Donald Chivens' Commentary on "Dealing with a Costly Error"
Author(s):
Donald Chivens
I. Getting Acquainted
After examining the facilities with lead operator Rick, Carl
astutely noticed the difference tween the safety features of
the acid and caustic distribution systems. Rick was unable to
explain the reason for the differences, which is not surprising
since he was an operator, not an engineer or manager. Since
Carl now had responsibility for these systems and since he had
recognized and questioned the safeguard differences, Carl
should have pursued this question with a superior, either plant
manager Kevin Rourke or an intermediate manager or plant
engineer.
II. A Problem
Carl has no alternative to acknowledging responsibility for
failing to have valve C-2 checked earlier, and he should
identify Rick as the one who left the valve open. Rick's
honesty should be noted here.
III. Taking Action
Kevin Rourke and Emerson have a responsibility to minimize
the damage caused by their accident, regardless of the
inability of the WTW to monitor or trace the spill. Damage
control would be most effective if WTW is given all known
information and uncertainties. It is interesting to note that
bureaucrats and watchdog environmental groups are sometimes so
anxious to "nail polluters" that honesty could be quite
costly--thus the temptation to be less than candid when
traceability is unlikely.
IV. Kevin Rourke's Response
Kevin Rourke certainly responded properly, in my opinion,
but his rationale is not admirable. His honest and prompt
response was based upon potentially much larger costs
associated with an unsuccessful cover-up, rather than holding
"paramount the safety, health and welfare of the public" (NSPE
Code of Ethics). Since both costs and the public welfare were
optimized by Kevin's decisions in this instance, Emerson
management and stockholders should view his actions positively.
One would hope that Kevin, the management, and the stockholders
would still view these actions as correct if the threat of
punishment for dishonesty were absent.
V. Rick Duffy
Rick Duffy was negligent, but there is a distinct difference
between making an error and consciously violating well-known
rules such as propping open a pump switch. Firing is not
warranted in my opinion in this case. Unless there was a prior
history of errors made by Rick, a formal reprimand would be
appropriate.
VI. Carl Lawrence
Although he realizes Carl was not necessarily negligent, but
he did not efficiently determine the problem, and he could have
brought the potential for this problem to Kevin's attention
when he first came to work for Emerson. Both of these factors
reflect upon Carl's job performance, but I would not view them
as grounds for taking actions against him. At a scheduled
performance review, both of the above factors should be noted
and discussed with Carl. There is always a gray area between
ordinary competence and negligence, while outstanding job
performance might well have gone unrecognized if it had
resulted in no spills occurring.
VII. Kevin Rourke Again
Kevin should indeed have a serious talk with Carl Lawrence.
His statement, "You have to tighten up your unit so that this
kind of thing never happens again," is appropriate. There are
many possibilities here for discussion regarding both
procedural changes and hardware safeguards. The subsequent
statement, "You can start by giving whoever left the valve open
his walking papers," does nothing to address the basic problem.
Carl should not cover up for Rick, but he should probably share
in the blame. Since the potentially dangerous situation
pre-dated Carl's employment, Kevin Rourke (and others) should
also share in the blame.
It could be appropriate to fire an employee for a conscious
violation of procedures, but to fire an employee for one
mistake is, in my opinion, a poor reaction, regardless of the
severity of the error. If Rick's years of service have been
reliable and error free, then given a second chance, he is
probably the least likely person to repeat such an error.
Kevin, Carl, Rick (and probably others involved) could together
create a plan to avoid the possibility of a repeat spill by
considering such items as:
- Create procedural changes whereby all critical valves
were checked by more than one operator.
- Consider hardware changes such as had been implemented on
the most heavily used tanks.
- Consider downstream sensor systems to give early warning
of failure.
VIII. Rick Duffy Again
Rick should not have had to quit, and he could even have
been encouraged to stay. Assuming that he does quit, his work
record appears to be quite good with the exception of this one
error. A carefully worded recommendation should reflect this
record and need not reference the details of any particular
incident. Carl could certainly agree to be a reference, and he
could give an honest (and quite good) recommendation for Rick.
This following type of statement might be appropriate:
Rick's generally outstanding performance as lead operator
suffered on isolated occasions under pressures from school and
family responsibilities.
IX. A Phone Call
Carl's recommendation letter should probably have made
reference to good but not flawless service, as mentioned above.
At the telephone call, he likewise should give an honest
overall impression of Rick's reliability. It is not necessary,
in my opinion, to give details of Rick's error to someone
outside of Emerson. Note that while Rick erroneously left open
a valve, the fault for the magnitude of the resulting damage
should be shared by others.
X. Another Company
Ethically, Nurrevo should inform WTW of its accident and
offer to share the clean-up costs. It seems unlikely that these
two spills would be so identical as to require precisely the
same cleaning procedure.
XI. Andrea Smith
Andrea's problem is that faced by all "whistle-blowers." She
is definitely endangering her career by circumventing her boss.
Without knowing the personalities involved and the
organizational structure, it is difficult to formulate her best
response.