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

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Event Analysis Root Cause Determinations

A2 – Equipment / Material A4 – Management / Organization AZ – Information to determine Cause LTA

AN No Causes Found A5 Communication A3 Individual Human Performance A7 Other A1 Design / Engineering A2 Equipment / Material A4 Management / Organization AZ Information to determine cause Less Than Adequate (LTA)

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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

• r known problem

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Event Analysis Root Cause Determinations

2 4 6 8 10 12 14 16

A4 – Management Challenges B1C05 - assessment did not determine cause of

previously event or known problem B3C08 - job scoping did not identify special circumstances

• r conditions

B5C03 - inadequate vendor support of change B5C04 - risks/consequences associated with change not adequately reviewed B1C08 - corrective action responses to a known or repetitive problem was untimely B5C05 - system interactions not considered B1C04 - follow-up did not identify problems

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Event Analysis Root Cause Determinations A4 – Management Challenges

B1C05 - assessment did not determine cause

• f previous event or known problem

B3C08 - job scoping did not identify special circumstances or conditions B5C03 - inadequate vendor support of change B5C04 - risks/consequences associated with change not adequately reviewed B1C08 - corrective action responses to a known or repetitive problem was untimely B5C05 - system interactions not considered B1C04 - follow-up did not identify problems

2 4 6 8 10 12 14 16 A4B1C05 A4B3C08 A4B5C03 A4B5C04 A4B1C08 A4B5C05 A4B1C04

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Event Analysis Root Cause Determinations

Problem Identification Failure to identify

• r correct root

causes of events in a timely manner can result in the continued existence of latent errors, leaving the BES vulnerable. Strategy

• Increasing Awareness:

Promote Root Cause Analysis as a fundamental learning organization practice

• Education: Provide learning
• pportunities regarding RCA

Activities

• Issue alerts regarding

common problems

• Add structure to NERC’s

Cause Code Analysis Process (CCAP)

• Outreach to various groups
• f stakeholders
• Hold conferences and

training on RCA and NERC’s CCAP Target for Success Decreasing trends seen in event data for AZ and A4 Cause Codes Current Progress

• Some activities in

progress; others in planning

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Questions and Answers