(Updates made 11/26/15 appear in [ ])
The Houston Chronicle’s Lise Olsen and Mark Collette continue their reporting of the November 15 incident at DuPont’s La Porte, TX facility that killed four workers. Wade Baker, 60, Gilbert “Gibby” Tisnado, 48, Robert Tisnado, 39, and Crystle Rae Wise 53, were asphyxiated by a release of methyl mercaptan [
related to a faulty valve . A faulty valve may have been part of the problem. Alexandra Berzon at the Wall Street Journal reported the trouble may have started with a blockage in the methyl mercaptan line, and that the operation was not properly vented.]
A former employee told the reporters that DuPont is a “stickler for safety”, but what does being a safety stickler really mean? I got a hint when I saw the first news reporting about the event. A photo of DuPont officials speaking to the media outside the facility showed an electronic sign that displayed the following message:
“Please take extra precaution when driving and walking.”
Really? Be safe when driving and walking? That’s the safety message at a plant that stores hundreds of tons of highly flammable and toxic chemicals?
Messages about “being safe” is what workplace safety has boiled down to in too workplaces. Are you wearing your safety goggles? Are you holding the handrail when walking up steps? Are you wearing your seatbelt while driving the forklift?
I can’t say I’ve seen a company safety sign that says “If forced overtime is making you fatigued, you can sue us when you get injured.” Or this one: “If you have to ask for a replacement part more than once, you should shut down the production line until you get it.”
DuPont makes millions selling its trademarked Safety Training Observation Program (STOP). It’s a behavior-based safety program that is all the rage in many industries (e.g., here, here.) The company claims the program will
“prevent injuries by increasing safety awareness and helping people talk with each other about safety.”
The workers I know fully aware of what is safe. Frankly, they aren’t too interested in putting their faith in “safety talk,” they want safety action. That translates into sufficient time, investment and personnel to do a job safely. Cutting corners on maintenance, skimping on personnel, and pushing production get to the root cause of catastrophic incidents, not whether a company is a stickler for counting days without a “lost-time accident.”
What we’re learning from the Houston Chronicle’s reporters is the smoke and mirrors of DuPont’s safety performance. They quote Congressman Gene Green (D-TX) who represents the La Porte, TX area:
“The unit where workers died had been shut down for five days before the accident and workers had reported persistent maintenance problems.”
The reporters paint the picture of a facility ill-equipped to handle an emergency—an especially scary revelation given this was a petrochemical plant. It’s a workplace at risk of a catastrophic event, but that it was also [
storing produced for use] methyl isocyanate (MIC)—the compound responsible for the 1984 Bhopal disaster. [I learned that this facility does not technically “store” MIC. They produce it for use in one of their products. Something akin to “just in time production.”] The Houston Chronicle’s reporting on problems with emergency response at the scene raises questions about the effectiveness of the seven-module emergency response curriculum that DuPont sells. Read just some of what went down at the La Porte facility on November 15 (as reported by the Chronicle’s Olsen and Collette):
- “No DuPont official contacted a special emergency industrial response network called the Channel Industries Mutual Aide (CIMA), a nonprofit formed to deal with potentially deadly disasters. … [CIMA’s chairman] said ‘(DuPont) didn’t set up an incident command center and connect with CIMA’” [Others on the scene say this is exactly true.]
- “DuPont apparently did not have enough emergency oxygen and masks on hand that Saturday for the workers who died trying to fix a leak or help others escape…” [Others say the problem wasn’t the number of emergency breathing apparatus, but that the responders weren’t properly trained and prepped to use them.]
- DuPont said in a statement ‘medical personnel could not reach the employees because they were not trained in the use of protective equipment’”
- “The firefighters didn’t know the layout of the building – a maze filled with pipes, towers, tanks and platforms. …Their breathing apparatus couldn’t provide enough air to explore the entire facility”
The Chronicle reporters note that the November 15 incident is the worst loss of life at the sprawling petrochemical complex—30 miles southeast of Houston—since the 2005 BP refinery explosion that killed 15 workers. Like this incident, the BP disaster was subject of an investigation by the US Chemical Safety Board (CSB). Sadly, I’m certain that the CSB’s findings about the BP incident will sound way too familiar to the families and co-workers of Wade Baker, Gilbert and Robert Tisnado, and Crystle Rae Wise. They included:
- Cost-cutting, failure to invest and production pressures;
- Reliance on the low personal injury rate…as a safety indicator;
- A “check the box” mentality was prevalent…where personnel completed paperwork and checked off on safety policy and procedure requirements even when those requirements had not been met;
- Lacked a reporting and learning culture. Personnel were not encouraged to report safety problems and some feared retaliation for doing so. The lessons from incidents and near-misses were generally not captured or acted upon;
- Safety campaigns, goals, and rewards focused on improving personal safety metrics and worker behaviors rather than on process safety and management safety systems;
- Outdated and ineffective procedures did not address recurring operational problems during start-up, leading operators to believe that procedures could be altered or did not have to be followed during the start-up process;
- The operator training program was inadequate. The central training department staff had been reduced…simulators were unavailable for operators to practice handling abnormal situations, including infrequent and high hazard operations such as startups and unit upsets; and
- …operators were likely fatigued from working long shifts for consecutive days.
I’ve no doubt there will be dozens of engineers examining valves, pressure gadget and other machinery and parts to identify the “root cause” of the incident that stole the lives of those four workers. But the “root cause” is never the gadget or gizmo. The root cause gets to the heart of the matter and asks “why” the situation occurred in the first place. The answer to that question will not be an “unsafe behavior” by the workers, but decisions made far up the chain of command.