Brent Read
Ruchi Ankleshwaria
Best Practices for Implementing an Effective
Corrective Action Program
June 3, 2014
Compliance User Group
“INSANITY IS DOING THE SAME THING,
OVER AND OVER AGAIN, BUT EXPECTING
DIFFERENT RESULTS.”
- Albert Einstein
Agenda
• What is a Corrective Action Program (CAP)
• Key elements of CAP
• Results of WECC’s Analysis of Industry
CAPs
• Examples of Implementing CAP
3
Background - Brent Read
• Joined WECC in June 2012
• 7 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
4
Background - Ruchi Ankleshwaria
• Joined WECC in March 2013.
• 6 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)
5
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
6
What is a CAP?
7
What is a Corrective Action?
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)
8
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
9
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
10
Key Elements of a Corrective Action
Program
11
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
12
Key Elements - Identify a Problem
• Determine if there is a problem
o Compliance violation
o Event
o Near miss
• Report problem to appropriate stakeholders
13
Key Elements - Evaluate the Problem
• Collect all relevant information and
documentation
• Analyze and validate the facts
• Determine scope
• Determine the Root Cause
14
Key Elements - Develop the Corrective
Action Plan
• 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
15
Key Elements - Develop the Corrective
Action Plan
• 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
16
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
17
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
18
How is the Corrective Action Program
different than a Mitigation Process?
CAP
MP
CAP utilized for any problems
(violation and non-violation)
MP utilized for violations
Focus on big picture
CMEP process
Demonstrates maturity of an
organization
Leads to strong controls
19
WECC’s Analysis of Industry CAPs
20
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
o Focus was on CAP process, not compliance
o Identified Effective Solutions
o Identified Lessons Learned
21
Effective Solutions for CAPs
22
Effective Solutions for CAPs
Identify the Problem
Evaluate the problem
Develop Corrective Action
Plan
Implement Corrective
Action Plan
Evaluate effectiveness of
Corrective Action Plan
23
Effective Solutions – Identify the
Problem
• Utilize defined “Trigger Points” to identify
potential problems
Feedback
Operational
Event
Monthly
Meetings
Internal
Audits
Process or
Procedure
Change
Inspection,
Monitoring,
Testing
24
NERC
Standard
Change
Problem
Effective Solutions - Evaluate the
Problem
• Store all information in a single location to
conducting the review
• Identify all stakeholders involved
• Conduct Gap analysis
25
Effective Solutions - Evaluate the
Problem
• 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
26
Effective Solutions – Evaluate the
Problem
• 5 Whys Methodology
Effective Solutions – Evaluate the
Problem
COM-002-2 R2:
I should always repeat back information
when communicating with my wife!
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)
Effective Solutions - Evaluate the
Problem
Contributing
Causes
Apparent
Causes
Direct
Causes
29
Root
Cause
Effective Solutions - Evaluate the
Problem
• 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
30
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.
31
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
32
Effective Solutions - Evaluate the
Problem
• Determine priority level based on
operational impact
• Develop a risk based matrix
33
Effective Solutions - Develop
Corrective Action Plan
• Develop a formal template for Corrective
Action Plans
34
o
o
o
o
o
o
o
o
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
Effective Solutions - Develop
Corrective Action Plan
• 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
35
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
36
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
37
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?”
38
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.
40
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.
41
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.
42
Examples
43
PRC-004-2.1a
44
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.
45
PRC-004-2.1a Example
A 230KV
transmission line
trips at one end.
46
PRC-004-2.1a Example
Identify
Problem
Evaluate
Problem
Develop
Corrective
Action Plan
Implement
Corrective
Action Plan
Evaluate
Effectiveness
47
• A 230 KV Transmission Line
tripped.
• Incorrect Procedure
Incorrect
The relay Procedure
setting
Relay were
Tripped inaccurate
• Review Relay Settings
• Review and Update Procedure
• Provide training on new procedure
• Update Relay Settings
• Update Procedure
• Train the employees on new procedure
• Monitor the line for future trips
• Track new relay calibration and actions
48
Example - NERC Standard
Changes
Problem
FAC008-1
FAC008-3
FAC009-1
49
Evaluate Problem: Map Old
requirements to the new requirements
50
FAC-008-3 R1
& R2
• New Requirements
FAC-008-3 R3
• Similar to FAC-008-1 R1 for TO
FAC-008-3 R4
& R5
• Retiring
FAC-008-3 R6
• Similar to FAC-009-1 R1
FAC-008-3 R7
• Similar to FAC-009-1 R2
FAC-008-3 R8
• New Requirement
Develop Corrective Action Plan
• Brief background of the problem –
o NERC standard FAC-008-1 and FAC-009-1 are retiring
on 12/31/2012 and are being replaced by a new
standard FAC-008-3 effective 1/1/2013
• Scope Of Work –
o Identify steps to be taken to comply with FAC-008-3
o Train the employees on the new standard FAC-008-3
• Assign Team and Leader – A, B, C
• Timeline for Completion – xx/xx/xxxx
51
Develop Corrective Action Plan
• Major Milestones –
o FAC-008-3 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-008-3 R3:
1. Confirm that Transmission facilities follow the facility ratings
guidelines specified in the sub-requirements of FAC-008-3 R3.
2. Confirm that one of the methodologies as specified in 3.1 is
being used for identifying facility ratings of transmission
facilities.
52
Develop Corrective Action Plan
• 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
53
Example - NERC Standard
Changes
Identify Problem
Evaluate Problem
Develop Corrective
Action Plan
Implement
Corrective Action
Plan
Evaluate
Effectiveness
54
• Two NERC Standards replaced by One new standard
• Potential for future non-compliance
• Map Old Requirements to the new Requirements
• Perform Gap Analysis
Corrective Action Plan
Put your plan to Action
• Perform Internal Audit to confirm Compliance is
maintained.
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
56 Get Management Sign Off on Closure
Tools and Resources
• U.S. Department of Energy Corrective
Action Program Guide
o http://www.lm.doe.gov/Office_of_Business_Ope
rations/Solicitations/RFP_Support/DOE_Directi
ves/050_DOE_G_414_15.aspx?__taxonomyid=791
57
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
58
Questions?
Brent Read
Sr. Compliance Risk Engineer, O&P
(801) 819-7689
[email protected]
Ruchi Ankleshwaria
Compliance Risk Engineer, O&P
(801) 883-6881
[email protected]