Taught to be fast. Taking H2S course we need to put the Scott pack on in seconds. So I'd imagine the time was them getting to the spot and doing rescue. We are always taught to be fast..fast and careful obviously. My first time taking the course we had to put the pack on and go through a completely dark room and find the dummy body and exit in a certain time.
Without using proper equipment n site analysis of site with Hazard posibilities for tht mistake 2 person died as they did not follow the right procedure guidelines followed by their training. May their soul rest in peace.
@@ploopyboy231 dude it had less then 1% oxygen so they might as well been passed out in a body of water fucking 3 minutes is about all the poor guy had. The foreman should of radioed that he needed a scba like the second it happened or a smart one would of located where they were prior and even brought one to the work spot just incase. The thing I never understand is how the hell they think they are gonna be able to rescue someone in such a clearly low oxygen environment I mean, do they just think the guy is just tired and thought he would take a nap?! I mean if homie can't fucking breathe in a certain space what in your mind makes you think you're superman and can not only be impervious to the low oxygen environment but be able to pick dude up and carry him up a latter you know how much you would need to breathe in to be able to have the oxygen to carry another man up a latter that is passed out?! He didn't stand a chance.
we were warned we had less than 3 minutes to exit an engineroom, as the navy used halon extinguishing systems for fires, which replaces all the oxygen in the space when activated. 3 minutes is a lot shorter than you think it is.
In a halon-protected data center where I worked, we had many large halon-delay plunger-type buttons on the building support columns to help us get out of the room. If the halon alarm would go off, we were to run to the exit pressing any delay buttons we passed by to add more seconds before the halon was released. The only halon event I knew of was when a industrial-sized battery exploded in a back room. I wasn't there at the time.
The best way to handle a situation like this is to consider EVERY confined space as a low/no oxygen space until proven otherwise with a meter. Also multiple readings at different levels, near the top o2 levels may be normal but drop as you go lower. Also toxic gas's tend to be heavier than air and may not register near the top
it did not say no inert gases it said N/A . meaning none applicable idk how it works in that field but in almost all others N/A is short for " i dont really know" or "im not sure enough to say yes or no to this question" meaning further investigation may be needed on the matter before a tru "permanent" answer is given it doesnt mean "NO" ., most companies will have "yes , no , N/A" as answers and N/A is jsut IDK . . some fields dont really need a yes or no like working at walmart and filling out your check list . "did you mop the restroom" "yes, no ,n/a" for example wouldnt kill somone if you put N/A and wouldnt need investigating so its more considered a maybe . but in a field like this a N/A should never be taken as yes or NO . when its a matter that can kill somone like "did you asure to vent all inert gases from the tank? YES, NO, N/A" in that case somone should have seen that N/A and made sure to do a test themselfs first.
@@TYcarterTracks you correctly state what N/A means - but in all fields it means Not Applicable. In your example of a Restroom being marked N/A typically that would be because there is either no Restroom or that maintenance of the restroom is handled by a 3rd party. Marking N/A on that form would indicate that the system being worked on does not have Nitrogen present, therefore purging of Nitrogen isn't applicable. I agree with the OP - a Work Permit that has a section to advise of the specific hazard that was filled in incorrectly is one of the biggest issues here - assuming that the workers were operating under the information provided, had they had the correct information, they may have made different decisions. That said - there's a lesson here from the world of Firearms, the Golden rule of safe handling is to treat all Firearms as loaded at all times. Had they treated all enclosed spaces as potentially containing lethal gases...
WRONG. The work permit indicated no hazard where the workers were SUPPOSED to be working - OUTSIDE the vessel! The scope of their job and permit did not involve entering the vessel at any time and nobody was supposed to be inside the damn thing! Had they gone through the second permitting process as required, I'm sure the vessel would have been checked and purged with air or someone properly equipped/trained to enter a low/no oxygen environment dispatched to enter the tank and retrieve the object. This is purely a case of unqualified individuals taking shortcuts and unnecessary risks. It's pretty sad that a DANGER - KEEP OUT sign isn't sufficient to keep people out. One shouldn't have to call out every danger posed in the area behind the sign. It's a dangerous area and you shouldn't be there. Period. Their permit allowed them to work outside the tank, and had they stayed where they were given permission to work then both of them would be alive.
@@fordguy8792 one of the few people on this entire thread to actually notice that 👍. Sadly, the daggum video said they would have had to have gotten a permit to enter the tank, yet there are so many comments about the permit not warning of nitrogen…… It was N/A, BECAUSE THEY WERE SUPPOSED TO BE WORKING OUTSIDE OF THE REACTOR
Just sent this to my 19 year old apprentice! This is huge for us small mechanical contractors trying to bring the next gen up to speed. Thanks for the video!
One problem with this video is that they show a document where nitrogen/inert gas is marked N/A which means there is missing information and they never mention it. It does not matter if you are trained or not if you do not know what you are dealing with, which I think this video completely overlooks/ignores.
That's awesome that you thaught about your younger apprentice. I'm in my 40s now but I remember how hard it was when I younger. It seems like the older generation always seemed to not be too helpful for whatever reason
I have a horror of having to stand in the Court of Inquiry on the death or serious energy of one of my team. Videos such as this make the hazards clear and apparent to the team, and I show them when we have some time.
I hate confined space entry permits and particularly nitrogen purged environments which have not been oxygen tested. Nitrogen is a silent killer, the human body has no natural protection, we are used to breathing 80% nitrogen, it does not create a gagging or choking reaction. Transport containers with fresh food and filled with N2 to preserve the cargo are very dangerous environments. I was always amazed at the lack of awareness of this problem, hopefully your video will spread the knowledge, thanks.
CO2 hazards in closed vehicles present another opportunity for disaster. And there's a number of people in the gig economy transporting food with dry ice in unsealed & semi-sealed containers & sleeping on the floors of their vans/trucks where the gas pools.
@@adamrodgers9175 Ishoud have been more specific. I often had to issue these permits, and put my name on it, to certify that I was OK with all the precautions. If I signed one, I would personally supervise the entry, it caused me great stress, and I would not relax until all personnel were out safely. It was possibly the most dangerous operation on site. The hate was me having the responsibility. I managed 30 years working in a very hazardous environment, signed hundreds of permits,and was pleased to retire without anyone getting seriously injured. OK we had a few slips trips and other minor injuries.
The sheet did say that nitrogen risks were "not applicable", which in my opinion is potentially the cause of this incident; perhaps the first worker, while trying to retrieve the tape, fell in, then his supervisor saw that he had fallen and was laying unconscious, assuming that he had hit his head, and attempted to rescue him while still not knowing about the lack of oxygen
Right! I worked in a wastewater treatment facility. 1) Mandatory short course about working in confined spaces. 2) NEVER enter a confined space before measuring H2S, O2 and CO2 levels and take apropriate actions when necessary.
This accident at DCR killed 2 of my union brothers of my local. This accident changed a lot of policy and procedures. It was a fatal lesson. I work at this refinary often, and whenever I see this particular unit, it makes me think how this could of been avoided. RIP
That sucks man...Hopefully part of that new standard procedure is to use a meter to check the tank before jumping in or spending prolonged time near an open cover.
This dude was having a bad day, boss was gonna chew him out for some tape issue that wasn’t his fault, he tries fishing it out, brain turning to mush, losing all rational, jumps into the tank, it’s just all down hill.
There really shouldn't be any repercussions for asking for help. The threat of loss wage or job is one of the reasons for attempting risky stunts such as this.
I had just started a new job where we had safety drilled in to us daily, including confined space. So I was tasked to give a tour to a VIP accompanied by our senior executive. We get to a large cell that is a confined space and the VIP wants to see inside. All the warning signs and barriers are in place, so I say "sorry, that's a confined space and hasn't been made safe for entry." The senior executive started screaming at me that "he can see clearly inside and there's no hazard." Meanwhile I refused by saying we had to follow safety protocol, figuring I was going to be fired at any moment. Fortunately the VIP intervened saying he had a meeting to get to and the next day something else captured the executive's attention to throw a tantrum over.
This is probably the most obvious, but in a way hidden, problem:. I always like to find out how the "executive" got to his position as "Sheriff of Nottingham". I dealt with loads of higher ups that were there for all the wrong reasons: relatives of others, went to school with buddies, shared their crack pipe (and yes, I mean white collar crack pipers), and their "default" management skills. In mining, agri, and const. they can get you killed.
Sometimes they do something like that as test against an unsuspecting worker, had you said "ok" and opened it up that raving senior executive might have said; "stop right there, you blatantly violated company safety rules, put lives in danger and you are FIRED" They did similar things on a fast food job I had years ago, they would call and place an order for delivery, wanting to check to see if you suggested soda and side dishes, was polite etc and just before you were about the send the order to the kitch the caller would say "ok, you can cancel that, this is a mystery shopper call, you did well, congrats!" One time it my shift manager on the phone not 10 feet away disguising her voice!
@@Vid_Master If I was the executive that would be what I would be trying to do. I would be trying to do ANYTHING I could think of to try to pressure you, even threatening to fire you if you continued to refuse. Once I was convinced that there was no way you were going to acquiesce, I would tell you "good job, you passed!" But, if I managed to get you to say "ok" I would have then told you to go to the office and get your last paycheck.
Many years ago I was in a chemical plant where a similar type accident occurred. During a turn-around (plant wide maintenance) a certain carbon steel pressure vessel was drained and the man ways opened up. Air was sparged in to create a safe atmosphere for workers. After a while, the tank was tested for oxygen and was deemed safe. Workers prepared themselves to enter the tank to do some work. I don't remember how many men entered but one died in the vessel from oxygen deprivation. Respirators were not used by these workmen as the vessel had been cleared for entry. What happened to the oxygen that caused one man to die for lack of it? The post mortem came to the conclusion that the oxygen was consumed by the internal surface of the tank rusting!
When my dad worked at Rolls Royce they had some people in to do construction work, part of which involved somebody working in a hole in the ground with a jackhammer. Mr. Jack Hammerer hooked up his jackhammer to one of the nearby airline mains and set to. Only problem was that it wasn't compressed air that he was hooked up to, it was argon that they used for welding; he filled up the pit with argon and asphyxiated.
@@someusername121 The trouble is most people can't hold their breathe over 45 seconds. Having an SCBA available with the alarm would be the safest route.
This is right. Contractors are not trained properly and the deaths and injuries do not count as on the job accidents for the facility involved. They may know how to do their job, but they are often sent into environments for which they are ill prepared.
