How Was This Accident Possible?Now We Know!The fog from Fred’s breath floated out from his words as he directed his crew to unload poles under the three phase pole line. He had his regular crew with him on this call-out, and he was glad to have two guys who knew how to work together. There was Buck a young farm boy, who loved deer hunting and fishing, when he wasn’t building pole lines, or chasing girls. There was Ralph, who loved rebuilding old cars and spending time with his three baby girls. They all looked like stair stepped versions of their beautiful red-haired mother, and he worked hard to give the family he loved everything he could. Ralph began his apprenticeship just a year after Fred, so the two men had spent thousands of hours working together, learning, and growing up. They both were seasoned line hands with over fifteen years of experience building pole lines, and spending Sunday afternoon cookouts together. The three men were called out, for the first icy cold night of winter at 3am, to repair a forty foot pole broken off at the ground. The tow truck had cleared the wreckage of the car that skidded into the base of the pole, so the crew was setup to begin unloading a new pole to begin the framing process. Fred was on the radio with Energy Control setting up the live-line clearance they would need to transfer the phases. Once again frustration welled up in him, since the switchman wouldn’t be to the substation for a half-an-hour. It was now 5am, two hours since they were called out, arrived at the shop, loaded up the pole and material, and drove twenty miles to the job, but the switchman still wasn't at the substation; typical! The fifty-five foot material handler bucket truck was set up to the rear of the worksite as a bump truck for oncoming traffic, and signs were placed in both directions warning drivers of, “Utility work ahead.” Buck grounded the line-truck to a pole ground, then climbed up into the turret of the center mount boom to operate the controls. Ralph began unlashing the straps from the pole trailer where ice had built up on the cold steel during the long drive to the job site. The ice made the log dogs and strap binders difficult to operate, so he pounded on the ice with a steel bar to break the ice apart to set the pole free. Buck raised the boom a few feet to clear the cradle and began rotating curb side one hundred and eighty degrees until the boom was over the pole trailer. He lowered the wench line down to the pole where Ralph had a steel cable cradling the pole above center. Ralph hooked the wench line to the steel cable, and went to the top of the pole to guide it into position. Buck lifted the pole a few feet to clear the trailer’s log dogs, so he began rotating curbside to place the trucks digger derrick and pole under the three phase line. The pole was placed knee high, butt heavy, and ready to be framed. Fred and Ralph began getting tools and material out of the truck bins while Buck proceeded to climb down from the turret to help frame the pole. As Buck placed his foot on the first step to climb down, his foot slipped off the icy step, so his body dropped onto the control levers. The loop on his canvas winter coveralls, designed to hold pliers, fell perfectly over the boom up lever. As he fell, his body became suspended hanging from his coveralls on the side of the turret. His weight pulled the boom up lever down, which began to raise the boom higher. Bucks first thought was one of embarrassment as he struggled to find some foothold, or handle to right himself before anyone noticed what had happened. He was unaware the boom was slowly rising and getting closer and closer to the roadside phase.
Fred was on the curbside of the truck, so he was the first one to notice the pole top rising and the boom moving. He yelled for Buck to stop, but the seconds seemed like minutes as there was no response. Ralph was on the roadside of the truck getting the drill and wood-bit and couldn’t see the boom or hear Fred’s voice calling to Buck saying, “Stop the boom.” Only seconds later the tips of the pole claws made contact with the roadside conductor sending sparks flying on the boom and at the loose pole ground connection. The sparks flew three times until the circuit breaker at the substation opened up.
After the arching stopped, Fred got into a position on the ground where he could see Buck hanging from the boom. Fearing the worst he leaped onto the back of the truck and climbed up to help Buck. Upon reaching him, Fred lifted him up, so Buck grabbed a handhold and righted himself with the agility of a cat. Fred immediately lowered the boom from the primary zone, and thought for a second, “Wow, that was a close one!” Then the very next second a question, and a terrifying fear arrived simultaneously in Fred’s mind; where is Ralph? Fred yelled out his friends name in a frantic question at the same time panic consumed his scream, Ralph?
Fred and Buck jumped from the belly of the line truck, and ran around the front of the truck to the road side pavement. There laying face down in a fetal position was Ralph with both hands still clutching the bottom edge of the front bin and ice melted around both knees. He was on his knees getting the drill out of the bottom shelf when the boom made contact with the roadside phase. Fred ran to Ralph calling his name and looking for signs of life. He told Buck to call for help as he began CPR on his buddy.
