Michael Davis' Commentary on "Dealing with a Costly Error"
Author(s):
Michael Davis
This is a complicated case. But the underlying theme seems
to be what to do with potentially useful information. So, it is
worth pointing out right away that most large organizations
under-use information, especially information generated near
the "bottom." They don't do this intentionally but by creating
an atmosphere in which information does not move to where it is
needed. Employees see problems but don't report them because
(in Rick Duffy's words) "it's somebody else's concern" or
because they suppose (again in Duffy's words) "[the company
doesn't] want to put out the money to change it."
Most companies should do more to ensure that the higher-ups
get the information available to those at the bottom. The
Japanese are better at that than we are. Our larger companies
are only now beginning to adopt such Japanese practices as
"quality circles." But even the Japanese could do more.
New to the job, Carl Lawrence, engineer, is an important
resource. He is looking at the plant with new eyes. He might
well pick up things invisible to those used to things as they
are. He won't be able to do that for long. Kevin Rourke, the
plant manager, should ask him for suggestions. But, even if
Rourke does not, Lawrence should tell Rourke what is bothering
him abut the caustic distribution system. He should, of course,
do this with due modesty. He has a lot to learn. There might be
a good reason for the difference between the acid distribution
system and the caustic distribution system. Still, part of
being a good engineer is seeing ways to improve exiting
systems. Lawrence has seen something, or at least thinks he
has. He owes it to his employer to pass that information
along.
The problem Lawrence faces several months later again
concerns information. He forgot that no one was working during
the early afternoon on the side of the building where the C-2
valve was. Whether or not he was to blame for forgetting that,
the fact that he forgot is important. Perhaps his forgetting
shows a need for an automatic shut-off valve or, at least, for
a written procedure, including a checklist, for handling
emergencies like the one that just occurred. Everyone makes
mistakes; the smart ones learn from them. The company will
learn less from this one if Lawrence does not report what he
did wrong. That is why, according to NSPE Code III.1, engineers
are supposed to "admit and accept their own errors when proven
wrong and refrain from distorting or altering the facts in an
attempt to justify their decision."
Lawrence should be slower about identifying Duffy as
responsible for leaving the valve open. A manager who blames
his subordinates is like the carpenter who blames his tools.
Rourke will press Lawrence if he thinks who left the valve open
is important. But, even if Rourke does not press him, Lawrence
will have to decide whether Duffy's part was important. If
Duffy's conduct was extraordinary, something unlikely ever to
happen again, there is no need to consider changing the
physical plant. Duffy was the problem. If, however, Duffy's
conduct was not all that unusual, this was an accident waiting
to happen. The plant, or its procedures, is the problem.
If Duffy's conduct was important, Lawrence probably should
tell Rourke the whole story while withholding Duffy's name.
Rourke can demand Duffy's name if he wants it. In the meantime,
the etiquette of protecting subordinates will have been
observed. If, however, Duffy's part was incidental, Lawrence
should simply say so: "It could have been anyone. I'd just as
soon not say who it was."
Of course, Lawrence's connection with Duffy makes the
decision harder. Duffy is not just another employee. He is more
like a friend. So, Lawrence has a conflict of interest. His
judgment may favor Duffy in a way it would not favor just
anyone he supervises. He should tell Rourke that too. Hearing
that, Rourke may not be so inclined to rely on Lawrence's
judgment concerning Duffy. His not relying on Lawrence's
judgment does not necessarily mean Rourke will fire Duffy. We
have no reason to suppose that Rourke's heart is made of stone.
But should he decide to fire Duffy, knowing Duffy and Lawrence
are close should make Rourke less inclined to assign Lawrence
the painful job of delivering the bad news.