In the oil patch in Canada we have spotters for that very reason. You don't know the contractors people, and during clean out it's usually a contracted out specialty. You also have a company Safety Officer on site making sure the crew is not doing something stupid.
@@ChangedMyNameFinally69 this situation doesn’t show that at all. Where does it say anywhere in this video that they’d have been fired? They were supposed to attach a pipe, then when they noticed the roll of duct tape, they needed to obtain a confined space permit. The video says they knew they needed the permit to enter, but apparently they didn’t want to wait. Not sure how that’s someone else’s fault…..
An accidental halon fire suppression discharge infiltrated our shop once back in the day. It was the cigarette smokers (me at the time among them) who acted as the canaries in the mine, so to speak. Quickly disoriented and stumbling towards the exit before our healthy co-workers felt a thing. Surreal is an understatement. Yes to the terrifying feeling of inhaling and not getting anything and the panic that comes quickly behind it, but moreover I was distracted by an escalating whistling sound in my head seemingly coming from everywhere, and my vision slowly shrinking to a pinpoint.
In 1986 I was watching a safety film in the welding shop where a crane operator, swung his boom into a high-voltage tension wire, realizing what he did, he then dismounted made contact with the ground and was instantly electrocuted to death, a fellow co-worker seen him laying on the ground went over to help him and he was electrocuted, a truck of three men driving by seen these two men laying down, two of them jumped out of a truck and they followed suit and we're both electrocuted, only the fifth man realized something was wrong there call in, for proper assistance,he lived to tell the story.
Bloody hell 😮that truly was an example of the domino effect ! So incredibly sad that those men lost their lives trying to save their colleague's life .
@@andymorin9163: I'd guess that part of it is that either the people responding haven't noticed the overhead line, or misjudge how far away you're supposed to be from the lines and anything in contact with it/that they may get into a dangerous position while they're tending to the people. Of course, seeing that it was a training video (hopefully _not_ a recreation of an actual incident, but I wouldn't be surprised) that should hopefully have taught those who saw it that very lesson...
That along with this case shows how important it is to first assess the area for any potential hazards such as fire or smoke, oncoming traffic, poisonous fumes or a lack of oxygen, downed power lines or damaged electrical wires or electricity, water, wild animals such as snakes, bees, wasps, spiders, dogs, raccoons, bats, and other animals, danger of an explosion, unstable buildings, or any other hazards before attempting to help people. The last thing that you want is to become an additional victim thus making things worse and potentially putting the lives of people attempting to rescue you in danger as well.
One place I worked had a guy inspecting electrical work done in a handhole. A handhole is only big enough for your hand and arm to fit inside. Unfortunately it's also big enough for your head. He stuck his head in to look at something and passed out from lack of oxygen. Since this was in the field on a Friday, his brother was the only one that was missing him the next day and went out looking for him. Of course, he found him dead with his head still in the handhole.
I never work alone for just that reason. It cost me a little but it's not worth your life. We had a conservation officer working a " bear barrel" and anethsetized the bear he had caught. He went into the barrel and the door changed shut, with him and the bear coming out of sedation. He had to ram his arm down the bears' throat to keep from getting killed, and survived with major scars and trauma. That changed what should always have been the protocol: you don't work with big animals alone.
@@Dwightstjohn-fo8ki Here its illegal to work alone in hazardous jobs. Even at metal workshop there needs to be other worker in same area. I once managed to get 8 of my fingers stuck in metal bending machine, and in case I had been alone, I would have been stuck there untill morning and likely lost my fingers. The machine had retarded emergency stop button that had to be pressed by hand... and well... my hands were occupied 😅
My dad worked on nuclear submarine assembly. They would weld in pure Argon gas environments. Similar to this accident, a worker dropped something accidently into one of these open tanks (the size of a large swimming pool with no water) and went in to quickly grab it. He passed out and his coworker went in after him and passed out. This was the 1960s and I think safety was less stringent back then regarding labeling of dangerous zones, etc.. Both workers died.
Seems like something that would happen at my previous job. That place was filled with management that improperly trained. Workers, if trained, ignored all training as they felt it was below them since they had worked x amount of years without an incident.
@Sean Stevenson no one selected these guys to do that job. They were supposed to attach a pipe to the outside, NOT ENTER THE REACTOR. The video made that crystal clear. They didn’t want to wait on the proper permit- sounds like natural selection to me.
Two men died at Union Carbide here in Louisiana the same way. It was in the 90s. By time I went to work there they had a 4 day orientation with a test that you could not get one wrong answer or you had to retake the whole test. It took as much as 6 to 8 hours to get a permit. It was the safest refinery but the slowest work pace that I've ever seen. People would sleep while waiting on a permit. Some got 40 hours of sleep in a month. Safety first.
I'm guessing the first worker wasn't autopsied. The markings on his body would have determined whether he fell in accidentally or not. The markings would have been more severe than they would be from a fall in a standing position even though the difference in distance was 5 feet.
So many mistakes here. The sign did not warn of a noxious atmosphere, the work permit did not mention nitrogen, whoever dropped the tape left it to be someone else's problem, the worker entered the confined space and then fell in, an emergency response team was not called immediately after the worker lost consciousness, and another employee entered the confined space without considering the nitrogen hazard. Entirely preventable at so many levels.
I bet the guy who dropped the tape feels like crud for the rest of his life. Seriously though, I want to know how a nitrogen filled reactor got marked as safe...
Personal monitors could have helped everything. In Canada we have been using them for years. I'm 31 now and started at 18. We were using them then. They aren't anything new.
@@adamrodgers9175 Based on my experience on working for an industrial contractor, it's simply about money - certain simple types of personal gas monitors like hydrogen sulfide monitors can be relatively cheap (those specifically are mandatory in a number of places I've worked at), but ones capable of monitoring multiple hazardous gases and alerting you of low-oxygen conditions are not, so the contractors won't buy them for their employees - they just have one or two locked away to be used to fulfil permit conditions when needed.
There was no noxious atmosphere where the workers were AUTHORIZED to be - OUTSIDE the tank. The scope of their job did not require them to be in the vessel, therefore no precautions were taken for someone to enter the tank! Had they simply reported the issue and gone through the proper channels then the appropriate measures would have been taken to ensure the vessel could be entered. These two numbskulls entered and area they were explicitly forbidden to enter and they paid with their lives as a result. Keep out means KEEP. THE. FUCK. OUT.
I feel like the worker couldn't get the tape and did intentionally climb in not because he was stupid, but because oxygen deprivation impaired his motion and judgement.
@@johnd5398 What. That's the whole premise of writing a comment. You're against the very concept of thought itself? Having a thought is the very prerequisite for writing a comment, and you're against people saying "I feel like"? What about "I believe" or "I think"? Also wtf, I don't wanna hear that in a medical setting "I feel like you have cancer", "I feel like we should operate" wtf
The whole point of the video is a root cause analysis to make it clear that this wasn’t all because of a cursed roll of tape. There were many other points of failure. But ok.
I've noticed that quite a lot of enclosed space accidents tend to have 2 victims. The initial victim who fell unconscious, and another worker who isn't aware of the danger and rushes in to help.
That is unfortunately very common. Of the people who die in confined spaces every year 60% of them were would be rescuers. All too often in confined space accidents when a person is overcome by oxygen deficiency or toxic gases other people who see them unconscious instinctively go into the confined space in a attempt to rescue the person but then become overcome as well thus resulting in multiple victims. That is why many confined space safety videos and guidelines constantly stress the importance of not entering any confined space to preform a rescue unless you or other people have proper training and equipment such as a breathing apparatus.
I worked at an electronics manufacturer in 1996-99, as a functional test technician. To make room for another surface-mount production line, the HALT/HASS testing chambers and functional test benches were moved into the same area that used to be office cubicles. In the original location for HALT/HASS, the nitrogen used for the cold cycle would not concentrate, but would be moved about and vented through the roof. However, in the new shared space, the airflow and air replacement rate was not adequate for the new purpose of the space. - We found out that the HALT/HASS leaked nitrogen badly after I and most of the other bench technicians had already been written up for falling asleep at our work stations. Air testing showed that at certain phases of HALT/HASS processes, the O2 in the room dropped as low as 10-12% at the height of our heads when seated. The HALT/HASS techs never sat down, so they had never encountered the problem. - The "fix" was to open a couple of windows and set up fans pushing air out the windows so air from the production floor would move in to replace it.
The first rule of rescue is to make sure that the scene is safe before entering it and if there are hazards at the scene you should either find a way to make the scene safe such as by extinguishing small fires or if you can’t make the scene safe then stay away from the area and do not enter and instead immediately call 911 and tell the dispatcher about what happened and then after calling 911 leave the rescue to first responders such as firefighters and technical rescue as they are properly trained and equipped to safely preform the rescue. Your natural instinct may be to go into the scene to help but if the scene is not safe then you should never enter it under any circumstances as by entering the scene you will likely become a victim yourself and remember you can’t help someone if you become a victim yourself. Tragically there have been many cases such as in confined space rescues, trench collapses, drownings, eletroucions by downed power lines, traffic collisions, hazardous material releases, and burning buildings where would be rescuers died attempting to preform a rescue.
I work at a company where equipment is regularly pressure-tested using nitrogen and sometimes cryo-tested with liquid nitrogen. For safety this is done inside a bunker and after test completion the system will enter a 15 minute purge and flush cycle during which it keeps the door locked. Every kind of gas, even inert ones, should be considered and treated as potentially dangerous or even fatal and even more so if it's under pressure. Two of my coworkers died in an incident involving equipment containing compressed air at a mere 5 bar while we routinely test at pressures of several hundred bar. To this day it reminds me that single mistake can mean "game over".
Having fallen victim to a confined inert atmosphere myself i know a bit about this. At less than 6% oxygen, one breath will spasm your larynx (voice box) blocking the airway. It feels like you’ve been karate chopped in the throat. First you lose control of your limbs, it starts in your feet, then hands and moves in towards your torso. Within 6-10seconds you will lying (most likely on your side) on the ground unconscious. Somewhere around the 4minute mark you will suffer a heart attack and by 5mins be dead and not be able to be resuscitated. The Reverend Death (there are documentaries about him on UA-cam) kills people in this manner using helium.
