Let’s Be Frank: Sometimes, People Should Be Blamed...

That might be a bit of a spicy title. But I am sure it got most of you thinking in the right direction right away. Think personnel safety incidents, process safety incidents, or any incident that has a potential human cause (and not all do, but most).

The reason I wanted to write about this and get people thinking about it is that I am of two minds myself about whether to blame individuals for events that happen. Can individual personnel be at fault for an incident? For sure. Is it always an individual’s fault, or is it an issue with the systems in place? Or does how blame gets assigned sometimes come down to convenience?

You can blame people–rightly or wrongly–or you can just blame the “systems” rightly or wrongly. But are either of these right? People can get pretty passionate about this topic. I would say that, at the variety of companies I have worked for over the years, this is often a very polarizing topic. There don’t seem to be many companies that take a middle ground on this topic.

Before I offer my two cents on the matter, let’s look at some famous incidents and examples and get into the meat and potatoes of what this means in the real world.

The General Slocum Disaster

This is one of those events that is starting to get lost in history.

On June 15, 1904, the ferry General Slocum caught fire and sank in the East River of New York City. At the time of the accident, she was on a chartered run carrying members of a church to a picnic. An estimated 1,021 of the 1,342 people on board died. This was considered the worse tragedy in NYC history until the 9/11 attacks.

The ship got underway on the East River at around 9:30 AM. As reported at the time, when it was passing East 90th Street, a fire started in the forward cabin or Lamp Room. The fire was possibly caused by a discarded cigarette or match. The disastrous fire was fueled by the straw, oily rags, and lamp oil strewn around this room.

The first discovery of the fire was at around 10 AM. Captain Van Schaick was not notified until 10 minutes after the fire was discovered. After he was notified of the fire, the captain ordered full speed ahead and directed the pilot to beach the ship on North Brother Island. The captain then descended to the hurricane deck and remained there until he was able to jump into shallow water after the ship was beached.

When the crew tried to use firefighting equipment, it was found that the pump-driven standpipe (that was on the ship for fighting fires) had a cheap linen hose attached to it that was rotting. When they tried to remove this and instead use a rubber hose, the coupling could not be removed. The crew then gave up firefighting operations as the available hand pumps and buckets could not provide enough water to affect the fire. The crew later said they had no firefighting drills in the previous year.

Additionally, it was stated by survivors that the way the lifeboats were tied in place (and apparently painted in place) made them unusable at the time of the fire.

But wait, it gets worse! Survivors also reported that some life preservers fell apart in their hands. There were also reports of children being placed in life preservers and tossed into the water, where they immediately sank.

Why did the children sink? It was discovered that many of the life preservers had been filled with cheap and less effective granulated cork and brought up to proper weight by the inclusion iron weights. Nonpareil Cork Works, supplier of cork materials to manufacturers of life preservers, placed 8 oz (230 g) iron bars inside the cork materials to meet minimum content requirements (6 lb [2.7 kg] of "good cork") at the time. Managers of the NonPareil Cork Works were indicted but not convicted. The life preservers on the Slocum had been manufactured in 1891 and had hung above the deck, unprotected from the elements, for 13 years.

It was reported at the time that the company was saving money by falsifying inspection reports.

Reports also indicate the captain abandoned ship as soon as the General Slocum ran aground along with a bunch of the crew.

Eight people were indicted from the company that owned the ship, including the captain. However, only the captain was convicted and only one of the three charges against him stuck–failing to maintain firefighting equipment and not having the crew do periodic firefighting drills.

The company paid a small fine despite evidence being uncovered in the investigation that demonstrated they had been falsifying inspection reports.

I look at this and see a breakdown of both systems and personnel. Should the captain have been held personally responsible? I think so, especially on the charge he was convicted of, which was not ensuring the firefighting equipment was being maintained or running the crew through firefighting drills. Somebody ultimately has to be responsible for some items.

This was the event that triggered US state and federal authorities to pass regulations regarding safety equipment on passenger ships.