Rourke's doubts about reporting the caustic spill differs
little from Lawrence's doubts about reportingwhat he knows to
Rourke. True, the information Rourke has is needed by the water
treatment works rather than by someone inside the company. The
organization having trouble using the information available to
some of its members is society as a whole. Where does Rourke's
ultimate loyalty lie? For an engineer, there is only one
answer, with the public. An engineer is, as such, committed to
"hold paramount the safety, health, and welfare of the public
in performance of his professional duties." (NSPE Code II.1)
Rourke, an engineer acting in his professional capacity, can
prevent serious harm to a public facility, harm for which the
plant he runs would be responsible. He certainly should notify
the waste treatment works about the caustic waste headed its
way, and he should be as candid as necessary to prevent the
harm that would otherwise occur.
Protecting the public interest in these circumstances will
probably serve Rourke's employer as well. The public tends to
make life miserable for businesses that don't pay enough
attention to the public interest. But engineers do not hold the
public safety, health, and welfare paramount for that reason
(or, at least, for that reason alone). Individuals organize
into professions in part to protect themselves from being
pressured into doing what they do not want to do. There is
strength in a common code of conduct. Engineers, whose
knowledge gives them the power to do the public great harm,
have agreed to make the public interest paramount to assure
that they will not be forced to harm the public. Each engineer
can say, "If you didn't want the problem handled in this way,
why did you want an engineer for the job?"
What should Lawrence do when someone considering Duffy for a
job calls, quotes Lawrence's letter of reference, and asks
whether he has omitted any negatives? Here again one person has
information that would be useful to another. Here, however, we
also have concerns about deception and about confidentiality,
both Duffy's and the company's. What should Lawrence say?
I don't think he can honestly say there are no negatives.
Causing a significant chemical spill (with thousands of dollars
in losses) is a negative in anyone's book. That negative is,
however, not necessarily decisive, and the full story is not
that damaging to Duffy. He clearly understood he had done
wrong. He did not lie about it. He was repentant. He might now
be a safer worker than someone who had never seen how much harm
his carelessness can do. Why not tell Duffy's prospective
employer the whole story? The story will do Emerson Chemical no
harm (assuming it behaved properly). Duffy might still get the
job. And, if he does, he will not get it under false
pretenses.
Unfortunately, Lawrence probably cannot tell the full story
without getting Emerson Chemical's permission. Insofar as
Lawrence will be telling more than the media have already
reported, he will be revealing confidential information. An
engineer should not "disclose confidential information
concerning the business affairs or technical processes of any
present or former client or employer without his consent."
(NSPE Code III.4) By preserving the confidences of their
employers, engineers make it easier for their employers to
share information with them and so, easier for them to do a
good job. Lawrence should probably tell his caller something
like this: "I can't talk now. I'll call you back in an hour or
so." He can then get clearance from whoever has authority to
give it.
Telling Duffy's potential employer a "white lie" is not a
justified (or even excusable) alternative to this cumbersome
process. Duffy has no right to expect Lawrence to lie for him.
And, under the circumstances, it is hard to see how such a lie
could be morally justified or excused. Such a lie would
therefore be a violation of an engineer's professional
obligations as well. Being morally inexcusable, such a lie
would amount to "conduct...likely to discredit the profession"
(NSPE Code III.3) and fall well short of "the highest standards
of integrity" (NSPE Code III.1).
Nurrevo has no more right to expect Andrea Smith to lie for
it than Duffy had to expect Lawrence to lie for him. But that
is not what Nurrevo is asking of Smith. Once Nurrevo learned
that Rourke's action would take care of both spills, it also
knew that the public interest was no longer at stake. The only
question was who would pay for the disaster for which Nurrevo
was a responsible as Emerson Chemical. There is, strictly
speaking, no "cover-up". Nurrevo has not denied its
responsibility. It has said nothing. Nurrevo is asking Smith to
keep this dirty secret. Smith owes her employer that much.
(NSPE Code III.4)
That is not to say all is well at Nurrevo. There is a good
chance that Fred Barnes did not tell his superiors about the
problem, that Nurrevo is developing a collection of dirty
secrets, and that those secrets will soon be numerous enough to
make everyone fearful of open communication. Nurrevo will not
be a pleasant place to work. If I were Smith, I would start
looking for another job.