1. An Initiative for the Bulk Power System

2.  “Given that most human factors safety programs are not data-driven, it only stands to reason that they have produced intervention strategies that are only marginally effective at reducing the occurrence and consequences of human error.”

3.  By collaborating to create a North American Near-Miss Database (NMDb)  Such an NMDb would facilitate the capture and analysis of near-miss incident data from the industry in order to: ◦ Improve understanding of human performance factors, and ◦ Identify and address challenges that could impact the reliability of the bulk electric system (BES)

4.  A near-miss is an incident in which no injury property damage or system reliability lapse occurred ◦ “You got lucky.”  There is currently no nationwide database for near-miss incidents in the BES  The resultant uncoordinated data is of little value to the industry as a whole

5.  WECC’s Human Performance Work Group (HPWG) has been collaborating with EPRI, NERC, NATF, BPA, Dominion (and more) to produce a white paper ◦ Released July 19, 2012  The goal is to develop and maintain an industry-wide Db as a large source of human performance, personnel safety, and BES reliability information

6.  Voluntary and Confidential report entry system  Processes to review and polish entered data to ensure anonymity and data value  A framework for analysis of reported incidents leading to “lesson learned”  Broadcast of the “lesson learned” to the entire industry  Regulatory agencies would be asked to remain at arm’s length

7.  Aviation Safety Reporting System ◦ http://asrs.arc.nasa.gov/ http://asrs.arc.nasa.gov/  National Fire Fighter Near-Miss Reporting System ◦ http://www.firefighternearmiss.com/ http://www.firefighternearmiss.com/  Federal railway Administration ◦ http://www.closecallsrail.org/ http://www.closecallsrail.org/

8.  The task group will prepare a proposal to secure funding for the implementation (the first 2 years) and ongoing support of the NMDb from: ◦ Department of Energy, ◦ Homeland Security, and/or ◦ Other interested parties

9.  “Since catastrophic failures are rare events in well-defended complex systems, collectively mindful organizations work hard to extract the most value from what little incident and accident data they have.”  “They actively set out to create a reporting culture by commending, even rewarding, people for reporting their errors and close calls.”