Nuclear Safety Culture (and Other) Problems in the U.S. Nuclear Weapons Complex

Los Alamos  Source: LANL

The Center for Public Integrity (CPI) has published a five-part report on safety lapses in the U.S. nuclear weapons complex—an array of facilities overseen by the Department of Energy (DOE).*  Overall, the report paints a picture of a challenged and arguably weak safety culture (SC).  Following is a summary of the report and our perspective on it.

Part I traces the history of radioactive criticality incidents (which have resulted in human fatalities) and near-misses at Los Alamos National Laboratory (LANL).  Analysis and production of plutonium pits, essential for maintaining the U.S. nuclear weapons inventory, has been halted for years because of concerns over safety issues.  In addition, almost all members of the site’s criticality analysis team quit over inadequate management support for the team’s efforts.

Part II discusses in more detail the impacts of the LANL shutdown.  Most significant, from our perspective, is a 2013 report that said “Management has not yet fully embraced its commitment to criticality safety.”  The 2013 report “also listed nine weaknesses in the lab’s safety culture that were rooted in a “production focus” to meet work deadlines. Workers say these deadlines are typically linked to financial bonuses.”

Speaking of bonuses, although the plant was not working, the contractors were judged to have exceeded expectations in getting ready to restart.  Accordingly, the contractors “received 74 percent or $10.7 million of the $14.4 million in profits available to them from the NNSA in the category that includes pit production and surveillance”

Part III covers incidents at other facilities and cultural shortcomings in the weapons complex.  It is the meatiest section of the report.  Most of the unfortunate events were industrial accidents (electric shocks, explosions, burns) but the nuclear hazard is always nearby because of the nature of the work.  Occasionally the nuclear factor is key, e.g., when LANL improperly packed a drum of waste they shipped to the Waste Isolation Pilot Plant where it exploded or when Nevada National Security Site personnel inhaled radioactive particles

This section captures the key point of the entire report: the DOE contractors make a lot of money ($2B in profit over the last 10 years), the financial rewards for safety are minimal and the financial penalties for accidents and such are minimal (1-3% of profits) and often waived.

Part IV details a 2014 incident in Nevada where over 30 personnel inhaled potentially cancer-causing uranium particles during laboratory experiments over a two-month period.  The researchers were annoyed by radiation alarms so they switched them off (which also turned off a safety ventilation system).  This was a self-inflicted wound that suggests a weak SC.

Part V focuses on a radiation exposure accident at the Idaho National Laboratory.  The accident occurred even though years before, the head of the safety committee had warned DOE managers about the hazards of handling the specific material involved in the accident.  The lab contractor made 92% of its contractually available profit that year.  The contractor has petitioned DOE to reimburse the contractor’s litigation expenses (including payouts to affected employees) associated with the accident.

NNSA’s Response

The National Nuclear Security Administration (NNSA) is a semi-autonomous agency within DOE that oversees U.S. nuclear weapons work.  In a statement** responding to the CPI report, the NNSA Administrator basically says the CPI report is incomplete and misleading with respect to LANL.  Unsurprisingly, he starts with “Safety is paramount . . . . [CPI] attacks the safety culture at . . .  (LANL) without offering all of the facts and the full context.”  However, he does not directly refute the CPI report, instead he provides the NNSA’s version of history: LANL paused operations because of concerns with the criticality safety program. Since then, “LANL has increased criticality safety staffing and demonstrated improvements in its performance of operational tasks.”  NNSA has withheld $82 million in fee payments to LANL.  Finally, LANL maintained its ability to fulfill its mission during the pause in operations.  Alternative facts?  You be the judge. 

Our Perspective 

The DOE says it wants safe production but is not willing to wield the hammer (higher financial incentives for safety and more penalties for unsafety) to drive that outcome.  In addition, DOE, constrained by Congress (which is bowing to their defense industry contributors), appears to deliberately understaff their own auditors and other procurement officials so they are unable to surface too many embarrassing problems. 

The contractors are rational.  They understand that production is the primary goal and they accept that bad things will occasionally happen in a hazardous environment.  They know they will make their profits no matter what happens, including facility shutdowns, because they can get paid for fixing problems they helped to create.

