Lessons Learned - A Critical Tool
From the People, Planet, Profits & Projects Blog
by Richard Maltzman,
Dave Shirley
View Posts By:
Richard Maltzman
Dave Shirley
Recent Posts
Saving the Sahel (Part 1)
You Can't Get They-ah From Hee-yah
Floating an idea into reality: the other side of the AI Project Paradox
The Environment of the Built Environment: an AI Paradox
Is plastic on your mind?
Categories
6th,
6th Edfition,
6th Edition PMBOK,
7th Edition,
7th Edition PMBOK,
8th Edition PMBOK,
8th Edition PMBOK Guide,
Activism,
actuarial,
actuary,
adapt,
addition by subtraction,
Africa,
africa,
agriculture,
airforce,
ajaita,
Alaska,
amazon,
analogous,
analytics,
ancient,
and more power,
antarctica,
anti-science,
apple,
apps,
architecture,
arctic,
arrakis,
Artificial Intelligence,
asch paradigm,
Assistant,
asthma,
astronomy,
automobile,
automotive,
autonomous cars,
b,
bankhar,
Banksy Crypto,
basalt,
baseball,
bats,
batter,
beauty products,
benefit,
benefits,
Benefits Realization,
beyond epica,
biases,
bicycle,
big data,
big dfata,
big dig,
bike,
biodiversity,
biomedicine,
birdhouse,
blockchain,
blood,
blue blood,
blue trees,
bluefin,
bluefin tuna,
book review,
boston,
boston university,
Boyce,
Brazil,
brazil,
Breakdown Structures,
BS,
building,
buildings,
built environment,
built environment,
bumblebee,
cake,
capacitor,
car,
Carbon,
carbon,
carbon capture,
carbon negative,
carbon neutral,
carbon pool,
carbon sequestration,
carbonate,
careers,
CEO,
ChatGPT,
chatGPT,
chatgpt,
chatgpt,
chess,
China,
china,
chopsticks,
citrus,
cli-fi,
climate,
climate change,
climate resilience,
climeworks,
Clumsy,
CO2,
co2,
CO2 Utilization,
coalition,
cobalt,
coffee pods,
cognition,
cognitive,
Collabortion,
colombia,
concrete,
Conflict,
construction 5.0,
cool projects xyloscope,
cooling,
coral,
corn,
cost of good quality,
cost of poor quality,
cost of quality,
crazy,
criticism of project management,
cryptocurrency,
CSR,
csr,
data,
data analytics,
data privacy,
datacenter,
dataset,
death spiral,
Decision Making,
decomposition,
Defense and Climate,
definition of a project,
deforestation,
dependencies,
dependency,
desert,
DIKW,
dikw,
dimopoulos,
disposal,
dna,
DOD,
dogs,
dolphins,
dream,
drilling,
drink,
dune,
dune,
dutch,
early start,
earth,
eatlocal,
eco-tourism,
ecological,
economic,
economics,
EKC,
electric grid,
electricity,
electronics,
elysis,
embodied carbon,
emerging technologies,
empower,
Energy,
energy efficiency,
environmental degradation,
escalate,
escalation,
ESG,
extreme weather,
fallacy,
FARC,
farming,
finance,
fish,
fish brains,
fishing,
fix,
fixing the earth,
flint water,
Flint Water Supply,
flood,
flooding,
Food supply chain,
food waste,
forest,
forest for the trees,
forestation,
forrestgump,
frank herbert,
Fruitcake,
fungus,
fusion,
Galvao,
garage,
gas,
gasoline,
geese,
gender equality,
gender partnerships,
generational differences,
Generative AI,
gladwell,
gold,
Goodness,
google,
Government,
GPT,
great pacific garbage patch,
green,
green building,
green buildings,
green energy,
green iguana,
green project,
green project management,
greening,
guest post,
gyre,
harkonnen,
Harvesting Benefits,
hawasina,
hedgehogs,
heursitics,
historical data,
hlb,
holitsic,
holland,
horseshoe crab,
human-caused climate change,
hydrogen,
hydrology,
ice,
iceland,
ignition,
iguana,
imagery,
impact,
india,
inequality,
information,
initiatives,
injection,
insurance,
intelligence,
interacting risk,
internal combustion engine,
invasive species,
investment,
isomer,
issue escalation,
issues,
ITER,
jobs,
Jupiter,
justification,
kids,
kill point,
knowledge,
koch brothers,
Kuznets,
laboratory,
LAL,
landscape mode,
lapampa,
launch,
LCA,
Leadership,
Leadership,
life cycle analyses,
life cycle analysis,
lifecycle,
Linkedin,
liquid,
lizard,
local,
long term,
long-term,
long-term thinking,
look up,
loud,
maintenance,
maker,
makermovement,
malcolm gladwell,
management,
marathon,
marine biology,
market,
mars,
Martin Luther King,
