Two U.S. Navy ships recently were involved in collisions at sea. It seemed impossible that one event, involving the USS Fitzgerald, would even occur. Then, a second collision occurred in the same region. In fact, in the last year, the Pacific fleet has experienced four serious navigational awareness errors, which has raised a question: Could the Navy have become so slack in discipline and readiness that these events were destined to happen?
We all know that, just as in the military, frontline leadership in the utility industry has a direct bearing on performance in the field. Yet after-action analysis indicates that when the Navy incidents occurred, the front line performed above expectations, indicating their competency and competency in their training as demonstrated by the actions of sailors. As was expected of the military, a quick response by Command relieved the ships’ leaders of their duties, citing loss of trust. Was Command correct? Did the ships’ leadership lose trust, or was it something else?
Some speculation arose among naval defense analysts that hackers may have caused electronic mayhem. A naval ship’s protection system depends on its electronic eyes and ears. Systems have evolved greatly since the days of the direct-wired blip from the antenna to the screen interpreted by a trained radar man. Early radar sent out a specific frequency wave that was several meters wide. The return wave depended on density of mass to return a reflection of that same frequency wave. The blip was interpreted by a trained observer to differentiate between an enemy bomber and a flock of geese. Today’s electronic radar frequency wave shifts are as small as 1 millimeter. A radar reflection comes back as thousands of bits that are interpreted by a computer. The radar screen now delivers an information-laden message to the radar man, who reads and reports the information displayed to him – by the computer. Some reports suggest that contemporary radar used by the military can detect a suitcase-sized drone that is miles away. The same types of systems scan for other threats, such as missiles and warplanes. If a hostile force wants to disable such protection, hacking a ship’s digital protection capabilities would make it vulnerable.
With that in mind, look at some of the newest designs in warships. The Zumwalt-class destroyers are virtually steel-enclosed. The bridge windows are narrow looking forward. The sideview windows angle forward at 45 degrees. The view angle seems to favor deck and docking observation. It seems to be the trend in design to limit bridge intrusion by limiting penetrable window space. In the latest Navy collision, which involved the USS John S. McCain, photos of the ship’s bridge show large windows and wing platforms off the sides of the bridge that project past the ship’s gunwales, allowing a clear view off both sides and to the rear of the ship.
That raises new questions. Where were the watch stations? Have we become so dependent on electronics that we no longer need a window on the world? What if the Navy is so dependent on digital systems that it no longer needs sailors in crow’s nests? What if a digital system is lying to the radar officer and no one is at the window?
A Direct Relationship
These conundrums have a direct relationship to our workplace. Have we become so dependent on the latest program that we no longer see the value in boots on deck? Or, a similar question: Do procedures get in the way of good practices that would otherwise perform the same function, preventing incidents? I have long been a proponent of approaching problem-solving with practical, simple actions. I know for a fact there are many times we make changes to solve a problem, not seeing the downside of the new process. I know there are processes in the workplace that don’t work, but we still engage in them. In fact, I have been criticized for “backing up” safety progress when I have wanted to undo a procedure or program that I could clearly see wasn’t working. Sometimes it may be that simply improving the traditional method would have made more sense.
Here’s an example: I have been analyzing tailboards for a couple years. In my experience, beginning in the early 1970s, every crew I worked on did a tailboard. Our foremen and linemen discussed the work, the procedures to be followed and what hazards to watch for. It was a good practice. Everybody from management down knew good planning prevented incidents. In my early days, a new federal agency, the Occupational Safety and Health Administration, was created by the Williams-Steiger Occupational Safety and Health Act of 1970. OSHA made a big difference in most workplaces but saw a need for more regulation for the utility industry. In 1994 OSHA published 29 CFR 1910.269, the electric power generation, transmission and distribution standard. The .269 standard included something not used in earlier standards – a recipe for conducting a pre-job hazard analysis. The requirements for the pre-job briefing didn’t mandate a form or retention of a form, but since the employer did have to be able to ensure pre-jobs were being conducted, document trails were created. In other words, “we must have a record” was the message to the crews and crew leaders. Then, in 2014, OSHA revised the 1910.269 general industry standard and the 1926 Subpart V construction standard, further expanding the detailed requirements for the pre-job hazard analysis. The agency added a paragraph for existing conditions and further and more directly emphasized the employer’s responsibility to ensure the pre-job conference is done as prescribed.
The new rules now came from two sections. Paragraph 1910.269(a)(4) held requirements for existing conditions, and paragraph .269(c) held all the detailed requirements for the pre-job briefing. So, the pre-job now required a crew review of the nominal voltages of lines and equipment; maximum switching-transient voltages; presence of hazardous induced voltages; presence of protective grounds and equipment grounding conductors; locations of circuits and equipment, including electric supply lines, communication lines and fire-protective signaling circuits; condition of protective grounds and equipment grounding conductors; condition of poles; and environmental conditions relating to safety. The subjects to be covered during the pre-job briefing remained the same: hazards associated with the job, work procedures involved, special precautions, energy-source controls and personal protective equipment requirements.
