Train the Trainer 101: Root Cause Analysis, Training and Lessons Learned
I’m not sure how I became an analyst. I don’t think it’s a career goal you necessarily plan for. My understanding of the analyst role is that it’s an individual who studies the elements of an event or occurrence. Analysts break down the elements of an event to learn how those elements are related. The purpose of analysis is to understand the nature of the event being studied. Through effective analysis, we ultimately create or assure desired outcomes and prevent or minimize the likelihood of undesired outcomes.
Over the past 10 years I have analyzed a half-dozen training accidents that occurred in apprentice training yards. Recently I also have seen a couple of videos of incidents involving apprentices in which no one was hurt; they were actually kind of funny to watch. But to an analyst, those videos have a lot more to offer than the lighthearted “been there” sympathy. Lineworkers often learn the hard way how not to do things. It’s that hard way that I want to eliminate because sometimes the hard way becomes the final act to what might have been a great life.
I was once engaged to write an opinion on a root cause analysis (RCA) that OSHA and a utility performed based on an incident that hospitalized three apprentices in a single event. OSHA only performs RCAs to identify where the employer may be at fault, but in this situation, the RCA listed all kinds of physical conditions and procedural mistakes that caused the incident. All of those items were causally related, but none were the real root cause. Before we move ahead in this edition of “Train the Trainer 101,” readers need to understand RCAs and how they fit into the lessons learned from training accidents.
The Art of Root Cause Analysis
The art of root cause analysis is a peculiar one. For an RCA to be effectively performed, knowledge of safety standards, performance standards, standards of care and – in particular – human performance is required. Software applications that provide RCAs are effectively employed by many utilities. They are mostly algorithm-based methodologies designed to lead the investigator to the most likely RCA. The development of these applications was intended to bring the art of RCA into a standardized protocol. A guided protocol should overcome the possibility of error that is posed when untrained investigators perform the infrequent task of determining an RCA, especially if those investigators do not have a good foundation in human performance. While these applications are widely employed and useful, the human element in the process can impact results. The issue with the use of any RCA application is the listing, evaluation and interpretation of causal factors that were present leading up to an incident.
Causal factors are elements associated with the undesired event under investigation. They affected the event being investigated, but causal factors are not the root cause. The root cause is the singular event that – if it had not occurred – the undesired event would not have occurred either. I recently reviewed two incidents that occurred a few years apart. Both incidents were so alike that you easily could have used the same written investigation report for both events. In each case, the investigators used an RCA application to determine a root cause that would be the basis for prevention. In the two cases, the root causes were the only thing different in the conclusions of the RCAs. Yes, you read that correctly: The exact same causal factors leading up to the events resulted in two entirely different RCAs. I could spend some time explaining the errors, but let’s leave it at this: If you want an RCA application to be effective, you must complete the training and follow the process. The point is that a root cause is not always easy to determine, but even more importantly, it is not always what you think it is. That brings us back to training.
An Industry Shortcoming
I’m aware of an apprentice named Thom who climbed to the top of a distribution pole to demonstrate rodeo-style hurt man rescue. Thom got to the mannequin successfully only because of his portable fall protection device. At the mannequin, he fumbled with the rigging. From the ground he was being encouraged with shouts of “Go, go, go,” “Wrap this,” “Pull that,” “Reach around that.” Thom was trying desperately to get the mannequin rigged and down in the infamous four minutes. Finally rigged, Thom reached around the mannequin and, using the hawkbill knife that he had sharpened to a razor’s edge for the demonstration, cut his own fall protection and fell 38 feet into life in a wheelchair. In another incident, a worker known as “Goob” cut his fall protection. You can still see the world-famous video on YouTube (https://youtu.be/gaH7pK-6n84). As hard as I have looked, however, I still don’t know how that worked out for Goob. But that’s where the lesson is – in Goob’s famous rescue fail.
We have a shortcoming in industry training that is exacerbated by the need to get lineworkers trained and in the air – or in the ditch, as the case may be. The problem is the difference between objective and subjective goal-setting for training. In the earlier narrative, I mentioned that Thom the apprentice got to the mannequin successfully only because of his portable fall protection device. There is a very important point to that observation, just as with the Goob video. Neither apprentice was subjectively competent to succeed in his task. This difference between subjective and objective is a critical concept that has a considerable role in training and particularly in the training of trainers.
Subjectivity occurs when an evaluation is influenced by personal experience, opinions or feelings. Objectivity is exactly the opposite. It happens when evaluation is not influenced by personal experience, opinions or feelings – just goals or facts. The personal experience referred to in the definitions of subjective and objective refers to the hands-on experience legitimately valued in the utility industry. To be absolutely clear, I agree that a good instructor has had a career full of experience obtained and knowledge learned, and this is not an indictment of our historical process of on-the-job training using lineworker mentors. I am a product of the on-the-job training process and still have great respect for those who taught me. This issue is not one of negligence or incompetence; it’s generic and maybe even a hidden organizational defect.
