Locked Out

As I’ve mentioned, not only am I fascinated by disasters and their root causes and how we react, I’m also fascinated by how we take steps to prevent them.  In my book IT Disaster Response: Lessons Learned in the Field I discuss the idea of blue-flagging on railroads.  The important concepts were two-fold: 1) a method of indicating that the train should not be moved and 2) controls on who could remove that indication.

During my recent power outage, I came across something similar.  It should be the featured image for this article.  It’s basically an orange flag locked to a utility pole.  Note the key word there, locked.

The photo doesn’t show the fact that this utility pole contained circuit breakers (I believe that’s the proper term in this context) for the overhead power lines. They had been tripped as a result of a tree further down the road taking out all three supply lines.

Close up of orange flag on utility pole, along with tag with lock-out information

Close-up with tag and flag.

So let’s analyze this a bit:

The orange flag itself was VERY visible. This ensures any other crews that might be in the area that there is something they need to notice.

There is a tag with detailed information. It’s hard to see in the above photo, but it includes who tagged it, the location, and date and some other information.

What’s not clear, is it’s padlocked to the pole.

Now, to be clear, this is NOT a physical lock-out like you see on some power panels (i.e. where the padlock physically prevents the circuit-breaker from being opened or closed).

In this case, a physical lock-out would most likely have to be placed 30′ in the air at the top of the pole where it wouldn’t be easily noticed.

But that said, this served its purpose. It alerted other crews to a danger in the area and presumably can only be removed by the person who put it there. And it contains information on that person so they can be reached if there are questions.

Since power was restored within 1 hour and I didn’t hear of any reports of line worker getting electrocuted, this appears to have worked.

Today’s take-away: when you have a change from the normal state of operation, what steps can you take to ensure that others don’t try to return items to a normal state of operations without confirming things first? By the way, for a good read-up on how bad things can go when intentions about a non-standard mode of operation don’t get properly communicated, I recommend reading up on the events leading up to the Chernobyl disaster.

Procedures are important. Deviating from them can have serious consequences. Do what you can to minimize the possibility of deviations.

 

3 thoughts on “Locked Out

  1. “Procedures are important. Deviating from them can have serious consequences. Do what you can to minimize the possibility of deviations.”

    I have to say I’m not entirely comfortable with that statement. Yeah, there are some procedures (such as tag outs and lock outs) that should NEVER be deviated from… But procedures can also become straightjackets. Or worse yet, crutches – “the accident wasn’t my fault, I was following procedures!”

    Procedural compliance is no substitute for educated operators and alert and intelligent operations.

    FWIW, when I was in the Navy we had a wide range of procedural compliance levels for different procedures… They ranged from “OK, at least have the book containing the procedure out at the console” to “Thou shalt not deviate from this procedure or it’s prerequisites, or it’s tools and materials list, by even the slightest amount”.

    • Thanks. I think you’re very right Procedures have a place and knowing WHY and the impact of violating them or NOT violating them is a critical skill.

      More so, if I can remember in a week, I may try to write a more nuanced post on this topic. There’s actually a lot to unpack here.

  2. Pingback: Failure is Required | greenmountainsoftware

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