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Incident Prevention Magazine

Incident Prevention is on a mission to be a major player in the reduction of job related accidents within utilities and telecommunications. The publication, our iP Safety Conferences and this site are dedicated to providing utility safety and operations professionals the resources to build safety programs and implement processes that lead to...

Incident Prevention is on a mission to be a major player in the reduction of job related accidents within utilities and telecommunications. The publication, our iP Safety Conferences and this site are dedicated to providing utility safety and operations professionals the resources to build safety programs and implement processes that lead to reduced work-related incidents.

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Danny Raines, CUSP

Voice of Experience: Understanding Induced Voltage

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.

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Jim Vaughn, CUSP

June-July 2018 Q&A

Q: Whenever we see graphics for single-point grounding, it’s always a cluster, a connection to the neutral, a connection to a phase and a chain connecting to the other two phases. But when we check with other utilities or consultants, we see all kinds of arrangements, such as bracket grounds with a single point or two sets of single-point grounds bracketing the workspace. Where do we find the definitive arrangement, and why are there so many variations?

A: Under OSHA, the employer is solely responsible for determining how they will meet the requirements of 29 CFR 1910.269(n)(3), “Equipotential zone,” which requires that grounding of de-energized phases be installed in an arrangement that prevents employees from being exposed to differences in electrical potential. In addition to 1910.269(n)(3), there also is Appendix C to 1910.269, “Protection From Hazardous Differences in Electric Potential,” as well as IEEE 1048-2016, “IEEE Guide for Protective Grounding of Power Lines,” a consensus standard that may be considered the authoritative best practice. IEEE 1048 is filled with detailed electrical data – from modeling to application – to explain how to create equipotential protection and effective tripping of grounded circuits that may inadvertently be energized.

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David McPeak, CUSP, CET, CHST, CSP, CSSM

Frontline Fundamentals: HP Principle Three: You Cannot Outperform Your Organization

What happens to a saltwater fish if we put it in fresh water? No matter what that fish does, no matter how well it can swim, no matter how strong it is and no matter how hard it tries, it cannot survive because we put it in the wrong environment.

When it comes to human performance, HP principle three states that individual behavior is influenced by organizational processes and values. It implies that incident causation goes deeper than individuals, and that to prevent incidents, organizational (systems) deficiencies must be identified and corrected. The challenge for an organization is to create an environment in which employees – the organization’s greatest asset – perform at their highest level. You do not want to create an environment in which latent organizational weaknesses set employees up for failure.

Us vs. Them
Imagine a group called Us and a group called Them. Them has a package labeled Profit that needs to get from Point A to Point B on or before a day called Standard. Them creates directions on how to get from Point A to Point B, which are contained in the Map. Them gives the Map to Us and instructs Us to go to Point A, pick up Profit and deliver it to Point B on or before Standard.

Us arrives at Point B two days late with only part of Profit because Us got lost. Them is furious and blames Us for losing part of Profit by not arriving at Point B on Standard. Us blames Them, complaining that the Map was wrong, which caused Us to get lost and be late. Two weeks later, this scenario is repeated, with more of Us losing part of Them’s Profit, so Them sends Middle Man to investigate and determine corrective action.

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Jim Willis, CMAS, CHS-V

Rethinking Utility Security

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The names Nathan Baker, Zackary Randalls, Alex Boschert and William Froelich may not be familiar to you, but their stories are tragically important for utility workers. Nathan worked for East Mississippi Electric Power Association in Clarke County, Mississippi. Zackary was employed by Pacific Gas and Electric Co. (PG&E) in Fresno, California. And Alex and William worked for Laclede Gas Co. (LGC) near St. Louis. Except for Alex and William, who were employed by the same company, there is no evidence that these men knew each other or their paths ever crossed, so what thread binds them together? They were murdered while doing their jobs for their respective companies. In a horrible twist of fate, three of the men were killed within a week of each other in 2017.

In 2012, Nathan was making a routine collection/disconnect call at a residence when he was shot; his body was dumped in one location and his truck abandoned in another. In 2017, Zackary was sitting on the passenger side of a PG&E truck when a gunman walked up to the window and fired at him. A few days later, Alex and William were connecting a residential natural-gas line when a man, believed to be upset about his electricity bill, shot the two men and then turned the gun on himself.

Troubling Reminders
These stories are troubling reminders of a trend of violence aimed at utility workers. Utilities go to great lengths to ensure their employees have the skills and training necessary to safely do their jobs, but there has been less of a focus on utility worker security. This has to change. It is time to rethink utility security. From the front door of the office to the crews in the field, we must change how we go about protecting employees. Lives depend on it.

