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7 LESSONS LEARNED: NUCLEAR SAFETY CULTURE The final chapter of this report focuses on the nuclear safety culture in Japan and lessons- learned for the United States. Safety culture is not an explicit element of the statement of task for this study (see Box 1.1 in Chapter 1). Nevertheless, the committee quickly came to understand that the lack of a strong nuclear safety culture was an important contributing factor to the Fukushima Daiichi accident. The committee also came to appreciate the important role that nuclear safety culture plays in nuclear plant operations and regulations in the United States. This chapter is organized into four sections: Section 7.1 describes the nuclear safety culture concept. Sections 7.2 and 7.3 describe and discuss the nuclear safety cultures in Japan and the United States, respectively. Section 7.4 provides two committee recommendations. 7.1 BACKGROUND ON NUCLEAR SAFETY CULTURE The term nuclear safety culture combines two concepts: safety and culture:  Safety is protection from harm and can be defined in terms of risk: an activity is considered to be safe when its associated risks are being controlled to acceptable levels.  Culture comprises the collective beliefs, values, and behaviors of individuals belonging to an organization (e.g., a company). It includes behavioral norms, shared attitudes, shared traditions, and mechanisms for incentivizing and reinforcing desired behaviors. Safety is considered to be an inviolable constraint and part of the social contract under which nuclear plants are allowed to operate. The shared responsibilities for nuclear plant safety are described in Sidebar 7.1. For purposes of this report, safety culture is perhaps best understood as those organizational processes that ultimately influence and reinforce an organizational culture that emphasizes safety. Taken together, these processes create a continuous desire for improvement that is fueled by individuals who, in turn, find motivation from the organization’s safety culture (Guldenmund, 2010). The safety culture concept was first applied to the nuclear power industry by the International Atomic Energy Agency’s (IAEA’s) International Nuclear Safety Advisory Group (INSAG, 1986). The term was used to explain how the lack of knowledge about risk and safety and failure to act appropriately contributed to the Chernobyl accident. According to this group (INSAG, 1992, p. 23-24), the Chernobyl accident was caused by a “deficient safety culture at Chernobyl and throughout the Soviet design, operating and regulatory organizations.” Prepublication Copy 7-1

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Chapter 7: Nuclear Safety Culture The use of the term by the U.S. Nuclear Regulatory Commission (USNRC) developed from a 1989 policy statement issued in response to unprofessional conduct and operator inattentiveness in nuclear plant control rooms.1 The statement stresses that management at nuclear power plants (p. 3425): “… has a duty and obligation to foster the development of a ‘safety culture’ at each facility and provide a professional work environment in the control room and throughout the facility.” The USNRC published a formal safety culture policy statement in 2011.2 That statement defines a nuclear safety culture as the “… core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment.” USNRC has taken the position that safety culture applies to all licensees, including nuclear plant operators. The Institute of Nuclear Power Operations (INPO; see Sidebar 7.2) has published guidance on the nuclear safety culture for the U.S. power industry (INPO, 2013). That guidance notes (ibid, p.6) that “… nuclear safety is a collective responsibility. The concept of nuclear safety culture applies to every employee in the nuclear organization, from the board of directors to the individual contributor. No one in the organization is exempt from the obligation to ensure safety first.” In its final safety culture policy statement (see Footnote 2 in this chapter), the USNRC notes that assessments of incidents involving U.S. civilian uses of nuclear materials demonstrate that significant mistakes occur when safety culture is weak. To prevent accidents from developing into severe core damage events, and to prevent large scale, long term contamination, the importance of maintaining high safety culture standards cannot be overemphasized (Hogberg, 2013). The IAEA promotes the development of a nuclear safety culture through workshops, written guidance, and peer review. The IAEA has also published guidance on enhancing the safety culture in nuclear installations (IAEA, 2002). The agency cautions (p. 3) that “The biggest danger in trying to understand culture is to oversimplify it in our minds. It is tempting to say that culture is just ‘the way we do things around here’, or ‘our basic values’, or ‘our rituals’, and so on. These are all manifestations of the culture, but none is the culture at the level that culture matters. A better way to 1 Policy Statement on the Conduct of Nuclear Power Plant Operations, 54 Federal Register 3424, 24 January 1989. Available at http://www.nrc.gov/reading-rm/doc-collections/commission/policy/54fr3424.pdf 2 Final Safety Culture Policy Statement, 76 Federal Register 34773, June 2011. Available at http://www.gpo.gov/fdsys/pkg/FR-2011-06-14/html/2011-14656.htm Prepublication Copy 7-2

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Chapter 7: Nuclear Safety Culture think about culture is to realize that it exists at several ‘levels’ and that we must endeavor to understand the different levels, but especially the deeper levels.” There is international acceptance by the nuclear power community that a strong nuclear safety culture needs to be adopted universally: by senior management of organizations operating nuclear power plants; by individuals who work in those plants; and by regulatory bodies and other organizations that set nuclear power policies. Indeed, this commitment to safety is an international priority, as evidenced by treaties such as the Convention on Nuclear Safety.3 7.1.1 Regulatory Independence To establish a strong nuclear safety culture, it is not enough for nuclear plant operators to adopt a safety culture: The establishment, implementation, and maintenance of a robust nuclear safety culture are also dependent on a strong and independent regulator. Noggerath et al. (2011, p. 45) notes that “A well established national safety culture depends not only on nuclear operators to meet the highest standards, but also on a nuclear authority to keep the national requirements updated and to require modernization of plants when necessary.” A Nuclear Energy Agency report asserts that (NEA, 1999, p. 11) “The nature of the relationship between the regulator and the operator can influence the operator’s safety culture at a plant either positively or negatively. In promoting safety culture, a regulatory body should set a good example in its own performance. This means, for example, the regulatory body should be technically competent, set high safety standards for itself, conduct its dealings with operators in a professional manner and show good judgment in its regulatory decisions.” The principle of “effective independence,” as explained by the IAEA, defines the international nuclear communities’ commitment to strong and effective regulation (IAEA, 2010, p. 6-7): “The government shall ensure that the regulatory body is effectively independent in its safety related decision making and that it has functional separation from entities having responsibilities or interests that could unduly influence its decision making.” “To be effectively independent, the regulatory body shall have sufficient authority and sufficient staffing and shall have access to sufficient financial resources for the proper discharge of its assigned responsibilities. The regulatory body shall be able to make independent regulatory judgments and decisions, free from any undue influences that might compromise safety, such as pressures associated with 3 See especially Articles 8, 10 – 14. The treaty text is available at http://www.iaea.org/Publications/Documents/Infcircs/Others/inf449.shtml. The United States and Japan have ratified this treaty. Prepublication Copy 7-3