The CPI report is not shocking to us and it shouldn’t be to you.  (Click on the DOE label to see our many posts on DOE SC.)  It merely documents what has been, and continues to be, business as usual at nuclear weapons facilities.  If you can tolerate the overwrought writing, Part III is worth a look.           


*  The Center for Public Integrity, “Nuclear Negligence” (June 28, 2017).  Retrieved July 5, 2017.  According to Wikipedia, CPI “is an American nonprofit investigative journalism organization . . .”

The report describes problems at the Idaho National Laboratory and some NNSA facilities.  Overall, NNSA oversees eight sites that are involved with nuclear weapons: Kansas City National Security Campus (non-nuclear component manufacture), Lawrence Livermore National Laboratory (weapon design), Los Alamos National Laboratory (design and testing), Nevada National Security Site (testing), Pantex Plant (weapon assembly and disassembly), Sandia National Laboratories (non-nuclear component design), Savannah River Site (nuclear materials) and Y-12 National Security Complex (uranium components).

**  “Klotz Responds To Center For Public Integrity's Series On Safety Culture At NNSA Sites,” Los Alamos Daily Post (June 20, 2017).  Retrieved July 10, 2017

Learning About Nuclear Safety Culture from the Web, Maybe

The Internet  Source:Wikipedia

We’ve come across some Internet content (one website, one article) that purports to inform the reader about nuclear safety culture (NSC).  This post reviews the content and provides our perspective on its value.

NSC Website

It appears the title of this site is “Nuclear Safety Culture”* and the primary target is journalists who want an introduction to NSC concepts, history and issues.  It is a product of a group of European entities.  It is a professional looking site that covers four major topics; we’ll summarize them in some detail to show their wide scope and shallow depth. 

Nuclear Safety Culture covers five sub-topics:

History traces the shift in attitudes toward and protection from ionizing radiation as the possible consequences became better known but the story ends in the 1950s.  Key actions describe the roles of internal and external stakeholders during routine operations and emergency situations.  The focus is on power production although medicine, industrial uses and weapons are also mentioned.  Definition of NSC starts with INSAG (esp. INSAG-4), then adds INPO’s directive to emphasize safety over competing goals, and a familiar list of attributes from the Nuclear Safety Journal.  As usual, there is nothing in the attributes about executive compensation or the importance of a systems view.  IAEA safety principles are self explanatory.  Key scientific concepts cover the units of radiation for dose, intake and exposure.  Some values are shown for typical activities but only one legal limit, for US airport X-rays, is included.**  There is no information in this sub-topic on how much radiation a person can tolerate or the regulatory limits for industrial exposure.

From Events to Accidents has two sub-topics:

From events to accidents describes the 7-level International Nuclear Event Scale (from a minor anomaly to major accident) but the scale itself is not shown.  This is a major omission.  Defence in depth discusses this important concept but provides only one example, the levels of physical protection between a fuel rod in a reactor and the environment outside the containment.

Controversies has two sub-topics:

Strengths and Weaknesses discuss some of the nuclear industry’s issues and characteristics: industry transparency is a double-edge sword, where increased information on events may be used to criticize a plant owner; general radiation protection standards for the industry; uncertainties surrounding the health effects of low radiation doses; the usual nuclear waste issues; technology evolution through generations of reactors; stress tests for European reactors; supply chain realities where a problem anywhere is used against the entire industry; the political climate, focusing on Germany and France; and energy economics that have diminished nuclear’s competitiveness.  Overall, this is a hodgepodge of topics and a B- discussion.  The human factor provides a brief discussion of the “blame culture” and the need for a systemic view, followed by summaries of the Korean and French document falsification events.

Stories summarizes three events: the Brazilian theft of a radioactive source, Chernobyl and Fukushima.  They are all reported in an overly dramatic style although the basic facts are probably correct.

The authors describe what they call the “safety culture breach” for each event.  The problem is they comingle overarching cultural issues, e.g., TEPCO’s overconfident management, with far more specific failures, e.g., violations of safety and security rules, and consequences of weak NSC, e.g., plant design inadequacies.  It makes one wonder if the author(s) of this section have a clear notion of what NSC is.

