February 2011 Cold Snap Event RecommendationsEvent ... DL/Cold_Snap_Event...impacted by the cold...

February 2011 Cold Snap Event RecommendationsEvent RecommendationsJanuary 23, 2011y ,Earl Shockley, Director of Reliability Risk Management

Recommendations - Electric

• February 1‐5, 2011 event occurred

• August 15 2011 joint report released• August 15, 2011 – joint report released

• There were a total of 26 electric recommendations issued:issued: Planning and reserves (5);

Coordination with generator owners/operators (5);Coordination with generator owners/operators (5);

Winterization (10);

Communications (4); and

Load Shedding (2)

• There were also six gas recommendations

2 RELIABILITY | ACCOUNTABILITY

Theme -Three “P’s”

• August 2003 Blackout delivered three distinct themes ll d th th “T’ ”called the three “T’s”. Trees

Tools Tools

Training

• The February 2011 Cold Snap event delivered threeThe February 2011 Cold Snap event delivered three distinct themes Predict

Planning

Preparation


Predict

First P – “Predict”

• The storm was not without precedent There were priorThe storm was not without precedent. There were prior severe cold weather events in the Southwest in 1983, 1989, 2003, 2006, 2008, and 2010. , , , , Good analyses were conducted

Good reports were written

Good recommendations were developed

No institutionalization of the recommendations and lessons

Can we now predict the same circumstances?


Planning

Second P – “Planning”

• On site visits with GO/GOPs revealed:On site visits with GO/GOPs revealed: Some plants had inadequate plans and safeguards in place

to address severe weather.o Lack of formal plans, procedures to address severe weather

o Lack of adequate knowledge of plant temperature design limits and the equipment most effected by freezingq p y g

o Failure to adequately apply and institutionalize knowledge and recommendations from previous severe winter weather events

Some plants had rigorous plans and safeguards in place Some plants had rigorous plans and safeguards in place, some required validation.

Can you predict which plants were most successful during the event?


Can you predict which plants were most successful during the event?

Preparation

Third P – “Preparation”

• Generators were generally reactive as opposed toGenerators were generally reactive as opposed to being proactive in their approach to winterization and preparedness. Many generators failed to adequately p p y g q yprepare for winter, including the following: Failed or inadequate heat traces,

Missing or inadequate wind breaks

Inadequate or lack of insulation

l h h l d h Failure to have or to maintain heating elements and heat lamps in instrument cabinets

Failure to have necessary resources and supplies


Failure to have necessary resources and supplies

BY FAILING TO BY FAILING TO PREPARE, YOU ARE PREPARING TO FAIL.

BENJAMIN FRANKLIN


Frozen Sensor

Aerator Sensor

3/8 inch tubing ‐exposed

R 14 GO/GOP E th t d t i t d i ti f f


R 14 ‐ GO/GOPs – Ensure that adequate maintenance and inspection of freeze protection elements is conducted on a timely and repetitive basis.

Inadequate Insulation

R‐16 GO/GOPs – inspect andinspect and maintain thermal

i l tiinsulation on all units.


Lack of Insulation

Notice burn marks (from torch) on bare tube

R – 18 GO/GOPs – Develop and annually conduct winter‐specific and plant‐specific operator awareness

Outside exposure


specific operator awareness and maintenance training.

Wind Break Design

Wind break was too

Feedwater Sensor Froze

Wind break was too Short

Wind BreakR – 17 GO/GOPs – Plan to erect

adequate wind breaks and enclosures,


adequate wind breaks and enclosures, where needed.

Corroded FreezeProtection Panel

R – 15 GO/GOPs – Inspect and maintain heat tracing equipment on all


R 15 GO/GOPs Inspect and maintain heat tracing equipment on all generating units.

Oil Burning Wands

R – 6 TOs, BAs, and GO/GOPs –if h i h h f lVerify that units that have fuel switching capabilities can

periodically demonstrate those p ycapabilities


Fuel Transfer Valves

Valve Froze


Lessons Learned

• NERC received a total of 55 lessons learned from entities impacted by the cold snap event.p y p

• The lessons learned were reviewed by NERC, categorized and consolidated into 22 individual lessons that align with the

d ti tli d i th j i t FERC/NERC trecommendations outlined in the joint FERC/NERC report “Outages and Curtailments during the Southwest Cold Weather Event” published on August 15, 2011.

• On September 30, 2011 the first two cold snap lessons learned were posted to correspond with the fall maintenance program for winter weather preparationwinter weather preparation.

• Two additional lessons learned have been posted.


Events Happen

Lab Tests Confirm Salmonella Source

16 RELIABILITY | ACCOUNTABILITYRELIABILITY | ACCOUNTABILITY

Reliability Risk ManagementConcepts

Severity

Avoid

InverseLearn and Reduce

Cost‐Benefit

Reporting Threshold


Trend lower tiered events – identify emerging reliability risk trends.

Drifting to Failure Concept*

Hi

Expectations: Desired approach to work (as imagined)Normal Practices: Work as actually performed

Hi

Drift

Managements Stated Expectations

“Normal”

liability

f NormalPractice

Real Margin for Error

Error

Latent Errors

Re

Latent Errorsunnoticed at the time made; often deeply or embedded within system.

RISK CLUSTERS ‐ Programmatic deficiencies, deficiencies in barriers and defenses, Latent organizational weaknesses and conditionsErrors in human performance and contextual factorsEquipment design and/or maintenance issues


Lo Time * Adapted from Muschara Error Management Consulting, LLC

Cold Snap EventDrifting to Failure*

Hi

Expectations: Desired approach to work (as imagined)Normal Practices: Work as actually performed

Hi

Drift

Stated Expectations

“Normal”

liability Normal

PracticeReal Margin for Error Error

Latent Error

Re

Latent Errorunnoticed at the time made; often deeply or embedded within system.

Linked Causal factors = examples above


Lo Time * Adapted from Muschara Error Management Consulting, LLC

Defense in Depth Concept*

When the wrong set of circumstances line up, major events occur…

Defense 1Defense 2Defense 3

Freezing weather, high winds

fDefense 4

Event


* Adapted from Dr. James Reason, Human Error 1990

Summary

• We do not want to lose our perspective of what happened during the winter of 2011happened during the winter of 2011

• Consider the three “P’s”

E i f d• Examine your safeguards

• We should consider the cost benefit as well as the risk to reliability and reputation:reliability and reputation: Institutionalize recommendation and learning's

Show that we not only can identify problems but also put the Show that we not only can identify problems but also put the necessary fixes in place.

• Have a passionate focus on reliability


p y

Questions ?Questions ?


February 2011 Cold Snap Event RecommendationsEvent ... DL/Cold_Snap_Event...impacted by the cold...

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