Editor’s caution: This article contains graphic descriptions of an actual industrial accident affecting the safety of operators on site, including the injuries of a colleague sustained during the incident, leading to his death.This article is not for sensitive readers, it is a story of a tragic incident, and the subsequent investigation and lessons learnt: “The accident wasn’t about a single failure—it was about a culture where ‘nearly safe’ seemed close enough and where slight hesitations, though voiced, were overlooked. That day taught me that leadership isn’t about control but instilling vigilance that leaves no margin for error,” author Previn Pillay, FAusIMM TFIEAust CEngT NER IntET (Aus) .
Image by Freepik
I was 22 years old when I witnessed my first major industrial accident. It was 5:30 am on a Wednesday. Walking onto the site as dawn broke, I was thinking about the usual things—what lay ahead for the day, my first coffee, the hum of machines gearing up for another shift.
Then, slicing through the stillness, I heard a fire truck’s siren wailing as it tore past, breaking every site speed limit as it rushed toward my work area. Before I could process what was happening, an ambulance blazed past in a screech of metal, lights blazing, and the icy grip of dread set in.
As I neared the plant, the calm of the early morning shattered into chaos. People were sprinting, some frantically waving the ambulance forward, others frozen in horror…
Then I saw him. A large man covered head to toe in a thick, oily, black substance, steam and stench rising from his body. It was as if he were dissolving before my eyes, the substance eating away at his skin. He was writhing, his mouth open in a scream so raw it cut through the noise. I stepped forward, instinctively wanting to help, but a hand gripped my shoulder, pulling me back.
“Wait! The paramedics are coming!”
“What happened?” I managed to stammer.
“Gabriel got burned,” a coworker choked out, his face ashen. “The digester blew up.”
Gabriel had been doused in black liquor, a deadly mix of caustic chemicals used in the pulp digestion process. The digester, a massive steel vessel pressurised with steam and chemicals, had ruptured. In a matter of seconds, Gabriel had been engulfed in a burning wave of black liquor—a corrosive nightmare designed to break down industrial materials, now eating through human flesh.
Time felt warped, everything moving in fragments. One moment, he was on the ground. The next, he was strapped to a stretcher, then lifted into the ambulance, disappearing toward the company helipad, where he would be airlifted to the burn unit.
In the minutes that followed, shock hung heavy over the site. The plant manager locked down the area, barricading off the digester, while the leadership team scrambled to piece together what had gone wrong. We huddled in the control room, replaying the accident in our minds while our hearts stayed with Gabriel.
Three days later, Gabriel succumbed to his injuries. Fourth-degree burns had claimed his life, searing past skin and tissue, penetrating tendons, cartilage, and organs. The shock of his death rippled through the site, triggering trauma that some still carry today. Therapy sessions were arranged, but for many, it wasn’t enough. The memory stayed seared in my mind—a visceral reminder of how fast things can turn in this line of work.
The aftermath: root cause, accountability, and leadership
An investigation began the day after the incident, aiming to uncover how this could have happened. What we found was a series of minor oversights—routine, almost trivial missteps that, in isolation, seemed insignificant. But together, they painted a picture of imminent danger.
The digester, we learned, had developed a blockage at 4:30am, just as the night shift neared its end. Blockages happened often, and the solution was straightforward: stop all feeds, let the pressure gradually release, and then inspect. But this time, the pressure gauge showed just above the safe limit, indicating the vessel was “nearly safe” to open. Gabriel, who had opted to tackle the issue himself, moved ahead, believing he could get it done before shift change.
As Gabriel loosened the final bolts, the digester ruptured. The gauge had malfunctioned, displaying a lower pressure than what had built up inside. And in that final second—too late to retreat—the explosion erupted, flinging him across the room in a scalding jet of black liquor and steam.
Our investigation closed with disciplinary action. The supervisor was fired—a decision that gnawed at me for years. He’d told the team to hold off, to let the morning shift handle it. But Gabriel, perhaps thinking he was sparing us a headache, went down into the pit alone. So why was the supervisor held responsible for what felt like a tragic accident?
It took years to untangle that question. Responsibility, I learned, is woven deeply into leadership. The accident wasn’t about a single failure—it was about a culture where “nearly safe” seemed close enough and where slight hesitations, though voiced, were overlooked. That day taught me that leadership isn’t about control but instilling vigilance that leaves no margin for error.
Ten leadership lessons from that day
- Command respect and clarity: The supervisor was technically in charge, but his authority hadn’t permeated the team. Gabriel felt empowered to act on his own, and it cost him. Authority must be clear, respected, and aligned with the safety and well-being of everyone.
- Listen and act, especially on concerns: Some team members voiced hesitation as they watched Gabriel working in the pit, but no one took the next step to stop him. Leaders must listen to concerns and, more critically, act on them. Sometimes, a single intervention can mean the difference between life and death.
- Vigilance is paramount in hazardous environments: Situations can spiral in seconds in high-risk settings. Vigilance isn’t optional; it’s the backbone of safety. Check, double-check and never assume conditions are “close enough.”
- Never hesitate to seek help: The fear of looking unprepared often keeps us from calling reinforcements. An extra pair of eyes or hands can be invaluable in critical situations. There’s no shame in calling for backup; it shows leadership and foresight.
- “Nearly safe” is never safe: We thought “nearly safe” was close enough. It wasn’t. Being nearly safe is a red flag, not a comfort in this industry. Never settle for less than absolute assurance.
- Equipment reliability is non-negotiable. A single malfunctioning gauge led to catastrophic consequences. Routine checks must prioritise critical equipment. Every tool and indicator needs to function flawlessly when lives are on the line.
- Empower everyone to lead: Leadership is not just the supervisor’s role. Every team member has the power—and responsibility—to intervene. If someone had taken that step, Gabriel might still be here today.
- Constantly refine procedures: Just because a procedure exists doesn’t mean it’s perfect. Revisit, question, and update standard practices. The SOP is a living document, not a relic.
- Routine does not mean insignificant: Routine inspections or small tasks are often the easiest to ignore. But it’s the routine that guards against the catastrophic. Treat each small check as if lives depend on it—because they might.
- Foster two-way communication: An authentic safety culture allows team members to challenge decisions from the highest ranks to the ground floor. Leaders must nurture an environment where questioning is a sign of strength, not insubordination.
Conclusion: lessons etched in experience
The accident that claimed Gabriel’s life taught me lessons that no textbook or training course ever could. I realised that leadership isn’t about managing tasks but cultivating a culture where safety isn’t just a protocol but an instinct.
Some moments stay with us, not just as memories but as codes by which we lead. Gabriel’s story is a call to vigilance—a reminder that “nearly safe” has no place in high-stakes environments and that in every moment, we hold lives in our hands. I hope these lessons reach those who might face similar decisions, instilling the vigilance and humility to protect those we lead.