The positive thing is that if the pipe or container did blow you wouldn't know. I hate to say it but this guy got lucky in his death, there are many horrible ways but this happened so fast that he wouldn't have had time to process it. One second he's breathing and looking at something, then a microsecond later he just doesn't exist anymore.
I've worked in an oil refinery a few times, and it's an unsettling feeling to know that some guy 50 feet away from you can do something wrong and kill you without warning.
It's all great except the people that are reading off a prompter and don't sound like they know this subject material. I don't understand why they don't put actual experts in front of the camera.
In my experience, managers will ignore all employee input regarding safety, then after catastrophe strikes they create a bunch of stupid new rules that don't address actual safety issues, but look good on paper.
Funny I used to work at a petroleum plant with such high potential dangers, managers and cowardly unions, so I quit after five years of bullshit. Now this happens and will happen again.
oh we all know this is true. Im sure that some low level employee was ignored and warned of what was gonna happened and guess what ? it happened. but profits = more important than safety of employees or the environment.
Whoever makes these videos at the USCSB, or whoever had the idea to make these, is a genius. They make safety FUN. (Okay, more accurately, ENGAGING, thank you for pointing that out)
@@KiloByte69 He said, "Whoever makes these videos at the USCSB, *or whoever had the idea to make these,* is a genius. They make safety FUN." Which implies he already had in my mind that USCSB may not have made the videos per se, so he applauded the individual who's idea it was to have the videos made in the first place.
Thank you CSB. I'm an area manager at a large chemical manufacturing plant and I take your videos and recommendations very seriously. This makes a difference
I was just hired as a field service engineer, so I'll likely be a contractor at a number of sites. Seeing videos like this get me on edge because it seems doubtful that contractors are briefed on the bug picture. I probably won't know if an operation is safe or not, and will have to take someone's word. Thank you for caring!
I just want to appreciate how realistic that CGI fire and smoke is. It's actually no big deal with current computer effects, but many animations just won't bother using Nuke or such.
Investigator Lauren Grim is the first person on all these videos that feels natural and she did the best job at explaining the incident. She should get more time in your future videos. As always, super good content. I use many of these lessons in my professional life.
That's the problem with using top field experts. They know their stuff inside and out, but not necessarily how to communicate it. It's a lot like university professors. They know their stuff hands down, but getting some of them to EXPLAIN it, to TEACH, is hard because they don't know how to teach and/or don't really want to.
@@tashkiira7838 Have you ever been to a scientific conference? I am currently doing my PhD and have attended a few conferences and the presentations are (mostly) just nightmarish. The slides are horrible, the structure is often horrible, the data representation is horrible, and sometimes the speech is horrible. Presentations on scientific conferences are cabinets full of horrors.
Yea, she has some public speaking skills and doesn't sound as robotic as some others just reading lines. I suspect she had a chance to edit the lines she spoke to be more "coloquial". Others seem to have just read off "tech lines " written by others,(I suspect engineers ) who have little or no public speaking/speech writing/presentation skills. The world of STEM,😎. As a statistician,I used to gather data about manufacturing processes and methods and properly classify business firms. And some of the people I spoke to, would be explaining what they did, and although they spoke clear English, I could hardly understand a word they were saying. -------------------------------------------------------------------------------- A story while I am stuck in bed. I am disabled vet There was one guy , we had the business he worked for as a "sand and gravel pit". The "sand" they "dug-up" and sold was $800K a ton, when "sand" sold normally at about $4 a ton. So I asked him what they did. He said about 25 words , I understood 2 of them. And I used to think I was smart (IQ154), Nope ! LOL The two words "computer" and "semi-conductor". The rest was technical jargon I had no clue of. Yea, They dug up and sold sand alright, in Sunnyvale California, a.k.a (Silicon Valley) LOL. Was actually a computer chip making firm. FYI -The "sand" in that area is high in silicon content and very clean. One of the original reasons so many computer firms started there.
These guys can make process safety interesting. That's amazing. The animations are first rate and the explanations are clear enough even for a layman like me.
all you need is common sense. They do break it down to why the failures happened and what can be done ot prevent them in the future. even when they dont have all the information they can conclude some things.
Considering the thickness of the walls on that reboiler ... hell yeah it must have been loud! I wonder what pressure levels it had right before the explosion. Like, 1000PSI? I'd do some calculations if I knew more about the specifics, like incoming steam/water temperature, efficiency, and how much propane was in there.
TylerWard335 were all in shut down season here in the tar sands in Fort mac. The hydrogen furnace at my site was 1 of 3 built, and now it's the only one left, the other 2 have blown up. Been 3 evacs this week. by this week, I mean last 4 days. Funny you mention how loud, I keep my earplugs in at emergency assembly area. Keel safe brother.
xwinger15 It's Suncor, Fort McMurray, Alberta, Canada. Northern Alberta is the 3rd largest deposit of oil known in our world to date. Out of the many major players here Suncor was the first to build here, proving profitability off of the extraction method required to separate sand from bitumen. It's boiler was built in 1964, and is still in use. One thing I can say I'm thankful for is our meticulous procedures in place that are centralized and tailored to specific needs of oil industry in Alberta. It may be a pain to take so much time, planning, check, balances, and safety precautions, but it keeps the train running, and employees alive. I'm a pipe welder in local 488.
That wouldn't have saved them, as the issue was the propane already present in the reboiler - they didn't let any more in. The pressure being supplied was water, and the outlet was also opened. Over-pressure relief needs to be present *everywhere*.
