effective operations and communications 2015 system operator seminar

Effective Operations and Communications

2015 System Operator Seminar

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Training Objectives

• System Operators will • Describe cause analysis and how to better analyze complex

problems • Describe how human performance improvement techniques

will reduce error rates and improve overall reliability • Describe the importance of effective communications and

how continued use of three way communication will help maintain high reliability in FRCC

• Describe changes to come in COM-002-4

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Cause Analysis

• Cause Analysis is a method of problem solving that attempts to identify why problems (events) happened.

• Many different methods of cause analysis – simple to complex

• Root Cause Analysis identifies the Root Cause that if removed prevents the final undesirable event from happening.

• Goal of Cause Analysis is to learn from events (etc.) and limit or eliminate reoccurrence

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Cause Analysis Ex.

Why ask WHY?

What’s done is done.

Why look further?

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Cause Analysis Ex.

• Piston was removed from a older model Jeep Wrangler with 107k miles

• Cylinders were fine…no abrasions (Got lucky!!!)• Approx. $2,500 to completely rebuild, using same block

Did the piston reach it’s end of life?

Did the previous owner not properly maintain the Jeep?

Not enough information to analyze?

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Cause Analysis Ex.

• Maintenance records were good• No history of ever over heating• Jeep was hit on right side, at 70k miles

• Right fender, radiator and fan blade were replaced• No damage to engine block

• Mechanic noticed scalding on other pistons

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Cause Analysis Ex.

So what happened • Fan blades were installed backwards• Caused Jeep to run slightly hotter than it should• New owner after repair so no baseline• Increased temperature was not noticeable to the driver and didn’t trigger warning lights

• Just MTF for piston?

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Cause Analysis Ex.

What would the Apparent Cause Analysis show us?• Vehicle broke down - why?• Piston failed – why?• Scalding on pistons why?• Vehicle ran hot – why?• Fan was installed backwards – why?• Design flaw – Why? We cannot be sure of this without locating documentation and the designer and understanding the design process

• We have to stop here

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Cause Analysis Ex.

• Corrective Actions:• Rebuild the engine with new piston and same block• Correct the direction of the radiator fan to properly cool the vehicle

• Make a more apparent marking on the fan blade to identify direction• Notify the manufacturer (mfg.) of the error detailing the trap Additional work with mfg. needed• Mfg. issue a bulletin to notify all customer/mechanics of the issue• Mfg. to revise the installation procedure explaining the importance of verify

the direction• Possibly Recall vehicles and modify the design so that the blades only fit the

proper direction

Could any of these action prevent recurrence?

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Cause Analysis Ex.

Through the power of a certain search engine I found a forum discussion that may explain part of the design process• Some of the CJs or Wranglers had reverse rotating water

pumps that are stamped with an “R” • If the Jeep is equipped with one of these water pumps then

the fan blades should be installed in the opposite direction• Thus, it seems Jeep was aware of this design issue and

there are other variables involvedhttp://www.jeepforum.com/forum/f12/correct-rad-fan-direction-574666/

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Human Performance (HP)

What is HP• Accomplishment of a task in accordance with agreed

upon standards of accuracy, completeness, and efficiency.

Definition from Businessdictionary.com

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• Video Removed to save Space

Video Removed to save Space

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Quotes from video (out of order)• Nobody wants to take lines out of service just to maintain

them• Like a bird on a wire – Hot suit - PPE• Our pilots are very smooth, like they can read our every

thought• Everything that we do, every move that we make is thought

of and rehearsed before• Not a job for a hot dog• As safe as crossing the street

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Pulled from NHTSA’s National Center for Statistics and Analysis Traffic Safety Facts – 2012 Data

Is crossing the street really safe?Yes, if done properly and with attention

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Human Performance



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Interesting Facts

In June 2011 Texas utilities (including CenterPoint) hired a vendor to spray-wash salt, sand and other contamination from transmission towers as a result of the drought conditions

NERC also released a Lesson Learned related to the same drought (released 07/26/2011)

Corrective Action

“The entity has employed an electrical contracting firm to treat all outside insulators at this station with a silicone coating to prevent buildup of contamination and therefore reduce the chances of a similar occurrence.”

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Local Example

• FPL has procedures to test for contamination in the field and in the lab (using field samples) • Test for soluble and non-soluble

• FPL also has remote contamination monitors in 11 sites along the East Coast of Florida that calculate salt contamination (Equivalent Salt Deposit Density-ESDD) once a day

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Human Performance (HP) Principles

• Things are the way they are because they got that way• People come to work to do a good job• People are fallible - Even the best people make mistakes• The people who do the work are the ones who have the

answers• Error-likely situations are predictable, manageable, and

preventable• Events can be avoided through an understanding of the

reasons mistakes occur and application of the lessons learned from past events (or errors)

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When Are Errors Likely to Occur?

