Wade L. Robison's Commentary on "Dealing with a Costly Error"
Author(s):
Wade L. Robison
I
If Carl Lawrence is supervisor of the caustic as well as the
acid distribution system, then he ought to talk with the plant
manager, Kevin Rourke, about why the two systems are different.
The main point of the talk ought to be to determine if the
caustic system as is safe as it can be, given the differences.
It is often easier, as an outsider, to notice differences that
might make a difference than it is for someone who has become
so familiar with things that he or she no longer notices the
details. Too much familiarity may bred not only contempt, but
indifference.
But an additional area of concern for Carl is whether there
are any written procedures for filling the tanks. If these are
standard, they should be. Even if they are not standard
normally, but are standard for the acid system, then they
should be. For the operating principle here ought to be that
distinctions ought not to be made between the two systems
without reasons, based on safety, for the differences. The more
differences there are, the harder it is to teach those
responsible for operating the system about them and the harder
it is to make sure that everyone does in a regular way exactly
what ought to be done. Establishing a similar set of procedures
for both systems has a safety advantage, that is, in making it
easier to train those working with the systems, since they will
need to learn only one set of procedures, not two, and in
making it easier for those using the systems, since they will
need to remember only one set of procedures for both, not
doublecheck each time they work on each to make sure that they
are following the right set of procedures.
That Rick has no problems with the setup, after working
there for four years, is some sign that it may not be a serious
problem. Carl knows Rick, but not enough about Rick to know how
good a judge he is of the safety issues involved. So what Rick
says has to be taken with a grain of salt: one worker has not
had any difficulties.
II
Carl should tell Kevin Rourke that he has located the
problem, that it is now solved, and that he is going to have to
look and see what can be done to prevent a reoccurrence. He
should certainly acknowledge responsibility for failing to have
C-2 checked earlier. He should also make it clear that what is
needed is some way to make sure that such failures as his
failure to remember that no one was on duty in that section do
not occur again.
Identifying Rick as the one who left the valve open is
another question. First, Carl does not know that Rick left it
open. What he knows is that Rick was assigned that section the
previous shift and that no one was assigned it afterwards. He
may infer that Rick left the valve open, but though Rick does
not remember turning it off, he--Rick--also says, "I can't
believe I forgot to turn it off!" For all Carl can know,
someone else may have come in and turned it on after Rick
turned it off.
Second, even if Rick left it open, it looks as though the
caustic distribution system was waiting for a disaster to
occur. If we leave doors open when we have pets, the pets are
bound to get out sometime or other; if we fail to close cabinet
doors when we open them, someone is bound to run into one
sooner or later. Similarly, if we have a system which has no
fail-safe mechanism so that if a mistake is made, it will
automatically correct itself, then accidents are bound to
occur. No doubt the person who causes the accident is
responsible to some extent. One can tell the person who runs
into the cabinet door to watch where they are going. But to
hold that person strictly liable ignores what features of the
system conspire to make such an accident easy.
So it is not obvious that Rick can be properly blamed here.
One does not have enough evidence to convict him in a court of
law, for instance, and so one has room for doubt. And, in
addition, one has to hold the system partly accountable for
making that kind of an accident easy.
So identifying Rick as the one who left the valve open is
probably a mistake. The most that Carl ought to say, if asked,
is that Rich had the previous shift in that section and that
the whole thing needs to be investigated.
III
Kevin should notify those at the wastewater treatment works
that some caustic waste had been released, that he is not sure
how much because he is not sure when the valve was left open,
but that he will deliver enough acid to counter whatever high
pH count the caustic waste might cause.
Since the wastewater treatment plant's pH meter is out of
service, he should offer to supply one from the company if he
has one and can spare it. Without such an offer, the offer of
as much acid as necessary is without much substance: the plant
will not be able to tell how much is needed.
Kevin ought to do these things just because it is the right
thing to do: if the caustic acid were to overwhelm the
organisms that such wastewater treatment plants use, then
effectively untreated waste would be discharged into the water
system of those who depend upon the waste treatment plant to
provide them with clean water. And they would be harmed by
having contaminated water. So Kevin owes an obligation to those
people to make sure that his company does not cause the
wastewater treatment plant to harm those who depend upon
it.
But there are also very practical reasons for notifying the
plant, delivering acid, and so on. There cannot be many plants
about that could cause such problems for a wastewater treatment
plant, and if something does occur, it is highly likely that
the authorities will trace the problem to the company. So the
company will get a bad name for polluting the city's water
supply and not doing anything to prevent the pollution when it
knew that something could be done, and, in addition, it is
likely to be sued by citizens and by the city. So its
reputation will be harmed, it will be suspected when future
incidents occur, and it may have to pay legal costs both to
protect itself and to pay damages should those who sue win.
