Is the safety culture at your refinery as poor as it is in some of these other videos? Aging equipment, broken and leaking equipment, failure to do inspections, routine overrides of safety interlocks and alarms, and "Mickey Mouse" operators?
@@gregorymalchuk272 No it isn't. In fact, HS&E constantly get hassled for being overly safety/security conscious, but I guess having no major incidents in 63 years really says something about the level of the work and planning they put in. Major shutdowns every 4 years with miniswoops in between to take care of maintenance and equipment, regular inspections, multiple failsafes and Ops that actually give a shit mean we get to come home every day. But it only takes one lapse in judgement, one mistake to change that.
Are you dumb enough not to know the difference between the two mounting designs? Do you understand how a top cap is secured? Cuz these two idiots apparently didn't! Never assume how something is put together, always analyze your machinery and review your documentation before operating a task above your facility's minimum risk rating.
If the actual valve assembly looks anything like the animation, I would have to say that was one of the most gobsmackingly stupid accidents to ever occur.
Having worked with the CSB a few times, that is EXACTLY how that valve assembly looks. I’m always shocked at how accurate they are from jobs I’ve worked on
Jake Row I'm not even in industry whatsoever and I would bet my life on the accuracy of this animation matching the real valve. These USCSB videos are the real deal. Absolutely top notch. I've tinkered around with 3D map creation before, and I can't even imagine how much time it must take them to create each one of these animations. Literally everything you see had to be calculated and drawn out on a computer much like CAD.
You guys are one of my all time favorite channels. I do not work in any of the industries you review but I love seeing your audits of processes and human factors that lead to disasters.
Yeah and I'm nothing but a hobbyist car mechanic. Tbh I was stunned when the thing didn't erupt as soon as they loosened/removed a few of the 4 bolts. What on earth was holding it shut after the 4 bolts were removed before they put the pipe wrench on the valve?!
I'm saying! These two were clueless had zero business turning ANY valves in a facility like that except the one that runs the door handle to the get the local fuck outsville
I just realized that I'm on my third day binge watching the USCSB channel. I'm binge watching a channel about chemical safety! But really, I don't even work around dangerous chemicals and I find these videos damn interesting.
30 years ago. OH&S/EH&S was still coming more into the picture. In fact, we're still not always accepted as we should be in some businesses and even in state institutions. Lots of room for growth, but the field has always been hindered by budgets and cutting. Long-term impacts are often.
Agamemnon No ! Operations on it permit should have located the down stream isolation valve . It should have been locked and tagged out . Bolts removed under fresh air , checked and replaced after bracket removal . Valve tested for packing and gasket leak and put back into service . Clearly for the gas to escape the way the animation shows . The line was under pressure . Taking the screws out and not touching the plug is not the answer . You have to touch the valve . And if the bracket is suck , you'll have to bang on it to get it lose . It's and old style bracket that's been there for years . No bolts , banging , gasket leak . You have to have more command sense . Training only does so much . Everyone is not meant to work in this types of places . Facts . #UAFitter
Even 100 years ago some idiot should have figured this design really sucked! SO how many decades have humans been designing and building pipelines, fittings and valves and whatnot and we STILL couldn't get it right 30 years ago??
I worked there from 2010-2011 and I live 25 mins east of BR, yet this is the first time hearing about this. I guess, like everyone else at the time, I was just too focussed on the aftermath of the flood we had 3 months earlier to remember anything else.
1:35 - were the operators blind then? I mean, if those gears look exactly like presented here and there wasn't any sludge or anything obstructing the view, you can't overlook that undoing those bolts will open the whole pipe.
@@CraigBelldina Where in the constitution is there a requirement for the government to build and maintain roads. Yet here we are, relying on government built roads to take us everywhere.
At 1:36 “…but unknown to the operators….”, I’m not a mechanic but if the animation rendering of the accident is anywhere near to the actual location, you don’t need to be a mechanical engineer, to understand that those 4 bolts hold together the top part of the valve and the main body! I actually jumped in my seat when I saw the animation of the bolts being removed, even before the voice said there was a problem! What the hell happened here? How can experienced operators not realise the danger of that operation and how was this gear removal considered “standard practice” with this kind of valve installation? Only 3% of the valves, but one was on the isobutane line! WTF man this is criminal stupidity!
This video is made to relay i]cold hard facts, distilled information, the lectures are usually associated with someone getting paid. That’s the difference.