The Exxon Valdez oil spill

This is one I am sure you have all heard of. Around midnight on March 24, 1989, the supertanker Exxon Valdez ran aground on Bligh Reef in Prince William Sound in Southern Alaska, causing one of the worst oil spills in US history. An estimated 11 million gallons of oil eventually spilled into the water, making it the largest spill in US waters until BP’s Deepwater Horizon oil spill.

Attempts to contain the spill did not go well. Wind and currents spread the oil more than 100 miles from its source, eventually polluting more than 700 miles of coastline. Hundreds of thousands of birds and animals were adversely affected or killed.

In this case, Exxon tried to scapegoat the captain (I think unfairly).

However, this one was investigated with “modern” analysis techniques and multiple factors have been identified as contributing to the incident:

The Exxon Shipping Company failed to supervise the ship's captain and provide a rested and sufficient crew for the Exxon Valdez. The National Transportation Safety Board found this practice was widespread throughout the industry, prompting a safety recommendation to Exxon and to the industry.

The third mate was found to have failed to properly maneuver the vessel, possibly due to fatigue or excessive workload, or faulty equipment as seen below. He was cutting out of known sea lanes because of icebergs that had been tracked in the area during the day.

While not in the official report, investigative journalists uncovered that the Exxon Shipping Company failed to properly maintain a piece of gear that is critical for situations like this. The ship was equipped with a Raytheon Collision Avoidance System (RAYCAS) radar, which, if functional, would have indicated to the third mate an impending collision with the Bligh Reef by detecting the radar reflector placed on the next rock inland from Bligh Reef for the purpose of keeping ships on course. This known issue was backed up by the ship’s maintenance logs.

Captain Hazelwood, who was widely reported to have been drinking heavily that night, was not at the controls when the ship struck the reef. In a 1990 trial, he was charged with criminal mischief, reckless endangerment, and piloting a vessel while intoxicated, but was cleared of the three charges. He was convicted of misdemeanor negligent discharge of oil. 21 witnesses testified that he did not appear to be under the influence of alcohol around the time of the accident. However, Exxon still tried to scapegoat him.

It is interesting to note that the conviction for negligent discharge of oil was overturned, because he reported the spill. The law was worded so that if the person responsible also reported the spill, then they were immune from prosecution under that law.

There are some other factors to consider that never came up in the official investigations:

• The US Coast Guard had recently quit tracking ships around Bligh Reef. Previously they tracked ships and would give radio communication assistance if the ships seemed to be drifting out of known safe sea lanes.
• The oil shipping industry had promised for years to put in iceberg tracking systems in this area but never had. The first mate was off course trying to avoid icebergs that had been spotted during the day.
• The Coast Guard had reduced its number of inspectors over the previous years and vessel inspections that were due on the Valdez had not been performed.

In this example should the captain or the first mate have been held to account? Unlike the case of the General Slocum, I do not think so at all. I think the worst the captain could have been held to was agreeing to sailing understaffed, but that was an apparent industry norm at the time. Reported maintenance was not done and other factors played way more of a role than the actions of the individuals involved.

Union Carbide Bhopal Disaster

Another one you should all have heard about before. The explosion at the Bhopal Union Carbide India Limited (UCIL) factory in 1984 is still the world’s most lethal industrial disaster. It is well established that in its immediate aftermath, many thousands of people died because of the inhalation of toxic fumes.

UCIL (bought by Dow in 2001) owned the insecticide plant and immediately tried to disassociate itself from legal responsibility. The “official” report at the time stated that the act was caused by sabotage by a previously unknown Sikh extremist group.

Let’s look at a summary of the lead-up to the situation:

• The plant opened in 1969 and produced the pesticide carbaryl, which was marketed as Sevin.
• Ten years later, the plant began manufacturing methyl isocyanate, or MIC. Union Carbide was originally importing this from other facilities in small batches to manufacture Sevin. To stay financially competitive, it was decided to do “reverse integration” and start manufacturing all components at the one facility.
• In 1984, the plant was manufacturing Sevin at one-quarter of its production capacity due to decreased demand for pesticides. Widespread crop failures and famine in the 1980s led to increased indebtedness and decreased capital for farmers to invest in pesticides.
• Local managers were directed to close the plant and prepare it for sale in July 1984 due to decreased profitability. When no ready buyer was found, UCIL made plans to dismantle key production units of the facility for shipment to another developing agriculture country. In the meantime, the facility continued to operate with safety equipment and procedures far below the standards found in its sister plant in Institute, West Virginia.
• The local government was aware of safety problems but was not keen to place heavy industrial safety and pollution control burdens on the struggling industry because it feared the economic effects of the loss of such a large employer.