Fred felt as if his movements were in slow motion as he tried to hurry and recall his first aid training. His mind was a blank slate as his thoughts were spinning out of control, and the scene before his eyes sent his stomach into his throat. Every moment seemed like an impossible bad dream that he wanted to wake up from, but the smells of burning flesh and the grimaced look on his friends face told Fred this nightmare was for real.
Buck returned from calling for help, then stared at his friend and mentor lying on the icy ground lifeless and still. Then the thought that would haunt him the rest of his days entered his mind as he screamed; Oh my god what have I done! Fred yelled at Buck to help him with CPR, so the young journeyman fell to his knees, and started chest compressions through the blinding tears that forever washed away his youthful exuberance for line work.
The two men worked feverishly on their friend, which seemed like an eternity, until they heard the distant sirens of the ambulance and police. The paramedics quickly took over Ralph’s care, so Fred and Buck, with nothing more left to do, sat on the ground in shocked silence of disbelief. Fred knew, Ralph’s wife in a few minutes would be receiving the worst phone call of her life, and he had no idea how he could ever face her and the girls after this accident. Fred lowered his head and began sobbing from the depths of his soul wondering; How could this accident happen to us?
Seeing the strongest man he knew lost in grief, Buck knelt beside Fred, put his arm on Fred’s shoulders as the cold air of a new sunrise was filled with sounds of suffering, as two lineman mourned the excruciating loss of a brother.
The next week was as close to hell on earth as human beings can collectively experience together. The only moments of peace were felt after mental exhaustion and physical fatigue forced their bodies into a restless sleep. However, the momentary escape ended the same way each morning with those few blissful seconds of calm, after waking up, being interrupted with a storm of thoughts and memories of that terrible morning. Visions of that day kept crashing reality back into their minds of images they longed to forget. The visitation and funeral were surreal events where the same question was asked over and over again; “Ralph was such a safety conscious lineman, how was this possible?” No answers ever came, because everyone secretly new they could slow the rate of accidents, but they had no idea how to stop them completely.
However, for the rest of this day, what caused the accident was a mute-point as the reverends words echoed off the stone walls and granite pillars of the cathedral. His words compassionately proclaimed; “Ralph is in a better place now,” but the place he just left now has a gaping hole in it that no amount of wishing can ever fill. His wife’s black vail failed to conceal the anguished tears rolling down her sweet face as she tries to comfort her three daughters, who just lost their greatest hero. As the gut wrenching feelings of loss sweeps through the congregation, there isn’t a dry eye in the house; which stands as a testament of the love that existed in Ralph’s family, but also in the many work place relationships as well.
The accident report came out a few months later, and found that the crew had followed the routine safety measures, and that ice on the step was the main cause of the accident. It was suggested that non-skid strips be placed on all walked on metallic surfaces, and ice be removed before climbing up into the belly of the line-truck. The accident was cited as being caused by human error and weather conditions. No mention of what series of human errors that caused the accident, or what preventative measures that can be taken to prevent these human errors in the future. We don’t train craftsmen to understand these human limitations, because we were raised to believe; “To err is human and to forgive divine.” We don’t really believe we can be trained from producing accident causing errors. However; the biological, learned, and evolutionary limitations we possess, that produce human errors, can be compensated for effectively.
The human limitations nobody talks about, or teaches to craftsman are as follows; The biological limitation of sight in that we actually take in much less visual information than we believe we do; the biological limitation in memory in that reconstructed memories of events or safety steps could be a compilation of separate details compiled to formulate an inaccurate memory; the learned limitations in our held beliefs that are accepted as true but act as error filled guideposts that move to confuse our emotional bearings and produce behaviors that fracture our co-dependent work relationships; and the evolutionary limitation in using the subconscious mind to control repetitious activities to conserve energy. These human limitations reside within everyone, so let’s see how these limitations were lining up to cause Ralph’s fatal accident.
Ralph would appear to be an innocent victim in this accident; however, there were errors he made that contributed to the lethal series of events. He became distracted from closely looking over the job site, because he was busy fighting the ice that froze the binders and log dogs on the trailer. Focusing on the ice, he never scanned the area to give his vision time to take in all the information. If he had, he would have seen that the roadside phase was only five feet from the top of the boom. With this knowledge, he could have taken an easy safety measure and thrown the diverter valve on the back of the truck into the outrigger position. This would make it impossible for the boom to move higher.
Ralph’s second error was in allowing his subconscious mind to take over while guiding the pole into position. Our subconscious minds are trained by repetitious activities we perform frequently; however, when the subconscious mind is driving our actions we are in a low level state of daydreaming. While daydreaming, we don’t take in new information, and we can’t compensate for the unexpected hazard. Ralph had unloaded poles thousands of times over the years, so he began thinking about and looking forward to his youngest daughters christmas play that night at the grade school. He remembered how cute she was last year, and how proud his wife looked; as the daydream went on and on and on!
