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20 leadership lessons from an industrial fatality

What I learned from my first major accident

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I was 22 when I saw my first major industrial accident.

5.30am on a Wednesday, I was walking into site for the start of shift, 6am to 2pm, looking forward to a cup of coffee before the start of duty.

The first thing to pierce the eerie calm of that beautiful spring morning was the wailing siren of the fire-truck as it hauled past me, shedding the site speed limit of 20km/hr like the kraken unleashed.

Before I could register, the company ambulance blazed past in a cacophony of flashing orange lights, red paint and reckless driving.

“What on earth is going on?”

Nearing my work area, I saw a handful of people careening , one running in my direction and then past me, a couple of guys flailing their arms to direct the ambulance whilst one operator bolted up the stairs to the control room.

The next sight shredded my eye-balls — a large, well built man covered in an oily black, steaming ooze, his identity indistinguishable, screaming and writhing on the ground, his skin melting off his body. I shouted an obscenity and ran forward. A hand yanked me back, “Wait! The paramedics will attend to him!”

“What happened?!”

“Gabriel got burned! The digester exploded!” It was Julius, filling me between ragged breaths, his face haunted.

The digester is a large vessel that uses high pressure steam and caustic soda to convert raw sugar cane bagasse to pulp, which is then transformed to paper. The process of digestion is a high temperature, high pressure chemical reaction. The by-product, black liquor, is actually spent caustic soda, which, after it has leached certain compounds from the bagasse, becomes a corrosive and dangerous liquid.

Gabriel was enveloped in this toxic chemical from head to toe.

The next moments happened faster than I could comprehend, yet time dilated and space billowed out. Gabriel was on a stretcher, then in the ambulance, then vanished. Spirited to the company helipad to be air-lifted to a burn-unit at one of the best hospitals in the country.

3 days later, Gabriel died, his body finally succumbing to fourth degree burns. The black liquor had melted his skin off, gone past tendons and cartilage and into the internal organs. It was a testament to his prodigious strength and fortitude that he survived 3 days what would have killed any other person much sooner.

In the minutes post-accident, frantic minds raced to “contain” the situation. The Manager had the area cordoned off with red barricading, signs put up, operations shut down, an emergency meeting called.

In the control room, my shift team (the incoming shift) and Gabriel’s team (the outgoing shift), were clustered around the leadership team, everyone trying to gather themselves, calm down and piece things together.

The digester had experienced a blockage — a routine occurrence, which every single operator and supervisor had handled before, nothing out of the ordinary. This time the blockage happened at 4.30am, close to the end of shift. Digester blockages are remedied by stopping all feeds to the process and allowing the pressure to come down until it drops to a defined lower limit, indicating that the vessel is depressurised and safe for opening and inspection.

Usually when an issue happens close to shift change-over time, if it’s not critical or damaging, then it will be handed to the incoming team to sort out. Especially if it’s a night shift problem. The outgoing team is tired from night duty, concentration levels are sub-optimal. It’s prudent to stop the plant, make the area safe and hand-over for the fresh team to complete the work.

When the blockage happened, the digester process was stopped, the SCADA screens in the control room were monitored to ensure the pressure dropped to the prescribed value. The team went down to the area to start opening the vessel and inspecting the blockage.

A gauge installed at the outlet of the digester is a physical indication of the pressure status at the vessel discharge. In this instance, the desired pressure was 5 KPA. The actual reading was 7KPA. The pressure was dropping slowly, but it was close, indicating the vessel was “pretty much safe.”

The discharge of the digester is located in a sunken pit, at the bottom of two flights of stairs. It’s designed this way so when the vessel is opened, any residual pulp and black liquor can discharge into a bunded area, into a drain which then recycles the material to a holding tank.

With the team in position, isolations done and permits filled, the tools and equipment were put in place for unblocking. The Supervisor checked his watch — 5:10am. We would be coming in soon to take over.

He told his crew to pack up. “Let’s hand it over guys, the next shift can open up the digester and carry on.”

Gabriel, sensing they could complete the work in their shift and save the next shift the trouble, decided otherwise. He picked up the heavy torque wrench and descended into the pit. The Supervisor half yelled at him to stop and come back up but, being dexterous for his size, he was already loosening the huge bolts which lock the discharge man-hole door in place. Of course, he had on all the requisite PPC — helmet, goggles, face shield, PVC suit, etc.

As he undid the bolts, loosening each one a little at a time, some black liquor started to drip out the opening. Nothing alarming. We’d all seen this a hundred times. The pressure on the gauge at this point was exactly 5KPA — safe to proceed. As more bolts were loosened, the flow increased and lumps of pulp started coming through. Still normal. But then the flow started to become a little bit worrying, more than was customary.

The rest of the team watched from the ground floor, staring into the pit and communicating, whilst Gabriel kept going. Some concerns were expressed about the higher than usual discharge flow. Gabriel soldiered on, undeterred. The Supervisor watched on, at this point thinking, “What’s the harm? He’s already started. he’s being industrious and proactive.”

In that infinitesimal space between one second and the next, the digester exploded.

