‘Mindful’ Health & Safety Culture: Repetition Fatigue

When you least expect it…

A consulting team was asked to develop an effective lockout/tagout training program for an industry-wide oversight group. The industry had suffered a spike in lockout-related incidents, including several fatalities over a 12-month period. Before building a “here’s how you put a lock on a power switch” training program, the team asked for the opportunity to come in and study the issue a bit.

While there were many scenarios in the accident reports they read, and many possible causes identified by the focus groups of operators and maintenance folks they interviewed, one surprising common pattern did emerge. The most common incident scenario involved a skilled, experienced, high seniority maintenance technician on a routine maintenance job, or a familiar repair job, doing something he had done time and again. Throw in something a little out of the ordinary such as a fuse that won’t come out, a missing tool, a helper who is late for his shift, preoccupying problems at home and the situation becomes even riskier.

In fairness, there were some “new on the job… never seen this before… didn’t know what to do” type incidents, but they were the exception, not the rule. More often it was the guy you would least expect to be involved in an accident – the Class A electrician, best in the shop – doing something he knew full well how to do.