A chart from the a nuclear safety study of DOE EM-LA and N3B’s legacy waste cleanup project at Los Alamos National Laboratory. Courtesy photo
A chart from the a nuclear safety study of DOE EM-LA and N3B’s legacy waste cleanup project at Los Alamos National Laboratory shows the lowest scoring attributes are Management Time In the Field and Operational Experience. Courtesy photo
BY MAIRE O’NEILL
maire@losalamosreporter.com
Oak Ridge Associated Universities (ORAU) conducted an independent evaluation of nuclear safety culture for Newport News Nuclear BWXT-Los Alamos (N3B) and the Department of Energy’s Los Alamos Field Office for Environmental Management (DOE EM-LA). The purpose of the evaluation was to measure perceptions and attitudes of members of the workforce and provide data that management can use to guide current and future culture improvements.
The evaluation noted that “Personal Commitment and Questioning Attitude” are foundational strengths of N3B and DOE EM LA’s safety culture. It states that both N3B and DOE EM-LA “generally present an environment where most workers are comfortable with pausing or stopping work” but that newer or less experienced employees describe not feeling comfortable calling a pause or stop to work and, instead, “rely on the judgment of more senior employees”. It claims that “tense relationship between N3B and DOE EM-LA is an important driver of perceived inconsistent policies and contributes to N3B workers being reluctant to raise concerns”.
“All data sources point to challenges with Leadership Accountability, and Management Engagement and Time in the Field. Employees believe that leaders are generally disengaged from day-to-day operations, value production over safety, and engage in punitive incident reviews. Lack of regular leadership presence in the field reinforces this perception for employees. Employees reported specific problems that have not been resolved in a timely manner, including concerns about inadequate and/or outdated facilities, vehicles, and equipment, unsafe road conditions, and difficulty getting PPE (including basic first-aid items),” the evaluation states.
Participants in the survey apparently appreciated the frequency of safety communication, but note that the volume of communications is “overwhelming and, at times, lacks relevance”.
“There are multiple communication channels and not all are effective for some audiences, contributing to mixed awareness of safety messages,” the evaluation states.
The evaluation indicates that high levels of workforce turnover and current staffing concerns make continuous learning paramount for safety with participants encouraging “longer-range planning for N3B and DOE EM-LA’s physical infrastructure that addresses root-level repairs rather than applying surface-level fixes”.
Based on findings, the study presents nine recommendations to support N3B and DOE EM-LA’s safety culture and catalyze improvements in underlying tools and processes. “Enhancing actions to engage in proactive problem solving, having leaders exemplify safety values through their presence and support, investing in critical infrastructure, clarifying policies and communications, and empowering a stable workforce will strengthen N3B and DOE EM-LA’s safety posture. In summary, N3B and EM-LA are encouraged to:
1. Model safety values and expectations through action, increased leadership presence in the field, and direct as well as respectful engagement between management and front-line employees.
2. Bolster communication and training around raising concerns to clarify N3B & EM-LA’s support for reporting errors and issues. Ensure interactions are respectful to foster and encourage a questioning attitude amongst employees.
3. Provide employees with tools and resources to perform their work safely.
4. Invest in workforce development through high-quality onboarding of new employees, and training and mentorship across organizational levels.
5. Foster and encourage new employees’ Questioning Attitude to support continued innovation and improvement within the organization.
6. Take proactive steps to rebuild trust and resolve tensions between N3B and DOE personnel at all organizational levels through collective team building and policy alignment, especially among executive leadership and between DOE Facility Representatives and Operations.
7. Synchronize safety communications at all organizational levels to present a unified and cohesive message that safety is an ever-present value at N3B & EM-LA.
8. Visibly support proactive problem solving and Risk-Informed, Conservative Decision-Making to counterbalance production pressures.
9. Share the results of this evaluation with the workforce in an accurate, timely manner and provide opportunities for feedback and discussion.
The purpose of the safety culture evaluation was to evaluate the status of N3B and EM-LA safety culture and use that knowledge to:
1. Analyze N3B and EM-LA management and employee perspectives and insights on the current state of organization culture.
2. Make recommendations regarding how N3B and EM-LA can move forward together in pursuit of a stronger safety culture. The scope of the evaluation was limited to safety culture subject areas and included administering a safety culture survey, conducting focus group discussions with members of the workforce, and conducting interviews with management.
• The survey response rate (67%) satisfied the minimum requirement of 50%, and the data are considered representative of the N3B workforce.
• Personal Commitment and Questioning Attitude were the highest rated items on the survey. However, several comments suggest that some workers may not be held consistently accountable for their actions, which contributes to recurring issues and lowered morale.
