Incident Prevention Magazine

System and utility operators are required by OSHA 29 CFR 1910.269(m) to have a procedure to de-energize their systems for protection of the employees working on those systems. The rules in 1910.269(m) do not specifically require a written procedure, but it is hard to imagine how an effective procedure could be maintained if it weren’t written. Unlike lockout/tagout, we refer to these programs as switching and tagging. Switching and tagging apply to transmission and distribution, including substations. The 1910.269 standard has a paragraph (d)(2) on energy control procedures for power plants that is much less rigorous than the traditional lockout/tagout for general industry found in 1910.147, “The control of hazardous energy (lockout/tagout).” Part 1910.147 specifically exempts “installations under the exclusive control of electric utilities for the purpose of power generation, transmission and distribution …”

Most substation entry and system control centers also have additional rules they must adhere to per the North American Electric Reliability Corp. (NERC) and the Federal Energy Regulatory Commission (FERC), including those pertaining to security and reliability of the bulk power systems across the U.S. and Canada.

It was a beautiful October day in Captiva Island, Florida, where my family and I were on a short vacation at the end of the summer season. I was in a room of the condo we had rented. Housekeeping had recently damp-mopped the tile floor in the room, and as I walked across it, I slipped and took a fall that resulted in a concussion after my head hit the tile. Thankfully, the concussion was minor, the embarrassment of the fall was short-lived, and my bruises healed quickly.

While assessing my injuries, however, I found a mass on the left side of my chest that seemed odd to me. Thinking it was an internal bruise, I ignored it for a few weeks, but the mass didn’t go away. I started monitoring the area, which was on my left breast on the outside edge of the nipple. After a few weeks of watching it closely, I made an appointment with my family doctor. He examined the area, declared it a fatty mass, and I went on my way. That was in November. Around the first week of December, I asked my wife, Vicki, to examine the mass to see what she thought. She did and immediately suggested I make another appointment to see the family doctor. That visit ended up being different since the doctor was no longer focused on my head injury. He felt the mass several times and eventually told me I needed a mammogram. And thus began my journey of addressing what was suspected to be breast cancer.

Over the years, I’ve received numerous questions about which duties lone workers can safely and legally perform, and which ones require more than one qualified worker to complete.

Tasks that require at least two qualified employees are defined in OSHA 29 CFR 1910.269(l)(2)(i), which states the following: “Except as provided in paragraph (l)(2)(ii) of this section, at least two employees shall be present while any employees perform the following types of work: installation, removal, or repair of lines energized at more than 600 volts; installation, removal, or repair of deenergized lines if an employee is exposed to contact with other parts energized at more than 600 volts; installation, removal, or repair of equipment, such as transformers, capacitors, and regulators, if an employee is exposed to contact with parts energized at more than 600 volts; work involving the use of mechanical equipment, other than insulated aerial lifts, near parts energized at more than 600 volts; and other work that exposes an employee to electrical hazards greater than, or equal to, the electrical hazards posed by operations listed specifically in paragraphs (l)(2)(i)(A) through (l)(2)(i)(D) of this section.”

It happens every so often – and more often than it should. A lineworker climbs a wood pole and the pole falls. With the advent of 100% fall protection, the climber is assured serious injury and often death if a pole falls while they are tied to it.

Several of these types of incidents have occurred in recent months. The first question is, why didn’t those poles get checked before anyone climbed them? The next question is, what can we do to prevent future falls?

Correct Depth is Key
First and foremost, correct depth is what keeps a pole in the air. Most companies have a specification that determines a pole’s installed depth based on its length. Another resource you can refer to is ANSI O5.1, “Wood Poles – Specifications and Dimensions.” Essentially, the taller a pole is, the deeper it needs to be buried in the ground to ensure it is stable. Across the industry, it is not uncommon for utilities to teach this rule of thumb: 10% of the pole height plus 2 feet.

Is it maintenance or construction? That’s a question that was asked regularly by industry workers for many years. These days, we can thank David Wallis and the committee members who diligently worked on the OSHA 29 CFR 1910.269 and 1926 Subpart V final rule published in 2014 for clearing things up.

