1. HUMAN PERFORMANCE – FUNDAMENTAL ERROR PREVENTION
Establishing the National Electrical Workers’ Near-Miss Reporting System Robert D. Schwermann Pacific Gas and Electric Company February 28, 2013
I look out at this room and see a lot of familiar faces and know that most of you have travelled quite a ways to be here. I want to say Thank you. I particularly want to thank PG&E for making it possible for me to have worked on this project for the past year plus has been gracious to support me being here today. I would like to especially thank my Director Eric Back for his attendance.
I also would like to thank our guests from other industries who have been so very helpful in getting us to this stage. Linda Connell from the ASRS, and Chief Rob Clemmons from the FFNM.
I also would like to thank NERC for so graciously offering to host the meeting at a late date after our initial plans changed.
HUMAN PERFORMANCE – FUNDAMENTAL ERROR PREVENTION

2. Why are we here?
WHAT DOES A PICTIRE OF A SAW BLADE HAVE TO DO WITH THIS MEETING
Tell story of the radial arm saw and almost cutting off my arm. Cause distraction, fatigue, repetitive boring , but dangerous work. I stopped in time and told my coworkers about it. The sharing of the story and my near-miss made a different on our crew that summer. We kicked in our brains and had no more incidents that summer. 12X4; 10X4’s 16 – 20 ft long
Since that time I have spent the last 40 years in the electric business and have seen other events happen. We have an industry of passionate people who care abou their work and their fellow workers. If you look at our policies and procedures most of them are written in blood. There must be a better way to learn from our mistakes and near mistakes.

3. History of the Proposal
2011 Established Western Electric Coordinating Council (WECC) Human Performance Work Group. (HPWG)
HPWG is situated under the Operator Training Subcommittee
Purpose:
Share information on Human Performance Improvement (HPI)
Assist others in WECC to establish HPI in their organizations
Determine a way to be proactive with developing training rather than reactive as the result of an event
I am not here representing myself. But a larger group of people who have been working on this project for the past year. The WECC HPWG initiated discussions at their meeting held in Salt Lake City held on Feb 21, 2012.  People attending the meeting either in person or on the phone represented the membership of the many utilities in the WECC region, NATF, NERC, AND EPRI.  It was decided at that time to pursue some form of a pilot program.  At the NERC Human Performance conference we had made contacts inside other systems such as the NTSB, the ASRS and the Fire Fighters NMDB and he would help us to get the ball rolling.
The common thing that we found was the industries that had them, seemed to be more proactive rather than reactive, based on what they were learning from things that never actually happened.
IN doing the research we have met other industry leaders this is intro to next slide.

4. History of the Proposal
Early 2012 WECC HPWG initiated conversations about near-miss reporting systems with the following:
Pacific Gas and Electric Company (PG&E)
Bonneville Power Authority (BPA)
Alberta Electric System Operator (AESO)
Electric Power Research Institute (EPRI)
North American Transmission Forum (NATF)
North American Electric Reliability Corporation (NERC)
Aviation Safety Reporting System
Fire Fighters Near-Miss Reporting System
Smaller focus group initiated action
White Paper published last July
Socialization of white paper in Industry.
The WECC HPWG initiated discussions at their meeting held in Salt Lake City held on Feb 21, 2012.  People attending the meeting either in person or on the phone represented a wide base of the industry in the west and a few national organizations. It was decided at that time to pursue some form of a pilot program.  About the same time we reached out to the ASRS and the Fire Fighters NMDB project personnel and they helped us go down tehe correct path.
Not all who started had the time to see it through, We did not always agree on the direction, and not all endorsed it. George Gila and Navin Bhatt of EPRI did a lot of the heavy lifting for us and I am grateful to them for us getting to this point. Also Phil Mayson of the AESO took the lead many times when I could not.
This idea has been discussed by a lot of people and a lot of different venues. This list is by no means to be all inclusive, but it is to show the diversity and breadth ……. but it became evident that the interest was growing…
The white paper that was written was a collaboration of our research and thoughts on how to move forward.

5. The White Paper – What we found out
There is currently no industry-wide reporting system for near-miss incidents.
Individual uncoordinated data is of little value because it is NOT available to the industry as a whole.
Some data exists but no method to distribute the data and lessons learned to industry.
There are examples from other industries that illustrate the importance of such a system.