What about a close to 0% oxygen environment? how quickly does this cause a victim to fall unconscious I'm asking for myself I don't trust pills and a knife scares me so this seems almost magical to me
Actually it is easy to explain: You can be there for as long as you can keep your breath minus 15 seconds (for exiting). If you inhale because you want to breathe you are pretty much too late (but might still be able to exit if you act fast and not breathe more). Unfortunately nitrogen environment feels like regular air. This is why pretty much 100% of people who breathe it think that "naa, the sign is wrong, it's safe to breathe". Most other gasses can be felt or at least heard (helium). But you can't lift a person if you are not working out in the gym.
It's not as light as helium. 75% of the air we breathe is nitrogen. If you get trapped, the nitrogen doesn't go anywhere. So it only floats a little bit.
Smarter Every Day did a great video on how oxygen depravation affects you in the context of why they tell you to put your mask on first before helping others on an airplane.
It's also the reason they tell pilots to put on their oxygen masks at the first sign of warning. Don't try to fix the O2 problem until you have it on--there's so little margin for safety.
@@gloomyblackfur399 I believe there's a story about a 747, somewhere around Japan, IIRC, which developed a hole so the pressure fell. They then flew around for quite a while before hitting a mountain, long enough for passengers to write letters or phone their families, all the while ground control tried to get the pilots to don their oxygen masks. Unfortunately, their judgement was already shot too much.
@@KaiHenningsen Look up "Helios Airways Flight 522". A maintenence worker forgot to turn a knob back to its default position and the plane never pressurized, killing everyone. A flight attendant tried to save the plane unsuccessfully. Sad story and shocking how such a small (in)action can cause such a massive tragedy.
Kai Henningsen Actually in that 747 Japan crash, the main cause was not impairment, it was that the initial explosive decompression severed hydraulic lines and caused the vertical part of the tail to fall off, making the plane uncontrollable. The pilots may have initially suffered some hypoxia but the plane descended enough that they apparently recovered and attempted to regain control for roughly half an hour before crashing. The fact that some passengers wrote goodbye letters also shows that there was enough time and oxygen for the pilots to try to recover - but the plane was just too damaged. Even if the pilots had put their oxygen masks on instantly, the outcome would have been the same.
@@Sashazur, JAL Flight 123, domestic short-haul, packed to the gills. Aft pressure bulkhead had been damaged in a tailstrike some seven years earlier, and improperly repaired. Pilots did an amazing job of keeping her aloft for as long as they did. 500+ souls aboard, worst single-aircraft accident in history. I believe that the fellow performing repairs may have committed suicide.
This is my first CSB video. I spent 28 years with a govt audit agency that basically farted around the edges of every important issue because of political concerns. Wow, what would I give right now to go back to the beginning of my career and steer myself to a REAL inspection, study organization like this. Few things infuriate me more than useless, careless, conscienceless managers that could care less about the people that make their lives possible than they would a fly they swatted on their way into 'work'.
The most peaceful way to go. The 'omg I can't breathe' panic one gets is only triggered by a high CO2 concentration -- not lack of oxygen in the lungs.
@@official-obama allegedly ?!? It's how your body works. It can cause death without you even noticing. There's zero pain, hell, even nitrous oxide (laughing gas) is used to reduce anxiety and pain. Show me ONE source stating it isn't peaceful
There is a job title for these specific situations. Confined space attendant, or (hole watch). I did the job for years. Monitoring the air in the space for people entering confined spaces, and keeping in touch with emergency response teams that specialize in confined space rescue. Usually boring, but suddenly can become life and death.
I had an incident in which I took a breath in but felt suffocated. I was working at a fast food place, a real hole in the wall type of place, and they had a fryer in the back going. They use propane for that particular fryer as it was a big fryer, I was taking care of it, sitting mostly just turning the meat a bit at a time. I heard a hissing noise and tried to find the source. I followed it to the propane tank (about 4 ft tall and 1 ft from side to side), as I was trying to pin point the leak I had my face about 5 inches from the tank and I was just coming to the top of the valve handle... there's were the leak must have been because I accidentally took in a small wiff of the stuff and automatically felt as if I couldn't breathe, as a natural reaction of not being able to breathe I tried to take in a full breath of air, but still, I felt like my lungs were out of air. Well, by this time I had moved my body away from the gas leak and slowly and surely I was able to breathe right. But yeah, that was a weird feeling. Taking a full breathe in but feeling as if your under water because your lungs are burning when they're out of air.
What stands out to me is that in 10 minutes the emergency crew was there and removed one of the victims. they had proper breathing and the Hoist. 10 minutes to have the proper equipment. sure that's because of the emergency but how much longer would following the proper channels have taken?
Genifer Teal It takes a long time. First, you have to find an operator (usually they're hanging out in the control room) and advise him whats up, he then has to find someone who is confined space qualified and locate the on-duty safety man (who SHOULD go to the site and take readings and observe the scope of work), then they have to apply for a confined space permit at the permit office, then someone has to checkout the necessary breathing apparatus and proper equipment to enter the vessel. Now everyone can go back up to the site and pull out the roll of tape. And by that time, you've lost your crane...
@@231mac That's fair but there has got to be a better way. Maybe having the control room issue permits and the safety guy bring gear, so if it's approved and safe they can get right to it. Safety guy isn't approving the gear and the control room is only issuing permits with the redundant approval of the safety guy? Or even just have control be a go-between to make it quicker. The emergency team had everything needed and got it done in 10 minutes.
This has happened in sewers, in underground cable tunnels, in car repair shop bays, in holes in the ground. Often multiple people are injured or perish in these accidents. Hoists, safety straps, gas meters, air movers, and standby personnel are all essential when working in confined spaces. This is basic stuff.
The reason why multiple people are injured in these incidents is because would be rescuers usually fellow coworkers often those who haven’t been trained upon seeing someone unconscious or having seen them gone down despite not having proper equipment such as breathing apparatus instinctively enter the space to attempt a rescue which results in them being overcome by the same hazardous atmosphere that overwhelmed their fellow coworker. Incidents like this unfortunately are in the majority of confined space incidents as 60% of people who die in confined spaces are would be rescuers. The would be rescuers motives for doing so while understandable needlessly risk the lives of not only themselves but others as well and usually make the situation worse due to there being more than one victim. It is better to have one victim than two or more as then the victim can be quickly and safely rescued preferably by a trained and equipped rescue team on-site. That is why one of most important confined space safety rules is too never enter a confined space to preform a rescue unless you are wearing proper protective equipment such as breathing apparatus and are properly trained to do so. Also if possible there should be a rescue team onsite who are properly trained and equipped to safely preform a confined space rescue as then if an emergency does happen they can quickly and safely rescue those who are trapped.
I also forgot to mention that this is the reason why multiple people are killed in these incidents. I myself don’t call them accidents but rather incidents. That is because an accident can’t be prevented but an incident can be prevented and virtually almost all confined space incidents like this would have been prevented had workers been trained and had followed proper safety procedures. this incident for example would have been prevented had the workers been trained on the hazards of confined spaces and how to be safe in and around them, had there been specific warnings about the potential for Nitrogen being in the confined space, if they had tested the atmosphere with both oxygen monitors and gas detectors and then waited until the space was properly ventilated, if the first worker had worn breathing apparatus, had there been hoists and ropes at the entrance to the space and had the first worker been tied to the hoist, had the workplace properly trained it’s employees on what to do in the event of a confined space emergency and reminded them about the dangers of attempting a rescue unless they have been properly trained or are wearing proper equipment such as breathing apparatus, and had there been a trained and equipped rescue team onsite and close by. Had those safety procedures been followed the incident would likely have been prevented and even if it still happened it would have been less deadly and the first victim may have survived. Here are some examples. Example 1. had they checked the atmosphere with air monitors or gas detectors and had waited for the space to be ventilated they would have detected the nitrogen and would have been able to enter the space safely. Example 2. Had there been specific warnings about nitrogen being in the confined space and had the workers been trained on the dangers of confined spaces and how to safely work in and around them they would have recognized the potential danger and the first worker may have not entered the space without ventilating the space or wearing a breathing apparatus thus preventing his death. Example 3. If he had worn a breathing apparatus the first worker wouldn’t have been overcome by the nitrogen meaning that he wouldn’t have died. If the incident still happened however had the would be rescuer been properly trained and had worn breathing apparatus he wouldn’t have been overcome and would have likely been able to safely rescue worker 1. Example 4. Had there been hoists, safety straps, and ropes at the entrance of the space and had the first worker been tied to the hoist, safety strap, and rope upon being overcome his coworkers would have been able to quickly and safely rescue him by pulling him out via the hoist, safety strap, and rope not only preventing the would be rescuer from being overcome and killed but also would have likely resulted in the first worker being successfully resuscitated which would have resulted in him being saved. Example 5. Had the workers been properly trained on what to do in the event of a confined space emergency and had they been constantly reminded about the importance of not attempting a rescue unless they are properly trained and have proper equipment such as breathing apparatus the foreman wouldn’t have entered the space thus preventing his death. Example 6. Had there been a properly trained and equipped rescue team on-site and nearby the rescue team would have been able to quickly and safely rescue worker 1 which would have likely resulted in him being successfully resuscitated thus resulting in him surviving the incident. In short this incident like with most confined space incidents was completely preventable and had proper safety procedures been followed the incident likely wouldn’t have happened in the first place and even if it had there wouldn’t have been as many deaths and the first worker could have even survived this incident.
Remember, this is a government agency. They can’t monetize the channel because of ethics policies about self-enrichment among government officials. They have enough subs and views that they could, but it would violate federal ethics laws.
hah, I am about to. I ended up here by studying up on the composition of both water & air, mainly due to people doing two things in the homesteading & the prepping worlds of youtube. I was looking up oxygen & hydrogen percentages in water & I was looking up oxygen & nitrogen percentages in air. So the things they are doing are large amounts of mulch importation & mylar bag food storage using oxygen absorbers. Which in my eyes, I believe you need oxygen to enter your digestive tract in your food where I believe it is directly absorbed by the digestive system into the bloodstream. People think this is crazy. But I believe I am correct. As far as I can tell it is only recently being looked into, & possibly recognized, by the medical profession. So basically I was looking at the composition of water to prove my stance. We must consume water or die... so, what are we getting from it? It, water, contains only Hydrogen & Oxygen. Interesting theory, eh? In the end perhaps I have too much time to think? I'm good with it.
While I was doing that, I decided to also google the dangers of each of those components. It is good to learn things outside the box. I had a teacher at some point in my education who stated that the education we are given in schools is merely likened to a "book report" after that the rest of our learning is up to us to pursue now that we have been taught the basics of how to proceed.
Yeah! I don't even work in a field like this but find these super interesting and informative. Makes me also appreciate and respect a lot of the engineering and workers involved day to day.
