In 1802, Éleuthère Irénée du Pont established a gunpowder mill on the Brandywine River in Delaware. Construction began in 1802 and gunpowder was first sold in 1804. The location provided resources necessary to operate the mill. Safety was a top priority, with strict rules and accountability measures in place. However, accidents still occurred such as explosions in 1807, 1815, and 1818 - the worst, which killed 34 people including children at the on-site school. Through these hardships, the du Pont family remained committed to running the business safely.

1. 201907 Case Study – du Pont P:1/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Why and How?
Φੰԋ‫ؼ‬ᙴǴ‫܌‬ Ԗ ‫ޑ‬ ٣ࡺ ೿ ё а Ⴃ ٛ Ǽ
ঁ ਢ К ၨ
ӕኬ‫ޑ‬ӃϺଯ॥ᓀ/О ‫ؠ‬ ᛈ ࣆ ወ ༈
ࣁ ϙ ሶ Ǻ
•‫׹‬ ٖ Ϧ љ ԋ ࣁ Ш ࣚ π Ӽ ‫ڂޑ‬ ጄ ᆶ ኱ ं (Φ ੰ ԋ ‫ؼ‬ ᙴ )?
•ԶѠ ᡼ ‫ޑ‬PCBౢ཰ ΋ Զӆ Ǵӆ ԶΟ р ٣ (֚ Զό Ꮲ )ǻ
Ǹϙ ሶ Ӣ ન ༟ ೷ ‫ٿ‬ ‫ޣ‬ ό ӕ‫ڮޑ‬ ၮ ?
Φ ੰ ԋ ‫ؼ‬ ᙴ
‫ڂޑ‬ ጄ
֚ Զό Ꮲ
ပ Н ‫ކ‬
Case Comparison

2. 201907 Case Study – du Pont P:2/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
In 1802, Éleuthère Irénée du Pont (1771-1834) established a gunpowder mill on the
banks of the Brandywine River near Wilmington, Delaware.
Comparison Case
໵ОᛰԋҽදࣽǺ
Ҕ ౷ ᕘ ણ ‫ک‬ Е ࣅ ણ Ȑ‫ٮ‬ ᅹ ȑа Ϸ ฮ ለ ႇȐ‫ٮ‬ ਼ ȑࡪ ྣ ϯ Ꮲ ी ໆ Ȩ΋ ౷ Β ฮ Ο Е ࣅ ȩ‫ޑ‬ К ‫ٯ‬ Ȑ፦ ໆ ฮ ለ
ႇ75%ǵ౷ ᕘ 10%ǵЕ ࣅ 15%ȑష ӝ ᇙ ԋǶ
Ϧ љ ᕴ ‫׫‬ ၗ 3.6࿤ ऍ ϡ Ǵว ଆ ިी 18ިǴ‫׹‬ ٖ ৎ ௼ э ‫ځ‬ ύ 12ިǴэ Ԗ ๊ ჹ ‫ޑ‬ Ѝ ଛ ៾ Ƕ
SourceǺhttps://kknews.cc/zh-tw/history/yemakyb.html

3. 201907 Case Study – du Pont P:3/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
Construction at the Brandywine location (brought in by 6740USD) was started in 1802in 1802,
and gunpowder was first sold in 1804first sold in 1804;
Comparison Case
The design of Director’s house should be constructed in such
a position that the whole plant be seen from its windows

4. 201907 Case Study – du Pont P:4/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
The location Nowadays- HagleyHagley MuseumMuseum
Comparison Case
྽ ԃ ‫ޑ‬ π բ ൑ ‫܌‬ /ᙍ ‫ؠ‬ ౜ ൑
Ϟ В ࢂ റ ‫ނ‬ ༜ ୔ /ߐ ౻ 15ᗔ

5. 201907 Case Study – du Pont P:5/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
The location provided all the necessities to operate the mill:
• a water flow sufficient to power it,
• available timber (mainly willow trees) that could be turned into charcoal
• close to the Delaware River to allow for shipments of sulfur and saltpeter,
• nearby stone quarries to provide needed building materials.
Comparison Case

6. 201907 Case Study – du Pont P:6/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
Commitment and Accountability
• Commitment and accountability were so strong that E. I. du Pont
lived at the site.
• The du Ponts raised seven children in the house, and in 2018, his
wife was injured and the house was severely damaged in an
explosion. Ultimately, several family members were injured or died
of work-related causes.
Comparison Case
Former president of Dupont- Crawford Greenwalt :
ȨMy company has had a safety program for 150 years. The
program was instituted as a result of a French law requiring an
explosives manufacturer to live on the premises with his family.ȩ
Crawford Greenwalt
1902-1993
Source: –James A. Klein “Two Centuries of Process Safety at DuPont” Process Safety
Progress V28(2), p114-122.
If you were Mr. du Pont, would you (and your family) live inside
the gunpowder mill plant site? Why?

7. 201907 Case Study – du Pont P:7/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
Commitment and Accountability
• For the next 170 years, members of the
DuPont family were actively involved in
running the company. Many family
members worked in the early powder
mills, built their homes and sent their
children to school buildings within sight
of the mills.
Comparison Case
Safety is more than just a program at DuPont;
it was a way of life that kept loved ones and personal property safe.

