human performance - southwest power pool · 2019. 2. 8. · characteristics, performance...

Human Performance: The Science behind the Tools

James Merlo, PhD October 2012

2 RELIABILITY | ACCOUNTABILITY

NERC Pillars

• Reliability – to address events and identifiable risks, thereby improving the reliability of the bulk power system.

• Assurance – to provide assurance to the public, industry, and government for the reliable performance of the bulk power system.

• Learning – to promote learning and continuous improvement of operations and adapt to lessons learned for improvement of bulk power system reliability.

• Risk-based model – to focus attention, resources and actions on issues most important to bulk power system reliability.


Top Priority Reliability Issues

• Misoperations of relay protection and control systems

• Human errors by field personnel

• Ambiguous or incomplete voice communications

• Right-of-way maintenance

• Changing resource mix

• Integration of new technologies

• Preparedness for high impact, low frequency events

• Non-traditional threats via cyber security vulnerabilities

NERC President’s Top Priority Issues for Bulk Power System Reliability, http://www.nerc.com/news_pr.php?npr=723 at http://www.nerc.com/fileUploads/File/News/NERC%20President%20Top%20Priority%20BPS%20Reliability%20Issues%201-7-11.pdf

http://www.nerc.com/news_pr.php?npr=723�

http://www.nerc.com/fileUploads/File/News/NERC President Top Priority BPS Reliability Issues 1-7-11.pdf�


• Misoperations of relay protection and control systems

• Human errors by field personnel

• Ambiguous or incomplete voice communications

• Right-of-way maintenance

• Changing resource mix

• Integration of new technologies

• Preparedness for high impact, low frequency events

• Non-traditional threats via cyber security vulnerabilities

Top Priority Reliability Issues

NERC President’s Top Priority Issues for Bulk Power System Reliability, http://www.nerc.com/news_pr.php?npr=723 at http://www.nerc.com/fileUploads/File/News/NERC%20President%20Top%20Priority%20BPS%20Reliability%20Issues%201-7-11.pdf

http://www.nerc.com/news_pr.php?npr=723�

http://www.nerc.com/fileUploads/File/News/NERC President Top Priority BPS Reliability Issues 1-7-11.pdf�


Reliability Risk Management Concept

Severity

Inverse Cost-Benefit

Reporting Threshold

Learn and Reduce

Avoid


Drifting to Failure*

Latent Error Inconspicuous and seemingly harmless buildup of “hidden” error and organizational weaknesses

Relia

bilit

y

Hi

Lo Time

Drift

Stated Expectations

“Normal” Practice

Real Margin for Error

* Adapted from Muschara Error Management Consulting, LLC

Expectations: Desired approach to work (as imagined) Normal Practices: Work as actually performed (allowed by mgmt!)

Error

Hidden hazards, threats, unusual conditions, & system weaknesses


Peer Check

Safety Check


Too Hard?

“Complicated Industry” “Come along way” “Can’t get to zero” “Automate, technology reduces the need for human operator”


Challenge

www.airlines.org/PublicPolicy/Testimony/Pages/testimony_5-13-09Senate.aspx&docid=qnHU9MAraY_WIM&w=550&h=403&ei=mdRbTvkrhLm3B8nyibgM&zoom=1&iact=rc&dur=62&page=2&tbnh=167&tbnw=216&start=50&ndsp=31&ved=1t:429,r:4,s:50&tx=110&ty=85


Human Performance

It is not a matter of if the automation fails, it

is a matter of when.


Stuff Happens


Human Performance Analysis

• We have not fully understood an event if we don’t see the actors’ actions as reasonable.

• The point of a human error investigation is to understand why people did what they did, not to judge them for what they did not do.

• The difference between an accident and a serious incident lies only in the result.


