Dealing with a Costly Error
originally titled: On The
Job
I. Getting Acquainted
Carl Lawrence was somewhat nervous on his first day at work.
Although a very good student, he had relatively little
practical experience in engineering. Yet, here he was,
supervisor of several acid and caustic distribution systems.
Plant manager, Kevin Rourke, gave Carl a tour of the facilities
and introduced him to the workers he would be supervising. Carl
was pleasantly surprised when he was introduced to Rick Duffy.
Rick and Carl's older brother were best friends in junior high
school, and Carl had always liked Rick.
Rick moved had away from Emerson City in the 10th grade, and
the Lawrence family lost track of him. Rick told Carl that he
went into the service right after high school. After that he
returned to Emerson City to take a job at Emerson Chemical as a
lead operator. Now married with two small children, Rick is
anxious to move ahead. So, he is enrolled in night classes at
the local university.
When Kevin Rourke finished showing Carl around the
facilities, he asked Rick to show him how the distribution
systems worked. As Carl and Rick moved from the acid to the
caustic distribution system, Carl noted a striking difference.
The acid distribution piping has spring loaded valves that
close automatically when not in use. To pump acid into a remote
receiving tank, a pump switch must be activated at the remote
location. The pump switch has to be held on by the operator
while the tank is filling. The penalty for propping the switch
on by other means is immediate dismissal. In contrast, no
similar precautions are taken with the caustic system.
One of the two caustic tanks in Carl's area is equipped with
a high-level alarm. The other, located in a less used area of
the building, is not. Both tanks have vents piped to trench
drains in the floor that are connected to the publicly owned
wastewater treatment works (WTW). Because of the many low
volume caustic use points throughout the area, the distribution
system is kept pressurized by an air-operated diaphragm pump.
So, if there is no caustic demand, the pump expends no energy.
But it immediately acts to restore the line pressure if any
valve is opened or if there is a leak in any of the pipes.
Carl asks Rick why the caustic system is so different. Rick
shrugs and says, "I don't really know. It's been this way at
least as long as I've been here. I suppose it's because the
acid distribution system is used so much more." Carl then asks
if the lead operators have written procedures for filling the
caustic tanks. Rick says he's never seen any--nor has there
been any review of the practice during the four years he has
been an operator. "Are you satisfied with this setup?" Carl
asks. "Well, I don't have any problems with it. Anyway, that's
somebody else's concern, not mine. I suppose they don't want to
put out the money to change it," Rick replies. "Don't fix the
wheel if it's not broken seems to be their attitude."
Should Carl talk with Kevin Rourke about the distribution
systems, or should he simply accept things as they are?
II. A Problem
[Several months later.] Carl Lawrence is alarmed by Kevin
Rourke's urgent, early afternoon message: "All supervisors
immediately check for open caustic valves. Supply tank is
empty. Pump still running--either an open valve or a leak.
Emergency order for caustic supply has been made." Carl
immediately tells his lead operators to make a check. They
report that everything is in order. However, by mid-afternoon
it is evident that the problem is still unsolved. The supply
tank is steadily emptying even though apparently all the valves
are closed and no leak has been discovered. At 4:00pm a lead
operator who has just arrived for the afternoon shift notices
an open valve in a seldom used area of the facility. Carl had
forgotten that no one was working on that side of the building
during the early afternoon. So, the seldom used valve wasn't
checked. Now, however, Carl remembers that Rick Duffy was
assigned that area during the previous shift.
The valve is immediately shut off. Then Carl phones Rick:
"Rick, you left the C-2 valve open; and we've got a real
problem on our hands. We've lost a lot of caustic down the
drain. What time was it when you opened the valve?" Rick
answers, "Carl, I don't remember. I've been real tired all day.
Pulled an all-nighter getting ready for my exam tonight, and I
was just wiped out when I went to work. I think I turned it on
near the end of my shift, but I just can't be sure. I can't
believe I forgot to turn it off!" Rick pauses and takes a deep
breath, "Man, I can't afford trouble right now. Jan's pregnant
again, and I've got another semester to go."
Now that Carl has located the problem, what should he say to
his plant manager, Kevin Rourke? Should he acknowledge
responsibility for failing to have C-2 checked earlier? Should
he identify Rick as the one who left the valve open?
III. Taking Action
Kevin Rourke is relieved to learn that the problem is an
open valve rather than a leak. No repairs would be required.
However, another decision is necessary. Since it is not known
how long the valve was open, there is some uncertainty about
how much caustic waste has been released and how much, if any,
has reached the publicly owned wastewater treatment works
(WTW). It is estimated that it takes 6 hours for waste from
Emerson to arrive at WTW. If Rick turned on the valve shortly
before he left work, there would still be time to arrange for a
supply of acid to be delivered to WTW to counter the higher pH
count that the caustic waste would cause. Even if he turned it
on earlier, sending a supply of acid to WTW would help control
the harm.
Kevin knew that the pH level at WTW had been on the high
side of its normal range before the pH meter that monitors the
pH of waste arriving of WTV went out of service. He also knew
that the meter would be still be out of service until late
evening. So, even if the caustic waste were to raise the pH to
an unacceptable level, it would be difficult, if not
impossible, to trace the problem to its source.
