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Brent Read Ruchi Ankleshwaria

Brent Read Ruchi Ankleshwaria. Best Practices for Implementing an Effective Corrective Action Program June 3, 2014 Compliance User Group. “ INSANITY IS DOING THE SAME THING, OVER AND OVER AGAIN, BUT EXPECTING DIFFERENT RESULTS. ” - Albert Einstein. Agenda.

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Brent Read Ruchi Ankleshwaria

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  1. Brent ReadRuchi Ankleshwaria Best Practices for Implementing an Effective Corrective Action Program June 3, 2014 Compliance User Group

  2. “INSANITY IS DOING THE SAME THING, OVER AND OVER AGAIN, BUT EXPECTING DIFFERENT RESULTS.” - Albert Einstein

  3. Agenda • What is a Corrective Action Program (CAP) • Key elements of CAP • Results of WECC’s Analysis of Industry CAPs • Examples of Implementing CAP

  4. Background - Brent Read • Joined WECC in June 2012 • 7 Years at a TO/TOP/DP/LSE in TX Interconnection • 4 years in engineering group • 3 years supervising/managing the control room • NERC Certified Transmission Operator • Enjoys long walks on the beach, Fightin’ Texas Aggie football, and bacon cheeseburgers

  5. Background - Ruchi Ankleshwaria • Joined WECC in March 2013. • 6 years of industry experience prior to joining WECC • 4 Years at a BA/TO/TOP/GO/GOP in the Western Interconnectionas an EMS Engineer and Project Controls Engineer. • 2 years as a Project Manager • Certified Project Management Professional (PMP)

  6. Background • WECC has reviewed over 5000 Violations and Mitigation Plans over the last 4 years. • WECC is continuously reviewing entities internal controls and risk analysis programs throughout the Western Interconnection • We have a unique perspective on practices in the Western Interconnection • We are able to see what processes different entities have implemented

  7. What is a CAP?

  8. What is a Corrective Action? Action to eliminate the cause of a detected non-conformity or other undesirable situation • There can be more than one cause for non-conformity. • Corrective Action is taken to prevent recurrence. *ISO 9000:2005(E)

  9. Benefits of a Corrective Action Program • Identify problems or near misses before they escalate to a violation • Identify root causes of problems • Develop effective solutions to resolve identified problems

  10. Benefits of a Corrective Action Program • Reduce the probability of repeat violation • Evaluate effectiveness of implemented solutions • Conduct trend analysis to implement and/or review performance metrics

  11. Key Elements of a Corrective Action Program

  12. Key Elements of CAP

  13. Key Elements - Identify a Problem • Determine if there is a problem • Compliance violation • Event • Near miss • Report problem to appropriate stakeholders

  14. Key Elements - Evaluate the Problem • Collect all relevant information and documentation • Analyze and validate the facts • Determine scope • Determine the Root Cause

  15. Key Elements - Develop the Corrective Action Plan • Identify action items • Should address the root cause • Include actions for prevention of recurrence • Develop time table and milestones • Include all applicable stakeholders to determine feasibility • Include progress meetings/checks

  16. Key Elements - Develop the Corrective Action Plan • If needed, develop short term solution • Interim action items to provide temporary fix • Use if the Corrective Action Plan has a long implementation and completion

  17. Key Elements - Implement the Corrective Action Plan • Complete the action items • Monitor progress • Compare progress to expected completion dates • Update progress to applicable stakeholders • Conduct “Post Mortem” upon completion

  18. Key Elements - Evaluate Effectiveness of the Corrective Action Plan • Review Corrective Actions • Determine if the Corrective Actions have resolved the problem and addressed all of the causes • Collect follow-up data related to the problem and corrective actions

  19. How is the Corrective Action Program different than a Mitigation Process?

  20. WECC’s Analysis of Industry CAPs

  21. WECC’s Methodology for Analysis of Industry CAPs • Developed a list of questions based on the Department of Energy CAP Model • Interviewed and reviewed documentation from multiple Registered Entities in WECC’s region • Conducted analysis of the entity responses • Focus was on CAP process, not compliance • Identified Effective Solutions • Identified Lessons Learned

  22. Effective Solutions for CAPs

  23. Effective Solutions for CAPs • Identify the Problem • Evaluate the problem • Develop Corrective Action Plan • Implement Corrective Action Plan • Evaluate effectiveness of Corrective Action Plan