It's not their fault, it's bad design on which accidents were bound to happen. Nice hindsight, but people aren't hyper-aware of all possibilities 100% of the day.
xXWOND3RBR3ADXx And that is barely the intelligence of these workers.... dare I call them ignorant This is a very poor indication of the basic education of American workers in industry today
when you work around a dangerous situation for a while, you start to loose the perception of danger, since you get more comfortable with the environment, I bet the guy wouldn't have touched them if it was his first few times, I also bet the guy was experienced... Mistakes are not reserved to the newbies, and it only takes one simple mistake to end up in a catastrophic situation
This accident should have never occurred. Just another reason all equipment must be designed with the assumption it will be operated by moron's. I build automated equipment for a living and we are constantly installing gaurding to prevent people from being able to almost intentionaly hurting themselves
software engineer student here, same goes in every industry, well, when someone's life is at risk, the stakes are higher, but no matter the industry, never ever trust the user.
You guys must not work with CNC machines much, if at all. They are crazy dangerous, have bizarre and confusing UIs, and basically zero safety. I think the only reason no one at my work has been hurt or killed by the CNC I operate is because they have no idea how to work the thing so they never try.
It is a shame that engineers have to design to the lowest human denominator. Because of those people, we no longer have lawn darts, lawnmowers have more warning stickers than technical data plates, and riding a bicycle now involves more worn safety equipment than mining.
Crazy how so many of these employees didn't realize that the top cap was held in place by the same nut and bolts that held the bracket for the gear box. Negligence? Maybe...or assuming the top cap was held to the bottom regardless of the bracket being there or not
at 1:18 and 1:55 the pipe wrench is applied to the valve in the wrong direction. the wrench needs to be flipped to rotate counter clockwise. it is shown correctly when the operators are holding it. also, at 1:28 the nuts appear to turn in the wrong direction to be removed from the bolts. Keep these videos coming, they are great!
The bolts are also way too long. Max 5mm. :) But, srly, I´m surprised that no one died. Isobutane isn´t that kind of friendly. Lucky them it wasn´t a pipe containing H2SO4 or H2S.
A plug valve or ball valve will turn 360 degrees in any direction with the actuator removed. It will not function as designed for flow but it will "spin" with no stops.
I'm amazed they could take them out at all without the thing blowing out. They should've only taken out the two side bolts holding the gearbox to the bracket.
If it didnt blow just from that it seems like that would have prevented the whole thing. Im no refinery worker but I do tinker a bit with mechanical stuff from time to time. I had to replace a radiator in my car and I know that if you just open the cap while the engine is still hot, you'll blow scalding chemicals all over the place. And the manual said that if you HAVE to remove it hot, get a thick towel and gradually turn it til it hisses then remove it when it stops hissing.
Kalel Kent Really ? So if the plug need replaced , or the seat need fixing , or even the valve needed replacing . How would you do it if you didn't remove the bolts ? Give it some thought . The bolts shouldn't have been the problem . This job minus basic safety procedures .
Tommy Petraglia I'm not sure what you call maintenance where your from , or work friend . But in my trade , that's exactly what they were doing . They were removing bolts and trying to remove an item . Any work on that valve on that valve live meant , the isolation valve downstream from it was suppose to be locked and tagged out .
It honestly seemed like a odd choice to remove the entire bracket, when the gearbox could have been removed from the bracket and leaving it in place instead.
i think key here is the 97% other valve assemblies being safe to unbolt. upon encountering this one, I would be like "huh? oh I guess it's these four instead" and feel like i've Solved the Problem. it wouldn't occur to me to consider the assembly as a whole if I was already used to considering it as separate components.
Durco plug valves were made this way a 30 years ago...floserve has since changed the design so this is less likely to happen..the adapter bracket is mounted independent from the bonnet bolts...this accident happened many times with this older design. Now the new design comes equipped with a warning tag not to remove the bonnet bolts
Every maintenance action should be required to have tech data SPECIFIC to the part in the techs hand and reviewed before touching anything. Good enough for aviation, good enough for industry.
