Wade L. Robison's Commentary on "Dealing with a Costly Error"


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 double check 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 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.


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.


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.


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."