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All case studies

Catastrophic failureEnergy2019

Vale S.A.

Vale Brumadinho Dam Collapse

Estimated impact: $7B in settlements and remediation; 270 deaths

F14

Decision Quality Index

Critical — 5 biases detected, 2 toxic combinations

A tailings dam at Vale's Córrego do Feijão iron ore mine in Brumadinho, Brazil, collapsed without warning, releasing 12 million cubic meters of toxic mud. 270 people were killed, including many mine employees eating lunch in the path of the flow. The dam had been certified as stable just months before.

Decision context

Whether Vale's upstream dam construction method and internal stability monitoring were adequate, given that a similar Vale-linked dam (Samarco) had collapsed just three years earlier.

Deep hindsight-stripped analysis coming soon. This case is part of our ongoing backfill to reconstruct what the platform would have flagged at decision time. The summary and bias profile below are drawn from primary sources.

Biases present in the decision

Hindsight BiasGroupthink★ Confirmation BiasCognitive MiseringOptimism Bias

3D Decision Knowledge Graph

Vale S.A. — 5 biases, 2 toxic combinations

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Decision

Critical

High

Medium

Toxic

Bias Intensity Profile

Severity × confidence across 5 detected biases

Toxic combinations

Echo Chamber
Optimism Trap

Reference class base rates

Across all 146 curated case studies in our library:

90%

base failure rate

10%

base success rate

Lessons learned

Confirmation bias: stability certificates were obtained from auditors who used the data provided by Vale rather than independent monitoring
The Samarco disaster (2015) should have been a direct warning, but Vale treated it as an isolated event rather than a systemic risk indicator
Placing employee facilities directly downstream of a tailings dam reflects a fundamental failure to internalize catastrophic risk

Source: Brazilian Federal Police investigation report (2020); Brazilian Senate CPI inquiry (2019) (Post Mortem)

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Lessons learned

Confirmation bias: stability certificates were obtained from auditors who used the data provided by Vale rather than independent monitoring

The Samarco disaster (2015) should have been a direct warning, but Vale treated it as an isolated event rather than a systemic risk indicator

Placing employee facilities directly downstream of a tailings dam reflects a fundamental failure to internalize catastrophic risk