IR 05000390/2016007
| ML16300A409 | |
| Person / Time | |
|---|---|
| Site: | Watts Bar  |
| Issue date: | 10/26/2016 |
| From: | Alan Blamey Reactor Projects Region 2 Branch 6 |
| To: | James Shea Tennessee Valley Authority |
| References | |
| EA-16-061 IR 2016007 | |
| Download: ML16300A409 (13) | |
Text
October 26, 2016
SUBJECT:
WATTS BAR NUCLEAR PLANT - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION (PART 1); AND SAFETY CONSCIOUS WORK ENVIRONMENT ISSUE OF CONCERN FOLLOW-UP; NRC INSPECTION REPORT 05000390/2016007 AND 05000391/2016007
Dear Mr. Shea:
On September 15, 2016, the U.S. Nuclear Regulatory Commission (NRC) completed the first part of a Problem Identification and Resolution biennial inspection, which included a Safety Conscious Work Environment Issue of Concern Follow-Up inspection at your Watts Bar Nuclear Plant, Units 1 and 2. The enclosed inspection report documents the inspection results, which were discussed on September 15, 2016, with Mr. Paul Simmons and other members of your staff.
In a letter dated March 23, 2016, the NRC issued a Chilling Effect Letter (CEL) entitled, Chilled Work Environment for Raising and Addressing Safety Concerns at the Watts Bar Nuclear Plant, (ML16083A479). The NRC determined there was sufficient evidence to support the existence of an environment within the Operations department where your employees did not feel free to raise safety concerns to management because they feared retaliation and did not feel that their concerns were being addressed. As a follow-up to the issuance of the CEL, this inspection included a focused assessment of the safety conscious work environment (SCWE). The staff evaluated the attributes of a SCWE as described in inspection procedure (IP) 93100, Safety Conscious Work Environment Issue of Concern Follow-up. IP 93100 identifies a SCWE as an environment in which employees are encouraged to raise safety concerns, are free to raise concerns both to their own management and to the NRC without fear of retaliation, where concerns are promptly reviewed, given the proper priority, appropriately resolved, and timely feedback is provided to those raising concerns.
The inspection team conducted 17 focus groups and 22 interviews with members of the Watts Bar staff and key management. A total of 136 employees participated in the focus groups and interviews. The information from the focus groups, interviews, and document reviews were organized into the themes that are discussed in the attached report. The team made the following key observations associated with the current work environment, which are explained in more detail in the report. Interviews and focus groups with Operations department staff indicated an improvement in the primary work environment conditions that prompted the issuance of the CEL, but focus groups within and outside of the Operations department indicated the existence of broader, previously unrecognized challenges to the maintenance of a positive safety culture, which continued to challenge the SCWE. The team identified substantial weaknesses in various attributes of a SCWE, which were found to be pervasive across various work units. Most prominent was that although most employees in the assessment indicated that they were personally willing to raise nuclear safety concerns, nearly half believed retaliation was a potential outcome for raising concerns. In addition, most employees did not believe that concerns were promptly reviewed or appropriately resolved, either by their management or via the Corrective Action Program.
The NRC has determined that, given the current state of the sites safety culture, you are not meeting the Commission's expectation that licensees establish and maintain a positive safety culture and safety conscious work environment as described in the Safety Culture and SCWE Policy Statements (76 FR 34773, June 14, 2011; 61 FR 24336, May 14, 1996). The inspectors did not identify any findings or violations of regulatory requirements of more than minor significance. The NRC will continue to inspect and monitor the sites safety culture and the progress of the actions identified in your response to the CEL to address the work environment issues. The observations made during this inspection will be reviewed in conjunction with the results of the second part of the inspection and included in the overall assessment and conclusions regarding the effectiveness of the PI&R program.
In accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding, of the NRC's Rules of Practice, a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRCs Public Document Room or from the Publicly Available Records (PARS) component of the NRC's Agencywide Documents Access and Management System (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Alan Blamey, Branch Chief Reactor Projects Branch 6 Division of Reactor Projects
Docket Nos.: 50-390, 391 License Nos.: NPF-90, NPF-96
Enclosure:
Inspection Report 05000390/2016007 and 05000391/2016007 w/Attachment: Supplemental Information
REGION II==
Docket No.:
50-390, 50-391
License No.:
Report No.:
05000390/2016007, 05000391/2016007
Licensee:
Tennessee Valley Authority (TVA)
Facility:
Watts Bar, Units 1 and 2
Location:
Spring City, TN 37381
Dates:
September 12 - 15
Inspectors:
C. Kontz, Senior Project Engineer (Team Lead)
S. Morrow, Human Factors Engineer (Lead Safety Culture Assessor)
D. Willis, Allegations Team Leader
M. Checkle, Senior Allegation Coordinator
N. Coovert, Senior Construction Inspector
G. Smith, Senior Resident Inspector Sequoyah
Approved by:
Alan Blamey, Branch Chief, Reactor Projects Branch 6 Division of Reactor Projects
SUMMARY OF FINDINGS
IR 05000390/2016007; 05000391/2016007; September 12 - 15, 2016; Watts Bar, Units 1 and 2; Biennial Inspection of the Problem Identification and Resolution Program.
