is risk-averse.  A conservative decision is weighted in favor of risk control at the expense of cost.” (p. 435)

In sum, nuclear thought leaders knew what good decision making should look like—but we still see cases that do not live up to that standard.

Rewards

Rewards or compensation were mentioned by people from nuclear operating organizations.  Incentive-based compensation was included as a key aspect of the TEPCO management approach (p. 551) and a nuclear lab manager recommended using monetary compensation to encourage cooperation between organizational departments. (p. 643)  A presenter from a power plant said “A recognition scheme is in place . . . to recognise and reward individuals and teams for their contribution towards quality improvement and nuclear safety enhancement.” (p. 805)

Rewards were also mentioned by several presenters who did not come from power plants.  For example, the reward system should stress safety (p. 322); rewards should be given for exhibiting a “caring attitude” about SC (p. 348) and to people who call attention to safety problems. (p. 527)  On the flip side, a regulator complained about plants that rewarded behavior that might cause safety to erode. (pp. 651, 656) 

Even in 1995 the presentations could have been stronger since INSAG-4** is so clear on the topic: “Importantly, at operating plants, systems of reward do not encourage high plant output levels if this prejudices safety.  Incentives are therefore not based on production levels alone but are also related to safety performance.” (INSAG-4, p. 11)  Today, our own research has shown that nuclear executives’ compensation often favors production.   

Systems Approach

We have always favored nuclear organizational mental models that consider feedback loops, time delays, adaptation, evolution and learning—a systems approach.  Presenters’ references to a system include “commercial, public, and military operators of complex high reliability socio-technical systems” (p. 260); “. . . assess the organisational, managerial and socio-technical influences on the Safety Culture of socio-technical systems such as nuclear power plants” (p. 308); “Within the complex system such as . . . [a] nuclear power plant there is a vast number of opportunities for failures to stay hidden in the system” (p. 541); and “It is proposed that the plant should be viewed as an integrated sociotechnical system . . .” (p. 541)

There are three system-related presentations that we suggest you read in their entirety; they have too many good points to summarize here.  One is by Electricité de France (EdF) personnel (pp. 193-201), another by Constance Perin (pp. 330-336) and a third by John Carroll (pp. 338-345). 

Here’s a sample, from Perin: “Through self-analysis, nuclear organizations can understand how they currently respond socially, culturally, and technically to such system characteristics of complexity, density, obscured signals, and delayed feedback in order to assure their capacities for anticipating, preventing, and recovering from threats to safety.” (p. 330)  It could have been written yesterday.

The Role of the Regulator

By 1995 INSAG-4 had been published and generally accepted by the nuclear community but countries were still trying to define the appropriate role for the regulator; the topic merited a half-dozen presentations.  Key points included the regulator (1) requiring that an effective SC be established, (2) establishing safety as a top-level goal and (3) performing some assessment of a licensee’ safety management system (either directly or part of ordinary inspection duties).  There was some uncertainty about how to proceed with compliance focus vs. qualitative assessment.

Today, at least two European countries are looking at detailed SC assessment, in effect, regulating SC.  In the U.S., the NRC issued a SC policy statement and performs back-door, de facto SC regulation through the “bring me another rock” approach.

So conditions have changed in regulatory space, arguably for the better when the regulator limits its focus to truly safety-significant activities.

Our Perspective

In 1995, some (but not all) people held what we’d call a contemporary view of SC.  For example, “Safety culture constitutes a state of mind with regard to safety: the value we attribute to it, the priority we give it, the interest we show in it.  This state of mind determines attitudes and behavior.” (p. 495)

But some things have changed.  For example, several presentations mentioned SC surveys—their design, administration, analysis and implications.  We now (correctly) understand that SC surveys are a snapshot of safety climate and only one input into a competent SC assessment.

And some things did not turn out well.  For example, a TEPCO presentation said “the decision making process is governed by the philosophy of valuing harmony highly so that a conclusion preferred by all the members is chosen as far as possible when there are divided opinions.” (p. 583)  Apparently harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards. 


