How Risk Assessment Fails — Again. This time at DuPont.

Casualty Evacuated by EMS
This entry is part 6 of 8 in the series Risk Assessment

A recent report released by the US Chemical Safety Board (CSB) looks at a series of acci­dents that occurred over a 33-​hour peri­od on January 22 and 23, 2010 at the DuPont Corporation’s Belle, West Virginia, chem­ic­al man­u­fac­tur­ing plant.

A num­ber of sig­ni­fic­ant fail­ures occurred, but I want to focus on one pas­sage from the press release that is telling, par­tic­u­larly con­sid­er­ing that DuPont is seen as a class lead­er when it comes to work­er safety. I would encour­age you to read the entire release. You can also have a look at the DuPont invest­ig­a­tion details on the CSB site. CSB also pro­duced a video dis­cuss­ing the investigation.

From the press release:

Internal DuPont doc­u­ments released with the CSB report indic­ate that in the 1980’s, com­pany offi­cials con­sidered increas­ing the safety of the area of the plant where phos­gene is handled by enclos­ing the area and vent­ing the enclos­ure through  a scrub­ber sys­tem to des­troy any tox­ic phos­gene gas before it entered the atmo­sphere. The ana­lys­is con­cluded that an enclos­ure was the safest option for both work­ers and the pub­lic.  However, the doc­u­ments indic­ate the com­pany was con­cerned with con­tain­ing costs and decided not to make the safety improve­ments. A DuPont employ­ee  wrote in 1988,  “It may be that in the present cir­cum­stances the busi­ness can afford $2 mil­lion for an enclos­ure; how­ever, in the long run can we afford to take such action which has such a small impact on safety and yet sets a pre­ced­ent for all highly tox­ic mater­i­al activities.[sic]”

The need for an enclos­ure was reit­er­ated in a 2004 pro­cess haz­ard ana­lys­is con­duc­ted by DuPont, but four exten­sions were gran­ted by DuPont man­age­ment between 2004 and 2009, and at the time of the January 2010 release, no safety enclos­ure or scrub­ber sys­tem had been con­struc­ted. CSB invest­ig­at­ors con­cluded that an enclos­ure, scrub­ber sys­tem, and routine require­ment for pro­tect­ive breath­ing equip­ment before per­son­nel entered the enclos­ure would have pre­ven­ted any per­son­nel expos­ures or injuries.”

The high­lighted pas­sage above shows one of the key fail­ure modes in risk assess­ment: fail­ure to act on the res­ults. So what’s the point of con­duct­ing risk assess­ments if they are going to be ignored? In a present­a­tion in 2010, a col­league of mine made this statement:

The risk assess­ment pro­cess is inten­ded to be used as a decision mak­ing tool that will help to pro­tect work­ers.” – Tom Doyle, 2010

This is a fun­da­ment­al truth. The risk assess­ment paper­work can­not pro­tect a work­er from a haz­ard, only action based on the report can do that.

When decision makers receive the res­ults from a risk assess­ment pro­cess and choose to ignore it, or as the press release stated, “…exten­sions were gran­ted by DuPont man­age­ment…”, man­age­ment is mak­ing a fun­da­ment­ally flawed decision. The risk assess­ment pro­cess inten­tion­ally exposes the haz­ards in the scope of the ana­lys­is, and expli­citly ana­lyzes the prob­able sever­ity of injury and occur­rence. Once the ana­lys­is is com­plete, choos­ing to ignore the res­ults, pre­sum­ing that there is no evid­ence that the res­ults are incor­rect, amounts to neg­li­gence in my opinion.

Does this mean that we should not con­duct risk assess­ments? Absolutely not! In the Western world, we are oblig­ated to pro­tect the safety of work­ers, includ­ing our col­leagues and employ­ees, as well as any­one else that may inten­tion­ally or unin­ten­tion­ally be exposed to the haz­ards cre­ated by our activ­it­ies. We are mor­ally and eth­ic­ally, as well as leg­ally, obligated.

Used cor­rectly, risk assess­ment in any of its many forms provides a power­ful tool to pro­tect people. Like any oth­er power­ful tool, it also takes sig­ni­fic­ant cour­age and skill to use cor­rectly. Defaulting to the cost argu­ment alone, as it appears that DuPont did in this case, res­ults in the type of fatal fail­ures seen in this tra­gic series of events.

Special thanks to my col­league Bryan Hayward, the Safety Engineering Network Group on LinkedIn, and SafTEng​.net.

What is your exper­i­ence with imple­ment­ing risk assess­ment? Have you exper­i­enced this kind of res­ult in your work? Share your exper­i­ences by com­ment­ing on this post!

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Author: Doug Nix

+DougNix is Managing Director and Principal Consultant at Compliance InSight Consulting, Inc. ( in Kitchener, Ontario, and is Lead Author and Managing Editor of the Machinery Safety 101 blog. Doug's work includes teaching machinery risk assessment techniques privately and through Conestoga College Institute of Technology and Advanced Learning in Kitchener, Ontario, as well as providing technical services and training programs to clients related to risk assessment, industrial machinery safety, safety-related control system integration and reliability, laser safety and regulatory conformity. Follow me on