Could this happen at my company Two Case Studies这会发生在我的公司 2个案例研究

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TwoBriefTeachingCases

JamesMerlo,NERC&JakeMazulewicz,DominionVAPower__________________________NERCHumanPerformanceConferenceMarch2021©2021.Dominion.Allrightsreserved.2Couldthishappenatmycompany?Thesecasestudiesareintendedonlytofosterthoughtfuldiscussionandmaynotshowcorrecttechnicalprocedures.ConsultyourofficialresourcesandyourSupervisorforcorrectpoliciesandprocedures.Namesanddetailsinthiscasemayhavebeenchangedandmaynotrepresentanyoneactualevent.3TheFirstEvent

4TheCause

5TheCause

6TheCause

7TheCause

Turntothepersonnexttoyou.

Spendafewminutesfindingouttheiranswertothisquestion.

Ifthisincidenthappenedatyourcompany,whatCorrectiveActionwouldbetaken,andwhatwouldtheresultsbe?Question9TheCause

10The

Cause

Apparent

114-8Questions

Turntothepersonnexttoyou.

Workingtogether,writedown4-8questionsyourealisticallycouldandwouldaskinaRootCauseAnalysisofthisevent.12TheRootCause

Whatcausedhimtoremovetheshield?

13TheRootCause

Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?

14TheRootCause

Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?

15TheRootCause

Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?Didhemakeanerror,ordidheplantoremoveit?

16TheRootCause

17TheRootCause

18TheRootCause

Whatcausedhimtoremovetheshield?Didsomeonetellhimtoremoveitordidhedoitonhisown?Didheremoveitjustthisonceordoesheremoveiteverytime?Didhemakeanerror,ordidheplantoremoveit?Wastheshieldlabeledasasafetydevice?Washetrainedorcertifiedtodothisprocedure?Ifweasked10otherequivalentlytrainedandexperiencedLinementodothatjob,wouldtheyalsoremovetheshield?(substitutiontest)

19TheRootCause

Wheninstructorsteachthisprocedure,dotheypointouthowthisshieldworksasasafetydevice?

ApparentCauseRootCauseCauseCorrectiveActionResultApparentCauseRootCauseCauseLinemanviolatedprocedureCorrectiveActionPunishlineman

forviolationResultApparentCauseRootCauseCauseLinemanviolatedprocedureCorrectiveActionPunishlineman

forviolationResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.ApparentCauseRootCauseCauseLinemanviolatedprocedureTrainingdidnotincludecriticalinfo.CorrectiveActionPunishlineman

forviolationUpdatethetraining.Sendbulletintolocaloffices.ResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.ApparentCauseRootCauseCauseLinemanviolatedprocedureTrainingdidnotincludecriticalinfo.CorrectiveActionPunishlineman

forviolationUpdatethetraining.Sendbulletintolocaloffices.ResultLinemandecidesthathiscompanyprizes“accountability”oversolutions,andtellsstoryofthisunfairnessuntilheretires.Incidentoccursagain.Incidentdoesn’treoccurformanyyearsifever.Linemanandotheremployeesseetheircompanysolveaproblemwithreasoninsteadofpower.TwoBriefTeachingCases

JamesMerlo,NERC&JakeMazulewicz,DominionVAPower__________________________NERCHumanPerformanceConferenceMarch202127TheSecondEvent

28TheCause

Turntothepersonnexttoyou.

Spendafewminutesfindingouttheiranswertothisquestion.

Ifthisincidenthappenedatyourcompany,whatCorrectiveActionwouldbetaken,andwhatwouldtheresultsbe?Question30TheCause

31The

Cause

Apparent

324-8Questions

Turntothepersonnexttoyou.

Workingtogether,writedown4-8questionsyourealisticallycouldandwouldaskinaRootCauseAnalysisofthisevent.33TheRootCause

Whatledhimtoleavethejumperinplace?34TheRootCause

Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?35TheRootCause

Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?Didhedoanythingdifferentthistimevs.previoustimeswhenhe’sdonethisjob?36TheRootCause

Whatledhimtoleavethejumperinplace?Didheuseanydefensestoremindhimselftoremovetheleads?Didhedoanythingdifferentthistimevs.previoustimeswhenhe’sdonethisjob?Washetrainedorcertifiedtodothisprocedure?Werethecorrectleadsidentifiedontheprint?Ifweasked10otherequivalentlytrainedandexperiencedfieldtechnicianstodothatjob,wouldtheyalsoforgettoremovetheleads?(substitutiontest)ApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceCorrectiveActionPunishFieldTechnicianforviolationResultApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceCorrectiveActionPunishFieldTechnicianforviolationResultIncidentoccursagain.FieldTechniciancan’tunderstandhowhemadethiserror,(andretellsstoryforyears).ApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceWiringandlogicdiagramsweredifferent.Noorganizationalprocesstoverifywiringdiagramsandprints.CorrectiveActionPunishFieldTechnicianforviolationResultIncidentoccursagain.FieldTechniciancan’tunderstandhowhemadethiserror,(andretellsstoryforyears).ApparentCauseRootCauseCauseFieldTechnicianleftjumperinplaceWiringandlogicdiagramsweredifferent.Noorganizationalprocesstoverifywiringdiagramsandprints.CorrectiveActionPunishFieldTechnicianforviolati

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Could this happen at my company Two Case Studies这会发生在我的公司 2个案例研究

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