Degree

Master of Business Administration Executive

Faculty / School

Faculty of Business Administration (FBA)

Year of Award

2021

Project Type

MBA Executive Research Project

Access Type

Restricted Access

Executive Summary

Human error has been a source of great concern in any industry and especially in power generation sector where a minor lapse by an operator may lead to losses amounting billions of rupees. However, estimating the scale of losses and their major precursors does merit a detailed and substantive analysis, especially in Pakistani perspective. In this study, we proposed to perform qualitative assessment of the leading sources of human error and its relationship with the nature and scale of production losses. The study is limited to power generation sector of Pakistan and to the extent of known relationships between the human errors leading to a production loss. The study also aims to identify operator errors that are perceived or being observed as precursors of production (or revenue) losses. Secondly, once identified, mitigation techniques and management controls must also be recommended to avoid their occurrences. Three major questions were formulated during the course of research study: 1. Is there any relationship between the production (or revenue) loss, excluding the machine/system damages, to the operator error(s)/mistake(s), in power GENCOs of Pakistan? 2. Are there any formal mechanisms/tools/techniques, practiced in the target sector, to prevent operator errors/mistakes? 3. What strategies would be effective to prevent the operator errors/mistakes and thus eventually may control the production (or revenue) losses? The objectives of the study were also formulated as below: 1. To identify (or assess) presence of a relationship between the production (revenue) lossand operator (human) error(s)/mistakes, as observed by the power GENCOs in Pakistan. 2. To ascertain availability/access of any formal mechanisms/tools/techniques, practiced in the industry, to prevent occurrence of operator error(s)/mistake(s). 3. To explore prevention techniques/strategies to prevent occurrence of operator error(s)/mistake(s). The proposed research methodology included conducting focus groups, survey questionnaires and interviews. At the beginning, two focus groups were conducted with the relevant operation & maintenance (O&M) personnel of the industry. From the first focus group (related to Operation department personnel of the sampled organization), the participants reported different situation that they experienced during their work experiences. According to them, major causes of error were identified as time pressure, multitasking, communication issues, complacency, and lack of identification of risk. Remedies for these were identified as updated training, use of operating experience, coaching and effective supervision by the supervisors. The panel suggested to incentivize the operations using reward and penalty schemes with few emphasized on individualized trainings. Finally, the panel suggested that without management commitment, things would not improve. Use of procedures that are technically valid and practicable were focused.

Effectiveness of job planning and using lesson learnt from industry were also recommended. The second focus group was related to maintenance department personnel of the sampled organization. They reported few situations where failures or loss of production occurred due to lack of procedure usage, lack of sufficient manpower. They also pointed out lack of proper mechanism for data gathering and keeping. Some indicated these in including as performance indicators for personnel promotion. Complacency, non-professional behavior, lack of maintenance procedures, time pressure of completing the job were the few causes discussed during the session. Regarding the solution, the group emphasized job ownership, use of modern tools, provision of better working environment and investing in mockup development as solutions to prevent human errors in maintenance jobs. Next, individual interviews were conducted with five (05) number of industry professionals. The professionals agreed that old plants are more vulnerable to human error due to excessive maintenance calls and manual operations thus may lead to more revenue losses and hence suggested plant automation being a solution that may prevent involvement of human. They also suggested that human performance parameters and reward/penalize the human behavioral based actions would be useful if implemented in true spirit. The third step of data collection was to perform a survey from industry professionals. Two parts of the survey include queries regarding organizational, personal and environmental factors. Third part include perceived solutions and final part include probing awareness on error prevention tools in the industry. In all 3780 responses were recorded from 108 participants who provided their valuable input through online response collection system (through Google Survey Form). Based on the participants’ responses, causes of human error could be sub-divided in to three prominent areas that include organizational, personal and environmental factors. According to the survey results, prominent among the organizational issues, are bad procedures, insufficient operator knowledge, and poor team work. Similarly, the personal factors skill level, motivation, experience, work attitude and self-discipline. Finally, the results indicate lighting being a significant environmental factor that must be taken care of. The perceived solutions as pointed out by the participants were training to prevent occurrence of errors. Similarly, job planning and scheduling being a solution as well. To prevent the re-occurrence of events, in-house incident reporting and learning system was considered as a good practice. Above all, the management commitment is the icing on the cake to enable rest of the parameters. Towards the end of report, a significant event analysis is also included which identifies the happening of blackout on January 9th, 2021, emerging from a human error during work at Guddu Thermal Power Station. The reasons leading to the event are non-compliance or partial compliance of earlier recommendations by NEPRA. This in fact was a significant manifestation of the scale of losses that a human error may cause and need immediate attention of regulator and functional organizations. At the end, based on the results of focus groups’ input, survey responses and interview responses, following recommendations were made to conclude the report:

1. Generating stations shall provide a comprehensive training plan especially focusing on human performance related objectives. A policy may be formulated with a title of Human (Operator) Performance Policy. The objectives of the policy shall be clearly target oriented and based on SMART principle, i.e. Specific, Measureable, Achievable, Relevant and Time Bound. 2. The regulator (i.e. NEPRA) shall provide guidelines and support to the generating stations for implementing the Human (Operator) Performance improvement plan. Initially, this may be introduced as a graded approach with penalizing areas with critical consequences and severity and incentivizing other areas. 3. Specific focus must be made to old/aging plants where errors are more likely to occur due to technological issues. NEPRA may also take steps to upgrade the safety measures for such stations and gradually phasing out vulnerable stations and encouraging automation. 4. Timely and effective training of personnel must be ensured incorporating updated practices and knowledge areas. A knowledge repository shall be made available to all generating stations who can access and retrieve the best practices. This can be implemented either through NTDC platform or through regulator (NEPRA) platform. 5. Human (Operator) Performance Indicators (HPI) program shall be introduced at all working levels. It is hoped that considering the above recommendations, the industry may avoid losses and productivity of catastrophic scale. Organizations that learn from events and continuously update their work practices accordingly, will survive.

Pages

vii, 66

Available for download on Monday, February 01, 2027

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