Regulators Don’t Fix Your Problems, You Do – NERC Cause Analysis Introduction
Regulators from many industries require root cause analysis of process failures, but not all approaches to RCA reflect best practices for requiring or even identifying a proper investigation. A few require compliance with highly structured reporting systems designed to support consistency, tracking, and validating research, such as NERC and DOE Cause Codes. Regulations can set expectations, but they don’t create excellence.
Best-in-class organizations don’t run by striving to meet regulatory requirements; that is often only a starting point. They learn from adverse events in a disciplined way that far exceeds external expectations. Proper RCA of equipment failures is one of those pieces. When regulators drive problem identification, it can signal that internal processes need strengthening.
1. Take the Equifactor® Equipment Troubleshooting & TapRooT® Root Cause Analysis Training to investigate failures properly.
2. Get to the Equipment Reliability and Maintenance Excellence track at the Global TapRooT® Summit to see how Best-In-Class organizations use Equifactor® Equipment Troubleshooting to eliminate those failures. Keep calm and TapRooT® on.
References can be found on this NERC page: https://www.nerc.com/programs/event-analysis/reference-materials
Interactive Introduction to Root Cause Analysis gives us a great intro to what ends up as ACA.
What’s the difference between Apparent Cause Analysis and Root Cause Analysis? Foliage vs roots.
“Once you ask that first ‘why’, you’re potentially starting down a narrow path.” A narrow path of confirmation bias, “the fastest way to validate the conclusion you’ve already jumped to” as one TapRooT® leader puts it (Cory Wald)! Using 5-whys, you risk losing the big picture, as NASA did, and missing a LOT of relevant and useful details, like NERC did when identifying THE root cause of the Challenger incident.
Oh geez, “you’re about to witness an event.”
Welcome to Earth, North American Electric Reliability Corporation! Correcting missing best practices and human error, regardless of motivations, is what RCA is designed to do.
Here’s the full story NERC provided in SnapCharT® form. The A+ tech only has one Causal Factor, and there are three.
There seems to be a Management of Change and many other issues involved, not explicitly called out. We can see easily that this evidence leads to no fewer than five root causes, with just the evidence NERC provided here.
Causal Factor 1: Tech left the old power box in the location
- Equipment Difficulty – Design – Environment not considered (snowy location)
- Training – continuing training NI (A+ Tech didn’t know weather)
- Corrective Action NI – Client chose not to install a new weatherproof box in a higher location
Causal Factor 2: Client switched off the wrong breaker
- Labels NI – similar to old system labels
Causal Factor 3: HM did not check for the power off
- LOTO NI – did not personally verify breaker was off
Let’s do a better job at identifying ALL the missing best practices. Whether you’re the contractor (A+), the client (Mrs. Muller), or a NERC-subject company (Ed’s organization, it seems), there are ways YOU can prevent each of these human errors from leading to a shock. You can only fix what you control.
