Let’s Be Frank: Well, They Sure Fired that Guy Quick

By Inspector Frank. April 25, 2024

I wrote an article on safety a while ago, specifically on whether failure in people or failure in systems causes safety incidents (“Let’s Be Frank: Sometimes, People Should Be Blamed...”). But there is another interesting phenomenon that I have seen occurring at big industrial sites for years, and that seems to be on the rise (or it at least goes through cycles). For lack of a better word, let’s call them witch hunts that occur after an incident or event.

When I started my career, there seemed to be a little more forgiveness in the industry. I don’t mean that there were nicer people around (without any data, I anecdotally think there were way more mean and angry people involved in oil and gas 25-30 years ago – or at least that’s what I tell my adult kids and junior co-workers), I just mean that it appeared to me that a lot of managers and/or companies would tend to take a calmer approach to personnel involved in incidents.

I think I am fairly safe in assuming that almost everyone reading this is either currently working or has worked at a facility that had “15 lifesaving rules,” “10 cardinal rules,” or some other variation of the “thou shall and thou shall not” set of site rules that always have the same rider: violation of these rules could result in discipline up to and including termination.

I have worked in places where these rules lean heavier toward personnel protection, sites where they lean heavier toward process protection, and some that have a mix. For personnel protection, the rules are quite often either driven by regulations, incidents that have occurred to that company, or incidents that have happened a lot and end up costing the company or the industry money. Totally acceptable. Obviously, if the company has had a lot of incidents with fall protection, it makes sense to stress that as a rule to follow and that not following it will result in disciplinary action. Same thing for process protection; if that facility, or company, or even industry has been having problems with, say, operational discipline (i.e., not following safe start-up procedures for a fired heater), it makes sense to stress those rules as being critical and have consequences when they are violated.

This wouldn’t be an Inspector Frank article if I didn’t hang a big “but what about” somewhere. Surprise, surprise! I have two issues with these types of ultimatum rules:

  1. Rapid progression to, or immediate, termination after violation of a rule, and
  2. Inconsistent application of the rules.

If you have been reading my articles for a while, you are aware that I quite often rail against poor management and poor application of rules. This is no different. My issues with “Cardinal Rules” are usually not the rules themselves or why they are there but rather have to do with how and when they are applied by line and senior management.

Let’s start with point #1, rapid progression to termination after violating a “golden rule.” I have really big issues with this, even at a conceptual level. In the article I referenced above, I talked about how sometimes people can be blamed, and sometimes systems can be blamed. As a starting point, let’s just assume a cardinal rule was broken, and it is a direct result of that employee’s actions, not some other factor. Now, does this employee have a history of not following procedures or violating safety rules? Okay, maybe termination is in order.

What if this was the first incident? He is a good employee, three years on payroll, no issues of note before he failed to wear fall protection above the company policy of 4 feet above grade without handrails, travel restraint systems, or other acceptable methods to prevent a fall. Maybe we are in a location where the OH&S rules actually say 10 feet, but company policy is more stringent because a worker fell and died at one of their facilities in Africa, and the policy changed around the world as a result of that event. His training records were reviewed, he’s fully trained, and he knows the company rules but broke them. Should he be fired? Well, if that is the policy around cardinal rules, then in many facilities, he likely just got terminated.

Is this a smart thing to do as an organization? I don’t think so. Is it an easy way to look like you are tough on rule breakers and have zero tolerance for cardinal rule violations? Yes, it is. It’s way easier than actually having managers and supervisors who are able to do their jobs. It’s way easier than doing performance management or just generally dealing with personnel.

But my real issue is this. That employee just learned a valuable safety lesson. If that employee had been chastised and put on a safety monitoring plan for the next three months, then it is likely he will never fail to follow that rule again. He will probably pay more attention to fellow workers and ensure they are safe. You spent money training this employee; they just learned something else the hard way that they will likely never forget, and you just sent them packing to use that hard-won lesson for someone else. Lot of wasted time and money.

You may be reading this and thinking, “Well, that wasn’t an expensive safety lesson. No one was hurt, and nothing was damaged.” Let’s change the scenario a little.

Maybe you have a cardinal rule around process safety management. One I have seen a lot is around operational discipline and how failure to follow the appropriate procedure during critical process operations (like at start-up and shutdowns) is a cardinal rule. And like other examples, failure to follow process critical procedures can result in progressive discipline up to and including termination.

I worked at a facility where an operator got terminated for breaking a process safety management cardinal rule. He was a senior operator (boardman, next in line for supervisor), and the units he worked in had an unplanned outage due to fuel gas issues tripping one of the heaters. This set of units was a big money maker, and everyone was trying to get the unit back up and stable, but they kept having issues with getting the hydrogen feed steady into the reactors, which kept tripping some of the automatic safety functions on the distributed control system (DCS). This competent and experienced operator called to override some of the instrumentation until they got the unit stable. Once it was stable, he dropped the overrides, and everything was back to normal. Except….

Except the procedure at this facility said an override could not be performed without the written approval of the area process engineer or designate. This all happened on a Saturday night, so he made a call not to wake up the engineer and did it without approval, verbal or written. There was an investigation and he admitted he overrode procedures to get the plant running stable. He was terminated four days later for violation of a cardinal rule.