• Participants had the most negative overall perceptions of Management Engagement and Time in Field. In the survey comments, participants reported that leadership is not seen in the field unless something has gone wrong.
• Statements pertaining to Open Communication had the greatest influence on the perceptions of N3B’s safety culture over the past year or anticipated culture over the next year.
• The lowest-scoring N3B item on the survey overall was “leaders are commonly seen in our work areas observing, coaching, and reinforcing safety expectations.” For DOE, the lowest-scoring item was “I believe that corrective actions that come out of Fact Findings prevent future reoccurrence of the same issues.”
• On average, N3B scored 2% lower and DOE EM-LA scored 3.9% lower than the DOE reference population though scores for Personal Commitment and Environment for Raising Concerns were slightly higher than those of the DOE reference population.
Some interesting statistics noted in the study include:
Half the respondents had tenure at DOE sites for less than 10 years while 45.6 percent had less than three years tenure at N3B. Personal Commitment and Questioning Attitude were among the two highest attributes while Management Time in the Field and Operational Experience had the lowest mean scores.
Many participants indicated that the safety culture is overall good or the best of any company they had worked at. Employees said they feel confident that they understand their responsibilities related to safety and are willing to communicate with or challenge others when they observe unsafe behaviors. They also reported trusting their immediate supervisors and indicated that they were not afraid to report a mistake made to their immediate supervisor.
Approximately 43% of the survey responses indicated a need for improvement under Work Processes, Leadership Accountability, and Safety Communication. “Regarding Work Processes, participants indicated that fragmented and unevenly applied policies and work procedures cause confusion across the board and get in the way of completing work efficiently. Some participants indicated that an overly rigid focus on the process over the product of the process makes it hard to get work done. Under Leadership Accountability, participants reported that some managers prioritize schedule/production over safety or are more concerned with conforming to regulations than advocating for employee safety. Participants felt that management often talks about the importance of safety, but that they do not see management consistently modeling safety behaviors,” the study states. “Examples of this include management not being routinely present in the field engaging with employees, not attending their own safety meetings, or engaging in punitive incident reviews that seek to place blame rather than address underlying issues.
With regard to Safety Communications, the study said most participants indicated that the sheer amount of information overload has led some employees to tune out safety communications.
“Some employees mentioned that they find it difficult to discern critical communication points. Additionally, participants indicated that communication silos exist within N3B, specifically between Environmental Remediation and CH-TRU – Transuranic Waste and that miscommunication between N3B and subcontractors has led to issues,” the study said.
Many employees apparently expressed concern about reported vehicle issues remaining unresolved, lack of adequate personal protective equipment (PPE) and first aid equipment (including AEDs), and/or facilities that were not fit for purpose.
“Employees also cited lack of workforce resources and qualified talent as undermining N3B’s production goals and placing undue strain on employees tasked with performing work at a pace designed for larger teams,” the study noted. Regarding Personal Commitment, some employees described a lack of personal accountability across N3B, “exacerbated by complicated systems that de-incentivize people to hold themselves and others accountable”. For Problem Identification and Resolution, employees cited “recurring issues as contributing to perceptions of feedback not being taken seriously”.
Some N3B employees expressed that the company operates on a reactive as opposed to proactive mindset when it comes to safety issues. Similarly, regarding Environment for Raising Concerns, employees reported that concerns raised are either overreacted to or used to place blame as part of fact-finding investigations — which has caused some to be reluctant to raise issues. Employees also described a lack of adequate training, or training uses as a “check-the-box” exercise.
Employees expressed a desire for better, high-quality, consistent training across the company. Comments related to Respectful Work Environment described a chilled work atmosphere where unprofessional behavior (e.g., yelling, verbal intimidation) is tolerated and rewarded,” the study noted.
Under the section on Managers, employee recruitment, selection, retention and development were described as a critical challenge area. “Of note, high levels of employee turnover due to workers retiring or leaving for (to work for) competitors poses a concern for adequate staffing levels across N3B’s workforce,” the study said.
Attrition was also noted as a concern of DOE staff who indicated it has caused an increase in the workload due to the lack of experience of new personnel. Several managers cited the need to improve the quality communications however they praised the high level of effort and attention to regular safety communications. Managers described a mixed environment around raising concerns, noting that employees are aware of channels for raising concerns “but do not always act on using them”.