Challenge

www.airlines.org/PublicPolicy/Testimony/Pages/testimony_5-13-09Senate.aspx&docid=qnHU9MAraY_WIM&w=550&h=403&ei=mdRbTvkrhLm3B8nyibgM&zoom=1&iact=rc&dur=62&page=2&tbnh=167&tbnw=216&start=50&ndsp=31&ved=1t:429,r:4,s:50&tx=110&ty=85


Flowchart for Human Performance


Sometimes it is a Human


Human Performance Tenets

• People are fallible, and all people make mistakes • Error-likely situations are predictable, manageable, and preventable • Individual behavior is influenced by organizational processes and values • People achieve high levels of performance largely because of the encouragement and reinforcement received from leaders, peers, and subordinates • Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events or near misses


Five Questions

• Elegant simplicity • Know thy user • The rat is never wrong • Actions not words • You can’t afford not to know the truth


Five Questions



Elegant simplicity

• Elegant simplicity Russians and the US Space Program How many tools in the box? The tool shouldn’t be harder than the task. Surround the truth…it is out there somewhere…


Human Performance Tools

• Two Minute rule

• Stop when unsure

• Self checking (also called STAR and touch STAR)

• Procedure use and adherence

• Three way communication

• Phonetic alphabet

• Pre-job brief

• Peer check

• Concurrent verification

• Independent verification

• Flagging operational barriers

• Place keeping

• Post job interview

• First Check


Read All About It


Five Questions



Know thy user

• Know thy user Human Ingenuity Only two hands, two eyes, see the pattern? If you only have a minute, it only takes a

minute… Set me up for success…please… Human nature


Darnell, M. J. (2006). Bad Human Factors Designs. Baddesigns.Com

Signs


Five Questions



The rat is never wrong

• The rat is never wrong Behaviorism Not enforcing a policy is like not having a

policy at all Don’t have a rule that you aren’t going to

enforce


The rat is never wrong

Human behavior is shaped by interaction in the world…

• Punishment stops behavior • Reinforcement shapes and sustains behavior


Silence is Consent


Punishment vs. Negative Reinforcement

Does the behavior increase or decrease?


Get ‘er done


Five Questions



Actions not words

• Actions not words It is not important unless it is checked. What is your story? Are you telling your story up or down? Live the dream


Tell your story…


Five Questions



You can’t afford not to know the truth

• You can’t afford not to know the truth Root cause Just Culture Near misses


A Tale of Two Cylinders


Or…When Good Pistons Go Bad!


Why Root Cause Versus Apparent Cause?

• Facts: Jeep had 107k miles

Cylinders were fine…no abrasions (whew, got lucky)

Approximately $2,500 to completely rebuild, same block just new pistons

Just mean time between failures for pistons…or maybe not


The Rest of the Story…

• Mechanic noticed some scalding on other pistons • No history of ever overheating


The Rest of the Story...

• Mechanic noticed some scalding on other pistons • No history of ever overheating • Jeep was hit on right side, at 70k miles • Right fender was replaced, radiator and fan blade...no

damage to engine block


The Rest of the Story…

• Mechanic noticed some scalding on other pistons • No history of ever overheating • Jeep was hit on right side, at 70k miles • Right fender was replaced, radiator and fan blade...no

damage to engine block • New fan blade was installed backwards!

• Jeep was running hotter than it should…just slightly…not enough to notice…and there was a new owner so there was no baseline


Peer Check

Safety Check


Can Your Organization Handle the Truth?

"Before you tell the "truth" to the patient, be sure you know the "truth,“ and that the patient wants to hear it."

Journal of Chronic Diseases (1963) Dr. Richard Clarke Cabot (1868-1939)


Five Questions

• Elegant simplicity Russians and the Space Program

• Know thy user Human Ingenuity

• The rat is never wrong Behaviorism

• Actions not words It is not important unless it is checked.

• You can’t afford not to know the truth Root Cause


Six Human Considerations

• Attention • Sensation • Perception • Cognition • Decision making • Action


Attention

• Spotlight metaphor • Each modality has its strengths • Multiple Resource Theory

53 RELIABILITY | ACCOUNTABILITY 53 53

Photo by isafmedia. Used with permission.

54 RELIABILITY | ACCOUNTABILITY 54 54

Photo by isafmedia. Used with permission.

Primarily Scanning

Primarily Focusing

The sniper’s mental state is Focused. The spotter’s mental state is Scanning. Both communicate effectively with each other. The result? Situational Awareness that you can bet your life on.

55 RELIABILITY | ACCOUNTABILITY 55


Primarily Scanning

Primarily Focusing

Communicating


Primarily Focusing

Primarily Scanning


Primarily Focusing

Primarily Scanning

Primarily Focusing

Primarily Scanning


Sensation

• Human limitations • Absolute Threshold • Physiological Psychology


Regular Insulin N (for NPH Insulin).