*  A. Carnino and G. Weimann, ed., “Proceedings of the International Topical Meeting on Safety Culture in Nuclear Installations,” April 24-28, 1995 (Vienna: ANS Austria Local Section, 1995).  Thanks to Bill Mullins for unearthing this document.

**  International Nuclear Safety Advisory Group, “Safety Culture,” Safety Series No. 75-INSAG-4, (Vienna: IAEA, 1991). INSAG-4 included a definition of SC, a description of SC components, and illustrative evidence that the components exist in a specific organization.

National Research Council: Safety Culture Lessons Learned from Fukushima

The National Research Council has released a report* on lessons learned from the Fukushima nuclear accident that may be applicable to U.S. nuclear plants.  The report begins with a recitation of various Fukushima aspects including site history, BWR technology, and plant failure causes and consequences.  Lessons learned were identified in the areas of Plant Operations and Safety Regulations, Offsite Emergency Management, and Nuclear Safety Culture (SC).  This review focuses on the SC aspects of the report.

Spoiler alert: the report reflects the work of a 24-person committee, with the draft reviewed by two dozen other individuals.**  We suggest you adjust your expectations accordingly.

The SC chapter of the report provides some background on SC and echoes the by-now familiar cultural issues at both Tokyo Electric Power Company (TEPCO) and Japan’s Nuclear Energy Agency.  Moving to the U.S., the committee summarizes the current situation in a finding: “The U.S. nuclear industry, acting through the Institute of Nuclear Power Operations, has voluntarily established nuclear safety culture programs and mechanisms for evaluating their implementation at nuclear plants. The U.S. Nuclear Regulatory Commission has published a policy statement on nuclear safety culture, but that statement does not contain implementation steps or specific requirements for industry adoption.” (p. 7-8)  This is accurate as far as it goes.

After additional discussion of the U.S. nuclear milieu, the chapter concludes with two recommendations, reproduced below along with associated commentary.

An Effective, Independent Regulator

“RECOMMENDATION 7.2A: The U.S. Nuclear Regulatory Commission and the U.S. nuclear power industry must maintain and continuously monitor a strong nuclear safety culture in all of their safety-related activities. Additionally, the leadership of the U.S. Nuclear Regulatory Commission must maintain the independence of the regulator. The agency must ensure that outside influences do not compromise its nuclear safety culture and/or hinder its discussions with and disclosures to the public about safety-related matters.” (pp. S-9, 7-17)

In the lead up to this recommendation, there was some lack of unanimity on the subject of whether the NRC was sufficiently independent and if some degree of regulatory capture has occurred.  The debate covered industry involvement in rule-making, Davis-Besse and other examples.

We saw one quote worth repeating here: “The president and Senate of the United States also play important roles in helping to maintain the USNRC’s regulatory independence by nominating and appointing highly qualified agency leaders (i.e., commissioners) and working to ensure that the agency is free from undue influences.” (pp. 7-14/15)  We’ll leave it to the reader to determine if the executive and legislative branches met that standard with the previous NRC chairman and the two current commissioner nominees, both lawyers—one an NRC lifer and the other a former staffer on the Hill.

Snarky comment notwithstanding, the first recommendation is a motherhood statement and borderline tautology (who can envision the effective negation of any of the three imperative statements?)  More importantly, it appears only remotely related to the concept of SC; even at its simplest, SC consists of values and artifacts and there’s not much of either in the recommendation.

Increased Industry Transparency

“RECOMMENDATION 7.2B: The U.S. nuclear industry and the U.S. Nuclear Regulatory Commission should examine opportunities to increase the transparency of and communication about their efforts to assess and improve their nuclear safety cultures.” (pp. S-9, 7-17)

The discussion includes a big kiss for INPO.  “INPO has taken the lead for promoting a strong nuclear safety culture in the U.S. nuclear industry through training and evaluation programs.” (p. 7-10)  The praise for INPO continues in an attachment to the SC chapter but it eventually gets to the elephant in the room: “The results of INPO’s inspection program are shared among INPO membership, but such information is not made available to the public. . . . Releases of summaries of these inspections by management to the public would help increase transparency.” (p. 7-21)

The committee recognizes that implementing the recommendation “would require that the industry and regulators disclose additional information to the public about their efforts to assess safety culture effectiveness, remediate deficiencies, and implement improvements.” (p. 7-17)

At least transparency is a cultural attribute.  We have long opined that the nuclear industry’s penchant for secrecy is a major contributor to the industry being its own worst enemy in the court of public opinion. 

