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Voice of Experience: Can Human Error Be a Root Cause?

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.

Accidents that have involved normalization of deviation often have been labeled as “pilot error” or “user error” – two types of human error. Fortunately, over the years, a number of incidents involving human beings, large machines and other equipment have been avoided due to advances in technology, safe work procedures and what is sometimes referred to as cockpit – or crew – resource management, which is commonly used in aviation and other industries in which human error can have catastrophic effects. In fact, the electric utility business has quite a bit in common with the commercial aviation industry: both industries involve complex, hazardous equipment and work procedures, as well as human personnel who must be trained to maintain a high level of expertise in their trade.

And those are not the only similarities. Up until the mid- to late 1990s, there was a huge problem in commercial aviation, namely horrible aircraft crashes that resulted in many fatalities and a great deal of damage in the crash areas. It was not uncommon for pilot error to be declared the primary cause of these accidents. However, while the truth is that the problem often was in the cockpit of the plane, it wasn’t necessarily the pilot’s fault alone. Instead, there was the belief – and a culture that backed up the belief – that the senior captain was always right and should never be questioned by the first officer. In essence, there was a lack of cockpit resource management, or CRM – a failure for both officers to contribute to the safe operation of the airplane.

After research was conducted and root cause investigations were performed, it was discovered that the culture of the cockpit crews was the result of longstanding tradition. Pilot error was then identified as a product of poor CRM. A lack of management of resources, personnel and equipment all contributed to continuing problems.

Commercial aviation has worked to correct its flaws through development and implementation of a better CRM system. Professional relationships among crew members, based on a foundation of mutual respect and understanding, give each member equal authority to intervene if they have any doubt or suspicion about how or why procedures are being executed. This helps crews to recognize and correct errors before real problems occur, and many times errors will be corrected without incident. In combination with advanced technology and redundant equipment, this has aided in creating what is today the safest commercial air travel environment in history.

Resource Management for Line Crews
Below-average crew resource management could very well be a causal or contributing factor in the continuing rise of contacts and fatalities in our industry. Human beings are going to make mistakes – that is a given. But part of the problem on our crews may be that, when one crew member sees another crew member incorrectly performing a task or otherwise being unsafe, he or she is unwilling to intervene based on intimidation and fear of retribution. There has been a longstanding belief in many organizations across the industry that the lead technician or senior lineworker is always right and should never be questioned. This needs to change – human error left uncorrected will lead to a greater number of incidents and accidents.

Just as the aviation industry is better today than ever before, electric utility systems, equipment and tools also are better. Unfortunately, statistics continue to indicate that electric utility employees are being injured or killed as a result of incidents that have dogged this industry for decades. We must realize that the only way to stop the cycle is through improved human performance management.

In summary, human error is real, but there is more to the problem in our industry than talented, trained employees simply making too many mistakes. The industry now needs to follow the lead of the commercial aviation industry and change our crew culture. Continue to improve training and human performance management for employees. Encourage all crew members to monitor and identify errors in judgment and procedures, and to speak up about them. A questioning attitude could save lives.

About the Author: Danny Raines, CUSP, safety consultant, distribution and transmission, retired from Georgia Power after 40 years of service and opened Raines Utility Safety Solutions LLC, providing compliance training, risk assessments and safety observation programs. He is also an affiliate instructor at Georgia Tech Research Center OSHA Outreach in Atlanta. For more information, visit www.electricutilitysafety.com.

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Thursday, 19 July 2018

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