Risk Control Projects Workforce Capability and Human Error Event - PowerPoint PPT Presentation

Risk Control Projects Workforce Capability and Human Error Event Analysis Root Cause Determinations James Merlo, Associate Director of Human Performance Reliability Issues Steering Committee Meeting April 16, 2013

Event Analysis Root Cause Determinations AZ Information to determine cause Less Than Adequate (LTA) A4 Management / Organization AZ – Information to A2 Equipment / Material determine Cause LTA A1 Design / Engineering A7 Other A4 – Management / A2 – Equipment / Organization A3 Individual Human Performance Material A5 Communication AN No Causes Found 2 RELI ABI LI TY | ACCOUNTABI LI TY

Event Analysis Root Cause Determinations A4 – Management / Organization B3C08 - job scoping did not identify special circumstances or conditions B5C04 - risks/consequences associated with change not adequately reviewed B1C03 - direction created insufficient awareness of impact of actions on safety/reliability B1C04 - follow-up did not identify problems B1C05 - assessment did not determine cause of previously event or known problem 3 RELI ABI LI TY | ACCOUNTABI LI TY

Event Analysis Root Cause Determinations 16 A4 – Management Challenges 14 B1C05 - assessment did not determine cause of previously event or known problem 12 B3C08 - job scoping did not identify special circumstances or conditions 10 B5C03 - inadequate vendor support of change B5C04 - risks/consequences associated with change not 8 adequately reviewed B1C08 - corrective action responses to a known or 6 repetitive problem was untimely B5C05 - system interactions not considered 4 B1C04 - follow-up did not identify problems 2 0 4 RELI ABI LI TY | ACCOUNTABI LI TY

Event Analysis Root Cause Determinations 16 A4 – Management Challenges 14 B1C05 - assessment did not determine cause of previous event or known problem 12 B3C08 - job scoping did not identify special circumstances or conditions 10 B5C03 - inadequate vendor support of change 8 B5C04 - risks/consequences associated with change not adequately reviewed 6 B1C08 - corrective action responses to a known or repetitive problem was 4 untimely B5C05 - system interactions not considered 2 B1C04 - follow-up did not identify problems 0 A4B1C05 A4B3C08 A4B5C03 A4B5C04 A4B1C08 A4B5C05 A4B1C04 5 RELI ABI LI TY | ACCOUNTABI LI TY

Event Analysis Root Cause Determinations Strategy • Increasing Awareness: Promote Root Cause Problem Analysis as a fundamental Identification learning organization practice Target for Success Failure to identify • Education: Provide learning Decreasing trends seen or correct root opportunities regarding RCA in event data for AZ and causes of events A4 Cause Codes in a timely Activities manner can • Issue alerts regarding Current Progress result in the common problems • Some activities in continued • Add structure to NERC’s progress; others in existence of Cause Code Analysis planning latent errors, Process (CCAP) leaving the BES • Outreach to various groups vulnerable. of stakeholders • Hold conferences and training on RCA and NERC’s CCAP 6 RELI ABI LI TY | ACCOUNTABI LI TY

Questions and Answers 7 RELI ABI LI TY | ACCOUNTABI LI TY