What should Kevin do? If he notifies the proper outside
authorities, how candid should he be in estimating how much
caustic waste has been released?
IV. Kevin Rourke's Response
Kevin Rourke notifies the local fire station, which then
alerts WTW. Kevin also immediately arranges for a large supply
of drums of hydrochloric acid to be taken to WTW in case it is
needed. Although the entire incident is quite costly, Kevin is
convinced he has acted correctly: "If I had done nothing, it's
possible nothing terrible would have resulted. But it would
have been a very risky thing. If the caustic overflow had
killed the micro-organisms that digest the sewage, WTW would
have had to report the out-of-compliance discharge to the state
environmental agency. If it ever got out that we were
responsible--and that we tried to cover it up--we would have
really paid through the nose; and I'd probably end up losing my
job. Our public reputation would really suffer, too."
Total costs to Emerson: Replacement costs for an estimated
several hundred gallons of wasted caustic; 30 drums of
hydrochloric acid to be used if needed; $60,000 to modify the
caustic distribution system.
Evaluate Kevin Rourke's actions and supporting rationale
from the standpoint of: a) WTW; b) Emerson management; c)
Emerson stockholders; d) other industries in the area that use
WTW; e) local citizens. Do you think Kevin Rourke did the right
thing?
V. Rick Duffy
Rick Duffy clearly was negligent. What should Carl Lawrence
do about it? If propping open a pump switch of an acid tank
warrants immediate termination, should Carl fire Rick for
leaving open the caustic valve? To what extent, if any, should
Carl be influenced by his friendship with Rick? By his
knowledge that Rick needs to keep his job?
VI. Carl Lawrence
Although he realizes Carl Lawrence was not responsible for
leaving the valve open, Kevin Rourke is upset that it took
Carl's unit so long to discover the problem. Why, he wonders,
didn't anyone check C-2 in this emergency situation? He also
wonders what he should say to Carl--and whether he should take
any action against him. Discuss.
VII. Kevin Rourke Again
Kevin Rourke decides he should have a serious talk with Carl
Lawrence. He expresses his disappointment at the quality of
Carl's initial investigation: "You have to tighten up your unit
so that this kind of thing never happens again. You can start
by giving whoever left the valve open his walking papers." Carl
is relieved that Kevin apparently is not taking any action
against him. But he is unhappy at the idea of firing Rick. What
should Carl do? Should he cover for Rick and tell Kevin he
doesn't know who left it open?
VIII. Rick Duffy Again
The next morning Carl Lawrence is mulling over what he is
going to say to Rick Duffy when he hears a knock on his door.
He is surprised to see Rick, and he is even more surprised at
what Rick says: "I know I really put you in a tough spot. I'm
really sorry I let you down. I want you to know that I quit
this morning, so you don't have to fire me. I've already
applied for another job. Look, Carl, I know I shouldn't be
asking you for any favors, but I need a couple of references.
Can I count on you?"
What should Carl say to Rick? What should he do? If he
writes a letter of recommendation, what should he say about
Rick's work performance?
IX. A Phone Call
Carl was surprised to receive a phone call about Rick Duffy
just two weeks after the accident."We've received a letter of
recommendation from you concerning Mr. Richard Duffy," said the
voice on the other end. "He's applied for a job in one of our
safety areas. He's one of the finalists for the job. Your
letter says he was a good lead operator, a reliable worker,
easy to get along with, and so on--no negatives at all. I'm
just calling to see if there's anything you might want to add
that would help us make our final decision." What should Carl
say?
X. Another Company
Imagine a similar accident occurring on the same day as
Emerson's at another company in the area. Although there is
enough spill to exceed safe limits at WTW, by the time the
problem is discovered and corrected at Nurrevo Ltd., Emerson
has already rectified the problem at WTW. Since Kevin Rourke
didn't know precisely how much caustic waste Emerson spilled,
he had no way of knowing that he was cleaning up Nurrevo's
spill as well. Should Nurrevo inform WTW of its accident and
offer to share costs with Emerson? Discuss.
XI. Andrea Smith
Andrea Smith is Kevin Rourke's counterpart at Nurrevo. She
is having a meeting with her immediate superior when Fred
Barnes brings her the bad news. She immediately concludes that
she will have to report the problem to WTW. But Andrea's
superior tells her not to act too hastily: "Let's make sure we
have the facts straight first. Go back to your unit and see
what else you can find out about this. Meanwhile I'll make some
inquiries." Fifteen minutes later Andrea discovers the problem
is serious enough that she is convinced she should contact WTW.
However, at that moment her superior steps into her office and
says, "It's okay, Andrea. You don't have to do anything--it's
all taken care off." Later she learns how it was "taken care
off." Somehow her superior learned of the Emerson Chemical
spill and that Kevin Rourke's actions actually solved both
problems at once. So, he decided Nurrevo would simply keep its
problem quiet.
Andrea Smith likes her job very much. She has worked hard to
get there, and she would like to advance within the company.
But now her superior has posed a problem. She definitely
disapproves of his cover-up. She wonders how far up the
organizational ladder she would have to go to find someone who
would agree with her. Would anyone? So she wonders what she
should do.