8. 201907 Case Study – du Pont P:8/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
Safety Design Concept (two century ago)
•• Spacing considerationsSpacing considerations were key to limiting the effects of possible explosions related to
manufacture of gunpowder.
• Mill buildings were constructed of three strongbuildings were constructed of three strong, stone walls, a weak fourth walla weak fourth wall made of
wood facing the river, plus a weak wooden roof that acted as a "safety valve
Comparison Case
Source: –James A. Klein “Two Centuries of Process Safety at DuPont”

9. 201907 Case Study – du Pont P:9/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
Internal Safety Rules( two century ago)
• Worker boots were supplied at company expense with wooden pegsboots were supplied at company expense with wooden pegs instead of nails
• The garments of the workers aregarments of the workers are pocketlesspocketless-- cannot carry knives or matches, or
anything, and are made of non-inflammable material. The buttons must not be metal.
•• NoNo one is allowed to go about with trousers turned up at the bottomtrousers turned up at the bottom, because grit is
collected in that way.
• The wooden wall faced the river so the boats were locked to the dock when productionboats were locked to the dock when production
was in progresswas in progress; DuPont's first lock out procedure.
Comparison Case
Source:http://www2.dupont.com/Phoenix_Heritage/en_US/1805_detail.html

10. 201907 Case Study – du Pont P:10/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Glory of du Pont
Safety Commitment and Accountability ( two century ago)
•• Members of the du Pont family and supervisors were accountable fMembers of the du Pont family and supervisors were accountable for the safeor the safe
operationoperation of the mills,
•• They present to startup new equipment or manufacturing processesThey present to startup new equipment or manufacturing processes.
• No employee may enter a new or rebuilt mill until a member of top management hastop management has
personally operated it.personally operated it.
• Management also gave personal instructions on how to safelygave personal instructions on how to safely roll powder kegs and
how to avoid dropping them.
Comparison Case

11. 201907 Case Study – du Pont P:11/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• The first explosion occurred in 1807 causing only damage to several buildings.
• The first safety rules in DuPont were established in 1811.
Comparison Case
Source:http://www2.dupont.com/Phoenix_Heritage/en_US/1805_detail.html

12. 201907 Case Study – du Pont P:12/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• The first company casualties occurred in an explosion in 1815 which caused 9 deaths
and cost the company $80,000, more than double the original investment($36,000) in
the entire company.
Comparison Case
https://www.timetoast.com/timelines/dupont-company-explosions
1802Ϧ љ ബ ҥ ‫׫‬ ၗ
ᚐ36,000ᗔ
1815‫ޑ‬ᛈ ࣆ ཞ Ѩ
80,000ᗔ(+9ԝ)
฻ ӕ‫ܭ‬ ॹ ഈ

13. 201907 Case Study – du Pont P:13/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• In 1817, they were faced with a more significant loss. Seventy-seven year old Pierre
Samuel DuPont, the financial founder of the company, died after working all night to
help fight a fire in the mill.
Comparison Case
Thomas Jefferson, the third U.S. President, encouraged the company
founder É. I. du Pont to manufacture gunpowder since the United
States at that time did not have reliable producers of high quality
powder, and perhaps because du Pont’s father had assured Jefferson
that du Pont gunpowder would ‘‘send bullets a fifth (feet) farther than
English or Dutch bullets travel.
፝ ΢ Դ η ..ό ‫ޕ‬ E.I. du Pontག ‫ڙ‬ ..

14. 201907 Case Study – du Pont P:14/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• A serious explosion that occurred in 1818 resulted in 34 deaths and injured many
children who were in the school building on the grounds at the time which remains the
worst process incident in DuPont company history.
Comparison Case
໾ Α ࠸ η ၟ ‫ۀ‬ η ..ό ‫ޕ‬ E.I. du Pontག ‫ڙ‬ ..
྽ ਔ ঩ π ό ၸ ω
100+Γ=>໾ Ϋ 1/3
ཞ Ѩ 12࿤ ᗔ

15. 201907 Case Study – du Pont P:15/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• A serious explosion that occurred in 1818 resulted in 34 deaths and injured many
children who were in the school building on the grounds at the time which remains the
worst process incident in DuPont company history.
Comparison Case
E. I. du Pontନ Α ा ᝢ ໣ ၗ ߎ ᔈ б ᜤ
ᜢǴӕਔ Ѹ ໪ Ӽ ኟ π Γᝩ ុ π բ Ǵ
а Ϸ གྷ ᒤ ‫ݤ‬ ዴ ߥ ғౢӼ ӄ Ƕ
1.࠹ Ѳ ‫׹‬ ٖ ৎ ௼ ཚ Ε ቷ ୔ ۚ Ր Ǵа ߄
ܴ ၗ Б ‫ک‬ മ π ӕғԝӅ ஻ ᜤ Ǵ྽ ฅ
ፔ Ψ ό ‫׆‬ ఈ ӆ ԛ ᛈ ࣆ Ƕ
2.࿣ ଚ Ǵന ߃ ৒ ‫ה‬ π Γ໯ ଚ Ǵё ࢂ ಃ
Β ԛ ε ᛈ ࣆ ‫ޔޑ‬ ௗ চ Ӣ ൩ ࢂ ΋ Ӝ π
ᓐ ໯ ଚ ၸ ໆ Ꮴ ठ ᇤ ᏹ բ Ƕ
3.‫ڋ‬ ‫ۓ‬ ٠ Ⴇ Ѳ ୺ Չ ᝄ ਱ ‫ޑ‬Ӽ ӄ ғౢբ
཰ ೕ ጄ Ƕ
Source: https://kknews.cc/zh-tw/history/yemakyb.html
ჹ ྣ ό ӕ Ў ҁ ჹ ‫ܭ‬ ਢ ௃ ‫ޑ‬ ௶ ॊ Ǵᡉ Ң ‫׹‬ ٖ ‫ޑ‬ commitment
and accountabilityࢂ ᒿ ๱ ٣ ࡺ ‫ޑ‬ ว ғ Զ೴ ‫؁‬ ග ϲ ǴԶߚ ΋
‫؁‬ ‫ډ‬ Տ ..