Nobody could describe what happened. The discharge of black liquor and pulp was higher than usual but nobody expected things to get so out of hand so fast. Hence only mild alarm was sounded but nobody acted to stop Gabriel, who’d thought he was doing the right thing.

Pushing to finish the job, he’d kept going and most of the bolts were loosened when the explosion happened. There was a tearing sound and the entire man-sized discharge door blew right off, bolts splintering, material surging out of the vessel in a boiling, corrosive blast of hot black liquor, steam and pulp.

The blistering stream struck Gabriel, lifting him off the floor, out of the pit and flinging him to the ground 20 meters away. Some onlookers were burned, up to second and third degree. Others were lucky as the molten spray missed them by millimetres.

The next events I saw myself, but nothing made sense. What actually went wrong?

Investigation uncovered that the gauge malfunctioned, displaying a wrong pressure when the actual pressure inside was much higher.

What followed was a series of investigations and hearings, followed by the firing of the Supervisor on duty.

For a long time I could not understand why the Supervisor had been fired. After all, he had told his crew to pack it up and hand over to the next shift. Gabriel had disobeyed his Supervisors instruction and gone down on his own.

The Supervisor had asked him to stop. So why was he being fired for something outside his control?

This was my first lesson in leadership. It took me years to get to grips with the intricate questions which this accident unveiled.

The immediate aftermath was the most traumatic period for everybody involved on the day. Many of the guys who had been there through the whole scene took months off work to attend therapy and counselling sessions.

Being young and naïve, and not witnessing the full chaos unfold, in a way shielded me. I was one of the few that did not need the therapy. But I did need support in other ways, and I had nobody to provide it at the time.

I grappled with questions of responsibility and accountability. To my mind, the Supervisor had been hard done by. Some people blamed the accident on the company — not caring enough about it’s people, so people felt pressured to “get the job done.” Others blamed the Manager and senior leaders — negligence, they failed to pick up the possibility of such an incident. There was a tumult of finger-pointing as everyone scrambled, some to cover their own behinds no doubt.

In the midst of all this, I was reminded of the day before the incident, Gabriel had come in for the night shift, I was leaving at the end of my day shift. During hand-over he was telling me about his plans for the future. He was busy building his first house, things were coming together and his fiancé was planning to move back down from the UK for their wedding.

12 hours later he was dying from a horrific industrial accident.

The fluctuating nature of industrial installations is emblazoned on my mind ever since. I always maintain a healthy appreciation for the fact that I’m responsible and accountable for some of the most high-risk, dangerous processes in the world.

Lessons I’ve learned:

  1. The Supervisor was only a leader in name and never had control of his team. The fact Gabriel was trying to do a good thing, in itself is commendable, but going against the instruction of the leader, indicates the team did not respect his authority.
  2. The Supervisor heard the concerns of the team but did not act, even when the situation started to give signs of a problem. Having the courage to act is vital and can save lives.
  3. In major hazardous installations, situations spiral faster than you can blink. Never take your eyes off things, never take anything for granted. Check and double check.
  4. When in doubt, ask for help. Do not be afraid to call in an extra pair of eyes/hands, request your superior’s help or pick up the phone and consult an expert. Remember the adage, measure twice, cut once.
  5. “Pretty much safe.” is not good enough. It falls in the same area as, “it’s close enough.” There are no half measures. Do it the right way.
  6. The Supervisor was scapegoated to protect higher-ups. Defective equipment should be picked up during routine plant maintenance inspections and actioned immediately, especially critical equipment that is used to make decisions about the process.
  7. Anyone can be a leader — the other team members voiced concerns but did not act. Anybody could have stepped in. Never feel your title or rank consigns you to being a “follower”. Great leaders understand how to be great followers.
  8. Do not let zeal overpower reason and wisdom. In heavy industry, the risks are not in the same category as in other environments.
  9. Assess and improve equipment, practises and processes. Never presume the current SOP (Standard Operating Practice) is the best version or the current equipment is optimal.
  10. Maintain appreciation and respect for the vagaries of industry. Even if something looks normal, dig deeper.
  11. Develop instincts you can trust; if something feels off, stop, investigate, go back to the drawing board.
  12. Learn from others who know more than you and have done it before. Good instincts are gained through hard work and tough experience.
  13. Keep records and never neglect routine checks because they’re easy. When something is easy, it’s also easy to skip or overlook. Routine may be some of the most important work you will ever do.
  14. Invest in your most valuable resource — people. The difference between good and great is Human Capital.
  15. Everyone should receive leadership training. It does not have to be costly. Get your trainers trained, then let them run site-based workshops to bring everyone up to speed.
  16. Foster two-way communication and transparency, up and down the line. People should feel empowered to challenge decisions.
  17. Engage with people so they feel your authenticity. You will activate not only their minds but also their hearts.
  18. Build trust and rapport so potential leaders reveal themselves and blossom.
  19. True leaders revel in the joy of persuading smart people.
  20. Create alignment so everyone understands their contribution. This is the first step in transforming a group into a team.

There are moments in life you will never forget; but no matter the outcome, always learn and grow.

Take care and be safe!

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