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Chapter 7: Nuclear Safety Culture changing political circumstances or economic conditions, or pressures from government departments or from other organizations. Furthermore, the regulatory body shall be able to give independent advice to government departments and governmental bodies on matters relating to the safety of facilities and activities.” “No responsibilities shall be assigned to the regulatory body that might compromise or conflict with its discharging of its responsibility for regulating the safety of facilities and activities.” Effective independence means that the nuclear regulatory body must be able to make decisions and perform its duties without undue pressure or constraints from the government, organizations that promote nuclear power, or organizations opposed to nuclear power (Bacon- Dussault, 2013). While regulators need to be independent of the organizations they regulate, they must exercise their regulatory authority in ways that support robust programs at nuclear power plants to identify and correct problems before they become significant safety issues. For example, a nuclear power plant in the United States can log over 100 “problems” daily requiring some sort of corrective action, but many of these problems typically have low safety significance. A system that encourages problem identification, reporting, and correction will operate most effectively when regulatory agencies use sound judgment to prioritize reported problems according to their safety significance. Plant operators will be more willing to disclose small problems—which can be caught and corrected before they become significant—when they understand that regulators will exercise their regulatory authority fairly. 7.2 NUCLEAR SAFETY CULTURE IN JAPAN FINDING 7.1: While the Government of Japan acknowledged the need for a strong nuclear safety culture prior to the Fukushima Daiichi accident, TEPCO and its nuclear regulators were deficient in establishing, implementing, and maintaining such a culture. Examinations of the Japanese nuclear regulatory system following the Fukushima Daiichi accident concluded that regulatory agencies were not independent and were subject to regulatory capture. The Government of Japan acknowledged the need for a strong nuclear safety culture by entering into the Convention on Nuclear Safety. Preamble clause iv and Article 10 of the Convention note that “Each Contracting Party shall take the appropriate steps to ensure that all organizations engaged in activities directly related to nuclear installations shall establish policies that give due priority to nuclear safety.” The Government of Japan also confirmed the priority of safety in its reporting to the IAEA on implementation of the Convention (Government of Japan, 2004, 2007, and 2010). These reports are a rich source of information about the status of Japanese efforts to implement a safety culture prior to the March 11, 2011, Fukushima Daiichi accident. Prepublication Copy 7-4

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Chapter 7: Nuclear Safety Culture The safety culture deficiencies at TEPCO and its regulator that contributed to the Fukushima Daiichi accident have been explicitly acknowledged in Japanese government reports (e.g., Government of Japan, 2011a,b; NAIIC, 2012). For example, NAIIC chairman Dr. Kiyoshi Kurokawa concluded (NAIIC, 2012, p. 9) that the “… accident at the Fukushima Daiichi Nuclear Power Plant cannot be regarded as a natural disaster. It was a profoundly manmade disaster—that could and should have been foreseen and prevented.” Dr. Kurokawa also commented on the mindset that led to the accident (ibid): “… nuclear power became an unstoppable force, immune to scrutiny by civil society. Its regulation was entrusted to the same government bureaucracy responsible for its promotion…. Only by grasping this mindset can one understand how Japan's nuclear industry managed to avoid absorbing the critical lessons learned from Three Mile Island and Chernobyl; and how it became accepted practice to resist regulatory pressure and cover up small-scale accidents. It was this mindset that led to the disaster at the Fukushima Daiichi Nuclear Plant.” TEPCO has acknowledged that it was ill-prepared for the March 11, 2011, earthquake and tsunami-induced flooding that occurred at the Fukushima Daiichi and Daini plants4: “Top management of [the] nuclear division did not show strong willingness in enhancing plant safety against external events even in a step-by-step manner…. They were stuck on probability of risk and did not have [a] clear idea to take practically effective countermeasures against external events in a timely manner…. Top management of nuclear division and safety experts did not try to face [the] regulatory body and the public squarely.” Chapters 3 and 4 of this report describe TEPCO’s preparation for and response to the earthquake and tsunami. On paper, TEPCO and its nuclear regulator were committed to a nuclear safety culture prior to the Fukushima Daiichi accident. However, there is strong evidence for a deficient safety culture in both of these organizations:  As noted in Chapter 3, for example, TEPCO and its nuclear regulator failed to take strong and timely action to implement improved seismic and tsunami safety standards for the Fukushima plants.  As noted in Chapters 2 and 4, Japanese regulatory agencies did not inform utilities of the USNRC’s B.5.b requirements for responding to beyond-design-basis events even after the USNRC made them public. TEPCO also failed to inform itself of these B.5.b requirements after they became public. 4 The quoted material is taken from slides presented to the committee by Mr. Akira Kawano (TEPCO) on November 26, 2012 (Kawano, 2012). Prepublication Copy 7-5

