Let’s Be Frank: Who is Responsible?

By Inspector Frank. October 31, 2019

Editor’s Note:  Writing under the pseudonym Inspector Frank, the author of this column offers a first-hand, candid view of what he has witnessed throughout his career. His purpose in sharing these experiences and opinions is to encourage readers to think deeper about what they do, why they do it, and the possible impact of their decisions.

Inspectioneering is committed to protecting the anonymity of pseudonymous authors. We do, however, hold these contributors to the same editorial standards as those writing under their own name. In this, we know the author’s identity and maintain communications regarding the author’s published works. If you have any questions, feedback, or concerns stemming from this article, please send an email to and we will forward your correspondence to the appropriate party.

Who is responsible?

I am sure everyone involved in any kind of work in industrial settings (not just within equipment integrity) has come across situations where things are not happening the way everyone thought they should. Shutdowns/turnarounds are usually a time when this really becomes apparent. If you’ve ever been involved in a turnaround (TA), it won’t be hard for you to imagine this scenario or something like it:

“What do you mean nobody inspected any of the exchanger lifting lugs before turnaround? We have to do all this now, the shutdown started yesterday; we have plenty of critical work to do. These exchangers need to come apart now!”

Everyone grumbles and gripes and the field execution personnel get down to the job of fixing somebody’s grievous mistake while trying to keep the job on track. Fingers will be pointed. Entire work groups will be condemned for their incompetence. Money gets spent like the company’s a drunken sailor on shore leave in order to throw more resources at the problem. This snafu can’t be allowed to interfere with the restart of operations...

I guarantee everyone reading this can think of at least one example of a job going off the rails because something rather important, “in the grand scheme of things”, got missed.

So, my question is how does something critical get missed? Furthermore, why do critical items continue to get missed over and over?

As with anything, you can probably find a plethora of reasons.

  • The issue wasn’t identified by equipment integrity.
  • It wasn’t identified by maintenance, or maybe operations.
  • It wasn’t planned/scheduled properly.
  • The execution team doesn’t know what they are doing.
  • No one realized that had to be done every shutdown.
  • Everyone thought Gary was taking care of that job and then he retired.
  • And so on and so forth.

People will panic, solutions will be created, and everyone will close out their action items and wait for the next disaster to deal with. But seldom do we try to answer the question of “how we can stop this from happening again?”

From my personal experience, I think the answer is ultimately quite simple. Who is responsible and are they held accountable?

Admiral Hyman G. Rickover (USN) directed the original development of United States naval nuclear propulsion and, for three decades, was the director of the U.S. Naval Reactors Office. If you don’t know much about him, I strongly suggest reading The Rickover Effect: The Inside Story of How Adm. Hyman Rickover Built the Nuclear Navy. He’s an interesting man who developed an outstanding system and has been credited with the U.S. Navy’s continuing record of zero reactor accidents.

He has many famous quotes attributed to him – many are thought provoking and some are downright humorous. But this has been one of my favorites since I first heard it:

“Responsibility is a unique concept... You may share it with others, but your portion is not diminished. You may delegate it, but it is still with you... If responsibility is rightfully yours, no evasion, or ignorance or passing the blame can shift the burden to someone else. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible.”

Read that again and focus on the last sentence. Now, think about a time during your work experience when something critical was missed, overlooked, poorly planned or executed. Was someone actually responsible for ensuring that it got done? More importantly, did they know they were responsible for it and did they understand its importance? Were they held accountable?

In an industrial setting, responsibilities have to be clearly laid out and the personnel to which those responsibilities are assigned must understand their importance and the rationale for their existence.

Let’s go back to the exchanger lifting lug example. In the facility in which this happened, it was decided that all lifting devices have to be inspected annually or, if used less than once per year, before each use. There was a group assigned to this task and lifting devices were put on an inspection frequency that met the criteria. The work was sent to be scheduled and everyone patted each other on the back and said “we got this.” So how come the exchanger lifting lugs didn’t get inspected?

