brent read ruchi ankleshwaria - wecc practices for implementing and... · evaluate the problem...

Brent ReadRuchi Ankleshwaria

Best Practices for Implementing an Effective Corrective Action Program

June 3, 2014Compliance User Group

“INSANITY IS DOING THE SAME THING, OVER AND OVER AGAIN, BUT EXPECTING

DIFFERENT RESULTS.”

- Albert Einstein

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• What is a Corrective Action Program (CAP)

• Key elements of CAP

• Results of WECC’s Analysis of Industry CAPs

• Examples of Implementing CAP

Agenda

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• Joined WECC in June 2012• 7 Years at a TO/TOP/DP/LSE in TX

Interconnectiono 4 years in engineering groupo 3 years supervising/managing the control room

• NERC Certified Transmission Operator• Enjoys long walks on the beach, Fightin’

Texas Aggie football, and bacon cheeseburgers

Background - Brent Read

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• Joined WECC in March 2013. • 6 years of industry experience prior to

joining WECCo 4 Years at a BA/TO/TOP/GO/GOP in the

Western Interconnection as an EMS Engineer and Project Controls Engineer.

o 2 years as a Project Manager • Certified Project Management Professional

(PMP)

Background - Ruchi Ankleshwaria

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• 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

Background

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What is a CAP?

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Action to eliminate the cause of a detected non-conformity or other undesirable situation1. There can be more than one cause for

non-conformity.2. Corrective Action is taken to prevent

recurrence.

*ISO 9000:2005(E)

What is a Corrective Action?

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• Identify problems or near misses before they escalate to a violation

• Identify root causes of problems

• Develop effective solutions to resolve identified problems

Benefits of a Corrective Action Program

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• Reduce the probability of repeat violation

• Evaluate effectiveness of implemented solutions

• Conduct trend analysis to implement and/or review performance metrics

Benefits of a Corrective Action Program

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Key Elements of a Corrective Action Program

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Key Elements of CAP

Identify the Problem

Evaluate the problem

Develop the Corrective Action Plan

Implement the Corrective Action Plan

Evaluate the effectiveness of Corrective Action Plan

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• Determine if there is a problemo Compliance violationo Evento Near miss

• Report problem to appropriate stakeholders

Key Elements - Identify a Problem

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• Collect all relevant information and documentation

• Analyze and validate the facts• Determine scope• Determine the Root Cause

Key Elements - Evaluate the Problem

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• Identify action itemso Should address the root causeo Include actions for prevention of recurrence

• Develop time table and milestoneso Include all applicable stakeholders to determine

feasibilityo Include progress meetings/checks

Key Elements - Develop the Corrective Action Plan

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• If needed, develop short term solutiono Interim action items to provide temporary fixo Use if the Corrective Action Plan has a long

implementation and completion

Key Elements - Develop the Corrective Action Plan

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• Complete the action items• Monitor progress• Compare progress to expected completion

dates• Update progress to applicable stakeholders• Conduct “Post Mortem” upon completion

Key Elements - Implement the Corrective Action Plan

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• 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

Key Elements - Evaluate Effectiveness of the Corrective Action Plan

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

CAPCAP utilized for any problems (violation and non-violation)

Focus on big picture

Demonstrates maturity of an organization

Leads to strong controls

MPMP utilized for violations

CMEP process

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WECC’s Analysis of Industry CAPs

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• 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 responseso Focus was on CAP process, not complianceo Identified Effective Solutionso Identified Lessons Learned

WECC’s Methodology for Analysis of Industry CAPs

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Effective Solutions for CAPs

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Effective Solutions for CAPs

Identify the Problem

Evaluate the problem

Develop Corrective Action Plan

Implement Corrective Action Plan

Evaluate effectiveness of Corrective Action Plan

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Effective Solutions – Identify the Problem

Problem

Inspection, Monitoring,

Testing

Process or Procedure Change

Internal Audits

Feedback

Monthly Meetings

Operational Event

NERC Standard Change

• Utilize defined “Trigger Points” to identify potential problems

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• Store all information in a single location to conducting the review

• Identify all stakeholders involved

• Conduct Gap analysis

Effective Solutions - Evaluate the Problem

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• Conduct a Root Cause Analysiso Common Root Cause Analysis Tools 5 Whys Methodology NERC Event Analysis process Open Discussions Internally Software Packages

o Identify all causes Apparent Cause Contributing Cause Direct Cause


Effective Solutions – Evaluate the Problem

• 5 Whys Methodology

Effective Solutions – Evaluate the Problem

My kids were late to school

We didn’t leave the house on time

I didn’t wake up early enough

I assumed my wife was dropping the

kids off

The night before, my wife told me she had to go to work early (but I

forgot)

COM-002-2 R2:I should always repeat back information

when communicating with my wife!

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Root Cause

Contributing Causes

Apparent Causes

Direct Causes

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• Contributing Causeo Any cause that is not self-sufficient; Contributes

to the overall cause• Apparent Cause

o The most identifiable or evident cause• Direct Cause

o The immediate, initiating, or primary cause


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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.