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Chapter 7: Nuclear Safety Culture  TEPCO has admitted to falsifying reports to its regulator in 29 cases between 1988 and 1998 and to frauds in safety-related inspections at the Fukushima Daiichi plant in 1993- 1994. Taken together, these examples provide evidence of a continuing lack of safety focus in the period prior to the Fukushima Daiichi accident. 7.2.1 Regulatory Capture The term regulatory capture refers to the processes by which regulated entities manipulate regulators to put their interests ahead of public interests (see Bratton and McCahery, 1995; Dal Bó, 2006; Helm, 2006.) In the context of this report, regulatory capture refers specifically to the manipulation of the NISA before the accident and therefore before regulatory restructuring. The problem with regulatory capture of NISA was highlighted by NAIIC, 2012 (p. 20): “The [Japanese] regulators did not monitor or supervise nuclear safety. The lack of expertise resulted in “regulatory capture,” and the postponement of the implementation of relevant regulations. They avoided their direct responsibilities by letting operators apply regulations on a voluntary basis.” The report also noted (p. 20) that TEPCO “manipulated the cozy relationship with the regulators to take the teeth out of regulations.” A commissioner of Japan’s new nuclear regulator, the Nuclear Regulation Authority (NRA; see Chapter 2), confirmed to U.S. Government Accountability Office investigators that regulatory capture existed prior to the Fukushima Daiichi accident (USGAO, 2014, p. 16): “An NRA commissioner told us that Japan’s restructuring of its nuclear regulatory system is necessary to address the issue of “regulatory capture”—the collusion between NISA and the nuclear industry—that compromised the nation’s nuclear safety prior to the accident and to regain the public trust, which the commissioner told us was NRA’s biggest challenge.” Prior to the Fukushima Daiichi accident, the NISA was part of the Ministry of Economy, Trade and Industry5 (METI), an aggressive advocate for promotion of nuclear power in Japan and abroad. The Japanese government contended that this association did not affect NISA’s independence (Government of Japan, 2004, page 8-1): “NISA has clear responsibilities for safety regulations pursuant to the Atomic Energy Basic Law and the Reactor Regulation Law and the functions of NISA are substantially separated, by the law, from those of other bodies or organizations concerned with the promotion or utilization of nuclear energy.” 5 Formerly the Ministry of International Trade and Industry. Prepublication Copy 7-6

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Chapter 7: Nuclear Safety Culture Nevertheless, analysts who have studied Japan’s regulatory structure have shown that Japanese nuclear safety regulators were subject to regulatory capture prior to the Fukushima Daiichi accident. These analysts have noted that METI’s dual and conflicting interests seem at odds with NISA’s mission to regulate nuclear power reactors (Dorfman, 2012; Wang and Chen, 2012; Aoki and Rothwell, 2013). METI was ultimately in charge of issuing licenses to Japanese nuclear plants. Kaufmann and Penciakova (2011) suggest that “To a significant extent, it appears that regulatory capture of NISA by Japan’s nuclear industry turned the regulator into a caretaker of industry rather than one for public safety.” NISA’s lack of regulatory independence has been described as a significant problem in regulatory practice (Wang and Chen, 2012; Benz, 2013; Dorfman, 2012). Analysts have described two practices that hindered effective regulatory control and impeded the implementation of a strong nuclear safety culture (Aoki and Rothwell, 2013; Dorfman, 2012; Wang and Chen, 2012). These are referred to as amakudari and amaagari (Wang and Chen, 2012; Wang et al., 2013; see also Schaede, 1995):  Amakudari means “descent from heaven” and it refers to the practice of hiring retired, high-profile public officials for private-sector jobs (Horiuchi and Shimizu, 2001; Dorfman, 2012; Wang and Chen, 2012). It also refers to the practice of maintaining a rigid hierarchy in nuclear utilities and regulatory agencies whereby when a senior-level person retires his junior would take his place (Wang and Chen, 2012).  Amaagari means “ascent to heaven” and is the movement of experts from the private sector into government or government advisory positions (Wang and Chen, 2012). Expertise in the nuclear energy technologies is difficult to obtain, so it was frequently necessary for the Japanese government and industry to take advantage of each other’s technical knowledge. It was not unusual for nuclear experts to move between the nuclear industry and its regulator during the course of their careers. However, the practices of amakudari and amaagari worked together to create a system that integrated the interests of the Japanese industry and regulators to produce a system that was insular, lacking in transparency, and difficult to improve. Wang and Chen (2012, p. 2613) assert that the nuclear regulator placed an overreliance on the technical expertise of the nuclear industry in designing and evaluating regulations: “Japan’s safety rulemaking is deeply flawed. Because NISA lacks full-time technical experts to draw up comprehensive regulations, it depended largely on retired or active engineers from nuclear-industry-related companies to set rulemaking.” Prior to the Fukushima Daiichi accident, Japanese government officials, the nuclear power industry, and regulators consistently argued that nuclear power was completely safe. This “safety myth” stifled an honest and open discussion about risks (Noggerath et al., 2011). 7.2.2 Changes Following the Fukushima Daiichi Accident The Japanese government called for a stronger emphasis on safety culture following the Fukushima Daiichi accident (Government of Japan, 2011a, p. XII-13, emphasis added): Prepublication Copy 7-7