6:10 this is why if you see people unconscious in a closed space like this, you should not enter to help them. If they were rendered unconscious because of a chemical incident, you cannot help them if you also die because you are not prepared.
Exactly. Whenever someone is unconscious in a confined space you should always assume that there are toxic gases or a lack of oxygen in the confined space until proven otherwise especially if you have no idea what caused the person to become unconscious. In that case immediately call 911 and if possible get a rescue team that is both nearby and is properly trained and equipped to preform a confined space rescue. Under no circumstances should you ever enter the confined space in an attempt to rescue the person unless you are properly trained and equipped to do so safely such as if you have a breathing apparatus.
The plant I work at recently had a turnaround, well one of the flanges didn't have a gasket and nuts were missing from the bolts. I was insulating the line when I noticed it I went to operations quick. Danger is everywhere.
Unfortunately too many companies and contractors care more about speed than safety. I understand wanting to get machinery back up and running as soon as possible, especially if it is interfering in the production process. But we as a whole society need to refocus on what is most impirtant: human life.
In the Canadian oil industry standard practice, especially on the annual scrubdown of stacks and confined spaces, a certified paramedic is an observer, whose ONLY JOB is to get help in the event someone goes down. In addition, a credentialed Safety Officer will write a written plan, and you DO NOT leave an unknown crew of outside contractors unsupervised Too many of these USA based incidents seem to lack ALL of these protocols, and it isn't 1955 any more.
One time the power went out at the grocery store I worked at. They made us move huge blocks of dry ice into the meat locker and frozen food containers. Both me and the other clerk passed out in the meat locker because of nitrogen and CO2 concentration and almost died. The front end manager found us like 20 min later and drug us out and next day we were pressured to sign these injury waivers. Didn’t even get the day off.
Rule #1. NEVER SIGN. SH*T (w/o a lawyer) You could probably fight this EASILY based on not being in your right mind after such a thing. Your signature would be invalid. I'd also would have given them an invitation to kiss my a💋💋, but that is just me. I'm old enough to ngaf. They'd try to fire you, and you'd have them on TWO counts. Wrongful dismissal and trying to force signatures. Oh, you can't sign anything under duress, either. Immediate invalidation. Talk to a lawyer to see what's where.
Argon is just as dangerous and used in welding shops but you won't find many welders who are aware of the dangers. It's common when welding pipes and cylinders to fill them first with the Argon so the inside of the weld does not get oxidised. Argon is heavier than air so it can fill up a room below the ventilation system. You can be fine standing up and then you get down on your knees to make the weld and you just submerged yourself in Argon and then you pass out and fall to the floor where the Argon is even more concentrated.
The feeling of suffocation is not caused by the absence of oxygen. The build up of CO2 is responsible for that. If you're breathing, you're constantly letting CO2 out of your body, which means you wouldn't feel the pain or panic. And the nitrogen itself is harmless (it's an inert gas which composes like 80% of our atmosphere). So the only thing indicating that something is wrong, would be dizziness. I have willingly experienced it just for fun (and almost everyone can) by making 2 or 3 deep breaths in a helium-filled balloon. Don't recommend it though, it feels like you've just drunk A LOT of alcohol
Being in a hurry to finish shutdown for production to commence is also a big problem. I've been in a situation that requires me to purge a gas plants ( the gas flare line)with Nitrogen using a Nitrogen Membrane unit before they proceed to hot work on the line. This purging operations have been timed and at the same time a boat have been called for back loading of equipment for demon. Time was ticking and the hydrocarbon in the vent side is still at 18%. I noticed that it wasn't reducing from that percentage and quickly called on the engineering that marked out the point to purge and points to isolate. They never want to listen as they were emphasizing on the cost of keeping the boat waiting and also for the cost of our Nitrogen equipment spread per day. I requested for the flare line diagram but they refused as they are still in a rush to rap up the shutdown. I have to go through the plant myself and discovered That the lines are have lots of 16inch pipe elevated up to 100ft for all module into a sludge catcher vessel (TANK) with no isolation valves and their vent with ¾ inch valve were kept closed. The only valves to the tanks were PSV and check valve the check valves are in locked open position. I discovered 32 number of this risers with vent valve closed. It was clear they never noticed. I draw a sketch of a P&ID diagram to explain this. This made them relax to rethink of the problems. Finally they pulled out the real p&ID diagram from their system and saw my scetch was similar. The job purging operations was re-planned and it took another 9hrs to reduce LEL to zero. The cost went up They missed the boat It took another 5 days to get the equipment off the platform because of their logistics plans. This made them pay more for standby. There would have been a huge explosion if this fault was neglected because of time and money as the hydrocarbon in this lines were reading to infinity on the gas tester when I finally got their vent opened. All 32 vent were opened simultaneously. This happened in one of the biggest oil and gas company worldwide I will not mention name. But I work with BG Technical limited Though I wasn't given an award but I know I've save lives and facility And we do our job Best.
We had an N2 asphyxiation incident in a space hardware testing lab I worked in. We had environmental (vacuum) chambers and we purged them with Nitrogen. You were supposed to open the door and go do something else for 15min. He stuck his whole upper body into the chamber immediately and set to work removing the test hardware from the "cold plate". He immediately passed out but fortunately someone was watching.
It is extremely bizarre, you think you’re breathing, but you aren’t. I had a N2 leak inside an elemental analyzer I was working on...wasn’t even a totally confined space, and it still made me almost pass out.
Wish I could do a request... Really want to see the oxygen generator accident that happened at the orange county waste district. there was also a electrical accident there too.
I have been in center and wing tanks on C-130s, 737s and other Boeings. Dealing with Kerosene (Jet A) in truly confined spaces requires you to be alert and aware at all times. Need to have someone you TRUST outside. We always had breather app outside pumping the air. You can't get into an aircraft wearing a scuba tank. just a hose and a mask. Like I said, we are professionals and this is what we do. I worked for some younger guy that was venting a tank on Gen Aviation bird using pressurized air and a venturi setup (this is not Jet A, it is AvGas). I walked into the hangar and immediately fled. Grabbed him and asked, "is this approved"? He said "what do you mean"? I said, "do you realize how much static electricity that compressed air and that venturi are creating"? His face just went pale. I spent the next ten minutes in the parking lot until returning to work. If that aircraft had exploded it would have torn that hangar down. FAE, fuel air explosives can be extremely dangerous, have even been used by the military.
After reading a few comments no mention of who signed off safe work permit without oxygen censored test of a tank. The m maintenance supervisor would be where the buck stops.
When the worker sat on the ledge and his legs broke the plane of entry then he is now considered inside the confined space. Any part of your body is not allowed to break the plane. Something this video should have mentioned
If you took swimming lessons growing up, you may remember "Reach or Throw, Don't Go!" I think the same applies to confined space rescue without specialized PPE.
I'm a journeyman millwright, there is so much we are not told. These two brothers didn't have to die if they were made aware. In my eyes this is murder. RIP
How is it murder? Their work permit was for OUTSIDE. Even the video said they didn’t want to wait for a confined space permit. They were never supposed to enter.
@@thetowndrunk988 - These investigators must hear dozens of these cowardly "Well technically..." excuses a day. And they crumple them up and throw them in the trash where they belong. The company put literally zero effort into warning these men that the exposed hole they were working directly over was extremely deadly. And that includes the sniveling pencil-pusher who wrote this permit.
@@CheshireCad considering the people that made this video were the investigators, and acknowledged it both in this video and their report, it’s pretty dumb to say “investigators wad it up and throw it in the trash bin”…… There’s a reason permits are required to enter confined spaces. There’s a reason workers are trained and told not to enter confined spaces without permits. It’s so the company doesn’t have to list every hazard known to mankind. These men knew they were supposed to get a permit to enter, but they entered anyways because they didn’t want to lose the crane…..
@@thetowndrunk988 - The video specifically drew attention to the permit, and the lack of a nitrogen gas warning. So they are explicitly stating that it was relevant to the accident. The contractors were working *directly above* a hole filled with an invisible, odorless, extremely deadly gas. A gas that could, and did, escape from the hole and contaminate the surrounding area in significant quantities. They could have easily been affected by leaning over the hole, which would not have required a confined space permit. And yet you're acting like writing "Warning: nitrogen gas in chamber" is some ludicrously unnecessary task. That even doing it "just in case" would somehow make the world worse through the sheer overabundance of caution. You are pathetically grasping at straws to try and paint this whole scenario as 100% the fault of the victims.
@@CheshireCad nitrogen isn’t a poison. It simply displaces oxygen. It was not deadly above that hole. They were assigned a specific job, and they took it upon themselves to enter the confined space, rather than pulling the proper permit, because they didn’t want to reschedule the crane. It’s their fault, plain and simple. When did personal responsibility take a backseat in this modern society?
Why were the workers not equipped with oxygen. Inconceivable negligent on the the workers and employer.. It goes to show you can't trust your employer, most unions give workers the right to refuse UNsafe workplace environment.. If you don't feel safe DON'T DO IT.
Yes. #1 The work order, while having a provision to indicate Nitrogen Purge, was filled out correctly. #2 They didn’t even have a atmosphere sensor device.
The world record for a breath hold is 22 min and 22 seconds. Most people can hold their breath for 30 seconds with confidence. The issue is our poor ability to consider everything that could happen. The unexpected is why we follow processes. RIP to those men.
I fired two highly trained technicians who went into an enclosed space without PPE because they wanted to save time. Two months later at a different job one of them died inside a storage tank, again citing proper PPE would take too long to put on. Very sad.
There’s stories where, to retrieve one asphyxiated man, six or more others head in, only for them all to die… it’s easy to throw caution to the wind when trying to rescue someone, but you can’t help them if you wind up needing rescue too.
There was a contractor fatality back in 2012 at Shell’s Ground Birch gas plant, we did not received enough information but it was related to N2 asphyxiation in a building.
mainly the work permit is the cause of that death not mention the nitrogen and second cause is the shortcut made by the contractor cost them they live and probably due to lock of Knowledge cause of less training … role is role even its take longer time ( do it right or not at all )
I'm assuming that by "sniffed" the OP means tested using the appropriate meters, which should be common practice where inert gases are involved - it certainly was when I worked in the oil and gas industry, both onshore and offshore.
Oh my god I was just reading comments in /r/OSHA about cleaning ice off liquid nitrogen lines and people warning it was unsafe due to the risk shocks could rupture the line and flood the area with nitrogen. Nitrogen is no joke people, regular nitrogen might be lighter than air but when it's that cool it's more dense, and poses an asphyxiation hazard even outdoors. Safety first, know the risks around you.
