Effective Operations and Communications 2015 System Operator Seminar

Training Objectives 2 System Operators will Describe cause analysis and how to better analyze complex problems Describe how human performance improvement techniques will reduce error rates and improve overall reliability Describe the importance of effective communications and how continued use of three way communication will help maintain high reliability in FRCC Add COM002-4

Cause Analysis Ex. 3 Why ask WHY? What’s done is done. Why look further?

Cause Analysis Ex. 4

5 Maintenance records were good No history of ever over heating Jeep was hit on right side, at 70k miles Right fender, radiator and fan blade were replaced No damage to engine block Mechanic noticed scalding on other pistons

Cause Analysis Ex. 6 So what happened Fan blades were installed backwards Caused Jeep to run slightly hotter than it should New owner after repair so no baseline Increased temperature was not noticeable to the driver and didn’t trigger warning lights Just MTF for piston?

Cause Analysis Ex. 7 What would the Apparent Cause Analysis show us? Vehicle broke down - why? Piston failed – why? Scalding on pistons why? Vehicle ran hot – why? Fan was installed backwards – why? Design flaw – Why? We cannot be sure of this without locating documentation and the designer and understanding the design process We have to stop here

Cause Analysis Ex. 8 Corrective Actions: Rebuild the engine with new piston and same block Correct the direction of the radiator fan to properly cool the vehicle Make a more apparent marking on the fan blade to identify direction Notify the manufacturer (mfg.) of the error with detailing the trap Additional work with mfg. needed Mfg. issue a bulletin to notify all customer/mechanics of the issue Mfg. to revise the installation procedure explaining the importance of verify the direction Possibly Recall vehicles and modify the design so that the blades only fit the proper direction Could any of these action prevent recurrence?

Cause Analysis Ex. 9 Through the power of a certain search engine I found a forum discussion that may explain part of the design process Some of the CJs or Wranglers had reverse rotating water pumps that are stamped with an “R” If the Jeep is equipped with one of these water pumps then the fan blades should be installed in the opposite direction Thus, it seems Jeep was aware of this design issue and there are other variables involved

Human Performance (HP) 10 What is HP Accomplishment of a task in accordance with agreed upon standards of accuracy, completeness, and efficiency. Definition from Businessdictionary.com

Human Performance (HP) 11 Video removed to save space

Human Performance (HP) 12 Quotes from video (out of order) Nobody wants to take lines out of service just to maintain them Like a bird on a wire – Hot suit - PPE Our pilots are very smooth, like they can read our every thought Everything that we do, every move that we make is thought of and rehearsed before Not a job for a hot dog As safe as crossing the street

Human Performance (HP) 13 Pulled from NHTSA’s National Center for Statistics and Analysis Traffic Safety Facts – 2012 Data Is crossing the street really safe? Yes, if done properly and with attention

Human Performance 14 Video removed to save space

Human Performance (HP) 15 Interesting Facts In June 2011 Texas utilities (including CenterPoint) hired a vendor to spray-wash salt, sand and other contamination from transmission towers as a result of the drought conditions NERC also released a Lesson Learned related to the same drought (released 07/26/2011) Corrective Action “The entity has employed an electrical contracting firm to treat all outside insulators at this station with a silicone coating to prevent buildup of contamination and therefore reduce the chances of a similar occurrence.”

Human Performance (HP) Principles 16 Things are the way they are because they got that way People come to work to do a good job People are fallible, and even the best people make mistakes The people who do the work are the ones who have the answers Error-likely situations are predictable, manageable, and preventable Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors)

Human Performance (HP) 17 Things are the way they are because they got that way Chart from NERC Cause Analysis Training

Human Performance Improvement (HPI) 18 Error Avoidance Tools/Techniques Pre job brief Peer check Questioning attitude Identified nomenclature (from bus to bus)

Human Performance Improvement (HPI) 19 Process Controls/Barriers Lock out/Tag out Confirmation pop-up screen Are you sure? Information Tags Screen Tags and One Line notes Checklists and Tailboards Access rights – Physical and Cyber

Effective Communication 20 “The single biggest problem in communication is the illusion that it has taken place.” George Bernard Shaw (Nobel Prize Winner for Literature) “If you have nothing to say, say nothing.” Mark Twain

Effective Communication 21 Effective communication requires effective listening Steps to Listening Process Hearing Attending Interpreting Responding Remembering

Effective Communication 22 Hearing The sense through which a person or animal is aware of sound : the ability to hear An involuntary action

Effective Communication 23 Attending Attending involves filtering out some sounds and focusing on others Attending is a psychological choice – The listener has to choose to focus on the sound he/she is attempting to listen to This is where we choose to tune out certain sounds or messages – Yes dear.

Effective Communication 24 Interpreting This is when we begin to make meaning (or understand) the sounds we hear and are attending This requires thought

Effective Communication 25 Responding At this point the listener has a meaningful message and he/she responds and reacts sending their own message. This can be non-verbal message. Yeah, uh huh, head nod etc.

Effective Communication 26 Remembering The listener stores the information for use at a later time

Effective Communication 27 Techniques to master listening Tune out other conversations and distractions Sit up straight Focus on what the sender is saying Put aside any biases to the sender or the message Allow the speaker to complete their statement Questioning attitude Repeat back Wait for confirmation before taking action

Effective Communication 28 Three-Way Communication (aka Three-Part) 1.Initiator will issue a directive/message 2.Receiver will repeat back the directive/message 3.Initiator will ensure the directive/message is repeated back correctly and acknowledge the response as correct

Effective Communication 29 Video removed to save space

Effective Communications 30 NERC Reliability Standards COM Currently Enforceable COM Awaiting FERC Approval FRCC Procedures FRCC Regional Voice Communications Handbook Procedure

Effective Communication 31 Make it simple use three-way for any instruction, directive, order, etc. Changes with COM Each BA, RC, TOP shall have communications protocols - Requires use of English, unless agreed to otherwise -Includes Distribution Providers in applicability -Requires three-way for Operating Instruction -Requires phonetic alphabet -Add Sampling

Effective Communication 32 Video removed to save space

Questions? 33