Someone Somewhere the Propane outlet was not open that was the problem so again Never bring a Pressure vessel online without opening the outlet or a vent
Thank you for these videos, we have used it before in México to our coompany to make changes and apply the recomendations of this videos and reports. It has let us improve our process and safety!
And that's why the CSB releases them so publicly. These aren't trade secrets, fractionators and heat exchangers are common knowledge (or at least common enough that even a slight engineering bent means you know roughly what they do). There's no harm to the subject company (the industry knows Williams had an explosion at Geismar, and roughly why, so it's not like that's a secret either). If the videos are disseminated publicly, it can prevent things from happening in other places, maybe.
It’s great that all US Government works are public domain with no copyright, so the entire world can freely utilize things like this, with our compliments. 🇺🇸 Very proud as an American to be helping the world’s workers lives be more safe.
When I worked maintenance at one of the largest freezer warehouses in the U.S. our management made maintenance a priority. After 10 years it was saving money that became a priority and they didn't care to keep up with maintenance. The ammonia alarms in the freezers were turned off because they gave false alarms. The sprinkler systems also did not work in the freezers and were turned off. Our managers always said that safety came first but that end up a lie. After many years instead of a once monthly safety training meetings they went to once yearly. Many new hires in maintenance had no idea what to do if there was an ammonia leak. There were many OSHA violations at our warehouse but they stopped inspections so management did not worry about violations. If a safety problem came up they covered it up if it cost them money. They would write us up for safety violations for not wearing an orange vest but turned a blind eye to far more serious violations such as the ammonia alarms and sprinkler systems did not work properly.
Additionally, there is no reason to have a "standby" heat exchanger that sits idle for over a year. The isolating valves were also idle. You can't trust a valve that is never periodically tested. Were a valve exercise program in place, the technicians would have been familiar with the process of switching from one heat exchanger to the other and the inherent dangers of only operating one set of valves.
I learn more about the chemical processes than safety in these videos sometimes. Love it! Sad for the accidents that are almost always preventable from a higher up decision making position.
as usual, great content. and as usual, the accident and resulting deaths were *completely* preventable. Hollywood and the like has the general public believing industrial accidents are always freak incidents that nobody could have seen coming. when in reality anyone paying attention to the process design and paperwork would have seen this (and nearly every other accident) years before it happened. all it would have took was following guidelines put in place by people smarter than us by the letter. but as usual, pinching pennies was deemed more important than thorough safety culture. these videos always leave me thinking not "how could this have happened!?", but rather "how did this not happen sooner? so many ignored issues". I long for the day the CSB investigations disappear, because there are no more accidents. but until then, very educational content
Indeed it was completely preventable, but you know, unfortunately, wherever humans go, there is the risk of things like this happening, no matter how fool-proof something is.
It is all about money. Same story over and over. Even where I work, we are constantly giving our recommendations based on regs and risk assessment matrices; but if the departments do not like what we have to say, they will find ways to go around us in order to get what they want. There needs to be a significant increase in the number of inspections, particularly in the academia area and healthcare facilities. But that requires more budget and more jobs for inspections to occur. Now that dumbo is in the White House, it looks like he is going to do the exact opposite of what is needed in terms of OSHA and EPA support.
I would add, that the language is failing all of us. Accident is simply wrong. Unforced errors, negligence and ignorance are not accidents. An accident is an unexpected event that is impossible to prevent... like a tree falling on a moving car, or being struck by lightning. Accents are relatively rare events. Yet 'incident' simply does not cut it to describe a preventable industrial disaster. The saddest thing is the CSB is a toothless tiger. It cannot force companies to learn from incidents at other factories. It can only 'recommend' changes which most companies clearly ignore. I don't know if the act covering the CSB gives it power on paper, or it has been de-funded to the point where enforcing its federal mandate is impossible. Either way, the corporations clearly control local and state governments
I have never worked in the kinds of industries shown in these videos, but I have learned so much watching them (chiefly that anything that prioritises profit over people costs working people their lives). Thanks for the fantastic work you do.
To be fair, it can be tough to get workers to follow safety processes. I worked as a safety & compliance officer for a construction company years ago. It was constant battle to get guys to even wear basic PPE, not to mention lockout/tagout.
Plants like that should have a scheduled big shut once every 12 months. The fact that the exchanger was running for 16 months, even when they could cut over to the secondary exchanger says everything about the plant's manager.
I used to write industrial checklists. Two requirements are strong paranoia and extreme fussiness, attention to detail. There should have been a local pressure gauge and an audible alarm on those reboilers. I agree with this report. The culture of safety appeared to be lacking.
These videos are amazing. Technical terms used in conjunction with layman’s terms, to produce a video that everyone can understand. Such an important subject matter too.
Wow these videos are actually genius. I am a youth from germany but thanks to the USCSB I now know a lot about safe working in petrol refineries. But on a serious note: I wish more companies / government agencies would make the efforts to produce videos of this kind. This is illustrative but without any dramatizing "bullshit".
Very sad loss of life and the investigation showed how it could have, and should have, been avoided. I never quite trusted pressure relief valves, and always installed them in parallel with a slightly higher rated bursting disc. Never have a fixed block valve in a vent line, even if locked open, there is always a chance of someone operating it, if it can be messed up, someone will. Maintenance blanks between flanges also used to give me sleepless nights, I would insist on personally checking the work if I had issued the permit, before signing off for return to service. I retired from the industry after 30 years and thankfully never responsible for a fatality,or serious injury, I cannot imagine how an engineer would cope with such an event. Good video, thanks.
CSB somehow captures the danger of an overpressurized and overheated vessel just through animation. I've also been binging safety videos but I just wanted to commend the animators for being able to do that.
