Machinery Safety 101

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

This entry is part 6 of 9 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, 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 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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Acknow­ledge­ments: US Chem­ic­al Safety Board for excerpts more…
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