Hindsight is 20/20


Perception

• Perception is Reality • Bottom Up versus Top Down • Expectations


What about the science…

• CAPITAL LETTERS

WORD

EASIER

FASTER

BUT BECOMES MORE DIFFICULT WHEN PART OF A SENTENCE BECAUSE…

We use context to read and the shape matters


Regular Insulin N (for NPH Insulin).

Hindsight is 20/20


Communicating


Biological Bases for Behavior

Cognition


Cognition

• What are you thinking about?

• Working memory versus Long Term Memory

• Experts versus Novices


Limited Working Memory • Mind's short-term memory is the “workbench” for problem solving and decision-making. • Actively involved during learning, storing, and recalling information. • Often expressed as 7+ or -2. • Limitations of short-term memory are at the root of forgetfulness; forgetfulness leads to omissions when performing tasks. • Applying place-keeping techniques while using complex procedures compensates for this human limitation.


Working Memory

• Size 7 +/- 2 chunks • VAFBICIADODIRA

– VA FBI CIA DOD IRA • Area codes • Credit card numbers are divided into

chunks…. • Expert memories…or really good

chunkers


Doubting me still….

• Alphabet 26 letters…

or 8 chunks?

ABCD EFG HIJK LMNOP QRS TUV WX YZ


Mental Model

• One’s understanding of a system, how it operates, its characteristics, performance parameters, couplings within itself and other systems and how one interacts with it.

• It is a representation of the surrounding world, the relationships between its various parts and a person's intuitive perception about his or her own acts and their consequences.

• Our mental models help to shape our behavior and define our approach to solving problems (a personal algorithm) and carrying out tasks, especially within a system.

• Mental models are like opinions, they can be partially or completely right or wrong, complete or incomplete and most often are unique for each individual.


Perfectly aligned mental model


Improper Mental Model Example

Some people believe that you can heat/cool a room faster by setting the thermostat to a higher/lower temperature than you really want, as if the thermostat were a valve for the heating/cooling system that lets more heat/cool air into the room the higher/lower you set it. In fact, the thermostat is simply an on/off switch for the heat/cool. It turns on as long as the room temperature is below/above the thermostat setting, and turns off when the thermostat setting is reached.

http://bettergui.com/blog/wp-content/uploads/2011/03/thermostat.jpg�


Contextual Task Analysis

Max Whittaker for The New York Times

Hydro Quebec


Decision Making

• Information overload • Experts vs Novices • Heuristics and Biases



Signs


Information Overload


Heuristics and Biases

• Avoidance of Mental Strain – Humans are reluctant to engage in lengthy concentrated thinking, as it requires high levels of attention for extended periods. Thinking is a slow, laborious process that requires great effort. People tend to look for familiar patterns and apply well-tried solutions to a problem. The mental biases and heuristics, or shortcuts, often used to reduce mental effort and expedite decision-making include:

• Assumptions – A condition taken for granted or accepted as true without verification of the facts.

• Habit – An unconscious pattern of behavior acquired through frequent repetition.


Heuristics and Biases

Confirmation bias – The reluctance to abandon a current solution—to change one's mind—in light of conflicting information due to the investment of time and effort in the current solution. This bias orients the mind to “see” evidence that supports the original supposition and to ignore or rationalize away conflicting data. Similarity bias – The tendency to recall solutions from situations that appear similar to those that have proved useful from past experience. Frequency bias – A gamble that a frequently used solution will work; giving greater weight to information that occurs more frequently or is more recent. Availability heuristic – The tendency to settle on solutions or courses of action that readily come to mind and appear satisfactory; more weight is placed on information that is available (even though it could be wrong).


• People generally seek evidence that will confirm, not falsify, a hypothesis

• Solve problems and syllogisms by applying information to pre-existing schemas

• More relevant = easier to solve

• The Bottom Line: People are not logic machines who can plug any problem into a logical formula

Confirmation Bias Continued


• Availability Heuristic

estimating the likelihood of events based on their availability in memory

if instances come readily to mind (perhaps because of their vividness), we presume such events are common

We tend to be overly influenced by events that come easily to mind

Availability Heuristic



Is the letter “k” most likely to occur in the first position of a word or the third position?


• Answer: “k” is 2-3 times more likely to be in the third position

• Most people respond that “k” is more frequent in the first position. Why does this occur?