A "Cultural" issue....that I speak about so often. The MOC ( Management of Change) process was used AFTER THE FACT as a CYA( "cover-your-a$$) effort....and not as a tool to identify hazards. It speaks to a larger work-culture issue as to how this company....and its design and operating staff.....view regulatory requirements. At some point having procedures and regulatory laws in-place is not enough....it's how the "Company" ( everyone.....top-to-bottom-and-sideways) has been trained and "believes" in the value of these safety protocols. It's a key element in safety training that I am involved with...and this "cultural" issue is often ignored or given short-shrift as to impact.
I love these animations of the people in the plant: "Hey, Joe! How was your lunch?" "Oh, pretty good... I had macaroni 'n' cheese." "How are Cathy and the kids?" "Oh, Johnny's doing well in school... He got all A's this semester!" *EXPLOSIONNNNN*
I don't about these companies which overlook safety over profits. But man, these animations and investigations are detailed. CSB is awesome. Keep up the good work. Hopefully these operations get audited frequently and save lives.
I've worked for Williams b4, building Liquid Extraction Plants.Tapping into flare stacks in refineries to make plastics, a lot of stainless on that one.
Be better to have audible alarm and pressure relief valves, and even better still stick with the original design which was probably done with care and attention to detail by true professionals.
Every time I watch these videos, I have the most effective and simplified safety fixes to all of them. For instance, these valves. With the power of simple magnetism, some wire, a light panel and and loud alarm. I can build of very inexpensive indicator panel at the vessel, that lights green for each valve opened correctly. Any valve not opened in sequence will cause a red light and the alarm to scream until that valve is opened. Total cost? About $400 for all the parts I need and you'd never see this issue. I can put one loud alarm on the panel, you won't forget. For good measure and another $100, I'll have a redundancy failsafe circuit.
Except it would all have to be an intrinsically-safe system using explosion-proof components and safety-rated industrial controllers - all signed off on by a Professional Engineer - so it would cost you $400,000.
Dragon Steel simply explains a fail safe system for double checking operation. Don't poo poo his thinking. The idea is totally sound, an idiot proof check system which Ibthink should be complusory on EVERY plant where human errors can kill people. Any design or installment cost is negligible compared to catastrophic consequences.
That's incredible when you're going for over 10 years and everything's been working fine you kinda don't think that anything's going to go wrong especially when it went wrong over 10 years ago
If there's one thing I've learned from these videos it's that working around all these pipes and valves is a deathtrap! Nobody knows what the hell is going on in any of them, whether or not flammable liquid or enough pressure to send you to the moon has built up!
Safety is job one, but most people forget that. First question to be asked is, "what could possibly go wrong?" The old AT&T, ("MA BELL"), System had a plaque on the wall in every building reading, "No job is so important, no service is so urgent, that we can't take the time to perform our work safely". The last time I was in an AT&T building, I noticed those plaques had been removed.
Most of these videos are very good. This one is not clear. What did the supervisor turn the hot water on the exchanger that had been out of service for over a year? If he intended to start up the exchanger, the isolation valves on the shell side must be open. Very strange. Years ago, as part of a maintenance procedure, a blind was placed upstream of a pressure relief valve protecting a reactor. This was done to prevent cleaning chemicals from damaging the PSV. The reactor was started up with the bind un-removed. As luck would have it, a run-away reaction occurred. Plant workers told me the reactor deformed to a totally spherical shape before it blew.
Why should he care? Hot water was the only way to start the process. No one knew the release valve was blocked on that side of the system.. The accumulation of leaked gas was also unknown. "We this do as usual".. 💥
I believe the Shell Chemical (now Kraton) at Marietta, OH had a similar problem. In an explosion probably 25 years ago, a process compression system exploded because a gate valve downstream of the compressor had been closed as the compressor operated. A cardinal rule in process compression: Always design with a relief/safety valve between the compressor and the first valve downstream of the compressor. In the situation at Shell the gate valve downstream had been closed while the compressor was operating...no relief/safety in between and an explosion resulted with several operators killed.
The block valves needed tagged/locked out for the 16 months it was out of service. + a working safety needed installed of course. This lack of safety valve has resulted in accidents elsewhere.
I don't think you really understand how big an explosion this was, and in how big a plant. Between shrapnel, falling debris, fire, and a dozen other things, across the entire plant, 160 injuries (many of which would be minor) is a little low.
"Jerry, I just want to commemorate that bangup job you did on the pre-use checklist the other day. Everyone, a toast to the most safety-conscious man in the plant!" * sweats *
"Jerry, I just want to commemorate that bangup job you did on the pre-use checklist the other day. Everyone, a toast to the most safety-conscious man in the plant!" * sweats *
"Jerry, I just want to commemorate that bangup job you did on the pre-use checklist the other day. Everyone, a toast to the most safety-conscious man in the plant!" "Haha...yeah..."
I've been an operator in the petrochem industry for 15 years and it's incredible to me how many accidents there still is. The industry is still evolving and standardizing, I suppose.
You see this all the time in the field and it’s usually so you can perform routine maintenance on the PRVs like rupture disc swaps without shutting down the process. However, there has to clear procedures on when it is appropriate to block in the valves. As mentioned in the video, the block valves should be locked open and operations should be notified when it needs to be closed.
You can be damn sure those who made that check on those questions knew perfectly well that they should not put any answer..after all if person will say yes..it would be that person responsibility..and that is how it happened for sure..