If that animation is acurte and that bracket was attach to the valve bonnet like that then it should of been pulled out of service and changed for a better safer design, also if you cannot notice that removing these bolts will make the bonnet lose then you shouldn't be working in or near any sort of refinery. Just my thoughts
Damn all they had to do was put the bolts back in before turning the stem. I’m not sure if the animation makes it looks simpler then it was but how do you not see the pressure containing cap was bolted with the gear box
Gear operated valve stuck, replace gearbox. Still stuck with replacement gearbox, tag-out system, purge system then replace valve. The production delay would have been cheaper than the cost of the damage that was done. (foresight rules, hindsight sucks) Do not attempt to override the design of the setup.
Definitely appears to be a lack of common sense in this case. A first year millright apprentice or backyard mechanic could have seen how that assembly was fastened together. So avoidable & unfortunate.
so who was really to blame for this accident? the two operators who mistakely removed the support bracket there by causing the chain of events or their supervisor for clearly not training these two well enough to know they could have removed the two bolts on the top and side of the support bracket and would still have been able to remove the gear box.
Similar accidents also occur, e.g. when workers need to remove a supported actuator but instead remove the valve stem support, which consequently flies out and releases a vapor cloud... Any bolt holding back pressure should be color coded in my opinion
Back in the day operators would not be removing bolts from anything. That's a pipefitter job. An experienced pipefitter would likely have caught this catastrophic error but who knows.
I understand the hindsight of this accident however employees MUST be trained on the design of equipment they are working on so they understand on a fundamental level what bolt holds what in place and why that’s important. This is coming from 20 years in the aerospace industry
As much as I like these videos, I really don't want the USCSB to make another one. That means something went *really* wrong and at least seriously injured somebody. I don't want that to ever happen again... ...but it will... ...and the USCSB will make a video about it as one of the scant few government agencies actually doing their jobs.
Most radios used in places with explosion hazards are sealed units, the only one you have to watch for is hydrogen gas as it is small enough to get past the gaskets.
Improper process safety training or lack of training, Do not take Permit to Work(PTW), High risk acceptance by operators, Lack of updated instructions and finally : Friends, for these tasks, a PSSR must be written, and the presence of a fire engine is required.
I dont work around this kind of stuff at all. But if what others are asking is true, and the assembly looked as it did in animation. I cringed hard when those bolts were removed.
Why would you not remove the horizontal bolts actually securing the gearbox to the bracket.. or have the common sense to put the bolts for the bottom of the bracket back into the valve pipeline before opening the valve?
There are lots of people putting the blame on the workers here, I understand why. But why didn't the plantowners replace all of these valves to the updated design. He literally said that 3% (3 of every 100 valve) was of this old design, relatively it could not cost that much to replace them with the modern ones.
Anytime I see pipeline or refinery workers slacking off, I'll know they're simply using the strat of "if I don't do my job at all, then I won't have the chance to make a critical mistake".
Based on the computer generated picture of the valve it seemed quite obvious that you should not remove those 4 bolts. Also, they're using the pipe wrench backwards. Way to go animation team.
Unless the valve was left hand threaded, that would be the first mistake I've seen out of dozens of these videos I've watched. This animation team is second to none. Give them a break, the pipe wrench thing is trivial and inconsequential anyway.
these valves are stone age simple. surely it was millwrights who messed this up? they're the only ones whose modus operandi is "remove all fasteners and wrench it until something happens"
Also, if your unable to shut/open the valve with the "normal equipment" it should be time to install or new one or repair/clean the valve (if there is enough time). Sadly this handling is normal in every Refinery and most chemical site. "Use a wrench to open/close the valve" should not be a term for a supervisor.
using a wrench on a sticky valve is perfectly normal. sometimes all it needs is to be turned. disassembling the valve requires bypassing the valve or shutting off the whole system
It should be enough to turn the valve via man power. But, its also depending why the valve is stuck. e.g. The pipe is normally transporting PCL3 (Phosphorus Trichloride) at ~150°C, the PCL3 should be a liquid at those temperature. In case of an shutdown (e.g. TAR) the pipes and valve needs to be cleaned, because the PCL3 will get solid. (IF the pipe isn´t dumped using N2) In this case there was no information about the stucked/hardly movable valve. They could have cleaned or change this valve. But, as I stated in my last post, lucky workers. In 6 days I´ll be working for ~4 weeks on Ineos near Dormagen (Bayer ChemPark), wish me good luck. It will be my hardest TAR. Lots of SCBA work.
yes, if they had removed the valve handle properly and wrenched it open, the thing to do would to be mark it as a sticky valve for later maintenance, they were lucky indeed good luck at chempark, you should be fine. slow is safe and safe is fast.