To better understand the value of the final rule, let’s review some brief history of the two standards. In 1972, the construction standard for building transmission and distribution systems was completed. Did you notice there was no mention of generation in that standard? We will address that shortly. Nearly 20 years later, around 1992, the 1910.269 electric power generation, transmission and distribution standard was completed and published in the Code of Federal Regulations. That was a significant event since it had taken two decades of research by OSHA construction committees and an unknown number of stakeholder meetings in which utility end users, contractors, cooperatives, municipals and investor-owned utilities expressed their concerns.

As I sit and write this article, I’m also gazing into my crystal ball, so to speak. I realize that life as we knew it just a few short months ago has changed. COVID-19 has made its way around the world and we are now working during an unprecedented time. Utilities have been designated as essential services, requiring employees to continue working as normally as possible, but with the pandemic in the background each day, I think it’s safe to say we are establishing a new normal. Back in the 1990s, I worked with an executive who once said, “Normal will never come back.” He was referring to competitive rates and regulations, but the coronavirus pandemic, too, will forever change the way utilities do business. And that means that, as we continue to move forward, we will need to put an equal amount of emphasis on both employee health and safe work practices.

So, what are some of the things we should currently be aware of regarding COVID-19 and utilities? And what should we be thinking about for the future?

Providing accurate, effective training to workers is one of the electric utility industry’s most pressing challenges. From my perspective, there are not enough appropriately qualified trainers to fill the open jobs available. As our industry’s attrition rate continues to increase, will we be able to provide the right training to new and existing employees? Each day, there are lineworkers being given work to do for which they are not adequately trained, endangering them and their co-workers. We need trainers to help correct this problem so that fewer lineworkers are hurt on the job.

I mentioned that our industry has a shortage of “appropriately qualified” trainers. There certainly are a number of individuals working for utilities and contractors who hold positions that have the word “training” or “trainer” in the title. But some of those individuals are newer lineworkers with limited experience working with crews. That can be a problem for their trainees, who need and rely on the guidance of trainers with real-life experience about how to plan and execute specific job tasks. Too many of these trainers lack a basic understanding of system grounding, distribution cover-up, and switching and tagging for employee protection. OSHA’s 29 CFR 1910.269 standard was updated in 2014, and our industry’s trainers must know and train students in accordance with those regulations.  

I find human performance a fascinating topic to teach during my supervisor training classes. Many readers of Incident Prevention are familiar with the topic. For those who aren’t, human performance is an analytical tool that examines how people accomplish tasks and why they perform those tasks in a particular way. Employees in the electric utility industry execute many of the same tasks each day. We do them according to the local culture’s work practices, primarily learned through on-the-job training. As older workers retire and new employees join the ranks, those work practices are passed down to the next generation. Sometimes the practices are not the safest approach and can lead to incidents and accidents.

At one point in our industry’s history, it was common to blame employees when incidents and accidents occurred, but we have learned over time that human error rarely is the root cause. That’s where human performance tools help employers identify and correct latent organizational weaknesses and errors. A company that invests in human performance analysis can minimize active errors on their job sites. Human performance training helps employees understand risk adversity, particularly how the coincidental experience of an injury-free work history can cause increased risk and exposure to an employee simply because nothing bad has happened to them so far. Workers can become so used to risky practices that they often will assume they’ll be alright today and in the future.

Each time I present an OSHA training class to electric utility workers, the topic of utility locates arises. That’s because, other than utility locates being a legal requirement in most states, it is critical for line crews to have up-to-date locates for their own safety. When locates are not in place, it’s more than just a possibility that an employer will face OSHA citations and other legal liabilities in the event of an employee’s injury or death.  

In most areas throughout the U.S., calling 811 will connect you with someone who can help you get applicable locates to ensure the safety and legality of your digging operation. Whether the job is to trench, backhoe or set a pole, locates must be made for the dates you will be working so that workers are safe and the employer can avoid potential legal action against them.

In the remainder of this article, I’m going to share two examples I’m aware of in which locates weren’t properly marked, resulting in property damage and one fatality. None of the errors was made intentionally, and each time the crews were simply trying to be productive for their respective companies. Nonetheless, the incidents and injuries occurred. 