Our Perspective

This report looks like what it is: a crowd sourced effort by a focus group of academics using the National Academy of Sciences’ established bureaucratic processes.  The report is 367 pages long, with over 350 references and a bunch of footnotes.  The committee’s mental model of SC focuses on organizational processes that influence SC. (p. 7-1)  I think it's fair to infer that their notion of improvement is to revise the rules that govern the processes, then maximize compliant behavior.  Because of the committee’s limited mental model, restricted mission*** and the real or perceived need to document every factoid, the report ultimately provides no new insights into how U.S. nuclear plants might actually realize stronger SC.


*  National Research Council Committee on Lessons Learned from the Fukushima Nuclear Accident for Improving Safety and Security of U.S. Nuclear Plants, “Lessons Learned from the Fukushima Nuclear Accident for Improving Safety of U.S. Nuclear Plants” Prepublication Copy.  Downloaded July 26, 2014.  The National Research Council is part of the National Academy of Sciences (NAS).  Thanks to Bill Mullins for bringing this report to our attention.

**  The technical advisor to the committee was Najmedin Meshkati from the University of Southern California.  If that name rings a bell with Safetymatters readers, it may be because he and his student, Airi Ryu, published an op-ed last March contrasting the culture of Tohoru Electric with the culture of TEPCO.  We posted our review of the op-ed here.

***  The committee was tasked to consider causes of the Fukushima accident, conclusions from previous NAS studies and lessons that can be learned to improve nuclear plant safety in certain specified areas.  The committee was directed to not make any policy recommendations that involved non-technical value judgments. (p. S-10)

Palisades: Back in the NRC’s Safety Culture Dog House

Our last Palisades post was on January 30, 2013 where we described the tortuous logic the NRC employed to conclude Palisades’ safety culture (SC) had become “adequate and improving.”  Or was it?  The NRC has recently parlayed an isolated Palisades incident into multiple requirements, one fleet-wide, to strengthen SC.  Details follow, taken from the resulting Confirmatory Order.*

The Incident

A Palisades security manager asked a security supervisor to cover a 2-hour partial shift because another supervisor had requested time off on Christmas Eve 2012.  Neither the manager nor the supervisor verified the supervisor had the necessary qualifications for the assignment.  He didn’t, which violated NRC regulations and the site security plan.  The problem came to light when two condition reports were written questioning the manager’s decision. (pp. 2-3)

How the Incident was Handled and Settled

Entergy requested Alternative Dispute Resolution (ADR), a process whereby the NRC and the licensee meet with a third party mediator to work out a resolution acceptable to both parties.

The Consequences

Entergy’s required corrective actions include what we’d expect, viz., action to improve and ensure adherence to security procedures.  In addition, Entergy is required to take multiple actions to strengthen SC.  These actions are spelled out in the Confirmatory Order and focus on several SC traits: (1) Leadership, Safety Values and Actions; (2) Problem Identification and Resolution; (3) Personal Accountability; (4) Work Processes; (5) Environment for Raising Concerns; and (6) Questioning Attitude and Proceeding In the Face of Uncertainty. (p. 4)

Specific requirements relate to (1) actions already implemented or to be implemented via Palisades’ Security Safety Conscious Work Environment Action Plan, (2) revising a Condition Review Group procedure to ensure the chairman considers whether the person assigned to a condition report is sufficiently independent, (3) developing and presenting a case study throughout the Entergy fleet that highlights the SC aspects of the event and (4) discussing the SC aspects of the issue with Palisades staff at three monthly tailgate meetings. (pp. 4-6, 11-12)