• Because it is easier to recall words starting with “k” , people overestimate the number of words starting with “k”



Which of the following are more frequent causes of death in the U.S.?

Rate how confident you are in your choice on a scale from 0 (guessing) to 100 (absolutely certain that your choice is correct).

1. All accidents or strokes? confidence rating?

2. Electrocution or asthma? confidence rating?

3. Homicide or diabetes? confidence rating?

4. Lightning or appendicitis? confidence rating?

5. Drowning or Leukemia? confidence rating?



Which of the following are more frequent causes of death in the U.S.?

1. All accidents (55,000) or strokes (102,000) 2. Electrocution (500) or asthma (920) 3. Homicide (9200) or diabetes (19,000) 4. Lightning (52) or appendicitis (440) 5. Drowning (3600) or Leukemia (7100)



Moving slow to move fast

• All human performance tools deliberately slow things down to ultimately speed things up by avoiding delays that accompany events triggered by active errors.

• When used conscientiously, these tools give the individual more time to think about the task at hand; about what is happening, what will happen, and what to do if things do not go as expected.


Action


Rasmussen’s Classifications

• Human Error Classifications Skill Based

Rule Based

Knowledge Based

• Driving example: Often times a human will operate in all three levels, going back and forth in a single event.


Improper Mental Model (cont)

• Skill - Does not really effect

• Rule – Usually not a factor

• Knowledge – Real problem



• Attention • Sensation

• Perception • Cognition

• Decision making • Action

Scan

Focus

Act


Situational Awareness

• Situational awareness is defined as the accuracy of a person’s current knowledge and understanding of actual conditions compared to expected conditions at a given time. DOE

• The perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.

Endsley, M. R. (1995). Toward a theory of situation awareness in dynamic systems. Human Factors, 37(1), 32-64.

104 RELIABILITY | ACCOUNTABILITY http://en.wikipedia.org/wiki/Situation_awareness

Situational Awareness

http://upload.wikimedia.org/wikipedia/en/9/99/SA_Wikipedia_Figure_1_Shared_SA_(20Nov2007).jpg�


Stress

• Stress is the body’s mental and physical response to a perceived threat(s) in the environment. It is the perception one has about his or her ability to cope with the threat.

• Stress in itself is not a bad thing. Some stress is normal and healthy. Stress may result in more focused attention, which in some situations could actually be beneficial to performance.

• The problem with stress is that it can accumulate and overpower a person, thus becoming detrimental to performance. Stress increases as familiarity with a situation decreases. It can result in panic, inhibiting the ability to effectively sense, perceive, recall, think, or act. Anxiety and fear usually follow when an individual feels unable to respond successfully.

• Along with anxiety and fear, memory lapses are among the first symptoms to appear. The inability to think critically or to perform physical acts with accuracy soon follows.


Is stress always a bad thing?

Inverted-U Hypothesis

emotional arousal vs task performance


TWIN - Error Precursors Task Demands Work Environment

Time pressure (in a hurry) Distractions / Interruptions High workload (memory requirements) Changes / Departure from routine Simultaneous, Multiple tasks Confusing displays / control Repetitive actions (monotony) Work - arounds Unclear goals, roles, or responsibilities Unexpected equipment conditions Lack of or unclear standards Back shift or recent shift change Complex / High information flow

Individual Capabilities Human Nature Unfamiliarity with task (first time) Stress Lack of knowledge (faulty mental model) Habit patterns Imprecise communication habits Assumptions Lack of proficiency; inexperience Complacency / over confidence Overzealousness for safety critical task Inaccurate risk perception Illness or fatigue – Fitness for duty Communication shortcuts Lack of big picture


Latent Organizational Weaknesses

Pre-Job Briefing Values & Norms

Communications – Oral & Written Maintenance Processes

Work Planning & Scheduling Procedure Development

Controls, Measures and Monitoring Goals & Priorities

Design & Modifications Organizational Structure

Task Structure Roles & Responsibilities

Written Guidance: Rules, Policies and Practices

Training & Qualification

A review of the INPO industry event data base reveals that events occur more often due to error-prone tasks and error-prone work environments than from error-prone individuals

Error-prone tasks and work environments are typically created by latent organizational weaknesses. Source: Reason – 1991 (modified)


Defenses

Defense 1

But it is possible that under the wrong set of circumstances, an event could occur….