I'm very impressed at the quality of the videos here. Compared to the NTSB, you guys might as well be a Hollywood blockbuster. And I think you use SFM to animate these, which is hilarious to me
These videos are very helpful based on how they explain what happened. There would be more value in these great videos by outlining the "why" behind how decisions were made and the factors influencing the decisions. This particular video eluded to safety culture and I would be most interested in assessment results.
See those Big Coloums or Vertical Tanks.... Imagine being up there Welding and a Fire breaks out below you.....WHERE DO YOU GO ???? NO WHERE...You BURN UP OR JUMP... Retired UA 342 WELDER HERE..It wasn't so Scary when I was working but now looking back it Scares the SHIT OUT OF ME...🤔🤔 .
I believe unions are good for employee safety. What are your thoughts? I grew up where & when unions were strong. I now live in a "right to work" state & I see how companies dont deal with complaints, they just fire you & hire another sucker!
Unfortunately the people in charge of implementing safety recommendations or regulations only see them in one way: costing the company money. And costing the company money is not something you want to do if you want to keep your job or be promoted.
-- Thanks to the CSB for producing and publicising this video! -- These are complex chemical facilities. Keeping them safe and productive takes a lot of skill and sustained attention. The companies running these have a lot of responsibility, for which they get well paid. They need to be held accountable.
The scary thing with many of these accidents is that you could be working right next to a dangerous container or pipe and not even know.
The positive thing is that if the pipe or container did blow you wouldn't know. I hate to say it but this guy got lucky in his death, there are many horrible ways but this happened so fast that he wouldn't have had time to process it. One second he's breathing and looking at something, then a microsecond later he just doesn't exist anymore.
@@tommybear1097 Morbid, yet true. I'd wanna go the same way if I were a chem plant employee involved in accident.
You are there, a second later you're everywhere.
I've worked in an oil refinery a few times, and it's an unsettling feeling to know that some guy 50 feet away from you can do something wrong and kill you without warning.
@Jimmy De'Souza have you ever seen the results of an explosion? the guy was most likely killed by shrapnel injuries or blast wave over pressure.
God I love these videos. Similar to junky Discovery shows but without all the bullshit, and actually educational for the teams at work.
You do realize the modern marvels engineering disasters episodes use these videos for content and merely summarize the content for the layperson.
Corey Schmidt Summarize? They always repeat everything 5 times. Could cut the episodes down to 2 minutes basically
It's all great except the people that are reading off a prompter and don't sound like they know this subject material. I don't understand why they don't put actual experts in front of the camera.
@@thomaszinser8714 That's a very good point.
@@thomaszinser8714 yes lets put a former Waffle house waitress in front of the camera.
Sad part is there was probably a maintenance guy who pointed this out and he was told by a "manager" it was ok because it was shut down
Managers are hazardous to everyone's health.
In my experience, managers will ignore all employee input regarding safety, then after catastrophe strikes they create a bunch of stupid new rules that don't address actual safety issues, but look good on paper.
100000000% agree
Funny I used to work at a petroleum plant with such high potential dangers, managers and cowardly unions, so I quit after five years of bullshit. Now this happens and will happen again.
oh we all know this is true. Im sure that some low level employee was ignored and warned of what was gonna happened and guess what ? it happened. but profits = more important than safety of employees or the environment.
Whoever makes these videos at the USCSB, or whoever had the idea to make these, is a genius. They make safety FUN.
(Okay, more accurately, ENGAGING, thank you for pointing that out)
USCSB doesn't make the videos, they hire a contractor.
@@KiloByte69 He said, "Whoever makes these videos at the USCSB, *or whoever had the idea to make these,* is a genius. They make safety FUN." Which implies he already had in my mind that USCSB may not have made the videos per se, so he applauded the individual who's idea it was to have the videos made in the first place.
@@silentype3008 He is just dropping info
Fun is not a word that I would use. They make it easy to understand than reading the case study or the full accident report (if readily available)
@@gorillaau laugh a little
Thank you CSB. I'm an area manager at a large chemical manufacturing plant and I take your videos and recommendations very seriously. This makes a difference
Thank you and bless you
Thank you for caring about your workers, if only more employers were like you when it came to safety
Sorry you have to work with drunk chemists all day
I was just hired as a field service engineer, so I'll likely be a contractor at a number of sites. Seeing videos like this get me on edge because it seems doubtful that contractors are briefed on the bug picture. I probably won't know if an operation is safe or not, and will have to take someone's word. Thank you for caring!
If the name of a machine ends with something that sounds like ”inator”, there’s a good chance that it will blow up
Boominator
Resinator (well its close) :-)
bomb doesn't have "inator" in its name, see? it must be safe 🤔
a bomb needs a det"inator" though lol.
Turboencabulator?
USCSB is the best
I just want to appreciate how realistic that CGI fire and smoke is. It's actually no big deal with current computer effects, but many animations just won't bother using Nuke or such.
@Crystal Dreams ?kcuf eht tahw ,em esucxE
It’s the government. It’s your taxes that pay for this high quality cgi
@@FishFind3000 it's fucking fantastic though
An excellent and eminently appropriate use of the taxes taken by the government
Yeah they've got some serious particle simulations in these! They even looked good (for the time) back in 2008 when they started posting them.
Investigator Lauren Grim is the first person on all these videos that feels natural and she did the best job at explaining the incident.
She should get more time in your future videos.
As always, super good content. I use many of these lessons in my professional life.
That's the problem with using top field experts. They know their stuff inside and out, but not necessarily how to communicate it.
It's a lot like university professors. They know their stuff hands down, but getting some of them to EXPLAIN it, to TEACH, is hard because they don't know how to teach and/or don't really want to.