Our Perspective

The incident appears localized and the NRC said it had very low security significance.  Maybe Entergy thought they’d avoid any sort of penalty if they requested ADR.  Looks to us like they gambled and lost.  The NRC must think so, they are fairly gloating over the outcome.  In the associated press release, the Region III Administrator says: “Using the ADR process allowed us to achieve not only compliance with NRC requirements, but a wide range of corrective actions that go beyond those the agency may get through the traditional enforcement process”.**

Is the NRC using an elephant gun to shoot a mouse?  Or is there some unstated belief that Palisades’ SC is not as good as it should be and/or Entergy as a whole doesn’t properly value SC*** and this is a warning shot?  Or is something else going on?  You be the judge.


*  C.D. Pederson (NRC) to A. Vitale (Entergy), “Confirmatory Order Related to NRC Report No. 05000255/2014406 and OI Report 3-2013-018; Palisades Nuclear Plant” (July 21, 2014).  ADAMS ML14203A082.

**  NRC Press Release “NRC Issues Confirmatory Order to Entergy Regarding Palisades Nuclear Plant,” No. III-14-031 (July 22, 2014).

***  Entergy has had SC issues at other plants.  Click on the Entergy label for our related commentary.

The European Union Shows Stronger Interest in Nuclear Safety Culture

Council of the EU building

The Council of the European Union (EU) recently updated its 2009 Nuclear Safety Directive.  The revised directive’s objectives include strengthening national regulatory authorities, increasing public transparency on nuclear safety matters and promoting an effective nuclear safety culture.  The last objective caught our eye and is the subject of this post.

Safety Culture in the 2009 Nuclear Safety Directive*

Safety culture (SC) did not get a lot of attention in the 2009 directive.  Specifically, “The establishment of a strong safety culture within a nuclear installation is one of the fundamental safety management principles necessary for achieving its safe operation.” (p. L 172/19)  That was it.

Safety Culture in the 2014 Amended Directive**

SC treatment in this version is more expansive.

“Indicators for an effective nuclear safety culture include, in particular: the commitment at all levels of staff and management within an organisation to nuclear safety and its continuous improvement; the promotion of the ability of staff at all levels to question the delivery of relevant safety principles and practices to continuously improve nuclear safety; the ability of staff to report safety issues in a timely manner; the identification of the lessons learnt from operational experience; and the systematic reporting of any deviation from normal operating conditions or arrangements relevant to accident management that have the potential to have an impact on nuclear safety.” (p. 10)

The foregoing is then restated in the form of requirements.  “Member States shall ensure that the national framework requires that the competent regulatory authority and the licence holder take measures to promote and enhance an effective nuclear safety culture. Those measures include in particular:

(a) management systems which give due priority to nuclear safety and promote, at all levels of staff and management, the ability to question the effective delivery of relevant safety principles and practices, and to report in a timely manner on safety issues, in accordance with Article 6(d);

(b) arrangements by the licence holder to register, evaluate and document internal and external safety significant operating experience;

(c) the obligation of the licence holder to report events with a potential impact on nuclear safety to the competent regulatory authority; and,

(d) arrangements for education and training, in accordance with Article 7.” (p. 28)

Our Perspective

We are pleased to see the EU strengthen its position on SC’s role in promoting and maintaining safe nuclear operations.  The 2014 version of the safety directive is obviously a major improvement over 2009.  The paragraph on management systems gives “due priority” to safety and reflects the notions of a Safety Conscious Work Environment and an Employee Concerns Program.

The other requirements on recording operating experience, reporting significant events and arranging training create a minimally acceptable framework for nuclear operations.

We recognize that this EU directive is a top-level policy document so we don’t expect any specifics but there are two other SC-related items that merit mention at the policy level.

One, the management system should have a top-level goal of identifying and correcting problems in a timely manner.  This is perhaps the most important artifact of a strong SC.  Such a goal should not be limited to issues like equipment problems but cover everything from plant siting to daily operations.