6. The White Paper - Follow-up
Conducted outreach to obtain industry wide support for an Electrical Worker Near-Miss Reporting System (EWRS)
Involved all parts of industry from the inception
Labor, Generation, Transmission, Distribution & other related field workers
Feedback has been predominately positive
Researched other reporting systems
Discussed funding potential
Discussed at multiple levels in the industry such as NERC meetings, Epri Conferences, WECC Meetings, and the other venues. For the most part Feed back has been positive
We Researched other reporting systems such as the ASRS and FF NMRS and also Discussed funding potential for our project.
We are fortunate to have leaders from other industry leaders to show their successes and failures and are willing to help us with items that we need to learn

7. Who has been participating
Discussions about the EWRS have been taking place for more than a year within the industry
interest is growing
EWRS has become an industry wide initiative
Learned from other more mature systems
Linda Connell - Aviation Safety Reporting System
Amy Tippett - Fire Fighters Near-Miss Reporting System
Since the white paper has been out and the group has started to tell others of our ideas the project has taken seed. We have had guidance from the Industry with an expanding base of interested parties
As we have been reaching out we have gotten support from other entities such as certain Utilities, the Generator Forum, Public Power, the Utility Safety and Ops leadership Network and others
Chief Rob Clemons FFRNMR

8. We are just getting the tip of the iceberg.
Events get our full attention because something bad (or very bad) has happened and we are strongly motivated to find answers and prevent repeat occurrences. Normally there is some sort of impact to System reliability when these happen.
Today, we are only analyzing events and as a result, our data is limited.
We have mature systems in this arena. Our regulator has a solid voluntary process in place. Large enough events aren’t voluntary, we get lot’s of help from our regulators.
What we are talking about is the gap….next slide…
We are

9. We need to look at the rest of the iceberg
A near-miss is an incident in which no injury, property damage, or system reliability lapse occurred. In other words, “You got lucky.” or again the near hits!
In these situations, we are not usually as strongly motivated to investigate. But, we could still learn from near-misses, if we were tracking and analyzing this data.
We have asked: How do we take advantage of this very large data set that is absolutely untapped at the national level?
There is a much larger pool of information available to us if we include near-misses.

10. Maintain EWRS independently as an industry-wide database
The Plan
Establish a collaborative group to lead the creation of an industry-wide Electrical Worker Near-Miss Reporting System (EWRS) in North America.
Maintain EWRS independently as an industry-wide database
All reporting confidential and sanitized before publication
Available to all as a large source of human performance, personnel safety and reliability information.
Such an System 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

11. Features of the EWRS
Voluntary submissions from all parts of the industry using a confidential report entry system
System set up with NO punitive measures
Processes to review each report and verify the data’s value and ensure confidentiality
A framework for trend analysis of the reported incidents leading to “lessons learned”
Broadcast of the “lessons learned” to the entire industry
EWRS must be Independent from regulatory agencies
Our plan calls for one central, independent, non-regulatory, entity to be created for the anonymous collection and confidential reporting of near-miss data.
This entity would be responsible for reviewing submissions in order to ensure the credibility of all reports, redact individual and organizational identifications, and facilitate the distribution of findings.
Trends identified from near-miss data also point to training needs.
There was a discussion in the Feb 21, 2012 HPWG meeting that the regulator could help us set up the project, but would not be part of the finished product and would have no more rights to the sanitized data than any other.
Today we will learn from other efforts that have shown success and as we learn about these we can realize that we can be as successful.

12. Successful Near-Miss Systems in Other Industries
Aviation Safety Reporting System
asrs.arc.nasa.gov
National Fire Fighter Near-Miss Reporting System
firefighternearmiss.com
Federal Railway Administration Close-Call Reporting System
closecallsrail.org
We have mature process’s for violations, event review’s
There are plenty of precedents.
We can learn from the ones that are seasoned and mature and we can learn from al of these.
We are very fortunate to have with us today representatives from what many consider to be the “Gold Standard” of all Near Miss System - The Aviation Safety Reporting System and from the NM system that serves a population most like ours – the National Firefighter NM system.

13. What is the Value of a Near-Miss Reporting System?
"We use near-miss reports in all training that we develop. We use them as operating experiences to discuss what can go wrong in the situation that is being covered and how that can be prevented. The more we learn from each other the safer we will be in the long term. Near-miss reports are great training tools!"
-Rob Archibold, Hiawatha Fire Department (IA) *
“As a result of our attitudes and efforts, we have been successful in dramatically reducing the number of injuries our personnel suffer over the past three years. The national Near- Miss Reporting System has played a major part in our efforts.”
Todd Bradley, Safety Officer, Burlington Fire Department (NC)*
* From the Firefighter Near Miss Monthly Reports
Not to steal Chief Clemons Thunder but some quotes from his organization shows the impact it has made on their Industry. Please take some time to read this.

14. HOLD THE PULL http://www.youtube.com/watch?v=tl0vLHJmsiw
Thank you IBEW for doing this video
Tell story of John Christiansen
I am here for the John’s of the world. We don’t want any more and we want a highly reliable system We can move closer to this goad with a near-miss reporting system
HOLD THE PULL
HUMAN PERFORMANCE INITIATIVE – FUNDAMENTAL ERROR PREVENTION TOOLS