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

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Presentation on theme: "Brent Read Ruchi Ankleshwaria Best Practices for Implementing an Effective Corrective Action Program June 3, 2014 Compliance User Group."— Presentation transcript:

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


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

4 4 Joined WECC in June Years at a TO/TOP/DP/LSE in TX Interconnection o 4 years in engineering group o 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

5 5 Joined WECC in March years of industry experience prior to joining WECC o 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

6 6 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

7 7 What is a CAP?

8 8 Action to eliminate the cause of a detected non-conformity or other undesirable situation 1.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?

9 9 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

10 10 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

11 11 Key Elements of a Corrective Action Program

12 12 Key Elements of CAP Identify the ProblemEvaluate the problem Develop the Corrective Action Plan Implement the Corrective Action Plan Evaluate the effectiveness of Corrective Action Plan

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

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

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

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

17 17 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

18 18 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

19 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 violationsCMEP process

20 20 WECC’s Analysis of Industry CAPs

21 21 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 o Focus was on CAP process, not compliance o Identified Effective Solutions o Identified Lessons Learned WECC’s Methodology for Analysis of Industry CAPs

22 22 Effective Solutions for CAPs

23 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 24 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

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

26 26 Conduct a Root Cause Analysis o 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

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

30 30 Contributing Cause o 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 Effective Solutions - Evaluate the Problem

31 31 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. Effective Solutions - Evaluate the Problem

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

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

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

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

36 36 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

37 37 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

38 38 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


40 40 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

41 41 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. Lessons Learned for CAP Implementation

42 42 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. Lessons Learned for CAP Implementation

43 43 Examples

44 44 PRC a

45 45 PRC a 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 46 A 230KV transmission line trips at one end. PRC a Example

47 47 A 230 KV Transmission Line tripped. Identify Problem Incorrect Procedure Evaluate Problem Review Relay Settings Review and Update Procedure Provide training on new procedure Develop Corrective Action Plan 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 actions Evaluate Effectiveness Relay Tripped The relay setting were inaccurate Incorrect Procedure PRC a Example

48 48

49 49 Example - NERC Standard Changes FAC FAC FAC Problem

50 50 Evaluate Problem: Map Old requirements to the new requirements 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 51 Brief background of the problem – o 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 – o Identify steps to be taken to comply with FAC o Train the employees on the new standard FAC Assign Team and Leader – A, B, C Timeline for Completion – xx/xx/xxxx Develop Corrective Action Plan

52 52 Major Milestones – o FAC 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 R3: 1.Confirm that Transmission facilities follow the facility ratings guidelines specified in the sub-requirements of FAC R3. 2.Confirm that one of the methodologies as specified in 3.1 is being used for identifying facility ratings of transmission facilities. Develop Corrective Action Plan

53 53 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 team o Quarterly reporting will be provided to senior management Develop Corrective Action Plan

54 54 Example - NERC Standard Changes Perform Internal Audit to confirm Compliance is maintained. Evaluate Effectiveness Corrective Action Plan Develop Corrective Action Plan Put your plan to Action Implement Corrective Action Plan 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


56 56 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

57 57 U.S. Department of Energy Corrective Action Program Guide o rations/Solicitations/RFP_Support/DOE_Directi ves/050_DOE_G_414_1- 5.aspx?__taxonomyid=791 rations/Solicitations/RFP_Support/DOE_Directi ves/050_DOE_G_414_1- 5.aspx?__taxonomyid=791 Tools and Resources

58 58 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

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

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