Monday, September 16, 2013

A Leader Takes the Blame

As a Project Manager in the Oil and Gas industry, I deal mostly with physical objects. LARGE, physical objects. These objects typically need to be tested prior to acceptance by the customer. In one case the test is called a lift test.

Picture from NOT the supplier for this story
The object in this case was long (50+ feet) and cylindrical, weighing over 30 tons. The cylinder was fabricated at one location, but that location didn't have the capacity to perform the lift test. The cylinder was rigged with the customer provided Kevlar slings, shackles, and other equipment; then loaded onto a barge and transported to a location with the crane capacity to perform the lift.

At the lift facility, the customer sent representatives to witness the lift. In fact, the customer's customer sent representatives to watch the lift. In addition there was a lift supervisor, two (2) quality personnel, two (2) safety personnel (including the safety manager), two (2) facility managers (one from the location of construction, one from the lift facility), four (4) third party inspectors, one (1) lift supervisor, and one (1) project manager (myself). We all had a chance to walk around the cylinder and inspect the rigging. We all participated in the Critical Lift Plan Briefing, and the Job Safety Analysis Briefing. Everything seemed to be in place, and the lift appeared to go well. The cylinder was removed from the barge, raised to a vertical position and then lifted off the ground to show that it hung perpendicular to the ground using the installation rigging. The cylinder was then lowered to the horizontal position and then back onto the barge. The lift rigging was removed for inspection... and this is where we hit our first problem.

The rigging was showing signs of wear. On all the slings, the Kevlar outer sleeve was separating, although the internal fibers of the sling were intact. Each of the slings has something called "tattletales" which are a safety measure. Tattletales are pieces of rope with little red marks on them. If the slings are overstressed, the tattletales will be pulled back into the sling, hiding the red marks. The tattletales had not moved during the lift. Essentially, the rigging was fine, except for the separation of the covers. The riggers started an inspection and looked at the detail cards on the slings. One of the sling wasn't rated for the load that was placed on it. In fact, the sling was underrated for the lift by more than 5 tons! He immediately notified his supervisor, who told the facility manager, who told me. This is a SERIOUS PROBLEM. If the sling had parted, more than 30 tons could have dropped, and who knows what could have happened. People could have been hurt and equipment damage.

An all stop was called, in order to determine the issue, what happened, and if we could safely perform the remaining lift. The members of the company went back to the office to discuss a path forward and make some phone calls. At this point, the customers and inspectors may not have known about the sling problem. We made some phone calls and had some discussions, then I asked the customers to join us.

I told them: "We are postponing the next lift in order to address an issue."

"What is the issue?"

At this point I didn't want to admit anything because we hadn't done our investigation, but I manned up and said: "We apparently used the wrong sling during the lift. We will try to locate the proper sling as well as determine how the wrong sling was used."

"Was the lift more dangerous than the briefing detailed?"

"No, with the proper equipment, the lift is no more dangerous than what was briefed."

"What was wrong with the equipment we used?"

I answered: "A sling was installed on the pile which wasn't rated for the load placed on it. I take full responsibility and we will have answers for you in the morning. If you have any questions, go through me. Everybody else here will be working on getting the lift on schedule."

For some reason, at this point the customers actually stopped asking questions, and two of them looked at each other and smiled. I learned later that, although we were in a separate office, two of the customers went outside for a "smoke break," and they stood outside the office and listened through an open window to the entire conversation that we had, including a suggestion to not tell the customer anything and keep moving forward with the lift.

In the end it turned out that the manufacturer of the sling provided the wrong sling. It met the measurements of the requested sling, but the load capacity wasn't correct. When the cylinder was rigged at the manufacturing facility, the rigger grabbed the sling that had the same measurements as indicated on the lift plan. He didn't check the load capacity, and nobody else did either. Nearly a dozen people onsite to ensure a good lift, and none of us checked the card to ensure it was the right sling.

We called the manufacturer, who immediately rushed three (3) new slings to the site overnight. The next morning I briefed the customer and all the representatives on what we had learned over the course of the night. The proper rigging was installed, and everybody verified the load capacities. the lift was performed and we still ran into the Kevlar issue with new slings, but at least this time we had the right equipment. In the end the cylinder hung the way it was supposed to.

The company made several corrections based off that event, including creating a couple of new forms specifically to check the rigging against the critical lift plan, as well as adding sign-offs to ensure that the rigging (slings, shackles, pins, etc.)  is checked by the rigger AND verified by the lift supervisor.

From a leadership side, here are a couple of lessons I learned:

1. Don't Assume (yes, again) that something is right. Check it, before it gets you in trouble. Now I had asked several times about the rigging, but didn't look at it directly.

2. As the Project Manager, I took ownership (Command) for the incident. I didn't ask for safety or the facility manager to explain what happened. It was my job, and happened while I was present. I also took responsibility, acknowledging what happened, that we would fix it, and that all questions should go through me. I didn't let it get to the other people present, because part of my job is to protect them. When we identified that a rigger grabbed the wrong sling, I didn't mention names. Nor did I say who the supervisor of the rigger was.

Now, we did have several conversations with them after this event, but that was in private, and constructive in order to prevent the issue from happening again.

3. Go with the truth, you never know what the people you are talking to may know. At the initial briefing, I didn't know that the customer's reps were standing outside the window listening to the entire conversation we were expecting to keep internal. I know that during the discussion we tried to figure out how much to acknowledge and what to say. If we had tried to cover anything up, the whole relationship with the customer would be jeopardized, and we needed to maintain it.

Thankfully, slings are rated to 3 to 5 times capacity. The slings didn't part and nobody was hurt, the test went well the following day, and we were all able to recover from the event. In the long run, it is another leadership lesson, which I hope won't be reinforced in the near future.

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