mean,
megawatt,
MeHg,
melting,
mercury,
metal,
Microgrid,
microplastics,
migration,
military,
millennial,
mindset,
minerals,
mission,
mitigate,
MLK,
mongolia,
museum,
museum of london,
nature,
nematodes,
net gain,
Net Project Success Score,
net zero,
netherlands,
network,
New book,
New Jersey,
New Practitioners,
new york,
NFT,
nitrogen,
noise,
noreaster,
norway,
nova,
NPSS,
NREL,
ocean,
ocean cleanup,
ocean life,
oil rig,
oil rigs,
oklahoma,
oman,
only murders in the building,
opportunity,
overall risk,
oxygen,
packaging,
pareto,
PBS,
permafrost,
persistence,
peru,
Pharmaceutical,
planet,
planet.com,
planning,
plant,
plasma,
plastic,
playground,
pm,
pm education,
pmbok,
pmbok guide,
pmnetwork,
PMXPO-2018,
podcast,
pollutants,
pollution,
poop,
poor,
portfolio,
power,
power skills,
privacy,
privacy concerns,
professors,
program,
Program Management,
project,
project leader,
project leadership,
project management,
project management 3.0,
project on fire,
project progress,
Project Success,
project success,
projecticity,
projectleadership,
projectmanagement,
projects,
psychology,
pulse of the profession,
purple bacteria,
purpose,
quiet,
rainforest,
rationale,
reef,
refugees,
renewable,
renewables,
Repair,
repair,
repeatable process,
repeatable processes,
repurpose,
research,
resource breakdown strucuture,
Resource Management,
reversing climate change,
revisionist history,
rich,
rigs2reefs,
ripe,
risk,
risk avoidance,
Risk Management,
risk mitigation,
risk response,
risk responses,
river,
robots,
rocks,
rules of thumb,
rural,
rural India,
russia,
Sarcasm/Irony,
satellite,
saudi,
schedule,
sci-fi,
Science,
science,
science-fiction,
scientific american,
screaming monkeys,
sea,
sea life,
Sea-Level Rise,
sea-level rise,
seagreens,
seawall,
seawater,
seawater temperature,
seaweed. beat;es. farming,
secondary risk,
selena gomez,
sequestration,
shipping,
skyscraper,
SLR,
smart cities,
smart city,
smelting,
social,
social pressure,
soil,
solar,
solar panels,
solar perovkites,
solar saheli,
sonic,
sponge cities,
SRI,
stage-gate,
stagegate,
stakeholder,
stakeholder management,
steward,
stewardship,
storage,
strategy,
stupid,
success,
suffer,
sulphur,
sunk cost,
supercapacitor,
supply chain,
survey,
Sustainability,
sustainability,
Sustainable Investing,
Sustainable Tourism,
sybiosis,
symbiosis,
system 03,
TBL,
temperature,
terraform,
terraforming,
test,
threat,
threats,
totem,
touchscreen,
tour,
tower,
Trains,
transparency,
transportation,
trash,
tree,
tree species,
trees,
trillion,
triple bottom line,
triple constraint,
truth to power,
UMass,
us army corps of engineers,
USDA,
vacuum,
value,
venus,
vision,
voice,
voltage optimization,
vw scandal,
washing machine,
waste,
wastewater,
water,
we mean business,
whales,
Whirlpool,
wind,
wisdom,
women,
Women in Project Management,
wood wide web,
woonerf,
Work Breakdown Structures (WBS),
world breakdown structure,
worms,
xian,
xylotron,
Yale
Date
One of the most valuable tools in the project manager’s tool kit is lessons learned. It can give a twenty-twenty hindsight perspective of a project to help avoid the mistakes of the past. George Santayana noted Spanish philosopher who, in Volume 1 of his Reason in Common Sense, coined the phrase “Those who do not learn from history are doomed to repeat it.” Sometimes, while we don’t know whether or not a “lessons learned” was conducted, it is good to go back and look at a project to see what we can learn so we don’t repeat history. Since the connection between sustainability and project management is a relatively new concept, we thought it would be interesting to take a look at an infamous project, Union Carbide’s Plant in Bhopal, India, from a sustainability perspective.
METHYL ISOCYANATE UN 2480
Shipping Name: Methyl isocyanate
Other Names: Isocyanic acid, methyl ester, Methylcarbylamine MIC
CAS: 624-83-9
WARNING! l POISON! BREATHING THE GAS CAN KILL YOU! SKIN AND EYE CONTACT CAUSES SEVERE BURNS AND BLINDNESS!