This inspection constituted the first part of the biennial inspection of the Problem Identification and Resolution Program and was conducted by a senior project engineer, senior resident inspector, human factors engineer, an allegations team leader, senior allegations coordinator, and a senior construction inspector. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process.
REPORT DETAILS
OTHER ACTIVITIES
4OA2 Problem Identification and Resolution
.1 Safety-Conscious Work Environment
a. Background
In a letter dated March 23, 2016, the NRC issued a Chilling Effect Letter (CEL) to the Watts Bar Nuclear Plant entitled, Chilled Work Environment for Raising and Addressing Safety Concerns at the Watts Bar Nuclear Plant, (ML16083A479). The NRC concluded that a chilled work environment existed in the Operations department because of a perception that operators were not free to raise safety concerns using all available avenues without fear of retaliation. Additionally, Region II identified and documented a safety conscious work environment (SCWE) cross-cutting theme during the 2016 mid-cycle assessment, due to the issuance of the CEL and a violation with a cross-cutting aspect in the SCWE cross-cutting area (Inspection Report 05000390/2016001; ML16098A323).
As part of the follow-up to the work environment issues, the NRC elected to include an assessment of the SCWE attribute of a licensees safety culture using inspection procedure (IP) 93100, Safety Conscious Work Environment Issue of Concern Follow-up.
As described in IP 93100, A safety conscious work environment (SCWE) is defined as an environment in which employees are encouraged to raise safety concerns, are free to raise concerns both to their own management and to the NRC without fear of retaliation, where concerns are promptly reviewed, given the proper priority, and appropriately resolved, and timely feedback is provided to those raising concerns. In contrast, a chilled work environment is one in which employees perceive that raising safety concerns to their employer or to the NRC is being suppressed or is discouraged and can occur because of an event, interaction, decision, or policy change.
b. Inspection Scope
The inspection was performed in accordance with IP 93100, Safety Conscious Work Environment Issue of Concern Follow-up, and other IPs as referenced by IP 93100.
The objectives of the inspection were to determine whether interim actions have improved the work environment in the Operations department since the CEL; if indications of a chilled work environment exist in other departments; if employees are reluctant to raise nuclear safety or regulatory issues; and if employees are being discouraged from raising nuclear safety or regulatory issues.
Specifically, the inspection team performed semi-structured interviews and focus groups using questions designed to address four primary elements of a SCWE:
1) employees willingness to raise concerns and whether managements behaviors encourage them to do so; 2) employees perception of the effectiveness of the corrective action program as the primary avenue to raise concerns; 3) employees perception of the effectiveness of an alternative program if one exists, such as an employee concerns program (ECP); and 4) employees perception of the effectiveness of management actions to detect and prevent retaliation and chilling effects.
The inspection team conducted 17 focus groups and 22 interviews with the licensees staff and key management. For the focus groups, the inspection team randomly selected 10 to 20 percent of employees from the following departments: Operations, Engineering, Maintenance, Work Management, Security, Chemistry, Radiation Protection, and Training. Each focus group consisted of employees at the same organizational level and from the same department. A total of 136 employees participated in the focus groups and interviews. The information from the focus groups, interviews, and document reviews were organized into the themes that are discussed in this report.
c. Observations
1) General
Based on the results of the interviews and focus groups, the inspection team identified deficiencies in the safety conscious work environment across multiple departments.
Although nearly all employees indicated that they were personally willing to raise nuclear safety concerns, many stated they did not feel free to raise concerns without fear of retaliation. In addition, most employees did not believe that concerns were promptly reviewed or appropriately resolved, either by their management or via the Corrective Action Program.
The inspection team observed that, in some work units, employees expressed a clear distinction between their willingness to raise nuclear safety concerns versus non-nuclear safety concerns. While nearly all employees stated that they were willing to raise nuclear safety concerns, many indicated that they would be unwilling to raise concerns that they believed to be unrelated to nuclear safety. Further, most employees did not believe that management would respond to or take action to resolve non-nuclear safety concerns. When questioned about what a non-nuclear safety concern was, employees gave examples of concerns that had potential ties to nuclear safety, such as deficient procedures, work orders that were inappropriately closed before all work was completed, personal safety concerns about working on live systems (e.g., safety systems that remain electrified or pressurized), and long-standing equipment issues. As a result, the inspection team determined that employees used a very narrow definition of nuclear safety when identifying the types of concerns that they were encouraged to raise. The potential negative consequences of making a distinction between nuclear and non-nuclear safety concerns is that employees may self-censor and decide not to raise a concern because they fear retaliation and do not believe it is tied to nuclear safety. The inspection team observed that employees perceptions about how management would respond to a concern, and whether the concern would be resolved in a timely manner, strongly influenced their overall willingness to raise any concerns.