When you mention “utility” and “security” in the same sentence, many people think of cybersecurity or physical security of large-scale infrastructure sites. Many have heard about the cyberattack on the Ukrainian electricity grid in 2015 and know about the steps taken in the U.S. to secure the grid. Some conceptualize utility security as protection against attacks like the one on the PG&E Metcalf substation – a major transmission grid link – that occurred in 2013. Although these are critically important security issues, they are not the only ones. Safety managers and senior staff with safety and security responsibilities also should focus on improving the security posture of utilities at the local level. This means securing office complexes, warehouses and operational facilities; taking steps to target-harden local transmission and distribution; and improving the protection afforded to both office and field personnel, whether company or contractor.

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Jesse Hardy, CSP, CIT, CUSP

Overcoming the Effects of Short-Service Employees

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“Are you calling his family, or do you want me to?” the superintendent asked. The project safety manager replied, “I’ll call his emergency contact after I find out where the ambulance is heading. Can you call the division manager and give her an update?” The superintendent shook his head as he surveyed the scene and said, “I’ll have to keep it short and simple for now, but tomorrow morning we’re going to need to be able to explain to everyone how a 19-year-old kid with three months of experience was able to jump into that piece of equipment and put it into an overhead power line.”

Although this is a fictional conversation, it may hit close to home for numerous industry workers, especially if your company is adapting to rapid growth by hiring new workers, also known as short-service employees (SSEs).

In its August 2017 issue, Incident Prevention published an article I wrote titled “Overcoming the Effects of Rapid Growth” (see https://incident-prevention.com/ip-articles/overcoming-the-effects-of-rapid-growth), which described how leaders can use operational analysis and powerful communication skills to overcome the effects of rapid company growth. In this article, I’m going to expand upon that topic by shifting the focus to overcoming the effects of rapid growth through SSE onboarding, field mentoring and coaching. That’s because if the Crucial Conversations skills I wrote about in the last article made an impact, and you now have hired the additional people you need to accomplish your company’s ever-growing mission, then it’s likely you are facing a different problem: How do I get these new people up to speed so they meet our quality and safety expectations?

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Guest — Erik Hager
Thanks for a great article - very informative, Erik [email protected] http://www.pacefactory.com... Read More
Wednesday, 01 May 2019 09:28
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Rob D. Adams, CLCP, CUSP

Scenario-Based Fall Protection Solutions

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At least once in their career, nearly every safety worker in the utility business has been – or will be – faced with the need to use fall protection in an area where there is no place to tie off. In my role as a safety technician, I work with personnel in both generation and transmission business units; fall protection is needed in this line of work, but I have found that anchorage points can sometimes be few and far between. It’s a problem that clearly needs to be solved, and in this article I will share what my company has done to provide scenario-based solutions.

Scenario One
During an outage preparation meeting a couple of years ago, I was presented with some fall protection issues that employees had been dealing with. These issues specifically related to anchorage points for crews working on our main steam stop valves. Once the grating and I-beams were removed from the valve pit area, all potential anchorage points were eliminated, and thus no fall protection could be properly anchored and used in the valve pit area. Given this problem, I contacted a fall protection solutions group that came to visit our facility and gathered information regarding our anchorage concerns. While the solutions group was on-site, we also discussed possible recommendations to solve the anchorage problem. In a follow-up email after our initial meeting, the solutions group provided detailed information about the different types of equipment we could use to eliminate our anchorage issues on this particular project. The detailed equipment recommendations were then presented to our company’s personnel, and ultimately the decision was made to purchase the recommended equipment.

That recommended equipment was two advanced portable fall arrest posts, which allow us to provide overhead tie-off and utilize small self-retracting lifelines, or SRLs, so that workers in the valve pit are equipped with complete fall protection. Among the advantages of the portable fall arrest posts is how the posts are mounted. They offer several mounting applications that range from weld-on plates to beam clamps that are designed to fit 6-inch to 14-inch I-beams, meaning that we can use the posts in numerous locations throughout the company. Time and time again, the equipment has proven to be the solution to many of our fall protection needs in both generation and transmission work, including in Scenario Two below.   