-
Fire fighting gear (including SCBA) provides NO protection. If exposure occurs, remove and isolate gear immediately and thoroughly decontaminate personnel
DO NOT USE WATER! REACTS VIOLENTLY WITH WATER OR STEAM!
|
Just after midnight on December 3, 1984, methyl isocyanate (MIC) gas began leaking from Union Carbide’s Plant in Bhopal, India. Before it was all over, approximately 10,000 gallons of the highly toxic gas had been released forming a deadly cloud that covered 25 square miles and killed or injured over 100,000 people. According to the Harvard Business School Case, “Bhopal became a symbol of corporate negligence and risk.” According to Newsweek, December 17, 1984, “It was like breathing fire…..” The following morning, while all the buildings were intact, it looked like a nuclear bomb hit. Dead humans and animals littered the ground. It was the worst industrial accident in history.
It is interesting that the Harvard Business Case[1] is that the roots of this disaster could be traced back to the mid-1960s when India was in the midst of its “Green Revolution.” In a socially responsible move, India wanted to eliminate chronic food shortages by boosting food production. One of the ways they wanted to do that was to make fertilizers and pesticides more readily available, thus the need for a manufacturing plant like the UC plant that used MIC in the production of pesticides.
As always, we like to give the caveat that we were not in the room when the planning decisions for the project were conducted, so we don’t know for sure what did or didn’t drive the decisions that were made. What we can do is look at the information available, which includes an organization’s reaction to the crisis, to provide some insight to not “repeat history.”
So what could have been done that may not have been done in the initial stages of the planning process for this project, specifically, the environmental risk assessment. Remember, we are looking at this as a retrospective and making some assumptions for the purpose of discussion. The gas is known to be highly toxic, see warning label above. UC’s name is on the plant. A risk encountered is whether or not UC will have enough control over the design and construction of the plant to provide the proper precautions when building this facility in the area of a city with a population of 900,000. The answer in hindsight is no, for a variety of reasons; vital parts of the plant including monitoring instrumentation and vent gas scrubbers manufactured in India by Indians (no control by US UC), limited safety training, employees selected and trained in India, many changes in design and configuration changes during the 10 years of construction, in other words, ceding of control to the Indians. Is that a good scenario for a company that has its name on the door? An observation we make because of the case study and other research into the disaster is that the executives of the US based UC seem to have felt that there was no liability for them because of the role of the Indian Government and the Indian engineers, builders, etc. Can that kind of accountability be delegated? We don’t think so. Sure, some of the responsibility can be delegated, but if your name is on the door, your name is on the door, and some of the profits are being returned to the US. You have no “case” for delegation of accountability.
Because of the toxicity of the gas, and the lack of control over some of the key safety factors, wouldn’t it be wise to take a very close look at the potential of a leak. Even if the likelihood is low, the impact will be very high. We conclude that there wasn’t much of a risk analysis done on the possibility of a leak by the circumstances surrounding the leak and the reaction to it. The storage tank holding the MIC showed a dangerously high pressure reading, but by the time it was caught, it was too late. At 2am (almost two hours after the tank started leaking) the plant’s emergency siren sounded. Thinking that a fire had broken out, “hundreds rushed toward the plant” right into the path of the gas. “The train station was littered with the bodies of railroad employees…tying up the station for 20 hours making it impossible to flee the disaster area.” Those who were wealthy enough to have cars tried to escape but were blinded by the gas causing numerous accidents. We would have thought that if the risk of a leak was more closely analyzed, a better plan would have been in place.
Looking back on the disaster, it is easy to speculate on what should have been done. But isn’t that what lessons learned are for? Some questions that could be asked:
-
Did they consider their ability to produce pesticides without stockpiling MIC?
-
Was the technology used in the Bhopal Plant inferior to that used in West Virginia?
-
Did UC know of safety issues at the Bhopal Plant?
-
Should the plant have been constructed further from a population center?
We have included sustainability as a criterion, which probably wasn’t as big a concern then as it is today and will be even more in the future. However, then and now, the consequences are the same; consumer backlash, law suits, devaluation of a company's stocks, etc. There are clear sustainability issues involved in this case, whether they called them that at the time, or not. Looking back on some of these “environmental” disasters can give project manager’s valuable insights for the future.
[1]Harvard Business School International Business Cases, Union Carbide’s Bhopal Plant, Rev. September 4, 1996.
Posted
by
Dave Shirley
on: August 08, 2011 09:42 AM |
Permalink
Comments (0)
Please login or join to subscribe to this item
Please Login/Register to leave a comment.
|
"People are always blaming their circumstances for what they are. I don't believe in circumstances. The people who get on in the world are the people who get up and look for the circumstances they want and, if they can't find them, make them."
- George Bernard Shaw
|