Smash 👊🏻
@@tashkiira7838 Have you ever been to a scientific conference? I am currently doing my PhD and have attended a few conferences and the presentations are (mostly) just nightmarish. The slides are horrible, the structure is often horrible, the data representation is horrible, and sometimes the speech is horrible. Presentations on scientific conferences are cabinets full of horrors.
Yea, she has some public speaking skills and doesn't sound as robotic as some others just reading lines. I suspect she had a chance to edit the lines she spoke to be more "coloquial". Others seem to have just read off "tech lines " written by others,(I suspect engineers ) who have little or no public speaking/speech writing/presentation skills.
The world of STEM,😎. As a statistician,I used to gather data about manufacturing processes and methods and properly classify business firms. And some of the people I spoke to, would be explaining what they did, and although they spoke clear English, I could hardly understand a word they were saying.
--------------------------------------------------------------------------------
A story while I am stuck in bed. I am disabled vet
There was one guy , we had the business he worked for as a "sand and gravel pit".
The "sand" they "dug-up" and sold was $800K a ton, when "sand" sold normally at about $4 a ton.
So I asked him what they did. He said about 25 words , I understood 2 of them. And I used to think I was smart (IQ154), Nope ! LOL
The two words "computer" and "semi-conductor". The rest was technical jargon I had no clue of.
Yea, They dug up and sold sand alright, in Sunnyvale California, a.k.a (Silicon Valley) LOL. Was actually a computer chip making firm.
FYI -The "sand" in that area is high in silicon content and very clean. One of the original reasons so many computer firms started there.
These guys can make process safety interesting. That's amazing. The animations are first rate and the explanations are clear enough even for a layman like me.
all you need is common sense. They do break it down to why the failures happened and what can be done ot prevent them in the future. even when they dont have all the information they can conclude some things.
This is why I’m becoming a process safety engineer!!! So these videos don’t have to exist anymore :(
I was there when this happened, it's unbelievable how loud it was.
Considering the thickness of the walls on that reboiler ... hell yeah it must have been loud! I wonder what pressure levels it had right before the explosion. Like, 1000PSI? I'd do some calculations if I knew more about the specifics, like incoming steam/water temperature, efficiency, and how much propane was in there.
TylerWard335 were all in shut down season here in the tar sands in Fort mac. The hydrogen furnace at my site was 1 of 3 built, and now it's the only one left, the other 2 have blown up. Been 3 evacs this week. by this week, I mean last 4 days. Funny you mention how loud, I keep my earplugs in at emergency assembly area. Keel safe brother.
way more than 1000PSI...
Barry Ross what site was that?? I never heard about anything about that...
xwinger15 It's Suncor, Fort McMurray, Alberta, Canada. Northern Alberta is the 3rd largest deposit of oil known in our world to date. Out of the many major players here Suncor was the first to build here, proving profitability off of the extraction method required to separate sand from bitumen. It's boiler was built in 1964, and is still in use. One thing I can say I'm thankful for is our meticulous procedures in place that are centralized and tailored to specific needs of oil industry in Alberta. It may be a pain to take so much time, planning, check, balances, and safety precautions, but it keeps the train running, and employees alive. I'm a pipe welder in local 488.
Basic rule: Never open pressure into a vessel without first opening an outlet for that pressure to exit the vessel.
That wouldn't have saved them, as the issue was the propane already present in the reboiler - they didn't let any more in. The pressure being supplied was water, and the outlet was also opened.
Over-pressure relief needs to be present *everywhere*.
No procedure sign off? Real dump mistake!
Ken Karnes don't eat beans with your ass closed.
Someone Somewhere
the Propane outlet was not open that was the problem so again Never bring a Pressure vessel online without opening the outlet or a vent
Someone Somewhere The output was closed.
"Propylene fractionator reboiler" is fun to say. It's so...industrial.
so true!
Sounds like a Bernoulli Convergenator or Flux Capacitor
"I sell propane and propane accessories"
It sounds scifi as fuck lmao
ah, perry the platypus, you're just in time to see my latest invention! behold - the propylene fractionator reboilinator!
Thank you for these videos, we have used it before in México to our coompany to make changes and apply the recomendations of this videos and reports. It has let us improve our process and safety!
And that's why the CSB releases them so publicly. These aren't trade secrets, fractionators and heat exchangers are common knowledge (or at least common enough that even a slight engineering bent means you know roughly what they do). There's no harm to the subject company (the industry knows Williams had an explosion at Geismar, and roughly why, so it's not like that's a secret either). If the videos are disseminated publicly, it can prevent things from happening in other places, maybe.
@@tashkiira7838 USCSB help the whole world, saving lives
It’s great that all US Government works are public domain with no copyright, so the entire world can freely utilize things like this, with our compliments. 🇺🇸 Very proud as an American to be helping the world’s workers lives be more safe.
When I worked maintenance at one of the largest freezer warehouses in the U.S. our management made maintenance a priority. After 10 years it was saving money that became a priority and they didn't care to keep up with maintenance. The ammonia alarms in the freezers were turned off because they gave false alarms. The sprinkler systems also did not work in the freezers and were turned off. Our managers always said that safety came first but that end up a lie. After many years instead of a once monthly safety training meetings they went to once yearly. Many new hires in maintenance had no idea what to do if there was an ammonia leak. There were many OSHA violations at our warehouse but they stopped inspections so management did not worry about violations. If a safety problem came up they covered it up if it cost them money. They would write us up for safety violations for not wearing an orange vest but turned a blind eye to far more serious violations such as the ammonia alarms and sprinkler systems did not work properly.