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Danny Bost, CUSP

Key Concepts of an Insulate and Isolate Program

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Most utilities and contractors that perform work on energized conductors use some form of cover-up program or process. Culture plays a big part in how we currently cover for protection. When a new lineworker joins the crew, that person learns the ways of senior members of the crew, and later that knowledge is passed on to the next new person. Having control of what we work on also has played a significant role in how we cover. If you have control of the energized conductor or equipment you are working on, you may not need as much cover for protection, right? The problem is, in numerous cases, something unexpected has occurred, resulting in a flash or contact event.

There also are other reasons why we continue to have flash and contact events. Today, there is more work to do than there are qualified lineworkers available to perform the work, so sometimes companies advance lineworkers through the ranks faster than they would have in the past so those employees can perform energized work. In addition, we don’t have the luxury of doing as much de-energized work as we once did. Sadly, according to the U.S. Bureau of Labor Statistics, over a period of five years – from 2011 to 2015 – there were 62 fatalities related to electrical contact.  

So, what does all of this information point to? Simply put, it is time for us to take what we have learned from the past and train today’s employees on how to insulate (cover) for those times when things could go wrong. Then, if they lose control of what they are working with, no injuries will occur.

That’s easy to say, but changing a company or department’s culture is not an easy thing to do, especially when the company or department employs longtime workers who have found repeated success with the control-and-cover method. Many companies have spent countless hours and dollars to improve their cover-up processes – and many times observations and audits indicate their crews are working just fine – yet events continue to occur. It’s no secret that lineworkers deal with differences of opinion about how cover should be applied.

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Jim Vaughn, CUSP

Train the Trainer 101: Current in Grounds Can Kill

Over the past six months, three things have happened that I want to mention. First, I have answered numerous questions from clients and Incident Prevention readers regarding personal protective grounding (PPG). Second, the industry has experienced a rash of injuries and fatalities related to current in grounded circuits. The incidents most often have been associated with induction, but not always. And third, I have consulted with utilities and contractors, large and small, who are just now recognizing they have issues understanding PPG. It’s been hard to gauge the numbers – such as the frequency of incidents and especially comparing the seriousness of injuries – because there is no reliable clearinghouse for tracking incidents other than fatalities reported to the U.S. Department of Labor.

All of this is beside the real point, however, which is that there is no reason for any of these incidents to have occurred at all. Well, there is one: The utility industry is behind the curve in their understanding of the phenomenon of current in grounded conductors. There is an explanation for that, and it’s time to write about it again.

Let me be clear: The purpose of this article is to work toward solving the problem, not to find fault. To understand how we got to where we are, let’s first talk about industry awareness. Anyone who does research on the fundamentals of utility system grounding will notice that we have been struggling with PPG since as early as the 1950s. This has been documented in various papers from the IEEE archives of “Proceedings of the IEEE” – one of the first electrical industry journals, established around 1927 – and in “IEEE Transactions on Power Systems” since 1985.  

As the IEEE 1048 standard, “IEEE Guide for Protective Grounding of Power Lines,” points out in the introduction to the 2003 edition, “Protective grounding methods have often not kept pace with their increasing importance in work safety as the available fault current magnitudes grow, sometimes to as high as 100 kA, and as right-of-ways become more crowded with heavily loaded circuits, leading to growing problems of electric or magnetic induction.” Did you notice the date of the standard? The 2003 edition is a revision of the 1990 standard on protective grounding. As I stated earlier, we’ve been struggling with PPG since as early as the 1950s. Over 60 years is a long time to still not have figured it out.

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Danny Raines, CUSP

Voice of Experience: When Training New Workers, Be Vigilant

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? 

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Jim Vaughn, CUSP

April-May 2018 Q&A

Q: Recently an event occurred during a trouble job that surprised us. We had an underbuild phase down that was broken midspan. Our crew was working from an insulated bucket, and we grounded both the feeder we were working on and the one above. While our crew was beginning to crimp the splice for the repair, an energized line a few spans away came in contact with the grounded phase our lineman was in contact with. The lineman was in an insulated bucket, but he still received a shock. He was not seriously injured. Can you help us understand this?

A: The explanation is simple. Grounded circuits will still have current flowing through them if they are energized. Where there are resistances in parallel paths with the grounded circuit, there will be a voltage drop and there will be current flow through the parallel path. The current level is limited by the resistance in the path. Insulated bucket trucks are not totally isolating. To confirm that, all you have to do is look at the electrical tests performed on insulating booms. The current flow on an insulating boom is limited to a value well below the current necessary to injure a worker. In your case, there was voltage drop in the gap between the grounded, energized phase and the insulating boom that was a path to ground. Your lineman bridged that gap when he was in contact with the phase while standing in the bucket. The voltage was high enough to penetrate his skin so that current could flow. He was protected from injury by the current-limiting function of the insulating boom. We know it takes about 50 milliamps of current through a worker to rise to the level of injury. Depending on the electrical integrity of the boom and the voltage involved, there were – and this is just a guess based on boom-test protocols – perhaps 50 microamps to 1 milliamp of current that could flow on the boom. That is well below the level of injury. Electrical integrity of the boom is paramount in protecting workers. That is why it is critical to wash and maintain the boom.