Many CSB videos involve chemistry and reactions I wouldn't understand or anticipate as someone outside the field, but this seemed so obviously wrong to do.
wow, wow & wow. Any grown man or women in any field should be able to tell that those bolts are holding the top plate. And that the top plate is access to the entire pipe.
if i was one of the workers my instinct wouldn't be to unscrew the bracket from the pipe but to unscrew the gearbox from the bracket. less work and seems way less dangerous and its clear to me that the bolts hold the top part down
In the workers' defense, the newer design was made so that removal of the vertical screws, not the higher, horizontal screws, was the proper procedure for removing the gearbox. The workers involved in the explosion removed the vertical screws, just as they would have done on 97% of the gearboxes at the facility.
It is yet an another tragedy in Baton Rough. Cabin Managers should be at the field and see the reality to prevent Human Errors !! and to prevent the loss of life of innocent personnel.
This seems painfully obvious to me as an untrained observer that those bolts were sealing that part of the equipment they could’ve probably put the bolts back on and everything would’ve been fine
whenever i'm doing any work at my job now, i'm hearing this narrator's voice in my head as i do it.
@Kilo Byte lol
@Kilo Byte I can actually hear the narrator saying that as I'm reading your comment. That is funny!
Kilo Byte It’s as if you’re reading my shift log report. 😂😂😂
You know, it probably makes you less likely to make mistakes.
Not sure if that's a good thing lol
I work at a refinery, and every single one of these videos brings me one breath closer to no longer working at a refinery.
Is the safety culture at your refinery as poor as it is in some of these other videos? Aging equipment, broken and leaking equipment, failure to do inspections, routine overrides of safety interlocks and alarms, and "Mickey Mouse" operators?
@@gregorymalchuk272 No it isn't. In fact, HS&E constantly get hassled for being overly safety/security conscious, but I guess having no major incidents in 63 years really says something about the level of the work and planning they put in. Major shutdowns every 4 years with miniswoops in between to take care of maintenance and equipment, regular inspections, multiple failsafes and Ops that actually give a shit mean we get to come home every day.
But it only takes one lapse in judgement, one mistake to change that.
@@LurkMoar101 FFS! There is NO such thing as being "overly" safety. A life can never be replaced by quick dollars.
Hey man …….stop look listen…….hydrocarbons DON'T play
Are you dumb enough not to know the difference between the two mounting designs? Do you understand how a top cap is secured? Cuz these two idiots apparently didn't! Never assume how something is put together, always analyze your machinery and review your documentation before operating a task above your facility's minimum risk rating.
If the actual valve assembly looks anything like the animation, I would have to say that was one of the most gobsmackingly stupid accidents to ever occur.
I agree....you can't make this up. Must not had a great deal of pressure or just loosening would have been ugly.
Having worked with the CSB a few times, that is EXACTLY how that valve assembly looks. I’m always shocked at how accurate they are from jobs I’ve worked on
Nope, there is worse.
These might not be the brightest crayons in the box.
Jake Row I'm not even in industry whatsoever and I would bet my life on the accuracy of this animation matching the real valve. These USCSB videos are the real deal. Absolutely top notch.
I've tinkered around with 3D map creation before, and I can't even imagine how much time it must take them to create each one of these animations. Literally everything you see had to be calculated and drawn out on a computer much like CAD.
You guys are one of my all time favorite channels. I do not work in any of the industries you review but I love seeing your audits of processes and human factors that lead to disasters.
so true tho
Sheesh, If the valve actually looked like this- you can tell plain as day that removing those bolts will lead to depressurization.
Well as the saying goes, you get what you pay for. In this case the lowest bidding contractor..... with a second grade education at best.
Those were refinery employees. Operators.
Yeah and I'm nothing but a hobbyist car mechanic. Tbh I was stunned when the thing didn't erupt as soon as they loosened/removed a few of the 4 bolts. What on earth was holding it shut after the 4 bolts were removed before they put the pipe wrench on the valve?!
@@Syclone0044 I suppose the pressure was not very high so rust and grime was enough to hold it together until force was applied with the wrench.
I'm saying! These two were clueless had zero business turning ANY valves in a facility like that except the one that runs the door handle to the get the local fuck outsville
2:38 when you’re leaving the toilet and someone wants to use it immediately afterward
Lol
I just realized that I'm on my third day binge watching the USCSB channel. I'm binge watching a channel about chemical safety!