16. 201907 Case Study – du Pont P:16/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
According the notes of workers, 5 explosions that occurred in 1819-1834. (5 in 16year)
• Jun 20, 1824, Mill, 1 causality perhaps
• Apr 26, 1825, Upper Yard, 1 causality
• Oct 27, 1825, Upper Yard, 1 causality
• Jun 14, 1828, Mill
• Aug 25, 1832, Mill, 2 causality
Comparison Case
Source: https://www.timetoast.com/timelines/dupont-company-explosions
ӧ О ᛰ ቷ ࿣ ଚ ՠ ό ࿣ ྟ @"

17. 201907 Case Study – du Pont P:17/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
Safety Record of E.I de Pont(1802-1834)
1802-1818
• 4 explosions (recorded/revealed) 43 deaths, and more wounded within 17year
1819-1834
• 5 explosions (recorded/revealed) 5 causalities within 16year
Comparison Case
1817, Pierre Samuel DuPont, died after
working all night to help fight a fire in the mill.
1818, 34 deaths and Bankrupt
Brother in Law and Wife server wounded
1815, 9 deaths and total loss

18. 201907 Case Study – du Pont P:18/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Р ໺ η
Comparison Case
ৎ ௼ ‫܌‬ Ԗԋ ঩ Ր ӧ Տ ‫ܭ‬ π ቷ ਒ ᜐ ಍ ΋ ‫܊ޑ‬ η ္ य़ Ǵ‫܌‬ Ԗӧ ‫׹‬ ٖ Ϧ љ π բ ‫ޑ‬ৎ ௼ ԋ ঩ ೿ ό
Ѝ ‫ڗ‬ ᖒ Н ǴВ த ‫܌‬ ሡ ࣣ җ Ϧ љ ‫ٮ‬ ๏ Ƕӄ ೽ ৎ ௼ ଄ౢ೿ ឦ ‫ܭ‬ Ϧ љ Ǵा ౜ ߎ ё а ᒿ ਔ ‫ڗ‬ Ҕ Ǵ
ा ћ ً ǴϦ љ ᕴ ᒤ ٣ ೀ ࢴ ٰ ଭ ً Ƕ
https://kknews.cc/zh-tw/history/yemakyb.html
1837-1850
1802-1834

19. 201907 Case Study – du Pont P:19/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
According the notes of workers, 14 explosions that occurred in 1834-1850. (13 in 17year)
• JUN 20, 1834, Upper Yard, 1 causality
• MAY 14, 1835, Mill
• SEP 15, 1835, Mill
• SEP 28, 1835, Mill, 2 causality
• MAY 17, 1836, Mill
• MAY 23, 1836, Mill
• NOV 22, 1836, Mill, 1 causality
• APR 12, 1837, Mill
• AUG 29, 1838, Mill
• OCT 11, 1838, Mill
• JUL 24, 1844, Lower Yard
• APR 1, 1846, Mill
• JUL 23, 1846, Mill, 1 causality
• APR 14, 1847, Upper Yard, 1 causality
Comparison Case
Source: https://www.timetoast.com/timelines/dupont-company-explosions
О ‫ؠ‬ ᆶ ᙍ ‫ؠ‬ ‫ޑ‬࿶ ᡍ ᙦ ൤

20. 201907 Case Study – du Pont P:20/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
Safety Record
Comparison Case
1802-1818
• 4 explosions, 43 deaths, and more wounded within 17year
1819-1834
• 5 explosions, 5 causalities within 16year
ᒃ Γ໾ Ϋ ǺР ᆶ ‫ۀ‬
ઇ ౢǺ‫ٿ‬ ԛ
1834-1850
• 14 explosions, 6 causalities within 17year
ᒃ Γ໾ Ϋ Ǻค
ઇ ౢǺค

21. 201907 Case Study – du Pont P:21/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
л ໺ ‫׌‬
Comparison Case
Վ ճ ౥ ཰ ‫ܭ‬ Ջ ᗺ ै ਠ ǴΓॺ ᆀ Վ ճ Ȩஒ ै ȩǶՎ ճ ҁ Γό ᔉ ࣆ ᛰ ‫מ‬ ೌ Ǵ‫מ‬ ೌ π բ ֹ ӄ ߞ
Һ ᨷ η ܎ ነ ੝ Ƕӧ ୘ ཰ ሦ ୱ ǴՎ ճ ჹ ӕՉ ཰ ว ဦ ࡼ з Ǵ៳ ฅ ࢂ О ᛰ ཰ ‫ޑ‬ε ஒ ै Ƕӧ ߏ ၲ
39ԃ ‫ޑ‬Һ ය ϣ Ǵд ೯ၸ Չ ཰ ‫ک཮ڐ‬ ঋԂӕՉ Ҿ཰ ‫ݤ଺ޑ‬ Ǵз ‫׹‬ ٖ ࡆ ୯ ᚳ ε คК Ƕ
https://kknews.cc/zh-tw/history/yemakyb.html
1837-1850
1850-1889

22. 201907 Case Study – du Pont P:22/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
the Brandywine location in 1854,
Comparison Case
Notable: safety space?
ᒿ ๱ ᗶ კ ε ৖ Զ੃ Ѩ @"
‫ב‬ ૶ л ߏ ‫ޑ‬௲ ᇧ ᆶ ඵ ች @

