United States Naval Nuclear Propulsion Program
9/12/2001 Afghanistan Iran
Pakistan India FIRST SHIPS ON STATION: CVN 65, CVN 70, SSN 719, SSN 722
NAVAL NUCLEAR PROPULSION PROGRAM
FOCUSED MISSION
Provide militarily effective nuclear propulsion plants and ensure their safe, reliable, and long-lived operation
CLEAR, TOTAL RESPONSIBILITY AND ACCOUNTABILITY FOR ALL ASPECTS
Research, development, design, construction Maintenance, repair, overhaul, disposal Radiological controls, environment, safety, and health matters Officer operator selection, operator training Administration (security, nuclear safeguards, transportation, public information, procurement and fiscal management) Centralized control of Programs Industrial Base/Vendors Spent fuel custody
SIMPLE, ENDURING, LEAN STRUCTURE
Director tenure 8 years, 4-Star Admiral/Deputy Administrator in NNSA Dual agency structure with direct access to Secretaries of Energy and Navy Small headquarters, field activities
EXECUTIVE ORDER 12344 SET FORTH IN PUBLIC LAW 98-525 AND 106-65
NAVAL NUCLEAR PROPULSION PROGRAM
Field Offices
REPORT TO DIRECTOR - Ensures focus on mission - Immediate identification of concerns
NAVAL REACTORS
380 people
DEDICATED LABORATORIES - Bettis Atomic Power Laboratory - Knolls Atomic Power Laboratory - GOCOs
NUCLEAR POWERED FLEET - 82 ships - Over 40% of major combatants
SHIPYARDS 4 Public / 2 Private
SPECIALIZED INDUSTRIAL BASE - 1 dedicated equipment prime contractor - Hundreds of suppliers
R&D/TRAINING REACTORS - Train 2500 students/year SCHOOLS - Nuclear Power School - Nuclear Field A School
103 reactors operating worldwide
LEAN, CENTRALLY CONTROLLED, DEDICATED, SUCCESSFUL
MASTERING NUCLEAR TECHNOLOGY
Defense in Depth
Design: simple, rugged, redundant, fail-safe, conservative
Rigorous quality control: on-site reps, detailed specs, HQ approval for deviations, separate logistics/supply, documentation (quality evidence) Comprehensive procedures and procedural compliance Oversight: NPEB, squadron, type commander, field office People: carefully selected; rigorous and continuous training
THE KEY IS PEOPLE CAREFULLY SELECTED, HIGHLY TRAINED, MOTIVATED
ENGINEERING = c1[PEOPLE]3
Engineered systems are used by people Engineering analysis is done by people Engineered equipment is maintained by people
YOU CANT ENGINEER PEOPLE OUT OF THE EQUATION
NAVAL NUCLEAR PROPULSION PLANT Pressurized Water Reactor
Multiple Safety Drivers...
which can be in tension.
Reactor Safety Ship Safety Crew [Worker] Safety Public Safety Environmental Safety
The tyranny of the OR
- Built to Last by James Collins & Jerry Porras
TRUE TO OUR ROOTS
Most technical requirements and administrative processes developed under ADM Rickover. His experience included time aboard ship (pre-WWII) and as head of Electrical Division of BUSHIPS.
One must create the ability in his staff to generate clear, forceful arguments for opposing view points as well as their own. Open discussions and disagreements must be encouraged, so that all sides of an issue will be fully explored. Further, important issues should be presented in writing. Nothing so sharpens the thought process as writing down ones arguments. Weaknesses overlooked in oral discussion rapidly become painfully obvious on the written page.
- H. G. Rickover
KEY SAFETY ATTRIBUTES
Self-regulating Multiple safety barriers Large margins to core damage Long time for response for many casualties Operator back-up Thoroughly and continuously trained operators Multiple systems
Since engineering is a profession which affects the material basis of everyones life, there is almost always an unconsulted third party involved in any contract between the engineer and those who employ him that is the country, the people as a whole Knowing more than the public about the effects his work will have, the engineer ought to consider himself an officer of the court and keep the general interest always in mind.
- H. G. Rickover
DEFENSE IN DEPTH IN ANALYSES
Engineering modeling Reactor safety and ship reliability for casualties Public safety
the NRC staff comments positively on the conservative design philosophy, the stringent standards for construction and materials, the incorporation of past operating experience, and the consideration of human performance in the VIRGINIA Class Submarines nuclear propulsion plant. The VIRGINIA Class Submarines nuclear propulsion plant represents an advancement in safety over previous submarine classes that the RNC has reviewed.
- NRC letter of October 15, 2002
SAFETY CULTURE
IAEA definition: The assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, protection and safety issues receive the attention warranted by their significance. Another definition: a work environment where a safety ethic permeates the organization and peoples behavior focuses on accident prevention through critical self-assessment, pro-active identification of management and technical problems, and appropriate, timely, and effective resolution of the problems before they become crises. (Jonathan Wert, 1986)
Culture the quality in a person or society that arises from an interest in excellence .... development or improvement of the mind by education or training.
- The Random House College Dictionary (1980)
MAKING A SAFETY CULTURE
Ingredients
Assembly the whole must net out as viewing safety as important; saying it is someone elses job does not suffice Characteristics organizational structure and rules must support Attitudes people have to believe, and show they believe, that safety is important Overriding if cost and schedule keep taking precedence, people get the message and the culture suffers Attention problems must be communicated to appropriate personnel Significance cognizant personnel must be capable of assessing impact on safety; to do so, they must be trained, given authority, given complete information. Accident prevention before they become crises fix problems while they are still minor Self-assessment know how well you are doing the job Management AND technical problems are not limited just to hardware
Summary: Identify, communicate, resolve, self-assess, train.
