NRC Activities Leading Up to the 

Safety Culture Policy Statement

February 2, 2010

Jose G. Ibarra Molly Keefe

Sr. Program Manager Human Factors An

Office of Enforcement Office of New Rea

U.S. Nuclear Regulatory Commission
Presentation

• Safety Culture Before Three Mile Island (TMI) Accident• TMI Lessons Learned, NRC Actions, and Chernobyl Acc• 1989 Policy Statement: Conduct of Operations• International Nuclear Safety Group (INSAG)• 1996 Policy Statement: Freedom to Raise Concerns• Events of the New Millennium• Davis-Besse Reactor Vessel Head Event• Shuttle Accident, General Accounting Office, Congressio

Committee

• Safety Culture Working Group and Palo Verde Independe

Culture Assessment 
Safety Culture Before Three MiIe Island 

Accident 

• Nuclear Industry would not have used such words as Safety Cultu• There were no human factors staff at nuclear power plants

– Most professionals were engineers at nuclear site

• Nuclear Industry did pay attention to safety• Operators trained and licensed and mentality existed that acciden

not occur due operator training and design safety features

• Radiation and Industrial Safety Training
TMI Lessons Learned

• TMI occurred in March 1979• Human Factors introduced the Man Machine Interface (M• Main Control Rooms need to be assessed for Human Fac

– Detailed Control Room Design Reviews/Functional An– Safety Parameter Display System

• Identified Importance of Operator’s role in operations and 

mitigation

– Re-doing Emergency Operating Procedures– Senior Technical Advisor

• Operators/Engineers accepted the human factors disciplin

especially after control room reviews and the Functional A
NRC Actions Due to TMI Assessmen

• TMI Action Plan (NUREG-0600) provided more work for s

scientists

• Human Factors Staff hired with various expertise in Man M

Interface and organization effectiveness

• NRC created Office for Analysis and Evaluation of Operat

Data (AEOD)

• NRC created Human Factors Division in Office of Nuclear 

Regulation

• NRC created Human Factors Branch in the Office of Nucl

Regulatory Research
AEOD Independent Work

• Established independent assessment of operational events• Assessed events at nuclear sites documented as Human Perfo

Reports

• Conducted Diagnostic Evaluations that included training, opera

management & organization

• Managed Technical Training including reactor simulators• Developed Emergency Response Procedures and built a top fa

monitor events

• Trained staff for highest level of NRC inspection called the Incid

Investigation Teams 
Lessons Learned From Chernobyl Accid• Accident occurred in April 1986• There was non adherence to procedures• There was non conservative decision making• There was lack of clear authority• There was poor training and understanding of th

experiment

• Production was put over safety• There existed a complacency culture
1989 Policy Statement: Conduc

Operations

• Safety Culture requires:

– Necessary full attention to safety matters– Personal dedication and accountability of all 

individuals engaged in any activity which has bearing on the safety of nuclear power plants

– Management has the duty and obligation to f

the development of a ‘safety culture’ at each and to provide a professional working enviroin the control room, and throughout the faciliassures safe operations
International Nuclear Safety Gro

(INSAG)

• 1991: INSAG-4, “Safety Culture,” was 

developed to emphasize safety culture cin nuclear industry

– Result of Chernobyl accident– International Atomic Energy Agency (IAEA) a

INSAG work led to development of guidance safety culture
INSAG-4 Definition

“That assembly of characteristics and 

attitudes in organizations and individwhich establishes that, as an overridpriority, nuclear plant issues receive attention warranted by their significa
May 14, 1996: Policy Statemen

Freedom of Employees in the Nuclear In

to Raise Safety Concerns without Fe

Retaliation. 

• Issued following retaliation for whistle-blowing is

Millstone

• Establish and maintain safety conscious work 

environment (SCWE)

• Applied to all NRC-regulated activities of license

contractors, and applicants
Events of the new Millennium

• Reactor Oversight Process (ROP) Implem

in 2000

– 3 cross-cutting areas have safety culture ties:

– Safety Conscious Work Environment (SCWE)– Problem identification and resolution (PI&R)– Human Performance
Events of the new Millenniu

• September 11, 2001 attacks

– Heightened importance of security at n

power plants

– NRC issues orders enhancing security 

NRC licensed facilities

– Resulted in Commission adding “nucle

security” to proposed safety culture de
Davis-Besse Reactor Vessel Head 

in 2002

• Discovery of boric acid corrosion 

degradation on the reactor pressure vessel

• Licensee’s root cause identified 

inadequate safety culture and an emphasis on production over safety
NRC Davis-Besse Lessons Learned 

Force

– NRC Davis-Besse Lessons Learned T

Force analysis:

• The owner failed to assure that plant s

issues would receive appropriate atten

• The NRC, the reactor owner, and the nuc

industry failed to adequately review, assefollow-up on relevant operating experienc

• The NRC failed to integrate known or ava

information into its assessments of licenssafety performance
NRC DBLL Task Force 

Recommendations

• The Task Force Report recommend

that the staff review NRC inspectionplant assessment processes

• Review would determine if there wa

need to change current NRC assesand inspection processes 
Task Force Follow-up Events• The Commission provided the 

following direction:

– Enhance the ROP treatment of cross-cutting 

to include safety culture 

– Ensure inspectors are properly trained – Develop a process to conduct safety culture 

evaluations for plants in the Degraded CorneColumn of the ROP Action Matrix
Other Influences

• General Accounting Office (GAO) 

recommendations

• U.S. Senate Committee on Environment 

Public Works concerns over Davis-Besse head event

• Columbia Shuttle accident in 2003
Safety Culture Working Group• Formed working group in 2004 with mem

from RES, NRR, and OE:

– Revised the cross-cutting issues to enhance 

culture

– Recommended adoption of the INSAG-4 def– Developed 13 components and correspondin

aspects of safety culture

– Revised baseline and supplemental inspecti

procedures 

– Developed training for NRC inspectors
2007 NRC Palo Verde Independe

Safety Culture Assessment

• First use of updated supplemental inspec

procedure

• Allowed the NRC to assess into safety cu

at Palo Verde
Where are we today?

• February 2009 SRM, “A Commissio

Policy Statement on Safety Culture”

– Directed Staff to reach out to all stake

and all types of licensees and certificaholders

– Solicit feedback into development of p

statement
Continued

• October 2009 Commission SRM to 

update Policy Statement:

– “Seek opportunities to comport NRC 

terminology, where possible, with that existing standards and references maintained by those that NRC regulat
Here We Are!
References

• SECY-04-0111, “Recommended Staff Actions 

Regarding Agency Guidance in the Areas of SaConscious Work Environment and Safety Cultu2004

• SRM/SECY-05-0187 (December 2005), "Status 

Safety Culture Initiatives and Schedule for NearDeliverables,“

• Millstone Time Magazine article: 

http://www.time.com/time/magazine/article/0,9106,00.html

• February 2009 SRM-COMGBJ-08-001