Two, the management system should include reference to an executive compensation scheme that rewards safety performance and the maintenance of a strong SC.


*  “Council Directive 2009/71/EURATOM of 25 June 2009 establishing a Community framework for the nuclear safety of nuclear installations,” Official Journal of the European Union (July 2, 2009).

**  Council of the European Union, “Council Directive amending Directive 2009/71/Euratom establishing a Community framework for the nuclear safety of nuclear installations,” Interinstitutional File: 2013/0340 (June 30, 2014)

Vit Plant Safety Culture Update

Hanford Waste Treatment Plant

DOE released a June 2014 follow-up assessment* on safety culture (SC) at the Hanford Waste Treatment Plant (WTP or the Vit Plant).  This post provides our perspective on the assessment.  We will not review every facet of the report but will focus on aspects that we think are important to understanding the current state of SC at the WTP project.

Overview

Back in 2011, the Defense Nuclear Facilities Safety Board (DNFSB) called the WTP safety culture (SC) “flawed.”  Following the DNFSB report, DOE conducted an assessment of the WTP SC and concluded “that a significant number of staff within ORP [DOE’s Office of River Protection] and BNI [Bechtel National Inc.] expressed reluctance to raise safety or quality concerns for various reasons.” (p. 1) 

Like DOE’s 2011 report, the current one is based on multiple data sources: structured interviews, focus groups, observations and a culture survey.  The report identifies many SC-related interventions that have been initiated, and lists positive and negative findings from the data collected.  Detailed assessment results are reported separately for ORP and BNI.**
 
WTP’s Safety Conscious Work Environment (SCWE)—Voicing Concerns, Challenging Decisions, Fear of Retaliation

The 2011 DNFSB critique focused on the treatment of project personnel who raised technical issues.  Some of these personnel complained about retaliation for bringing up such issues.  These issues can be raised in the Employee Concerns Program (ECP), the Differing Professional Opinions (DPO) process and challenging management decisions.  In what is arguably the report’s most significant finding, perceptions of conditions in these areas are worse than they were in 2011 for ORP and unchanged for BNI. (pp. 4-5)

Supporting Details

Although ORP senior management pointed to recent reductions in ECP concerns, “[s]ome interviewees indicated that they perceived a chilled environment at ORP and they did not believe that ECP concerns and DPO issues were always addressed or resolved in a timely manner.  Additionally, some interviewees described being told by supervision not to write a DPO because it would be a career limiting decision.” (p. B-21)  Interviewees from both ORP and BNI said they lacked trust in the ECP. (pp. B-22/23)

Most ORP employees believe that constructive criticism is not encouraged. (p. 4)  Within ORP, only 30% of all ORP survey respondents (and 65% of managers) feel that they can openly challenge decisions made by management. (p. B-21)  In BNI/URS, the numbers are 45% of all respondents and 75% of managers. (p. B-22)

“The statement that management does not tolerate retaliation of any kind for raising concerns was agreed to by approximately 80% of the ORP, . . . 72% of the BNI and 80% of the URS survey respondents.” (pp. B-21-22)  In addition, “Anonymous PIERs [Project Issues Evaluation Reports] are used a lot because of fear of retaliation.” (p. B-23)  

All in all, hardly a ringing endorsement of the WTP SCWE.

Decision Making, Corrective Action and Compensation

Safetymatters readers know of our long-standing interest in how SC is reflected in these key artifacts.

Decision Making

“Interviewees provided some examples of where decision making was not perceived to reflect the highest commitment to safety”  Examples included downgrading or elimination of assessment findings, the margin of safety in corrective action plans and the acceptable level of risk for the project.  (p. B-9)  Looks like there's some room for improvement in this area.

Corrective Action

Within BNI, there are positive comments about the corrective action process but the assessment team “observed a lack of accountability for a backlog of corrective actions at a PIRB [Performance Improvement Review Board] meeting.  There is a perceived lack of accountability for corrective actions in timeliness, ownership, and quality, ...” (p. B-16)

“[O]nly about 18% of all ORP interviewee respondents believed that employees are encouraged to notify management of problems they observe and that there is a system that evaluates the problem and makes a determination regarding future action.” (p. 13)

Plenty of room for improvement here.