• High Level of Stress• High Work Load• Time Pressures• Poor Communications• Vague or Incomplete Work Guidelines• Overconfidence in Abilities• First Time on the Task• High Level of Distractions• First Work Day after Time Off• 30 Minutes after a Meal – or After Waking

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Things are the way they are because they got that way

Chart from NERC Cause Analysis Training

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Human Performance Improvement (HPI)

Error Avoidance Tools/Techniques• Effective Training• Pre job brief• Peer check (also Self Check)• Site-Check• Questioning attitude• Adherence to Practices and Procedures• Identified nomenclature (from bus to bus) • Effective Communication

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Human Performance Improvement (HPI)

Process Controls/Barriers• Lock out/Tag out• Confirmation pop-up screen

Are you sure?

• Information Tags• Screen Tags and One Line notes• Checklists and Tailboards• Access rights – Physical and Cyber

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Effective Communication

“The single biggest problem in communication is the illusion that it has taken place.”

George Bernard Shaw

(Nobel Prize Winner for Literature)

“If you have nothing to say, say nothing.” Mark Twain

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Effective Communication Ex.

Releasing a clearance issued by a System Operator (SO) SO to Switchman: “You can remove your red tag from the 525-564 Tie Switch”

• Switchman to SO: “I can remove my red tag from the 525-564 Tie Switch”

• SO to Switchman: “That is correct”

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Effective Communication Ex.

• Switchman to SO: “At 14:36 I removed my red tag and closed the 525-564 Tie Switch”

• SO to Switchman: “At 14:36 you removed your red tag from the 525-564 Tie Switch”

• Switchman to SO: “That is correct”

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• The switch stayed closed for nearly two weeks and crews had been working hot on one side of the closed switch

• Reclosing was only off on one side of the closed switch

• The master one-line diagram in the control room was also posted with the 525-564 Tie Switch in the open position even though it was closed

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• The Area Lead Lineman questioned why the switch was in the closed position

• After a review the error was found and subsequent re-training was administered

• The Switchman who had closed the device attended all the company safety meetings to reinforce crews to never switch from memory and truly listen to what is being said

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• The SO was reading his order off his switching check list and wasn’t listening

• The field Switchman had over 30 years of experience and was performing switching from memory

• Normally after releasing a clearance you remove tag then close a device, but this was a normal open switch

• If the SO was listening he could have corrected the Switchman

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Effective communication requires effective listening

Steps to Listening Process• Hearing• Attending• Interpreting• Responding• Remembering

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HearingThe sense through which a person or animal is aware of sound : the ability to hear

An involuntary action

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AttendingAttending involves filtering out some sounds and focusing on others

Attending is a psychological choice – The listener has to choose to focus on the sound he/she is attempting to listen to

This is where we choose to tune out certain sounds or messages – Yes dear.

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InterpretingThis is when we begin to make meaning (or understand) the sounds we hear and are attending

This requires thought

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RespondingAt this point the listener has a meaningful message and he/she responds and reacts sending their own message. This can be non-verbal message.

Yeah, uh huh, head nod etc.

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RememberingThe listener stores the information for use at a later time

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Techniques to master listening• Tune out other conversations and distractions

• Sit up straight

• Focus on what the sender is saying

• Put aside any biases to the sender or the message

• Allow the speaker to complete their statement

• Questioning attitude

• Repeat back

• Wait for confirmation before taking action

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Three-Way Communication (aka Three-Part) 1. Initiator will issue a directive/message 2. Receiver will repeat back the directive/message3. Initiator will ensure the directive/message is repeated

back correctly and acknowledge the response as correct

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Effective Communications

NERC Reliability StandardsCOM-002-2 Currently EnforceableCOM-002-4 Awaiting FERC Approval

FRCC ProceduresFRCC Regional Voice Communications Handbook Procedure

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Make it simple use three-way for any instruction, directive, order, etc.

Changes with COM-002-4Applicability - Includes Distribution ProvidersR1 - Each BA, RC, TOP shall have communications protocolsR1.1 - Requires use of English, unless otherwise agreedR4 - Requires assessment of protocols (e.g. sampling) and corrective action to address deviation from protocolsR5 & R6 - Requires three-way for Operating Instruction

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Operating Instruction – NERC Definition

A command by operating personnel responsible for the Real-time operation of the interconnected Bulk Electric System to change or preserve the state, status, output, or input of an Element of the Bulk Electric System or Facility of the Bulk Electric System. (A discussion of general information and of potential options or alternatives to resolve BES operating concerns is not a command and is not considered an Operating Instruction.)

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Questions?

effective operations and communications 2015 system operator seminar

Documents

apparent cause analysis

complexroot cause analysis

goal of cause analysis

cause analysis3cause

reoccurrence cause analysis

analysis8cause analysis

failure7cause analysis

repair6cause analysis