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David McPeak, CUSP, CET, CHST, CSP, CSSM

Frontline Fundamentals: HP Principle Two: Your Crystal Ball

I have fond memories of G.I. Joe. When I was a kid, I played with the toys and watched the cartoons. I sang along with the theme song and was ready to say “knowing is half the battle” in unison with the hero at the end of each episode, after Cobra had been defeated. The Joes were smart to realize that knowledge is power, and knowledge is especially powerful when it comes to safety, and more specifically, incident prevention.

Imagine for a moment what it would be like to know the future – think about how powerful it could make you. How much money could you make if you could predict winning lottery numbers or the winner of a sporting event? Think about all the undesirable outcomes you could avoid – such as getting injured – if you knew the exact date and time they were going to happen.

It’s unlikely you will ever know exactly what the future holds, but you can use human performance (HP) to predict, manage and prevent error-likely situations that could have led to incidents. In other words, the second principle of HP – that error-likely situations are predictable, manageable and preventable – gives you a crystal ball.

Let’s define what is meant by the term “error-likely situations.” These situations occur when error precursors are present and negatively impact decision-making. Error precursors, which are grouped into four categories – task, work, individual and nature – include such things as imprecise communication, departures from routine, distractions, inaccurate risk perception, overconfidence and time pressure (see more in the TWIN Model of Error Precursors sidebar).

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Bart Castle

Three Overlooked Processes for Increasing Safe Work Practice

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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.

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Pam Tompkins, CSP, CUSA, CUSP

How to Develop a Contractor Safety Management Standard

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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.”

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Hugh Hoagland and Zarheer Jooma, BSEE, M.S.

Using Arc Protective Blankets as an Engineering Control Method

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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.

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Dan Brenden

Using Technology to Eliminate Aerial Device Overloads

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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.”

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Jim Vaughn, CUSP

Train the Trainer 101: Lessons from Puerto Rico

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.

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Danny Raines, CUSP

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.

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Jim Vaughn, CUSP

February-March 2018 Q&A

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.

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David McPeak, CUSP, CET, CHST, CSP, CSSM

Frontline Fundamentals: HP Principle One: People Screw Up

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.

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Kate Wade

Chris Grajek Honored at 2017 USOLN Safety Award Ceremony

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On October 2, the Utility Safety & Ops Leadership Network (www.usoln.org) held its annual award ceremony at the iP Utility Safety Conference & Expo in Louisville, Ky. During the event, USOLN board members presented the John McRae Safety Leadership Award to Chris Grajek, CRSP, CUSP. Grajek currently serves as safety and work methods director for Allteck Line Contractors based in Burnaby, British Columbia.  

The John McRae Safety Leadership Award was created to honor McRae, a fourth-generation lineman who enjoyed a 42-year career before passing away July 27, 2010. He was active in the military reserves for nearly 30 years and instrumental in establishing the Massachusetts Municipal Lineman’s Association. McRae, a member of San Diego’s IBEW Local 465, spoke across the country about electrical training and went on to assist in the launch of Incident Prevention magazine.

“The John McRae award is a great honor, and even more so coming from an industry full of great leaders and professionls,” Grajek said after winning the award. “I never had the opportunity to meet John, but he sounds like an incredible leader and mentor. I take comfort in surrounding myself with those types of people whenever the opportunity presents itself.”

Grajek was selected to receive the award due to his commitment to the USOLN and its work. “Chris has dedicated himself to the Utility Safety & Ops Leadership Network by serving on the CUSP exam development committee and, more recently, the CUSP governing board,” said Carla Housh, USOLN executive director and publisher of Incident Prevention magazine. “He, along with other Canadian CUSP credential-holders, recognizes the benefits of the program and has worked to support and advance CUSP growth for Canadian utilities. Chris’ safety leadership knowledge, along with his passion for advancing the CUSP program, has had a significant impact on the success of the Northern program, and we are sincerely appreciative of his efforts.”

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KNOWLEDGE, INSIGHT & STRATEGY FOR UTILITY SAFETY & OPS PROFESSIONALS

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