STEPPING STONES

                      -More people would learn from their mistakes if they were not so busy denying them

It was in December 1988. It was just one year after I had completed my Executive Trainee training at Singrauli and Ramagundam. Ramagundam unit 4, first 500 MW power unit of South India was commissioned in June 1988. Boiler water silica had been maintaining high and condenser tube leakage was suspected. To check this , it was planned to isolate condenser passes one by one. I was asked to stay at Cooling Water pump house control room to take care of any eventuality in CW pumps. One CW pump was stopped and one condenser pass was isolated as planned. After 15 minutes suddenly running CW pump also had tripped on discharge pressure high protection and as a result unit tripped. I was suspecting by mistake unit people might have closed the other condenser valve also causing the pressure high trip. Similarly unit people had suspected that I might have closed running pump discharge valve resulting the pump trip. Suddenly two Japanese people had come running to me from CW pumps which are located in other room and told me that they had activated the protection to check its healthiness. Here I have to describe the background of the event. CW pumps are Hitachi make and these people had commissioned the pumps around one year before. Meanwhile NTPC commissioning team had checked the protections and suspected the discharge pressure high protection was not functioning properly and same was reported to Hitachi. These people were experts of CW pumps but did not know the relevance of the pumps with the rest of the plant. So they had tested the protection without informing NTPC people as they thought that running the pump without this protection was not good  for the pump. 

Immediately I told them what had happened due to their action and explained about the loss of production. They were apologetic and came to unit control room and tendered apologies to everyone present there. As usual initially our people were very angry and scolded them. However later on our people had told these things do happen during initial commissioning phase and assured them that it would not be reported to Hitachi head office. But our people were surprised to receive an apologetic letter from Hitachi Japan. When contacted it had come to our knowledge that matter was reported by those two people only to their company. When asked for the reason for their reporting the answer given by them was indeed a lesson to me. Hitachi will take somebody’s genuine confession in the right spirit whereas deliberate suppression of wrongdoing will be viewed very seriously.

After six  years similar incident occurred. By the time I was unit controller of unit 6. Generator stator is cooled by water. There are two primary water pumps for this purpose. One pump runs continuously and other is a standby. Permit was given to electrical maintenance for checking the module of one pump. While they were working on the module, running pump tripped on supply failure causing the unit to trip. When asked, our electrical maintenance immediately answered that fuse of the running pump might have failed  at the same time. But when pump was started after putting back the same fuse it was running normal. Even though everybody had suspected that it was too much of a coincidence to believe the matter was left there.

I remembered above two incidents after reading the book “ The Power of Habit “ by Charles Duhigs given to me at corporate centre recently. In that two incidents are described about the approach of Paul O Neil when he was CEO of Alcoa. In one of the incidents a worker jumps the safety rope and try to fix the problem of a machine. While he is attending suddenly machine takes start killing the worker on the spot. Analyzing the incident Paul concludes the following reasons. In his own words: “ We killed this man. It’s my failure of leadership. I caused his death. And it’s the failure of all of you in the chain of command.” The errors identified for the cause of the accident includes two managers who had seen the worker jumping safety rope but failed to stop him, a training program that hadn’t emphasized that he would not be blamed for breakdown, lack of instructions that he should find a manager before attempting to repair and absence of a system that automatically stops the machine if someone steps into pit.

In another incident at Alcoa Mexico plant, there was build up of fumes within one of the facilities causing temporary sickness to few workers. The problem was immediately resolved. Workers also recovered fully in two three days. But the plant manager failed to report the incident to headquarters Incident came to Paul’s notice when a nun complained about it during a shareholder’s meeting. Plant managers even though he was one of the most valuable executives otherwise was fired immediately. The reason explained by CEO was “ He got fired because he didn’t report the incident, so no one else had the opportunity to learn from it. Not sharing an opportunity to learn is cardinal sin”.

Primary water incident described earlier is not an isolated incident. Many times all these years I am observing that people not only do not accept their mistakes but also deny  the failure of even equipments in their area instead blame others and other equipment for the problem. As a testimony to this we can see only very few near misses are reported in the plant. This I feel is done because system rewards the people who defend and cover better than others compared to learners and who honestly admit their mistakes. In a country which taught the world about work with detachment ( Karma Yoga ) people identify themselves with equipment and failure of equipment is taken as person’s failure.

In one of the personality development books I read this : When a little child tries to walk and falls an Indian mother will immediately takes him into her lap curses the floor and kisses the child whereas an Israeli  mother encourages him to try once more telling him that these things do happen while learning a new thing. In her anxiety to show her affection and love Indian mother prevents the child to see the reality, teaches him to shift the blame,  denies the opportunity to learn and not allow him to try harder.

Mahatma Gandhi writes in My Experiments with Truth that committing mistakes is not that bad, but not learning from them is disastrous. He describes incidents like how he had learned from stealing some money from his father’s pocket when he was child and some more incidents when he had tempted (near misses ) to commit mistakes before  realizing the values he stood for. In one of the major events in response to a violent incident in a remote  village of  the then United Provinces Chaurichaura he suspended a national movement only to demonstrate the people that for him non violence is more important than freedom of the country for which he dedicated his life.   

We should have the courage to honestly accept our mistakes, discuss them, analyze them dispassionately emphasizing more about issues rather than persons and more importantly learn from them ,  spread the message so that entire organization will benefit from it.

At  the same time organization also should empathize with employees who accept genuine mistakes but punish willful  and habitual offenders. Not disclosing an incident should never be accepted and pardoned. Management should emphasize more about the incidents rather than persons.