2) Response to Chilling Effect Letter
When asked about the chilling effect letter, all employees indicated that they had received communications from management explaining the letter. Many employees expressed disappointment in the initial communications from management, which seemed to downplay the issue by focusing on the perception of a SCWE problem.
However, employees noticed a shift in the tone of more recent communications, which suggested management ownership for the chilled work environment in Operations and commitment to address work environment issues across the entire site. Most employees also indicated that they are cautiously optimistic about the recent management changes. However, employees were not generally aware of specific actions to address the root causes of the chilled work environment beyond recent management changes and increased communications.
Multiple focus groups expressed skepticism about the sustainability of positive changes in the work environment, particularly given their experiences with frequent management changes. While staff had noted increased communications, the information provided was not always seen as open and honest. For instance, communications were seen as incomplete, often over-emphasizing positives, and down-playing challenges. Employees noted that the incomplete communications gave the impression that management was controlling the story, which contributed to a lack of trust in management. Some groups felt they had no basis to judge whether positive changes would last, and noted that the next planned outage in Spring 2017 would be an effective indicator of whether there have been true changes in the work environment. Multiple groups observed that the safety conscious work environment is particularly challenged during outages because of the added schedule pressure.
3) Environment for Raising Concerns
Most licensed operators in both interviews and focus groups reported slight improvements in the work environment since the CEL, and expressed that they felt free to execute their duties without undue external pressure. However, many employees, including licensed operators, believed that retaliation for raising safety concerns has occurred in the past, and therefore remained cautious when deciding when and how they would raise concerns. Many based this belief on management actions they considered to be retaliatory in nature. Employees provided examples of dismissive, disrespectful, or blaming behaviors that did not encourage the raising of concerns. In spite of this, most employees stated they would raise nuclear safety concerns.
The inspection team observed a lack of trust between employees and management regarding their environment for raising concerns, particularly beyond the level of first line supervision. While most employees felt free to raise issues to their first line supervisor, they would be hesitant to raise concerns to middle or upper management. In addition, employees did not feel that first line supervision was supported by upper management.
For example, some employees believed that first line supervisors who regularly raised concerns up their management chain were subject to ridicule from higher levels of management and received more negative performance appraisals.
Many employees noted that the continuous turnover and rotation of managers had created instability in their departments. Employees from different departments provided examples of having from six to sixteen different managers in the past six years. Most employees expressed frustration with the frequent management changes because they felt it led to changing priorities and a lack of long-term accountability. For example, employees indicated that because managers would not remain in a position for a long period of time they could make decisions that prioritized short-term gains over long-term improvements. Other examples included beliefs that managers were more concerned with meeting metrics and production goals than fully addressing issues with degraded equipment, ensuring procedures were updated, or improving work processes. The lack of management visibility or development of relationships with employees had also contributed to a lack of trust between management and staff.
4) Other Safety Culture Observations
In addition to questions regarding the environment for raising concerns, the inspection team asked questions related to other traits of a positive safety culture, such as decision making, questioning attitude, problem identification and resolution, and work processes.
The team sought to determine the extent to which weaknesses in other safety culture traits may be driving the identified deficiencies in the safety conscious work environment.
Most employees indicated that they have the authority to stop work and expressed a willingness to stop when they believed the work to be unsafe or work instructions were unclear. However, most employees also noted that there was a strong sense of production over safety throughout the organization. Many employees expressed the opinion that if they raised issues that would disrupt critical path activities then they would be viewed negatively by management. Focus group participants provided examples of disrespectful behavior, intimidation and shopping around work to other employees or contractors who would be less likely to raise issues.
When asked about the Corrective Action Program (CAP), all focus groups stated that they could enter issues into the CAP; however, most believed the CAP was ineffective at resolving issues. The CAP was characterized as a problem identification, but not a problem resolution tool. Employees expressed frustration with the lack of feedback, and issues that were closed to trend or repeatedly deferred.
5) Employee Concerns Program
Most employees stated that they were aware of the Employee Concerns Program.
However, many employees were not aware or did not perceive ECP as independent from management. Some employees did not believe that management would take action to resolve issues identified through ECP.