It isn’t apparent how helpful this site will be for newbie journalists, it is certainly not a complete “toolkit.”  Some topics are presented in an over-simplified manner and others are missing key figures.  In terms of examples, the site emphasizes major accidents (the ultimate trailing indicators) and ignores the small events, normalization of deviance, organizational drift and other dynamics that make up the bulk of daily life in an organization.  Overall, the toolkit looks a bit like a rush job or unedited committee work, e.g., the section on the major accidents is satisfactory but others are incomplete.  Importantly (or perhaps thankfully) the authors offer no original observations or insights with respect to NSC.  It’s worrisome that what the site creators call NSC is often just the safety practices that evolved as the hazards of radiation became better known. 

NSC Article

There is an article on NSC in the online version of Power magazine.  We are not publishing a link to the article because it isn’t very good; it looks more like a high schooler’s Internet-sourced term paper than a thoughtful reference or essay on NSC.

However, like the stopped clock that shows the correct time twice per day, there can be a worthwhile nugget in such an article.  After summarizing a research paper that correlated plants’ performance indicators with assessments of their NSC attributes (which paper we reviewed on Oct. 5, 2014), the author says “There are no established thresholds for determining whether a safety culture is “healthy” or “unhealthy.””  That’s correct.  After NSC assessors consolidate their interviews, focus groups, observations, surveys and document reviews, they always identify some improvement opportunities but the usual overall grade is “pass.”***  There’s no point score, meter or gauge.  Perhaps there should be.

Our Perspective

Don’t waste your time with pap.  Go to primary sources; an excellent starting point is the survey of NSC literature performed by a U.S. National Laboratory (which we reviewed on Feb. 10, 2013.)  Click on our References label to get other possibilities and follow folks who actually know something about NSC, like Safetymatters.


*  Nuclear Safety Culture was developed as part of the NUSHARE project under the aegis of the European Nuclear Education Network.   Retrieved June 19, 2017.

**  The airport X-ray limit happens to be the same as the amount of radiation emitted by an ordinary banana.

***  A violation of the Safety Conscious Work Environment (SCWE) regulations is quite different.  There it’s zero tolerance and if there’s a credible complaint about actual retaliation for raising a safety issue, the licensee is in deep doo-doo until they convince the regulator they have made the necessary adjustments in the work environment.

Nuclear Safety Culture Update at Pilgrim and Watts Bar

Pilgrim

Watts Bar

A couple of recent reports address the nuclear safety culture (NSC) problems at Pilgrim and Watts Bar.  This post summarizes the reports and provides our perspective on their content.  Spoiler alert: there is not much new in this news.

Pilgrim

The NRC issued their report* on phase C of their IP 95003 inspection at Pilgrim.  This is the phase where the NRC conducts its own assessment of the plant’s NSC.  The overall finding in the cover letter is: “The NRC determined that programs and processes at PNPS [Pilgrim] adequately support nuclear safety and that PNPS should remain in Column 4.”  However, the letter goes on to detail a host of deficiencies.  The relative good news is that Pilgrim’s NSC shortcomings weren’t sufficiently serious or interesting to merit mention in the cover letter.

But the NRC had plenty to say about NSC in the main report.  Highlights include the finding that NSC is a “fundamental problem” at Pilgrim.  NSC gradually deteriorated over time and “actions to balance competing priorities, manage problems, and prioritize workload resulted in reduced safety margins.”  Staffing reduction initiatives exacerbated plant performance problems.  Personnel were challenged to exhibit standards and expectations in conservative decision-making, work practices, and procedure use and adherence.  Contributing factors to performance shortcomings include lack of effective benchmarking of industry standards and the plant’s planned 2019 permanent shutdown.  The NRC also noted weaknesses in the Executive Review Board, Employee Concerns Program and the Nuclear Safety Culture Monitoring Panel. (pp. 8-10)

Watts Bar

In April the TVA inspector general (IG) issued a report** castigating TVA management for allowing a chilled work environment (CWE) to continue to exist at Watts Bar.  The IG report’s findings included: TVA's analyses and its response to the NRC’s CWE letter were incomplete and inadequate; TVA's planned corrective actions are unlikely to have long-term effectiveness; precursors of the CWE went unrecognized by management; and management has inappropriately influenced the outcome of analyses and investigations pertaining to Watts Bar NSC/SCWE issues.  Staff stress, fear and trust issues also exist.

