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Dealing with a Costly Error



Author(s) Michael Pritchard
Authoring Institution Center for the Study of Ethics in Society at Western Michigan University
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Contributor(s) Michael Pritchard
Notes Case study originally published in “Teaching Engineering Ethics: A Case Study Approach” by Michael Pritchard. Center for the Study of Ethics in Society, Western Michigan University, 1992.
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Authoring Institution (obsolete) Center for the Study of Ethics in Society, Western Michigan University
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Year 1992
Publisher National Academy of Engineering, Online Ethics Center
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  • Posted 12 years and 9 months ago


    In retrospect, Carl should have talked with Kevin Rourke
    about the distributions systems, if he foresaw a problem there.
    But Carl has little practical experience; if he accepted
    Kevin's explanation--that the caustic system is used so much
    less--he might well have accepted things as they are. It may be
    that it isn't an ethical question so much as a matter of
    judgment as to whether there will be a problem. But if Carl
    anticipates that there is likely to be a problem, with severe
    environmental consequences, such as a leak or a valve left open
    which would discharge excessive amounts of caustic into the
    waste water system, he should at least raise the question of
    whether it would be wise to modify the caustic distribution
    system. The cost might be such, and the risk of a problem so
    remote, that it would be reasonable to do nothing. But if Carl
    has a concern, he should pursue the matter.


    When the emergency arises and Carl has located the problem,
    he must immediately report it to the plant manager. He also
    needs to report that it isn't known how long the valve was
    open, and that requires reporting who left it open and that he
    failed to have it checked earlier. To do otherwise would be
    irresponsible, and since he would have eventually had to
    acknowledge what he knew, he would be better to be as
    informative as possible about it now.


    Even if it were impossible to trace the excessive caustic
    waste to its source, it would be irresponsible of Kevin not to
    report it and to do everything he can to neutralize it. If
    there is any question about it, think about the situation from
    the point of view of those who operate the waste water
    treatment plant. Look at it from the point of view of the
    general public.


    From the point of view of the WTW, Kevin's actions were
    responsible and helpful. Otherwise, they might have had a
    serious problem on their hands.

    Emerson management and stockholders might be short-sighted
    and think that it could have saved money by Kevin's not
    disclosing the source of the caustic discharge. They might
    think that they could have avoided the cost of the hydrochloric
    acid used to correct the problem and the modification of the
    caustic distribution system which they felt that they had to
    make after being a source of accidental discharge. But
    enlightened self-interest would dictate that Kevin's rationale
    is correct, wouldn't it? They might also be enlightened enough
    to think of others affected and want to be a public-spirited
    company as well. Other industries and local citizens that use
    WTW would be inconvenienced and perhaps have to share the cost
    if the WTW service is disrupted.

    Suppose, however, that Emerson Chemical is losing money.
    Every unnecessary expense puts them that much closer to
    backruptcy, and that will cost jobs. Does that make a
    difference? Suppose that disclosing and correcting the problem
    is going to cost millions instead of tens of thousands. Is
    there a point at which being a responsible company is too


    Friendship does mean something, and awareness of the
    hardship that would be caused by someone being fired counts
    too. It has weight but not absolute weight. It can be
    outweighed by poor job performance. Is this is a single case of
    negligence in Rick's job performance, or is it part of a

    Carl is responsible for those who work under him; so he
    can't just ignore the problem. He can talk to Rick about
    whether Rick isn't neglecting his work for his studies and
    whether he shouldn't think about cutting back on the latter if
    he can't do both.


    Kevin is also responsible for those who work under him.
    Carl's unit was negligent in checking C-2 in an emergency
    situation. He needs to find out not only who was negligent in
    leaving the valve open, but why it wasn't discovered in the
    emergency check. So he does need to have a serious talk with
    Carl. Whether he needs to take any action against Carl probably
    depends on Carl's general performance. Has he been negligent in
    any other work, so far as Kevin knows?