Compensation

In the area of compensation, it appears some rewards for Bechtel are based on SC behaviors. (p. B-8)  We consider that a very positive development.

Concerns Over ORP Working More Collaboratively with Bechtel

On the surface this looks like a positive change: two entities working together to achieve a common goal.  However, this has led to at least two concerns.  First, as described in the report, some ORP personnel believe ORP is abdicating or compromising its responsibility to perform oversight of Bechtel, in other words, ORP is more of a teammate and less of an umpire. (pp. B-4, -9, -14)  Second, and this reflects our perspective, changing the relationship between the entities can result in revised system dynamics, with old performance-oversight feedback loops replaced by new ones.  The rules of engagement have changed and while safety may still be the number one priority, the cultural milieu in which safety is achieved has also changed.

Another complication is caused by the role of Bechtel Corporate.  The report says corporate’s values and goals may not be well-aligned with BNI’s need to prioritize SC attributes and behavior.  This can lead to a lack of transparency in BNI decisions. (pp. 5, 7)  That may be a bit of weasel wording in the report; in more direct terms, corporate’s number one priority is for the money train to keep running.

Bottom Line on SC at WTP 

A strong SC is, in some ways, about respect for the individual.  The concerns that WTP personnel  express about using the ECP or DPO process, or challenging management decisions suggest that the WTP project has a ways to go to inculcate an adequate level of such respect.  More importantly, it doesn’t appear they have made any significant process toward that goal in the last few years.

Morale is an aspect of the overall culture and at the WTP, morale is arguably low because of lack of progress and missed schedules. (pp. 6, B-10)  There is undoubtedly plenty of work to do but on a day to day basis, we wouldn’t be surprised if some people feel their work is not meaningful.


*  DOE Office of Environment, Safety and Health Assessments (now the Office of Independent Enterprise Assessments), “Independent Oversight Follow-up Assessment of Safety Culture at the Waste Treatment and Immobilization Plant” (June, 2014).

**  ORP has line management responsibility for the WTP, BNI is the primary contractor and URS Corporation (URS) is a major subcontractor.

Catching Up on DOE’s SCWE Extent of Condition Review

Hanford Waste Treatment Plant

On May 29, 2014 DOE submitted its partial response to the Defense Nuclear Facilities Safety Board (DNFSB) Recommendation 2011-1 in a report* on DOE’s Safety Conscious Work Environment (SCWE) extent of condition review and recommended actions for ongoing safety culture (SC) improvement at DOE facilities.

(Quick history: The June 9, 2011 DNFSB report on DOE’s Hanford Waste Treatment Plant (WTP or the Vit Plant) said the WTP SC was “flawed.”  The report’s recommendations included that DOE should conduct an extent of condition review to determine whether WTP SC weaknesses existed at other DOE facilities.  DOE agreed to perform the review but focused on SCWE because, in DOE’s view, the issues at WTP were primarily SCWE related.)

This post summarizes the report’s findings then parses the details and provides our perspective.

 Report Findings and Recommendations

The report was based on data from eleven independent SC assessments and thirty-one SCWE self-assessments conducted by individual organizations.  The DOE review team processed the data through their analyzer and homogenizer to identify four primary SC attributes** to focus on for continuous improvement in DOE:

• Demonstrated safety leadership
• Open communication and fostering an environment free from retribution
• Teamwork and mutual respect
• Credibility, trust and reporting errors and problems

Further processing through the bureaucratizer yielded three recommended actions to improve the SC attributes:

• Form a DOE SC Improvement Panel to ensure leadership and focus on DOE's SC initiatives
• Incorporate SC and SCWE concepts and practices into DOE training
• Evaluate contract language to incorporate clear references to SC  (pp. 3-4)

Our Perspective

We reviewed the DOE independent assessments on January 25, 2013 and the self-assessments on March 31, 2014.  From the former we concluded that issues similar to those found at the WTP existed at other DOE facilities, but to a lesser degree than WTP.  The self-assessments were of such varying quality and credibility that we basically couldn’t infer anything.***

The Analyzer

The DOE team reviewed all the assessments to identify specific issues (problems).  The team binned issues under the SC attributes in DOE's Integrated Safety Management System Guide and then counted the number of issues under each attribute; a higher count meant a more serious problem.  They performed a similar exercise to identify positive organizational trends (strengths) mentioned in the assessments. 