Many industries use bucket trucks to help workers accomplish tasks. In the electric utility industry, we use bucket trucks – often referred to as insulated aerial devices – to help maintain and improve productivity and safety. The trucks are the most reliable when all of the manufacturer’s recommendations are followed and routine maintenance is performed. Manufacturing performance standards for insulated aerial devices can be found at ANSI A92.2 and OSHA 29 CFR 1910.67.

I have performed fields audits for many companies over the years, and I want to share some facts about operational safety and proper use of insulated aerial devices. It’s critical for every company to have documentation that sets expectations for all employees about the safe and proper use of bucket trucks.

In this edition of “Voice of Experience,” we’re going to examine a recent incident that helps to illustrate the point that when workers follow the rules of OSHA 29 CFR 1910.269(n), “Grounding for the protection of employees,” it can save lives.

Background Information
A transmission crew was assigned the task of transferring conductor and guys on the inside phase of a 115-kV three-pole angle. The pole had been set by another crew and was ready for the transfer; the three-pole-angle structure was sitting in a swampy area not accessible by trucks that day. The crew went in on a Marsh Master with tools to work on the structure.

A clearance had been arranged by the crew leader to de-energize and ground the 115-kV line. The switching order was reviewed and dispatched by a system operator at the origination point of the 115-kV line, about 25 miles west of the work location. There was a three-way GOAB switch approximately 25 miles east of the work location. The system operator was to initiate the switching order at the power plant. A crew person was assigned to open the GOAB switch. Two bucket trucks were assigned to ground on either side of the three-pole-angle midspan when the line was de-energized.

As I’ve recently traveled around the U.S. speaking to different utilities, contractors and municipals, I’ve found that attrition is greatly affecting the workforce. And as more and more workers retire, the industry will need to hire new workers to fill those vacated roles – new workers who will need the appropriate training to safely and effectively perform their jobs.

I’ve written about the value of training in the past, specifically about how the quality of training and performance management has a direct effect on the safety of employees and the productive abilities of the workforce. In this installment of “Voice of Experience,” I want to take the opportunity to review some of the basic skills a lineworker should possess in order to help ensure quality construction for the employer and decrease safety issues for everyone working in field.

Those of us in the industry tasked with record-keeping sometimes struggle with all of the different reporting scenarios. OSHA 29 CFR 1904, “Recording and Reporting Occupational Injuries and Illness,” gives us guidelines, but even the most thorough research of compliance requirements can still lead to questions and confusion.

For example, workers’ compensation cases may not be recordable as OSHA cases due to exceptions in the agency’s record-keeping rules. Workers’ compensation is mandated by each state, while OSHA 1904 is a federal record-keeping standard.

Further, OSHA’s record-keeping standard was updated in 2002, at which time many changes were made, including some that made the standard easier to understand but others that made it more difficult. Additional changes were made effective January 1, 2015. While basic reporting has essentially remained the same over the years, it’s important to be aware of the 2015 change found at 1904.39(a)(2), which states, “Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.” These requirements were added to provide OSHA insight on less serious injuries in certain industries that typically have a higher incident/DART rate.

The electric utility industry is experiencing more major catastrophic storms than ever. Hurricanes, tornadoes, and snow and ice storms are taking their toll on both systems and employees. It was just several months ago that we were dealing with back-to-back hurricanes – Florence and Michael – and now we’re well into a winter that has dealt large swaths of the country plenty of snow and record-breaking low temperatures. 

At some point I stopped counting the number of storms I have worked during my 51 years in the industry. What I do know is that each storm has been a learning experience for me. One thing I’ve noticed over time – in addition to the increase in the number and severity of natural disasters – is that mutual assistance from other utilities and contractors has become a significant resource for host utilities that have suffered damage from these events. In light of that, I want to share some information that may help things go more smoothly for you and your crews during future restoration efforts.