    If Carl claims that he doesn't know who left the valve open,
    he is showing a lack of control over his department as well as
    being dishonest; so that probably won't help the situation. If
    he thinks that Rick has otherwise don't excellent work, he may
    try to persuade Kevin to rescind the order that he be


    If Carl thinks that Rick has been doing excellent work and
    thinks that there is a possibility of changing Kevin's mind, he
    might ask Rick to reconsider his resignation. If he would want
    Rick to stay on the job, he can say that in a letter of
    reference. There isn't any need for Carl to tell Rick that he
    has orders to fire him, unless the subject comes up. He also
    doesn't need to say that in a letter; nor need he say that Rick
    was guilty of a serious case of negligence if that was the only
    one. If, however, Rick's work hasn't been good, and Carl cannot
    honestly write a letter which speaks well of his work, Carl
    should explain that to Rick, telling him what he would say in
    the letter and letting Rick decide whether he still wants him
    to be a reference. It is possible for a letter to call
    attention to good points without stressing the bad ones. For
    example, the very fact that Rick has regret over his negligence
    shows something about his character. Carl may be able to talk
    about that even if he can't recommend his job performance.


    Carl will have to make an honest estimate of Rick's future
    performance. If he sincerely believes that Rick will be
    reliable in the future, he could say nothing about the open
    valve. If he thinks that Rick's studies are interfering with
    his work, he could suggest that the prospective employer raise
    that question with Rick. But it will likely cost Rick the job.
    He should do it only if, in his judgment, Rick can't handle
    both; and maybe he shouldn't do it even then.


    If Nurrevo doesn't know of WTW's spill, it is in exactly the
    situation that Emerson was in, and so the above reasoning would
    apply to it. If, however, Nurrevo finds out that WTW has
    already disclosed that it has had a spill and will provide the
    hydrochloric acid to take care of it, Nurrevo is a different
    situation. The spill will be taken care of. There will be no
    damage to the WTW. So it is not a question of environmentally
    damaging consequences. There is, however, a question of
    fairness. If Emerson is cleaning up Nurrevo's mess, Nurrevo
    should in fairness share costs. Isn't that what Nurrevo would
    want if it cleaned up Emerson's mess?


    Andrea could argue with her superior, claiming that in
    fairness Nurrevo should report and share costs. If she doesn't
    get anywhere with him, she could take the matter to someone
    further up in the company, but is it worth it?

  • Posted 12 years and 9 months ago


    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

    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.


    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.


    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

    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.


    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

    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.


    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

    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.


    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.


    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.


    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.


    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.


    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.


    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."

  • Posted 12 years and 9 months ago

    Carl Lawrence has a problem on his first day on the job. He
    finds that the caustic distribution system does not have as
    many safety precautions as the acid distribution system. He
    sees immediately that there are chances for a mishap. The plant
    manager really should be encouraged to improve the caustic
    distribution system before an accident, but it is not always a
    good idea to raise problems on your first day on the job. The
    manager may be inclined to say, "Look, you don't know your way
    around yet; don't start out by making trouble." Carl may in
    fact not have all the relevant information. Perhaps he should
    begin by trying to find out whether there have been mishaps in
    the past and making some estimates on what kind of improvements
    should be made and how much they would cost.

    Rick's negligence in leaving the valve open poses a conflict
    problem for Carl. His obligation to the plant and to the public
    conflicts with his obligation to his friend, Rick. Carl's
    dilemma is accentuated by the realization that Rick could make
    a similar mistake again. If Rick's negligence was due to lack
    of sleep, there is every reason to believe that Rick may make a
    similar mistake in the future. In this case, however, Carl must
    distinguish between the difficulty of doing what is right
    because it is hard to do from an emotional standpoint and a
    situation in which he really does not know what is right. Carl
    may believe that his obligations to the plant and to the public
    outweigh any obligation to Rick, but still find it hard to fire
    Rick. But maybe he doesn't have to fire Rick. Perhaps he can
    find a way to have Rick moved to a part of the plant where
    safety is not so crucial. Or perhaps he can help Rick find
    another job. A person should always look for ways to satisfy as
    many of the moral demands he faces as possible. Carl probably
    should feel some obligation to help Rick if possible. After
    all, Rick is a friend, and he is probably trying to do the best
    he can under difficult circumstances.