At 11.00 PM on December 2, 1984, while most of the one million residents of Bhopal slept, an operator at the plant noticed a small leak of methyl isocyanate (MIC) gas and increasing pressure inside a storage tank. The vent-gas scrubber, a safety device designed to neutralize toxic discharge from the MIC system, had been turned off three weeks prior.

Apparently, a faulty valve had allowed one ton of water for cleaning internal pipes to mix with forty tons of MIC. The addition of water into the tank caused a runaway chemical reaction, resulting in a rapid rise in pressure and temperature. The exothermic reaction, chloroform concentrations higher than normal, and the presence of an iron catalyst caused by the corrosion of the stainless-steel tank wall, resulted in the generation of massive amounts of heat.

A 30-ton refrigeration unit that normally served as a safety component to cool the MIC storage tank had been drained of its coolant for use in another part of the plant. Pressure and heat from the vigorous exothermic reaction in the tank continued to build. The heat and pressure eventually lifted the safety valve. The gas flare safety system was out of action and had been for three months due to a corroded pipe.

At around 1:00 AM on December 3, loud rumbling reverberated around the plant as the safety valve opened, sending a plume of MIC gas into the early morning air. Within hours, the streets of Bhopal were littered with human corpses and the carcasses of buffaloes, cows, dogs, and birds. An estimated 3,800 people died immediately, mostly in the poor slum colony adjacent to the plant.

An exact death toll has never been established. Union Carbide, not surprisingly, set the toll on the low end at 3,800, while municipal workers claimed to have cleared at least 15,000 bodies in the immediate aftermath of the accident. The final death toll was estimated to be between 15,000 and 20,000, while a half million survivors suffered respiratory problems, eye irritation, or blindness.

It is interesting to note that the Dow/Union Carbide website today still cites the reason for the incident as “deliberate sabotage.”

In June 2010, seven former employees of Union Carbide’s Indian subsidiary were found guilty of death by negligence. They were fined about $2,000 each and sentenced to two years’ imprisonment, then released on bail.

This example has always horrified me, especially the way local plant operators were left running a plant that was being disassembled around them with the company trying to reduce spending.

In my mind, this is definitely a case of systems gone wrong, and maybe corporate greed run amok, but I find it hard to place individual blame on anyone. Although being able to see the internal Union Carbide communications might provide evidence that there are individuals to blame, based on what is available I don’t see it.

Conclusion

In some of the above examples above, people were blamed wrongly, and in others their individual actions were at least partially responsible.

Some companies I have worked at stand by the “fact” that any incident/accident is the fault of not having the right systems or layers of protection in place.

Other places I have worked would more or less immediately fire people involved in incidents where they made the wrong choice or decision.

I don’t think either one is completely right and I will leave you with this as my final thought: I worked in a refinery where a heater was blown up when operations intended to re-light it after an unplanned loss of fuel gas had shut it down. There was a very detailed procedure for how to do this safely. The operators involved were both senior, and one of them had helped review and update the safe heater lighting procedure a few years earlier.

The procedure was mostly followed, except for the part about waiting 15 minutes after a failed lighting attempt. Also, after a failed lighting attempt the gas/oxygen mix in the heater was supposed to be checked to ensure there was no flammable/explosive atmosphere existing in the heater casing before another attempt was made.

They tried to light it and failed. Instead of waiting and doing the gas testing, they tried again in three minutes and exploded the heater. Thankfully, neither of them was seriously injured. Neither of them was officially reprimanded or punished in any way and the cause was an “unclear procedure” that was then rewritten, even though it had been clear to start with.

I look at this and can’t help but think that personnel should have been held to account for this incident, but what do you think?