We could be picky and ask if all the issues (or strengths) were of essentially the same importance or magnitude but the team had a lot of data to review so we’ll let that slide.  Concurrently identifying strengths was a good idea; it harkens back to Peter Drucker who advised managers to build on strengths.****

The Homogenizer

Here’s where we begin to have problems.  The team focused on identifying SC attributes and developing recommendations that applied to or affected the entire Department, essentially boiling their results down to a one-size-fits-all approach.  However, their own data belies that approach.  For example, the Leadership attribute “Open communication and fostering an environment free from retribution” was identified as both an issue AND a strength. 

In plain English, some organizations don’t exhibit the desired communication attribute and others do.  One proper fix is to identify who is doing it right, define what exactly they’re doing, and develop a method for transferring that approach to the problem organizations.  The report even says this attribute “is an area in which management can learn lessons from those sites where it was deemed a strength so that best practices can become commonplace” but this statement is buried at the end of the report. (p. 22)

The DOE entities exhibit a wide variety of scale, scope, mission and organizational and technical complexity.  The Department’s goal should be to recognize that reality, develop it as an overall strength and then build on it to create site- or organization-specific interventions.

The Bureaucratizer

The proposed fixes would basically create a top-level coordinating and oversight group, enhance SC and SCWE training and modify contracts.  The recommendations reflect a concerted search for the lowest common denominator and a minimum amount of real change.

If the SC Improvement Panel is established, it should focus on setting or refining SC policy and ensuring those policies are implemented by line management, especially field management.  They should also be involved in evaluating major SC issues.  If things aren’t going well, this group should be the first to ask the hard “Why?” questions.  But most of the panel’s proposed tasks, viz., maintaining SC visibility, providing a forum for evaluating SC status and overseeing training improvements, are low-value make work.

“[S]afety culture training for all personnel, up and down the management chain, will be updated and/ or developed to ensure that roles and responsibilities are understood and personnel have the capabilities needed to play their part in continuously improving DOE's safety culture; . . .” (p. 24)  This is a standard fix for almost any perceived organizational problem.  It doesn’t require managers to do anything different.

Modifying contracts to incorporate clear references to SC is only a beginning.  What are the carrots and the sticks to incent the contractors to actually develop, measure and maintain an effective SCWE and strong SC?

Bottom Line

This report comports completely with an organization that resembles a fifty foot sponge.  You can kick it as hard as you like, your foot goes in deep and you think you’ve had an effect, but when you withdraw your foot, the organization fills in the hole like your kick never happened.  I thought I heard a loud pop on May 29.  I now realize it was likely DNFSB Chairman Winokur’s head exploding when he read this report.

But Wait, There’s More

Remember the question the DNFSB initially asked in 2011: Do WTP SC issues exist elsewhere in DOE?  Well, the answer is: “Review of assessment results from both [independent and self assessments] indicated there is a SCWE extent of condition that requires additional and ongoing actions to improve performance.” (p. 28, the penultimate page of the report)


*  J. Hutton (DOE) to P.S. Winokur (DNFSB) May 29, 2014 letter transmitting DOE Consolidated Report for DNFSB Recommendation 2011-1, Actions 2-8 and 2-9 (May 2014).

** DOE considers SC in three focus areas: Leadership, Employee Engagement and Organizational Learning.  Each focus area has a set of associated attributes that describe what a positive SC should look like. (pp. 4-5)

***  The report puts the self-assessments in the best possible light by describing them as learning experiences for the organizations involved. (p.9)

****  Drucker was referring to individuals but, in this case, we’ll stretch the blanket to cover organizations.  For individuals, weaknesses should not be ignored but the energy required to fix them, if it’s even possible, is often too great.  However, one should keep an eye on such weaknesses and not allow them to lead to performance failure.