    Kevin Rourke's decision to take responsibility for the
    caustic overflow involved considerable expense, but there is no
    indication that it placed the company in financial distress.
    His action might have prevented a disaster for the city, for
    himself, and for the company. One of the ways of analyzing this
    issue is from he standpoint of utilitarianism, which requires
    that we act in such a way that we maximize the well-being of
    everyone affected by the action. A form of utilitarianism that
    might be especially relevant here is cost/benefit analysis.
    From the standpoint of balancing costs versus benefits, it
    looks like Kevin did the right thing. The only complication is
    that we must balance an actual cost against a possible benefit.
    Nevertheless, the action seems rational from a cost/benefit
    standpoint. It is important to keep in mind that, from a
    utilitarian standpoint, the costs and benefits of everyone
    potentially affected by the action must be considered. Of
    course the cost are primarily charged to the company
    (stockholders), whereas the benefits accrue to the company as
    well as the managers and employees (who might lose their job if
    the plant were closed) and the larger population. But then the
    company created the problem in the first place.

    Another way to evaluate Kevin's action is to ask whether we
    would approve of his action if we placed ourselves in the
    position of those who could be affected by a caustic overflow.
    These groups would include the local citizens, other managers,
    stockholders, and other employers.

    It is not possible to consider all of the moral issues
    raised in this case, but two more deserve some consideration.
    With respect to Rick's request for a letter of recommendation,
    Carl must weigh his personal loyalty to Rick against his
    obligation to fail to inform a potential employer of Rick's
    liabilities as an employee. A dishonest letter of
    recommendation can cause another employer to make a decision
    that is not properly informed. Carl must ask himself whether he
    would like to be in the position of the potential employer if
    he (Carl) writes a letter that fails to mention Rick's

    Carl faces an even more serious problem when he is informed
    that Rick may be employed in one of the "safety areas." This
    presumably means that Rick is being considered for employment
    in an area where alertness is at a premium. Without the
    information about Rick, the employer may be about to make a
    seriously misinformed decision.

    With respect to Nurrevo's accepting responsibility for its
    own accident, we might first ask whether an individual should
    accept responsibility for harms he or she has caused, even if
    he or she could avoid taking such responsibility. The answer to
    this question is in general clear: if a person does not take
    such responsibility, he or she is overriding other people's
    freedom of action by forcing them to pay for a harm they did
    not cause. Then one must ask whether the same analysis applies
    to corporate responsibility. That is, are corporations
    responsible for their actions just like people are?

  • Posted 12 years and 9 months ago


    Here we have an engineer who, on his first day on the job,
    discovers a waste disposal system which he doubts is up to par.
    Should he point this out to someone? Yes; if Carl has concerns
    about the system, why shouldn't he express these concerns to
    the plant manager? His buddy Rick has a 'don't rock the boat'
    attitude, but why assume Rick adequately represents the
    position of management? As a new employee, perhaps Carl in a
    position to see things or make suggestions which old-timers
    wouldn't notice, and which management might be glad to correct.
    Rick thinks management doesn't want to spend the money to make
    changes in the system, but whether they do or not is not Carl's
    decision. His professional responsibility would seem to be to
    make recommendations where appropriate. If management doesn't
    choose to follow the recommendations, Carl can consider what to
    do next; if Rick's view turns out to be correct and management
    doesn't even want to hear about the problems, then Carl has
    some fundamental reevaluation of his own place in such a


    Now there is an unacceptable discharge caused in part by
    employee negligence. But Carl is also responsible because he
    forgot to check one valve. Carl has little choice but to
    acknowledge responsibility for failing to check C-2. Anything
    else would be evasion, dishonest, and avoidance of
    responsibility. However once he accepts responsibility there's
    no need to identify the culprit unless he's asked, but if he is
    asked, he has no choice but to do so. It's his job to know
    who's doing what, and he's the agent of management in
    evaluating his subordinates.