IV
I think that Kevin Rourke did the right thing--despite the
costs. The local citizens were spared potential harm to their
health through polluted wastewater not properly treated by the
plant. The owners and stockholders of Emerson gained the credit
of being associated with a company that takes responsibility
for its mistakes and tries to correct them, and they also
probably saved money since the $60,000 plus (for modifications
to the caustic distribution system, and more for the several
hundred gallons of wasted caustic, and so on) is likely to be
less than the lost to the company from paying lawyers to defend
it against law suits, some of which they might well lose. In
addition, one can argue that nothing is of more value to a
company than its good name. Lose the name and one effectively
loses sales that one cannot measure. One will not know how many
would have purchased products from the company but for its bad
name. So keeping its good name for $60,000 plus is a
bargain.
From the standpoint of the wastewater treatment plant,
Emerson becomes a good neighbor, one willing to let them know
when they may have problems because of something that has
happened at the plant. So the plant can be somewhat less
vigilant and concerned about Emerson's discharges than it might
otherwise be. Emerson's action may put it at a short-term
competitive disadvantage vis-a-vis any other similar firms in
the area that may make the same products and discharge similar
wastes, but the disadvantage is for the short-term only. Any
other such firm would be at a competitive advantage only if
they released waste and did not bother to help clean it up, but
then such a firm would face the same problem that they are
likely to be tracked down--and have to pay lawyers, citizens,
and the city--and so suffer long-term losses.
V
If Rick Duffy was negligent, Carl should reprimand him. But
he should not fire him. There was no rule for what would happen
if someone left open the caustic valve. So to penalize Rich for
doing that would be to make him subject to a rule that could
only come into existence after his failure. That would be
unfair. In addition, Carl himself thought there might be a
problem with the caustic system, and, as the story has
unfolded, he clearly failed to do anything to make it any
safer. So he has to share part of the blame here for allowing a
system to continue in which such accidents could so easily
occur.
The friendship between Carl and Rick is irrelevant here. If
we are to assume that Rick was negligent and so deserves some
sort of reprimand, Carl cannot rescind the reprimand, or lessen
its severity, out of any friendship to Rick. That would be
unfair to any others who might be similarly reprimanded, but
have the bad luck not to be friends with the supervisor.
VI
Kevin rightly should be concerned. It is puzzling that he
himself had not paid any attention to the differences in the
two systems and to whether those differences might not cause
problems for the plant, but, then, he might respond that is why
he hires people like Carl. It is their job, not his, to tell
him what the problems are. So he needs to talk to Carl to ask
him why nothing was said about the sorts of problems that might
come up, to determine what Carl now thinks ought to be done to
prevent similar occurrences in the future, and to encourage
Carl to talk to him in the future about whatever problems he
considers important.
What seems missing in this situation is an open exchange of
views between Carl and Kevin, the sort of "Why is this done
this way?" and "I'm not sure, but let's figure it out" that may
require a change in both Kevin and Carl. Kevin ought to ask
himself what it is about him, or the structure of organization
in the plant, that would account for Carl's not coming to him
about the problem, and he needs to ask Carl what could be done
to improve communication between the two of them. If one solves
problems by dialogue, one needs to make sure that the
conditions that make dialogue possible exist.
VII
Carl in fact does not know for sure that Rick left the valve
open, though the evidence certainly points that way, and as has
been said, he has to bear part of the responsibility for not
pursuing the matter to begin with to change the system so such
accidents were less likely to happen. And he ought to tell
Kevin that. Firing Rick is not the place to start. They should
start by figuring out how to change the system so that if
someone forgets to do something, as is bound to happen, nothing
untoward occurs. And Carl ought to tell Kevin that as well.
It is also unclear, even if Rick were responsible, that it
is appropriate to fire someone for one mistake if, as seems the
case here, the past work record is not only clear of any
mistakes, but more than adequate. We all make mistakes, and if
one mistake were enough to justify firing us, we would no doubt
all have been fired from more than one job by now. What is
required for such action is a pattern of irresponsibility or
stupidity. The pattern need not be of great duration to justify
firing in some cases, but it is hard to imagine a situation
where a single mistake would be enough to justify firing. Kevin
is acting out of anger here, and if he were to apply the
principle he is adopting to his own situation, he would find
that he should be fired too: after all, he made the mistake of
not checking the caustic acid system to be sure that it would
not cause problems.