Somebody out there knows that they were the one that dropped that tape roll and didn't bother to go through with whatever protocol should have been followed to report and remove it. That is a heavy burden to carry.
They were probably hypoxic before they went into the reactor. Your brain cells basically start to self destruct once they are deprived of oxygen for 5 to 7 minutes. What an unfortunate accident. RIP.
You can take a deep breath because theres an atmosphere there, just not the right atmosphere so you breathe in but feel like you get no air because there is not enough air in the air
What I want to know is why was it still purging if they were gonna put the elbow on? the only time to purge it is to remove to spent catalyst because catalyst combust when exposed to air so they purge it to prevent that but after all the catalyst is remove they should've stopped purging it
Another problem too is on Any job site or at Any plant, you'll always have that One foreman or boss that'll chew you out for trying to go through the correct safety procedure just to save time. The, "Wtf just grab the tape and lets go already" type. Not in this case here, but I'm sure its happened.
All things considered, a 10min response from the man down radio call to actual extraction is incredibly fast.
Taught to be fast. Taking H2S course we need to put the Scott pack on in seconds. So I'd imagine the time was them getting to the spot and doing rescue. We are always taught to be fast..fast and careful obviously. My first time taking the course we had to put the pack on and go through a completely dark room and find the dummy body and exit in a certain time.
Without using proper equipment n site analysis of site with Hazard posibilities for tht mistake 2 person died as they did not follow the right procedure guidelines followed by their training.
May their soul rest in peace.
It is.. 10 mins seems like alot of time but not when shtf
Yeah, that's complete BS it was definitely longer.
@@ploopyboy231 dude it had less then 1% oxygen so they might as well been passed out in a body of water fucking 3 minutes is about all the poor guy had. The foreman should of radioed that he needed a scba like the second it happened or a smart one would of located where they were prior and even brought one to the work spot just incase. The thing I never understand is how the hell they think they are gonna be able to rescue someone in such a clearly low oxygen environment I mean, do they just think the guy is just tired and thought he would take a nap?! I mean if homie can't fucking breathe in a certain space what in your mind makes you think you're superman and can not only be impervious to the low oxygen environment but be able to pick dude up and carry him up a latter you know how much you would need to breathe in to be able to have the oxygen to carry another man up a latter that is passed out?! He didn't stand a chance.
we were warned we had less than 3 minutes to exit an engineroom, as the navy used halon extinguishing systems for fires, which replaces all the oxygen in the space when activated. 3 minutes is a lot shorter than you think it is.
It always get down to how long it takes you to figure out something is wrong. Its always better to panic now and avoid the rush.
is that system in every room? pretty scary. Is there a visual & audio cue that something is wrong?
In a halon-protected data center where I worked, we had many large halon-delay plunger-type buttons on the building support columns to help us get out of the room. If the halon alarm would go off, we were to run to the exit pressing any delay buttons we passed by to add more seconds before the halon was released. The only halon event I knew of was when a industrial-sized battery exploded in a back room. I wasn't there at the time.
A buddy of mine knew a guy who died from not getting out in time.
They should supply oxygen and masks, like Cyberdyne Systems did in T2.
I think the worst part is that the safe work permit specially stated NO inert gases. That's worse than a missing sign, that is deadly misinformation.
The best way to handle a situation like this is to consider EVERY confined space as a low/no oxygen space until proven otherwise with a meter. Also multiple readings at different levels, near the top o2 levels may be normal but drop as you go lower. Also toxic gas's tend to be heavier than air and may not register near the top
it did not say no inert gases it said N/A . meaning none applicable idk how it works in that field but in almost all others N/A is short for " i dont really know" or "im not sure enough to say yes or no to this question" meaning further investigation may be needed on the matter before a tru "permanent" answer is given
it doesnt mean "NO" ., most companies will have "yes , no , N/A" as answers and N/A is jsut IDK . . some fields dont really need a yes or no like working at walmart and filling out your check list .
"did you mop the restroom" "yes, no ,n/a" for example wouldnt kill somone if you put N/A and wouldnt need investigating so its more considered a maybe .
but in a field like this a N/A should never be taken as yes or NO . when its a matter that can kill somone like "did you asure to vent all inert gases from the tank? YES, NO, N/A" in that case somone should have seen that N/A and made sure to do a test themselfs first.
@@TYcarterTracks you correctly state what N/A means - but in all fields it means Not Applicable. In your example of a Restroom being marked N/A typically that would be because there is either no Restroom or that maintenance of the restroom is handled by a 3rd party.
Marking N/A on that form would indicate that the system being worked on does not have Nitrogen present, therefore purging of Nitrogen isn't applicable.
I agree with the OP - a Work Permit that has a section to advise of the specific hazard that was filled in incorrectly is one of the biggest issues here - assuming that the workers were operating under the information provided, had they had the correct information, they may have made different decisions.
That said - there's a lesson here from the world of Firearms, the Golden rule of safe handling is to treat all Firearms as loaded at all times. Had they treated all enclosed spaces as potentially containing lethal gases...
WRONG. The work permit indicated no hazard where the workers were SUPPOSED to be working - OUTSIDE the vessel! The scope of their job and permit did not involve entering the vessel at any time and nobody was supposed to be inside the damn thing! Had they gone through the second permitting process as required, I'm sure the vessel would have been checked and purged with air or someone properly equipped/trained to enter a low/no oxygen environment dispatched to enter the tank and retrieve the object.
This is purely a case of unqualified individuals taking shortcuts and unnecessary risks. It's pretty sad that a DANGER - KEEP OUT sign isn't sufficient to keep people out. One shouldn't have to call out every danger posed in the area behind the sign. It's a dangerous area and you shouldn't be there. Period. Their permit allowed them to work outside the tank, and had they stayed where they were given permission to work then both of them would be alive.
@@fordguy8792 one of the few people on this entire thread to actually notice that 👍. Sadly, the daggum video said they would have had to have gotten a permit to enter the tank, yet there are so many comments about the permit not warning of nitrogen……
It was N/A, BECAUSE THEY WERE SUPPOSED TO BE WORKING OUTSIDE OF THE REACTOR
Just sent this to my 19 year old apprentice! This is huge for us small mechanical contractors trying to bring the next gen up to speed. Thanks for the video!
One problem with this video is that they show a document where nitrogen/inert gas is marked N/A which means there is missing information and they never mention it. It does not matter if you are trained or not if you do not know what you are dealing with, which I think this video completely overlooks/ignores.
That's awesome that you thaught about your younger apprentice. I'm in my 40s now but I remember how hard it was when I younger. It seems like the older generation always seemed to not be too helpful for whatever reason
@@TheExileFox I think their permit was only for the outside of the tank. Not to enter the tank.
He didn't watch it
I have a horror of having to stand in the Court of Inquiry on the death or serious energy of one of my team. Videos such as this make the hazards clear and apparent to the team, and I show them when we have some time.
I hate confined space entry permits and particularly nitrogen purged environments which have not been oxygen tested.
Nitrogen is a silent killer, the human body has no natural protection, we are used to breathing 80% nitrogen, it does not create a gagging or choking reaction. Transport containers with fresh food and filled with N2 to preserve the cargo are very dangerous environments.
I was always amazed at the lack of awareness of this problem, hopefully your video will spread the knowledge, thanks.
CO2 hazards in closed vehicles present another opportunity for disaster. And there's a number of people in the gig economy transporting food with dry ice in unsealed & semi-sealed containers & sleeping on the floors of their vans/trucks where the gas pools.
Wow, never thought about that one. Thank you for sharing.
Exactly... CO2 chokes u
You hate confined space permits ? That makes no sense.
@@adamrodgers9175 Ishoud have been more specific.
I often had to issue these permits, and put my name on it, to certify that I was OK with all the precautions. If I signed one, I would personally supervise the entry, it caused me great stress, and I would not relax until all personnel were out safely. It was possibly the most dangerous operation on site.
The hate was me having the responsibility. I managed 30 years working in a very hazardous environment, signed hundreds of permits,and was pleased to retire without anyone getting seriously injured. OK we had a few slips trips and other minor injuries.
No oxygen level meters? Some people do not even climb into sewers without an oxygen meter.
I know Im shocked they allowed anyone to enter without at least one person wearing one
The sheet did say that nitrogen risks were "not applicable", which in my opinion is potentially the cause of this incident; perhaps the first worker, while trying to retrieve the tape, fell in, then his supervisor saw that he had fallen and was laying unconscious, assuming that he had hit his head, and attempted to rescue him while still not knowing about the lack of oxygen
Right! I worked in a wastewater treatment facility. 1) Mandatory short course about working in confined spaces. 2) NEVER enter a confined space before measuring H2S, O2 and CO2 levels and take apropriate actions when necessary.
I just test confined spaces with an open flame. It is very safe and totally reliable
@@kerrykalls7732 And hope there are no flammable vapours present...otherwise BOOM!!!!!!!!!!!!
This accident at DCR killed 2 of my union brothers of my local. This accident changed a lot of policy and procedures. It was a fatal lesson. I work at this refinary often, and whenever I see this particular unit, it makes me think how this could of been avoided. RIP
That sucks man...Hopefully part of that new standard procedure is to use a meter to check the tank before jumping in or spending prolonged time near an open cover.
@Ron B fuck off ron b where do you work the cubicle ?
Air monitoring and training. I've worked in the oilfield for years, we always had monitors on us and checked the air before going into anything.
*refinery
*could have
@@ophello Untold millions have died from typos like this
This dude was having a bad day, boss was gonna chew him out for some tape issue that wasn’t his fault, he tries fishing it out, brain turning to mush, losing all rational, jumps into the tank, it’s just all down hill.
Also, couldn’t get one of those handy “rescue hoists” for the tape?
Just leave the damned tape it won't deter the unit operation and it's certainly not worth dying for
There really shouldn't be any repercussions for asking for help.
The threat of loss wage or job is one of the reasons for attempting risky stunts such as this.
Worse the reactor itself had no additional manhole for maintenance...opened would fill reactor with air after ~1min.
@@WadcaWymiaru it was purging, so the pressure differential would have been too great to bring air in.