23. 201907 Case Study – du Pont P:23/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
According to notes of workers, 36 explosions that occurred in 1850-1889. (36 in 39year)
• MAR 11, 1852, Mill, 2 causality
• MAY 31, 1854, Wagons, 3 causality
• AUG 22, 1857, Grainery, 1 causality
• JAN 20, 1859, Mill, 2 causality
• AUG 8, 1863, Upper Yard, 1 causality
• MAY 10, 1864, Lower Yard, 1 causality
• JUL 23, 1864, Lower Yard, 1 causality
• APR 19, 1872, Upper Yard, 2 causality
• JUL 3, 1873, Millwright Shop, 1 causality
• AUG 14, 1873, Lower Yard, 1 causality
• MAY 20, 1876, Upper Yard, 4 causality
• DEC 27, 1882, Foundry, 1 causality
• MAR 29, 1884, Nitro Glycerin House, 3 causality
Comparison Case
Source: https://www.timetoast.com/timelines/dupont-company-explosions
Ϧ љ О ‫ؠ‬ ᛈ ࣆ ᆶ ໾ Ϋ ೱ ԃ ว ғǴ٠ ҂ ᒿ ๱ ”ख़ ຎ ”Ӽ ӄ Զ႟ ᙍ ‫ؠ‬

24. 201907 Case Study – du Pont P:24/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• On May 31, 1854, three of DuPont‘s wagons carrying 450 kegs of powder (11,250
pounds) exploded on 14th Street in Wilmington. The explosion instantly killed the
wagons’ drivers(3Γ), two bystanders, and fourteen horses.
• It also demolished or severely damaged all nearby buildings, destroyed a significant
portion of 14th Street, and crushed water and sewer pipes beneath the street.
• Angry citizens demanded that both the DuPont Company and its owners be brought to
justice for causing such devastating destruction in their city.
Comparison Case
https://www.hagley.org/research/digital-exhibits/dangers-transporting-powde r
གྷ གྷ ଯ໢ ਻ ᛈ ..

25. 201907 Case Study – du Pont P:25/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
Safety Record
Comparison Case
1834-1850
• 14 explosions, 6 causalities within 17year
ᒃ Γ໾ Ϋ Ǻค
ઇ ౢǺค
ൎ ቷ ‫ל‬ ‫ݾ‬ Ǻค
1850-1889
• 36 explosions, 23 causalities within 17year
ᒃ Γ໾ Ϋ ǺԖ
ઇ ౢǺค
ൎ ቷ ‫ל‬ ‫ݾ‬ ǺԖ
Lammot du Pont
He died in 1884
during an explosion,
ᚒ Ѧ ၉ Ǻ
ࡐ ӭ Γ ཮ ம ፓ Ӽ ӄ ሦ Ꮴ (ӳ Ⴝ Ԗ ӳ ሦ Ꮴ ൩ ૈ ҉ ߥ Ӽ ந )ǴԶব ঁ Ϧ љ ሦ
Ꮴ Γ ඪ ᇥ Ծ ρ К ‫׹‬ ٖ Ϧ љ ‫ޑ‬ ৎ ߏ ‫׳‬ ख़ ຎ Ӽ ӄ ǻ ԶᏱ Ԗ ຬ ભ ख़ ຎ Ӽ ӄ ‫ޑ‬
ሦ Ꮴ Γ ‫ޑ‬ ‫׹‬ ٖ Ϧ љ Ǵவ Ԝ ൩ ૈ ଯ ܾ ค ኁ ؒ Ԗ О‫ؠ‬ ᛈ ࣆ ᆶ ໾ Ϋ ǻ

26. 201907 Case Study – du Pont P:26/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• Approximately 100 people died in explosions from 1805 to 1860,
Comparison Case
Men in powder houses usually have an
arranged plan of escape in their minds,
and at the least unexpected noise, have
not hesitated to plunge into the canal.
The men were wont to say that
daydreaming was dangerous; when a man
got to musing, it was time to look for him
‘‘on the other side of the creek.

27. 201907 Case Study – du Pont P:27/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Β ‫׌‬ ໺ Ο ‫׌‬ ‫ޑ‬ ‫ٽ‬ η
Comparison Case
Eugene graduated from the University of Pennsylvania and joined the family business
in 1861. He started as an assistant to Lammot du Pont in the Brandywine Mills
laboratory and soon gained a reputation as a black powder expert. ᔅ Ϧ љ ᙯ ࠠ ǹО ᛰ
=>ࣆ ᛰ ǹৎ ௼ Ҿ཰ =>౜ ж Ҿ཰
1890-19021850-1889
‫ך‬ ঢ ‫ך‬ η
‫ך‬ ԝ ‫ܭ‬ π
ቷ О ‫ؠ‬

28. 201907 Case Study – du Pont P:28/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰComparison Case
Shadow of du Pont
F&E Accidents
Explosion at Upper Mill in 1890 killed 12 people.
Notable:
safety space?

29. 201907 Case Study – du Pont P:29/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
ᙑ ‫׹‬ ٖ 1802-1902
வৎ ௼ Ҿ཰ ᡂ ԋ О ᛰ ཰ ࣚ ᔅ Ь Ǵ
ё а ೯ၸ ި ҽ ௓ ‫ڋ‬ ‫ځ‬ д Ҿ཰ ‫ޑ‬ၗ
ౢ(ᚰ ᘐ /ᖄ ӝ ‫ۓ‬ ሽ )Ǵՠ ࢂ ࠅ ค‫ݤ‬
ჹ ೭ ٤ Ҿ཰ ჴ ࡼ ᆅ ౛ Ƕ
1837-1850
1802-1834
1850-1889
1890-1902
1902ԃ ‫׹‬ ٖ ԭ ԃ Ǵฅ Զӧ ೭ ԃ ሦ ೑ Ѐ ߎ ँ ฅ
ѐ Ш Ǵ൳ ঁ ԃ ᗌ ‫ޑ‬ ဠ ٣ ௛ Ћ ό Ϸ Ǵ᝺ ள ന ӳ
‫ޑ‬ ᒤ ‫ݤ‬ ൩ ࢂ ‫ע‬ ‫׹‬ ٖ Ϧ љ ፤ ๏ ᝡ ‫ݾ‬ ჹ Ћ ܎ ϻ
݅·ើ ቺ Ϧ љ Ǵ྽ ਔ ‫ޑ‬ ՗ ሽ ࢂ 1200࿤ ऍ ϡ Ƕ
ဠ ٣ ύ ோ ΋ ‫ޑ‬ ԃ ᇸ Γ Ǵബ ‫ۈ‬ Γ Ҳ ႜ ϣ ‫ޑ‬ ම ৊
Ն ᅟ ѷ ႜ ቺ ε ࣁ ό ᅈ Ǵд ᝺ ள ઒ ‫ے‬ ୷ ཰ ࡛ ૈ
਒ ပ д Γ ϐ Ћ ǴՖ ‫ݩ‬ ፤ ๏ Ћ Π ௳ ஒ ‫ޑ‬ ჹ Ћ Ƕ
Source: https://kknews.cc/zh-tw/history/yemakyb.html
ຍ‫ۯ‬ਢ‫ݺ‬ऱల‫׀‬