Thom, the apprentice who made it to the mannequin earlier, was the victim of two objective influences that resulted in his fall. The first was lack of climbing competence. Thom never would have been sent up a 40-foot pole if he had not been in a personal fall arrest system (PFAS). He didn’t have the developed skill or technique to safely climb. He was allowed to go up because he trained in a PFAS and couldn’t fall. Using the PFAS, Thom could get to the top of the pole – objective met. But he lacked technique and skill. His hook-sets were tentative, and his body was off-center and oriented uncomfortably because his PFAS was not properly adjusted or periodically adjusted during his ascent. The second objective influence might be called the “git-r-done” mentality. I love the Larry the Cable Guy of the 1990s, but he didn’t do us any favors. It’s not really his fault. Git-r-done was a comedy phenomenon that was supposed to make light of simple men completing manly tasks using unsophisticated methods resulting in unrestrained celebration. I am in favor of all of those characteristics in problem-solving, especially the unrestrained celebration, but we might have taken git-r-done a little too far.
In both Thom’s and Goob’s cases, a second precursor was the encouragement of the people on the ground. If you look objectively at the two scenarios, both apprentices were trying very hard to succeed. It is the nature of man to seek approval, and that begins with successful completion of a difficult task. However, in both cases, the level of problem-solving displayed shows that the two men were not at the competency level necessary to succeed. Goob’s pole strap was out too far, his feet were poorly positioned for maneuvering, and the management of his rigging also was poor. Thom was in the exact same circumstances. He told me that on the pole, he was not confident in his climbing skills, but he knew he couldn’t fall because of his PFAS. When he got to the top, his problem-solving skills were limited by his lack of experience and compromised by the pressure of the shouts from below offered by well-intentioned co-workers.
In training, we first reach competency and then press for timely and efficient completion of the task. Until an apprentice demonstrates a level of problem-solving and skill independent of the trainer’s instruction, the process must be patient and orderly. Just getting to the top of the pole is a measure of objective quality. Getting to the top of the pole while demonstrating skill is a subjective quality.
Where Do RCAs Fit In?
So, where do RCAs fit into these and the other training yard incidents I mentioned earlier? The root cause was trainer competency, but that’s not because the trainers were not competent to train. Instead, they were not trained to train. I hate to even write that without first preparing the reader because it wasn’t the trainers’ fault. The missing competency was not skill or knowledge as a lineworker. What was missing in each incident was the understanding of the nature of the person being trained and the importance of recognizing subjective indicators of competency necessary to ensure safe and effective performance of learned skills. In the training world, this skill is known as technology transfer. Effective technology transfer is based on an understanding of the nature of the learning, the nature of the learner, modalities of training and subjective indicators of training success, as well as meeting objective measures of competency.
Two of the previously mentioned training yard incidents were falls. In both cases, the instructors deviated from their planned training methodologies and bowed to the pressure of the trainees to have speed-climb events. One apprentice climbed off the top of the pole, and one gaffed himself and almost bled to death. In both cases, their climbing skill was not characterized by positive hook-sets, technique, hand position, body orientation or even looking up.
In another case, apprentices using trial and error to learn how to compress sleeves with a 60-ton press blew hydraulic hoses and hospitalized two individuals. The utility’s investigation blamed the failed hose that “should have been capable of containing the hydraulic pressure.” But the RCA revealed that the hose was plugged into a universal pump open-center system that prematurely forced pressure into the hose of the closed center head, preventing operation of the spring-loaded quick coupling. The apprentices forced the coupling, breaking the hose. The problem wasn’t a bad hose, it was an objective-based training discipline. Squeeze the sleeve without bending it. The initial introduction to the task and training methodology lacked necessary elements of instruction and preparation, which should have been audited by observation of the steps following an orderly process to a successful conclusion.
The Bottom Line
The bottom line here is that I am using RCA to lobby for an across-the-board review of the nature of training in our industry. We have too many examples of trainees pushed ahead of their skill competencies, resulting in preventable incidents, and it’s not limited to just climbing in 100 percent fall protection. We should examine our training processes and how we train our trainers. Training of trainers leverages their experience, craft skills and knowledge by giving them the technology transfer skills that will make them successful. Audit your training programs, and train on technology transfer, positive subjective analysis of performance, effective methodologies and meeting objective training measures.
I was once challenged by a utility manager who was concerned about the cost and return on investment of training the utility’s trainers. He said it was frustrating to spend money and time training trainers just to have them leave. That manager’s attitude is another example of the error of relying on an objective concern. The subjective concern would be, what if you don’t train your trainers and they stay?
About the Author: After 25 years as a transmission-distribution lineman and foreman, Jim Vaughn, CUSP, has devoted the last 20 years to safety and training. A noted author, trainer and lecturer, he is a senior consultant for the Institute for Safety in Powerline Construction. He can be reached at [email protected].