What’s Gone Wrong?
Here is what I think has gone wrong: All the topics and requirements found in the OSHA rules are correct. These are the things we should be training our crews and crew leaders to look at and discuss before we begin the work. But the delivery of our training, the employer’s emphasis on documentation, and crew perception and values have drained the value from the process. We are now focused on the process and its perceived value over the most important part – effective analysis of the hazard. And just to clarify, “effective” analysis isn’t how well we identified the issue (i.e., wrote it down), but how well our identification and subsequent remediation of the hazard effectively controlled it, preventing injury.
Here is a prime example: A crew reconductoring feeder cables from industrial breakers had a contact that injured an industrial electrician. The crew had been in the enclosures for the breakers dozens of times over the previous month. Every day they checked a box labeled “check for voltage” – along with many other boxes – on their four-page pre-job form. Yet every day they had been working within inches of a 4-kV control voltage transformer mounted in the corner of the cabinet, until finally one of the electricians laid a ground wire across it.
I’ll give you another example. A mobile crane was parked on a sandy roadside with its 40-inch-diameter wheels chocked with 6-inch rubber chocks. Yes, it was on the pre-job form. The crew clearly had checked the “chocked all parked equipment” box. But the purpose of chocking is not to satisfy the form – it’s to keep the crane from rolling away. In this case, when the crane wanted to roll away, it simply buried the chocks, rolled away and struck a parked pickup truck, which happened to be mine.
As I have been addressing this issue, I have lost count of the number of times I have seen a foreman spend an hour before work filling out a pre-job form. The situation usually goes something like this: At the crew meeting, the foreman spends 20 minutes reading the form to the crew. Having completed the form and conversation, the folder goes on the hood of the truck and a job discussion follows, covering what the crew is going to do. Unfortunately, the pre-job form covers routine task hazards like “stay out of the bite” and “wear all PPE,” not the tasks the crew is going to execute to complete the day’s work. It goes smoothly, but the work discussion that follows the reading of the pre-job form does not tie the hazards to any of the tasks being discussed after the pre-job form is laid aside.
The result is that I can conduct a crew audit later that day and have a crew member tell me what they are doing and what’s going to happen next, but they can’t tell me what’s on the briefing form. Or, I can drive up to a job and find phases spread on link sticks and ropes, but I see nothing of the form discussing the procedure or hazards of pulling #4 copper phases out of line with the poles.
As you might have guessed by now, it seems that in some workplaces, OSHA’s good intention and the employer’s intent to establish documentation of their good intention have turned the pre-job briefing into its own separate activity, with little to do with the actual discussion and conduct of the work. Be clear that it’s not happening everywhere, and we have seen progressive improvement of safety performance across the industry. In fact, the utility construction industry has an incident rate average below 2 according to the latest figures from the U.S. Department of Labor. That is a result of many initiatives, not just tailboards, from OSHA and the industry. The example of tailboards I’ve provided demonstrates how a process can become the focus of energy and activity without accomplishing the goal.
So, how do we fix these types of issues? We have to anticipate and prevent them from happening in the first place. There is no rule that states there must be a new policy to fix something that just happened. On most occasions, a proper analysis of an event will demonstrate there already is a practice in place that would have prevented the root cause of an incident. So, my No. 1 rule is, be sure new procedures are well-thought-out solutions to an absence of controls, not an emotional response to a perceived need for a new control.
My No. 2 rule is, don’t let procedures become a “task.” Procedures must be a tool toward the goal of an incident-free workplace. They must come with training that identifies purpose, goals, execution and measurement.
My No. 3 rule is to audit, audit, audit. When you write a procedure, write the audit mechanisms into the procedure and then schedule the mechanisms into your safety officers’ days and weeks ahead. If the goals are not being achieved, change the procedure or get rid of it. Actively question your crews about newly implemented policies. Explain and support the policy implementation and audit process. The best way to weaken your credibility as a safety organization is to throw out new policies or procedures that don’t make sense or don’t work. The second-best thing you can do to weaken your credibility is to ignore policies that don’t work and keep them on the books.
As to the U.S. Navy, Command handed down the results of the review and orders for both the USS Fitzgerald and USS McCain collisions on November 1 of this year. Both ships’ duty officers failed to post watchmen. While there were other contributing factors listed, the report concluded that an effective bridge watch was a basic safety measure that would have identified the risk posed by the approach of the other ships and prevented the collisions.
So, keep sailors on the bridge. Keep policy and procedures simple and direct. Don’t give up on out-of-the-box thinking, but don’t let new ideas distract you from the task. Make sure your next new idea adds value to things that work. And lastly, send us your ideas and comments on what works for you.