In response, TVA management pointed out the corrective actions that were taken or are underway since the first draft of the IG report was issued.  Additionally, TVA management “has expressly acknowledged management's role in creating the condition and its responsibility for correcting it."

Our Perspective

This is merely a continuation of a couple of sad stories we’ve been reporting on for a long time.  Click on the Entergy, Pilgrim, TVA or Watts Bar labels to get our earlier reports. 

The finding that Pilgrim did not adequately benchmark against industry standards is appalling.  Entergy operates a fleet of nuclear plants and they don’t know what industry standards are?  Whatever.  Entergy is closing all the plants they purchased outside their service territory, hopefully to increase their attention on their utility-owned plants (where Arkansas Nuclear One remains a work in progress). 

We applaud the TVA IG for shining a light on the agency’s NSC issues.  In response to the IG report, TVA management put out a typical mea culpa accompanied by claims that their current corrective actions will fix the CWE and other NSC problems.  Well, their prior actions were ineffective and these actions will also probably fall short.  It doesn’t really matter.  TVA is too big to fail, both politically and economically, and their nuclear program will likely continue to plod along forever.


*  D.H. Dorman (NRC) to J. Dent (TVA), “Pilgrim Nuclear Power Station – Supplemental Inspection Report (Inspection Procedure 95003 Phase ‘C’) 05000293/2016011 and Preliminary Greater-than-Green Finding” (May 10, 2017).  ADAMS ML17129A217.

**  TVA Inspector General, “NTD Consulting Group, LLC's Assessment of TVA's Evaluation of the Chilled Work Environment at Watts Bar Nuclear Plant - 2016-16702” (April 19, 2017).  Also see D. Flessner, “TVA inspector general says safety culture problems remain at Watts Bar,” Chattanooga Times Free Press (April 21, 2017).  Retrieved May 25, 2017.

A Nordic Compendium on Nuclear Safety Culture

A new research paper* covers the challenges of establishing and improving nuclear safety culture (NSC) in a dynamic, i.e., project, environment.  The authors are Finnish and Swedish and it appears the problems of the Olkiluoto 3 plant inform their research interests.  Their summary and review of current NSC literature is of interest to us. 

They begin with an overall description of how organizational (and cultural) changes can occur in terms of direction, rate and scale.

Direction

Top-down (or planned) change relies on the familiar unfreeze-change-refreeze models of Kurt Lewin and Ed Schein.  Bottom-up (or emergent) change emphasizes self-organization and organizational learning.  Truly free form, unguided change leads to NSC being an emergent property of the organization.  As we know, the top-down approach is seldom, if ever, 100% effective because of frictional losses, unintended consequences or the impact of competing, emergent cultural currents.  In a nod to a systems perspective, the authors note organizational structures and behavior influence (and are influenced by) culture.

Rate

“Organizational change can also be distinguished by the rate of its occurrence, i.e, whether the change occurs abruptly or smoothly [italics added].” (p. 8)  We observe that most nuclear plants try to build on past success, hence they promote “continuous improvement” programs that don’t rattle the organization.  In contrast, a plant with major NSC problems sometimes receives shock treatment, often in the form of a new senior manager who is expected to clean things up.  New management systems and organizational structures can also cause abrupt change.

Scale

The authors identify four levels of change.  Most operating plants exhibit the least disruptive changes, called fine tuning and incremental adjustment.  Modular transformation attempts to change culture at the department level; corporate transformation is self-explanatory. 

The authors sound a cautionary note: “the more radical types of changes might not be easily initiated – or might not even be feasible, considering that safety culture is by nature a slowly and progressively changing phenomenon. The obvious condition where a safety-critical organization requires radical changes to its safety culture is when it is unacceptably unhealthy.” (p. 9)

Culture Change Strategies

The authors list seven specific strategies for improving NSC:

• Change organizational structures,
• Modify the behavior of a target group through, e.g. incentives and positive reinforcement,
• Improve interaction and communication to build a shared culture,
• Ensure all organizational members are committed to safety and jointly participate in its improvement,
• Training,
• Promote the concept and importance of NSC,
• Recruit and select employees who will support a strong NSC.

