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Chemical Factory lost precious material – Opinion about case

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In a Chemical Factory, A precious material spill into Reactor.

After a short research, night before at the control room there were a lot of alerts so the operator disconnected the alert.

Does that operator should be punished or not?

My opinion is that the Operator shouldn’t be punished:

  • The operator for a reactor apparently works there for a lot of time cause he was at night shift and operated the reactor.
  • If the operator shut down the alert of the leak, it means that he learned it from other operators.
  • According to this behavior we can learn a lot about the culture and norms of that company.
  • 3 new things that I leaned at this lesson are:

  • After about 3.5 times of repeating a task, then a person would learn about 80% of an operation.
  • “Best Practice” – although it is talked a lot, the true meaning is that there are things that will be learned only while experiencing practically.
  • When researching a case or abnormal event, while failures are researched and investigated, also successes should be researched and learned.