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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Footer,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Footer,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Footer,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,4/15/2013,#,Two Brief,Teaching,Cases,James Merlo,NERC,&Jake Mazulewicz,Dominion VA Power,_,NERC Human Performance Conference,March 2021,2021.Dominion.All rights reserved.,2,Could this happen,at my company?,These case studies are intended only to foster thoughtful discussion and may not show correct technical procedures.Consult your official resources and your Supervisor for correct policies and procedures.Names and details in this case may have been changed and may not represent any one actual event.,3,The First Event,4,The Cause,5,The Cause,6,The Cause,7,The Cause,8,Turn to the person next to you.Spend a few minutes finding out their answer to this question.If this incident happened at your company,what Corrective Action would be taken,and what would the results be?,Question,9,The Cause,10,The,Cause,Apparent,11,4-8 Questions,Turn to the person next to you.,Working t,ogether,write down 4-8 questions you realistically could and would ask in a Root Cause Analysis of this event.,12,The Root Cause,What,caused,him to remove the,shield,?,13,The Root Cause,What,caused,him to remove the,shield,?,Did someone tell him to remove it or did he do it on his own?,14,The Root Cause,What,caused,him to remove the,shield,?,Did someone tell him to remove it or did he do it on his own?,Did he remove it just this once or does he remove it every time?,15,The Root Cause,What,caused,him to remove the,shield,?,Did someone tell him to remove it or did he do it on his own?,Did he remove it just this once or does he remove it every time?,Did he make an error,or did he plan to remove it?,16,The Root Cause,What,caused,him to remove the,shield,?,Did someone tell him to remove it or did he do it on his own?,Did he remove it just this once or does he remove it every time?,Did he make an error,or did he plan to remove it?,Was the shield labeled as a safety device?,17,The Root Cause,What,caused,him to remove the,shield,?,Did someone tell him to remove it or did he do it on his own?,Did he remove it just this once or does he remove it every time?,Did he make an error,or did he plan to remove it?,Was the shield labeled as a safety device?,Was he trained or certified to do this procedure?,18,The Root Cause,What,caused,him to remove the,shield,?,Did someone tell him to remove it or did he do it on his own?,Did he remove it just this once or does he remove it every time?,Did he make an error,or did he plan to remove it?,Was the shield labeled as a safety device?,Was he trained or certified to do this procedure?,If we asked 10 other equivalently trained and experienced Linemen to do that job,would they also remove the shield?(substitution test),19,The Root Cause,When instructors teach this procedure,do they point out how this shield works as a safety device?,Apparent Cause,Root Cause,Cause,Corrective Action,Result,Apparent Cause,Root Cause,Cause,Lineman violated procedure,Corrective Action,Punish lineman,for violation,Result,Apparent Cause,Root Cause,Cause,Lineman violated procedure,Corrective Action,Punish lineman,for violation,Result,Lineman,decides that his company prizes“accountability”over solutions,and,tells story of this unfairness,until he retires.,Incident occurs again.,Apparent Cause,Root Cause,Cause,Lineman violated procedure,Training did not include critical info,.,Corrective Action,Punish lineman,for violation,Result,Lineman,decides that his company prizes“accountability”over solutions,and,tells story of this unfairness,until he retires.,Incident occurs again.,Apparent Cause,Root Cause,Cause,Lineman violated procedure,Training did not include critical info,.,Corrective Action,Punish lineman,for violation,Update,the training.Send bulletin to local offices.,Result,Lineman,decides that his company prizes“accountability”over solutions,and,tells story of this unfairness,until he retires.,Incident occurs again.,Apparent Cause,Root Cause,Cause,Lineman violated procedure,Training did not include critical info,.,Corrective Action,Punish lineman,for violation,Update,the training.Send bulletin to local offices.,Result,Lineman,decides that his company prizes“accountability”over solutions,and,tells story of this unfairness,until he retires.,Incident occurs again.,Incident doesnt reoccur for many years if ever.Lineman and other employees see their company solve a problem with reason instead of power.,Two Brief,Teaching,Cases,James Merlo,NERC,&Jake Mazulewicz,Dominion VA Power,_,NERC Human Performance Conference,March 2021,27,The Second Event,28,The Cause,29,Turn to th
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