30. 201907 Case Study – du Pont P:30/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
ཥ ‫׹‬ ٖ 1902-1919
• வৎ ௼ Ҿ཰ ᡂ ԋ ౜ ж Ҿ཰ (ϸ Ԏ ܎ ථ ǴϦ љ ӝ ‫ٳ‬ ᆶ ϩ ‫ܨ‬ )ӭ ‫ف‬ ϯ ࿶ ᔼ Ǵ ‫ע‬Դ ΋ ፸ ‫ޑ‬ђ ‫܁‬
բ ‫ݤ‬ ᙯ ᡂ ࣁ ౜ ж Ҿ཰ ࿶ ᔼ ᆅ ౛
• в ಒ ዬ ᗺ ࡕ ‫׹ޑ‬ ٖ ၗ ౢۚ ฅ ‫ٿ‬ ७ ‫ܭ‬ ဠ ٣ ॺ ‫ޑ‬՗ ी Ǵ، ‫ۓ‬ ԋ ҥ ΋ ৎ ཥ ‫ޑ‬Ϧ љ ǺE. I. ‫׹‬ ٖ ·
ቺ ѭ ವ О ᛰ Ϧ љ Ǵ೭ ৎ Ϧ љ ջ ஒ Ҕ ٰ ௗ ᆅ ӝ ‫ٳ‬ ຾ ٰ ‫ޑ‬ၗ ౢǶࣽ ᅟ ୗ ճ Ҕ ঁ ΓᎶ Κ Ǵᇥ ܺ
‫ځ‬ д Ҿ཰ ‫ިޑ‬ ܿ ஒ ި ҽ ፤ ๏ ‫׹‬ ٖ Ǵ‫܈‬ ‫ޣ‬ ࿼ ඤ ཥ Ϧ љ ‫ިޑ‬ ҽ
଄୍&ಔ ᙃ ᆅ ౛ 0 ! ! ! ‫מ‬ ೌ 0 ! ! ! ሦ ೑ ᏾ ӝ
‫׹‬ ٖ ৎ ௼ ύ ‫ޑ‬ ഞ ࣪ ౛ π ᔅ π Ӽ

31. 201907 Case Study – du Pont P:31/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
ཥ ‫׹‬ ٖ 1902-1919
• In 1911, at a corporate management meeting, it was stressed that ‘‘In the
manufacture of explosives, we have three important points to consider—
safety of operation, quality of product, and the last of all the cost .’’ In addition:
safety being put at the top of the list
•Safety Commissions were formed to study and promote accident prevention
measures, DuPont first started collecting safety statisticssafety statistics in 1912.
•Safety Commission meetings of three operating departments in 1913, for
example, required over two weeks and resulted in 300 recommendations.
•A corporate Safety Divisioncorporate Safety Division was established in the Engineering Department in
1915 (Department Head: Lewis Amory De Blois)
– serve as central clearinghouse for evaluation and purchase of all safety items.
– acted in an advisory capacity for all plants, which included technical training,
safety inspections,
– review of all construction projects during the design stage
•The goal of zero injuries was first mentioned in corporate directives
໒ ‫ۈ‬ Ԗ Ӽ ӄ ೽ ߐ (௦ ᖼ PPE/ Ӽ ӄ ૽ ግ ᆶ ዽ ਡ / ቩ ਡ ࡌ ቷ Ӽ ӄ )
ᆶ ᙍ ‫ؠ‬ ಍ ी

32. 201907 Case Study – du Pont P:32/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
F&E Accidents
• Despite the many safety precautions, 288 explosions occurred from 1804 to 1921
• The 1915 explosion occurred in the Packing House killed 30 people.
Comparison Case
Ӽ ӄ ೽ ߐ ‫ޑ‬ ԋҥ Ꮴ Ӣ ‫ܭ‬ Ԝ ԛ ᛈ ࣆ ?

