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HUMAN PERFORMANCE – FUNDAMENTAL ERROR PREVENTION

Establishing the National Electrical Workers’ Near-Miss Reporting System Robert D. Schwermann Pacific Gas and Electric Company February 28, 2013. HUMAN PERFORMANCE – FUNDAMENTAL ERROR PREVENTION . Why are we here?. History of the Proposal.

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HUMAN PERFORMANCE – FUNDAMENTAL ERROR PREVENTION

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  1. Establishing the National Electrical Workers’ Near-Miss Reporting SystemRobert D. SchwermannPacific Gas and Electric CompanyFebruary 28, 2013 HUMAN PERFORMANCE – FUNDAMENTAL ERROR PREVENTION

  2. Why are we here?

  3. History of the Proposal • 2011 Established Western Electric Coordinating Council (WECC) Human Performance Work Group. (HPWG) • HPWG is situated under the Operator Training Subcommittee • Purpose: • Share information on Human Performance Improvement (HPI) • Assist others in WECC to establish HPI in their organizations • Determine a way to be proactive with developing training rather than reactive as the result of an event

  4. History of the Proposal • Early 2012 WECC HPWG initiated conversations about near-miss reporting systems with the following: • Pacific Gas and Electric Company (PG&E) • Bonneville Power Authority (BPA) • Alberta Electric System Operator (AESO) • Electric Power Research Institute (EPRI) • North American Transmission Forum (NATF) • North American Electric Reliability Corporation (NERC) • Aviation Safety Reporting System • Fire Fighters Near-Miss Reporting System • Smaller focus group initiated action • White Paper published last July • Socialization of white paper in Industry.

  5. The White Paper – What we found out • There is currently no industry-widereporting system for near-miss incidents. • Individual uncoordinated data is of little value because it is NOT available to the industry as a whole. • Some data exists but no method to distribute the data and lessons learned to industry. • There are examples from other industries that illustrate the importance of such a system.

  6. The White Paper - Follow-up • Conducted outreach to obtain industry wide support for an Electrical Worker Near-Miss Reporting System (EWRS) • Involved all parts of industry from the inception • Labor, Generation, Transmission, Distribution & other related field workers • Feedback has been predominately positive • Researched other reporting systems • Discussed funding potential

  7. Who has been participating • Discussions about the EWRS have been taking place for more than a year within the industry • interest is growing • EWRS has become an industry wide initiative • Learned from other more mature systems • Linda Connell - Aviation Safety Reporting System • Amy Tippett - Fire Fighters Near-Miss Reporting System

  8. We are just getting the tip of the iceberg.

  9. We need to look at the rest of the iceberg There is a much larger pool of information available to us if we include near-misses.

  10. The Plan • Establish a collaborative group to lead the creation of an industry-wide Electrical Worker Near-Miss Reporting System (EWRS) in North America. • Maintain EWRS independently as an industry-wide database • All reporting confidential and sanitized before publication • Available to all as a large source of human performance, personnel safety and reliability information.

  11. Features of the EWRS • Voluntary submissions from all parts of the industry using a confidential report entry system • System set up with NOpunitive measures • Processes to review each report and verify the data’s value and ensure confidentiality • A framework for trend analysis of the reported incidents leading to “lessons learned” • Broadcast of the “lessons learned” to the entire industry • EWRS must be Independent from regulatory agencies

  12. Successful Near-Miss Systems in Other Industries • Aviation Safety Reporting System • asrs.arc.nasa.gov • National Fire Fighter Near-Miss Reporting System • firefighternearmiss.com • Federal Railway Administration Close-Call Reporting System • closecallsrail.org

  13. What is the Value of a Near-Miss Reporting System? "We use near-miss reports in all training that we develop. We use them as operating experiences to discuss what can go wrong in the situation that is being covered and how that can be prevented. The more we learn from each other the safer we will be in the long term. Near-miss reports are great training tools!" -Rob Archibold, Hiawatha Fire Department (IA) * “As a result of our attitudes and efforts, we have been successful in dramatically reducing the number of injuries our personnel suffer over the past three years. The national Near- Miss Reporting System has played a major part in our efforts.” • Todd Bradley, Safety Officer, Burlington Fire Department (NC)* * From the Firefighter Near Miss Monthly Reports

  14. HOLD THE PULL http://www.youtube.com/watch?v=tl0vLHJmsiw HUMAN PERFORMANCE INITIATIVE – FUNDAMENTAL ERROR PREVENTION TOOLS

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