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

A recent report released by the US Chemical Safety Board (CSB) looks at a series of accidents that occurred over 33 hours 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 telling press release, particularly considering that DuPont is seen as a class leader regarding worker safety. I would encourage you to read the entire release. You can also look at the DuPont investigation details on the CSB site. CSB also produced a video discussing the investigation.

USCSB — Fatal Exposure: Tragedy at DuPont

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.”

USCSB Press Release

The highlighted passages above show the key failure modes in risk assessment: failure to act on the results. So what’s the point of conducting risk assessments if they will 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; the 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 makes 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? No! In the Western world, we are obligated to protect the safety of workers, including our colleagues and employees, and anyone else who 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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