33. 201907 Case Study – du Pont P:33/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
ཥ ‫׹‬ ٖ 1902-1919
• Starting in 1916, standardized ‘‘‘‘safety instruction sheetssafety instruction sheets’’ for correct
practices for working safely were issued by the Safety Division, and over 150
had been distributed throughout the company by mid-1919.
• Senior company leadership, including du Pont family members, continued to
strongly support safety during this period and made changes as needed to
improve the safety organization.
•Over the next 10 to 15 years, the Safety Division was very active making
plant inspections,plant inspections, compiling and analyzing accident statistics, conducting
special investigations of new processes, and participating in design reviews.
•In 1926, safety and fire protection were merged to form the Safety and Fire
Protection Division.
•A set of Safety and Fire Protection standardsSafety and Fire Protection standards was subsequently issued
around 1930, including for example, Safe Practices in Entering Tanks.
Detailed, periodic inspections based on these standards were also conducted
at plants.
໒ ‫ۈ‬ Ԗ ҅ Ԅ ‫ޑ‬ Ӽ ӄ ೕ ጄ ǵ೛ ࡼӼ ӄ ኱ྗᆶ ዽ ࢗ࿎Ꮴ

34. 201907 Case Study – du Pont P:34/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
ཥ ‫׹‬ ٖ 1902-1919
•The success of these programs is evident from safety statistics collected
during this period. Fatality rates were reduced from 5.66 per million hours of
exposure in 1910 to 0.09 by 1931. Injury rates and days lost were similarly
reduced by 90-95% from 1913 to 1931
•Despite the interest of top management, the company initially made the error
of placing the responsibility for safety largely on the safety department rather
than the operating personnel. Hence, early results were not deemed
satisfactory. In 1917, the approach to safety was reorganized and, as one
vice president later put it, “management took over the responsibility.’’ This
responsibility was made clear to the operating personnel by the continued,
detailed involvement of top executives in safety. What had changed was
accountability: in 1919 . . . it was a company axiom that all injuries ultimately
reflected a failure of the operating managers.
•1912 ϸ Ԏ ܎ ථ ‫ݤ‬ ਢ ᒿ ๱ ಔ ᙃ ‫ޑ‬ ԋߏ ᆶ ೽ ߐ ϩ π ‫׹‬ ٖ Ψ ම ࿶ ҍ Π
ᒱ ᇤ Ǻ”ᇡ ࣁ Ӽ ӄ ࢂ Ӽ ӄ ೽ ߐ ‫ޑ‬ ೢ Һ ”
ᗋ ӳ Ԗ ኘ ໶ ϸ ҅ ӣ ٰ …

35. 201907 Case Study – du Pont P:35/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
DuPont financial analysis in 1919
ଯ ໘ Ь ᆅ ᆶ ஑ ཰ ࿶ ౛ Γ ‫ޑ‬ ඵ ች
• வ(Т ᘐ /อ ය )ཞ ੻ ߄ ‫فޑ‬ ࡋ ࣮ -Ӽ ӄ ࢂ ຤ Ҕ Ѝ р /ຫ Ͽ ຫ ӳ
• ٣ ࡺ ё а ೷ ԋ Ϧ љ ၗ ౢᆶ ި ܿ ៾ ੻ ᝄ ख़ ‫ڙ‬ ཞ ǹ
• ၗ ౢബ ೷ ԏ ੻ Ǵѝ Ԗၗ ౢӼ ӄ คဤ Ǵԏ ੻ ‫ޑ‬ബ ೷ ω ૈ ࡭ ុ
• ި ܿ ៾ ੻ (ߏ ය )ന ε ϯ ‫فޑ‬ ࡋ Զ‫ق‬ Ǵό ᔈ ၀ ࣁ Α อ ය ཞ ੻ ߄ ӳ ࣮ ǴԶᡣ ܿ Ջ ᚯ Α ӆ অ
•• ό ൂ ࢂ ी ฝ ‫܄‬ ‫ޑ‬Ⴃ ٛ ᆢ অ ߥ Ꭶό ൂ ࢂ ी ฝ ‫܄‬ ‫ޑ‬Ⴃ ٛ ᆢ অ ߥ Ꭶ ((ᗉ խ คႣ ᝾ ғౢύ ᘐᗉ խ คႣ ᝾ ғౢύ ᘐ ))ǴԶࢂ ‫׳‬ǴԶࢂ ‫׳‬ ᑈ ཱུ Ӧ ी ฝ ‫܄‬ ॏ жᑈ ཱུ Ӧ ी ฝ ‫܄‬ ॏ ж -- Ҕ ‫׳‬ ཥҔ ‫׳‬ ཥ
ਏ ౗ ‫׳‬ ଯ‫ޑ‬ғౢ೛ ഢ ٰ ‫ڗ‬ ж ᙑ ‫ޑ‬ғౢ೛ ഢਏ ౗ ‫׳‬ ଯ‫ޑ‬ғౢ೛ ഢ ٰ ‫ڗ‬ ж ᙑ ‫ޑ‬ғౢ೛ ഢ ǶǶ
Comparison Case
‫ܓ‬ ᑮ ෷ ᇷ ข ၜ
᠏ ෷
ᦞ ટ ዋ ථ

36. 201907 Case Study – du Pont P:36/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
ӭ ‫ف‬ ϯ ᆶ ಔ ᙃ ࢎ ᄬ ፓ ᏾ 1921
•வ ύ ѧ ໣ ៾ ‫ک‬ ᙍ ૈ ೽ ߐ =>ࡌ ҥ Ծ ‫ݯ‬ ‫ޑ‬ Ӛ ٣཰ ဂ Ǵа ౢ ࠔ ձ Զ ό ࢂ а ᙍ ૈ ٰ ᄬ ࡌ
ಔ ᙃ
•٣཰ ೽ ᕴ ࿶ ౛ ନ Α ؒ Ԗ ᐱ ҥ ‫ݤ‬ Γ ၗ ਱ Ǵ୷ ҁ ΢ ൩ ࣬ ྽ ‫ܭ‬ ΋ ঁ Ҿ ཰ ‫ޑ‬ ᕴ ࿶ ౛ Ƕ٣
཰ ೽ Π य़ ೛ ࿼ ᙍ ૈ ೽ ߐ Ƕ