    Carl is obviously at fault for not remembering the open
    valve, but there's a question why Carl wasn't provided with a
    checklist of cut-off valves to be referred to in such an
    emergency. Simply telling everybody to check the valves doesn't
    seem like an adequate safety procedure. Carl is a new employee
    so perhaps he can't really be expected to implement better
    procedures than are provided.


    Kevin needs to talk to the WTW people and explain the
    situation, which is that caustic waste is moving towards the
    waste treatment works. Kevin estimates a range of values for
    the quantity of caustic waste likely to reach WTW, and offers
    to send however much acid is necessary, according to the
    estimation of the WTW people. (They are in a better position to
    know their current pH level than he is). His obligation is to
    avoid down-stream damage or danger. Evidently he is tempted to
    try to avoid the issue entirely on the basis that WTW wouldn't
    be able to trace the waste to its source at Emerson. Presumably
    this means he would ignore the spill and let the excess waste
    reach WTW, where it would do whatever damage such stuff does.
    This 'the hell with you' attitude is about as unethical as you
    can get. Being less than candid, as also suggested by the
    question, is not much better, since it implies doing less than
    necessary to fix the problem or limit the damage.


    Kevin acts responsibly and notifies the authorities: it's
    not clear why there should be disagreement about this from any
    differing points of view. His rationale is a self-interested
    one, which ought to convince management and stock-holders. The
    cost to Emerson is not given ($60,000 +) but it should not seem
    excessive, even from a self-interested point of view,
    considering the risks involved in trying to cover-up. Kevin
    Rourke indicates he's worried about losing his job, which
    should reassure Emerson management and stockholders that
    company incentives work to encourage appropriate behavior.
    Although Kevin does not mention any obligation Emerson might
    have to correct its errors before actually damage or harm is
    caused, this additional rationale ought to please WTW and local
    citizens. As for other industries, they should be pleased that
    Kevin has given them a model of responsible crisis


    Rick's excuses for his mistake are rather pitiful, and he
    has to expect discipline. One hopes there are company policies
    and procedures regarding employee gross negligence.
    Unfortunately it's up to Carl to impose the necessary
    discipline. Clearly personal considerations have to be left out
    of it; he can't treat one employee more leniently than another
    because of a past relationship. If Carl is inclined to favor
    Rick, he might try to pass the buck to someone else who's more
    impartial, but this attempt at a cop-out probably won't raise
    his stock in the company. He's best off steeling himself to the
    task. From Rick's point of view, it might actually be fairer if
    Carl does excuse himself, since Carl might be overly harsh in
    order to overcome the possibility of being too lenient. As for
    Rick's personal situation, this might give him a case for easy
    treatment based on mercy or personal hardship, so if he wants
    to make a plea for mercy, he should have that right, but the
    proper place to make it would be not at Carl's level, where
    even-handed discipline should be administered, but at a higher
    level in the company somewhere. Of course this assumes the
    company has proper policies in place for giving a fair hearing
    to accused employees, and it should be stressed how important
    it is to have such policies, since situations such as the Rick
    error are inevitably going to arise. It also might be noted
    that it is Rick who has the bad attitude about 'don't rock the
    boat.' He attributes this to the company, but there's nothing
    in the case to substantiate that, and one point against it: the
    fact that Kevin acted responsibly in part due to fear for his
    job were he to cover-up and fail. Perhaps Rick's failure at the
    switch that day is in part due to his own attitude of
    indifference to job performance. And perhaps also he has too
    many things on his mind at this point in his life to act as a
    responsible employee.


    Carl is at fault for forgetting about valve C-2, and should
    be disciplined also, though there's not enough information in
    the case to know how serious was his failing to remember that
    no one was at the "seldom used area." Evidently three hours or
    so passed before the open valve was finally noticed; what was
    Carl doing during that time? Shouldn't he have remembered about
    the "seldom used area" sooner than that? Shouldn't he have
    called all the lead operators together to brain-storm the
    problem, and if so wouldn't one of them have remembered the
    "seldom used area"? On the other hand, Carl is a new employee,
    who has evidently not been given any training in how to handle
    a situation like this, so there's a lot of mitigation. Kevin
    ought to be able to take all these factors into account if he
    is to arrive at a just solution regarding Carl.