  24. Effective Solutions – Identify the Problem • Feedback • Operational Event • Monthly Meetings • Utilize defined “Trigger Points” to identify potential problems • NERC Standard Change • Process or Procedure Change • Internal Audits • Inspection, Monitoring, Testing • Problem

  25. Effective Solutions - Evaluate the Problem • Store all information in a single location to conducting the review • Identify all stakeholders involved • Conduct Gap analysis

  26. Effective Solutions - Evaluate the Problem • Conduct a Root Cause Analysis • Common Root Cause Analysis Tools • 5 Whys Methodology • NERC Event Analysis process • Open Discussions Internally • Software Packages • Identify all causes • Apparent Cause • Contributing Cause • Direct Cause

  27. Effective Solutions – Evaluate the Problem • 5 Whys Methodology

  28. Effective Solutions – Evaluate the Problem COM-002-2 R2: I should always repeat back information when communicating with my wife!

  29. Effective Solutions - Evaluate the Problem

  30. Effective Solutions - Evaluate the Problem • Contributing Cause • Any cause that is not self-sufficient; Contributes to the overall cause • Apparent Cause • The most identifiable or evident cause • Direct Cause • The immediate, initiating, or primary cause

  31. Effective Solutions - Evaluate the Problem Example: Company ABC failed to test 10 relays at a single substation within it’s defined maintenance and testing interval. The entity discovered the due dates for maintenance and testing with 2 days remaining in the maintenance and testing interval but could not complete the testing within the short time frame.

  32. Effective Solutions - Evaluate the Problem • Apparent Cause: Notification system failure • Direct Cause: Scheduling error in asset management program • Contributing Cause: Personnel limitations in the 2 day window

  33. Effective Solutions - Evaluate the Problem • Determine priority level based on operational impact • Develop a risk based matrix

  34. Effective Solutions - Develop Corrective Action Plan • Develop a formal template for Corrective Action Plans • Brief background of the problem • Root cause(s) of the problem • Scope of work/Action items • Identify stakeholders and resources • Assign the team and Leader • Major milestones • Timeline for completion • Reporting Frequency

  35. Effective Solutions - Develop Corrective Action Plan • Involve Management • Develop thresholds to determine level of management involvement is needed • Develop a review plan that incorporates the necessary level of management

  36. Effective Solutions - Implement Corrective Action Plan • Track Major milestones • Set up recurring meetings for tracking and progress reporting. • Document and review “Lessons Learned” throughout the process • Involve all stakeholders

  37. Effective Solutions - Evaluate Effectiveness • Conduct “Lessons Learned” sessions • Develop internal database or third part software for tracking • Develop trends to monitor the recurrence of the problem

  38. Lessons Learned • At the end of the interviews with the participating entities we asked one final question… “What guidance would you provide to a company just developing a Corrective Action Program?”

  39. Lessons Learned for CAP Implementation • Keep the process very simple. • Properly plan implementation of CAP. • Don’t implement CAPs on issue that are very minor and can be quickly resolved. • Have dedicated Corrective Action Team.

  40. Lessons Learned for CAP Implementation • Remove conflict of bias in the process. • Get management sign off for approval and closure of the CAPs. • Use common terminology that is used within the organization. • Don’t commit to solving a problem with a new technology unless you are very confident.

  41. Lessons Learned for CAP Implementation • Use Train the Trainer Approach. • Train the leaders and set expectations from them. • All the leaders should convey the same message through out the Organization.

  42. Examples

  43. PRC-004-2.1a

  44. PRC-004-2.1a Example Summary – Transmission Operator, Generator Owner and Distribution Provider should analyze their misoperation and develop and implement corrective action plan to avoid future misoperation of similar nature.

  45. PRC-004-2.1a Example A 230KV transmission line trips at one end.

  46. PRC-004-2.1a Example

  47. Example - NERC Standard Changes Problem

  48. Evaluate Problem: Map Old requirements to the new requirements • FAC-008-3 R1 & R2 • New Requirements • FAC-008-3 R3 • Similar to FAC-008-1 R1 for TO • FAC-008-3 R4 & R5 • Retiring • FAC-008-3 R6 • Similar to FAC-009-1 R1 • FAC-008-3 R7 • Similar to FAC-009-1 R2 • FAC-008-3 R8 • New Requirement

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