Presentation on theme: "Brent Read Ruchi Ankleshwaria"— Presentation transcript:
1 Brent Read Ruchi Ankleshwaria Best Practices for Implementing an Effective Corrective Action ProgramJune 3, 2014Compliance 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 CAPsExamples of Implementing CAP
4 Background - Brent Read Joined WECC in June 20127 Years at a TO/TOP/DP/LSE in TX Interconnection4 years in engineering group3 years supervising/managing the control roomNERC Certified Transmission OperatorEnjoys 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 WECC4 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 ManagerCertified Project Management Professional (PMP)
6 BackgroundWECC 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 InterconnectionWe have a unique perspective on practices in the Western InterconnectionWe are able to see what processes different entities have implemented
8 What is a Corrective Action? Action to eliminate the cause of a detected non-conformity or other undesirable situationThere 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 violationIdentify root causes of problemsDevelop effective solutions to resolve identified problems
10 Benefits of a Corrective Action Program Reduce the probability of repeat violationEvaluate effectiveness of implemented solutionsConduct trend analysis to implement and/or review performance metrics
12 Key Elements of CAP Identify the Problem Evaluate the problem Develop the Corrective Action PlanImplement the Corrective Action PlanEvaluate the effectiveness of Corrective Action Plan
13 Key Elements - Identify a Problem Determine if there is a problemCompliance violationEventNear missReport problem to appropriate stakeholders
14 Key Elements - Evaluate the Problem Collect all relevant information and documentationAnalyze and validate the factsDetermine scopeDetermine the Root Cause
15 Key Elements - Develop the Corrective Action Plan Identify action itemsShould address the root causeInclude actions for prevention of recurrenceDevelop time table and milestonesInclude all applicable stakeholders to determine feasibilityInclude progress meetings/checks
16 Key Elements - Develop the Corrective Action Plan If needed, develop short term solutionInterim action items to provide temporary fixUse if the Corrective Action Plan has a long implementation and completion
17 Key Elements - Implement the Corrective Action Plan Complete the action itemsMonitor progressCompare progress to expected completion datesUpdate progress to applicable stakeholdersConduct “Post Mortem” upon completion
18 Key Elements - Evaluate Effectiveness of the Corrective Action Plan Review Corrective ActionsDetermine if the Corrective Actions have resolved the problem and addressed all of the causesCollect follow-up data related to the problem and corrective actions
19 How is the Corrective Action Program different than a Mitigation Process? CAPCAP utilized for any problems (violation and non-violation)Focus on big pictureDemonstrates maturity of an organizationLeads to strong controlsMPMP utilized for violationsCMEP process
21 WECC’s Methodology for Analysis of Industry CAPs Developed a list of questions based on the Department of Energy CAP ModelInterviewed and reviewed documentation from multiple Registered Entities in WECC’s regionConducted analysis of the entity responsesFocus was on CAP process, not complianceIdentified Effective SolutionsIdentified Lessons Learned
23 Effective Solutions for CAPs Identify the ProblemEvaluate the problemDevelop Corrective Action PlanImplement Corrective Action PlanEvaluate effectiveness of Corrective Action Plan
24 Effective Solutions – Identify the Problem Utilize defined “Trigger Points” to identify potential problemsFeedbackNERC Standard ChangeOperational EventMonthly MeetingsProcess or Procedure ChangeInternal AuditsInspection, Monitoring, TestingProblem
25 Effective Solutions - Evaluate the Problem Store all information in a single location to conducting the reviewIdentify all stakeholders involvedConduct Gap analysis
26 Effective Solutions - Evaluate the Problem Conduct a Root Cause AnalysisCommon Root Cause Analysis Tools5 Whys MethodologyNERC Event Analysis processOpen Discussions InternallySoftware PackagesIdentify all causesApparent CauseContributing CauseDirect Cause
27 Effective Solutions – Evaluate the Problem 5 Whys Methodology
28 Effective Solutions – Evaluate the Problem My kids were late to schoolWe didn’t leave the house on timeI didn’t wake up early enoughI assumed my wife was dropping the kids offThe 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 CauseContributing CausesApparent CausesDirect Causes
30 Effective Solutions - Evaluate the Problem Contributing CauseAny cause that is not self-sufficient; Contributes to the overall causeApparent CauseThe most identifiable or evident causeDirect CauseThe 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 failureDirect Cause: Scheduling error in asset management programContributing Cause: Personnel limitations in the 2 day window
33 Effective Solutions - Evaluate the Problem Determine priority level based on operational impactDevelop a risk based matrix
34 Effective Solutions - Develop Corrective Action Plan Develop a formal template for Corrective Action PlansBrief background of the problemRoot cause(s) of the problemScope of work/Action itemsIdentify stakeholders and resourcesAssign the team and LeaderMajor milestonesTimeline for completionReporting Frequency
35 Effective Solutions - Develop Corrective Action Plan Involve ManagementDevelop thresholds to determine level of management involvement is neededDevelop a review plan that incorporates the necessary level of management
36 Effective Solutions - Implement Corrective Action Plan Track Major milestonesSet up recurring meetings for tracking and progress reporting.Document and review “Lessons Learned” throughout the processInvolve all stakeholders
37 Effective Solutions - Evaluate Effectiveness Conduct “Lessons Learned” sessionsDevelop internal database or third part software for trackingDevelop trends to monitor the recurrence of the problem
38 Lessons LearnedAt 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.
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 ExampleA 230KV transmission line trips at one end.
47 PRC-004-2.1a Example Develop Corrective Action Plan Relay TrippedThe relay setting were inaccurateIncorrect ProcedureIdentify ProblemA 230 KV Transmission Line tripped.Evaluate ProblemIncorrect ProcedureDevelop Corrective Action PlanReview Relay SettingsReview and Update ProcedureProvide training on new procedureImplement Corrective Action PlanUpdate Relay SettingsUpdate ProcedureTrain the employees on new procedureEvaluate EffectivenessMonitor the line for future tripsTrack new relay calibration and actions
49 Example - NERC Standard Changes ProblemFAC-008-1FAC-009-1FAC-008-3
50 Evaluate Problem: Map Old requirements to the new requirements Similar to FAC R1 for TORetiringSimilar to FAC R1Similar to FAC R2FAC R1 & R2FAC R3FAC R4 & R5FAC R6FAC R7FAC R8New 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 1/1/2013Scope Of Work –Identify steps to be taken to comply with FAC-008-3Train the employees on the new standard FAC-008-3Assign Team and Leader – A, B, CTimeline 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 teamQuarterly reporting will be provided to senior management
54 Example - NERC Standard Changes Two NERC Standards replaced by One new standardPotential for future non-complianceIdentify ProblemMap Old Requirements to the new RequirementsPerform Gap AnalysisEvaluate ProblemCorrective Action PlanDevelop Corrective Action PlanPut your plan to ActionImplement Corrective Action PlanPerform Internal Audit to confirm Compliance is maintained.Evaluate Effectiveness
56 Tools and Resources Checklist for Implementing Corrective Action Plans Identify the ProblemProvide Background informationConfirm the scope of workPerform Root Cause AnalysisList the Corrective ActionsIdentify the timelines for completionGet formal Management ApprovalMonitor progress during implementationUpdate the stakeholdersDocument Lessons LearnedGet Management Sign Off on Closure
57 Tools and ResourcesU.S. Department of Energy Corrective Action Program Guide
58 Summary Involve all applicable Stakeholders Perform Trend Analysis Provide easy access to ReportingKeep It SimpleConduct Root Cause AnalysisInvolve ManagementConduct Periodic Evaluation