Incident Prevention Magazine

Have you ever seen or heard a restaurant, vehicle dealership or retailer claim, “We care little about service”? On the contrary, don’t many of these businesses – if not most – make bold claims about the quality of their services? How many, though, take the time needed to do the work, pay attention to the details, and become known for meeting or exceeding their claims?

Now, think for a moment. Have you ever seen or heard an electric utility organization of any variety claim, “We care some about safety performance”? I doubt it. If you look at 100 electric utility website landing pages, it’s likely you will see slogans about safety. Investigate those sites further and it is common to see safety listed as a company value or guiding principle. Yet just as some retail establishments tout their high-quality service while acting in ways that make it clear that “service” is more a buzzword than a business practice, so, too, are there electric utility companies and contractors that publicly state their concern for safety while their day-to-day actions don’t back up those claims.

Job descriptions, job safety analyses, tailboard meetings, PPE and training are important components of an effective safety program. But even for companies that are truly focused on providing a safe working environment for their employees, there are at least three other components that contribute to a consistently safe workplace, yet tend to get overlooked: effective interviewing, onboarding and mentoring processes.

Have you ever questioned whether a contractor or subcontractor was qualified to perform electric power work? If so, you should consider developing a contractor safety management standard. This type of standard defines minimum safety requirements that contractors must adhere to when they perform work for your company.

Years ago, many electric power organizations used contractual language and a hands-off approach to establish contractor safety responsibilities. In fact, organizations hired contractors to perform work they felt was unsafe because they knew the contractor would do whatever it took to complete the job. These work practices have significantly changed throughout organizations that recognize employers share responsibility for working conditions and safety at multiemployer worksites. Utilities and contractors are adopting a shared commitment to worker and system safety within their organizations.

Regulatory Requirements
In the preamble to 29 CFR 1910.269 – the electric power generation, transmission and distribution standard – OSHA states the following: “When OSHA promulgates new safety and health standards, it does so against this background principle that employers share responsibility for working conditions, and thus for OSHA compliance, at multiemployer worksites. Therefore, when the Agency issues a new safety or health standard, it is with the intention that creating, exposing, and controlling employers at multiemployer worksites will exercise their respective responsibilities to ensure that affected employees are protected as required by the standard.”

While engineering controls are preferred over personal protective equipment for worker protection, many engineering controls, such as arc-resistant switchgear, require the purchase of new electrical equipment in order to fully implement them. When replacing equipment, this type of installation makes total sense, but it rarely can be the only company policy to mitigate arc flash in all facilities.

OSHA always prefers that organizations use the highest option possible on the hierarchy of controls. This is clear in the preamble to 29 CFR 1910.269, in which OSHA states the following: “NFPA 70E-2004 warned that ‘[d]ue to the explosive effect of some arc events, physical trauma injuries could occur’ … OSHA expects that the hazard analysis required by paragraph (g)(1) in the final rule will identify nonthermal hazards, including physical trauma hazards posed by flying debris, associated with employee exposure to electric arcs. … [OSHA requires] employers to address [these hazards] … [and] provide shields and barriers necessary to protect employees from physical trauma hazards. However, as noted by NFPA 70E, not all arc events pose physical trauma hazards from flying debris; therefore, this protection will not always be necessary …”

The 2018 NFPA 70E standard rightly took out the reference to 40-cal/cm² exposures posing a hazard from arc blast, since arc blast is more a function of containment and current than calories. In fact, our recent research surveyed the literature on arc blast pressure waves and found that many of the formulas did not come close to predicting our lab data from 4,000A to 12,000A (E. H. Hoagland, C. Maurice, A. Haines and A. Maurice, "Arc Flash Pressure Measurement by the Physical Method, Effect of Metal Vapor on Arc Blast," in “IEEE Transactions on Industry Applications,” vol. 53, no. 2, pp. 1576-1582, March-April 2017). New work continues to expand this knowledge and will be presented to the IEEE Electrical Safety Workshop this March in Fort Worth, Texas.

Knowing bucket capacity and understanding how to read a jib load chart are two critical elements of aerial device operation. While both tasks are fairly straightforward, it is crucial to stay within the allowable capacity of the unit. The platform capacity and material-handling capacity provided by the manufacturer are not recommendations – they are absolute maximum capacities that ensure the machine is not overloaded. Overloading equipment can result in overturning or boom failure. Equipment damage also may occur, resulting in costly repairs and a shortened usable life for the aerial device.

A fully equipped lineworker with PPE plus tools and materials for typical line maintenance can quickly add up to 700 pounds or more for distribution work, and upward of 1,000 pounds for transmission work. Bucket capacity is identified on the ID plate and inside of the basket on most aerial devices. In addition, be aware of dual-rated buckets with different capacities based on configuration and use as a material handler; these types of buckets are available from some manufacturers. Before climbing in, lineworkers should verify that their weight – in addition to the platform liner, if used, and all of their tools and equipment – doesn’t exceed the bucket’s capacity.

“Don’t forget to account for boots, harness, tools and any components you may add to the bucket once you are elevated,” said Kyle Wiesner, aerial products engineering manager for Terex Utilities. “Tools such as phase lifters, crimpers, hydraulic drills or chain saws all add up. Weight of personal clothing can change with the weather, so don’t forget to recalculate come winter. If a component is in the bucket while work is being performed, that weight needs to be factored in as well.”

