Donald Chivens' Commentary on "Dealing with a Costly Error"

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 engineer.

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 appropriate.

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 response.