Lost in his low level daydream, Ralph went to the street side bin to get the drill and bit, because he didn’t have the conscious awareness to remember that two weeks prior they all decided to move the drill and bit to the curbside rear bin. He was operating from old subconscious information, so he never should have been in the roadside area where he couldn’t see the pole raise or hear Fred’s calls to stop the boom. If he knew to choose to remain consciously aware around hazards, he would have never allowed a daydream to put himself in the wrong place at the wrong time.
Ralph's errors alone were not enough to overcome the conscious awareness for hazards, of the entire crew, to end up causing this accident. There had to be other errors by Fred and Buck in order for their unified power of situational awareness to become overwhelmed. Accident prevention is compounded by using all the skills of each team member, and accidents are created by the compounding of a series of human errors. The more errors that occur the more likely an accident will take place, and Fred unknowingly contributed his share of errors.
Fred contributed to the accident by first allowing himself to become frustrated by how long it was taking the switchman to get to the substation. When we carry limiting beliefs that situations should always unfold the way we think they should, or that our perceptions of others incompetence are always accurate, we misguide our emotions.
We are misguided when we have little or no actual information, but we formulate complete storylines of what is true. When we are doing this, we are setting ourselves up for strong negative emotions. These emotions limit our abilities to think clearly, lowers our available intelligence, and creates compulsive thinking. Compulsive thoughts revolve around in our minds growing stronger from the emotional fuel they produce, and routinely block out large segments of each day. Fred being frustrated set himself up to notice fewer details at the work site.
Being distracted by his frustration, Fred didn’t perform his usual visual scan of the work area. Normally he would take a minute and look over the work area, while he repeated to himself; What am I not seeing? Not doing this and being frustrated made him emotionally blind to his surroundings; furthermore, his inability to see the work area was compounded by the glare of the spotlights reflecting off the ice. There was weather created obstacles that kept him from seeing the hazard clearly, and he as well was suffering from an age inflicted visual degeneration that was secretly hampering his depth perception. All of these elements lined up perfectly to keep him from noticing the close proximity of the road side phase to the top of the boom.
Fred also was more relaxed having his regular two guys on his crew, and he trusted them to work safe. We can have confidence in another person’s abilities to work safe, but we must keep in mind that people who are not trained to recognize their own limitations are more prone to perform an accident producing error. Confidence can actually be false confidence when it bestows abilities upon a person that they have never really been trained to do effectively. Since we are not trained to recognize our human limitations, we remain more vulnerable, and we don’t know how to recognize the limiting weaknesses within others. Being vulnerable, we need others to watch our backs, question our recall of safety steps, stay on the lookout for hazards we may not see, disrupt our ruminating story lines produced from self-imitating beliefs, or knock us out of a day-dream.
Fred could have seen the icy steps on the line truck, or noticed Ralph going roadside to get a drill he knew was moved curb-side weeks prior. Fred could have been more aware that the combined noise of two diesel engines running and highway traffic would make it impossible for Buck or Ralph to hear his initial shouts to stop the boom. To have confidence and faith in others are good signs of strong relationships, but nobody is infallible when their safety training is incomplete. We must never let our guards down and allow confidence in others abilities lessen the wariness we hold for their safety. Often it is the people we trust the most, that when we work with them, we let our guards down, but they are the ones who we are the most emotionally connected to. When they have an accident we are more emotionally devastated, but we actually do less to protect them than someone we don’t trust. Fred would never intentionally do anything to hurt Ralph, but they were both producing errors. However, it was the additional affect of weather, Bucks errors, and bad luck that took this accident to its fatal conclusion.
Buck was full of energy, and excited to be working overtime with his favorite crew members. He always worked hard for Fred and Ralph, because they took him under their wing years ago and taught him a trade he dearly loved. Buck believed his inexperience could always be compensated for with hustle that the older men appreciated and commented on in praise. On this morning, his inexperience and hustle worked against everyone’s safety when he perceived hustle as moving faster to get more done. Buck hooked up the truck’s grounding cable to the pole ground, but didn’t pull all the cable off the reel. When the boom made contact with the roadside phase the spool of grounding cable became a high resistance choke coil. The resistance of the choke coil was then added to the resistance of the loose grounding clamp connection on the ground rod. The high resistance to ground made the voltage of the truck much higher than it needed to be, so the high voltage had to seek other paths to ground. In safety situations the quality of one’s actions trumps the quantity of the actions every time.
