Misdirected Power

Posted September 13th, 2005

The error that caused the power outage in California was “misdirected power” by employees. A Wall Street Journal article quotes Kim Hughes, spokeswoman of the L.A. Department of Water and Power. The article says “employees … ‘misdirected power’ down lines” that could not bear the load, and protective relays tripped as designed. I love it when the public relations folks give their reports about disruptions caused by the errors and mistakes that occur in complex systems. I enjoy seeing terms like “misdirected power” in relation to the power company. Why can’t people just say things with clarity?

It is much better to use plain language, like the company website contains tonight:
The incident occurred at 12:32 p.m., when technicians inadvertently cut into “control” wires, sending a signal to the transmission system to begin shutting down automatically to protect the system from further damage. This protects customer and system power equipment from further damage.

As a person whose work the past five years was to prevent human error by individuals, groups, and an entire organization, the most important thing I learned was that it was important to state clearly and plainly when an error was made. Attempts to mask incidents with clever phrases are an example of misdirected power, even if the phrase is accurate.

The people with whom I worked learned to acknowledge when mistakes were made so the organization could learn from them. Acknowledgment includes taking responsibility for the causes and bad effects of the errors. Organizations that move from excuse making and blaming to individual and corporate accountability are well on the journey to being a highly reliable organization. That is the right direction for a power company, or any other company.

This entry was posted on Tuesday, September 13th, 2005 at 10:18 pm and is filed under In the News, Operational Excellence.