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• Apparent Cause: Notification system failure• Direct Cause: Scheduling error in asset

management program• Contributing Cause: Personnel limitations in

the 2 day window


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• Determine priority level based on operational impact

• Develop a risk based matrix

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• Develop a formal template for Corrective Action Planso Brief background of the problemo Root cause(s) of the problemo Scope of work/Action itemso Identify stakeholders and resourceso Assign the team and Leader o Major milestones o Timeline for completiono Reporting Frequency

Effective Solutions - Develop Corrective Action Plan

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• Involve Managemento Develop thresholds to determine level of

management involvement is neededo Develop a review plan that incorporates the

necessary level of management

Effective Solutions - Develop Corrective Action Plan

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• Track Major milestones• Set up recurring meetings for tracking and

progress reporting. • Document and review “Lessons Learned”

throughout the process• Involve all stakeholders

Effective Solutions - Implement Corrective Action Plan

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• Conduct “Lessons Learned” sessions

• Develop internal database or third part software for tracking

• Develop trends to monitor the recurrence of the problem

Effective Solutions - Evaluate Effectiveness

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• 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?”

Lessons Learned

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• 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.

Lessons Learned for CAP Implementation

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• 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.


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• 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.


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Examples

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PRC-004-2.1a

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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.

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A 230KV transmission line trips at one end.


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• A 230 KV Transmission Line tripped.

Identify Problem

• Incorrect ProcedureEvaluate Problem

• Review Relay Settings• Review and Update Procedure• Provide training on new procedure


• Update Relay Settings• Update Procedure• Train the employees on new procedure

Implement Corrective Action Plan

• Monitor the line for future trips• Track new relay calibration and actionsEvaluate

Effectiveness

Relay Tripped

The relay setting were inaccurate

Incorrect Procedure


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Example - NERC Standard Changes

FAC-008-1

FAC-009-1

FAC-008-3

Problem

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Evaluate Problem: Map Old requirements to the new requirements

• New Requirements

• Similar to FAC-008-1 R1 for TO

• Retiring

• Similar to FAC-009-1 R1

• Similar to FAC-009-1 R2

FAC-008-3 R1 & R2

FAC-008-3 R3

FAC-008-3 R4 & R5

FAC-008-3 R6

FAC-008-3 R7

FAC-008-3 R8 • New Requirement

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• Brief background of the problem –o NERC standard FAC-008-1 and FAC-009-1 are retiring

on 12/31/2012 and are being replaced by a new standard FAC-008-3 effective 1/1/2013

• Scope Of Work –o Identify steps to be taken to comply with FAC-008-3o Train the employees on the new standard FAC-008-3

• Assign Team and Leader – A, B, C

• Timeline for Completion – xx/xx/xxxx


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• Major Milestones –

o FAC-008-3 R1 and R2: 1. List facility ratings of each element within the generating facility

in the facility rating spreadsheet. 2. Confirm that sub-requirements of R1 and R2 are adhered to

while identifying and documenting Facility Ratings.

o FAC-008-3 R3: 1. Confirm that Transmission facilities follow the facility ratings

guidelines specified in the sub-requirements of FAC-008-3 R3. 2. Confirm that one of the methodologies as specified in 3.1 is

being used for identifying facility ratings of transmission facilities.


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• Develop Schedule for restoring compliance.

• Provide training on the new requirements and changes to the existing requirement.

• Identify reporting requirements. o Monthly progress reporting will be done to the

compliance teamo Quarterly reporting will be provided to senior

management


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Example - NERC Standard Changes

• Perform Internal Audit to confirm Compliance is maintained.

Evaluate Effectiveness

Corrective Action PlanDevelop Corrective Action Plan

Put your plan to ActionImplement

Corrective Action Plan

• Two NERC Standards replaced by One new standard• Potential for future non-complianceIdentify Problem

• Map Old Requirements to the new Requirements• Perform Gap AnalysisEvaluate Problem

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Checklist for Implementing Corrective Action Plans Identify the Problem Provide Background information Confirm the scope of work Perform Root Cause Analysis List the Corrective Actions Identify the timelines for completion Get formal Management Approval Monitor progress during implementation Update the stakeholders Document Lessons Learned Get Management Sign Off on Closure

Tools and Resources

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• U.S. Department of Energy Corrective Action Program Guideo http://www.lm.doe.gov/Office_of_Business_Ope

rations/Solicitations/RFP_Support/DOE_Directives/050_DOE_G_414_1-5.aspx?__taxonomyid=791

Tools and Resources

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Summary

Keep It Simple

Involve all applicable

Stakeholders

Provide easy access to Reporting

Involve Management

Conduct Periodic

Evaluation

Conduct Root Cause

Analysis

Perform Trend

Analysis

Brent ReadSr. Compliance Risk Engineer, O&P(801) [email protected]

Ruchi AnkleshwariaCompliance Risk Engineer, O&P(801) [email protected]

Questions?

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