After rushing through the truck grounding, Buck climbed the icy truck to get into the turret seat. He didn’t give the ice on the steel surfaces or steps much thought since it had been almost a year since they last saw an ice storm. His memory didn’t recall the safety meetings or guidance from past crew members advising him to scrape the ice off the steel deck and steps. His mind left any thought of ice as he focused on getting thepole into position for framing. To distract him further, from noticing the ice, the cold wind was blowing right in his face as he controlled the boom. Sitting high up, on the turret, there was no wind block, so his eyes began watering which blurred his vision. With limited sight, Buck never noticed how close the boom was to the road side phase.
Once Buck got the pole in the position to frame, he was thinking about the framing scheme, of this pole, as he allowed his subconscious mind to control his actions of climbing down. The subconscious is past programming that is void of any knowledge of current hazardous conditions. His subconscious was trained over years of climbing into the turret seat when there was’t any snow or ice on the truck. As soon as he took the first unconscious step with no extra care, his foot immediately slid off the step and he was falling. Bad luck made the loop on his canvas coveralls get snagged on the boom up lever, and his 165 pounds was not enough weight to break the canvas stitching. This held the lever down which started raising the boom slowly.
Buck had no idea what his coveralls were hung up on, but his first instinct was to get himself free before anyone saw what happened. This fear cost precious seconds of time that could have changed the outcome had cries for help filled the air. It is our deep seated limiting beliefs that can instantly stop us from yelling for help in fear of being embarrassed in front of our peers. These beliefs grow when hazing apprentices goes to far, or childhood bullying leaves emotional scars on young minds. The best learning environment is always free of unneeded harassment, and an open environment for questions. Buck held back from calling for help, and never saw the boom rising. He heard the arching hit three times and new something was seriously wrong, but didn’t know what had just happened.
After calling for help, Buck stared at the scene on the pavement in disbelief. He immediately took blame for the whole accident; however, every accident has many layers of errors that must line up uninterrupted to produce an accident. The accident wasn’t completely his fault, no more than any one person can take credit for all the good work a crew does in a day. The formula for accidents is always equal to our potential for self-awareness minus our error producing limitations. There are always many opportunities to change the outcome of any accident, but we are less likely to make these changes when we don’t know about the human limitations that produce the accident causing errors. We can exponentially increase the number of positive changes we produce by training craftsmen about the human limitations we all possess, and the compensation strategies available for error prevention.
There is much more going on during each accident than accident reports ever record, because we are much more complicated than we realize. Part of our complexity is that we can change and create compensation strategies for new hazards. However, technology produces increasingly dangerous hazards at a faster pace than our human evolution produces compensation strategies. We become set up for failure by the inventions of our own intellect. We need to speed up our evolution to compensate for technological hazards with new training that unlocks the power of our greatest safety device, the mind. We can grow, with the right training, to understand ourselves and our mind/body relationships better than we ever have before. We will be able to diagnose problems as they occur, and as any repairman will state; “Understanding the system in need of repair is the most important piece of the diagnostic and repair procedures.
Understanding ourselves is the missing key to safety awareness that would unlock our true potential. Our full potential has never before been utilized in accident prevention. If we utilize what we have learned from the countless lives lost by work-place accidents, then accidents like Ralph’s will not be in vain.
Everyday we resist the need to implement new changes into our existing safety programs. This failure to act is yet another error we all own setting up some future craftsman for an accident. It is not only the errors performed on a crew that creates an accident, but the errors that keeps crew members from ever receiving the best training possible. In the past, the view taken for the cause of accidents has been very small, because it only focused on the individuals on the scene at the time. We cover them in layers of physical barriers, and train endlessly on step by step procedures.
This is a good start, but as an analogy,what we do is like the shape of a glazed donut around accidents. The parts we can really sink our teeth into, and what we desire the most all revolve around the central causes of accidents. We can’t see the gaping hole of missing information that is closest to the central cause of most accidents. The information most critical to the elimination of human error produced accidents is missing within safety programs. We are the answers for the problems that plague us the most, and if we finally work to grow ourselves as diligently as we grow technology, the answers would be clear for all to see. Until that day arrives, Be Safe!
This story was based on a real accident; however, any similarities to any actual accidents is purely coincidental. For detailed information, that dwarfs the information in this article, of what to teach, and how to implement a program to grow the safety culture over time buy the book; Be Safe, Growing Awareness for Accident Prevention in Dangerous Occupations. For sale at powerlineman.com bookstore. Thanks Steve Opper