Voice of Experience: Why Did I Do That?

I have often wondered why people – myself included – do the things they do. If you have ever investigated an accident or been the first one on the scene, you know it does not take much more than a quick glance to identify the most obvious contributing factors that led to the situation. The questions asked always lead to the causal factors, and you have to dig really deep to identify the root cause, but these things still don’t fully explain why the accident occurred.

A 10-year NIOSH study of utility workers has indicated a disturbing trend – the failure of workers to follow training and the proper use of PPE and cover equipment (for more information, see www.cdc.gov/niosh/docs/98-131/pdfs/98-131.pdf, page 9, “Epidemiology of Electrocution Fatalities.”) Again, how do we explain why? Do workers fail to recognize hazards? Do they have a total disregard for rules and regulations? What causes an employee to overestimate their ability to control a situation? Is it complacency?

The answers are complicated, but can be found in the elements of human performance. Employees commit errors without consequences every day. When nothing bad happens in the short term as a result of their actions, workers continue to take risks. But a long-term consequence is that terrible accidents continue to occur year after year, and after each one happens, everyone wonders, “What could have been done to prevent this? Why did this have to happen to such a wonderful, hardworking, skilled worker?”

Management teams, safety supervisors and trainers see these accidents as personal failures. I have personally felt this pain throughout my 47-year utility industry career, and accidents are still occurring. When all the data has been collected and studied, I believe 2013 is going to be viewed as a bad year based on the numbers I have seen so far.

Knowledge, Rules and Skills
Let’s get back to why accidents occur. The industry has recognized that human performance is predictable and many accidents are preventable if employees are properly managed. Dr. James Reason began studying human performance several decades ago and discovered that all workers, who are in a constant state of learning, fall into three stages of skill set abilities: knowledge-based, rule-based and skill-based.

Employees are knowledge-based early in their careers. With a little experience, they move to a rule-based level and, after many years of experience, they become skill-based. When people start new jobs, they give a high level of attention to their tasks because they are still learning how to complete them correctly. As experience is accrued, workers become more comfortable and confident, which results in them also becoming less focused on their tasks. How does this attitude affect personal safety?

Safety precautions protect the worker from the utility system, and proper management of human performance protects the utility system and workers from other workers. The principles of human performance are that:
• People are fallible, and even the best among us make mistakes.
• Error-likely situations are predictable, manageable and preventable.
• Individual behavior is influenced by organizational processes and values.
• People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders, peers and subordinates, and also based on personal pride for their individual accomplishments.
• Events can be avoided when people understand the reasons why mistakes occur and when they use lessons learned from past events to realize dangers in future situations.

Active and Latent Errors
In the study of human performance, it’s been recognized that there are two types of errors that affect the safety of employees: active and latent. An active error is one that has an immediate impact, such as a flash or contact that results in death. Latent errors are acts and policies that are allowed to go uncorrected for long periods of time and usually contribute to an active error. Examples of latent errors include an organization not requiring PPE, improper switching orders, improperly marked underground distribution cables and an employee failing to check for an absence of voltage after de-energizing. Latent organizational weaknesses – such as neglecting to provide all proper tools, not communicating safety policies to employees and tolerating risky behaviors – are also contributors to unsafe performance.

An overestimation of one’s ability to control situations is a result of human nature. We are not as good as we think we are. Humans are fallible and make mistakes. We are creative, but we are not built for consistency. And regardless of what we think, we are limited in our ability to multitask. Even the best are easily distracted or overloaded in the face of adverse conditions. Rarely is a tool or mechanical failure the cause of an accident. Even if that is the cause, it’s often due to a human’s poor maintenance of the tool or machine. A latent error could have been a contributing factor. When all factors are considered, error-likely situations are many times predictable.

Today, the number of skill-based industry workers is declining while newer, less experienced employees are taking over their roles. Managers also face the additional challenges of both generational differences and personality differences. Addressing these issues requires more training, greater supervision, strong communication skills and a solid understanding of the value systems of different employees.

Further, managers must never forget that if opportunities to commit errors are not systematically identified, preventable active and latent errors will not be eliminated. Even when opportunities to commit errors are identified and eliminated, people still commit other errors due to unanticipated actions based on existing conditions. Consequently, additional means are necessary to protect facility equipment. Reducing the error rate minimizes the frequency of mistakes happening, but not the severity of the events that do occur. Only implementing barriers will prevent an event. Defense barriers, controls and safeguards arranged in a layered sequence provide assurance that if one of them fails, the remaining barriers will function as needed to reduce the chances of events and errors. If multilayer barriers fail, an event will be allowed to occur.

In summary, proper training combined with effective management of human performance will reduce the likelihood of accidents and incidents. To improve human performance, efforts should be made to reduce the occurrence of errors at all levels of an organization, and to enhance the integrity of barriers, controls and safeguards that are found to be weak or missing. Reducing errors and properly managing defenses will lead to a workplace free of significant events, which will, in turn, result in performance improvement within the organization.

About the Author: Danny Raines, CUSP, safety consultant, distribution and transmission, retired from Georgia Power after 40 years of service and opened Raines Utility Safety Solutions LLC, providing compliance training, risk assessments and safety observation programs. He is also an affiliate instructor at Georgia Tech Research Center OSHA Outreach in Atlanta. For more information, visit www.electricutilitysafety.com.