37. 201907 Case Study – du Pont P:37/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
The Challenge of Safety
•The most severe challenge to the company’s safety focus might be expected
to have occurred during the hard economic times of The Depression in the
1930s. However, the company’s efforts to understand and control the hazards
of its processes continued: Special studies are continually being made of the
hazards arising out of the use of various materials or processes . . . Where
sufficient information is not obtainable . . . experiments and tests are
conducted .
• As accidents are reduced, their further reduction becomes increasingly
difficult.
Ӽ ӄ ‫ޑ‬ ࡷ Ꮿ Ǻ
•ӵ Ֆ ӧ ό ඳ ਻ ᆶ ᖝ ཞ ‫ޑ‬ ਔ ‫څ‬ Ǵ࡭ ុ ‫׫‬ ၗ ᆶ
ख़ ຎ Ӽ ӄ ǻ
•ว ғ ‫ޑ‬ ٣ ࡺ ᙍ ‫ؠ‬ ຫ Ͽ Ǵा ຾ ΋ ‫؁‬ Ⴃ ٛ ᆶ ෧
Ͽ ཀ Ѧ Ψ ຫ ֚ ᜤ …

38. 201907 Case Study – du Pont P:38/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Inheritance of du Pont
Comparison Case
Process Safety Management (PSM)
•the modern era of Process Safety Management (PSM) at DuPont began with
a serious process accident in Louisville, Kentucky in 1965, which resulted
in12 fatalities, 61 injuries, and a property loss of over $50 million.
•An annual review was also instituted to ensure that process additions or
changes did not create new hazards, and in following years, many sites
conducted annual, in-depth process hazard reviews to evaluate the process
safety of site processes.
•By 1973, new guidance was issued that detailed suggested hazard review
methodologies and frequencies. A corporate guideline for Process Hazards
Reviews was issued later in 1978 following several serious incidents, and a
comprehensive, integrated corporate Process Hazards Management (PHM)
guideline was issued in 1979,
‫׹‬ ٖ ‫ޑ‬PSMό ࢂ ᐉ ‫ޜ‬ р Ш Ǵ
Զࢂ Ӣ ࣁ Ξ ೏ ख़ ε ٣ ࡺ Ѻ ᖍ ….

39. 201907 Case Study – du Pont P:39/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
Safety Commitment, Accountability & Felt Leadership
Comparison Case
1817, Pierre Samuel DuPont, died after
working all night to help fight a fire in the mill.
1818, 34 deaths and Bankrupt
Brother in Law and Wife server wounded
1854, Angry citizens demanded that both the DuPont
Company and its owners be brought to justice.
1857, Alexis DuPont fatally injury in an explosion
while fighting a fire of a powder mill.
Commitment and accountability is cultivated from bloods and
tears of continuity accidents and painful lessons.
The safety culture and commitment of duPont is
psychological paranoid rather than rational risk management!
(Only the paranoid survive.)
1815, 9 deaths and total loss

40. 201907 Case Study – du Pont P:40/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
Shadow of du Pont
Safety Commitment, Accountability & Felt Leadership
Comparison Case

41. 201907 Case Study – du Pont P:41/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
The Truth and Whole Picture of du Pont History and Story ?
Comparison Case
ಔ ᙃ ᆶ Ҿ཰ ၮ բ ‫ޑ‬ҁ ፦ ൩ ࢂ ‫ٿ‬ ᜤ Ǻ
ा ଭ ‫ٽ‬ າ ǵΞ ा ଭ ‫ٽ‬ ό Ӟ ૛
ӧ а ΢ ௃ ნ Π Ǵճ ্ ᜢ ߯ Γ Ԗ ӵ Ζ и ၸ ੇ /
Ӛ ᡉ ઓ ೯

42. 201907 Case Study – du Pont P:42/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
The Truth and Whole Picture of du Pont History and Story ?
Comparison Case
‫ڹ‬ ၡ Չ ӭ Ѹ ‫ـ‬ ଲ
‫ـ‬ ଲ ࢲ Π ٰ Ǵω Ꮲ ཮ Ͽ ‫و‬ ‫ڹ‬ ၡ
р ٣ ω Ꮲ ཮ ό ૈ ୂ π ෧ ਑
ฅ Զр ٣ ᐒ ౗ ࢂ ਔ ໔ ‫ޑ‬ ‫ڄ‬ ኧ

43. 201907 Case Study – du Pont P:43/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
The Truth and Whole Picture of du Pont History and Story ?
Comparison Case
΋ ᇥ ‫׹‬ ٖ
• ബ ᒤ Γम ܴ ઓ ‫ݓ‬ ǴғԶ‫ޕ‬
ϐ(π Ӽ ࡐ ख़ ा )
• ᆶ π ቷ Ӆ Ӹ Ϋ ‫ޑ‬
commitment
• ೛ ቷ Ꮴ Ε Ӛ ᅿ Ӽ ӄ ೛ ी ᆶ
բ ཰ Ӽ ӄ ೕ ‫ۓ‬
• ৎ ௼ Ҿ཰ ᆶ ԋ ঩ ‫܍ޑ‬ ᒍᆶ
໺ ‫܍‬
• ջ ߡ ᎁ ၶ ό ඳ ਻ ᗋ ࢂ ୲ ࡭
‫׫‬ ၗ π Ӽ
• ᇡ ‫ۓ‬ Ӽ ӄ ࢂ ౜ ൑ ‫ޑ‬ೢ Һ (Զ
ό ࢂ π Ӽ ‫ޑ‬ೢ Һ )
• வό ᘐ ග ϲ Ӽ ӄ ‫فޑ‬ ࡋ Ǵ
ว ৖ р STOP/ PSM/ Ӽ ӄ
Ў ϯ
ќ ΋ ᇥ ‫׹‬ ٖ
• ബ ᒤ Γӧ Ո ఽ ᄐ ภ ௲ ૽ ྽ ύ Ꮲ
཮(ό ள ό )ख़ ຎ Ӽ ӄ (֚ ԶᏢ ϐ)
• Ր ӧ ቷ ϣ ࢂ Ӣ ࣁ ว ғख़ ε ٣ ࡺ
೏ ճ ্ ᜢ߯ Γा ‫؃‬ ‫ޑ‬ᔈ ᒥ Ӻ က
୍
• ջ ߡ Ԗు ࡋ ‫ޑ‬Ӽ ӄ ሦ Ꮴ ᆶ ‫܍‬
ᒍǴ٣ ࡺ ᆶ ᙍ ‫ؠ‬ ᗋ ࢂ ΋ ӆ ว
ғǶ
• ᒿ ๱ Ҿ཰ ‫ޑ‬ᄽ ϯ ᆶ ᙯ ࠠ ǴӼ ӄ
ӧ ‫׹‬ ٖ ‫܈‬ ೚ ࢂ ΋ ᅿ ሺ Ԅ ᆶ ᐕ ў
૶ Ꮻ Ƕ
• Ӛ ᅿ ‫ޑ‬Ӽ ӄ ᐒ ‫ڋ‬ ᆶ Ћ ‫ݤ‬ Ǵό ၸ
ࢂ வ٣ ࡺ ྽ ύ ว ৖ р ٰ ‫ޑ‬ჹ ฼
(ᓐ ภ ᙴ ᓐ ᆶ Φ ੰ ԋ ‫ؼ‬ ᙴ )Ƕ