This sounds like a set up in Final Destination
Lauren Grim. Great name for a CSB Investigator,
I like it too
Narrator: Unable to become a mortician, or work at the coroner's office, she reluctantly sought a career in safety. Little did she know...😂
I'm glad your organization exists and that you produce these videos for the public. That's so excellent.
That's a badass logo animation USCSB has got there.
I hope I’m not the only single that watches these on Friday nights. Fascinating.
Additionally, there is no reason to have a "standby" heat exchanger that sits idle for over a year. The isolating valves were also idle. You can't trust a valve that is never periodically tested. Were a valve exercise program in place, the technicians would have been familiar with the process of switching from one heat exchanger to the other and the inherent dangers of only operating one set of valves.
I learn more about the chemical processes than safety in these videos sometimes. Love it! Sad for the accidents that are almost always preventable from a higher up decision making position.
Informative videos + clickbait-free video titles + things go boom = hammering that sub button.
Also, a serious BINGE!
as usual, great content. and as usual, the accident and resulting deaths were *completely* preventable. Hollywood and the like has the general public believing industrial accidents are always freak incidents that nobody could have seen coming. when in reality anyone paying attention to the process design and paperwork would have seen this (and nearly every other accident) years before it happened. all it would have took was following guidelines put in place by people smarter than us by the letter. but as usual, pinching pennies was deemed more important than thorough safety culture. these videos always leave me thinking not "how could this have happened!?", but rather "how did this not happen sooner? so many ignored issues". I long for the day the CSB investigations disappear, because there are no more accidents. but until then, very educational content
Indeed it was completely preventable, but you know, unfortunately, wherever humans go, there is the risk of things like this happening, no matter how fool-proof something is.
My high school electronics teacher always said that most accidents are actually neglec-ccidents
that might be my new favorite phrase
It is all about money. Same story over and over. Even where I work, we are constantly giving our recommendations based on regs and risk assessment matrices; but if the departments do not like what we have to say, they will find ways to go around us in order to get what they want. There needs to be a significant increase in the number of inspections, particularly in the academia area and healthcare facilities. But that requires more budget and more jobs for inspections to occur. Now that dumbo is in the White House, it looks like he is going to do the exact opposite of what is needed in terms of OSHA and EPA support.
I would add, that the language is failing all of us. Accident is simply wrong. Unforced errors, negligence and ignorance are not accidents. An accident is an unexpected event that is impossible to prevent... like a tree falling on a moving car, or being struck by lightning. Accents are relatively rare events.
Yet 'incident' simply does not cut it to describe a preventable industrial disaster.
The saddest thing is the CSB is a toothless tiger. It cannot force companies to learn from incidents at other factories. It can only 'recommend' changes which most companies clearly ignore.
I don't know if the act covering the CSB gives it power on paper, or it has been de-funded to the point where enforcing its federal mandate is impossible.
Either way, the corporations clearly control local and state governments
3:59 - I like how the control panels are DJ mixers.
More like a mixing desk, but yes - a quick way to get the right sort of texture for the animators I guess.
I was there that day when it exploded. Very scary because I wasn’t that far from the area. One of the most nerve racking thing I’ve ever been thru
I have never worked in the kinds of industries shown in these videos, but I have learned so much watching them (chiefly that anything that prioritises profit over people costs working people their lives). Thanks for the fantastic work you do.
To be fair, it can be tough to get workers to follow safety processes. I worked as a safety & compliance officer for a construction company years ago. It was constant battle to get guys to even wear basic PPE, not to mention lockout/tagout.
Sweet, another beautiful new CSB report. Now lets hope these hard lessons are learned and lives are actually saved going forward.
"Maintenance and safety waaa spensive don't wanna"
* Explosion and death happens
"HIRE THE MOST EXPENSIVE LAWYERS AVAILABLE"
Anyone else go on binges of watching these?
The sound design in this video is really great. 4:28 sent chills down my spine.
That's because they used alot of dj-mixers in the control room 3:57
@@noijze haha, good one
You would think at some point, they would have installed a simple pressure gauge on this pressure vessel.
The dial would have spun noticeably at startup. Propane expands almost as much as water does when it boils..
@@tashkiira7838 would be nice if there was a pressure sensor and emergency dump valves for this.
Plants like that should have a scheduled big shut once every 12 months. The fact that the exchanger was running for 16 months, even when they could cut over to the secondary exchanger says everything about the plant's manager.
omg finally. I've been having to go back and watch past videos I've seen several times.
I used to write industrial checklists. Two requirements are strong paranoia and extreme fussiness, attention to detail. There should have been a local pressure gauge and an audible alarm on those reboilers. I agree with this report. The culture of safety appeared to be lacking.
These videos are amazing. Technical terms used in conjunction with layman’s terms, to produce a video that everyone can understand. Such an important subject matter too.
These USCSB videos are fantastic. I'm so glad that they took the time to make these detailed videos about accidents so we can all learn from them.
Wow these videos are actually genius. I am a youth from germany but thanks to the USCSB I now know a lot about safe working in petrol refineries. But on a serious note: I wish more companies / government agencies would make the efforts to produce videos of this kind. This is illustrative but without any dramatizing "bullshit".
Quarantine 2020, I'm addicted to this channel and have been binging on these videos for hours. So good.
I wish Seconds from Disaster would consult with these folks at the USCSB like Mayday/ACI works with the NTSB!
I always learn so much from the CSB videos. Thank you for all the hard work that makes this critical information available to us all!
I don't live in US neither have anything to do with the type of equipment in your videos, but I enjoy watching them. thank you for making these.