But really, I don't even work around dangerous chemicals and I find these videos damn interesting.
It's the narrator. He's so compelling. He really should be narrating bigger productions.
Me too
Should have screwed the top cap back on first. Also, thats a remarkably dumb design for a support bracket.
it's why they aren't used anymore. the millwrights should have been paying attention.
was 30 year old design, 97% of the valves were updated to the safer design but this one wasnt
30 years ago. OH&S/EH&S was still coming more into the picture. In fact, we're still not always accepted as we should be in some businesses and even in state institutions. Lots of room for growth, but the field has always been hindered by budgets and cutting. Long-term impacts are often.
Agamemnon
No ! Operations on it permit should have located the down stream isolation valve . It should have been locked and tagged out . Bolts removed under fresh air , checked and replaced after bracket removal . Valve tested for packing and gasket leak and put back into service . Clearly for the gas to escape the way the animation shows . The line was under pressure . Taking the screws out and not touching the plug is not the answer . You have to touch the valve . And if the bracket is suck , you'll have to bang on it to get it lose . It's and old style bracket that's been there for years . No bolts , banging , gasket leak . You have to have more command sense . Training only does so much . Everyone is not meant to work in this types of places . Facts . #UAFitter
Even 100 years ago some idiot should have figured this design really sucked! SO how many decades have humans been designing and building pipelines, fittings and valves and whatnot and we STILL couldn't get it right 30 years ago??
What a great channel! As an aspiring engineer, it definitely makes me more conscious of safety in my designs.
HEHE...If you make anything idiot proof....Nature will invent a better idiot..
These videos always have consistently great animation and are among the best documentary (or perhaps they are the best) videos produced.
I worked there from 2010-2011 and I live 25 mins east of BR, yet this is the first time hearing about this. I guess, like everyone else at the time, I was just too focussed on the aftermath of the flood we had 3 months earlier to remember anything else.
1:35 - were the operators blind then? I mean, if those gears look exactly like presented here and there wasn't any sludge or anything obstructing the view, you can't overlook that undoing those bolts will open the whole pipe.
This is one outfit that needs to be left ALONE! GO USCSB!
Lewie McNeely please point to where in the Constitution this is a federal requirement
@@CraigBelldina Where in the constitution is there a requirement for the government to build and maintain roads. Yet here we are, relying on government built roads to take us everywhere.
@@CraigBelldina pls shut the fuck up you useless libertarian
1:40 no one can misunderstand what exactly happening in this animation. great work
At 1:36 “…but unknown to the operators….”, I’m not a mechanic but if the animation rendering of the accident is anywhere near to the actual location, you don’t need to be a mechanical engineer, to understand that those 4 bolts hold together the top part of the valve and the main body! I actually jumped in my seat when I saw the animation of the bolts being removed, even before the voice said there was a problem! What the hell happened here? How can experienced operators not realise the danger of that operation and how was this gear removal considered “standard practice” with this kind of valve installation? Only 3% of the valves, but one was on the isobutane line! WTF man this is criminal stupidity!
Thanks for the video. I love them all!!!
After watching several USCSB videos, it occured to me that being a contractor in a chemical facility is not a recommended position.
The animation quality in this one awesome. A big thumbs up to the animators. This 3 minute animation is equivalent to 3 hours of lecture :)
This video is made to relay i]cold hard facts, distilled information, the lectures are usually associated with someone getting paid. That’s the difference.
As soon as I saw the picture of the gearbox attached to the valve plate, it was obvious what was going to happen
Thanks, USCSB team, for awareness. very small issue but consequence very high
Ahhhhhhh
Bababooey
I mean...come on...LOOK at the valve, look at it! You can freaking tell the difference....man...
It's not their fault, it's bad design on which accidents were bound to happen. Nice hindsight, but people aren't hyper-aware of all possibilities 100% of the day.
1:30 pause, Lol as a simpleton I could have told you not to touch those 4 lower bolts
xXWOND3RBR3ADXx
And that is barely the intelligence of these workers.... dare I call them ignorant
This is a very poor indication of the basic education of American workers in industry today
when you work around a dangerous situation for a while, you start to loose the perception of danger, since you get more comfortable with the environment,
I bet the guy wouldn't have touched them if it was his first few times, I also bet the guy was experienced... Mistakes are not reserved to the newbies, and it only takes one simple mistake to end up in a catastrophic situation
@Klaa2 well you already knew it was going to happen....
