The Nuclear Regulatory Commission (NRC) issued a Chilled Work Environment Letter to the Tennessee Valley Authority (TVA) on March 23, 2016, about safety culture problems at the Watts Bar nuclear plant. TVA promised to take steps to restore a proper safety culture at the plant.
Nearly 13 months later, has a proper safety culture been restored at Watts Bar?
No, according to a report issued April 19, 2017, by the TVA Office of the Inspector General (TVA OIG).
Fig. 1. (Source: D. Lochbaum)
The TVA OIG report paints a very disturbing picture of conditions at Watts Bar. I monitored safety culture problems at Millstone (1996-2000), Davis-Besse (2002-2004), and Salem/Hope Creek (2004-2005). The problems described in the TVA OIG report are comparable to the unacceptable conditions that existed at Millstone and Davis-Besse. A difference is that the NRC did not allow Millstone or Davis-Besse to operate until those safety culture problems were corrected to an acceptable level.
The TVA OIG report explains why TVA keeps reporting that the chilled work environment at Watts Bar was confined to the Operations Department and did not contaminate other work organizations at the site: The TVA Office of the General Counsel instructed the Employee Concerns Program and others within TVA not to use “chilled work environment” and to use “degraded work environment” instead. So, while TVA cannot find chilled work environments outside Operations, they find “degraded work environments” almost every place they look. But through an artifice of semantics conjured up by TVA’s attorneys, no chilled work environments are being found.
The TVA OIG didn’t buy the semantics: “Additionally, when 75 percent of a work group at a nuclear utility perceives that they are working in a chilled environment as is the case with ECP at TVA, it would seem reasonable to conclude that there is a chilled work environment in that group and unreasonable to pass it off as a ‘degraded work environment’.”
How bad is the chilled work environment at Watts Bar? The TVA OIG report indicates that 75% of the Employee Concerns Program (ECP) staff did not feel safe to raise concerns without fear of retaliation. ECP is supposed to be the organization that workers with safety concerns can go for help resolving them. When the helpers feel chilled, how can they truly help workers?
The ECP hired two individuals from outside TVA in February 2016 to conduct an independent investigation of the work environment at Watts Bar. According to the TVA OIG, this investigation was independent and forthright, but the ensuing report was anything but independent. The TVA OIG reviewed emails and interviewed the independent investigators and found that “the term ‘chilled work environment’ was edited out of the text of the report by ECP personnel.” In fact, the independent investigators did not write the six-page Executive Summary for “their” report—ECP wrote it. ECP wrote that a “degraded work environment” rather than a “chilled work environment” existed at Watts Bar. TVA OIG reported being unable to find “degraded work environment” being used within TVA or elsewhere prior to this “independent” report.
One of the two independent investigators told the TVA OIG that TVA management “did not like the fact that he stated that TVA management contributed to the poor SCWE [safety conscious work environment]” at Watts Bar. He was not invited back to participate in subsequent debriefing activities which “he attributed to management’s reaction to his report-out to them of the results from Phase I.” In other words, TVA shot the messenger.
The TVA OIG report states that “both the independent investigation commissioned by TVA and the SRTR [Special Review Team Report] were inappropriately influenced by TVA management” and that “the independent investigators were told by TVA ECP what they could and could not put in their report and the Executive Summary of that report was written by ECP, not the independent investigators.”
As to whether the chilled work environment issues were confined to the Operations Department, “Through personnel interviews conducted by OIG investigators, it was learned that many instances of HIRD [harassment, intimidation, retaliation, and/or discrimination] have occurred or have been alleged to have occurred in Operations and in other departments at WBN [Watts Bar Nuclear].” More specifically, surveys conducted during 2016 after workers raised concerns that led to the NRC’s Chilled Work Environment Letter being issued reveal safety culture issues outside of the Operations Department at Watts Bar.
Maintenance Department: 36% of workers feel free to report problems and concerns. 55% of workers believe they could report problems and concerns without fear of retaliation. 91% of the workers witnessed behavior contrary to a healthy nuclear safety culture.
Chemistry Department: 50% of workers feel free to report problems and concerns. 50% of workers believe they could report problems and concerns without fear of retaliation. 50% of the workers witnessed behavior contrary to a healthy nuclear safety culture.
Security Department: 34% of workers believe they could report problems and concerns without fear of retaliation. 67% of the workers witnessed behavior contrary to a healthy nuclear safety culture.
Engineering Department: 67% of workers believe they could report problems and concerns without fear of retaliation. 66% of the workers witnessed behavior contrary to a healthy nuclear safety culture.
Radiation Protection Department: 78% of the workers witnessed behavior contrary to a healthy nuclear safety culture.
The TVA OIG explicitly states “TVA’s continuing denials have been found to be incorrect by the NRC and independent assessors: a chilled work environment exists in at least several departments at WBN and within the ECP program itself.”
The TVA OIG makes an interesting observation regarding the 51 actions that TVA identified as necessary to correct the problems expressed in the NRC’s Chilled Work Environment Letter—none of them pertain to TVA’s upper management. The TVA OIG states “It is certainly worth considering whether this might be at least a contributor, if not a root cause, of the failure of any of the CAPRs [corrective actions to prevent recurrence], remediation plans, and the like to correct the continuing recurrence of chilled work environments at TVA over the past decade.” Indeed!
Watts Bar Needs a Proper Safety Culture
The TVA OIG report makes it extremely clear that Watts Bar lacks a proper safety culture and that lack is broader than just within the Operations Department.
Watts Bar needs a proper safety culture because it is the fundamental foundation for nuclear safety overall. If workers do not raise safety concerns—either out of fear of retaliation or out of distrust that management will correct them—the inventory of unresolved safety concerns increases over time. Nuclear power plants are robust and require a large number of failures and malfunctions before an incident morphs into a disaster. The rising number of unresolved safety concerns reduces the number of failures needed to facilitate such transformations.
Proper safety cultures cannot be acquired from eBay or Amazon. Senior managers must make it happen. If TVA’s senior managers can’t or won’t make it happen, either TVA needs new senior managers or NRC needs to write TVA another letter—a stronger letter perhaps along the lines of a Show Cause Order compelling TVA’s lawyers to explain why Watts Bar can continue to operate safely with “degraded work environments” all over the site.
In the meantime, if Watts Bar experiences a disaster, it won’t be an accident. It’ll be an outcome of operating a nuclear power reactor with a safety culture documented to be woefully inadequate.