Transcript Could this happen at my company?

TWO BRIEF
TEACHING
CASES
James Merlo, NERC
& Jake Mazulewicz,
Dominion VA Power
__________________________
NERC Human Performance Conference
March 2013
©2013. Dominion. All rights reserved.
COULD THIS
HAPPEN
AT MY
COMPANY?
These case studies are intended
only to foster thoughtful
discussion and may not show
correct technical procedures.
Consult your official resources
and your Supervisor for correct
policies and procedures. Names
and details in this case may
have been changed and may not
represent any one actual event.
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THE FIRST EVENT
3
THE CAUSE
4
THE CAUSE
5
THE CAUSE
6
THE CAUSE
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QUESTION
Turn to the person next to you.
Spend a few minutes finding out their
answer to this question.
If this incident happened at your
company, what Corrective Action
would be taken, and what would the
results be?
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THE CAUSE
9
THE
CAUSE
Apparent
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4-8 QUESTIONS
Turn to the person next to you.
Working together, write down 4-8
questions you realistically could and
would ask in a Root Cause Analysis
of this event.
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THE ROOT CAUSE
What caused him to remove the shield?
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THE ROOT CAUSE
What caused him to remove the shield?
• Did someone tell him to remove it or did he do it
on his own?
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THE ROOT CAUSE
What caused him to remove the shield?
• Did someone tell him to remove it or did he do it
on his own?
• Did he remove it just this once or does he remove
it every time?
14
THE ROOT CAUSE
What caused him to remove the shield?
• Did someone tell him to remove it or did he do it
on his own?
• Did he remove it just this once or does he remove
it every time?
• Did he make an error, or did he plan to remove it?
15
THE ROOT CAUSE
What caused him to remove the shield?
• Did someone tell him to remove it or did he do it
on his own?
• Did he remove it just this once or does he remove
it every time?
• Did he make an error, or did he plan to remove it?
• Was the shield labeled as a safety device?
16
THE ROOT CAUSE
What caused him to remove the shield?
• Did someone tell him to remove it or did he do it
on his own?
• Did he remove it just this once or does he remove
it every time?
• Did he make an error, or did he plan to remove it?
• Was the shield labeled as a safety device?
• Was he trained or certified to do this procedure?
17
THE ROOT CAUSE
What caused him to remove the shield?
• Did someone tell him to remove it or did he do it
on his own?
• Did he remove it just this once or does he remove
it every time?
• Did he make an error, or did he plan to remove it?
• Was the shield labeled as a safety device?
• Was he trained or certified to do this procedure?
• If we asked 10 other equivalently trained and
experienced Linemen to do that job, would they
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also remove the shield? (substitution test)
THE ROOT CAUSE
When instructors teach this procedure,
do they point out how this shield works
as a safety device?
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Apparent Cause
Cause
Corrective
Action
Result
Root Cause
Apparent Cause
Cause
Lineman violated
procedure
Corrective Punish lineman
Action for violation
Result
Root Cause
Apparent Cause
Cause
Lineman violated
procedure
Corrective Punish lineman
Action for violation
Result
Lineman decides that
his company prizes
“accountability” over
solutions, and tells
story of this unfairness
until he retires.
Incident occurs again.
Root Cause
Cause
Apparent Cause
Root Cause
Lineman violated
procedure
Training did not include
critical info.
Corrective Punish lineman
Action for violation
Result
Lineman decides that
his company prizes
“accountability” over
solutions, and tells
story of this unfairness
until he retires.
Incident occurs again.
Cause
Apparent Cause
Root Cause
Lineman violated
procedure
Training did not include
critical info.
Corrective Punish lineman
Action for violation
Result
Lineman decides that
his company prizes
“accountability” over
solutions, and tells
story of this unfairness
until he retires.
Incident occurs again.
Update the training. Send
bulletin to local offices.
Cause
Apparent Cause
Root Cause
Lineman violated
procedure
Training did not include
critical info.
Corrective Punish lineman
Action for violation
Result
Lineman decides that
his company prizes
“accountability” over
solutions, and tells
story of this unfairness
until he retires.
Incident occurs again.
Update the training. Send
bulletin to local offices.
Incident doesn’t reoccur for
many years if ever.
Lineman and other
employees see their
company solve a problem
with reason instead of
power.
TWO BRIEF
TEACHING
CASES
James Merlo, NERC
& Jake Mazulewicz,
Dominion VA Power
__________________________
NERC Human Performance Conference
March 2013
27
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Turn to the person next to you.
Spend a few minutes finding out their
answer to this question.
If this incident happened at your
company, what Corrective Action
would be taken, and what would the
results be?
29
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Turn to the person next to you.
Working together, write down 4-8
questions you realistically could and
would ask in a Root Cause Analysis
of this event.
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What led him to leave the jumper in
place?
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What led him to leave the jumper in
place?
• Did he use any defenses to remind himself to
remove the leads?
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What led him to leave the jumper in
place?
• Did he use any defenses to remind himself to
remove the leads?
• Did he do anything different this time vs. previous
times when he’s done this job?
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What led him to leave the jumper in
place?
• Did he use any defenses to remind himself to
remove the leads?
• Did he do anything different this time vs. previous
times when he’s done this job?
• Was he trained or certified to do this procedure?
36
What led him to leave the jumper in
place?
• Did he use any defenses to remind himself to
remove the leads?
• Did he do anything different this time vs. previous
times when he’s done this job?
• Was he trained or certified to do this procedure?
• Were the correct leads identified on the print?
37
What led him to leave the jumper in
place?
• Did he use any defenses to remind himself to
remove the leads?
• Did he do anything different this time vs. previous
times when he’s done this job?
• Was he trained or certified to do this procedure?
• Were the correct leads identified on the print?
• If we asked 10 other equivalently trained and
experienced field technicians to do that job, would
they also forget to remove the leads? (substitution
test)
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Apparent Cause
Cause
Field Technician left
jumper in place
Corrective Punish Field
Technician
Action for violation
Result
Root Cause
Apparent Cause
Cause
Field Technician left
jumper in place
Corrective Punish Field
Technician
Action for violation
Incident occurs again.
Result
Field Technician can’t
understand how he
made this error, (and
retells story for years).
Root Cause
Cause
Apparent Cause
Root Cause
Field Technician left
jumper in place
Wiring and logic diagrams
were different. No
organizational process to
verify wiring diagrams and
prints.
Corrective Punish Field
Technician
Action for violation
Incident occurs again.
Result
Field Technician can’t
understand how he
made this error, (and
retells story for years).
Cause
Apparent Cause
Root Cause
Field Technician left
jumper in place
Wiring and logic diagrams
were different. No
organizational process to
verify wiring diagrams and
prints.
Corrective Punish Field
Technician
Action for violation
Incident occurs again.
Result
Field Technician can’t
understand how he
made this error, (and
retells story for years).
Create process to verify
wiring diagrams.
Cause
Apparent Cause
Root Cause
Field Technician left
jumper in place
Wiring and logic diagrams
were different. No
organizational process to
verify wiring diagrams and
prints.
Corrective Punish Field
Technician
Action for violation
Incident occurs again.
Result
Create process to verify
wiring diagrams.
Check of wiring
diagrams reveals two
Field Technician can’t more latent errors in the
understand how he
system that could easily
made this error, (and
have led to incidents had
retells story for years). they not been found.
TWO BRIEF
TEACHING
CASES
James Merlo, NERC
& Jake Mazulewicz,
Dominion VA Power
__________________________
NERC Human Performance Conference
March 2013