    Carl gets off easy when Kevin decides not to take any action
    against him and he should be relieved. In my view Kevin is too
    kind; he ought to tell Carl that his performance was less than
    sterling and that he's got to do better. Carl in his turn
    should complain to Kevin about the lack of training and of
    standard procedures for dealing with crises. There's enough
    responsibility here so that no one needs to feel that his
    performance was superior.

    At the same time, Kevin's way of talking to Carl is a bit
    odd. His discipline against Carl seems to be to require him to
    fire Rick. Perhaps Kevin has read Carl correctly and
    understands that he is not about to let this mistake occur
    again, and that tightening up his unit is exactly what he
    intends to do. If so, Kevin is probably correct in not taking
    further action against Carl. At the same time, it may seem
    unfair to fire Rick and let Carl off scott free. But there is a
    difference: Rick had an ordinary responsibility which was easy
    to perform, but which he forgot due to other things on his
    mind. Carl on the other hand was faced with an unanticipated
    crisis for which he had neither experience nor training. Carl's
    failure was not improvising a solution under pressure, whereas
    Rick failed to perform a routine task in the course of ordinary
    business. So their situations are not at all comparable.

    If Carl wants to protect Rick, he better not try it by
    lying. Kevin is going to tell him that it's his responsibility
    to find out who left the valve open; this can't be too
    difficult, and he ought to have known by now anyway. If Carl
    thinks friendship requires him to protect Rick, he can try and
    defend Rick to Kevin. If Rick has a good case, Kevin may
    respond favorably: there's nothing to indicate that Kevin is
    especially tough-nosed or insensitive (and in fact given his
    responsible action in notifying WTW, there's reason to believe
    he is ethically sensitive). Perhaps Kevin shouldn't order Rick
    fired without knowing all the facts, which Carl can put before
    him. Of course there's a risk that Kevin doesn't want to hear
    any excuses from Carl, and won't be pleased at Carl for
    defending a negligent employee; but if Carl feels he owes it to
    Rick, he will take that risk.


    Rick gets Carl off the hook by resigning. Now he needs a job
    and asks Carl for references! His gall is almost beyond belief.
    He totally screwed up, cost the company big bucks, nearly
    knocked out the wastewater plant, put both Carl's and Kevin's
    jobs in jeopardy, and now wants a recommendation. If I were
    Carl, I'd agree to write it. First I'd tell Rick what I'd put
    in it. I'd think of all the good things I could say about Rick
    (which are not insignificant, considering his willingness to
    work hard, study and get ahead) but also I'd feel obliged to
    mention the circumstances of his departure from Emerson. If I
    felt that Rick's action was an isolated incident, I'd say so.
    If I were worried about his possible bad attitude and mounting
    personal problems, I'd say that. The point would be to provide
    enough information so that the potential employer can determine
    on his own judgment whether Rick's goof at the valve was an
    unfortunate and understandable mistake of a basically
    conscientious person who would likely become a valued employee,
    or was a sign of irresponsibility. And I'd leave it to Rick to
    decide whether that's the kind of letter he wants potential
    employers to read.


    Carl goofs again by failing to do the above, and lets
    himself in for the unpleasant but not unforeseeable consequence
    of having to explain himself on the phone. Should he explain to
    the new employer what the negative is in Rick's background? He
    might then have to excuse his failure to mention it in the
    letter, which might prove a bit awkward and might not do Rick
    and good by making his mistake seem more serious than Carl
    would like.