“Both N3B and DOE management reported a lack of leadership accountability and open communication. While the overall sentiment from interviews is that managers, both from N3B and DOE, hold themselves accountable, one manager stated that “there are supervisors who question the accountability of others but rarely themselves”, the evaluation noted. “One DOE manager reported that N3B likes to place blame on DOE and play the ignorance card adding ‘there’s no accountability on their part’. Conversely, an N3B manager reported that DOE fails to provide timely feedback to N3B resulting in surprising performance feedback that should have been addressed through regularly scheduled meetings with both parties. The lack of effective communication channels between N3B and DOE was observed and reported by several managers in both parties. The tension in the relationship was a point that one manager said, ‘needs to improve’. The conflict between them has led to a situation where each party perceives the other as lacking accountability,” the evaluation stated. “This perception is hindering progress and contributing to a breakdown in mutual communication. The tense relationship between N3B and DOE could be a contributing factor to reporting concerns as an essential aspect of ensuring a safe and productive work environment. The fact-finding events may also be impacted by the nature of the relationships and accountability. One manager stated, ‘We need to improve consistency in how they are conducted and in explaining the ‘why’ behind them. They should be professional and non-punitive’.”
The evaluation noted that vehicle incidents are a cause of fear of punitive action, and that they were a primary concern for the site at the time of the survey.
“An N3B manager stated, ‘I’m afraid to drive a company vehicle for fear of an incident [from] backing into something’. Fortunately, there are many ways to report concerns, and individuals typically feel empowered to raise immediate safety concerns in Environmental Remediation, though the reporting numbers are reportedly low. The sentiment was generally not the same for CH-TRU. Some managers expressed that CH-TRU employees are discouraged from talking to ‘outsiders’ and that there is fear of retaliation or being ‘bullied’ internally. There were also reporting concerns shared as part of the DOE EM-LA and N3B interface. One DOE EM-LA manager stated that N3B minimizes the visibility of DOE reporting methods for N3B personnel, sharing, ‘N3B does not promote that employees can share concerns with DOE’,” the evaluation said.
One DOE manager acknowledged that there was a fear culture under a different DOE Field Office Manager that actively retaliated against employees while another manager stated that the new DOE Field Office Manager is setting the expectation that retaliation will not be tolerated, the evaluation said.
“Among newer or less experienced employees, there is a culture of seeking permission before entering issues into the system. This may be due to a lack of confidence in their ability to assess the situation and determine the appropriate course of action. It may also be due to a fear of retaliation for reporting a problem that may be deemed insignificant by others. Some managers reported that CH-TRU is ‘militant’ in how the organization is run and there is fear of reporting concerns,” the evaluation states. “During interviews, managers described a culture where individuals do not feel comfortable speaking up for problem identification and resolution because of the expectation that their concerns will be ignored or that they will simply be assigned to fix the problem themselves. This has led to a lack of ownership around issue resolution, with confusion about who is responsible for addressing certain problems. While it is important for employees to be empowered to solve issues facing them at work, it is not reasonable to expect them to be solely responsible for their resolution, especially when the issue is a concern around a wider procedure or process. One manager expressed that clear roles and responsibilities need to be established to ensure that everyone understands who is responsible for addressing specific issues.”
One N3B manager stated that the DOE Facility Representatives have a “gotcha” approach to hazard identification, which inhibits the trust of openly collaborating on the cleanup projects entrusted to N3B. In addition, a DOE manager shared that “gotcha” behavior of the facility representatives lingers from legacy management and that the new administration actively encourages facility representative to collaborate and be a resource to N3B personnel, the evaluation states.
“Additionally, conflict between N3B and DOE may contribute to withholding of information. In some cases, employees may be hesitant to report concerns to individuals with whom they have a contentious relationship. This can lead to a breakdown in communication and create an environment where concerns are not adequately addressed,” the evaluation says.
The evaluation states that a healthy safety culture produces work with respect to hazards and relevant work procedures. Each level of the organization is expected to actively participate in the development of work practices and follow the approved work practices. Engaging in this behavior creates Teamwork and Mutual Respect in a collective culture of safe work.
“The make-up of N3B across several organizations and quick takeover from Triad/LANL has resulted in inconsistent and outdated procedures, creating a situation where employees follow different processes when performing the same tasks. This lack of standardization can lead to confusion, errors, and inefficiencies. In some cases, management has reported that procedures irrelevant to the operation are required to be maintained while essential procedures need revision,” the evaluation states. “A positive highlight of procedures in the interviews was the adaptation of resolutions to safety concerns becoming procedures. Newer employees who do not have the experience of more seasoned staff members are particularly vulnerable to this issue of outdated procedures. New employees rely on clear, vetted procedures to perform their work correctly and safely. However, it seems that procedures are not routinely used and integrated into processes, leading to frustration among employees who know that the procedures do not make sense.”
The Los Alamos Reporter sat down with EM-LA and N3B leaders earlier this week to discuss the report. See separate story.