Defense 2 Defense 3

Defense 4

Event

Hazard

110 RELIABILITY | ACCOUNTABILITY RELIABILITY | ACCOUNTABILITY

Set Me Up for Success

• Distractions

• Interruptions

• Unplanned changes

Those things that “set-up” a mistake to happen

Task demands are greater than the worker’s abilities

Confusing conditions make the job harder

New techniques not used before

Mental shortcuts

Lack-of or unclear standards

Illness / Fatigue


Reliability

Equipment Reliability Human Performance Human Interaction with Equipment (coupled w/Automation)


835

432

48 20

0

100

200

300

400

500

600

700

800

900

Unnecessary Trips during fault

Unnecessary Trips other than fault

Failure to trip Slow trip

Misoperation Count by Category (total reported)

Misoperation Categories (2011 Q2-Q3)

Mis

oper

atio

n Co

unt

Misoperation Category


Misoperation Causes (2011 Q2-Q3)

424

305

219

155

88 91

43 10

0

50

100

150

200

250

300

350

400

450 Total Reported

Mis

oper

atio

n Co

unt

Misoperation Cause


138

96

63

8

0

50

100

150

200

250

300

350

Electromechanical Microprocessor Solid state Unknown

Misoperation Relay Technology (2011 Q2-Q3)

Mis

oper

atio

n co

unt

Misoperations by Relay Technology (only Relay Failure/Malfunction Cause)


68

316

19 21

0

50

100

150

200

250

300

350

Electromechanical Microprocessor Solid State Unknown

Mis

oper

atio

n co

unt

Misoperations by Relay Technology (only incorrect Settings/Logic/Design Error Cause)

Misoperation Relay Technology (2011 Q2-Q3)


Mental Model of the System

• Apparent simplicity with hidden complexity Fitting your understanding

into the system constraints (hardware and software)

Different manufacturers, diverse applications and tools, requires different approaches

• Design for a person to use, set and operate


Malcolm K. Sparrow John F. Kennedy School of Government, Harvard University

Solving Problems: Untying the Knot


Initiative

The Reliability Risk Management Group (RRM) has designed, developed, and implemented the North American Energy Reliability Corporation (NERC) Causal Code Assignment Process to allow accurate, efficient trending and subsequent analysis of events for sharing and providing a cooperative forum focused on improving the reliability of the Bulk Power System (BPS).

NERC CCAP North American Electric Reliability Corporation Causal Code Assignment Process An event and data analysis tool


Purpose

• Establish NERC causal coding program to guide, assist, and inform industry

• Venue to share data across NERC • Opportunity to collect and disseminate reliability data • Expanded communication channel to reach parts of

industry and Electric Reliability Organization • Foster trust and collaboration between Applicable

Governmental Agency, ERO and stakeholders


Cause Code Assignment Process (CCAP)

• A1 Design/Engineering Problem • A2 Equipment/Material Problem • A3 Individual Human Performance LTA • A4 Management Problem • A5 Communication LTA • A6 Training Deficiency • A7 Other Problem


A3 - Human Performance

Cause Code Assignment Process (CCAP)

• A1 Design/Engineering Problem • A2 Equipment/Material Problem • A3 Individual Human Performance B1 SKILL BASED ERROR

B2 RULE BASED ERROR

B3 KNOWLEDGE BASED ERROR

B4 WORK PRACTICES

• A4 Management Problem • A5 Communication LTA • A6 Training Deficiency • A7 Other Problem


A3 - Human Performance Cause Code Assignment Process (CCAP)

• A3 Individual Human Performance B1 SKILL BASED ERROR

o C01 Check of work LTA

o C02 Step was omitted due to distraction

o C03 Incorrect performance due to mental lapse

o C04 Infrequently performed steps were performed incorrectly

o C05 Delay in time caused LTA actions

o C06 Wrong action selected based on similarity with other actions

o C07 Omission / repeating of steps due to assumptions for completion

B2 RULE BASED ERROR

B3 KNOWLEDGE BASED ERROR

B4 WORK PRACTICES


NERC CCAP


25

49

66

46

3732

2723

0

10

20

30

40

50

60

70

2010Q4 2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3

Qualified Events by Quarter

2010Q4 only contains two months of data – Field trial began in Oct 2010

2012Q3 only contains two months of data


23

19.43

8.30

0

5

10

15

20

25

30N

ov-1

0

Dec

-10

Jan-

11

Feb-

11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Qualified events (October 25, 2010 - August 25, 2012)

