The Danger of Deference in Risk Management

When you don’t know how to do something, it’s usually best to defer to the experts and let them take care of it. But what if the people you thought to be the experts actually aren’t? What if they’re not qualified at all?

The Danger of Deference

Blindly deferring to another party to solve a problem can create enormous issues that have catastrophic results. This is exactly what happened in Hawaii in 2011. A tragic explosion occurred when five employees of Donaldson Enterprises Incorporated (DEI), were disassembling fireworks and storing them in a tunnel inside a mountain. One day, while the employees were working under a tent outside the tunnel, it began to rain. The employees moved their work into the tunnel, carrying materials inside with metal carts.

Suddenly, a fire began, most likely from the carts creating friction with loose black powder (highly explosive mix of charcoal, sulfur and potassium nitrate, used inside fireworks to propel them into the air) and fireworks went off inside the tunnel while the employees were inside. Those five employees lost their lives. 

How in the EHS hell did this happen?

Deference #1: DEI’s qualifications weren’t verified before the project began. 

The government’s main contractor for disposal of illegal goods and prohibited materials, VSE Corporation, acquired a number of illegal fireworks, but didn’t have experience in firework disposal. They decided to subcontract this task to DEI, because the company had previously worked with the military to dispose of explosives. VSE was content to leave it at that, and no one thought to verify that DEI was actually capable of the job they were given.

It turned out that DEI had none of the appropriate qualifications for disposing of illegal fireworks, such as a Resource Conservation and Recovery Act (RCRA) certification, which includes the proper treatment, storage, and disposal of hazardous waste, or complete RCRA training, which includes emergency preparedness, recordkeeping, reporting, and best practices to safeguard human health and the environment.

Another reason for VSE hiring DEI may have been that DEI had a clean safety record, with no major incidents. There’s a common belief that if a contractor hasn’t had any safety incidents before, they must know how to complete jobs successfully and safely. But, the absence of incidents does not mean an absence of risks. There can be incredibly risky procedures taking place, and employees have just been lucky enough to not have been hurt yet. And as this example shows so clearly, lack of previous incidents doesn’t tell you anything about what might happen if the company takes on responsibilities that it lacks the proper experience and training to do.

Deference #2: No one questioned the lack of standard analysis. 

When DEI created their planned procedures for this job, they didn’t perform a hazard analysis to see how dangerous the procedures for disposal would be. Even through three iterations—each more unnerving than the last—there was no procedure for evaluating risks in a comprehensive way, which looked at potential causes of types of accidents and their consequences.

As the procedures weren’t thoroughly considered for their level of risk, possibly because they lacked the tools for a deeper analysis, no one truly had any idea of the looming threat to employee safety. 

• 1st plan: Desensitize fireworks by soaking in diesel fuel for 48 hours; place soaked fireworks in empty barrels and burn on an empty shooting range.  
  • This had a mixed result; some fireworks burned as expected, but some exploded due to the diesel not soaking through the fireworks’ shells.  
• 2nd plan: Cut a slit into firework shells with box cutters (without gloves, goggles, any kind of PPE) to better absorb fuel. 
  • This worked, but DEI decided to speed up the process with another procedure change. 
• 3rd plan: Disassemble fireworks entirely (still no PPE); store empty shells and loose black powder in cardboard boxes lined with household garbage bags.  

Deference #3: No one thought critically about the proposed procedures. 

Even those of us who aren’t EHS experts felt their stomach drop while reading that. How is it that no one thought to speak up and question any of the proposed procedures from DEI? VSE continued their assumption that DEI would know the right, safest way to dispose of the fireworks, deferring and enabling the incident to happen. 

So, how can we avoid falling into the danger of deference and avoid future incidents like this?

Take control of your contractors with a Control of Work system.

DEI never should have been hired for this job of disposing of fireworks, but VSE didn’t realize that because they had no “Control of Work” systems in place. “Control of Work” relates to ensuring that working procedures are as safe as possible, without any unplanned losses or damage to a facility, its equipment or its people.

A strong Control of Work system includes first verifying that all contractors who are being considered for a job have the knowledge and experience to complete the job needed, including any relevant licenses or certifications.

Some safety management software manages the verification of contractors for you, making the process of determining the right partner as simple as can be. The VelocityEHS Control of Work allows you to easily manage Operational Risk at every level of the organization. Including permit-to-work, contractor management, visitor management, and additional tools this software will help you ensure that all onsite visitors have been properly vetted, trained, and approved.

Empower your people with risk bowties.

Bowtie risk assessments are a simple, visual representations of the relationship between risks, the incidents they may cause, and the consequences of not properly addressing them. They democratize workplace safety and risk management knowledge by making risk factors and their pathways clear and simple for all employees to understand. When everyone knows the risks and the controls in place to keep everyone safe, they’ll know immediately when something is questionable, like slicing into firework shells with no PPE.

Ultimately, there shouldn’t be much deference in a well-rounded risk program, where every employee feels empowered with knowledge about risk and safety. It’s everyone’s job to think critically about the tasks being performed and how they’re being performed.

If you’re looking for a deeper look into risk bowties, we’re offering an intensive risk bowtie assessment training course on September 7 & 8. This course is led by two risk experts and will provide a detailed overview of risk and risk management, hands-on experience building bowties in the VelocityEHS risk management solution, and CEUs after full attendance.

The danger of deference isn’t limited to one aspect of environmental health & safety. Whether it’s for chemical management, industrial hygiene or ergonomics, when people who don’t have the proper qualifications are tasked with managing EHS concerns, everyone is at risk and in danger.

Keep your employees as safe as possible and avoid the danger of deference by having a clear control of work and using bowties to clearly communicate risk pathways to everyone.