This accident should have never occurred. Just another reason all equipment must be designed with the assumption it will be operated by moron's. I build automated equipment for a living and we are constantly installing gaurding to prevent people from being able to almost intentionaly hurting themselves
software engineer student here, same goes in every industry, well, when someone's life is at risk, the stakes are higher, but no matter the industry, never ever trust the user.
You guys must not work with CNC machines much, if at all. They are crazy dangerous, have bizarre and confusing UIs, and basically zero safety.
I think the only reason no one at my work has been hurt or killed by the CNC I operate is because they have no idea how to work the thing so they never try.
@Aaron Provance -
YES , it should be designed for people from the movie "Idiocracy" from 2006
It is a shame that engineers have to design to the lowest human denominator.
Because of those people, we no longer have lawn darts, lawnmowers have more warning stickers than technical data plates, and riding a bicycle now involves more worn safety equipment than mining.
Another very good CSB video! Thank you.
These videos are so well done.
Crazy how so many of these employees didn't realize that the top cap was held in place by the same nut and bolts that held the bracket for the gear box. Negligence? Maybe...or assuming the top cap was held to the bottom regardless of the bracket being there or not
"Whatta ya think? It's probably welded, yeah? Okay, here goes." BOOM!
😂😂😂
at 1:18 and 1:55 the pipe wrench is applied to the valve in the wrong direction. the wrench needs to be flipped to rotate counter clockwise. it is shown correctly when the operators are holding it. also, at 1:28 the nuts appear to turn in the wrong direction to be removed from the bolts. Keep these videos coming, they are great!
The bolts are also way too long. Max 5mm. :)
But, srly, I´m surprised that no one died. Isobutane isn´t that kind of friendly.
Lucky them it wasn´t a pipe containing H2SO4 or H2S.
I noticed that, though it would still work it WAS backwards, and a crescent wrench would have been far more appropriate than a pipe wrench!
A plug valve or ball valve will turn 360 degrees in any direction with the actuator removed. It will not function as designed for flow but it will "spin" with no stops.
Should they've put the bolts back in place before trying to turn the valve?
I'm amazed they could take them out at all without the thing blowing out.
They should've only taken out the two side bolts holding the gearbox to the bracket.
If it didnt blow just from that it seems like that would have prevented the whole thing. Im no refinery worker but I do tinker a bit with mechanical stuff from time to time. I had to replace a radiator in my car and I know that if you just open the cap while the engine is still hot, you'll blow scalding chemicals all over the place. And the manual said that if you HAVE to remove it hot, get a thick towel and gradually turn it til it hisses then remove it when it stops hissing.
Anyone know what program the animations are done in?
Soon as i seen them removing the outer bolts it was clear that they were about to compromise the integrity of those pressure plates.
Kalel Kent
Really ? So if the plug need replaced , or the seat need fixing , or even the valve needed replacing . How would you do it if you didn't remove the bolts ? Give it some thought . The bolts shouldn't have been the problem . This job minus basic safety procedures .
Tim Lett
They weren't performing maintenance on the valve. They needed to operate the valve to perform maintenance further along the stream
Tommy Petraglia
I'm not sure what you call maintenance where your from , or work friend . But in my trade , that's exactly what they were doing . They were removing bolts and trying to remove an item . Any work on that valve on that valve live meant , the isolation valve downstream from it was suppose to be locked and tagged out .
I love these videos, I work in oil and gas and you never know when one of these videos might save your ass. Informative
It honestly seemed like a odd choice to remove the entire bracket, when the gearbox could have been removed from the bracket and leaving it in place instead.
Has ExxonMobile censored this video ? This video is rather brief.
i cant seem to find one of these vids on the 1989 explosion in baton rouge
i think key here is the 97% other valve assemblies being safe to unbolt. upon encountering this one, I would be like "huh? oh I guess it's these four instead" and feel like i've Solved the Problem. it wouldn't occur to me to consider the assembly as a whole if I was already used to considering it as separate components.
Why does it almost always seem as if it’s contractors who get hurt or killed?
Under what scenario could removing those 4 bolts possibly NOT result in a massive release?! It's hard to imagine what these 2 were thinking.
1:25 I was thinking, "They didn't take off the bolts holding the whole stem into the pipe, did they!?"