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Chapter 7: Nuclear Safety Culture “All those involved with nuclear energy should be equipped with a safety culture … Learning this message and putting it into practice is a starting point, duty and responsibility of those who are involved with nuclear energy. Without a safety culture, there will be no constant improvement of nuclear safety.” The government has taken a series of actions to improve its regulatory institutions and its commitment to nuclear safety. Most notably, the government established6 a new regime for regulating civilian nuclear power (See Chapter 2, especially Figure 2.12). This regime includes the NRA as an extra-ministerial organization of the Environment Ministry. This agency combines the roles of the former Nuclear Safety Commission and NISA as well as the monitoring functions of MEXT. The NRA is responsible for promulgating rules and regulations for nuclear plants and is also charged with evaluating whether current Japanese plants can resume operations (Bacon- Dussault, 2013; Ferguson and Jansson, 2013; Geller, 2014). The Authority has been established as an “Article 3” organization under Japanese law, which means that it has greater independence than NISA (Shiroyama, 2012). The Japanese government is taking at least two additional steps to improve the effective independence of Japanese regulation of nuclear power:  Not allowing senior-level regulators from the Nuclear Regulation Authority to assume jobs in METI or MEXT; and  Limiting the ability of regulators from seeking jobs in the nuclear industry. The committee was not tasked to evaluate the effectiveness of this new regulatory structure. Nevertheless, past history suggests that Japan’s new regulatory organizations are unlikely to be effective unless they establish and closely adhere to good safety culture practices. Discussions involving the new Japanese regulatory structure and its effectiveness continue as Japan considers the restart of some of its nuclear reactors (Geller, 2014). 7.3 NUCLEAR SAFETY CULTURE IN THE UNITED STATES FINDING 7.2: The establishment, implementation, maintenance, and communication of a nuclear safety culture in the United States are priorities for the U.S. nuclear power industry and the U.S. Nuclear Regulatory Commission. 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. 6 Nuclear Regulatory Commission Establishment Act, June 2012. Prepublication Copy 7-8

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Chapter 7: Nuclear Safety Culture 7.3.1 U.S. Nuclear Regulator The USNRC regulates the commercial uses of nuclear material, including nuclear power, to protect people and the environment. The agency has documented its expectations for the nuclear safety culture in a series of policy pronouncements, including a 1989 Policy Statement on the Conduct of Nuclear Power Plant Operation (see Footnote 1 in this chapter). The policy statement declares that (p. 3425) “Each individual licensed by the [US]NRC to operate the controls of a nuclear power reactor must be keenly aware that he or she holds the special trust and confidence of the American people, conferred through the [US]NRC license, and that his or her first responsibility is to assure that the reactor is in a safe condition at all times.” In 2011, after a public input process, the USNRC published a Final Safety Culture Policy Statement (see Footnote 2 in this chapter) that establishes nine traits of a positive safety culture: 1. Leadership Safety Values and Actions: Leaders demonstrate a commitment to safety in their decisions and behaviors. 2. Problem Identification and Resolution: Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. 3. Personal Accountability: All individuals take personal responsibility for safety. 4. Work Processes: The process of planning and controlling work activities is implemented so that safety is maintained. 5. Continuous Learning: Opportunities to learn about ways to ensure safety are sought out and implemented. 6. Environment for Raising Concerns: A safety conscious work environment is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. 7. Effective Safety Communication: Communications maintain a focus on safety. 8. Respectful Work Environment: Trust and respect permeate the organization. 9. Questioning Attitude: Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. A safety conscious work environment is an important element of a strong nuclear safety culture (see point 6 above). The USNRC defines7 a safety conscious work environment (p. 2) as “an environment in which “employees feel free to raise safety concerns, both to their management and to the [US]NRC, without fear of retaliation.” The safety culture policy statement is not a regulation. Moreover, licensees are not required to adopt it or modify inconsistent practices. The policy statement also does not contain 7 USNRC Regulatory Issue Summary 2005-18 Guidance for Establishing and Maintaining a Safety Conscious Work Environment. Available at http://www.nrc.gov/reading-rm/doc-collections/gen-comm/reg-issues/2005/ri200518.pdf Prepublication Copy 7-9

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Chapter 7: Nuclear Safety Culture specific implementation steps. It leaves implementation to licensees and recommends that implementation begin immediately. The statement clearly sets out the USNRC’s expectation (p.14) “that individuals and organizations performing regulated activities establish and maintain a positive safety culture commensurate with the safety and security significance of their activities and the nature and complexity of their organizations and functions.” The USNRC views its policy statement as a living document and closely monitors actual nuclear power plant events that occur both domestically and internationally. 7.3.2 U.S. Nuclear Industry The U.S. nuclear industry has also demonstrated a clear and strong commitment to nuclear safety. INPO has taken the lead for promoting a strong nuclear safety culture in the U.S. nuclear industry through training and evaluation programs (Sidebar 7.2). The Nuclear Energy Institute, an industry advocacy group, supports INPO’s activities. INPO was established to promote excellence, safety, and reliability in nuclear plant operations (see Sidebar 7.2). The organization strongly endorses the nuclear safety culture as a key operating feature, and philosophy, of its membership (INPO, 2004) and also asserts that every nuclear power station needs a strong safety culture. INPO has established eight key principles that apply to a healthy nuclear safety culture (INPO, 2004, p.1 and 2013, p. 318): 1. Everyone is personally responsible for nuclear safety 2. Leaders demonstrate commitment to safety 3. Trust permeates the organization 4. Decision-making reflects safety first 5. Nuclear technology is recognized as special and unique 6. A questioning attitude is cultivated 7. Organizational learning is embraced 8. Nuclear safety undergoes constant examination INPO’s key principles are slightly different from the USNRC key traits, which were described earlier. This difference is not surprising given that the USNRC traits apply to all of its licensees, whereas INPO is speaking for its membership, which comprises nuclear plant operators. The INPO principles show that implementation of the nuclear safety culture is an organizational obligation that begins at the top of the corporate ladder and applies to every worker at nuclear plants. The principles make clear that the special nature of nuclear power production demands an enhanced level of diligence and that continuous improvement is the expected norm. Organizational learning through continuous training, communications, and discussion is imperative, because highly complex technologies such as nuclear power generation 8 This report contains two addendums: Addendum I: Behaviors and Actions that Support a Healthy Nuclear Safety Culture, by Organizational Level describes nuclear safety behaviors and actions that contribute to a healthy nuclear safety culture by organizational level―executive/senior manager, manager, supervisor, and individual. Addendum II: Cross-References provides cross-references from Traits of a Healthy Nuclear Safety Culture to the safety culture guidance developed by the Department of Energy and the Energy Facility Contractors Group. Prepublication Copy 7-10

