2.29.2008

Florida Power Outage: Was a Lack of Lean the Problem?

When I read about the power outage that occurred in Florida earlier this week, I couldn’t help but wonder whether an application of lean tools might help prevent this kind of event in the future.

You probably heard about the rolling blackout that cut power to several million people in the Sunshine State. The earlier reports describe a kind of snowball effect triggered by some small incidents. According to
CNN.com,

Florida authorities are investigating how a small fire and a switch failure at an electrical substation outside Miami triggered a power failure that affected millions of people.
When a nuclear power plant sensed the disruption, it shut down. In turn, the state's power grid triggered rolling blackouts Tuesday across the state…


Florida Power & Light President Armando Olivera said a disconnect switch failed at 1:08 p.m. ET Tuesday at an automated substation west of Miami, and a piece of equipment that controls voltage caught fire about the same time. Neither failure by itself would have caused a widespread outage, he said

Utility workers are trying to piece together what happened, but Olivera said the "initiating event" was the failure of the disconnect switch.

"These systems are all designed so that you can handle two contingencies," he said. "If you had a switch that failed, protective devices would have isolated the problem. That did not occur today. That's the part we don't have an answer for…"

The substation trouble set off a sequence of events that within two to three minutes had knocked numerous power plants off-line -- including the Turkey Point nuclear power plant south of Miami.

Olivera said Turkey Point's two nuclear reactors and a natural gas-powered generation unit automatically shut down when the plant's systems detected a fluctuation in the power grid.

"In a fraction of a second, the demand was far greater than the power plants that were online generating electricity could handle," he said. "When you have that kind of imbalance, we have a system that kicks in and it starts turning people's lights off, essentially balancing the demand with what's available."

We’re dealing here with automatic actions (or reactions) by technology, not processes conducted by people.

Nonetheless, I find myself gripped by a strong urge to reach into the lean toolbox. Ask “why” five times to figure out what happened. Create a process map (if not an actual value stream map) to identify process triggers and figure out whether something is set up improperly. And so on.

The power plants shutting down after detecting a fluctuation in the power grid brings to mind a worker stopping a line by pulling an andon cord, which is often the correct response to a problem. But was the shutdown supposed to happen in this case? I don’t know, and someone needs to find out.

What do you think? Can lean be applied here? Would it help prevent problems in the future? Post your comments below.

1 comments:

Ian Furst said...

Hey Ralph,
I find myself stuck between my lean systems training and my anaesthesia training. In lean there's a desire to create a process flow map. In anaesthesia we're taught that major disasters are usually the result of multiple small failures. I could point to a bunch of medical example but a better one is the Chernobyl disaster. If you can break the cycle at any one of the steps you avert disaster. In this case (in lean terms) I think the failure wasnt' due to process flow or waste but bad process Kaizen. www.waittimes.blogspot.com