I had just started a new job where we had safety drilled in to us daily, including confined space. So I was tasked to give a tour to a VIP accompanied by our senior executive. We get to a large cell that is a confined space and the VIP wants to see inside. All the warning signs and barriers are in place, so I say "sorry, that's a confined space and hasn't been made safe for entry." The senior executive started screaming at me that "he can see clearly inside and there's no hazard." Meanwhile I refused by saying we had to follow safety protocol, figuring I was going to be fired at any moment. Fortunately the VIP intervened saying he had a meeting to get to and the next day something else captured the executive's attention to throw a tantrum over.
This is probably the most obvious, but in a way hidden, problem:. I always like to find out how the "executive" got to his position as "Sheriff of Nottingham". I dealt with loads of higher ups that were there for all the wrong reasons: relatives of others, went to school with buddies, shared their crack pipe (and yes, I mean white collar crack pipers), and their "default" management skills. In mining, agri, and const. they can get you killed.
Insane!!!
I thought you were going to say that he was testing you, to see if you would break safety protocol under pressure.
Nope, the guy is just an idiot! XD
Sometimes they do something like that as test against an unsuspecting worker, had you said "ok" and opened it up that raving senior executive might have said;
"stop right there, you blatantly violated company safety rules, put lives in danger and you are FIRED"
They did similar things on a fast food job I had years ago, they would call and place an order for delivery, wanting to check to see if you suggested soda and side dishes, was polite etc and just before you were about the send the order to the kitch the caller would say "ok, you can cancel that, this is a mystery shopper call, you did well, congrats!"
One time it my shift manager on the phone not 10 feet away disguising her voice!
@@Vid_Master If I was the executive that would be what I would be trying to do. I would be trying to do ANYTHING I could think of to try to pressure you, even threatening to fire you if you continued to refuse. Once I was convinced that there was no way you were going to acquiesce, I would tell you "good job, you passed!" But, if I managed to get you to say "ok" I would have then told you to go to the office and get your last paycheck.
Many years ago I was in a chemical plant where a similar type accident occurred. During a turn-around (plant wide maintenance) a certain carbon steel pressure vessel was drained and the man ways opened up. Air was sparged in to create a safe atmosphere for workers. After a while, the tank was tested for oxygen and was deemed safe. Workers prepared themselves to enter the tank to do some work. I don't remember how many men entered but one died in the vessel from oxygen deprivation. Respirators were not used by these workmen as the vessel had been cleared for entry. What happened to the oxygen that caused one man to die for lack of it? The post mortem came to the conclusion that the oxygen was consumed by the internal surface of the tank rusting!
Wow that... sucks. Jeez...
I feel like entering any confined space should be mandatory to carry an oxygen level sensor that beeps when you need to get the fuck out.
I think I heard of this incident.
When my dad worked at Rolls Royce they had some people in to do construction work, part of which involved somebody working in a hole in the ground with a jackhammer. Mr. Jack Hammerer hooked up his jackhammer to one of the nearby airline mains and set to. Only problem was that it wasn't compressed air that he was hooked up to, it was argon that they used for welding; he filled up the pit with argon and asphyxiated.
@@someusername121 The trouble is most people can't hold their breathe over 45 seconds. Having an SCBA available with the alarm would be the safest route.
Its hard to watch this, I was there that night and was the last person to talk to that young man that night. Never will forget...
This is right. Contractors are not trained properly and the deaths and injuries do not count as on the job accidents for the facility involved. They may know how to do their job, but they are often sent into environments for which they are ill prepared.
In the oil patch in Canada we have spotters for that very reason. You don't know the contractors people, and during clean out it's usually a contracted out specialty. You also have a company Safety Officer on site making sure the crew is not doing something stupid.
this is why (20 years ago for me) contracting company liability bonds started at $1 million minimum. and i was a one-man-act.
How much training does it take to obey a simple KEEP OUT sign?
@@fordguy8792 As situations like this show, stuff isn't properly labeled and they're forced into it at risk of being chewed out or fired
@@ChangedMyNameFinally69 this situation doesn’t show that at all. Where does it say anywhere in this video that they’d have been fired? They were supposed to attach a pipe, then when they noticed the roll of duct tape, they needed to obtain a confined space permit. The video says they knew they needed the permit to enter, but apparently they didn’t want to wait. Not sure how that’s someone else’s fault…..
An accidental halon fire suppression discharge infiltrated our shop once back in the day. It was the cigarette smokers (me at the time among them) who acted as the canaries in the mine, so to speak. Quickly disoriented and stumbling towards the exit before our healthy co-workers felt a thing. Surreal is an understatement. Yes to the terrifying feeling of inhaling and not getting anything and the panic that comes quickly behind it, but moreover I was distracted by an escalating whistling sound in my head seemingly coming from everywhere, and my vision slowly shrinking to a pinpoint.
Yikes 😳
Well that sounds terrifying
In 1986 I was watching a safety film in the welding shop where a crane operator, swung his boom into a high-voltage tension wire, realizing what he did, he then dismounted made contact with the ground and was instantly electrocuted to death, a fellow co-worker seen him laying on the ground went over to help him and he was electrocuted, a truck of three men driving by seen these two men laying down, two of them jumped out of a truck and they followed suit and we're both electrocuted, only the fifth man realized something was wrong there call in, for proper assistance,he lived to tell the story.
Rule 1 of emergency response: don't add to the pile of bodies. Chain-reactions of multiple drownings are also very common.
how do people not know to stay in their vehicle if a power line touches it? you're safe so why move?
Bloody hell 😮that truly was an example of the domino effect ! So incredibly sad that those men lost their lives trying to save their colleague's life .
@@andymorin9163: I'd guess that part of it is that either the people responding haven't noticed the overhead line, or misjudge how far away you're supposed to be from the lines and anything in contact with it/that they may get into a dangerous position while they're tending to the people.
Of course, seeing that it was a training video (hopefully _not_ a recreation of an actual incident, but I wouldn't be surprised) that should hopefully have taught those who saw it that very lesson...
That along with this case shows how important it is to first assess the area for any potential hazards such as fire or smoke, oncoming traffic, poisonous fumes or a lack of oxygen, downed power lines or damaged electrical wires or electricity, water, wild animals such as snakes, bees, wasps, spiders, dogs, raccoons, bats, and other animals, danger of an explosion, unstable buildings, or any other hazards before attempting to help people. The last thing that you want is to become an additional victim thus making things worse and potentially putting the lives of people attempting to rescue you in danger as well.
Every single person interviewed that works for CSB is wonderfully nerdy!
in their hood bow ties are selling out.............
Thank God for nerds!
One place I worked had a guy inspecting electrical work done in a handhole. A handhole is only big enough for your hand and arm to fit inside. Unfortunately it's also big enough for your head. He stuck his head in to look at something and passed out from lack of oxygen. Since this was in the field on a Friday, his brother was the only one that was missing him the next day and went out looking for him. Of course, he found him dead with his head still in the handhole.
I never work alone for just that reason. It cost me a little but it's not worth your life. We had a conservation officer working a " bear barrel" and anethsetized the bear he had caught. He went into the barrel and the door changed shut, with him and the bear coming out of sedation. He had to ram his arm down the bears' throat to keep from getting killed, and survived with major scars and trauma. That changed what should always have been the protocol: you don't work with big animals alone.
@@Dwightstjohn-fo8ki what nightmares are made of, hot dang!
@@Dwightstjohn-fo8ki Here its illegal to work alone in hazardous jobs.
Even at metal workshop there needs to be other worker in same area.
I once managed to get 8 of my fingers stuck in metal bending machine, and in case I had been alone, I would have been stuck there untill morning and likely lost my fingers.
The machine had retarded emergency stop button that had to be pressed by hand... and well... my hands were occupied 😅
@@jarskil8862 I had a loaded pallet jack roll onto my foot. My supervisor stood dumbfounded for a while looking at me instead of helping.
nutty putty cave anyone?
My dad worked on nuclear submarine assembly. They would weld in pure Argon gas environments. Similar to this accident, a worker dropped something accidently into one of these open tanks (the size of a large swimming pool with no water) and went in to quickly grab it. He passed out and his coworker went in after him and passed out. This was the 1960s and I think safety was less stringent back then regarding labeling of dangerous zones, etc.. Both workers died.
Seems like something that would happen at my previous job. That place was filled with management that improperly trained. Workers, if trained, ignored all training as they felt it was below them since they had worked x amount of years without an incident.
It's called natural selection
@Sean Stevenson no one selected these guys to do that job. They were supposed to attach a pipe to the outside, NOT ENTER THE REACTOR. The video made that crystal clear. They didn’t want to wait on the proper permit- sounds like natural selection to me.
Two men died at Union Carbide here in Louisiana the same way. It was in the 90s. By time I went to work there they had a 4 day orientation with a test that you could not get one wrong answer or you had to retake the whole test. It took as much as 6 to 8 hours to get a permit. It was the safest refinery but the slowest work pace that I've ever seen. People would sleep while waiting on a permit. Some got 40 hours of sleep in a month. Safety first.
Just don't do it an in enclosed space. Lol
I'm guessing the first worker wasn't autopsied. The markings on his body would have determined whether he fell in accidentally or not. The markings would have been more severe than they would be from a fall in a standing position even though the difference in distance was 5 feet.
Given it was an industrial accident and unclear exactly what happened, I would assume they did autopsies on both victims.
How would he not fall in accidentally? You mean on purpose?
@@mr.coffee6242: As in "he went in there deliberately to get the tape" vs "he didn't intend to actually go in, but slipped" I think?
So many mistakes here. The sign did not warn of a noxious atmosphere, the work permit did not mention nitrogen, whoever dropped the tape left it to be someone else's problem, the worker entered the confined space and then fell in, an emergency response team was not called immediately after the worker lost consciousness, and another employee entered the confined space without considering the nitrogen hazard. Entirely preventable at so many levels.
I bet the guy who dropped the tape feels like crud for the rest of his life.
Seriously though, I want to know how a nitrogen filled reactor got marked as safe...
@@djcfrompt Because they were not supposed to enter it!
Personal monitors could have helped everything. In Canada we have been using them for years. I'm 31 now and started at 18. We were using them then. They aren't anything new.
@@adamrodgers9175 Based on my experience on working for an industrial contractor, it's simply about money - certain simple types of personal gas monitors like hydrogen sulfide monitors can be relatively cheap (those specifically are mandatory in a number of places I've worked at), but ones capable of monitoring multiple hazardous gases and alerting you of low-oxygen conditions are not, so the contractors won't buy them for their employees - they just have one or two locked away to be used to fulfil permit conditions when needed.