Ex engineer gasoline tanker 600 feet!These type of incidents are exactly why i got out of the industry.Saved My life!
Thanks for the high quality content, honest and factual, and not dumbed down. Perfect!
I used to work at a medicine plant in Elkton Virginia. we watched videos like this all the time.
I love these. I load them into an ASMR queue and go to sleep listening to them. Good job, US gummint
Your explosion animations are so awesome!
Very sad loss of life and the investigation showed how it could have, and should have, been avoided.
I never quite trusted pressure relief valves, and always installed them in parallel with a slightly higher rated bursting disc. Never have a fixed block valve in a vent line, even if locked open, there is always a chance of someone operating it, if it can be messed up, someone will.
Maintenance blanks between flanges also used to give me sleepless nights, I would insist on personally checking the work if I had issued the permit, before signing off for return to service.
I retired from the industry after 30 years and thankfully never responsible for a fatality,or serious injury, I cannot imagine how an engineer would cope with such an event.
Good video, thanks.
the key is the relief valve was isolated from the reboiler by the MOC of adding isolation manual valve.
Literally hooked to this channel now
been waiting for so long for this, I love these videos, so informative
Behold, my Propylene Fractionator!
*4:36*
CURSE YOU PERRY THE PLATYPUUUUS!
As a 25 year US nuclear plant operations veteran these videos astound me.
I’m an sro and these are literally absurd I would definitely go with E0 and fucking leave if this was happening in my room.
CSB somehow captures the danger of an overpressurized and overheated vessel just through animation. I've also been binging safety videos but I just wanted to commend the animators for being able to do that.
These videos should be mandatory for all government agencies. We, the public, would greatly benefit.
A "Cultural" issue....that I speak about so often. The MOC ( Management of Change) process was used AFTER THE FACT as a CYA( "cover-your-a$$) effort....and not as a tool to identify hazards. It speaks to a larger work-culture issue as to how this company....and its design and operating staff.....view regulatory requirements. At some point having procedures and regulatory laws in-place is not enough....it's how the "Company" ( everyone.....top-to-bottom-and-sideways) has been trained and "believes" in the value of these safety protocols. It's a key element in safety training that I am involved with...and this "cultural" issue is often ignored or given short-shrift as to impact.
Man I love CSB’s videos
I love these animations of the people in the plant: "Hey, Joe! How was your lunch?" "Oh, pretty good... I had macaroni 'n' cheese." "How are Cathy and the kids?" "Oh, Johnny's doing well in school... He got all A's this semester!" *EXPLOSIONNNNN*
I don't about these companies which overlook safety over profits. But man, these animations and investigations are detailed.
CSB is awesome. Keep up the good work. Hopefully these operations get audited frequently and save lives.
Strong believer in the programs involved. Participated in many reviews in my 50 years in the Chemical Industry
As a NDT technician I find these videos well done and interesting!
I've worked for Williams b4, building Liquid Extraction Plants.Tapping into flare stacks in refineries to make plastics, a lot of stainless on that one.
This is my favorite USCSB video
I love these videos.
I want them to get a T.V show like Air Crash Investigation or whatever they call it. These are the jobs I want to do.
Catie Adair
Me too! I'm so weird. X'D
It's just crazy that these HE's were not fitted with pressure and temperature sensors.
Raymond Edge They most likely were, with pressure gauges and thermometers. That doesn’t prevent anything.
Be better to have audible alarm and pressure relief valves, and even better still stick with the original design which was probably done with care and attention to detail by true professionals.
Great job as usual. There should be more people watching these videos!!!
Every time I watch these videos, I have the most effective and simplified safety fixes to all of them. For instance, these valves. With the power of simple magnetism, some wire, a light panel and and loud alarm. I can build of very inexpensive indicator panel at the vessel, that lights green for each valve opened correctly. Any valve not opened in sequence will cause a red light and the alarm to scream until that valve is opened. Total cost? About $400 for all the parts I need and you'd never see this issue. I can put one loud alarm on the panel, you won't forget. For good measure and another $100, I'll have a redundancy failsafe circuit.
Except it would all have to be an intrinsically-safe system using explosion-proof components and safety-rated industrial controllers - all signed off on by a Professional Engineer - so it would cost you $400,000.
^^^^ this.
Dragon Steel simply explains a fail safe system for double checking operation. Don't poo poo his thinking. The idea is totally sound, an idiot proof check system which Ibthink should be complusory on EVERY plant where human errors can kill people. Any design or installment cost is negligible compared to catastrophic consequences.
That's incredible when you're going for over 10 years and everything's been working fine you kinda don't think that anything's going to go wrong especially when it went wrong over 10 years ago
If there's one thing I've learned from these videos it's that working around all these pipes and valves is a deathtrap! Nobody knows what the hell is going on in any of them, whether or not flammable liquid or enough pressure to send you to the moon has built up!
Man, I am so jealous of Vanessa's sharp style. I can't get away with wearing anything red, much less a neckpiece. She's rocking it...
"Fractionator" sounds like an evil mathematic weapon devised by Dr. Doofenshmirtz .
These are amazing videos thank you.
Safety is job one, but most people forget that. First question to be asked is, "what could possibly go wrong?" The old AT&T, ("MA BELL"), System had a plaque on the wall in every building reading, "No job is so important, no service is so urgent, that we can't take the time to perform our work safely". The last time I was in an AT&T building, I noticed those plaques had been removed.
Anyone else binge-watching these vids right now ?
February 2024
Excelente as animações!!!
Parabéns.
I just love this narrator.
