About the Author xvii Foreword xix Preface xxiii Acknowledgments xxvii Introduction xxix 1 The Lens of System Safety 1 Demonstrated Performance 6 Demonstrating Results in Moving Beyond Compliance 6 A Task Example 7 Crosstalk: Questions for Thought and Discussion 9 Further Reading 10 2 What We Can Learn from a Nuclear Mishap 13 Before Regulations and Standards 13 Learning from System Safety 14 A Culture of Compliance 16 Applying Systems Safety Concepts 17 An Evolution in Safety Management 17 Outside the United States 17 The UK Leaps Forward 18 The NIOSH Prevention Through Design National Initiative 18 The DuPont Company 19 Signaling a Shift from Compliance Only to Include Risk-Based Safety Management 20 Conclusion and Recommendations 21 Crosstalk: Questions for Discussion 22 Further Reading 22 3 The Limitations of a Compliance-Based Safety Culture 25 Introduction 25 Comparing the United States to Other Countries 25 Low Frequency/High Consequence 26 Addressing Residual Risk 26 Applying Critical Thinking 29 An Unintentional Oversight - Nonelectrical Workers 34 Crosstalk: Questions for Discussion 39 Reference 40 Further Reading 40 4 A Case History of Breakthrough Performance 43 Introduction 43 A Strategy for Change 43 Understand the Business Consequences 45 Engage All Employees 46 Stimulate Near-Miss Reporting 46 Apply Quality Improvement Model - Plan-Do- Check-Act 48 Build Networks 48 Challenge Accepted Practices 49 Improve Collaboration Among Management, Electrical Experts, and Safety Professionals 50 Use Standards as Tools 51 Promote PtD 51 Address Life Cycle: Design, Construct, Operate, Maintain, Dismantle 52 A Shift in Safety Management Mindset 52 Low-Frequency/High-Consequence Injuries 52 The Heinrich Accident Triangle 53 A New Model - The Safety Risk Pyramid 57 Crosstalk: Questions for Discussion 58 Reference 59 Further Reading 59 5 Our Electrical World 61 All Workers Have Risk for Exposure 63 Implications 64 Exposure Scenarios 66 Assessing What Workers Are Included in Your Program 67 Crosstalk: Questions for Discussion 69 Further Reading 69 6 Collateral Injuries, Consequences, and Benefits 71 Introduction 71 Operational Excellence 71 Electrical Mishaps and Collateral Consequences 72 Incidents Gleaned From Newspaper Accounts and Incident Reports 74 Loss of Normal and Backup Electric Power 74 Missing Grounding and Bonding in a Railcar Unloading Station 75 Six-Hour Outage in San Francisco Bay Area 76 Millions in Northeast Without Power 76 Delmarva Peninsula Blackout 76 Hospital Power Outage 76 Chlorine Release due to Power Outage 77 Impact on Operations Requiring High Reliability of Electrical Systems 77 Technology 78 Personnel 79 Facilities 80 Occupational Safety and Health Management Systems 81 Synergy and Optimization 82 Contractor Safety Management 82 Incident Investigations 82 Design Reviews 83 Inherently Safer Technology and Designs 83 Process Heat Tracing 83 Grounding, Bonding, and Lightning Protection 83 Electric Utility and Backup Power Reliability Improvement 83 Auditing Processes 83 Drawings and Documentation 84 Hazard Analysis 84 Emergency Response Planning 84 Procedures for Shutdown and Restart 84 Crosstalk: Questions for Thought and Discussion 84 Further Reading 85 7 The Value of Vulnerability 87 Introduction 87 Perceived Vulnerability 88 Where Does Electrical Safety Begin? 90 Likelihood 91 A Look at Theory 93 Risk Perceptions Are Primarily Feeling Based 95 The Role of Stories 96 Presenting Narratives 97 Crosstalk: Questions for Discussion 98 References 98 Further Reading 98 8 Safety Management Systems 101 Core Elements of OSHMS Standards 102 Management Leadership 102 Worker Participation 103 Hazard Identification and Assessment 103 Risk Control 104 Education and Training 105 Program Evaluation and Improvement 106 Overcoming Barriers for Small Organizations 109 The Hierarchy of Controls 110 Elimination 112 Substitution 112 Warnings 113 Administrative Controls 113 Personal Protective Equipment 114 A Challenge to Electrical Safety Experts 114 Crosstalk: Questions for Discussion 116 Further Reading 117 9 Prevention Through Design 119 The Value of Prevention 119 Safety at the System Level 121 Risk Assessment and Control 122 Risk Treatment or Control 123 Residual Risk 125 Prevention Through Design 126 The System Life Cycle 127 "Other" Workers 129 A Special Case: Construction 130 Learning from Other Countries 130 Opportunities 131 Barriers in Construction 132 The Financial Burden 133 Crosstalk: Questions for Discussion 135 Further Reading 135 10 The Intersection of Safety and Reliability 139 A New Era in Electrical Safety 140 Maintenance and Reliability Management Systems 141 Maintenance Systems 142 Reliability - An Improvement Process 143 Differentiating Equipment Critical to Personnel Safety 144 Electrical Safety Critical Maintenance 144 Electrical Safety Dependent Maintenance 144 Inherently Safer Maintenance Technologies 145 Remote Racking 145 Remote Operation 146 Remote Monitoring 147 Smart Substations and Motor Control Centers 148 IR View Ports and Viewing Panes 148 Insulating Oil Monitoring 149 Partial Discharge Analysis 149 Temporarily Reduced Protection Settings 150 Online Temperature Monitoring 150 Other Opportunities 150 Crosstalk: Questions for Discussion 152 Further Reading 152 11 Residual Risk and the Psychology of Lower Order Controls 155 Power of Risk Assessment 158 Risk Assessment and Hierarchy of Controls: An Application Example 159 Human Performance Limitations of Lower Order Controls 161 Human Performance: Attention as a Limitation of Lower Order Controls 161 What Is Attention? 162 Limited Resources: The Defining Feature of Attention 162 Sustained Attention 162 Inattentional Blindness 163 Advancing Risk Assessment 164 Factors of Attention 164 Crosstalk: Questions for Discussion 164 References 165 Further Reading 165 12 Measure What You Need to Manage 167 Lagging and Leading Metrics 167 TRIR is Misleading 168 Challenging the Norm 169 Work Safe Alberta 170 American Society of Safety Professionals 170 National Safety Council 170 US Occupational Safety and Health Administration 171 Center for Chemical Process Safety 171 Hard Risk and Soft Risk 172 Crosstalk: Questions for Discussion 174 Further Reading 175 13 End Game 177 Cultural Drift 178 High-Profile Example of Cultural Drift 180 Underlying Cultural Drift 180 Psychology of Risk in Cultural Drift 181 Our Mental Calculators: Two Methods of Processing Risk 181 The Availability Heuristic: Making Decisions Based on What Comes to Mind 182 Understanding Risk: Feelings as Input 182 Instilling Vulnerability to Counter Cultural Drift 183 "It Could Be Me" 184 What You Can Do 185 There Is No End 187 Crosstalk: Questions for Discussion 188 References 189 Further Reading 189 Appendix Occupational Electrical Injury and Fatality Statistics 193 2011-2022 Data Summary 194 Occupations Having the Most Electrical Fatalities in the United States, 2011-2023 196 Top Causes of Occupational Electrical Fatalities in the United States, 2011-2023 197 2003-2010 Data Summary 197 Electrical Safety Then and Now 1992-2010 198 Twenty Years of Electrical Injury Data Shows Substantial Electrical Safety Improvement 198 Index 203.