This section includes a literature review for examples of the specific strategies.

Project Organizations

The nature of project organizations is discussed in detail including their time pressures, wide use of teams, complex tasks and a context of a temporary organization in a relatively permanent environment.  The authors observe that “in temporary organisations, the threat of prioritizing “production” over safety may occur more naturally than in permanent organizations.” (pp. 16-17)  Projects are not limited to building new plants; as we have seen, large projects (Crystal River containment penetration, SONGS steam generator replacement) can kill operating plants.

The balance of the paper covers the authors’ empirical work.

Our Perspective 

This is a useful paper because it provides a good summary of the host of approaches and methods that have been (and are being) applied in the NSC space.  That said, the authors offer no new insights into NSC practice.

Although the paper’s focus is on projects, basically new plant construction, people responsible for fixing NSC at problem plants, e.g., Watts Bar, should peruse this report for lessons they can apply that might help achieve the step function NSC improvements such plants need.


*  K.Viitanen, N. Gotcheva and C. Rollenhagen, “Safety Culture Assurance and Improvement Methods in Complex Projects – Intermediate Report from the NKS-R SC AIM” (Feb. 2017).  Thanks to Aili Hunt of the LinkedIn Nuclear Safety Culture group for publicizing this paper.

Nuclear Safety Culture at the 2017 NRC Regulatory Information Conference

NRC 2017 RIC

Nuclear Safety Culture (NSC) was assigned one technical session at the 2017 NRC Regulatory Information Conference (RIC).  The topic was maintaining a strong NSC during plant decommissioning.  This post reviews the session presentations and provides our perspective on the topic.

Nuclear Regulatory Commission (NRC)*

The presenter discussed the agency’s expectations that the requirements of the SC Policy Statement will continue to be met during decommissioning, recognizing that plant old-timers may experience issues with trust, commitment and morale while newcomers, often contractors, will need to be trained and managed to meet NSC standards going forward.  The presentation was on-target but contained no new information or insights.

International Atomic Energy Agency (IAEA)**

This presentation covered the IAEA documents that discuss NSC, viz., the General Safety Requirement “Leadership and Management for Safety,” and the Safety Guides “Application of the Management System for Facilities and Activities,” which covers NSC characteristics, and “The Management System for Nuclear Installations,” which covers NSC assessments, plus supporting IAEA Safety Reports and Technical Documents.  There was one slide covering decommissioning issues, none of which was new.

The slides were dense with turgid text; this presentation must have been excruciating to sit through.  The best part was IAEA did not attempt to add any value through some new approach or analysis, which always manages to muck up the delivery of any potentially useful information. 

Kewaunee***

The Kewaunee plant was shut down on May 7, 2013.  The shutdown announcement on Oct. 22, 2012 was traumatic for the staff and they went through several stages of grieving.  Management has worked to maintain transparency and an effective corrective action program, and retain people who can accept changing conditions.  It is a challenge for management to maintain a strong NSC as the plant transitions to long-term SAFSTOR.

It’s not surprising that Kewaunee is making the best of what is undoubtedly an unhappy situation for many of those involved.  The owner, Dominion Resources, has a good reputation in NSC space.

Vermont Yankee****

This plant was shut down on Dec. 29, 2014.  The site continued applying its process to monitor for NSC issues but some concerns still arose (problems in radiation practices, decline in industrial safety performance) that indicated an erosion in standards.  Corrective actions were developed and implemented.  A Site Review Committee provides oversight of NSC.

The going appears a little rougher at Vermont Yankee than Kewaunee.  This is not a surprise given both the plant and its owner (Entergy) have had challenges in maintaining a strong NSC. 

Our Perspective

The session topic reflects a natural life cycle: industrial facilities are built, operate and then close down.  But that doesn’t mean it’s painless to manage through the phase changes. 

In an operating plant, complacency is a major threat.  Complacency opens the door to normalization of deviation and other gremlins that move performance toward the edge of the envelope.  In the decommissioning phase, we believe loss of fear is a major threat.  Loss of fear of dramatic, even catastrophic radiological consequences (because the fuel has been off-loaded and the plant will never operate again) can lead to losing focus, lack of attention to procedural details, short cuts and other behaviors that can have significant negative consequences such as industrial accidents or mishandling of radioactive materials.