This is valve 101 stuff here.
Unbelievable........how could anybody be that careless?
*Exxon employees have always treated us contractors horrible.*
Why are the pipe wrenches in this video always used backwards? Bad graphic.
Durco plug valves were made this way a 30 years ago...floserve has since changed the design so this is less likely to happen..the adapter bracket is mounted independent from the bonnet bolts...this accident happened many times with this older design. Now the new design comes equipped with a warning tag not to remove the bonnet bolts
Every maintenance action should be required to have tech data SPECIFIC to the part in the techs hand and reviewed before touching anything.
Good enough for aviation, good enough for industry.
There should be a CSI: CSB TV show.
In the animation the Stillson wrench is applied in the wrong direction.
Lol "a peice of equipment called a gearbox"
Ben Harris “the gearbox uses gears..”
Its attached with a support bracket.
Man... some people don't seem to give a single thought during such procedures.
We just had a refinery explosion yesterday in wisconsin im excited to see the animation on what happened
wisconsindabber Me too!! Where was it? Are you sure the USCSB is investigating?
If that animation is acurte and that bracket was attach to the valve bonnet like that then it should of been pulled out of service and changed for a better safer design, also if you cannot notice that removing these bolts will make the bonnet lose then you shouldn't be working in or near any sort of refinery. Just my thoughts
Why they didn’t screw a bolts back to the went?
THANK YOU! You guys rock, thx so much for this. =)
"Accepted practice"? Just how often do the gear boxes fail to operate? Sounds like a problem right there.
Shoulda got a "Line Break Permit"
i imagine they couldve put the bolts back on and it wouldve been fine, but its always the little things you dont think of that get you
Why not shut it after opening it?
YOU'RE BACK!
:D
Damn all they had to do was put the bolts back in before turning the stem. I’m not sure if the animation makes it looks simpler then it was but how do you not see the pressure containing cap was bolted with the gear box
Gear operated valve stuck, replace gearbox.
Still stuck with replacement gearbox, tag-out system, purge system then replace valve. The production delay would have been cheaper than the cost of the damage that was done. (foresight rules, hindsight sucks)
Do not attempt to override the design of the setup.
Did anyone else notice that the pipe wrench was backwards in all the animations
why remove 4 bolts? There were only 2 attaching the gear box to the bracket.
raul garcia
Look at the video again
Definitely appears to be a lack of common sense in this case. A first year millright apprentice or backyard mechanic could have seen how that assembly was fastened together. So avoidable & unfortunate.
so who was really to blame for this accident? the two operators who mistakely removed the support bracket there by causing the chain of events or their supervisor for clearly not training these two well enough to know they could have removed the two bolts on the top and side of the support bracket and would still have been able to remove the gear box.
Watching the pipe Wrench be used incorrectly again and again bothered me
wow, I saw this as soon as the bolts came out... DUH.... and yet, these refineries require a piece of paper...
Similar accidents also occur, e.g. when workers need to remove a supported actuator but instead remove the valve stem support, which consequently flies out and releases a vapor cloud... Any bolt holding back pressure should be color coded in my opinion
The animator has obviously never used a pipe wrench.
Using a pipe wrench takes ten points off your IQ which is why the animator wasn't the one who caused an explosion at a refinery.
Thanks for animation
Back in the day operators would not be removing bolts from anything. That's a pipefitter job. An experienced pipefitter would likely have caught this catastrophic error but who knows.
The pipe wrench is animated backwards
Who could look at that design and not realize that the bolts were holding the whole valve assembly together?
I understand the hindsight of this accident however employees MUST be trained on the design of equipment they are working on so they understand on a fundamental level what bolt holds what in place and why that’s important. This is coming from 20 years in the aerospace industry
As much as I like these videos, I really don't want the USCSB to make another one.
That means something went *really* wrong and at least seriously injured somebody. I don't want that to ever happen again...
...but it will...
...and the USCSB will make a video about it as one of the scant few government agencies actually doing their jobs.
Maybe I’m just dense, but it looks to me like if you take the plate off, you’re taking the whole thing apart? I wouldn’t have done it.
Wouldn’t them using the radio while in the vapor have caused a spark?
Most radios used in places with explosion hazards are sealed units, the only one you have to watch for is hydrogen gas as it is small enough to get past the gaskets.
Coom Valve
The technician with the wrench looks like actor Ron Livingston of Office Space.
