The event points to breakdowns in operational controls because required procedures, sketches, tie-point standards, and locating practices were not fully applied or verified before field work resumed. It also reflects gaps in safety assurance and contractor oversight, since existing controls such as procedure use, walk-through preparation, communication expectations, and repeat-back practices (aka.three-way communication) did not prevent confusion or damage to the underground service.

Description of event:

During a leak investigation initiated by a residential odor-of-gas notification, an employee damaged an underground gas service while bar holing. The most recent service card available, dated 1988, contained only a single tie-in point reference to identify the service location. The tie-in point was excessively long and did not clearly reference its origin (e.g., roadway, curb, sidewalk, or structure), making accurate field location difficult. Current standards and company’s best practices require a minimum of two clearly defined reference points for tie points to improve the accuracy and reliability of asset location. The investigation also determined that the service did not have a tracer wire installed, further limiting the ability to accurately locate the asset.

Key Causal Factors and Root Causes:

Primary Causal Factor: Procedure steps for detailing the service location was not utilized and followed correctly.

• Management System – SPAC Not Used – Enforcement NI
• Work Direction – Preparation – Walk-Thru NI

Causal Factor: Contracting crew was told their work was not going to be stopped/held up. Crew thought they were cleared to gas in main with the current gauge set up.

• Communications – No Comm. Or Not Timely – Late Communication
• Communications – Misunderstood Verbal Comm. – Repeat back not used
• “Stop Work Authority” policy and guidance was not adhered to.

Key Corrective Actions:

• Contractor conducted two safety stand-downs to reinforce the importance and requirement to follow Procedures.
• The Gas Construction policy was forwarded to the contractor, with additional communication emphasizing the importance of correctly following all Procedures.
• Tie-in Procedure requirements will be reviewed for future work to confirm continued compliance with Company Gas Construction policies. This will be reinforced internally through Contractor Oversight and externally through Contractor Management for distribution to the workforce.
• Leads/Supervisors will reinforce expectations with crews during HUB calls and on-site to ensure two-gauge points are installed and all SOP steps related to tie-in work are followed.
• Communication will be issued to crews and contractors reinforcing adherence to Procedures and confirming applicable sketches are available, reviewed, and followed in the field.
• Construction standards will be reviewed to identify and address any potential gaps related to gauge point requirements.
• Highlight in HUB meetings and communications the importance of clear and concise communication between workers, managers, supervisors, etc., when restarting work after a safety stop.
• Reinforce the importance of the “Repeat Back.” This gives both the workers and Supervisors/managers clarity of what is going on and eliminates potential confusion.

Key Lessons Learned:

• Make sure all Procedures are reviewed prior for your work/task and are always followed correctly.
• If any potential deviation of the Procedure is required, contact Gas Control to debrief and explain the situation.
• Be as clear and concise as possible when communicating regarding work stoppages and restarts. If there is uncertainty, do not restart work until confusion/issue is cleared up.
• Utilize the "Repeat Back" process to mitigate confusion or unclarity around any verbal direction or communications.
• Reenforce that EVERYONE has Stop Work Authority and where disagreement occurs, escalate the issue to clarify.

Supplemental Lessons Learned Focus

Three-Way Communication for Utility Workers

The purpose of effective communication is to ensure understanding between two or more people. It is an important defense in the prevention of errors that can result in incidents. While the effects of mishaps due to ineffective communication will differ, the unfortunate organization can find itself facing legal, regulatory and financial consequences, and its people dealing with a significant emotional event as a result of a lost teammate.

Many industries have established protocols for effective communication. For example, in the medical field, 66 percent of all sentinel events reported from 1995 to 2005 were related to ineffective communication, according to The Joint Commission, a nonprofit that accredits and certifies nearly 21,000 U.S. health care organizations and programs. The commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” To help combat this issue, organizations in the medical field have begun requiring their employees to engage in a repeat-back process when information is verbally communicated to them. This is because, in general, verbal communication presents a much greater risk for misunderstandings than written communication.

How Does Three-Way Communication Work?

The repeat-back process – sometimes referred to as three-way communication – is also used in the electrical and gas utility industry, typically in situations when workers are not face to face and must talk to each other via radio, telephone or similar technology. If your organization hasn’t already implemented this form of communication, safety managers should strongly consider doing so in the near future. By making the tool part of the fabric of your communication culture, employees can help to prevent the undesirable consequences that may result if an important message is not accurately transmitted or received.

Tool Usage and At-Risk Practices

So, when should you use three-way communication?

There are an infinite number of situations in which it is applicable, including during task assignments that impact equipment or activities, the safety of personnel, the environment or the electrical grid. For instance, it is ideal for workers to use the repeat-back process during switching activities, when communicating the conditions of equipment, when communicating the value of an important rule, and during operation or alteration of equipment.

Be aware, however, that although three-way communication is an excellent, highly effective tool that can reduce the possibility of an incident occurring on a job site, there can also be risks associated with its use, such as:

• The sender stating too much information or multiple actions in one message. Messages should be kept concise and focus on one action or task at a time.
• The sender not providing enough information for the receiver to understand the message.
• The sender not verifying that the receiver clearly understands the message. Verification is critical to the repeat-back process.
• The sender using the word “incorrect.” Because “incorrect” contains the word “correct,” use of either term may confuse the receiver if he or she is having a hard time understanding the sender. It is better to use the words “right” and “wrong” – or similar words or phrases – than “correct” and “incorrect.”
• The receiver failing to ask for clarification of the message, if needed.
• The receiver taking action before the repeat-back process is complete.
• The receiver being mentally preoccupied with another task.

Adopted from an article written by Rey Gonzalez May 20, 2016 posted in Tailgate Topics published by Incident Prevention