There was no noxious atmosphere where the workers were AUTHORIZED to be - OUTSIDE the tank. The scope of their job did not require them to be in the vessel, therefore no precautions were taken for someone to enter the tank! Had they simply reported the issue and gone through the proper channels then the appropriate measures would have been taken to ensure the vessel could be entered.
These two numbskulls entered and area they were explicitly forbidden to enter and they paid with their lives as a result. Keep out means KEEP. THE. FUCK. OUT.
I feel like the worker couldn't get the tape and did intentionally climb in not because he was stupid, but because oxygen deprivation impaired his motion and judgement.
ANY time a sentence, in a non-medical setting or context, begins with "I feel like", it's complete bullshit.
@@johnd5398 i feel like the sun will not turn into an apple in the next second
@@leaderofcommunistchina1427 I feel like drinking a nice cup of tea.
@@johnd5398 I feel like you're correct.
@@johnd5398 What. That's the whole premise of writing a comment. You're against the very concept of thought itself? Having a thought is the very prerequisite for writing a comment, and you're against people saying "I feel like"? What about "I believe" or "I think"?
Also wtf, I don't wanna hear that in a medical setting "I feel like you have cancer", "I feel like we should operate" wtf
Poor bastards. All because of a Cursed roll of tape.
They explain everything except who put that fucking roll of tape down there.
@Sean Stevenson lol
The whole point of the video is a root cause analysis to make it clear that this wasn’t all because of a cursed roll of tape. There were many other points of failure. But ok.
@@mjotoprobably fell out of one of their pockets. Either way if they followed their rules and procedures they would have been fine
I've noticed that quite a lot of enclosed space accidents tend to have 2 victims. The initial victim who fell unconscious, and another worker who isn't aware of the danger and rushes in to help.
That is unfortunately very common. Of the people who die in confined spaces every year 60% of them were would be rescuers. All too often in confined space accidents when a person is overcome by oxygen deficiency or toxic gases other people who see them unconscious instinctively go into the confined space in a attempt to rescue the person but then become overcome as well thus resulting in multiple victims. That is why many confined space safety videos and guidelines constantly stress the importance of not entering any confined space to preform a rescue unless you or other people have proper training and equipment such as a breathing apparatus.
I worked at an electronics manufacturer in 1996-99, as a functional test technician.
To make room for another surface-mount production line, the HALT/HASS testing chambers and functional test benches were moved into the same area that used to be office cubicles.
In the original location for HALT/HASS, the nitrogen used for the cold cycle would not concentrate, but would be moved about and vented through the roof.
However, in the new shared space, the airflow and air replacement rate was not adequate for the new purpose of the space.
-
We found out that the HALT/HASS leaked nitrogen badly after I and most of the other bench technicians had already been written up for falling asleep at our work stations.
Air testing showed that at certain phases of HALT/HASS processes, the O2 in the room dropped as low as 10-12% at the height of our heads when seated. The HALT/HASS techs never sat down, so they had never encountered the problem.
-
The "fix" was to open a couple of windows and set up fans pushing air out the windows so air from the production floor would move in to replace it.
lot of confined space deaths happen when a rescue is attempted
We are taught not to do the rescue. If someone goes down you leave and prepare to do a proper rescue.
"Reach or Throw Don't Go" as I learned in swim lessons
The first rule of rescue is to make sure that the scene is safe before entering it and if there are hazards at the scene you should either find a way to make the scene safe such as by extinguishing small fires or if you can’t make the scene safe then stay away from the area and do not enter and instead immediately call 911 and tell the dispatcher about what happened and then after calling 911 leave the rescue to first responders such as firefighters and technical rescue as they are properly trained and equipped to safely preform the rescue. Your natural instinct may be to go into the scene to help but if the scene is not safe then you should never enter it under any circumstances as by entering the scene you will likely become a victim yourself and remember you can’t help someone if you become a victim yourself. Tragically there have been many cases such as in confined space rescues, trench collapses, drownings, eletroucions by downed power lines, traffic collisions, hazardous material releases, and burning buildings where would be rescuers died attempting to preform a rescue.
I work at a company where equipment is regularly pressure-tested using nitrogen and sometimes cryo-tested with liquid nitrogen. For safety this is done inside a bunker and after test completion the system will enter a 15 minute purge and flush cycle during which it keeps the door locked. Every kind of gas, even inert ones, should be considered and treated as potentially dangerous or even fatal and even more so if it's under pressure. Two of my coworkers died in an incident involving equipment containing compressed air at a mere 5 bar while we routinely test at pressures of several hundred bar. To this day it reminds me that single mistake can mean "game over".
Having fallen victim to a confined inert atmosphere myself i know a bit about this. At less than 6% oxygen, one breath will spasm your larynx (voice box) blocking the airway. It feels like you’ve been karate chopped in the throat. First you lose control of your limbs, it starts in your feet, then hands and moves in towards your torso. Within 6-10seconds you will lying (most likely on your side) on the ground unconscious. Somewhere around the 4minute mark you will suffer a heart attack and by 5mins be dead and not be able to be resuscitated. The Reverend Death (there are documentaries about him on UA-cam) kills people in this manner using helium.
That was horrifyingly detailed and I wish that I hadn't read it. Thank you.
The media and scientists always lie about the effects of a nitrogen death.
What about a close to 0% oxygen environment? how quickly does this cause a victim to fall unconscious
I'm asking for myself
I don't trust pills and a knife scares me so this seems almost magical to me
@@WaverAlpha LMAO
@@WaverAlpha Hope you did it.
Actually it is easy to explain: You can be there for as long as you can keep your breath minus 15 seconds (for exiting). If you inhale because you want to breathe you are pretty much too late (but might still be able to exit if you act fast and not breathe more). Unfortunately nitrogen environment feels like regular air. This is why pretty much 100% of people who breathe it think that "naa, the sign is wrong, it's safe to breathe". Most other gasses can be felt or at least heard (helium).
But you can't lift a person if you are not working out in the gym.
It's not as light as helium. 75% of the air we breathe is nitrogen. If you get trapped, the nitrogen doesn't go anywhere. So it only floats a little bit.
Smarter Every Day did a great video on how oxygen depravation affects you in the context of why they tell you to put your mask on first before helping others on an airplane.
It's also the reason they tell pilots to put on their oxygen masks at the first sign of warning. Don't try to fix the O2 problem until you have it on--there's so little margin for safety.
@@gloomyblackfur399 I believe there's a story about a 747, somewhere around Japan, IIRC, which developed a hole so the pressure fell. They then flew around for quite a while before hitting a mountain, long enough for passengers to write letters or phone their families, all the while ground control tried to get the pilots to don their oxygen masks. Unfortunately, their judgement was already shot too much.
@@KaiHenningsen Look up "Helios Airways Flight 522". A maintenence worker forgot to turn a knob back to its default position and the plane never pressurized, killing everyone. A flight attendant tried to save the plane unsuccessfully. Sad story and shocking how such a small (in)action can cause such a massive tragedy.
Kai Henningsen Actually in that 747 Japan crash, the main cause was not impairment, it was that the initial explosive decompression severed hydraulic lines and caused the vertical part of the tail to fall off, making the plane uncontrollable. The pilots may have initially suffered some hypoxia but the plane descended enough that they apparently recovered and attempted to regain control for roughly half an hour before crashing. The fact that some passengers wrote goodbye letters also shows that there was enough time and oxygen for the pilots to try to recover - but the plane was just too damaged. Even if the pilots had put their oxygen masks on instantly, the outcome would have been the same.
@@Sashazur, JAL Flight 123, domestic short-haul, packed to the gills. Aft pressure bulkhead had been damaged in a tailstrike some seven years earlier, and improperly repaired. Pilots did an amazing job of keeping her aloft for as long as they did. 500+ souls aboard, worst single-aircraft accident in history. I believe that the fellow performing repairs may have committed suicide.
This is my first CSB video. I spent 28 years with a govt audit agency that basically farted around the edges of every important issue because of political concerns. Wow, what would I give right now to go back to the beginning of my career and steer myself to a REAL inspection, study organization like this. Few things infuriate me more than useless, careless, conscienceless managers that could care less about the people that make their lives possible than they would a fly they swatted on their way into 'work'.
This is the video we had to watch for our confined space entry course.
The most peaceful way to go. The 'omg I can't breathe' panic one gets is only triggered by a high CO2 concentration -- not lack of oxygen in the lungs.
Fr. Of the deaths on this channel this is one of the kinder ones
according to a google search, nitrogen apparently isn't that peaceful
@@official-obama It's extremely peaceful, you don't even realize anything is wrong.
@@tomservo5007 allegedly you do, look it up
afairc, the government classified it as torture or something?
@@official-obama allegedly ?!? It's how your body works. It can cause death without you even noticing. There's zero pain, hell, even nitrous oxide (laughing gas) is used to reduce anxiety and pain. Show me ONE source stating it isn't peaceful
I appreciate the work of the CSB so very much.. OSHA doesnt do enough
my dad used to work for a company as a reactor entry technician one of his jobs were to recover bodies from incidents just like this
There is a job title for these specific situations. Confined space attendant, or (hole watch). I did the job for years. Monitoring the air in the space for people entering confined spaces, and keeping in touch with emergency response teams that specialize in confined space rescue. Usually boring, but suddenly can become life and death.
It's the boring part that gets a lot pf people killed, that and young people trying to make a good impression.
I had an incident in which I took a breath in but felt suffocated.
I was working at a fast food place, a real hole in the wall type of place, and they had a fryer in the back going. They use propane for that particular fryer as it was a big fryer, I was taking care of it, sitting mostly just turning the meat a bit at a time. I heard a hissing noise and tried to find the source. I followed it to the propane tank (about 4 ft tall and 1 ft from side to side), as I was trying to pin point the leak I had my face about 5 inches from the tank and I was just coming to the top of the valve handle... there's were the leak must have been because I accidentally took in a small wiff of the stuff and automatically felt as if I couldn't breathe, as a natural reaction of not being able to breathe I tried to take in a full breath of air, but still, I felt like my lungs were out of air.
Well, by this time I had moved my body away from the gas leak and slowly and surely I was able to breathe right. But yeah, that was a weird feeling. Taking a full breathe in but feeling as if your under water because your lungs are burning when they're out of air.
What stands out to me is that in 10 minutes the emergency crew was there and removed one of the victims. they had proper breathing and the Hoist. 10 minutes to have the proper equipment. sure that's because of the emergency but how much longer would following the proper channels have taken?
