Sunday, January 25, 2015
Did the culture of reprisal at LANSLLNS contribute to the WIPP disaster?
Was the culture of reprisal at LANSLLNS a contributing factor to the ~0.5 billion dollar WIPP environmental disaster? Were experienced lab employees reluctant to speak up when it could have made a difference in the WIPP outcome?
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Or did experienced employees think they could make a simple change that no one would notice?
Or was it hurry up and get the job done and don't worry about material compatibility or a thorough Failure Mode Effects Analysis (FMEA) review for the procedure change. "Remember what happened to Billy Bob when he raised a change in procedure safety concern and the delay it created?"
Is the WIPP disaster one of many failed, skipped, or cursory process reviews currently in play at LANL or LLNL? It is a reasonable question given the gross negligence in the WIPP situation. Read the DOE IG report.
Has the LANS WIPP change in "kitty litter" (organic vs. inorganic chemical compatibility) peer review occurrence and the associated FMEA document surfaced? Does it exist? Was the change reviewed in any fashion? If the FMEA document does exist, was there a cell in the FMEA form with a catastrophic result for a failure?
The only reprisal present when I worked in the EWMO Division at LANL, is if you didn't cut corners and hurry up. In fact, the most intimidating manager in this program was Jim Blakenhorn, who is now at WIPP responsible for leading the WIPP investigation. There is a major conflict of interest with many of the managers leading the WIPP investigation, on-site recovery manager, many are former LANL managers. The whole WIPP "story" is wrought with deception and corruption.
LLNL CONTENT ONLY
BS. Though some personal excesses are inevitable, the is no regular, tolerated culture of retaliation at
LLNL.
LLNL contributed little or nothing to WIPP. Nothing to the release. We dont know what it does or how it is done.
From another topic but with possible relevance here:
"...Don't forget Mara, Knapp, Anastasio, and McMillan were/are from Livermore. We were created to be competitive, however, LANS/LLNS brought us together at the hip. Its an incestuous culture, like it or not. You in denial!..."
"...BS. Though some personal excesses are inevitable, the is no regular, tolerated culture of retaliation at LLNL.."
As clearly written in the FMEA description of terms, if the probability is low of an event ("no regular tolerated culture of retaliation at LLNL"), where the event here is failure to raise a concern, but the resulting consequence is catastrophic, the event must be addressed to the satisfaction of the design review committee, and or involved agencies.
Unfortunately lab employee fear of retaliation can easily bleed over from a low impact (non-catastrophic) activity to a high impact activities with catastrophic potential. This is why a consistently applied "open door" safety policy at the labs is of paramount importance to lab employees and the surrounding communities. We do wish to have a "6 Sigma safety" culture at the labs yes?
I do not doubt that there some culture of reprisal but I would that the situation is more complicated. If there is any one culture that is a problem at the labs and LANL in particular is that of a bad management culture. This leads to three things, (1) Us versus them mentality, where workers do not trust managers and fear them. If the workers lose trust in the management than these leads to all sorts of problems. (2) Management never leads it only reacts and the reaction is not address problems but to cover themselves. This of course means that these problems are never fixed and arise again. (3) Management positions are not based on merit or qualifications but award systems for being loyal to the management. Overtime this means that you have very poor quality managers. Of course one of the reasons they need to cover themselves is because they are so poorly qualified. A common analogy that managers seem to often use is that the labs are a house of cards, a myth, that you cannot shake and could come down at any moment. The thing is that it is actually described the managers much better.
There had always been some this as far as I can remember but once the contract change occurred it went into overdrive as the number of managers grew. Many of the new managers have very little to do in terms of actual work so they then create this narrative that the labs themselves have very little to do. They only interact with other managers, avoid communicate with the workforce, and belittle those who do real work all so that they can keep the facade going in their own minds. In private you can talk with some of them and they will admit some of this but will say that the lab has changed and the whole modern United States is corrupt and one has to adapt to the new reality. They than go to make a list of how things or just as bad at Universities, the military, Wall street, etc. Personally I do not believe this and even if part of it is true one should run to embrace it but should try to resist it.
Did anyone notice the email that was sent out by Charlie this weekend on retaliation? Something is going on.
"...I do not doubt that there some culture of reprisal but I would that the situation is more complicated..."
I agree, but a cultural of reprisal can wick its way into a procedure, activity, or review process. It does not take frequent reprisals to "refresh" the fear or hesitation to speak up, especially when manager/employee trust is already fragile. Fear of blow back is hard to reverse once established. If "Billy Bob" gets burnt by his manager for raising a concern or "stepping on his toes", the manager's victory is shallow, short lived, and can have long term consequences for the labs.
"Six Sigma" quality management at LANSLLNS?
From the web link below, LANSLLNS would struggle with
"Three Sigma"
-well defined responsibility and accountability at ALL levels
and fail to reach
"Four Sigma"
-quality of supervision, attitude toward safety, manager/employee communication, hazard correction, employee involvement, program awareness, support for safety, safety climate, and management credibility"
https://safety.cat.com/cda/files/3066657/7/6+Sigma+Safety_Williamsen.pdf
"Sigma" is a mathematical term to indicate a "standard deviation" from an average or normal distribution of data based on some model of fit for the data. "Six sigma" is used as an indication that a data point is sufficiently removed (i.e., six times the standard deviation) from the data fit to be excluded from consideration as relevant or accurate; it is an outlier legitimately allowed to be discarded from the data set. Or in this bastardized case of use of the term, the users intend it to mean that their "six sigma" is so much removed from (i.e., better than) the average that it is exceptional. Just a bureaucratic misuse of a perfectly good mathematical concept.
"...Just a bureaucratic misuse of a perfectly good mathematical concept..."
How dare anyone attempt to size up the cluster of failures or work culture at LANSLLNS with some newfangled industry accepted metric. Maybe we should grade on a curve? Drop the lowest grade?
Push ownership for the WIPP disaster back on the state of New Mexico and move on?
There is a big misunderstanding here. We only want to be thought of like a regular "for profit" company when the LANSLLNS worker bee "losers" are complaining about low morale, and management practices. We want to be sheltered from any industry accepted measure of our LANSLLNS performance, and we certainly don't want to be penalized for gross negligence at WIPP.
We are a different breed of "for profit" Google like companies, without ownership of pesky business operation risk factors.
Look how are the workers at LANL/LLNL different from Wallmart workers? We both cost money and are a necessary evil in order to make a profit. If LLNLs/LANS could get rid of all the workers than there would be no safety and security incidents. However we still need people to fill the shelves and run the cash registers so we still need workers at the labs. In any case we have to make do, so WIPP occurs because of the "workers", so it goes, it is the burden than the managers must bear.
9:02 and 8:48 nailed it. Six sigma is a farce and exists in name only at the Lab. Management at LANL is a farce and exists in name only. I don't think it will ever recover, certainly not under DOE. Like so many before me I'm pulling the rip cord before this rocket hits the ground.
I don't think it will ever recover, certainly not under DOE. Like so many before me I'm pulling the rip cord before this rocket hits the ground.
January 30, 2015 at 5:16 AM
Were not a rocket at LANL bro, we are in a Yugo and its about catch on fire. Get out!
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