In a “Will the last person out please turn off the lights” environment, maintaining everyone’s focus on safety is challenging for people who operated the plant, often spending a large part of their careers there.  The lack of local history is a major reason to transfer work to specialty decommissioning contractors as quickly as possible. 

In 2016, NSC didn’t merit a technical session at the RIC; it was relegated to a tabletop presentation.  As the industry shrinks, we hope NSC doesn’t get downgraded to a wall poster.


*  D. Sieracki, “Safety Culture and Decommissioning,” 2017 RIC (Mar. 15, 2017).

**  A. Orrell, “Safety Culture and the IAEA International Perspectives,” 2017 RIC (Mar. 15, 2017).

***  S. Yeun, “Maintaining a Strong Safety Culture after Shutdown,” 2017 RIC (Mar. 15, 2017).

****  C. Chappell, “Safety Culture in Decommissioning: Vermont Yankee Experience,” 2017 RIC (Mar. 15, 2017).

Totally Nude, Naked Nuclear Safety Culture

I admit it.  The title is a cheap April Fools trick to draw new, perhaps less conventional, visitors to Safetymatters.  The only thing you’ll see here is the naked truth about nuclear safety culture (NSC), which we have been preaching about for years.

We’ve repeatedly listed the ingredients for a strong NSC: decision-making that recognizes goal conflicts and establishes clear, consistent safety priorities; an effective corrective action program; a mental model of organizational functioning that considers interrelationships and feedback loops among key variables; a compensation plan that rewards safety performance; and leadership that walks the talk on NSC.

We’ve also said that, absent constant maintenance, NSC will invariably decay over time because of complacency and system dynamics.  Complacency leads to hubris (“It can’t happen here”) and opens the door for the drift toward failure that occurs with normalization of deviance and group think.  System dynamics include constant environmental adaptations, goal conflicts, shifting priorities, management incentives tilted toward production and cost achievements, and changing levels of intra-organizational trust. 

NSC in practice appears to have approached an asymptote to the ideal.  Problems still occur; currently Entergy, TVA and AREVA are in the hot seat.  We have to ask: Is the industry’s steady-state NSC a low-intensity war of Whac-a-Mole?  You be the judge.

Nuclear Safety Culture: Catching up with the NRC

NRC Building

No big nuclear safety culture (NSC) news has come out of the Nuclear Regulatory Commission (NRC) so far in 2017 but there have been a few minor items worth mentioning.

New Leadership Model for NRC*

In 2015, the NRC staff proposed developing an explicit NRC leadership model that would complement the agency’s existing Principles of Good Regulation and Organizational Values (Principles).  The model’s attributes would include “empowering employees . . . creative thinking, innovation, and informed risk-taking . . . .”  The Commission disagreed, saying staff should focus on the characteristics of the Principles that support the identified organizational attributes.

Subsequent staff research identified performance improvement opportunities in the areas of employee decision-making, empowerment and consensus, employee creativity, informed risk-taking and innovation.  They are re-proposing an explicit leadership model that focuses on “Empowerment & Shared Leadership, Innovation & Risk Tolerance, Participative Decision-Making, Diversity in Thought, Receptivity to New Ideas and Thinking, and Collaboration & Teamwork . . . .”

This was a significant social science project to rationalize development of a highly specified management model.  Could it contribute to improving the agency’s “effectiveness, efficiency, and agility”?  Or is it, in essence, a regulation that would suck energy away from what NRC leaders need to do to succeed in a changing environment?  You be the judge.

NRC Lessons-Learned Program (LLP)**

This program was established after the Davis-Bessie fiasco to review agency, nuclear industry and outside incidents for lessons-learned that verify or could strengthen NRC processes.  Because a recognized lesson-learned leads to an NRC corrective action plan (i.e., resource usage) there is a high threshold for accepting proposed lessons-learned.  In the past year, six incidents ranging from the government response to the Flint, MI water crisis to two gripe papers published by the Union of Concerned Scientists passed a preliminary screen.  Ultimately, none of the items met the LLP minimum criteria although all were addressed by other NRC groups or processes.  