Monthly average = 13.86 events

Event Trending *

* Control chart of monthly events, with control limits calculated by using 3-month Moving Average method


14.16

4.75

0

2

4

6

8

10

12

14

16

18

20N

ov-1

0

Dec

-10

Jan-

11

Feb-

11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Category 1 Events (October 25, 2010 - August 25, 2012)

Category 1 Events *

Monthly average = 9.45 Cat 1 events

* Control chart of monthly events, with control limits calculated by using 3-month Moving Average method


0

2

4

6

8

10

12

14

16

18

20

Nov

-10

Dec

-10

Jan-

11

Feb-

11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

FRCC

MRO

NPCC

RFC

SERC

SPP

TRE

WECC

Total

Category 1 Events (October 25, 2010 - August 25, 2012)

Category 1 Events (by Region)

Monthly average = 9.60 Cat 1 events


-

0.0050

0.0100

0.0150

0.0200

0.0250

0.0300

FRCC

MRO

NPCC

RFC

SERC

SPP

TRE

WECC

Total

Cat 1 events normalized by 1000 miles of Transmission Line


Red lines indicate timeframe of concern



Red lines indicate timeframe of concern

-

0.0005

0.0010

0.0015

0.0020

0.0025

0.0030

FRCC

MRO

NPCC

RFC

SERC

SPP

TRE

WECC

Total

Cat 1 events normalized by 1000MW NDC


Cause Coding Initial Look

The following is an initial look at cause of events NERC has currently cause coded.

Cause coding of all events captured in the NERC database has not been completed.


Cause Code Definitions

Short Title Definition Design/Engineering Problem An event or condition that can be traced to a defect in

design or other factors related to configuration, engineering, layout, tolerances, calculations, etc.

Equipment/Material Problem Is defined as an event or condition resulting from the failure, malfunction, or deterioration of equipment or parts, including instruments or material.

Individual Human Performance LTA

An event or condition resulting from the failure, malfunction, or deterioration of the individual human performance associated with the process.

Management Problem An event or condition that could be directly traced to managerial actions, or methodology (or lack thereof).

Communications LTA Inadequate presentation or exchange of information.

Other Problem The problem was caused by factors beyond the control of the organization

LTA = Less Than Adequate


Root Cause determinations

NERC has “Cause Coded” 229 out of 305 Qualified Events (75%, as of 8-25-2012). Of these events, we were able to assign some type of “Root Cause” coding for 173 events (~75%).

40% of the reports did not contain sufficient information to determine causal factors.

2510%

2811%

42%

4318%

62%

198%

21%

42%

11046%

Region =(All); Year =(All)

A1 Design/Engineering Problem

A2 Equipment/Material Problem

A3 Individual Human Performance LTA

A4 Management Problem

A5 Communication LTA

A7 Other Problem

AN No Causes Found

AX Overall Configuration Issue

AZ

A-Level Cause Codes (241 entered)


2519%

2821%

43%

4333%

65%

1914%

22%

43%

Region =(All); Year =(All)

A1 Design/Engineering Problem

A2 Equipment/Material Problem

A3 Individual Human Performance LTA

A4 Management Problem

A5 Communication LTA

A7 Other Problem

AN No Causes Found

AX Overall Configuration Issue

A-Level Cause Codes (131 entered : removing AZ)

Identified Root Causes

Discounting the 46% of reports that did not contain sufficient information to determine root causes, we have assigned root cause for 131 events.

See Deeper dive Chart




0

1

2

3

4

5

6

7A

4B3C

08

A4B

5C04

A4B

1C03

A4B

1C04

A4B

1C05

A4B

1C06

A4B

5C05

A4B

1C08

A4B

1

A4

A4B

1C09

A4B

3C09

A4B

4

A4B

5

A4B

5C02

A4B

5C03

A4B

5C13

A4B

2C07

A4B

3C05

A4

"Management Problem" Cause FactorsA4B3C08 = Job Scoping did not identify special circumstances or conditionsA4B5C04 = Risks/consequences associated with change not adequately reviewedA4B1C03 = Management direction created insufficient awareness of impact of actions on safety/reliabilityA4B1C04 = Management follow-up did not identify problemsA4B1C05 = Management assessment did not determine cause of previously event or known problemA4B1C06 = Previous Industry or in-house experience was not effectively used to prevent recurrenceA4B5C05 = System interactions not consideredA4B1C08 = Corrective action responses to a known or repetitive problem was untimely