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Chapter 7: Nuclear Safety Culture can fail in unexpected and unique ways (INPO, 2004 p. 4-6). The World Association of Nuclear Operators9 has joined INPO in recognizing the centrality of the nuclear safety culture for nuclear plant operations worldwide.10 Nuclear plant owners evaluate their safety cultures using various means. INPO provides biannual evaluations of nuclear plant operations (see Sidebar 7.2). Additionally, plant owners have established safety review groups, usually as a requirement of their USNRC licenses. These groups typically consist of the plant manager, other plant personnel, and members who are independent of the plant or utility. The groups meet at regular intervals to review plant operations from a safety perspective and report their findings to the plant’s senior vice president and other plant management. Some utilities have also voluntarily established high-level independent review groups that visit the plant and report to the utility’s senior management and/or board of directors (INPO, 2005). These groups consist of people who are independent of the plant and utility and typically include people who have served in high level positions in the industry and the USNRC. Efforts are also being made to develop safety culture metrics and relate them to nuclear safety. For example, INPO has developed a questionnaire instrument to measure safety culture at U.S. nuclear plants. It administered the survey to 63 nuclear plants (97 percent of operating plants) with an average of 46 respondents per plant (48 percent response rate). Morrow and Barnes (2012) evaluated the survey results to assess how the safety culture factors identified from the INPO survey relate to safety performance at nuclear plants. They note that (ibid, p. 48) “The overall safety culture survey results were significantly correlated with concurrent unplanned scrams, forced outage hours, inspection findings, and cross- cutting aspects.” But that (ibid, p. 49) “Additional, ongoing research would be necessary to determine whether the relationships observed are consistent over time, whether the same factors consistently emerge in subsequent survey administrations within the nuclear power industry, and whether different safety culture factors are uniquely related to different aspects of performance.” 7.3.3 Discussion Committee members have a range of views about the current status of the nuclear safety culture in the United States. A selection of committee views is provided in this section to frame the committee’s recommendations in Section 7.4. The committee did not undertake a formal 9 WANO is an international not-for-profit organization comprised of nuclear power companies and associated organizations with a mission to promote nuclear safety. 10 WANO Guideline 2006-02, Principles for a Strong Nuclear Safety Culture, January 2006. This report has limited distribution. However, the report’s contents are described in a paper by a WANO staff member. That paper can be accessed at https://gnssn.iaea.org/NSNI/SC/SCPoP/Papers%20prepared%20for%20meeting/Todd%20Brumfield_Evaluation%2 0of%20Safety%20Culture%20in%20WANO%20Pre-Startup%20Reviews_Paper.pdf Prepublication Copy 7-11

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Chapter 7: Nuclear Safety Culture assessment of the status of the U.S. nuclear safety culture because that was not part of its study charge. 7.3.3.1 Independence of the U.S. Regulator Prior to the Fukushima Daiichi accident there were some clear differences between the nuclear regulatory system in Japan and the United States. Prior to 1974, for example, the U.S. Atomic Energy Commission was responsible for both promoting and regulating the use of nuclear power. The U.S. Congress found it in the public interest to segregate these functions into separate agencies. The Energy Reorganization Act of 1974 abolished the U.S. Atomic Energy Commission and reorganized its functions into two new agencies: the USNRC became responsible for the regulation of civilian nuclear activities and the Energy Research and Development Administration (which subsequently became part of the Department of Energy) became responsible for nuclear energy research and promotion. As an independent federal agency, the USNRC is not part of the executive branch of the federal government—although as a matter of policy it generally follows the laws, regulations, and guidance that apply to executive agencies. The USNRC’s authority comes from the statutes enacted by Congress; moreover, the agency is ultimately answerable to Congress, particularly to its authorizing and appropriation committees (Gutierrez and Polonsky, 2007). A recent letter11 from the chair of a Senate congressional committee makes this point clear: “The United States Constitution gives Congress broad authority over Executive Branch agencies like the [US]NRC. As an ‘independent agency’ [US]NRC is independent from the Executive Branch—not Congressional oversight.” The USNRC must also answer to a number of other stakeholders including industry, public interest groups, and communities that host USNRC-regulated facilities. All of these stakeholders seek to influence USNRC actions, which is traditional in the U.S. system of government. The USNRC must take into consideration the preferences of its stakeholders and the broader public while maintaining its independence as a regulator. A recent letter from a House congressional committee stressed the importance of balance in USNRC regulatory decisions12: “In the Atomic Energy Act, Congress declared that nuclear energy should “make the maximum contribution to the general welfare (Section 1 (a))” which recognizes nuclear energy’s vital role in contributing to our nation’s energy security. In choosing such language, Congress endeavored to balance the benefits 11 Letter from Senator Barbara Boxer, Chair of the Senate Committee on Environment and Public Works, to USNRC Chairman Allison Macfarlane, November 26, 2013, concerning a USNRC decision to withhold certain information requested by the committee. Available at http://www.epw.senate.gov/public/index.cfm?FuseAction=PressRoom.PressReleases&ContentRecord_id=94f17a8e -bf47-43f0-5627-96a1508794b7 12 Letter from the House Committee on Energy and Commerce to USNRC Chairman Allison Macfarlane, January 15, 2013. Available at http://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/letters/20130115NRC. Prepublication Copy 7-12

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Chapter 7: Nuclear Safety Culture of nuclear energy with protection of public health and safety. Our goal as legislators and yours as regulators should be to preserve that balance.” The USNRC has had to navigate carefully among competing interests to preserve its regulatory independence. Committee members hold a range of views about whether the USNRC is being successful in maintaining appropriate independence and balance in its regulatory decision making. Some members note that there is a natural tension between the regulator, which ultimately answers to the public and its representatives in Congress, and the regulated industry, which answers to its shareholders. This situation is not unique to the nuclear industry. Regulatory independence necessarily involves the continuous balancing of interests between the public and private spheres. Other committee members point to two specific examples as evidence for the possible erosion of independence: filtered vents and industry participation in the rulemaking process. These examples are described in the following paragraphs. The USNRC is currently involved in a rulemaking to determine whether filtered vents should be added to nuclear plants with Mark I and Mark II containments (see Sidebar 5.5, Appendix F, and Appendix L). In early 2013, Senate and House committees sent letters13 to the USNRC complaining that the agency was moving too quickly with costly post-Fukushima safety upgrade requirements. The letters criticized a USNRC staff recommendation that the agency require owners of nuclear plants with Mark I and Mark II containments to install filtered vents to reduce radioactive releases in the event of an accident. Some committee members view these letters as an effort to weaken the agency’s regulatory independence. Other committee members view the congressional letters as a normal part of the give and take in the U.S. regulatory process. They point out that the Union of Concerned Scientists also sent a letter to USNRC14 urging it to reject requests to weaken critical post-Fukushima safety reforms or slow down their implementation. As another example, in the late 1990s, the USNRC came under pressure from Congress15 to reduce the regulatory burden on the nuclear industry by moving to risk-informed, performance-based regulations. At about the same time, the Center for Strategic and International Studies recommended (CSIS, 1999) that the USNRC and the industry should strive to work in a more informal and constructive atmosphere and conduct an open dialogue with the public to arrive at regulatory procedures. The USNRC committed to using risk information and risk analysis as part of a policy framework and initiated a policy of increased industry participation in regulatory activities. Some committee members perceive that, as a result of this USNRC commitment, the industry began to participate more actively in USNRC activities such as rulemakings and implementing 13 The letters can be found here: http://www.epw.senate.gov/public/index.cfm?FuseAction=Minority.PressReleases&ContentRecord_id=a79c7514- cf71-9bab-769a-0f4d16587726&Region_id=&Issue_id= and http://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/letters/20130115NRC.pdf 14 Available at http://www.ucsusa.org/news/press_release/nrc-should-reject-calls-to.html 15 For example, Senator Pete Domenici (see Domenici et al., 2004) states that he met privately with the then-chair of the USNRC, Dr. Shirley Jackson, to directly address what some nuclear industry representatives saw as an “adversarial attitude” toward the nuclear industry. Jackson had been aggressively pursuing design basis flaws and the USNRC had issued a series of significant fines based on these problems. Senator Domenici alleges that he threatened to reduce the USNRC’s budget unless greater cooperation with industry was seen. Prepublication Copy 7-13

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Chapter 7: Nuclear Safety Culture guidance development, including initiating voluntary industry programs in lieu of USNRC regulatory action. This resulted, for example, in a USNRC decision to allow the industry to voluntarily implement severe accident management guidance at nuclear plants (see Chapter 5). These voluntary industry programs have not always been successful. Following the Fukushima Daiichi accident, for example, the USNRC’s Near-Term Task Force (see Chapter 5) examined the implementation of severe accident management guidance at U.S. nuclear plants. It found inconsistent implementation of this guidance by licensees. The Task Force recommended that the USNRC initiate a rule making on severe accident management guidance (see Chapter 5) to replace the voluntary program. Other committee members note that the committee does not have enough information to determine whether industry participation in regulatory processes has increased since the late 1990s or whether voluntary initiatives are being substituted for regulatory actions. These members also note that industry, including Electric Power Research Institute and vendor organizations such as BWR and PWR owners groups have been active participants in the regulatory process and the development of voluntary initiatives since before the late 1990s.16 Industry is well organized and has a deep resource base to support a high level of participation in the regulatory process. Vigorous involvement of outside parties occurs in other U.S. regulatory agencies and is anticipated by the laws that govern federal rulemaking. Indeed, it is important for the USNRC to carefully consider the advice it receives from outside parties when it makes regulatory decisions. It is also essential that the USNRC balance the interests of those outside parties with those of the broader public. This requires independent (and wise) technical and policy judgments by USNRC staff and commissioners. The importance of regulatory independence was highlighted in a recent speech by USNRC Chairman Allison Macfarlane: “A nuclear regulator must be independent, but simply being separated from promotional activities on an organization chart isn’t enough. The regulator must be adequately funded and staffed with highly-competent subject matter experts. It must have the authority to stop an activity if it identifies a safety concern, even if it means that a project is delayed. It must be able to shut down a plant that’s not operating safely, even if it means a population is temporarily deprived of electricity.” “To have this authority, a regulator must have the ability to make truly independent safety decisions, with the confidence that those decisions won’t be overturned for political reasons. Put another way, safety and security must be the entire government’s priorities.” Adequate funding and highly-competent staff are necessary, but not sufficient, conditions for regulatory independence. It also requires strong leadership that maintains a laser-focus on safety and does not allow itself to become distracted by outside pressures. The president and Senate of the United States also play important roles in helping to maintain the USNRC’s 16 For example, the industry responded to the USNRC’s safety culture policy statement (see Footnote 2) through a voluntary initiative. It also voluntarily proposed the FLEX initiative in response to the USNRC’s Mitigation Strategies Order (EA-12-049) for beyond-design-basis external events (see Chapter 5 and Appendix F). Prepublication Copy 7-14

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Chapter 7: Nuclear Safety Culture 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. The loss of regulatory independence is often hard to identify and in fact it may go undetected until a tragic accident occurs. See, for example, the April 2010 Deepwater Horizon accident (NAE, 2011) and the September 2010 rupture of a Pacific Gas and Electric (PG&E) Company natural gas transmission pipeline in San Bruno, California (NTSB, 2011). 7.3.3.2 Regulatory Capture Some committee members point to specific incidents as evidence for the possible capture of the USNRC by industry. A well-documented example is the near-accident at the Davis-Besse nuclear plant in 2002. On February 16, 2002, during a refueling outage, the Davis-Besse plant conducted a routine inspection of the nozzles entering the head of the reactor pressure vessel. These inspections indicated that three control rod drive mechanism nozzles had indications of cracking, which had resulted in leakage through the reactor's pressure boundary. During repairs of the nozzles it was discovered (OIG, 2002, p. 14) that the “[reactor pressure vessel] head material adjacent to the nozzle had disintegrated and that the affected (or 'wastage') area was approximately 5 inches long, up to 4 to 5 inches wide, and 6 inches deep. The remaining thickness of the [reactor pressure vessel] head in the wastage area was found to be approximately 3/8 inch which was the stainless steel cladding on the inside surface of the RPV head. This was the only material preventing a breach of the reactor coolant pressure boundary and leak of radioactive coolant into the containment building.” An investigation of the incident by the USNRC’s Office of the Inspector General noted that (OIG, 2002, p. 23) “[US]NRC appears to have informally established an unreasonably high burden of requiring absolute proof of a safety problem, versus lack of reasonable assurance of maintaining public health and safety, before it will act to shut down a power plant.” “The USNRC staff had articulated this standard to the Office of the Inspector General (OIG) as a rationale for allowing Davis-Besse to operate until February 16, 2002, even in light of information that strongly indicated Davis-Besse was not in compliance with USNRC regulations and plant technical specifications and may have operated with reduced safety margins.” Committee members agree that the Davis-Besse incident was a serious safety violation. Some committee members also note that this incident took place over 10 years ago and is not necessarily indicative of current conditions. Moreover, the USNRC took several steps to address this problem once it was discovered: the Davis-Besse plant was shut down for repair, the company was fined and subjected to more intensive regulatory scrutiny, and the USNRC took several steps to strengthen the safety culture components of its reactor oversight process (USNRC, 2011e). For example, the USNRC’s resident inspector training was augmented to Prepublication Copy 7-15

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Chapter 7: Nuclear Safety Culture include safety culture and inspection procedures were developed to assess safety culture at plants with degraded performance. The USNRC has also been criticized for failing to enforce fire regulations at U.S. nuclear plants. The USNRC issued prescriptive fire safety regulations following a fire at the Browns Ferry nuclear plant (located in Alabama) in 1975. Some nuclear plants have had difficulties in meeting these regulations and have sought exemptions (USGAO, 2008). The Union of Concerned Scientists (UCS), arguably the most technically informed public-interest stakeholder on nuclear power issues in the United States, has criticized the USNRC’s regulatory performance on this issue (UCS, 2013a, p. 5): “The NRC has for many years turned a blind eye to the broad use of unapproved manual actions and long-term use of compensatory measures. It has known for two decades about substandard insulation widely used to protect electric cables but has not corrected the situation.” USGAO (2012) noted that the USNRC is making progress in resolving this issue but that some challenges remain. UCS has been issuing annual reports on the performance of the USNRC (UCS, 2011a, 2012, 2013b, 20114). These reports include discussions of recent incidents at U.S. nuclear plants and the USNRC’s responses. The most recent UCS recent report (UCS, 2014) report praised the USNRC’s performance: “The Nuclear Regulatory Commission (NRC) demonstrated it can be an effective watchdog in 2013" … "In many cases, the agency does an admirable job protecting the public and industry workers by enforcing safety regulations.” The report also offers criticisms of the USNRC’s performance: “… But the agency too often turns into Mr. Hyde, and that kind of behavior could lead to a serious accident.” Some committee members note that the USNRC exhibits independence from the U.S. nuclear industry in many matters. For example, the USNRC ordered that the vents in Mark I and II BWRs be hardened and severe accident capable (Order EA-13-10917; see Appendix F) even though it did not pass the backfit rule’s cost-effectiveness test; the USNRC noted that (p. 7 of Order) “These modifications are needed to protect health and to minimize danger to life or property because they will give licensees greater capabilities to respond to severe accidents and limit the uncontrolled release of radioactive materials.” The requirement to extend station blackout capabilities through order EA-12-049 (see Appendix F) is a similar example. 17 Available at http://pbadupws.nrc.gov/docs/ML1314/ML13143A321.pdf Prepublication Copy 7-16

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Chapter 7: Nuclear Safety Culture 7.4 RECOMMENDATIONS 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. 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. The Fukushima Daiichi accident demonstrates that statements in support of a strong nuclear safety culture are no guarantee that one exists. In fact, the development and maintenance of a strong nuclear safety culture requires a focused and sustained commitment from all involved parties:  Nuclear plant operators  Nuclear plant management  Nuclear industry organizations  Nuclear regulators—both staff and leadership  Executive and legislative branches of government The committee sees opportunities to improve the transparency of U.S. industry and regulator efforts to assess and improve their nuclear safety cultures. This 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. The committee fully recognizes that any such disclosures need to be carefully planned and implemented so that they do not inhibit the full and prompt reporting of safety problems. The committee also recognizes that some types of information, for example personnel- and security- related information, should not be disclosed to the public. The committee judges that there would be several tangible benefits from increased communication with stakeholders and disclosures: It would help to demonstrate the nuclear industry’s commitment to safety in both word and deed and demonstrate the USNRC’s commitment to safety and regulatory independence. Public feedback from such disclosures might also improve the quality of safety culture assessment and improvement activities. There are tangible benefits associated with a more frank and direct relationship between the nuclear industry, nuclear plants, and host communities (Richardson et al., 2013, p. 266). Continuing public support for nuclear power depends on the safe operation of nuclear plants. Nuclear plants must be—and must also be seen by the public to be—safe and well regulated. Many U.S. nuclear plants have been granted 20-year license renewals18 and spent fuel is stored at 18 See http://www.nrc.gov/reactors/operating/licensing/renewal/applications.html Prepublication Copy 7-17

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Chapter 7: Nuclear Safety Culture all operating plants and is likely to remain on site for an indeterminate period of time. Consequently, nuclear plants by necessity will have long-term relationships with their communities and would likely benefit from strengthened community relationships and communication efforts. Indeed, open and transparent communication is an important component of the nuclear safety culture and essential to maintaining confidence in nuclear power (Macfarlane, 2012). Including the public by extending communication and engagement is consistent with the principles that underlie a strong nuclear safety culture. Prepublication Copy 7-18

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Chapter 7: Nuclear Safety Culture SIDEBAR 7.1 Who is Responsible for Nuclear Plant Safety? Nuclear plant safety begins with a plant’s design and construction and extends through its full life cycle including operation, maintenance and, inevitably, decommissioning. Consequently, a number of organizations are responsible for plant safety: plant and equipment designers and manufacturers; constructors; plant owners/operators, from upper management through reactor operator and plant maintenance staff; and regulators who set, oversee, and enforce the standards and requirements for plant design, construction and operation. These organizations have a shared responsibility to protect public safety and the environment during both normal and off-normal plant operations. These organizations play different but complementary roles in meeting their shared responsibilities:  Regulators are independent institutional bodies whose focus is on protection of the public and the environment, not for the promotion of nuclear technology or protection of investment in assets.  Design, manufacturing, and construction firms are responsible for building as much inherent safety and environmental protection into the plants as can be reasonably achieved.  Plant owners/operators are responsible for operating their plants so that safety and environmental protection goals are achieved. Other organizations also contribute to nuclear plant safety. These include national authorities who appoint regulators’ leadership and appropriate regulators’ funding; governmental organizations such as the USNRC’s inspector general and the Government Accountability Office, which conduct independent investigations of USNRC and industry actions; and public- interest organizations which offer technical critiques and advice. The plant owner/operator’s first, foremost, and overriding responsibility is to ensure the safe operation of its plants. The owner/operator has other responsibilities, of course, including the provision of a reliable supply of electric power and protection of plant investments. A major accident can challenge the continued viability of an operating company, so owner/operators could elect to adopt stricter safety standards and management practices than required by regulations. The ultimate responsibility for nuclear plant safety and environmental protection resides with the plant’s owners, managers, and operating staff and the agencies that regulate them. Five decades of nuclear plant operating experience demonstrate clearly that it is not possible to anticipate all combinations and permutations of operating conditions that can occur at a nuclear plant. Consequently, safety cannot be achieved only through rules, regulations, hardware design, and operating procedures. It also requires onsite intelligence, learning, and decision-making by plant operating staff. More importantly, it requires “commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment.” (INPO 2013, p. iv). The nuclear industry and its regulators can work together to promote nuclear safety, especially through the development of common understandings of problems and potential solutions. However, safety can be compromised if plant owner/operators adopt a compliance- Prepublication Copy 7-19

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Chapter 7: Nuclear Safety Culture only operating philosophy. On the other hand, regulators can become ineffective or even captured by the nuclear industry if independence is lost. Both of these situations can weaken the industry and regulator’s responsibilities to protect the public interest. Prepublication Copy 7-20

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Chapter 7: Nuclear Safety Culture SIDEBAR 7.2 Institute of Nuclear Power Operations The Institute of Nuclear Power Operations (INPO), a not-for-profit organization headquartered in Atlanta, Georgia, was established by the nuclear power industry after the 1979 Three Mile Island nuclear accident. It has instituted several important efforts to foster and improve a safety culture at U.S. nuclear power plants. One of INPO’s safety culture activities involves linking its evaluation of nuclear power plants to the ability of plant owners to obtain liability insurance. INPO evaluations are carried out at each plant every two years. INPO evaluation teams spend approximately two weeks at each plant, interviewing plant personnel and watching their actions on the job. The evaluation team meets daily, prepares a report, and presents that report to plant management and to the utility’s chief nuclear and chief executive officers. The report rates the plant’s performance using a numerical scale. If a plant receives a low rating, its chief executive officer and chief nuclear officer may be asked to make a presentation to INPO to explain what steps have been taken to correct deficiencies. Plants that receive a high rating are eligible for a discount on their liability insurance provided by an industry insurance organization. INPO also maintains and/or sponsors training for nuclear power plant personnel at all levels. For example, training is given to first- and second-line supervisors, potential plant managers, as well as members of the board of directors of nuclear power companies. INPO also provides technical consulting to its member companies on an as-needed basis. INPO collects, analyzes, and publishes “lessons learned” from events that occur at nuclear plants in the United States and abroad. When appropriate, INPO requires its members to implement enhancements in response to these lessons. A number of such have been made based on lessons learned from the Fukushima Daiichi accident. The results of INPO’s inspection program are shared among INPO membership, but such information is not made available to the public. INPO judges that this limited sharing encourages candor and places the decision about what information to release to the public in the hands of company managements. The reports are also available at INPO for review by the USNRC. Additionally, INPO encourages each plant to allow USNRC regional staff to review the reports on site. The USNRC does not review INPO inspection reports in detail, but the agency is aware of the overall results of these inspections. Lochbaum et al. (2014, p. 151-152) note that because these inspection results are not made public, the public cannot determine how serious the identified problems are or whether, or to what extent, the identified problems have been addressed. Releases of summaries of these inspections by management to the public would help increase transparency. Prepublication Copy 7-21

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