REDUCING human error is recognised in the power-generation industry as a key factor in improving energy availability, as well as reducing safety-related events. Achieving a sustainable culture change that leads to a reduction in human error during power plant operations and maintenance is a significant challenge to the power sector in general and to Eskom in particular.
Human error was the likely cause of an explosion at Medupi Power Station’s unit 4 generator on August 8. Eskom has announced that “the employees responsible for managing and executing intricate work at Medupi unit 4 of the power plant have been placed on precautionary suspension until results of an ongoing investigation are revealed”. According to Eskom, it appears there was a deviation from procedures when the turbo-generator was purged with carbon dioxide.
Commentators, including some in government circles, often consider significant events in the power generation sector that are caused by human error to be acts of sabotage or negligence. On December 29, 2020, Fin24 reported that in December 2019 President Cyril Ramaphosa cut short a foreign trip to announce that sabotage had contributed to severe power cuts. But the Hawks and the prosecuting authority closed the case, citing a “lack of evidence to validate the initial suspicion”.
In 2006, the then Minister of Public Enterprises, Alec Erwin, announced that a bolt that had been left in the generator after routine maintenance at Koeberg nuclear power station “did not get there by accident”. He said the police had identified suspects and arrests were imminent. “Let me be very clear on this. The bolt that caused the generator’s destruction did not get there by accident,” Erwin said.
Supporting Erwin, the then Minister of Minerals and Energy, Lindiwe Hendricks, stated that “other forces were at play”. Hendricks even went as far as to suggest that the bolt that had been left in the generator after routine maintenance could be linked to a fightback campaign against the government’s transformation drive.
Eskom own investigation has proved that both Erwin and Hendricks were wrong. Human error and not sabotage was the cause of the loose bolt that caused the generator failure at Koeberg in 2006. Ramaphosa was also wrong. Human error and not sabotage was the cause of the multiple-unit trips at Tutuka Power Station in December 2019. Those who are alleging acts of sabotage at Medupi’s unit 4 generator must calm down. Human error does not necessarily imply sabotage.
The current leadership at Eskom and in the government think they are in danger; hence, they continue to look for signs and threats of that danger. They do not appreciate any other evidence to the contrary. It is for this reason that they characterise human error at Eskom as acts of sabotage. This is delusional.
My experience in the power generation sector has taught me that mistakes will always be made. Further, there is a need for discipline where there is evidence of negligence or intentional violation of procedures and safety rules. In the same vein, there is sufficient data in the power generation sector that suggests that discipline administered to “set an example” always causes people to hide information and mistakes. Errors should not be hidden. It is preferable to learn from them.
My view is that Eskom has suspended the employees who were involved in the Medupi unit 4 incident to set an example and to be seen to be doing something by the public. This is unusual in the history of Eskom, and it is bound to fail.
Human errors fall into two major categories: unintended actions and intended or planning failures. Unintended actions are slips or lapses, and they are the major forms of error in the skills-based operating mode. Skills-based slips and lapses cannot be eliminated by simply asking people to try harder or by threatening them with arrest or suspension. Intended errors are mistakes (misinterpretations) or violations (wilful deviation from procedure). Mistakes are both in the rule- and knowledge-based operating modes.
The public does not know which one of the error mechanisms (slips, lapses, mistakes and wilful violations) is dominant at Eskom. I am convinced that the board of Eskom and its executive management do not know either. You cannot manage what you do not know. It is for this reason that there are so many repeat failures at Eskom. These repeat failures have led to a constrained electricity supply since 2018.
We stopped load shedding on August 8, 2015 until June 2018 because we managed the power system on the basis that Eskom’s engineers, technicians, artisans and operators behave rationally and perform very reliably except under a certain combination of plant conditions. These conditions are typically unusual or unfamiliar accident conditions.
We also understood the combined effects of performance-shaping factors in the context of human performance. We were totally focused on the causal relationship between the error mechanisms and the combined effects of the following performance-shaping factors: training, communication, supervision, staffing, human-system interface, organisational factors, stress and environmental conditions. We refrained from labelling our engineers, technicians, artisans and operators, who are undoubtedly Eskom’s most valued resource, as delinquents.
Most importantly, we built a high-performance culture based on meritocracy. We built it from the top. I used the card system. General managers would earn a blue card for exceeding performance expectations, or they would earn a green card for meeting performance expectations. A yellow card would be issued to general managers who failed to meet performance expectations. General managers who earned three yellow cards in a quarter would get a red card. A red card automatically meant 14 days’ suspension without pay. Three red cards in a year meant dismissal based on performance.
General managers who earned blue and green cards were rewarded handsomely. Some of them were even given permanent drivers to make them feel important. They had earned it because they stopped load shedding. The human resources director who is still at Eskom today did not want this performance management approach. She pushed back because she was not performance-driven. I did it anyway. The general managers liked it, and they supported it. It worked, and it produced the desired results. Most importantly, it stopped load shedding.
I conclude with a quote from Harry S. Truman: “No one who accomplished things could expect to avoid mistakes. Only those who did nothing made no mistakes.”
Matshela Koko is Eskom’s former interim group chief executive.