The LLP Oversight Board is considering whether the LLP should be discontinued, the threshold should be lowered, or the status quo approach should be continued.  Our concern is that the hard-headedness which characterizes the nuclear industry has also infected the LLP and prevents them from being open to actually learning anything from the experience of others.

Continued NSC Pressure on Problem Plants

Finally, NRC continues to (rightfully) squeeze plants with recognized NSC problems to fix such problems.  Arkansas Nuclear One (ANO) has a Confirmatory Action Letter (CAL) that requires the plant to implement specific improvement steps, including establishing a NSC Observer function to monitor leader behavior and enhancing decision making to ensure NSC aspects are considered.***  We discussed ANO’s NSC problems at length on June 16, 2016.

Watts Bar received part 2 of an inspection report on plant performance in the areas of NSC and Safety Conscious Work Environment (SCWE).****  It was a continuation of the beat down they received in part 1 (which we reviewed on Nov. 14, 2016).  The major findings were site-wide challenges to Watts Bar’s SCWE and weaknesses in the criteria used to evaluate NSC standards.  The inspection team’s detailed findings were too numerous to list here but included disagreeing with the site’s interpretation of safety “pulsing” data, management relaxing the standards for evaluating NSC data, overly limited assessment of NSC survey results and weaknesses in the training for NSC monitors.  The report is worth reading to show what a diligent inspector sees when looking at the same plant-produced NSC data that management has been cherry-picking for positive results and trends.

Our Perspective

The first calendar quarter of 2017 looks like business as usual at the NRC, at least when it comes to NSC.  That’s probably as it should be; we really don’t want them to be too distracted by the downsizing and problems occurring in the U.S. commercial nuclear industry.  The agency is trying to figure out how to be more agile and, without saying so, looking forward to having to do the same work with fewer resources.  (While some costs, e.g., plant inspection activities, are variable and can scale down with the industry, our guess is much of their work/cost structure is more-or-less fixed.)

There was a safety culture session at the recent Regulatory Information Conference, which we will separately review.


*  Memo from V.M. McCree to NRC Commissioners, “Re-Examination of the Need for a U.S. Nuclear Regulatory Commission Leadership Model” (Feb. 6, 2017).  ADAMS ML16348A323.

**  Memo from V.M. McCree to NRC Commissioners, “Annual Report on the Lessons-Learned Program” (Feb. 17, 2017).  ADAMS ML16231A323.

***  Letter from T.R. Farnholtz (NRC) to R. Anderson (ANO), “Arkansas Nuclear One – NRC Component Design Bases Inspection and Confirmatory Action Letter Follow-up Inspection Report 05000313/2016008 AND 05000368/2016008” (Feb. 28, 2017), pp. A3-5/-6.  ADAMS ML17059D000.

****  Letter from J.T. Munday (NRC) to J.W. Shea (TVA), “Watts Bar Nuclear Plant – NRC Problem Identification and Resolution Inspection (Part 2); and Safety Conscious Work Environment Issue of Concern Follow-up; NRC Inspection Report 05000390/2016013, 05000391/2016013” (March 10, 2017), pp. 2, 13-16.  ADAMS ML17069A133.

Nuclear Safety Culture at the Department of Energy—An Update

We haven’t reported on the U.S. Department of Energy’s (DOE) safety culture (SC) in awhile.  Although there hasn’t been any big news lately, we can look at some individual facts and then connect the dots to say something about SC.

Let’s start with some high-level good news.  In late 2016 DOE announced it had conducted its 100th SC training class for senior leaders of both federal and contractor entities across the DOE complex.*  The class focuses on teaching leaders the why and how of maintaining a collaborative workplace and Safety Conscious Work Environment (SCWE), and fostering trust in the work environment. 