I read the menu board and placed my order through the drive-through speaker. In her native Spanish, the employee assisting me rapidly confirmed my order and asked several follow-up questions; I answered “yes” to each question even though I didn’t understand what she was asking me. In the end, the order totaled $9.62. When I opened the contents of the bag, it was like opening a Christmas present, since I had no idea what I had just ordered. And, well, it was Christmastime after all, even though I happened to be in Puerto Rico.

That experience was my first lesson as an American who only speaks English in a place where – although both Spanish and English are official languages – Spanish is the dominant language. Over the years I had wondered why non-English-speaking workers would indicate understanding during training when they didn’t understand. Now I realize it’s a case of assumptions. I thought I knew what the employee at the fast food restaurant was asking, but I was way off. I had never been on that end of the conversation, and now I have a fresh perspective on non-native English speakers and training in the U.S.

I also have a new appreciation for the people of Puerto Rico. While there recently, I was in daily contact with people who’d had no power for 12 weeks. And for some of them, they knew it would be many more weeks before they did have power – and that might be a little optimistic. Not one person was rude or even expressed aggravation at their plight. In contrast, I am aware of utilities that had their front-office glass shot up by angry customers three days after a storm passed.  

Even in Puerto Rico’s larger cities, such as San Juan in the northern part of the island and Ponce in the south, where some power has been restored, there are still few working streetlights or traffic signals. Driving outside of San Juan, where there is no working traffic control, has become a mix of jousting and bluff. The practice is to speed up to the intersection and see if anyone slows. If they do, you are in. If they don’t, you wait and surge forward at the next driver. Yet this contrived system of driving is absent the aggression and manic reaction you might expect. No one blows their horn, points a gun at you or even gestures. It’s how you get around, and everyone is simply working it out.

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.

Editor’s Note: This installment of “Q&A” addresses some common questions Incident Prevention receives throughout the year. Most are misunderstandings of the wording or intent of OSHA standards. From time to time iP has addressed the following scenarios – or similar ones – because they never seem to go away. In the following answers, the research or interpretation methods employed have been summarized to help readers become more familiar with interpretation and construction of the standards.

Q: Does OSHA 29 CFR 1910.269(l)(12), “Opening and closing circuits under load,” prohibit the use of non-load-break dropout fused switches or lifting of hot-line clamps to break loads? The rule reads as follows: “(i) The employer shall ensure that devices used by employees to open circuits under load conditions are designed to interrupt the current involved. (ii) The employer shall ensure that devices used by employees to close circuits under load conditions are designed to safely carry the current involved.”

A: This rule often is mischaracterized as prohibiting opening or closing under load using a non-load-break switch or a bare hot-line clamp. The rule does prohibit opening or closing a switch or hot-line clamp (“device”) under load if the employee performing the task could be injured by the act. If the employee can safely perform the act, there is no violation. To explain, there are two keys to properly interpreting this rule. One is the location of the rule; it is found in 1910.269(l), “Working on or near exposed energized parts.” The purpose of the paragraph is protection of employees, as stated in the section following the title: “This paragraph applies to work on exposed live parts, or near enough to them to expose the employee to any hazard they present.”

When OSHA reviews potential violations of the standard, they typically consider three issues: if there was a rule in place, if the employer knew about the rule and if an employee was exposed to danger by violating the rule. OSHA also will review consensus standards and best practices, as well as unadopted consensus standards, which sometimes are used in de minimis conditions and General Duty Clause violations. We know this because when we read public notice citations, we find unadopted consensus standard language used in the notice of violation without reference to the unadopted standard.

The first principle of human performance (HP) is that people are fallible and even the best make mistakes, or in simpler terms, people screw up. How error-prone are we? Studies vary, but for our purposes, we will use an average of five mistakes per hour. That’s a lot of mistakes, and a scary thing to think about is we often are not aware of our mistakes.

Let’s consider how this relates to safety, and more specifically, how HP Principle One needs to be incorporated into your safety and health management system. Safety programs tend to be based on the concept that if there is a rule and the rule is good, people will always follow the rule and perform perfectly, which simply is not the case.

While it would be fantastic if no one ever made another mistake – no one tripped and fell in the right-of-way, no one skipped a step in a switching procedure, no one dropped a tool from a bucket, no one forgot to look before backing – that is not realistic, and it is irresponsible to assume mistakes will not happen.

Executives, managers, supervisors and safety professionals, you need to acknowledge that mistakes will happen, and ensure safety by design and defense in depth are being utilized to protect your employees from their mistakes. Utilize these concepts, and the consequences of errors will have little impact on the safety and health of the workforce. If you are responsible for investigating incidents, don’t forget to put yourself in employees’ shoes as you examine motivation, perhaps thinking about what you might have done in a similar situation. People rarely intend to hurt themselves, and part of your job during an incident investigation is to think about employees’ decisions, which likely made sense to them at the time. Be careful about the tendency toward Monday morning quarterbacking that starts with, “Here’s how I would have done that job and that would never happen to me.” If you haven’t already, educate yourself on organizational HP tools such as benchmarking, observations and self-assessments. Being critical of people does not engender appreciation of the value of investigations and cooperation.