Most employees stated that they can be open and honest when participating in ECP surveys and other safety culture assessments. However, the inspection team noted that many employees were not able to differentiate between the different safety culture assessments that they take. For example, ECP pulsing surveys were often confused with other surveys that ask similar questions about safety culture and SCWE, but also required employees to report identifying information such as their work unit, tenure, age range, and gender. As a result, the ECP pulsing surveys were not viewed as anonymous, which also affected employees overall perception of the ECP. In addition, most employees did not recall communications regarding the results of the assessments, or saw changes made to the work environment prior to the next assessment. This created a continuous cycle of employees providing feedback but not seeing any action as a result of that feedback. Such action can discourage continued employee engagement and is interpreted by employees to mean management is not supportive of employees raising any concerns, including nuclear safety concerns.
6) Nuclear Safety Culture Monitoring Panel
The team interviewed multiple members of the Nuclear Safety Culture Monitoring Panel (NSCMP), and all members reported improvements in recent meetings of the NSCMP.
For example, after the CEL the panel met monthly rather than quarterly to provide more timely reviews of safety culture trends. Panel members also reported more engagement during meetings, and the addition of craft level employees rather than just management at the meetings to provide additional insights regarding the work environment in different departments.
However, from the inspection teams review of the NSCMP procedures and meeting minutes from 2014 through August 2016, the NSCMP did not appear to be self-critical of key safety culture traits that were precursors for the issues that led to the chilled work environment in Operations. Specifically, the team noted that the safety culture trait, leadership safety values and actions, was only identified as an improvement opportunity on two occasions since 2014. On both occasions, the trait was rated as an improvement opportunity due to issues identified by external organizations (e.g., Quality Assurance and Institute of Nuclear Power Operations). Further, the leadership safety values and actions trait has remained acceptable since fourth quarter of 2015, yet leadership deficiencies were identified as a root cause of the chilled work environment in Operations in early 2016. This suggested that the NSCMP may have difficulty self-identifying safety culture issues, particularly when the source relates to leadership behaviors.
The inspection team also observed considerable fluctuations in the NSCMP ratings of safety culture from meeting to meeting, primarily based on recent examples of positive or negative performance. For example, the NSCMP rated the safety culture trait, environment for raising concerns as a strength in November 2015, during the same time period that the chilled work environment developed in the Operations department.
Since that time period, the environment for raising concerns trait has been rated as acceptable during multiple meetings, including the NSCMP meeting immediately before the chilling effect letter was issued (March 2016) and the meeting two months after the chilling effect letter (May 2016). This gives the impression that the NSCMP believed the site had resolved the issues associated with the environment for raising concerns in May 2016. The rating of acceptable was based in part on pulsing survey results, which showed that high percentages of employees were willing to raise concerns. However, the data did not indicate whether employees feel encouraged to raise concerns, whether they believe they may be retaliated against for raising concerns, or whether employees believed concerns will be appropriately addressed and resolved.
The inspection team observed that NSCMP members have not received specialized training regarding how to draw conclusions about safety culture. Given the fluctuations in the safety culture ratings, it was not clear that the NSCMP members shared a common understanding of the nuclear safety culture standards they were trying to achieve when assessing whether a safety culture trait was a strength, acceptable, or an improvement opportunity. As a result, the inspection team did not have confidence that the NSCMP provided an accurate snapshot of the safety culture at the site, or that the NSCMP would be able to detect and correct a gradually declining safety culture prior to the development of a chilled work environment.
7) Summary
Based on the inspection teams limited assessment, the licensees safety culture and safety conscious work environment were not consistent with the Commission's expectations as described in the Safety Culture and SCWE Policy Statements (76 FR 34773, June 14, 2011; 61 FR 24336, May 14, 1996). There were strong indications that similar stressors and precursors that allowed the chilled work environment to develop in the Operations department also existed in other departments. These underlying issues included perceptions that decision making favored production over safety, lack of effective problem resolution, lack of trust between management and staff, and beliefs that employees who raised concerns, including nuclear safety concerns, were at risk of being retaliated against for doing so. At the time of the inspection, most employees noted slight improvements in the work environment since the issuance of the CEL, and licensed operators reported that they felt free to execute their duties. However, the interviews and focus groups indicated deficiencies in the SCWE, specifically ensuring management behaviors encouraged the raising of concerns, the effectiveness of the CAP and ECP for resolving concerns, and the effectiveness of management actions to detect and prevent retaliation and chilling effects.
4OA6 Meetings, Including Exit
On September 15, 2016, the inspectors presented the inspection results to Mr. Simmons and other members of the site staff.
ATTACHMENT:
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee personnel
Gordon Arent, Licensing Manager
NRC personnel
Jared Nadal, Senior Resident Inspector
LIST OF REPORT ITEMS
None