I would like to ask those of you reading this article to reflect on your professional life in 2018. What was different from previous years? Was safety at your company better, worse or about the same? As I sit and write this article during the first week of October 2018, I know that so far this year, the electric utility industry has suffered more than 20 fatal accidents and over 30 serious flashes and contacts. I don’t know what’s going to happen between now and the end of the year, but I pray no one else gets hurt.

The fact is, our industry has suffered extremely high numbers of fatalities since around 2013. The last I heard, in 2017 we had 45 fatalities between investor-owned utilities, cooperatives, contractors and municipals. NIOSH and EPRI started doing research in the mid-1990s through approximately 2006, and they found that the electric utility industry recorded 24 to 28 fatalities each year. The causes of those fatalities included contacts, falls and vehicle accidents.

What continues to amaze me is that our industry has the investigation and root cause analysis measures to identify why accidents keep happening, but we fail to implement the measures available to us to prevent recurrences of these types of accidents. The majority of fatalities occur during energized line work, yet they keep happening. Why? On one hand, while it’s true that lineworkers are some of the best trained craft workers out there, even the most seasoned lineman is human and can make an error in a moment of stress, or if his mind wanders or for any number of other reasons. 

2018 is turning out to be a devastating year in our industry. The frequency of energized contacts, flashes, severe injuries and fatalities continues to increase. Why – in a professional trade that requires such an extensive amount of apprenticeship time – do lineworkers have such high incident and accident rates?

In this installment of “Voice of Experience,” I want to review two accidents I am familiar with so that we can dive into why they happened, and how you can prevent them from happening on your job sites.

The First Accident
In the first accident, a journeyman lineman lost his right arm to the shoulder. The immediate cause was a 7.2-kV electrical contact phase to ground.

The day of the accident, the journeyman was running a little late, so he drove his personal vehicle to the job site to avoid losing more time. An apprentice lineman had driven a bucket truck to the job site for the journeyman to use. All employees gathered to discuss the job plan. The job, which had been in progress for several days, was reconductoring approximately 5,000 feet of an existing three-phase 12.4-kV line from #2 ACSR to 397 MCM. New poles were set, and old conductors were spread on layout arms. The new conductors had been pulled in and sagged to tension the day before. The day the accident occurred, there was discussion during the job briefing about moving the new conductors from roller blocks and tying them in on the new insulators with preform ties. The structure where the incident occurred was a 45-foot Class 3 with a 10-foot wood arm. Insulated layout arms were mounted on the ends of arms. The middle and field-side phases were set to the field side of the arm. The existing energized road-side phase was on a short arm set to the road side of the pole. All three of the old phases were still energized. The new conductors had system safety grounds installed on each end, as required by standards.

Many recent articles I have read in other magazines and via social media emphasize the importance of worker training. I couldn’t agree more. It is both important and valuable that employers invest in training for new employees entering the industry as well as current employees. While the return on investment cannot always be accurately measured and calculated, the ROI does exist nonetheless – just imagine what injury and fatality statistics would look like if we did not train our workers.

One of an employer’s training-related responsibilities is to investigate cases of failure to follow training that result in property damage, injuries or fatalities. OSHA also obligates employers to report any accident that requires medical attention beyond first aid, if the accident is work-related. And risk management professionals and certified loss control professionals are required to investigate property damage involving employees for insurance purposes. Loss control can be difficult to track because damage is not always immediate, and the cost of damages may not be directly attributable to failure to use proper training. In addition, a bad underground splice or a failed connection on primary or secondary that results in property damage may or may not be recorded by an employer as a failure to use proper training.

I understand that we are human beings, and because we are human, we make mistakes. And yet, I would like for all of us to think about the possibility of following all rules and regulations all the time – in short, I want all of us to strive to operate excellently. By adhering to what we learn in our training and using the correct procedures to perform our work, we can protect lives and prevent property damage.

It has taken the electric utility industry many years to understand induced voltage. When I started working in the 1960s, it was explained to me that voltage remaining on de-energized lines was static voltage that had to be bled off or else it could be deadly. Now, when I speak to groups about temporary system grounding for the protection of employees, I occasionally still hear the term “static voltage” being used to describe what really is induced voltage from a nearby energized line. Even today, not everyone in the industry completely understands induced voltage.

