The new power-grid that failed the backup generator.
Airports have backup generator to
supply power whenever a grid fails. Normally these generators faithfully take
over and keep on running whenever a grid is overloaded and just quit.
One day an old and failing grid
which supplied power to a city also affected an updated supply of power to an
airport. The intent was an update for the city to avoid breakdowns due to
overloads, and life at the airport electrical field would also be perfect.
In a safety management system (SMS)
an operator must conduct risk analyses and plan to mitigate potential hazards. Whenever there are operational changes, an
operational risk analysis is conducted and both current risks and residual
risks must be managed with implementation of corrective action plan (CAP) and
check of CAP’s effectiveness.
Before continue reading, take a
minute to evaluate if there could be any residual risks of upgrading the grid.
The assumption is that an upgrade is able to take on the load without breakdowns.
However, should a breakdown occur, it is expected that the backup generator is
taking over. Overall, it is a safety
improvement to operational control. After analyzing for possible residual risks, make
a comment to this risk as being: “None”,
or “Yes”, and if “Yes”, give an example of what this risk could be.
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A generator failure often causes
major consequences.
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Over a few years the new and
improved grid faithfully supplies power to the airport with no need for backup
power. Then, on a cold and dark winter night there is an overload and the grid fails.
Further, there is no generator backup power, since the generator also failed
and left the airport without power for hours. The generator had a fuel
“backflow” issue and is not operational.
When the airport was operating on
the old and inferior grid with several losses of power, the backup generator
would operate frequently. This frequency in operation kept enough fuel pressure
in the system to allow for start-up and operation whenever the power
failed. With the new and improved power supply
which was operating steady over a few years, the generator was not started as frequently
and fuel pressure on the generator was slowly backing up. When power was required
on this dark winter night, there was no fuel pressure in the system to allow
for start-up.
The residual risk of more reliable
power had not been assessed. It is often assumed that implementing new and
improved operational equipment or procedures solve the problems. It is often assumed
that new CAPs are effective and there is no need to assess for residual risks
or establish timeline to evaluate effectiveness.
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Evaluation of CAP effectiveness keeps
operations on track.
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Whenever there is a change in a
process, the process must be evaluated for effectiveness. Remember, the process
which just failed and required a new CAP was at one time a new process and assessed
as operational effective.
BirdsEye59604
A lot of companies miss this aspect of Risk Management. When a company does Root Cause Analysis and comes up with the root cause(s) to a problem, they forget to do a risk analysis on the changes to be made to mitigate or eliminate the root cause of the problem. Often, the change adds additional risk. For Example: An airport up north had a problem with deer on the runway. The RCA reveals that they needed a "deer fence" around the airport. A few months after the deer fence was install a small plane came in for a low level landing and hit the fence. So the mitigation of the deer problem introduced an additional hazard. Interesting look at Risk Mitigation. Risk is talked about a lot in the SMS Memory Jogger II available at dtitraining.com
ReplyDeleteI needs to spend some time learning more or understanding more.
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