Reaction to the Valukas Report on GM Ignition Switch Problems

CEO Mary Barra and Anton Valukas

General Motors released the report* by its outside attorney, Anton Valukas, investigating the hows and whys of the failure to recall Chevy Cobalts due to faulty ignition switches.  We blogged on these issues and the choice of Mr. Valukas on May 19, 2014 and May 22, 2014 indicating our concern that his law firm had prior and ongoing ties to GM.  The report is big, 314 pages, and for some reason is marked as “Confidential, Attorney-Client Privileged”.  This is curious for a report always intended to be public and tends to highlight that Valukas and GM are in a proprietary relationship - perhaps not the level of independence one might expect for this type of assessment.

Our take, in brief, is that the Valukas report documents the "hows" but not the "whys" of what happened.  In fact it appears to be a classic legal analysis of facts based on numerous interviews of “witnesses” and reviews of documentation.  It is heavy with citations and detail but it lacks any significant analysis of the events or insight as to why people did or did not do things.  “Culture” is the designated common mode failure.  But there is no exploration of extent of condition or even consideration of why GM’s safety processes failed in the case of the Cobalt but have been effective in many other situations.  Its recommendations for corrective actions by GM are bland, programmatic and process intensive, and lack any demonstrable linkage to being effective in addressing the underlying issues.  On its part GM has accepted the findings, fired 15 low level engineers and promised a new culture.

The response to the report has reflected the inherent limitations and weaknesses of the assessment.  There have been many articles written about the report that provide useful perspectives.  An example is a column in the Wall Street Journal by Holman Jenkins titled “GM’s Cobalt Report Explains Nothing."**  In a nutshell that sums it up pretty well.  It is well worth reading in its entirety.

Congressional response has also been quite skeptical.  On June 18, 2014 the House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations, held a hearing with GM CEO Barra and Valukas testifying.  A C-SPAN video of the proceeding is available and is of some interest.***  Questioning by subcommittee members focused on the systemic nature of the problems at GM, how GM hoped to change an entrenched culture, and the credibility of the findings that malfeasance did not extend higher into the organization.

The Center for Auto Safety, perhaps predictably, was not impressed with the report, stating: “The Valukas Report is clearly flawed in accepting GM’s explanation that its engineers and senior managers did not know stalling was safety related.”****

Why doesn’t the Valukas report explain more?  There are several possibilities.  Mr. Valukas is an attorney.  Nowhere in the report is there a delineation of the team assembled by Mr. Valukas or their credentials. It is not clear if the team included expertise on complex organizations, safety management or culture.  We suspect not.  The Center for Auto Safety asserts that the report is a shield for GM against potential criminal liability.  Impossible for us to say.  Congressional skepticism seemed to reflect a suspicion that the limited scope of the investigation was designed to protect senior GM executives.  Again hard to know but the truncated focus of the report is a significant flaw.

What is clear from these reactions to the report is that, at a minimum, it is ineffective in establishing that a full and expert analysis of GM’s management performance has been achieved.  Assigning fault to the GM culture is at once too vague and ultimately too convenient in avoiding more specific accountability.  It also suggests that internally GM has not come to grips with the fundamental problems in its management system and decision making.  If so, it is hard to believe that the corrective actions being taken will be effective in changing that system or assuring better safety performance going forward.


*  A.R. Valukas, "Report to Board of Directors of General Motors Company Regarding Ignition Switch Recalls" (May 29, 2014).

**  H.W. Jenkins, Jr., "GM's Cobalt Report Explains Nothing," Wall Street Journal (June 6, 2014).

***  C-SPAN, "GM Recall Testimony" (June 18, 2014).  Retrieved June 26, 2014.

****  C.Ditlow (Center for Auto Safety), letter to A.R. Valukas (June 17, 2014), p. 3.  Retrieved June 26, 2014.