Should he have violated procedure? No. Should he have been terminated? This is a little tougher. I wasn’t his supervisor or in that chain on the process side, and I did not really know him, but he was apparently well thought of and very knowledgeable. In fact, a few years earlier they had used him as an SME during the design phase of units he was familiar with. What I am getting at is he did not seem to have a history of issues or violating orders.

It seems like a big waste, but it leads to point #2 above: inconsistent application of the rules.

This operator was terminated. If you go back to the article I referenced above about responsibility (“Let’s Be Frank: Sometimes, People Should Be Blamed...”), you can read about the two operators blowing up a furnace while attempting to light it. Neither of them was terminated. That was the same facility that fired the operator above for overriding the DCS, and the two events were only a few years apart, and there were no significant changes to any of the rules in that time.

What was different was that there were different direct supervisors and superintendents. There is nothing worse than having employees at a facility see complete inconsistency in the application of disciplinary action. Do you want to kill morale and build a toxic culture? That’s a good start.

No matter the event or rule, these are expensive lessons your employees and maybe your company just learned. And they just got escorted out the door. That expensive lesson that you spent on a worker, who I guarantee has learned something from the experience, is now benefitting some other company.

I have a personal experience for you that reinforces my point. This is from my army days. I was a green infantry private who had just finished basic and trade training and been posted to a mechanized infantry battalion. We were doing battle group level training, and the battalion I was in was set up in a lager for a week or so. A full camp was set up; field kitchens, a field hospital, and some field maintenance shops were erected. Security was out and it was like we had built a mini base in the middle of nowhere.

We had sentries out for operational security, maintenance of the camp, and providing fire watch. One night, I was on the 0300 hrs fire watch shift and had the responsibility to refuel the generators for the field kitchen at 0330 hrs sharp so that when the cooks started prepping breakfast, the generators were ready to start up.

We were training, but it was fully tactical. One element of that is no white light used anywhere. Any lights that were used outside of closed tents or vehicles had to be hooded and have the red lens on, both to reduce visible light and not ruin anyone’s night vision who was on duty.

I went to the fuel dump to grab a jerry can to top up the kitchen generators. NATO has a standard for jerry can color. The green plastic jerry cans are all made the same and can be used for a multitude of fluids. They just change the color of the plastic ring and keeper that attaches the lid to the container. For example, the gasoline jerry cans have a red ring, the diesel ones have a yellow ring, and potable water has a blue ring.

The field kitchen’s generators were gas-powered, so I whipped out my hooded, red-lensed flashlight to find a red-ring jerry can at the fuel dump. Guess what? A yellow ring looks red under a red light. I merrily topped up the four gasoline generators with diesel, woke up my shift replacement, and went to bed….

I was awakened by my section commander about 60 minutes later, asking what the hell I had done to the generators. The cooks couldn’t get them started. We went to investigate and, by smell, realized I had put diesel in and understood what had happened (you can see my cunning and investigative mind was already developing).

We drained the tanks and, with a hell of a lot of starter ether and some choice words, got the kitchens up and running. I only screwed meal timings up for about 600 people, including some having to skip a hot breakfast because they were rolling out, so obviously, no big deal, and no one gave me a hard time or anything…

I was ordered to see the company commander later that morning, and we had a good talk about all of my issues and failings. But he ended that conversation with two statements. The first was that as punishment when we were in lager, I was getting up every morning at four, regardless of other duties and timings I had, and would act as prep/dishwasher/gopher for the cooks. The second was that I would research the effects of low light, filtered light, and night vision goggles on color perception and then present my findings to the company in a lecture, including my tale of woe.

I was new; could they have thrown the book at me? For sure. Did I get punished? Yes – although the worst punishment was dealing with my peers for the next few months. Did I learn something? Hell yes. Would I ever make that mistake again? Hell no. Did it get turned into a learning moment for the rest of the unit? Yes.

Again, sometimes a rule violation should result in progressive discipline. But immediate termination? I don’t think so. People do tend to learn from their mistakes.

I think any rule that is going to be enforced with termination as its potential first step is just lazy and inefficient management at its finest. However, if that is the path you are going to take, then at least do it consistently across the organization.

But as always, I am willing to hear other sides to this story and other thoughts.

“It’s fine to celebrate success but it is more important to heed the lessons of failure.” – Bill Gates

“You don’t learn to walk by following the rules. You learn by doing, and by falling over.” – Richard Branson

Comments and Discussion

Posted by William Oliphant on June 10, 2024
"Error is normal. Even the best people make... Log in or register to read the rest of this comment.

Add a Comment

Please log in or register to participate in comments and discussions.

Inspectioneering Journal

Explore over 20 years of articles written by our team of subject matter experts.

Company Directory

Find relevant products, services, and technologies.

Training Solutions

Improve your skills in key mechanical integrity subjects.

Case Studies

Learn from the experience of others in the industry.


Inspectioneering's index of mechanical integrity topics – built by you.

Industry News

Stay up-to-date with the latest inspection and asset integrity management news.


Read short articles and insights authored by industry experts.

Expert Interviews

Inspectioneering's archive of interviews with industry subject matter experts.

Event Calendar

Find upcoming conferences, training sessions, online events, and more.


Downloadable eBooks, Asset Intelligence Reports, checklists, white papers, and more.

Videos & Webinars

Watch educational and informative videos directly related to your profession.


Commonly used asset integrity management and inspection acronyms.