SAFETY CONSCIOUS WORK ENVIRONMENT
PROGRAM PHILOSOPHY
Centralized technical control of all aspects Personal responsibility for technical, safety, radcon, environmental In-depth technical understanding of all aspects of work at all levels HQ involvement in all aspects (design, procedures, operations) Organization with internal checks to ensure thorough review Prompt reporting, evaluation, and correction of problems Rigorous theoretical and practical training; continuing training at all levels Conservative designs with ample safety margins; prevention first Rigorous quality assurance of all aspects Thorough testing of equipment prior to fleet application Formality, discipline, and precision Emphasis on close, frequent technical oversight Skepticism, frankness, self-criticism, integrity, & attention to detail.
PREVENT BIG PROBLEMS BY WORKING HARD ON THE SMALL ONES
NNPP TRIANGLE VIEW OF PROBLEMS
CENTRALIZED TECHNICAL CONTROL
Director responsible for all aspects of work Frequent oral & written reports from all Program activities HQ Outstanding personnel; management technically trained Directly oversees adequacy of all technical requirements Exercises technical approval over contractors, SYs, & vendors Multiple reporting chains ensure problems promptly brought to attention of cognizant personnel Oversees all personnel actions related to the Program Directs and oversees all logistic support functions Controls special nuclear material, including shipment Responsible from R&D throughout life to final disposal Periodic audits by cognizant technical personnel
KNOWLEDGEABLE AND DEMANDING CUSTOMER
CLOSE, FREQUENT TECHNICAL OVERSIGHT
On-site field offices do surveillance, auditing Activity self-assessment capability reviewed Periodic HQ reviews (DOE labs) and audits (shipyards) by cognizant technical leads Regular letters to Admiral & top HQ staff on issues Reporting deviations from normal operation HQ technical approval for almost every design detail and procedure
ASSURING PERFORMANCE TO HIGH STANDARDS
ASSURE PLANTS OPERATE WITHIN SAFE LIMITS
Compliance with technical requirements Detailed procedures and description Analyses for casualty conditions Operation only by highly trained, qualified operators Rapidly reporting deviations from normal operation via multiple paths Strong, continuing maintenance
QUESTIONING ATTITUDE
CONTROL OF WORK
Naval nuclear shipyard organization set Nuclear work groups Test and refueling organization Maintenance controlled by NR documents General process specified in NR manual Detailed testing prior to unrestricted operations Multiple oversight: internal shipyard organization, ships crew, NR field office.
YOU GET WHAT YOU INSPECT, NOT WHAT YOU EXPECT
NR HQ TECHNICAL APPROVAL PROCESS
Cognizant technical organization submittal NR HQ review Lead engineer Internal section agreement Concurrence of other sections Copy to ADM Resolution of any dissent Additional iterations may be required
You must tell me the technically correct answer. Once we decide that a way forward is technically acceptable, we should then consider the schedule and cost implications of these solutions.
- ADM Bowman
LESSONS LEARNED
Learn from your mistakes. Even better, learn from other peoples mistakes. When the unexpected happens, investigate. Understand the consequences had it happened under less fortuitous circumstanceswhat if? Dont assume it wont happen again. Evaluate need for corrective action. May need preliminary action (e.g., procedure or training change) while waiting for longer term (hardware modification)
Those who do not learn from history are doomed to repeat it.
- George Santayana
EXAMPLES FROM PRIME CONTRACTOR
Reactors and nuclear facilities are designed, constructed, maintained, and operated in accordance with applicable requirements and in a manner that protects people, the environment, and property. Every employee is personally responsible for performing their duties in a manner that preserved the nuclear safety values Line organizations have the primary responsibility for reactor and nuclear safety. This responsibility is not diminished by reviews external to the line organizations. Reactor and nuclear safety-related activities are formally reviewed by an organization of knowledge experts independent of the line organizations.
Line organizations have the primary responsibility for reactor and nuclear safety
QUESTIONS THAT SHOULD BE ASKED
What are the acceptance criteria (i.e. , what is the basis for accepting this recommendation)? What is the consequence of failure that this recommendation is designed to prevent? What are the areas and levels of uncertainty (has there been an uncertainty analysis performed)?
What is the level of conservatism or margin to failure?
What change in the margin to failure will result from accepting the recommendation? Is there a precedent for the recommendation?
How does this recommendation affect other design areas and/or how does it interact with other historical design changes and safety requirements?
Why should this recommendation be accepted (i.e., what is the benefit)? QUESTIONING ATTITUDE
ADM Bowmans Core Values - The Culture
Technical Excellence - technically correct solution identified, technically expert decision makers, minority opinions, appropriate conservatism, simple/robust designs, cautiously challenge status quo Responsibility - own your job, face facts & tell the truth, mainstream safety, overlapping responsibilities People - selectivity, continuing training, professional competence, personal responsibility, dedication, longterm perspective, decisive Formality and Discipline - decisions and their basis are documented, written procedures, procedural compliance, dont live with deficiencies, dont normalize deviance, effective communications CONSTRUCTIVE DISSATISFACTION
COMMITMENT TO SAFETY
Mainstreamed carried out day-to-day as a normal way of doing work by all personnel. An enduring deep fundamental core value of the organization, not a short term program or add-on.
In a submarine environment, with these constraints, there is only one way to ensure safety: it must be embedded from the start in the equipment, the procedures, and, most importantly, the people associated with the work.
- ADM F. Bowman (as quoted in NNBE Progress Report of July 15, 2003; p 16)
