Your Lineworkers, Your Legacy
I’m not sure how I became an analyst. It wasn’t something I planned for. Various types of analyst roles exist, but I primarily analyze incidents, breaking down and studying the elements of events to identify causes and effects. Incident analysis, done well, ultimately helps prevent undesired future outcomes.
Over the last 15 years, I have analyzed a half-dozen apprentice training yard accidents and watched two videos of apprentice-involved incidents. These events are reminders that lineworkers frequently learn their lessons the hard way. I continue striving to change that fact because – far too often – the hard way becomes the final act to what could have been a great life.
I was once asked to write an opinion about a root cause analysis (RCA) conducted by OSHA and a utility. The analysis focused on a singular event that put three apprentices in the hospital. OSHA performs RCAs only to identify whether employers are at fault. The analysis I was asked to write about stated that the incident’s cause was various physical conditions and procedural mistakes. But while the conditions and mistakes were causally related, none was the true root cause.
That concerning realization is the reason I wrote this article: to clarify what a good RCA entails and explore its relationship with lessons learned from training accidents.
A Peculiar Art Form
RCA is a peculiar art form that requires analysts to be knowledgeable about safety standards and human performance principles. Numerous utilities use RCA software applications, mostly algorithm-based methodologies designed to help investigators determine the most likely root cause. The applications were developed to standardize RCAs, offering guided protocols to prevent investigator errors. However, the human element can still impact results. A persistent issue with RCA application use is listing, evaluating and interpreting the causal factors that preceded an incident.
Causal factors contribute to the incident under investigation, but they are not the root cause. The root cause is the singular event that prompted the incident; if it had not occurred, the incident would not have occurred either.
I recently reviewed two incidents so similar in nature that the same investigation report could have been written for both. In these cases, which took place a few years apart, investigators used RCA software to determine a root cause. The only difference between the two final RCA reports? You guessed it: the identified root cause. Two entirely different RCA conclusions resulted from the very same causal factors. My point here is that an RCA application is only effective when users complete the software training and stick to its process. Root causes are not always easy to determine, and they are not always what we initially believe they are – which brings us back to training.
Introducing Thom and Goob
To demonstrate rodeo-style hurt man rescue, an apprentice named Thom climbed to the top of a distribution pole. He successfully reached the mannequin only because of his portable fall protection device. Thom then fumbled with the rigging, desperately trying to get the mannequin down in four minutes. He could hear encouragement from the ground, shouts of “Go, go, go,” “Wrap this,” “Pull that,” “Reach around that.” Finally rigged, Thom reached around the mannequin and, using the hawkbill knife that he had sharpened to a razor’s edge for the demonstration, cut his own fall protection. He fell 38 feet, right into life in a wheelchair.
In another rescue incident (see https://youtu.be/gaH7pK-6n84), a worker nicknamed Goob also inadvertently cut his fall protection. I don’t know how that worked out for him, but for lineworkers reading this, the lesson is found in Goob’s now-infamous rescue fail.
We have an industry training shortcoming that is exacerbated by our need to get lineworkers trained and in the air (or in the ditch). The problem lies in the difference between objective and subjective training goals. Earlier, I stated that Thom’s portable fall protection device was the sole reason he reached the mannequin. Neither Thom nor Goob was subjectively competent enough to successfully complete their tasks. The difference between subjectivity and objectivity plays a considerable role in training, particularly when training trainers.
Subjectivity vs. Objectivity
Objective evaluation is rooted only in facts and goals. Subjective evaluation is influenced by the evaluator’s personal experience, feelings and opinions. In this context, “personal experience” is legitimate hands-on utility industry experience.
Note: To be clear, I believe that good instructors possess a great amount of career experience and industry knowledge. This is not an indictment of on-the-job (OTJ) training using lineworker mentors. I am a product of the OTJ process and have great respect for those who taught me. Negligence and incompetence are not the issues I am addressing here. The problem is generic in nature and perhaps even a hidden organizational defect.
Thom, the apprentice who made it to the mannequin, fell victim to two objective influences that resulted in his fall. First, he was not a competent climber. It is unlikely that Thom would have climbed a 40-foot pole had he not been wearing a personal fall arrest system (PFAS). He was allowed to do so because he had trained in a PFAS that everyone believed would prevent his fall. Using the system, Thom got to the top of the pole, but his hook sets were tentative. His body was off-center and uncomfortably oriented because he did not periodically adjust his PFAS during ascent.