Now let’s turn to a more localized situation.  In Feb 2014, a storage drum burst at the DOE’s Waste Isolation Pilot Plant (WIPP) in New Mexico, resulting in a small release of radioactive material.  The drum burst because a sorbent added to the waste had been changed without considering the difference in chemical properties.**  This has been an expensive incident.  The plant has been closed for over three years; it was authorized to reopen in Jan 2017 and shipments are scheduled to resume in April 2017.*** 

The drum that burst came from the Los Alamos National Laboratory (LANL).  The WIPP Recovery Plan envisions continuing the pre-incident practice of the waste generators being responsible for correctly packing their waste: “All waste generators will have rigorous characterization, treatment, and packaging processes and procedures in place to ensure compliance with WIPP Waste Acceptance Criteria [WAC].”****  As we said in our May 3, 2016 post: “For this approach to work, WAC compliance by the waste generators . . . must be completely effective and 100% reliable.”  In the same post, we reported the Defense Nuclear Facilities Safety Board (DNFSB) had recognized this weak link in the chain.  However, because DNFSB cannot force changes it could only recommend that DOE “explore defense-in-depth measures that enhance WIPP’s capability to detect and respond to problems caused by unexpected failures in the WAC compliance program.”

As described in the current WAC, WIPP’s “defense-in-depth” appears to be limited to the local DOE office and the WIPP contractor performing Generator Site Technical Reviews, which cover sites’ implementation of WIPP requirements.*****  These reviews are supposed to assure that deficiencies are detected and noncompliant shipments are avoided but it’s not clear if any physical surveillance is involved or if this is strictly a paperwork exercise.

The foregoing is important because it ties to SC.  Firstly, WIPP has had SC issues, in fact, a deficient SC was identified as contributing to shortcomings in the handling of the aftermath of the drum explosion.  (We reviewed this in detail on May 3 and May 5, 2014.)  WIPP SC is supposedly better now: “NWP [the WIPP contractor] has made continuous improvements in their safety culture and has really embraced the recommendations provided in the 2015 review, as well as subsequent reviews and surveys.”^  Secondly, other SC problems, too myriad to even list here, have arisen throughout the DOE complex over the years.  (Click on the DOE label to see our reports on such problems.)

Finally, we present a recent data point for LANL.  In DOE’s report on criticality safety infractions and program non-compliances for FY 2016, LANL had the most such incidents, by far, of the DOE’s 24 sites and projects.^^  Most of the non-compliances were self-identified.  Now does this evidence a strong SC that recognizes and reports its problems or a weak SC that allows the problems to occur in the first place?  You be the judge.

Our Perspective

Through initiatives such as SC training, it appears that at the macro level, DOE is (finally) communicating that minimally complying with basic regulations for how organizations should treat employees is not enough; establishing trust, mainly through showing respect for employees’ efforts to raise safety questions and point out safety problems, is essential.  That’s a good thing.

But we see signs of weakness at the operational level, viz., between WIPP and its constellation of waste generators.  Although we are not fans of “Normal Accident” theory which says accidents are inevitable in tightly coupled, low slack environments, e.g., a nuclear power plant, we can appreciate the application of that mental model in the case of WIPP.  Historically, one feature of the DOE complex that has limited problems to specific locations is the weak coupling between facilities.  When every facility with bomb-making waste is shipping it to WIPP, tighter coupling is created in the overall waste management system.  Every waste generator’s SC can have an impact on WIPP’s safety performance.  The system does need more defense-in-depth.  At a minimum, WIPP should station resident inspectors at every waste generator site to verify compliance with the WAC.

Bottom line: DOE is trying harder in the SC space but their history does not inspire huge confidence going forward. 


*  “DOE Conducts 100th Safety Culture Training Class” (Dec. 29, 2016).

**  Organic kitty litter had been substituted for inorganic kitty litter.  See this Jan. 10, 2017 Forbes article for a good summary of the WIPP incident.

***  “WIPP Road Show Early Stops Planned in Carlsbad & Hobbs,” WIPP website (Feb. 27, 2017).  Retrieved March 7, 2017. 

****  DOE, “Waste Isolation Pilot Plant Recovery Plan,” Rev 0 (Sept. 30, 2014), p. 24.

*****  DOE, “Transuranic Waste Acceptance Criteria for the Waste Isolation Pilot Plant,” Rev 8.0 (July 5, 2016), pp. 20-21.

^  DOE, “Department of Energy Operational Readiness Review for the Waste Isolation Pilot Plant” (Dec. 2016), p. 33.

^^   DOE, “2016 Annual Metrics Report to the Defense Nuclear Facilities Safety Board – Nuclear Criticality Safety Programs” (Jan. 2017), p. 3.