44. 201907 Case Study – du Pont P:44/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰ
΋ ӆ ᚼ ᓀ‫ޑ‬௃ ‫ݩ‬ Π Ǵว ғ٣ ࡺ ᆶ ᎁ ၶ ཀ Ѧ ࢂ Ѹ ฅ
ჹ ‫ܭ‬ Ӽ ӄ ‫ޑ‬ख़ ຎ ᆶ ࡭ ុ Ǵ‫ڗ‬ ، ‫ܭ‬ ࢂ ց ΋ ӆ ว ғ٣ ࡺ
གྷ ा ҉ ុ ࿶ ᔼ Ǵჹ ‫ܭ‬ Ӽ ӄ ‫ޑ‬ख़ ຎ ᆶ ा ‫؃‬ Н ྗ К ε ৎ གྷ Ⴝ ‫ޑ‬ଯ
ख़ ຎ Ӽ ӄ ό ‫ـ‬ ள ૈ ୼ ᔅ շ Ϧ љ Ӹ ࢲ ᆶ ᕇ ճ ǹՠ ࢂ ߏ Φ Ӹ ࢲ ‫ޑ‬Ϧ љ ΋ ‫ۓ‬ (‫ޕ‬ ၰ ा )ख़ ຎ Ӽ ӄ
Case Comparison
Inferences of du Pont History and Story

45. 201907 Case Study – du Pont P:45/45
΢ᙴᙴ҂ੰǵύ ᙴᙴట ੰǵΠ ᙴᙴς ੰ
΢ᙴᙴ୯ ǵύ ᙴᙴΓ ǵΠ ᙴᙴੰᇡ᛽գԾρᇡ᛽գԾρᇡ᛽գԾρᇡ᛽գԾρEnd
eshwayne@gmail.com
Phone:0922516248
Mindful Choice and Decision
ፏ Չ ค த ǵፏ ‫ݤ‬ ค ‫ך‬
Ǹ ‫ܫ‬ Π ‫ך‬ ୺ ᆶ ‫ך‬ ᄌ
Ǹ Γ཮ҍ ᒱ ǵ೛ ഢ ᐒ Ѡ ཮ࡺ ም
ό ࢁ ‫ܭ‬ Ӣ ݀
Ǹ ၸ ѐ ؒ р ٣ Ǵό ж ߄ ҂ ٰ ό ཮р ٣
Ǹ ௗ ‫ڙ‬ ᇤ ղ ᆶ ٣ ࡺ ว ғ‫ޑ‬ё ૈ Ǵவύ Ꮲ ಞ
ᜢ ྣ ୏ Ј ଆ ‫ۺ‬
Ǹ ໣ ᡏ Ј ᄊ (բ ࣁ ᆶ ό բ ࣁ )༟ ೷ ಔ ᙃ ᅾ ᅽ
Ǹ ຫ ᝺ ள ό ཮р ٣ Ǵຫ ཮р ٣ /р ٣ ፂ ᔐ ຫ ε
Ǹ གྷ ள ᇻ ΋ ٤ (ό ा ጁ ள ѝ ഭ ᒲ ᆶ KPI)
PDSA:
Ǹ Ծ ρ ‫٣ޑ‬ ࡺ ࿶ ᡍ ࢂ ന ٫ ‫ؼ‬ ৣ ᆶ ‫ؼ‬ ᛰ
Ǹ ձΓ‫ޑ‬࿶ ᡍ ‫܈‬ ‫ڋ‬ ࡋ ೕ ጄ ा Ӣ Ӧ /Ӣ ਔ /Ӣ ω ‫ڋ‬ ‫ە‬
ჹ ‫ܭ‬ Ӽ ӄ ‫ޑ‬ ख़ ຎ
ࢂ ΋ ᅿ ࿶ ၸ ਔ ໔
Ե ᡍ ‫ޑ‬ ಔ ᙃ DNA
ᆶ ᗦ ‫܄‬ ඵ ች
֚ Զό Ꮲ /ό ख़ ຎ
Ӽ ӄ Ǵѝ ࢂ Ӣ ࣁ ࢲ
ள ό ୼ Φ /ᗋ ؒ Ꮲ
‫ډ‬ ඵ ች ᆶ ࿶ ᡍ