Consider the following simplified progression of events (minus the yelling and finger pointing):

  1. Process unit shuts down and is made ready for maintenance activities.
  2. Exchangers start coming apart as per the plan and schedule.
  3. Six exchangers have had channels removed before an alert crane operator realizes none of the lifting lugs have been tagged “OK for lift.”
  4. Work shuts down.
  5. TA Execution is asked why the lifting lugs had not been inspected. To which they respond: “Was not in our plan.”
  6. Planning and scheduling asked why these tasks weren’t put in the plan. “Wasn’t identified as TA or pre-TA work.”
  7. Integrity asked why this work wasn’t identified. “Not in our scope of equipment, lifting devices belong to Reliability.”
  8. Reliability asked why the work wasn’t identified for planning and scheduling. “Lifting lugs are not part of the lifting device scope we put together."

So, let’s rewind back to planning of the TA to see what went wrong.

Reliability had been assigned a project to ensure all lifting devices were identified and an inspection plan was set up as per the requirements. A team was formed. The team did not consider lifting lugs on exchangers to be a lifting device (they focused on cranes, overhead beams and davit arms). No one had thought to establish or define what was meant by a lifting device. It was a team project and the group didn’t think about lifting lugs. The team put out a list of items and how often they needed to be inspected and they completed the project – on time and under budget!

Planning and scheduling are responsible to ensure identified work gets loaded into the plan and scheduled for completion. But they aren’t responsible to ensure all work has been identified. They took the list reliability had created and made it into an executable plan. They met their deadlines.

Execution took the scheduled plan and started to get the job done. They weren’t responsible to ensure all work was identified and loaded into the plan. Their job is to execute the plan on schedule and on budget.

So who was held to account? No one was held to account because no one was assigned as being responsible for the program. Reliability thought it was just a one-time project. Reliability was told to make a list of lifting devices, how they needed to be inspected along with frequency and give it to planning and scheduling. That was the end of their project.

In the end, they got chastised for missing lifting lugs, and the lifting device inspection program got assigned to Integrity.

So, the failure was: no one was made responsible until it was too late. Someone should have had the responsibility to clearly define what the requirements of the project were. After it was set up someone should have been made specifically responsible for its ongoing life and execution.

Critical things do get missed. But if someone is responsible and knows they can be held accountable for that activity, then they will own it and they will fix it. It seems very simple, but I see this problem re-occurring over and over again across multiple companies. We get good at reactively solving problems as they appear, but are we proactively working towards examining and fixing the potential larger issues? 

Take a look at your organization and the critical activities it performs. For all of those critical activities, can you point to a position and say they are responsible for that activity? If you can’t, why not and, more importantly, can it be fixed? 

I see this as an industry cultural problem that potentially comes out of any large bureaucracy. Modern bureaucracies tend to have some common features that actually seem as if they were set up to avoid responsibility and accountability, especially at the managerial level. Think of your facility or organization as you read the following points: 

  • In most production facilities, yesterday is ancient history and many of our systems don’t track past decisions to fix responsibility or hold people accountable.
  • Typically, there are no fixed standards for measuring work performance and set goals are changeable at the demands of production. Process throughput is what gets measured while individual performance is more subjectively assessed by the supervisors. 
  • Bureaucracies can separate managers from the consequences of their actions, thereby diminishing responsibility.
  • Managers who get tied to bad decisions don’t tend to get promoted, so managers prefer systems that very specifically keep responsibility vague or not personal.
  • Decisions get made at meetings by group consensus. This diffuses both responsibility and accountability and makes holding people accountable difficult after the fact.

So what’s the solution? At a corporate level it’s not easy. Cultural shifts do not happen overnight and they need people championing them for anything to happen. However, we can all hold ourselves responsible and accountable to ourselves and our positions. That will help as part of the start of systemic change. Beyond that, I don’t know.

I do know that if I walk into a facility and discover I can’t point the finger at the person responsible for what I am to be involved with, it’s going to be chaos.

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Comments and Discussion

Posted by Don MacIsaac on November 4, 2019
Interesting article, Inspector Frank. It's... Log in or register to read the rest of this comment.

Posted by Josh Miller on December 26, 2019
I wholeheartedly agree with the assessment of... Log in or register to read the rest of this comment.

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