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Organizational Learning: Our Path to Safety

It is certainly in our interest to learn to extract 'wisdom nuggets' from others.

Have you ever read an incident report and then thought, "I would never have done that?"  

If so, you have something very valuable to contribute and we would like to collect and share it with your peers throughout the industry. It doesn’t have to be easily quantified or packaged, we’ll help with that part, but it does need to be “hard won” wisdom.  Some sense or learning that you’ve acquired through a near miss, actual event or simply an evolved work practice. Something that created a permanent shift in your thinking and that then became crucial to your ongoing safety and success. Something you wish everyone knew.

We would like to collect these personal rules and understand the reasons that lead to the creation of the rule. We can learn from your ongoing, personal successful work practices, and give you appropriate credit for sharing.

As I’ve shared in a previous column, 66 linemen were tragically killed on the job last year in the United States. We’re all focused on reducing that number to zero. We have conducted extensive accident analysis and implemented changes in policies and practices.  We have learned a lot from studying what has gone wrong.  But, we need to remember that as tragic as serious injuries and fatalities are for all involved, we have also safely worked hundreds of millions of hours.

We can and should learn as much from safe performance as we learn from what has gone wrong.

I’ve found it is harder to learn from successes because we take for granted the wisdom we have acquired over the years.  We don’t know what we know.  Psychologists call this hard to share know-how, tacit knowledge. They call easy to share know-how, explicit knowledge.

Rick Bush has a buddy – Frank Kinnan - who describes explicit knowledge as knowledge that we can easily classify into categories and facts.  It is what you see in manuals, specifications, and procedures.  Looks a lot like an existing training program or documented work procedures.

He describes tacit knowledge as insights that we have yet to categorize, but are nonetheless very valuable.  This knowledge takes the form of insights, intuitions and hunches and it guides the actions we take, drives our commitments and ideals, and is revealed in our values and demeanor. This currently undocumented wisdom is a critical component of what we use to work safely.

A critical part of learning is to mine insights from those with great wisdom. If we are to cope with extensive retirement-related turnover and increasing system complexity, we need to become more intentional about capturing tacit knowledge from senior folks and converting it to explicit knowledge, such that it can be used by those with less experience.  This process is appropriately labelled “externalization.”   

We often share our knowledge through stories. Sometimes stories are welcome and sometimes they are not, but it is certainly in our interest to learn to extract “wisdom nuggets” from others. I remember a test technician telling me that electrons want to “return home” through the substation ground grid when a 12kV line faults six miles from the substation.  In fact, the current flowing from the earth to the transformer neutral is what allows the ground relay to detect difference between the phases and trip.  Took him several times to talk me into it, but the returning home part will stick with me forever.

What precipitated this story?  While responding to a lock out as a new substation operator, I came across the fire department standing by a downed conductor that was still energized.  The conductor was arcing and dancing on the asphalt, like a welder unable to draw a bead. Why didn’t the breaker trip?  In fact, the locked-out circuit of course tripped, but the circuit with the downed conductor laying in the street did not. Suffice it to say the test technician carefully thought through what he knew and put it into terms that I could understand.

T&D World wants to help with this industry-wide challenge.  We want to help kick start this process by asking you questions about your approach.  The questions will follow in succeeding issues, as well as at different events, such as the lineman’s rodeo in the Fall. We’ll then begin to share and collect this information in a manner that others find helpful. 

What do you have to contribute? I’m sitting right here at my desk. Ping me with an e-mail at [email protected]. Let’s start a dialog and take actions to assure we never reach the number 66 again.



TAGS: Safety
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