1. Brent Read Ruchi 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 Interconnection as 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 Identify the Problem Evaluate the problem
Develop the Corrective Action Plan
Implement the Corrective Action Plan
Evaluate the effectiveness of Corrective Action Plan

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?
CAP
CAP utilized for any problems (violation and non-violation)
Focus on big picture
Demonstrates maturity of an organization
Leads to strong controls MP
MP utilized for violations
CMEP 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
Utilize defined “Trigger Points” to identify potential problems
Feedback
NERC Standard Change
Operational Event
Monthly Meetings
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
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 R2:
I should always repeat back information when communicating with my wife!

29. Effective Solutions - Evaluate the Problem
Root Cause
Contributing Causes
Apparent Causes
Direct Causes

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?”

40. 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.

41. 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.

42. 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.

43. Examples

44. PRC a

45. 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.

46. PRC a Example
A 230KV transmission line trips at one end.

47. PRC-004-2.1a Example Develop Corrective Action Plan
Relay Tripped
The relay setting were inaccurate
Incorrect Procedure
Identify Problem
A 230 KV Transmission Line tripped.
Evaluate Problem
Incorrect Procedure
Develop Corrective Action Plan
Review Relay Settings
Review and Update Procedure
Provide training on new procedure
Implement Corrective Action Plan
Update Relay Settings
Update Procedure
Train the employees on new procedure
Evaluate Effectiveness
Monitor the line for future trips
Track new relay calibration and actions

49. Example - NERC Standard Changes
Problem
FAC-008-1
FAC-009-1
FAC-008-3

50. Evaluate Problem: Map Old requirements to the new requirements
Similar to FAC R1 for TO
Retiring
Similar to FAC R1
Similar to FAC R2
FAC R1 & R2
FAC R3
FAC R4 & R5
FAC R6
FAC R7
FAC R8
New Requirement

51. Develop Corrective Action Plan
Brief background of the problem –
NERC standard FAC and FAC are retiring on 12/31/2012 and are being replaced by a new standard FAC effective 1/1/2013
Scope Of Work –
Identify steps to be taken to comply with FAC-008-3
Train the employees on the new standard FAC-008-3
Assign Team and Leader – A, B, C
Timeline for Completion – xx/xx/xxxx

52. Develop Corrective Action Plan
Major Milestones –
FAC R1 and R2:
List facility ratings of each element within the generating facility in the facility rating spreadsheet.
Confirm that sub-requirements of R1 and R2 are adhered to while identifying and documenting Facility Ratings.
FAC R3:
Confirm that Transmission facilities follow the facility ratings guidelines specified in the sub-requirements of FAC R3.
Confirm that one of the methodologies as specified in 3.1 is being used for identifying facility ratings of transmission facilities.

53. Develop Corrective Action Plan
Develop Schedule for restoring compliance.
Provide training on the new requirements and changes to the existing requirement.
Identify reporting requirements.
Monthly progress reporting will be done to the compliance team
Quarterly reporting will be provided to senior management

54. Example - NERC Standard Changes
Two NERC Standards replaced by One new standard
Potential for future non-compliance
Identify Problem
Map Old Requirements to the new Requirements
Perform Gap Analysis
Evaluate Problem
Corrective Action Plan
Develop Corrective Action Plan
Put your plan to Action
Implement Corrective Action Plan
Perform Internal Audit to confirm Compliance is maintained.
Evaluate Effectiveness

56. Tools and Resources 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

57. Tools and Resources
U.S. Department of Energy Corrective Action Program Guide

58. Summary Involve all applicable Stakeholders Perform Trend Analysis
Provide easy access to Reporting
Keep It Simple
Conduct Root Cause Analysis
Involve Management
Conduct Periodic Evaluation

59. Questions? Brent Read Sr. Compliance Risk Engineer, O&P (801) 819-7689
Ruchi Ankleshwaria
Compliance Risk Engineer, O&P
(801)