Event Analysis Program

James MerloAssociate Director, Human Performance, Reliability Risk ManagementFebruary 28, 2013

2 RELIABILITY | ACCOUNTABILITY

Program Background

• Initiated October 2010• Approved by NERC Board of Trustees February 2012• ONLY process with detail of what and why• Event analysis training in demand• Cause coding supports analysis• Feedback to industry critical

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Event Counts

Event Category Count (Total) Count (2013) Comments

CAT 1 169 6

CAT 2 85 3 2- EMS event (2b) 1 LOOP (2d)

CAT 3 9 0

CAT 4 3 0 SW Winter Weather (2011)SW Blackout (2011)Derecho (2012)

CAT 5 1 0 Hurricane Sandy (2012)

Total CAT 1-5 267 9

Non-Qualified Occurrences

reported

1452 58

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2912%

21388%

Cause-coded Events

To be CC'd

The Cause Coding status of 242 closed (through 15 February 2013)

259%

24291%

Closed Events

Open

The status of 267 Events (through 15 February 2013)

Summary All Time

EA Program beganOctober 2010

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Root Cause Determinations

A2 – Equipment / Material

AN No Causes Found

A5 Communication

A3 Individual Human Performance

A7 Other

A1 Design / Engineering

A2 Equipment / Material

A4 Management / Organization

AZ Information to determine cause LTA

A4 – Management / Organization

AZ – Information to determine Cause LTA

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Deeper Dive into Organizational Issues (Based on Root Cause)

A4B3C

08

A4B5C

04

A4B1C

03

A4B1C

04

A4B1C

05

A4B1C

06

A4B1C

08

A4B1C

09A4B

1

A4B5C

05

A4B5C

03

A4B5C

13A4B

5A4B

4

A4B5C

02

A4B3C

09 A4

A4B2C

07

A4B4C

06

A4B3C

050

1

2

3

4

5

6

7

8 A4 – Management / Organization B3C08 - job scoping did not identify special circumstances

or conditions B5C04 - risks/consequences associated with change not

adequately reviewed B1C03 - direction created insufficient awareness of impact

of actions on safety/reliability B1C04 - follow-up did not identify problems B1C05 - assessment did not determine cause of previ-

ously event or known problem

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All Causes for Management /Organization

A4B1C

05

A4B3C

08

A4B5C

03

A4B5C

04

A4B1C

08

A4B5C

05

A4B1C

04

A4B1C

03

A4B1C

06

A4B2C

08

A4B5C

13A4B

5A4B

4

A4B1C

09A4B

1

A4B3C

09

A4B5C

02

A4B4C

05

A4B3C

11

A4B2C

07

A4B4C

06A4B

2A4B

3

A4B5C

01

A4B5C

09 A4

A4B3C

05

A4B1C

01

A4B1C

07

A4B4C

02

A4B5C

10

A4B4C

010

2

4

6

8

10

12

14

16

A4 – Management / Organization B1C05 - assessment did not determine cause of

previously event or known problem B3C08 - job scoping did not identify special circum-

stances or conditions B5C03 - inadequate vendor support of change B5C04 - risks/consequences associated with

change not adequately reviewed B1C08 - corrective action responses to a known or

repetitive problem was untimely B5C05 - system interactions not considered B1C04 - follow-up did not identify problems

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Questions and Answers

Michael MoonSenior Director of Reliability Risk Management404-446-2567 office | 609-651-9693 cellMike.Moon@nerc.net

 Ben McMillanRisk Analysis Engineer, RRM404-446-9729 office | 404-823-1362 cellBen.Mcmillan@nerc.net  

James MerloAssociate Director, Human Performance, RRM404-446-2560 office | 404-387-5249 cellJames.Merlo@nerc.net