NPPD’s Root-Cause Investigations Presented by: Russ Nyffeler, CHMM Environmental Compliance Auditor Nebraska Public Power District Phone: (402) 563-5467.

NPPD’s Root-Cause Investigations

Presented by:

Russ Nyffeler, CHMMEnvironmental Compliance AuditorNebraska Public Power DistrictPhone: (402) 563-5467Email: [email protected]

2006 APPA Engineering & Operations Technical Conference

Nebraska Public Power District

• Nebraska’s largest electric utility • Formed in 1970 from a merger of 2

utilities • Public corporation and political

subdivision of the state of Nebraska• Governed by an elected 11-member

Board of Directors• NPPD’s energy mix includes coal,

nuclear, hydro, oil/gas, and wind • We have 5,096 miles of transmission

lines, 267 substations, irrigation canals, dams and reservoirs.

Ainsworth

NPPD’s Environmental Department

• Environmental Department started in 1972 with a staff of 2

• Currently we have a staff of 20 working out of 7 different locations

• Environmental Auditing program– Compliance audits,– vendor audits and – environmental incident

investigations

EMS Evolution

• Structure/Staff – Corporate and Field• Environmental Policy Statement • Policies and Procedures• Environmental Assessment Program• DEED EMS Grant • Establishing Performance Indicators

(site specific and corporate)

NPPD Corporate Performance Indicators

• 2005 NPPD’s CEO established Key Performance Indicators (KPI) and goals for the District – Financial, – Safety and – Environmental

• 2005 Environmental Goal, < 20 Preventable Environmental Incidents

• 2006 Goal, < 18

Environmental Incident

An environmental incident is defined as the occurrence of an event that results in the reporting of that event and/or it’s impact to a federal, state or local environmental regulatory agency. Would include:– any NOV, – permit violation or non-compliance, – Reportable chemical or petroleum release– from a regulatory inspection or through an

internal assessment.

Incident Investigations

• Environmental tracks and reports incidents to management and the employees monthly

• ECA is responsible to oversee incident investigations– Prevent reoccurrence– Increase Environmental Awareness and

Accountability – Identify and Minimize Risk– Continuous Improvement – Provide documentation

NPPD Process

• Incident occurs• Reported to ENV/Conduct immediate

corrective actions • Determine if the event requires an

investigation?• If yes, a team or individual is

assigned to do the investigation• Team performs the analysis and

determines the apparent/root cause

NPPD Process Cont.

• Report results and recommended corrective actions are sent to management

• Site management selects and implements corrective actions

• Corrective actions are incorporated into the final report and tracked through work management process

• Applicable sites are notified-lessons learned

Root Cause Definition

• Root causes are:• Specific underlying causes• Those that can be reasonably

identified• Those management has control to

fix• Those for which effective

recommendations for preventing can be generated

Four Major Steps

1. Data collection 2. Organize and analyze

information (Causal factor charting)

3. Root cause identification4. Recommendation generation and

implementation

Develop Initial Scope, Plan, and Schedule

• Between responsible manager and RC leader

• Agree on initial bounds, resources, budget and schedule

• Revisit scope w/managers as things progress or change

Describe the Problem

• Describe the Problem– what happened leading up to the

event– who found it– when was it found etc.

• Write a Problem Statement

Problem Statement

• Using active, explicit language a problem statement describes:– the desired state, – the actual state, and – the difference or gap between the

two– the real, expected or potential

consequences

Data/Evidence Collection

• Retention• Organized• Timing• On Scene • Conduct Interviews

Interviewing

• Designed opportunity to question and listen

• Process to release and record information

• Plan interview • Location of interview• Take good notes• Telephone interviews are last resort• Obtain full name and job title

Interviewing Cont.

• Position Description, qualifications• Name of supervisor• Role at the time of the event, where and when• Were they making decisions or following

directions• Then what, what else did you see, who told

you that, what did you do, please expand on that a bit,

• Summarize, confirm and fill in the gaps• Closure questions, have I forgotten anything?

Is there anyone else should be interviewed? • Encourage value judgments

Root Cause Analysis Methodologies

• Event and Causal Factors Chart• Change Analysis• Barrier Analysis• Kepner-Tregoe Problem Solving• TapRoot® • Why Staircase Tree• TimeLine• Human Performance Evaluation

Event and Causal Factors Charting

• Gather and Organize your data• Arrange data/events chronologically

leading to the incident• Complete by adding secondary

events and conditions• Identify causal factors and items of

note• Enclose events in rectangles and

conditions in ovals

Change Analysis

• Identify the incident• Identify a comparable incident free

event• Analyze the differences for their

effects on the incident• What is different about this

task/process between when the incident occurred and when it did not?

Barrier Analysis

• Involve tracing of pathways of the incident

• Identification of any failed or missing countermeasures (barriers) that could or should have prevented the event – Inspections, engineering,

procedures, training, etc.

Cause Validation

• What extent the cause adversely affects, affected timing or occurrence or magnitude of the incident

• Extent supported by evidence, shows up on casual factors chart, existed during the event, permissive or forcing cause

Developing Recommended Corrective

Actions (CA)• Immediate/Interim actions

– How effective have they been?– What benefits of the immediate

actions should you include in your long term CA?

– Is it necessary to do anything further?

Developing Corrective Actions (Cont.)

• What CA or preventive actions will accomplish the following:– Restore original form, fit or function– Modify or control potential problem

causes– Enable the organization to detect

and respond to the onset of similar problems or causes before they occur

Developing Corrective Actions (Cont.)

• What has been done in the past – worked well? Or failed?

• Each root cause and contributing cause must have an appropriate CA or justification to why not

• Need a clear connection between identified RC and CA

• Each CA should be specific, measurable, accountable, realistic, and timely (SMART)

• Think unintended consequences, If we implement this CA what could go wrong?

Writing Corrective Actions

• Be bold, precise, and imperative• Start with “active” verbs, (revise,

install, include)• Never use evaluate, consider, discuss

(can’t measure)• Arrange CA from most to least

important chronological order of the due dates

• Think Benefits of CA, “ This will result in the …” This will reduce the …”

• Think Specification, write a clear well defined specification

Report Contents

• Start early in the process and make progress daily, (problem statement)

• Less is more• Plain simple professional language• Tables and figures, if they do not help

the reader leave them out• Simple digital photos cropped to focus

on the subject, include captions and items like a ruler for scale

• Who, what, where, when

Failed crimp connection. Note how light the crimp is in comparison to the crimp connection that did not fail.

Crimp connection that did not fail. Note crimp.

Report Format

• Cover page• Mission Statement• Problem Statement• Safety and Environmental

Significance• Evaluation• Cause(s)• Corrective actions taken and

recommended

Other Considerations

• Legal (protection) • Costs vs. Benefits • Limitations (endless exercise)• Resources

– Internet – Nuclear (DOE)– Transportation (DOT)– Health Care, manufacturing, etc.

THANK YOU!

Russ NyffelerEnvironmental Compliance Auditor

Nebraska Public Power District

(402) [email protected]