(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.
If you were to look at all Dupont workers including office and salesperson you might well find that auto and truck accidents are among the largest causes of death and injury to the company. In particular it is almost certainly the greatest cause among office workers. Also if they drive chemicals around in trucks a spill with a truck could be far worse. As an example back in the early 1970s an ammonia truck overturned on a freeway in Houston. http://blog.chron.com/bayoucityhistory/2011/05/35-years-later-houstons-deadly-ammonia-truck-disaster/
This disaster killed 7 and damaged the lungs of many more. Image if a truck carrying methyl isocyanate were to overturn on some cities freeway it could be as bad as bophal. So transport safety is a big thing to worry about.
A friend who used to work for DuPont told me a story about a cow-orker who was injured off the job (while skiing) and because the accident resulted in the use of sick leave time, it was rated as a lost time accident.
Don A,
Using sick leave and experiencing a lost-time incident are not the same thing, and one does not lead to the other. Given companies’ aversion to having to record an injury incident as a lost-time incident, I doubt your friend has the story right.
It is the responsibility of the organization to provide better work safety measures, proper medical aid. Hope such policies are implemented by every organization.
I worked at the La Porte plant for 8 years. Smoke and mirrors doesn’t even begin to describe the attitudes that prevailed among management and workers! This plant was OLD, it had horrible housekeeping, it had horrible upkeep, it was a ticking time bomb! Safety was talking heads, not real actionable items. We talked safety a lot ….but I know first hand, safety procedures were not followed, unsafe behaviors were not changed or challenged, management and workers were cavalier about clear and present dangers, poo pooing issues and assuring the workforce “no work would be done if it wasn’t done safety.” I saw plenty of unsafe conditions and reported them..what did I get?? Terminated!
Bulls-eye…………This describes the the safety culture at this corporation that claims to be a leader in safety.
I am a current employee of the company and observation from the an outsider is remarkably accurate. I have often wondered what others see from the outside because I see what goes on within the corporation.
I see the signs she speaks of, I see the numbers being presented and all the other smoke and mirrors described in the article.
Safety starts at the top of an organization.
This takes management commitment, worker buy in and of course resources which means cash. The recent trend in the corporation starts with Ellen Kullman. Her record in safety is amongst the worst of any CEO to ever lead the company. She has taken large bonuses and at the same time cut workers and the resources to put safety first.
Many times DuPont takes the “blame the worker” stance on incidents and issues. This tends to be self serving and does not really address the issues going on in the corporation. Under her leadership the trend has been one of a knee jerk reaction and is evident in this most recent tragedy. The statement that we will do a “top to bottom investigation” is such a reaction. Where was the commitment before the incident? the resources? the preventative maintenance? the inspection and all of the other key elements in a good Process Safety Management (PSM) program? It would be interesting to see if there have been cuts at the plant recently especially in light of the attempt to spin off its performance chemicals.
The real issues are never addressed when she sends Aaron Woods to the podium as her PR puppet, to make blanket statements such as “safety is a core value”. Mr Woods knows nothing of PSM and his statements are to fend off litigation that always follows tragedy.This does nothing to protect the workers.
The recent trend within the corporation has been of increased incidents increased exposures, and sadly increased deaths. The company continues to spew toxic chemicals into the atmosphere. Is this the kind of “core value” you want in your company? Is the the kind of chemical company you want in your back yard?
Kullman has been oddly quiet on this most recent issue, only offering Mr.Woods statement to the public. You would expect a great leader to step forward and share the blame for this declining safety. The public should be outraged that this leader in safety would have all the releases and incident shown to have occurred at La Porte and all other sites within the corporation.
If this corporation wants to be a leader in safety then changes are needed and this may start with new management, including a new CEO, one that truly wants the “core values they rhetorically state in all statements releases by the company.
Changes are needed before even more devastating incidents happen within DuPont.
Safety starts at the top of an organization.
This takes management commitment, worker buy in and of course resources which means cash. The recent trend in the corporation starts with Ellen Kullman. Her record in safety is amongst the worst of any CEO to ever lead the company. She has taken large bonuses and at the same time cut workers and the resources to put safety first.
