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.