    Why mention it at all? It's usually possible to evade such
    questions. It might even be possible to argue that Carl has no
    obligation to the unknown potential employer, but he does have
    some ties to Rick. It could be also argued that letters or even
    personal conversations concerning recommendations are all part
    of the 'recommendation game:' They are expected to contain
    puffery and little else, and readers discount them accordingly.
    A great recommendation means the candidate is no worse than
    fair, a mildly positive recommendation means the candidate is
    poor, and a recommendation containing any negatives at all
    means the candidate is terrible and essentially unhirable. This
    may be an unfortunate situation, it could be said, but that's
    the way the game is played and Carl as a very junior person is
    in no position to change the rules.

    The short answer to this is that even if these are the rules
    (which is doubtful) by playing according to them Carl is both
    reinforcing them and putting his own credibility in danger. Bad
    rules should be circumvented where possible, not strengthened
    by being followed. And even if Carl has no obligation to the
    unknown potential employer, he does have an obligation to
    people he might write recommendations for in the future; it is
    better for them that he establish a reputation for candor.
    Anyway it's not clear that he doesn't have an obligation to the
    potential unknown employer; we have obligations to strangers,
    and among them is the obligation to tell the truth. Carl's
    obligation to Rick, based on ties of family friendship, is to
    do his best for him, but not to the extent of concealing
    material facts. Therefore Carl ought to tell the truth about
    Rick's lapse, but try to convince the employer that Rick really
    is a worthy person, as presumably Carl believes. (Of course if
    Carl really doesn't think Rick can be trusted with another job,
    then he never would have written the letter of recommendation
    in the first place).


    In this scenario, another company, Nurrevo, by odd
    coincidence has an accident similar to Emerson's on the very
    same day. Since Kevin's responsible action in dispatching
    hydrochloric acid to WTW has solved Nurrevo's problem, Nurrevo
    may be tempted to pretend that nothing happened at their place.
    Despite this natural temptation, Nurrevo should inform Emerson
    and offer to share costs, though they might be forgiven if they
    feel that in doing so they are going the extra mile. Emerson
    costs would have been the same in any case, Nurrevo might
    reason, so why should they offer to share them? They probably
    have no legal obligation, since their spill has been cleaned
    up, although Emerson might want to contest this in court.
    Sharing costs would be the decent thing to do, however, since
    Nurrevo has benefitted by Emerson's expenditure. What they
    actually do might depend on whether there's a cooperative
    atmosphere, or whether the two companies are in cut-throat
    competition, in which case Nurrevo might be tempted to rejoice
    at Emerson's bad luck.


    Andrea Smith is Kevin's counterpart at Nurrevo, which means
    she's a plant manager. I imagine this is not a terribly exalted
    position and does not put her in a very strong position to
    challenge higher management, or to search up the ladder for
    someone who might take her view of things. She wants to report
    her spill to WTW, but her superior, Fred, doesn't want to move
    too quickly, hoping that there's been some mistake somewhere.
    As it turns out, Fred's faith in Higher Providence is rewarded:
    news of Emerson's spill arrives just in time to forestall
    Nurrevo's report to WTW. Andrea is not too pleased with Fred's

    Not to confess is a higher management decision which Andrea
    seems powerless to alter without excessive risk to herself, and
    so she should be guided by the rule of prudence, which says
    pick your battles carefully and remember how little ammunition
    you have. Not everything with which you disagree needs to be
    challenged. The ethical failure here does not involve any risk
    to public heath or safety, nor any harm to employees, nor does
    it involve theft, fraud tax evasion, stock manipulation etc. It
    involves failure to admit responsibility, which is dishonest
    but not itself harmful, and failure to share costs with a
    competitor, which is not very nice but perhaps not a mortal
    sin. So Andrea might want to consider filing the incident away
    for future reference in her memory banks.

  • Posted 12 years and 9 months ago

    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

    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

    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.

  • Posted 12 years and 9 months ago

    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

    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

    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:

    1. Create procedural changes whereby all critical valves
      were checked by more than one operator.

    2. Consider hardware changes such as had been implemented on
      the most heavily used tanks.

    3. 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

Cite this page: "Dealing with a Costly Error" Online Ethics Center for Engineering 6/25/1992 OEC Accessed: Tuesday, May 21, 2019 <>