VIII
Carl should say that he is sorry to see Rick forced to leave
in such a way and that of course he will write a letter of
recommendation. In the letter, there is no need to mention what
he suspects Rick did regarding the valve. Again, it is an issue
of what standards we are to hold people to. If Carl were to
hold Rick to the standard of never making a mistake, then no
one would ever get a letter of recommendation from Carl, Carl
included. What is important is whether the mistake is part of a
pattern of Carl's behavior, or whether it is explicable in such
a way that would explain his apparently exemplary work for the
four years he worked at the plant. And given Carl's going to
school, having a wife who is pregnant, and holding down a
full-time job, such a mistake is explicable. That is, it is
understandable that someone who is otherwise fully competent
and responsible might, under such circumstances, make a
mistake. One should not make a judgment about their character,
or their capacity to work well, based on that one mistake, but
on their basic competence and sense of responsibility.
Of course, one could judge here that Rick is not quite as
responsible as he should be. When initially asked about the
caustic system, his response was that though he did not have
any problems with it, "that's somebody else's concern, not
mine." He thus indicated that he was not willing to initiate
any act that called for responsibility over matters not
obviously of direct concern to him. So if Carl is going to
write a letter of recommendation, he should take that initial
response into account--just as he should take into account any
of Rick's actions that might tell on his character.
The bottom line here is thus that he should mention Rick's
apparent mistake only if it is indicative of his character,
that from what we know it evidently is not, and that therefore
he should not mention it.
IX
If he should not mention the apparent mistake in a letter,
he should not mention it over the phone either. The principle
is not that one should never say on the phone what was is
unwilling to write, but that one should never say on the phone
what one had good reasons not to write. Carl had good reasons
for not mentioning the apparent mistake in his letter of
recommendation, and those good reasons have not changed because
the person receiving it has called.
X
Nurrevo ought to inform the wastewater treatment plant of
its accident for just the reasons given above for Emerson's
informing the plant of its accident. Among other things, it is
difficult to keep such things quiet, and should information
about the accident get out, Nurrevo would not only have the
sorts of problems Pro-Growth would have had, but also the
additional problem that people would think that it was trying
to piggyback on Emerson's accident--taking advantage of their
accident and trying to make it look as though the magnitude of
the problem, whatever that was, was entirely Emerson's fault.
It is wrong to cheat, and it is even worse to cheat and allow
someone else to take the blame for one's cheating.
XI
We find ourselves in many moral problems because we
neglected to do something early enough on in a process: a
mistake early on sets up a moral complication. Here Andrea
should not have accepted, at his word, her superior's remark
that Andrea did not have to take care of the problem because
"it's all taken care of." She no doubt assumed that he had
called the wastewater treatment plant, but she ought to have
checked. That would have forced him either to lie to her or to
explain to her, as he later did, that Nurrevo was piggybacking
on Emerson's problems. She should then have given to Fred
Barnes all the reasons we have already given in regard to
Emerson's informing the wastewater treatment plant. That is,
she should have initiated a discussion with him about what they
ought to do, making it clear to him what her concerns were and
putting him in a position where he would have to articulate his
reasons for doing what he did.
She wonders how far up the organizational ladder she would
have to go to find someone who would listen to her concerns,
but she has to start with her superior and give him a chance.
That he acted as he did may only mean that he would act that
way when he has not thought about the issue much, and when he
thinks about it and considers Andrea's concerns, he may
reconsider his action.
So she must first give him a chance. After that, it will be
time enough to consider what else to do. Clearly, if the
reasons she thinks call for disclosure are as significant as
those we discussed earlier in regard to Emerson, and there is
no reason to think the reasons would be any different, then she
has an obligation to go further up the organizational ladder
should Fred Barnes not wish to pursue the matter. She also has
an obligation to tell him what she intends to do--after, of
course, they have talked it through and he has had a chance to
consider what ought to be done.
If it comes to that, he will feel pressured, and he will be
pressured, and that will no doubt create an awkward situation
for Andrea. But advancing within a company at the cost of
ignoring what is moral is not laudable. Her primary concern
ought to be able to figure out a way to make her point without
causing the kinds of ripples a confrontation might provoke. So
if she has to confront Fred, it ought to be low-key. "Is there
someone else I can talk to about this; I'm really feeling
uncomfortable about letting it rest here." Or, "Could we both
go to X [our superior] and see what he [or she] thinks about
this? I don't think either of us should have it on our heads if
the worse comes down."