Most of these videos are very good. This one is not clear. What did the supervisor turn the hot water on the exchanger that had been out of service for over a year? If he intended to start up the exchanger, the isolation valves on the shell side must be open. Very strange.
Years ago, as part of a maintenance procedure, a blind was placed upstream of a pressure relief valve protecting a reactor. This was done to prevent cleaning chemicals from damaging the PSV. The reactor was started up with the bind un-removed. As luck would have it, a run-away reaction occurred. Plant workers told me the reactor deformed to a totally spherical shape before it blew.
He opened it because he didn't expect it to be filled with propane, or at least not enough to cause the explosion that killed him.
Manager may not have understood or thought about the consequences of what he was doing - open valves A, B, C, and D... but order matters.
First rule of operations......Never allow a supervisor to do operations work !!
Why should he care? Hot water was the only way to start the process. No one knew the release valve was blocked on that side of the system.. The accumulation of leaked gas was also unknown.
"We this do as usual".. 💥
@@hallerd plus the block going to the relief was closed
I believe the Shell Chemical (now Kraton) at Marietta, OH had a similar problem. In an explosion probably 25 years ago, a process compression system exploded because a gate valve downstream of the compressor had been closed as the compressor operated. A cardinal rule in process compression: Always design with a relief/safety valve between the compressor and the first valve downstream of the compressor. In the situation at Shell the gate valve downstream had been closed while the compressor was operating...no relief/safety in between and an explosion resulted with several operators killed.
Awesome, informative content!
Great video!
interesting to see how these animations get better over time.
Your Channel has taught me more than school did. would of been awesome to learn all this stuff in high school.
Yeah… because everyone should learn process hazard analysis in high school
The block valves needed tagged/locked out for the 16 months it was out of service. + a working safety needed installed of course. This lack of safety valve has resulted in accidents elsewhere.
160 injuries?! were they standing around about to celebrate the decade plus of the valve system working without issue?
I don't think you really understand how big an explosion this was, and in how big a plant. Between shrapnel, falling debris, fire, and a dozen other things, across the entire plant, 160 injuries (many of which would be minor) is a little low.
"Jerry, I just want to commemorate that bangup job you did on the pre-use checklist the other day. Everyone, a toast to the most safety-conscious man in the plant!"
* sweats *
"Jerry, I just want to commemorate that bangup job you did on the pre-use checklist the other day. Everyone, a toast to the most safety-conscious man in the plant!"
* sweats *
"Jerry, I just want to commemorate that bangup job you did on the pre-use checklist the other day. Everyone, a toast to the most safety-conscious man in the plant!"
"Haha...yeah..."
One guy: "I, uh, lost sleep over it"
Second: "I totally missed my pilates class and got fat"
Third: "Ow, my uterus!"
I've been an operator in the petrochem industry for 15 years and it's incredible to me how many accidents there still is. The industry is still evolving and standardizing, I suppose.
3ds max it’s UA-cam bro. I don’t proofread all my comments before posting
thank you for excellent IIR! I will use it for safety moment💓
USCSB did a great job with these videos. 👍
Yeah don't put valves between the PRV's.
You see this all the time in the field and it’s usually so you can perform routine maintenance on the PRVs like rupture disc swaps without shutting down the process. However, there has to clear procedures on when it is appropriate to block in the valves. As mentioned in the video, the block valves should be locked open and operations should be notified when it needs to be closed.
You can be damn sure those who made that check on those questions knew perfectly well that they should not put any answer..after all if person will say yes..it would be that person responsibility..and that is how it happened for sure..
Information is POWER !! 💪
I'm very impressed at the quality of the videos here. Compared to the NTSB, you guys might as well be a Hollywood blockbuster. And I think you use SFM to animate these, which is hilarious to me
The Impact report you linked had its url truncated, you should consider editing it. Another great video, always interesting to watch these.
These videos are very helpful based on how they explain what happened. There would be more value in these great videos by outlining the "why" behind how decisions were made and the factors influencing the decisions. This particular video eluded to safety culture and I would be most interested in assessment results.
See those Big Coloums or Vertical Tanks.... Imagine being up there Welding and a Fire breaks out below you.....WHERE DO YOU GO ???? NO WHERE...You BURN UP OR JUMP... Retired UA 342 WELDER HERE..It wasn't so Scary when I was working but now looking back it Scares the SHIT OUT OF ME...🤔🤔
.
I believe unions are good for employee safety. What are your thoughts? I grew up where & when unions were strong. I now live in a "right to work" state & I see how companies dont deal with complaints, they just fire you & hire another sucker!
Unfortunately the people in charge of implementing safety recommendations or regulations only see them in one way: costing the company money. And costing the company money is not something you want to do if you want to keep your job or be promoted.
Yeah, they think it's cheaper to pay wrongful death lawsuits.
@@phiksit it's cheaper to ban this type of stuff. Give it 20 years it all will be
All process engineers and safety personnel should be required to watch all of these videos
-- Thanks to the CSB for producing and publicising this video!
-- These are complex chemical facilities. Keeping them safe and productive takes a lot of skill and sustained attention. The companies running these have a lot of responsibility, for which they get well paid. They need to be held accountable.
😂 That's totally the voice of Winnie the Poo. 😂
Even tho this makes no sense to me, it's still interesting to watch. The animations are amazing too!
One Thing I learn from CSB videos: Its always the Reboilers
Some of the best videos on UA-cam. Virtually no idea what’s going on here but hey..I see something go boom..I understand
Very informative and detailed video. Plese make more videos like this, but let's hope for less accidents in the future