The carrot and the whip In RCA Second Part

Have you ever heard the phrases

• ·        “if the results of this investigation are different from what was found previously someone’s professional standing is going to be questioned”
• ·        “Whatever your conclusions might be we are not going to change ours”
• ·        “ you are here to check the methodology , not to change the conclusions”

For me this is practically a constant occurrence, so much that I am expecting the moment when they will be uttered.

Little do they understand the purpose of an “independent” RCA .

I am not called to verify what they have concluded but to find if something went missing.

Every time it goes that way, something was missed, sometimes grossly, sometimes on purpose.

Unfortunately I am not a consultant of the type that will tell you

“this is a move in the right direction”

And once the payment is secure, he would send an e-mail correcting the stand.

I tell them straight in, sometimes while I am still in their installation.

Beware this is a double bladed weapon. It can accelerate the corrective actions and turn you into a hero. Or more possible you will be seen as a villain, by the same people you are working with and that have made everything possible to swerve your way into their conclusions. 

In the long run they will all turn friendly again. If they survive the wrath of top management that will feel betrayed and concurrent with their primary instincts will want revenge.

In one occasion I was investigating the catastrophic fire of a couple of railroad cars of a unit train, about 100 cars. The rail company wanted to impose large fees for conveying this particular product. Lets us notice that the product has been conveyed by train for 20 years without mishap. Suddenly there was a catastrophic mishap , and yes the product was combustible , under the proper conditions it could self ignite. Being this track in particular 1000 kms long and there was nothing left of the cars the RCA was “difficult”. So I started at the beginning,

·        have they followed the procedures?

·         are the procedures written or discussed?

·         who is in charge of loading the cars, are they trained?

·        where is the QC station before the cars leave the installation?

·        what is the QC procedure?

·        Do they have ways of measuring the reactivity of the product?

·        How do they measure the temperature?

·         Who is responsible for the safety of the cargo?

To make the story short there were many sources of ignition included the migrants that ridded the train and that ignited fires to keep warm, the used signal flares dumped into the cars. In general the material could withstand those IS before a catastrophic failure.

 But on the source

·        Had no written procedures.

·        The procedure was verbal if any, and not everybody knew what to do

·        There were many operators loading the cars from different stock yards not all of them with experience.

·        The infra red sensors were not installed in the loading stations, probably on purpose

·         the blending bin had thermocouples and a strip chart recorder without paper, also probably intentionally.

·        And someone had ordered the pay loader operators to load from the “ Lote 6” the rejection lot , that had remnant red hot material .This was the most probable cause of the incident , as the material can be red hot inside of a pile for months , if you load this waste under a fresh pile you get paid handsomely (500 dlss per ton ) for waste , the client needs not know. (this might be what they wanted to keep secret).

·        The railroad cars had wooden floors. There was no specification for metal floors.

This was the second problem , the floors will burn and the load will be dumped under the car , and it might cause a derailment , (not very probable but possible) it would depend on how fast the load is dumped under the car. But now the carrier takes notice , and the client too. A very bad show .

·        The material had variable reactivity and was not measured, fines are more active in general than pellets, when fresh from the reactor but loose its reactivity soon , sooner in humid environments. so you either screen your export product, or you wait, or both. This product was not screened. Seems to me they were supposed to wait a week , in he loading of many cars they did not. they were probably hard pressed by sales and R&D to ship.

I reported the findings, and they did not like it, I do not know what caused the fire but there was more than one way to achieve the result, some of them within management grasp.

One week later they were at my office talking with my VP telling him that I was non grata persona in their plant. Six months later none of them remained in the organization. Unknown to them, it was one of their larger stock holders, who asked me personally to go visit them, as a special favor as he knew, I have been 3 years out of my home, precisely solving runaway reoxidation issues in much larger plants overseas.

My guess , my VP talked, or the stakeholder asked for my report .

It is difficult to explain why you have not implemented the fixes and continue to have incidents. One year later the plant new management hired me as contract consultant.

Lesson learned, if you have probable cause and proposed corrective actions, you will be held accountable if you do nothing even if nothing happens, you can judge what to do first and what not to do. Doing nothing because you do not like the consultant is no excuse. You cannot hide your head in a hole and pray nothing will happen.

After an Incident

The owners of the money do not appreciate inaction.