The “git-r-done” mentality was the second objective influence. Although I love 1990s-era Larry the Cable Guy, he didn’t do us any favors, but it’s not really his fault. Git-r-done was a comedy phenomenon that made light of simple men using unsophisticated methods to complete manly tasks, resulting in their unrestrained celebration. I am in favor of all those things, especially the unrestrained celebration, but the industry may have taken git-r-done too far.
Encouragement from people on the ground was an additional event precursor in both Thom’s case and Goob’s case. Objectively, both apprentices were working hard to succeed; it is human nature to seek approval from others. But the level of problem-solving Thom and Goob displayed demonstrated that the two men did not possess the competence needed. Goob’s pole strap was too far out, and he displayed poor foot positioning and poor rigging management skills. Thom’s circumstances were the same. He explained to me that he had not felt confident in his climbing skills while on the pole but believed his PFAS would protect him. When Thom reached the top, his problem-solving skills were compromised by his lack of experience and the pressure of well-intentioned coworkers shouting encouragement from below.
Competence is the first goal of industry training. Next, trainees are coached to both competently and efficiently complete their tasks. Until an apprentice demonstrates adequate problem-solving and skill competency independent of trainer instruction, the process must be unrushed and orderly. An apprentice simply climbing to the top of a pole is an objective measurement of quality. Climbing to the top with demonstrated skill is a subjective measurement.
Where Do RCAs Fit In?
Trainer competency was the root cause of Thom’s incident, Goob’s incident and the other training yard incidents I referenced earlier. But that is not because the trainers were incompetent. Rather, they had not been sufficiently trained to train other workers. I hate making that statement without first preparing readers because these incidents truly were not the fault of industry trainers. They did not lack lineworker skills or knowledge; they lacked understanding of the individuals who they were training. An effective trainer understands the nature of the trainee and recognizes subjective indicators of their competence to safely perform learned skills. Those trainers with effective technology transfer skills understand the nature of the learning and the learner, training modalities, subjective indicators of training success and objective competency measures.
Falls accounted for two of the previously referenced training yard incidents. In both instances, the instructors bowed to trainee pressure, deviating from their planned training methodologies to instead oversee speed-climbing events. One apprentice climbed off the top of a pole. The other gaffed himself and almost bled to death. Neither had climbing skill characterized by good hook sets, technique, hand position and body orientation. In fact, neither even looked up while ascending.
In yet another case, apprentices used trial and error to learn how to compress sleeves with a 60-ton press. Blown hydraulic hoses hospitalized two individuals. The utility’s investigation blamed a failed hose that “should have been capable of containing the hydraulic pressure.” But the RCA revealed that the hose had been plugged into a universal pump open-center system, which prematurely forced pressure into the hose of the closed center head, preventing operation of the spring-loaded quick coupling. The apprentices forced the coupling and broke the hose. So, the problem wasn’t a faulty hose but an objective-based training issue: “Squeeze the sleeve without bending it.” That initial introduction to the task and the training methodology lacked requisite preparation and instruction elements, which should have been audited by observing the steps via an orderly process.
The Bottom Line
I am now going to use RCA to lobby for a comprehensive review of the nature of our industry’s training. We have too many examples of trainees pushed beyond their skill level, and they are not limited to climbing in 100% fall protection. Let’s audit our training processes, including how we train our trainers, ensuring that we provide them with the technology transfer skills they need to successfully pass on their experience, craft skills and other knowledge.
A utility manager once challenged me about the cost of training the organization’s trainers. He said it was frustrating to spend the time and money just for them to eventually leave. His attitude is one more example of mistakenly relying on objective concerns. His subjective concern should have been, what if we don’t train our trainers and they stay?
About the Author: After 25 years as a transmission-distribution lineman and foreman, Jim Vaughn, CUSP, has devoted the last 28 years to safety and training. A noted author, trainer and lecturer, he is a senior consultant for the Institute for Safety in Powerline Construction. He can be reached at jim@ispconline.com.