Deeper Dive into Management


0

2

4

6

8

10

12

A2B6C01 A2B6C07 A2B3C03 A2B6C04 A2B6C06 A2B5C02 A2B3C02 A2B5C04 A2B2C01

A2

"Equipment/Material Problem" Cause Factors

A2B6C01 = Defective or failed partA2B6C07 = Software FailureA2B3C03 = Post maintenance / Post-modification Testing LTAA2B6C04 = End-of-life failureA2B6C06 = ContaminantA2B5C02 = Fabricated item did not meet requirementsA2B3C02 = Inspection / Testing LTAA2B5C04 = Product acceptance requirements LTAA2B2C01 = Preventive maintenance for equipment LTA

Deeper Dive into Equipment


0

1

2

3

4

5

6

7

8

9

A1B4C02 A1B2C01 A1 A1B1C02 A1B2C05 A1B3C01

A1

"Design/Engineering Problem" Cause Factors

A1B4C02 = Testing of design/installation LTAA1B2C01 = Design output scope LTAA1 = Design/Engineering problemA1B1C01 = Design input obsoleteA1B2C05 = DEsign input not addressed in design outputA1B3C01 = Design / documentation not complete

Deeper Dive into Design


Lessons Learned – Published (2012)

Region Lessons Learned Brief Description Date TRE TRE-LL-05 – Plant Onsite Material and Personnel Needed for a Winter

Weather Event 1/06/2012

TRE TRE-LL-06 - Plant Operator Training to Prepare for a Winter Weather Event 1/06/2012

TRE TRE-LL-07 - Transmission Facilities and Winter Weather Operations 1/06/2012

NPCC LL-54 - DC Supply and AC Transients 3/06/2012

WECC LL-58 – Saturated Bus Auxiliary Current Transformer causes Bus Differential Operations during Line Fault 3/06/2012

TRE TRE-LL-34 – Rotational Load Shed 3/06/2012

WECC LL-59 - Auxiliary Relay Contact Contamination 6/19/2012

WECC LL-60 – Remote Terminal Units not on DC Sources 6/19/2012

WECC LL-61 – EMS Database Corruption Problem 6/19/2012

WECC LL-62 – Unmanned Forklift contact with Energized Bus 6/19/2012

RFC LL-65 – Excessive Resource Utilization 6/19/2012

TRE LL-66 – Alarm Interpretation Leads to Generator Stator Coil Failure 6/19/2012

NPCC LL-67 – Protective Relaying Digital Input Board Loading 6/19/2012


Lessons Learned – Published (2012)

Region Lessons Learned Brief Description Date TRE LL-80 – Wind Farm Winter Storm Issues 9/12/2012

TRE LL-81 – Transformer Oil level issues during cold weather 9/12/2012

TRE LL-82 – Winter storm inlet air duct icing 9/12/2012

SPP LL-83 – Capacity Awareness during an energy emergency event 9/12/2012

SPP LL-84 – Electricity and Natural Gas interdependency 9/12/2012

http://www.nerc.com/page.php?cid=5|385


Peer Check

Safety Check


Opportunities

• RRM has a tremendous opportunity for collaboration between the ERO and industry

• Working towards appropriate balance for Event reporting

• Mine all sources possible

• Near-miss database white paper http://www.wecc.biz/committees/StandingCommittees/OC/OTS/HPWG/Shared%20Docu

ments/Forms/DispForm.aspx?ID=106&Source=http%3A%2F%2Fwww%2Ewecc%2Ebiz%2Fcommittees%2FStandingCommittees%2FOC%2FOTS%2FHPWG%2FShared%2520Documents%2FForms%2FAllItems%2Easpx&RootFolder


No Vampires at NERC


Got Collaboration?


Questions and Answers

Michael Moon Senior Director of Reliability Risk Management 404-446-2567 office | 609-651-9693 cell [email protected]

James Merlo Associate Director, Human Performance, RRM 404-446-2560 office | 404-387-5249 cell [email protected]

Ben McMillan Risk Analysis Engineer, RRM 404-446-9729 office | 404-823-1362 cell [email protected]

mailto:[email protected]�




