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This presentation was produced under contract
number DE-AC04-00AL66620 with
Differing Professional
Opinion Program
THE SAFETY VALVE IN THE
FEEDBACK PROCESS
What is a DPO?
• “A Differing Professional Opinion is a
– Conscientious expression of a professional judgment
that
• Differs from the prevailing staff view,
• Disagrees with a management decision or policy
position, or
• Takes issue with a proposed or an established practice
– Involving technical, legal, or policy issues that,
– In the professional judgment of the submitter,
– Adversely affect the environment, and/or the safety
and health of the public and/or persons engaged in
work at the Plant.”
WI 02.04.01.17.04
“People do not always argue
because they misunderstand one
another; they argue because they
hold different goals”
William H. Whyte Jr.
What is NOT a DPO?
• Issues that are administrative in nature
(e.g., procedures for review and comment
or Price-Anderson enforcement
procedures)
• Personnel issues (e.g., performance
elements, evaluations and ratings or work
assignments by management)
What is NOT a DPO?
• Issues that relate to contracts not
relating to technical ES&H issues (e.g.,
fees or contract negotiations)
• Issues related to collective bargaining
What is NOT a DPO?
• Issues that are addressed through the
grievance process or personnel appeal
procedures
• Issues that relate to wrongdoing
(Differing Professional Opinion Manager
(DPOM) refers these to Internal Audit)
What is NOT a DPO?
• Issues submitted anonymously or for
which confidentiality is requested
• Issues that have been considered and
already addressed under this process
unless significant, new information is
available.
What examples of potential,
ongoing or historical
DPO’s
can you think of?
Why a DPO Program?
• Genesis within DOE
– DNFSB 2004-1 Implementation Plan
• Commitment to implement a DPO program within
DOE
– Action Items 4.a-b: Columbia & D-B Lessons Learned
Report
• Commitment for DOE contractors to implement a
DPO process and adopt in contracts
– Action Item 4.c: Columbia & D-B Lessons Learned
Report
Columbia & Davis-Besse
Pantex Studied the
DOE Columbia/D-B Report in 2006
Absence of DPO Process
Prominent in DOE Report
Pantex DPO Program
• Timeline
– “On radar” as DNFSB 2004-1 Concern
– Issue #4 from Anonymous Letter Response
Action Plan (PER 2007-0059)
– Impact evaluation of DOE M 442.1-1 & added
to contract in FEB 07
– DPO Implementation team formed late FEB
– Process Development late FEB to early APR
– Bulletin, WI & PX Form published 13 APRIL.
Key DPO Building Blocks
Bulletin # 967
• Applies to employees &
BWXT subcontractors
• Seeks to establish an
environment that
supports the raising of
issues.
• Requires impartial,
competent evaluation
• Recognizes positive
outcomes when
appropriate.
Bulletin # 967
• NO RETALIATION!!
None
of
this!!
DPO WI 02.04.01.17.04
• Sets clear conditions
for acceptance of
formal DPO
• Requires submitter to
attempt resolution
through management
chain, when possible.
• Allows for both
accelerated and
extended reviews.
DPO Preconditions
“… no time limits for completion of these
discussions, no tracking requirements,
and no requirements to keep written
records….”
PX-5476
• Used to evaluate
acceptability of a DPO
• Submitter provides as
much detail as possible
• Submitter recommends
reviewers for DPO
• Can be used for classified
DPOs.
DPO Process Overview
Reject and/or resubmit NO
YES
Employee or Problems Attempt
Submitter’s Issue
Subontractor w/ staffing Issue To Resolve issue
NO YES Accepted into
Technical Issue thru Mgmt chain Through Mgmt
DPO Process
RE: ES&H ? Chain ?
NO
DPOM
DPOM Verifies DPOM Appoints
Recommends Ad FDM Assigns
Sufficient Final Decision
Hoc Review Panel Panel Members to
Information from Manager (FDM) w/
to FDM w/in 10 Review DPO
Submitter in 10 days
days
AHP Issues
Recommendation FDM transmits
Ad Hoc Panel Submitter
w/in 30 days to recommendations
(AHP) Members Accepts
FDM to DPO Submitter
Review DPO Findings?
*
YES
Final Decision FDM recognizes
FDM coordinates documented and/ Submitter’s efforts
any actions w/ line or implemented. as appropriate *Alternate processes available.
managers
DPO’s &
the Safety Conscious
Work Environment
(SCWE)
A Strong Combination
DPO &SCWE
• A SCWE safety-conscious-work-
environment describes a workplace in
which all employees
– Contribute to a priority focus on safety by
speaking up about safety concerns
– Because they feel comfortable and valued
doing so.
• At its core, SCWE is about the free flow of
information relating to safety
A SCWE Reduces Formal DPOs
• Leaders: How SCWE are You? Do you:
– Encourage Issues?
– Listen? (for both scope and perception)
– Act on Issues?
– Give Feedback?
– Walk the Talk?
– Promote the Programs?
– Know Your Command Climate?
Team Members …
• Are you
– Passionate & unguarded in your discussion of issues?
– Deeply concerned about the prospect of letting down your
peers?
– Slow to seek credit for your own contributions, but quick to
point out those of others?
• Do you
– Call out one another’s deficiencies or unproductive
behaviors?
– Quickly & genuinely apologize to one another when you
say or do something damaging to the team?
– Challenge one another about your plans and approaches?
How Do We Voice Our Concerns?
When Do We Speak Up?
Why Team Dysfunction Occurs
When Team Dysfunction Occurs …
• The DPO Program is the “safety valve”
when our information “free flow” fails or
trust falters.
The “Pinball” Approach to a
Safety Culture
Protection Bankruptcy
Unrocked
Boat
Better defenses
converted to
increased
production
Catastrophe
Production
Seeking Differences Within a
Strong Safety Culture
Pantex DPO Experience
• Only 1 formal DPO thus far…
– Involved an environmental remediation issue
– Good bit of “management consternation” at
outset until process was understood
– Resulted in Company NOT siding with
Submitter, ALTHOUGH …
– Improvements to overall program were
requested by Ad Hoc Review Panel.
– Submitter accepted results.
Wait a Minute!
What have we learned so far?
Lessons Learned: Submitter
• DPO Program Manager needs to work
with Submitter to make sure issue can be
understood by independent Final Decision
Manager.
• Make sure Submitter agrees with stated
issue prior to beginning evaluation.
Ad Hoc Review Panel
Lessons Learned:
Ad Hoc Review Panel
• Appropriate technical credentials essential!
• Be Flexible in time lines
– Make sure that Ad Hoc Review Panel fully
understands issue and has framed it properly before
evaluation period begins.
• Work with Submitter & Majority-Opinion Holders
(Manager, Technical Authority, etc.) to gather
pertinent information and analyze issue.
Final Decision
Manager
The Need for a Solid
Reputation & Independence
Recognize
Courage & Positive
Contributions …
President & General Manager’s
Expectations
• Informal DPO’s are being actively worked and vetted in
each organization.
• We all benefit from the act of putting our arguments in
writing.
– Important technical decisions should not be based solely on
verbal discussions or PowerPoint presentations.
• “There is no excuse for a manager not understanding the
technical details of his or her business.”
– Demand debate. Confront difficult issues.
• “We should do things so well that no one can criticize us.”
– This often requires strong technical, written arguments, both
for and against a proposed solution.
The Need for the Differing View
• "One must create the ability in his staff to generate clear,
forceful arguments for opposing viewpoints as well as for
their own. Open discussions and disagreement 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 one's arguments. Weaknesses overlooked
in oral discussions become painfully obvious in the
written page."
Admiral H.G. Rickover
QUESTIONS?
Supplemental Slides
DPOs: Gone Missing
Seldom Discussed: K-Reactor
Well-Studied: Columbia & Challenger
A Case for the DPO Program
A Review of the
Decision to Restart
K-Reactor
(SRS)
K-Reactor Background
• Constructed in 1953
• Expected to run for 5 years at 250 MWth
• Operated from 1954 to 1988 at 2500 MWth
• 1988: K, L, & P Reactors Shutdown due to
operator errors and design problems with
emergency core cooling
systems.
• … around the same time…
Hanford N-Reactor permanently
shut down, Rocky Flats shut
down, Fernald shut down.
Commercial Reactor vs. K-Reactor
Basic Design
Primary Coolant Loop
No Secondary Coolant Loop
Environment
Environment
Secondary Coolant Loop
Primary Coolant Loop
Savannah River Site L-Reactor
R-Reactor
K-Reactor
P-Reactor
Swamp
Reviewer’s Troubling Findings
105-K Area
• Inadequate tritium
liquid effluent
monitoring
Reactor • Effluent samples
monitored only once
every 72-hours.
• Review team had
significant concerns
in accepting
Cooling substandard sampling
Tower
protocols
Outbrief Didn’t Go Well
• DOE Pre-Start finding on liquid effluent tritium
monitoring
• Significant pushback on reviewer from the
contractor
– Contractor position: Existing and planned
improvements “were acceptable”
• DOE-SR Customer felt same pressure to
proceed on schedule
• Quite a dilemma.
A Fateful Decision
OR
?
The Decision
• Accepted change of
pre-start to post-start
finding to meet
schedule.
• Contractor’s planned
improvements – and
Secretary’s looming
disappointment –
used to justify change
in finding significance.
13 December 1991
Restart Authorized
14 December 1991
Reactor Testing Begins
22 December 1991
Reactor leak begins in one of
9000 steam generator tubes
24 December 1991
(48 hours later)
Reactor Leak Detected
150 gallons of tritiated water released
6000 Curies of tritium headed to Savannah River
Reactor Shutdown
Christmas Eve 1991
… “Consultant” gets a call at home
from a friend working holiday shift at
K-Reactor …
“Anger Lingers After Leak at
Atomic Site”
“‘It's the overall picture that bothers me,’ said State
Representative Harriet Keyserling of Beaufort. ‘Two
years ago they had a similar spill, and an internal
report said they had to start monitoring it in a different
way. Two years later, they have never done it. Now
when everyone is screaming, they say, ‘We're going
to do it tomorrow.’”
New York Times, 13 JAN 1992
“3 Lawmakers Press to Keep Weapons
Reactor Shut”
“Democratic and Republican members of the South Carolina
Congressional delegation urged Energy Secretary James D.
Watkins today to keep an old reactor at the Savannah River
nuclear weapons plant shut down until new safety measures are taken
and the Energy Department prepares a study justifying a need to start it.
…
“…The letter, which is the most explicit statement of doubt about
the Savannah River plant's safety that has ever been issued by
South Carolina lawmakers, comes a month after an accident that
spilled 150 gallons of radioactive water into the Savannah River. The
spill caused radiation levels in the river to exceed Federal safety limits,
prompting a public water system downstream that serves 50,000
people around Beaufort, S.C., to shut its intake valve.”
New York Times, 17 JAN 1992
“Savannah River Reactor to Stay Shut
1,200 Layoffs Set”
“A battered old nuclear reactor at the Energy
Department's Savannah River, S.C., weapons plant that is
the nation's only source of a radioactive gas used in nuclear
warheads will not be restarted, Energy Secretary Hazel R.
O'Leary has announced…
“… At least 1,200 workers at the plant near Aiken, S.C.,
will be laid off, O'Leary said.”
The Washington Post, 31 MAR 1993
1996
K-Reactor placed in cold
shutdown
9 Years Pass
K-Reactor Take-Aways
1. From a radiological standpoint, 6. Differing professional
the release was minimal opinions were not solicited
- 6000 Ci < 0.08 mrem to MEOI or welcomed
2. Annual tritium liquid effluent 7. Trust given to DOE by South
releases were 7,000 Ci higher Carolina, Georgia and
on average…. Air effluent Congress was significantly
releases: 1.9 E05 Ci average* harmed
3. No residual environmental 8. “I told you so” mentality
damage allowed Congress to withhold
But…. K-reactor funding & kill the
project.
4. This “non-event” proved to be
the tipping point…. 9. $3B Wasted.
5. Time pressures & Facilitative
assumptions propagated 10. Nation’s only source of tritium
technically indefensible for weapons program lost for
practices over 18 years.
*DOE/EH-0644
Revisiting NASA
Challenger Disaster: 28 JAN 1986
… & 7 Years Later
Columbia Disaster: 1 FEB 2003
Has NASA Learned?
7 Months
Post-Columbia
Or not … 17 Months Pre-Columbia!
NASA Was “Talking the Talk”
NASA Wasn’t “Walking the Talk”
• NASA Technical Standard prohibited
launch IF foam shedding occurs
– 112 Launches pre-Columbia showed
evidence of foam shedding
• No actions taken
– By Columbia (STS-107)… foam strikes during
takeoff were “routine” and not evaluated after
82% of missions back to STS-1
• CAIB: “The machine was talking to us, but
nobody was listening.”
On Launch Day, 16 JAN 03
• 3,233 Criticality 1/1R critical item list
hazards that had been waived.
– Criticality 1/1R component failures result in
loss of the orbiter and crew.
• CAIB: “The unexpected became the
expected, which became the accepted.”
That’s nice, but …
Where’s the DPO connection?
Application to DPO’s
• Organizational accidents are not necessarily “self-
revealing” at the time a fateful management decision is
made.
• Managers must look for the “weak signals” of concern
their employees may be providing.
• Raising safety issues – big and small – must be
encouraged and welcomed.
“Sometimes when I consider what tremendous
consequences come from little things … I am tempted to
think there are no little things.”
Bruce Barton
