When we think of occupational health and safety, we rarely think of sugar. It’s a sweet additive and makes our food taste better. But on November 12, 2024 at a small caramel coloring manufacturing factory in Louisville, Kentucky, it became deadly. What came out of the two-year investigation from the U.S. Chemical Safety and Hazard Investigation Board’s (CSB) report in late May 2026 revealed a series of lapses, but mostly a lack of leadership over the course of nearly 20 years; the facility had previously had a fatality in 2003 from similar issues. Those issues, according to the CSB, multiplied after turnover and inattention to key details, causing the catastrophic failure.

This case study provides OSH professionals with a roadmap to prevent such massive failures; indeed, reading and using these reports will help any safety specialist regardless of their industry. Most of the lessons and root causes from CSB, OSHA, and other investigations can be applied to any industry or type of business.

The Events of November 12, 2024

D.D. Williamson and Co, LLC of Louisville, Kentucky had been in business since the 1860s and had been producing caramel coloring for soft drinks and foods since just after World War II. In December 2021, the company was acquired by Givaudan Group, located in Switzerland.

That morning, a batch of caramel was being mixed in Reactor 6 and proceeded normally. However, by the early afternoon, the sugar began decomposing and began accelerating quickly. Reactor 6 was a 2,500 gallon mixing tank and failed to properly vent the carbon dioxide, which was building up. The vent valve failed and did not open, thus blocking-in the gas, which also caused the temperature to rise quickly.

At 2:54pm that day, six employees were in a control room nearby, attempting to troubleshoot the issue. There were an additional 24 employees on site, as well as at least four contractors and visitors. The six employees could not identify the reason for the high temperatures—they had never seen this before. Three minutes later, Reactor 6 blew up. Two employees were killed when the control room collapsed on them. Three other employees were seriously injured by the blast, receiving broken ribs, lacerations, and a concussion.

The Victims, the Damage, the Aftermath

Kevens L. Dawson, Jr. was a rail operator and five days shy of his 50^th birthday. He left behind three children, a grandson, and devoted girlfriend and her children. 29-year-old maintenance technician Austin Jaggers was a devoted father to his little girl, loved to restore cars, and had a zest for life.

The facility was destroyed by the explosion, estimated at $30 million; an additional $10 million in damage impacted the surrounding neighborhood. The factory, although zoned for industrial use, was surrounded by residential homes to the north and to the south. Debris and projectiles were blown far, in some cases over 400 feet away. Reactor 6’s shell, weighing nearly 2,000 pounds, went over 200 feet, resting against a home. Emergency officials issued a shelter-in-place order for the area that lasted nearly two hours and affected three nearby schools.

Following the deaths and destruction, which shook the closeknit neighborhood of Clifton, the city began to demolish the structure. A city council member introduced legislation to prevent the owner from using the site for an industrial purpose. The family of Austin Jaggers filed a lawsuit against the companies involved in the Reactor 6 process.

Sugar, Safety, and Systems

Unfortunately, this was not the first time that a major incident had occurred at the very same location. On April 11, 2003, a vessel explosion killed an employee and forced the evacuation of neighbors. CSB the explosion occurred from a runaway decomposition of caramel.

The “Just Sugar” Mentality

All occupations, no matter where they are or what they do, have risks associated with them. Everything we do on a daily basis has risks, whether we drive a car or take a bus or train to work. Safety starts with a mentality of working to reduce the most likely risks and provide an environment that is safe and healthy to work in.

The “Just Sugar” mentality is similar to it’s cousin: the “It Won’t Happen Here” mentality. These are both “thinking traps,” what psychologists call cognitive distortions, and inhibit the ability to think critically and problem solve effectively. This appears to be an issue in this case, particularly because of the 2003 explosion.

Lack of Leadership

The CSB report called both D.D. Wiliamson and Givaudan sorely lacking in safety leadership; “the Louisville facility was seriously deficient in its management of process safety throughout much of its operating history,” the report concluded. In addition to the turnover of key personnel, which caused a loss of institutional knowledge, the company prepared and approved a new safety manual—but it was never used.

Importantly, the CSB review concluded, there was no individual or position assigned to oversee the elements of safety, environmental health, or risk management. They did not have any ability to conduct hazard identification or risk assessments, they lacked strong company leadership to champion the cause and did not follow their own written Environmental Health and Safety Management System Manual. The plan was just a binder on a shelf.

Hazard Analysis and Emergency Preparation

A hazard analysis was never completed for any of the reactors following a 2008 review. Importantly, they never documented issues related to the possible hazards of runaway sugar decomposition.

Safety documents and hazard risk analyses are not just merely paper for paper’s sake; they are crucial historical knowledge that is needed to support key business decisions and operations. They are used to train and ensure proper implementation of critical processes. Without them, people will be left in the dark—and with deadly consequences.

Another challenge in this situation was the lack of adequate emergency preparation; while the company had an evacuation meeting point, they were hampered by fallen power lines. Unfortunately, the group had no documentation about who was in the buildings and thus were only able to do a head-count based on memory. This created significant confusion when one of the victims, who pronounced his name “Kevin” while being spelled differently, was also the name of a member of the finance team. Kevens Dawson’s body was recovered at 1am.

Lessons from Louisville

The tragic events on November 12, 2024 at the Givaudan Sense Colour caramel coloring plant represent an opportunity to reinforce critical safety lessons. Safety professionals and leaders need to take responsibility for safety: it shouldn’t be a slogan, but a way of operating.

Safety needs to be proactive, thinking about what could go wrong, reviewing processes, and training everyone. Policies aren’t just a book on a shelf, but about making sure actions and decisions are documented, communicated, and implemented.

Finally, having an individual or a team of experienced, trained, and competent safety professionals is a must. They must have the knowledge and authority to act. After all, it’s never “just sugar.”