Many times DuPont takes the “blame the worker” stance on incidents and issues. This tends to be self serving and does not really address the issues going on in the corporation. Under her leadership the trend has been one of a knee jerk reaction and is evident in this most recent tragedy. The statement that we will do a “top to bottom investigation” is such a reaction. Where was the commitment before the incident? the resources? the preventative maintenance? the inspection and all of the other key elements in a good Process Safety Management (PSM) program? It would be interesting to see if there have been cuts at the plant recently especially in light of the attempt to spin off its performance chemicals.
The real issues are never addressed when she sends Aaron Woods to the podium as her PR puppet, to make blanket statements such as “safety is a core value”. Mr Woods knows nothing of PSM and his statements are to fend off litigation that always follows tragedy.This does nothing to protect the workers.
The recent trend within the corporation has been of increased incidents increased exposures, and sadly increased deaths. The company continues to spew toxic chemicals into the atmosphere. Is this the kind of “core value” you want in your company? Is the the kind of chemical company you want in your back yard?
Kullman has been oddly quiet on this most recent issue, only offering Mr.Woods statement to the public. You would expect a great leader to step forward and share the blame for this declining safety. The public should be outraged that this leader in safety would have all the releases and incident shown to have occurred at La Porte and all other sites within the corporation.
If this corporation wants to be a leader in safety then changes are needed and this may start with new management, including a new CEO, one that truly wants the “core values they rhetorically state in all statements releases by the company.
Changes are needed before even more devastating incidents happen within DuPont.
As someone who cannot sing the praises of DuPont enough, I am stunned and dismayed by the La Porte Works fatalities, and not just because they happened, but by the response.
I worked as a DuPont manufacturing line supervisor and held manufacturing engineering positions in the old Explosives Department in the early 1970s. I was SOLD on the idea of safety. It was our “religion.”
Even while working rotating shifts (which means plant senior management might not always be on site) the supervisor(s) took responsibility for the line and what to do in case of an accident. For the supervisor (and I am not familiar with the exact circumstances, so there may be more to the story) calling “911” and in effect asking “tell me my job,” was shocking. Plant supervision MUST react to plant problems, not the local fire department who do not know what they are walking into. It’s management’s responsibility to manage and that means managing the plant during a crisis. At least that’s what the old guard use to tell those of us coming up, otherwise who needed us?
If the reports are true about the condition of the La Porte Works safety equipment and personnel preparedness, something serious has happened to the DuPont I knew.
There has been a tendency–a fad shall we say–to bring in “new blood.” The Board of Directors used to be the heads of the various operating departments and there was a wisdom in that. That is no longer the case. New blood at the top may have changed things. I don’t know. I surely am not saying CEO Kullman is directly responsible for the state of affair at La Porte Works, but I wonder if safety is in the blood of DuPont in the same way it was for those who cut their teeth in the manufacturing departments a generation ago. A generation ago, if it happens on “your watch,” you are responsible.
This has happened on not just Kullman’s watch, but the watch of the top management at DuPont. It’s time to dust off the Safety How manuals hand them out to everyone (top management included) and not just mouth the words, but have an old tent revival!
People’s lives, and livelihood, may well hang in the balance.
Katherine Lawrence
MBA, HBS 1976
DuPont alum 1969-1974
DuPont has been labeled a repeat offender. They did not learn from the death of a worker from phosgene at the Belle WV site.
The company has also been placed into the Severe Violators program by OSHA.
There were large fines and release incidents at the Darrow LA site and the Chambers Works site in Deepwater NJ.in late 2014.
We never want to blame Ellen Kullman , however facts are facts….Six deaths in 5 years while she leads the company in addition to all the other releases and incidents in the corporation. It is truly time for her to step down as her core values have dissipated and clearly her MIND IS NOT ON TASK. We want a feel good discussion versus one that brings results….she loses her job so be it, she had the ability to change that and she did not.
If we want to talk about response, lets talk about the response from Ellen Kullman. Not one word to the public on this and not one word to the public on her decline in safety. She sent her PR puppets to make boiler plate statements.
Is this the kind of safety you want? Is this the kind of response you want from your leaders? Six people are dead under her watch and will never be coming back, yet she took raises, stock options and other forms of compensation during this time. Would that compensation have fixed the non working fans in the unit? Would that have helped the families who have lost loved ones?
Enough of the rhetoric and safety program manuals talk, lets get to back to real safety ,one that deals with the hazards and not behavior based safety that tells you to hold the hand rail when going up and down stairs.
Do the right thing Kullman, before more are killed under your watch. STEP DOWN!