Improper process safety training or lack of training, Do not take Permit to Work(PTW), High risk acceptance by operators, Lack of updated instructions and finally : Friends, for these tasks, a PSSR must be written, and the presence of a fire engine is required.
I dont work around this kind of stuff at all. But if what others are asking is true, and the assembly looked as it did in animation. I cringed hard when those bolts were removed.
Why would you not remove the horizontal bolts actually securing the gearbox to the bracket.. or have the common sense to put the bolts for the bottom of the bracket back into the valve pipeline before opening the valve?
There are lots of people putting the blame on the workers here, I understand why.
But why didn't the plantowners replace all of these valves to the updated design. He literally said that 3% (3 of every 100 valve) was of this old design, relatively it could not cost that much to replace them with the modern ones.
Reminds me of that accident, on this one hotel, where the floors collapsed..
Anytime I see pipeline or refinery workers slacking off, I'll know they're simply using the strat of "if I don't do my job at all, then I won't have the chance to make a critical mistake".
Based on the computer generated picture of the valve it seemed quite obvious that you should not remove those 4 bolts.
Also, they're using the pipe wrench backwards. Way to go animation team.
Unless the valve was left hand threaded, that would be the first mistake I've seen out of dozens of these videos I've watched. This animation team is second to none. Give them a break, the pipe wrench thing is trivial and inconsequential anyway.
these valves are stone age simple. surely it was millwrights who messed this up? they're the only ones whose modus operandi is "remove all fasteners and wrench it until something happens"
Also, if your unable to shut/open the valve with the "normal equipment" it should be time to install or new one or repair/clean the valve (if there is enough time).
Sadly this handling is normal in every Refinery and most chemical site. "Use a wrench to open/close the valve" should not be a term for a supervisor.
using a wrench on a sticky valve is perfectly normal. sometimes all it needs is to be turned. disassembling the valve requires bypassing the valve or shutting off the whole system
It should be enough to turn the valve via man power. But, its also depending why the valve is stuck.
e.g. The pipe is normally transporting PCL3 (Phosphorus Trichloride) at ~150°C, the PCL3 should be a liquid at those temperature.
In case of an shutdown (e.g. TAR) the pipes and valve needs to be cleaned, because the PCL3 will get solid. (IF the pipe isn´t dumped using N2)
In this case there was no information about the stucked/hardly movable valve. They could have cleaned or change this valve.
But, as I stated in my last post, lucky workers.
In 6 days I´ll be working for ~4 weeks on Ineos near Dormagen (Bayer ChemPark), wish me good luck. It will be my hardest TAR. Lots of SCBA work.
yes, if they had removed the valve handle properly and wrenched it open, the thing to do would to be mark it as a sticky valve for later maintenance, they were lucky indeed
good luck at chempark, you should be fine. slow is safe and safe is fast.
Many CSB videos involve chemistry and reactions I wouldn't understand or anticipate as someone outside the field, but this seemed so obviously wrong to do.
As much as I love your videos, it irks me to no end your animations show using wrenches backwards.
But maybe that's part of the point i guess..?
wow, wow & wow. Any grown man or women in any field should be able to tell that those bolts are holding the top plate. And that the top plate is access to the entire pipe.
A wheel And a very complex and unique and rare gear box
Like the gear box is saooooo rare
The coom
Who needs enemies when you have employees like that"
if i was one of the workers my instinct wouldn't be to unscrew the bracket from the pipe but to unscrew the gearbox from the bracket. less work and seems way less dangerous and its clear to me that the bolts hold the top part down
In the workers' defense, the newer design was made so that removal of the vertical screws, not the higher, horizontal screws, was the proper procedure for removing the gearbox. The workers involved in the explosion removed the vertical screws, just as they would have done on 97% of the gearboxes at the facility.
so they wasnt smoking 0n the job....glad you clear that up...
It is yet an another tragedy in Baton Rough. Cabin Managers should be at the field and see the reality to prevent Human Errors !! and to prevent the loss of life of innocent personnel.
coom valve
This seems painfully obvious to me as an untrained observer that those bolts were sealing that part of the equipment they could’ve probably put the bolts back on and everything would’ve been fine
Total unfamiliarity / awareness of mechanism design and safe practice.
Em i the only one that is getting very annoyed that they are using the pipe wrench wrong!
If it was isobutane that was released the workers near the gas first must have become so high