So, what exactly is induced voltage? Here are some things utility safety and operations professionals should understand. The electromagnetic field around an energized conductor produces capacitive and magnetic coupling to all nearby objects within the electromagnetic field. The voltage level of the energized conductor and the physical length of the de-energized conductor that is exposed to the energized (source) conductor will determine the amount of voltage on the de-energized conductor or equipment. A de-energized conductor or piece of equipment will remain energized as long as the source remains energized and de-energized equipment remains ungrounded. Properly installed temporary system safety grounds can be used to create an equipotential work zone for employees.

The induced voltage found on de-energized equipment is not static, and it can’t be bled off. System safety grounds that have been installed simply give the induced voltage a conductive connection to ground. Once grounds are removed, the induced voltage returns to exactly the same amount of voltage instantly. It is voltage of 60 cycles per second in a steady-state condition, because there is no path in which electricity can flow other than the energized, isolated conductor or equipment. If grounds are applied to de-energized conductors, the voltage immediately will collapse to near zero, but now the physics have changed and a current flow is established in the system safety grounds. The amount of current flow in ground sets is determined by the amount of induced voltage on the de-energized equipment before the grounds were installed, and the resistance of the ground set and the ground. In addition, the more ground sets that are applied to a de-energized line, the less current flow there is in each set of grounds.

In today’s electric utility environment, there are many training demands and opportunities due to new and inexperienced employees entering the workforce as older, more experienced workers continue to retire. New employees entering the field require – and are hungry for – information and hands-on experience, and they’re excited by the chance to engage in line work. To rubber-glove energized primaries and perform bare-hand transmission work is fascinating to younger workers and often provides them with an indescribable level of satisfaction and accomplishment. Ours is an exciting occupation, to say the least.

And yet ours also is an occupation that can be riddled with hazards. That’s why all of our employees must be given a strong foundation of skills training for their own protection. In our industry, many consider basic line skills training to be the most important type of training workers can receive, and I agree.

Considering recent annual accident totals reported by the U.S. Bureau of Labor Statistics, there is great reason for employers to be vigilant about the training of their workers. The electric utility industry suffered more than 40 fatalities in 2017 alone. Some of those deaths occurred because of falls and vehicle accidents, but a great number more occurred when an unprotected part of a worker’s body made contact with an energized conductor or piece of equipment. Phase-to-ground contacts that resulted in severe burns also were reported about once per week. These types of incidents are almost always preventable, so why do they continue to occur? Does it have something to do with training or human performance? Is there something else going on? 

In light of some recent incidents in the electric utility industry, numerous root cause investigations have been conducted to determine why those events occurred. The frequency of the events and their similarities are alarming. Some of the more recent cases involved induced voltages from nearby energized lines to de-energized lines and equipment. In one instance, an employee opened a system safety ground and got in series with ungrounded and grounded equipment and conductors, which resulted in severe burns to the employee. Another incident involved an uninsulated boom truck contacting primary conductors. The truck was not grounded or barricaded, and the event resulted in one fatality and one severe injury.

When all the final numbers are tallied, 2017 may wind up being one of the more devastating years in the electric utility industry’s recent past. So, why is our industry suffering the same types of incidents today as in previous decades? There are many contributing factors associated with each event. Among those named in many incident-related reports – including reports on the incidents I referred to in the previous paragraph – is human error. Some have even said human error is the root cause of some of these events, but I don’t agree. There typically is a more direct root cause of an incident than any mistakes made by employees.  

Human Error and Normalization of Deviation
Before we go any further, let’s review what is meant by the term “human error.” If you search online, you’ll come up with a variety of sources that define the term, but to put it briefly, human error is an individual’s deviation from intention, expectation or desirability.

Speaking of deviation, one related phenomenon that is suspected of playing a role in many incidents is normalization of deviation. This occurs when humans become used to, for instance, executing a task in such a way that does not meet defined performance standards; over time, however, even though this inferior execution does not meet the standards, it nonetheless becomes an accepted practice. When this behavior is endorsed by others, some may recognize it as poor or unacceptable performance, but they may not feel comfortable intervening, or they may not be permitted to intervene.