Genifer Teal It takes a long time. First, you have to find an operator (usually they're hanging out in the control room) and advise him whats up, he then has to find someone who is confined space qualified and locate the on-duty safety man (who SHOULD go to the site and take readings and observe the scope of work), then they have to apply for a confined space permit at the permit office, then someone has to checkout the necessary breathing apparatus and proper equipment to enter the vessel. Now everyone can go back up to the site and pull out the roll of tape. And by that time, you've lost your crane...
@@231mac Sounds like they could save a lot of time if the permits, equipment, and safety check all came drom the same guy.
@@RobinTheBot That's considered to be 'checking your own work' and creates more safety issues.
@@231mac That's fair but there has got to be a better way. Maybe having the control room issue permits and the safety guy bring gear, so if it's approved and safe they can get right to it. Safety guy isn't approving the gear and the control room is only issuing permits with the redundant approval of the safety guy? Or even just have control be a go-between to make it quicker.
The emergency team had everything needed and got it done in 10 minutes.
A manual crane (shop crane?) isn’t the right tool for the job when you’re lifting 4000lbs of steel up multiple stories
They both were probably impaired/dropping blood oxygen levels before even going down, from breathing while leaning over the opening.
My condolences to their families. Sad to know this could had being avoided
This has happened in sewers, in underground cable tunnels, in car repair shop bays, in holes in the ground. Often multiple people are injured or perish in these accidents. Hoists, safety straps, gas meters, air movers, and standby personnel are all essential when working in confined spaces. This is basic stuff.
The reason why multiple people are injured in these incidents is because would be rescuers usually fellow coworkers often those who haven’t been trained upon seeing someone unconscious or having seen them gone down despite not having proper equipment such as breathing apparatus instinctively enter the space to attempt a rescue which results in them being overcome by the same hazardous atmosphere that overwhelmed their fellow coworker. Incidents like this unfortunately are in the majority of confined space incidents as 60% of people who die in confined spaces are would be rescuers. The would be rescuers motives for doing so while understandable needlessly risk the lives of not only themselves but others as well and usually make the situation worse due to there being more than one victim. It is better to have one victim than two or more as then the victim can be quickly and safely rescued preferably by a trained and equipped rescue team on-site. That is why one of most important confined space safety rules is too never enter a confined space to preform a rescue unless you are wearing proper protective equipment such as breathing apparatus and are properly trained to do so. Also if possible there should be a rescue team onsite who are properly trained and equipped to safely preform a confined space rescue as then if an emergency does happen they can quickly and safely rescue those who are trapped.
I also forgot to mention that this is the reason why multiple people are killed in these incidents. I myself don’t call them accidents but rather incidents. That is because an accident can’t be prevented but an incident can be prevented and virtually almost all confined space incidents like this would have been prevented had workers been trained and had followed proper safety procedures. this incident for example would have been prevented had the workers been trained on the hazards of confined spaces and how to be safe in and around them, had there been specific warnings about the potential for Nitrogen being in the confined space, if they had tested the atmosphere with both oxygen monitors and gas detectors and then waited until the space was properly ventilated, if the first worker had worn breathing apparatus, had there been hoists and ropes at the entrance to the space and had the first worker been tied to the hoist, had the workplace properly trained it’s employees on what to do in the event of a confined space emergency and reminded them about the dangers of attempting a rescue unless they have been properly trained or are wearing proper equipment such as breathing apparatus, and had there been a trained and equipped rescue team onsite and close by. Had those safety procedures been followed the incident would likely have been prevented and even if it still happened it would have been less deadly and the first victim may have survived. Here are some examples.
Example 1. had they checked the atmosphere with air monitors or gas detectors and had waited for the space to be ventilated they would have detected the nitrogen and would have been able to enter the space safely.
Example 2. Had there been specific warnings about nitrogen being in the confined space and had the workers been trained on the dangers of confined spaces and how to safely work in and around them they would have recognized the potential danger and the first worker may have not entered the space without ventilating the space or wearing a breathing apparatus thus preventing his death.
Example 3. If he had worn a breathing apparatus the first worker wouldn’t have been overcome by the nitrogen meaning that he wouldn’t have died. If the incident still happened however had the would be rescuer been properly trained and had worn breathing apparatus he wouldn’t have been overcome and would have likely been able to safely rescue worker 1.
Example 4. Had there been hoists, safety straps, and ropes at the entrance of the space and had the first worker been tied to the hoist, safety strap, and rope upon being overcome his coworkers would have been able to quickly and safely rescue him by pulling him out via the hoist, safety strap, and rope not only preventing the would be rescuer from being overcome and killed but also would have likely resulted in the first worker being successfully resuscitated which would have resulted in him being saved.
Example 5. Had the workers been properly trained on what to do in the event of a confined space emergency and had they been constantly reminded about the importance of not attempting a rescue unless they are properly trained and have proper equipment such as breathing apparatus the foreman wouldn’t have entered the space thus preventing his death.
Example 6. Had there been a properly trained and equipped rescue team on-site and nearby the rescue team would have been able to quickly and safely rescue worker 1 which would have likely resulted in him being successfully resuscitated thus resulting in him surviving the incident.
In short this incident like with most confined space incidents was completely preventable and had proper safety procedures been followed the incident likely wouldn’t have happened in the first place and even if it had there wouldn’t have been as many deaths and the first worker could have even survived this incident.
I would like to know who dropped the roll of tape and was like "Meh, oh well no harm done".....
Someone that's been huffing too much nitrogen
Someone who knew his boss would order him to his death to get the tape he dropped.
Or maybe they dropped it and were like “nah, I’m not going into there and getting asphyxiated”...
Imagine being that guy and living knowing your laziness killed 2 people.
And THANK YOU USCSB for NO ads in your safety videos. SO refreshing!
Remember, this is a government agency.
They can’t monetize the channel because of ethics policies about self-enrichment among government officials. They have enough subs and views that they could, but it would violate federal ethics laws.
Anybody else binge watching these in 2018?
hah, I am about to. I ended up here by studying up on the composition of both water & air, mainly due to people doing two things in the homesteading & the prepping worlds of youtube. I was looking up oxygen & hydrogen percentages in water & I was looking up oxygen & nitrogen percentages in air. So the things they are doing are large amounts of mulch importation & mylar bag food storage using oxygen absorbers. Which in my eyes, I believe you need oxygen to enter your digestive tract in your food where I believe it is directly absorbed by the digestive system into the bloodstream. People think this is crazy. But I believe I am correct. As far as I can tell it is only recently being looked into, & possibly recognized, by the medical profession. So basically I was looking at the composition of water to prove my stance. We must consume water or die... so, what are we getting from it? It, water, contains only Hydrogen & Oxygen. Interesting theory, eh?
In the end perhaps I have too much time to think? I'm good with it.
While I was doing that, I decided to also google the dangers of each of those components. It is good to learn things outside the box. I had a teacher at some point in my education who stated that the education we are given in schools is merely likened to a "book report" after that the rest of our learning is up to us to pursue now that we have been taught the basics of how to proceed.
Yeah! I don't even work in a field like this but find these super interesting and informative. Makes me also appreciate and respect a lot of the engineering and workers involved day to day.
@@CheapSushi Yes, they are interesting. Merry Christmas out there! 🎅
Yea these USCSB vids are great for safety training. I use them all the time for my classes.
There's always time for safety!
6:10 this is why if you see people unconscious in a closed space like this, you should not enter to help them. If they were rendered unconscious because of a chemical incident, you cannot help them if you also die because you are not prepared.
Exactly. Whenever someone is unconscious in a confined space you should always assume that there are toxic gases or a lack of oxygen in the confined space until proven otherwise especially if you have no idea what caused the person to become unconscious. In that case immediately call 911 and if possible get a rescue team that is both nearby and is properly trained and equipped to preform a confined space rescue. Under no circumstances should you ever enter the confined space in an attempt to rescue the person unless you are properly trained and equipped to do so safely such as if you have a breathing apparatus.
The plant I work at recently had a turnaround, well one of the flanges didn't have a gasket and nuts were missing from the bolts. I was insulating the line when I noticed it I went to operations quick. Danger is everywhere.
Imagine being the dude who was responsible for losing the tape in the reactor man what a trip
Unfortunately too many companies and contractors care more about speed than safety.
I understand wanting to get machinery back up and running as soon as possible, especially if it is interfering in the production process.
But we as a whole society need to refocus on what is most impirtant: human life.
In the Canadian oil industry standard practice, especially on the annual scrubdown of stacks and confined spaces, a certified paramedic is an observer, whose ONLY JOB is to get help in the event someone goes down. In addition, a credentialed Safety Officer will write a written plan, and you DO NOT leave an unknown crew of outside contractors unsupervised Too many of these USA based incidents seem to lack ALL of these protocols, and it isn't 1955 any more.
One time the power went out at the grocery store I worked at. They made us move huge blocks of dry ice into the meat locker and frozen food containers. Both me and the other clerk passed out in the meat locker because of nitrogen and CO2 concentration and almost died. The front end manager found us like 20 min later and drug us out and next day we were pressured to sign these injury waivers. Didn’t even get the day off.
Murica intensifies
Here such accident would lead X higher up getting fired.
Probably should have taken the form walked out and found a lawyer
@@jarskil8862 Yeah because America is the only country with corruption. Where do you live, fantasy land?
Rule #1. NEVER
SIGN.
SH*T
(w/o a lawyer)
You could probably fight this EASILY based on not being in your right mind after such a thing. Your signature would be invalid.
I'd also would have given them an invitation to kiss my a💋💋, but that is just me. I'm old enough to ngaf. They'd try to fire you, and you'd have them on TWO counts. Wrongful dismissal and trying to force signatures.
Oh, you can't sign anything under duress, either. Immediate invalidation.
Talk to a lawyer to see what's where.
"drag"
Argon is just as dangerous and used in welding shops but you won't find many welders who are aware of the dangers. It's common when welding pipes and cylinders to fill them first with the Argon so the inside of the weld does not get oxidised. Argon is heavier than air so it can fill up a room below the ventilation system. You can be fine standing up and then you get down on your knees to make the weld and you just submerged yourself in Argon and then you pass out and fall to the floor where the Argon is even more concentrated.
Taking deep breaths and still feeling like you're suffocating must be a horrible, terrifying way to go...
The feeling of suffocation is not caused by the absence of oxygen. The build up of CO2 is responsible for that. If you're breathing, you're constantly letting CO2 out of your body, which means you wouldn't feel the pain or panic. And the nitrogen itself is harmless (it's an inert gas which composes like 80% of our atmosphere). So the only thing indicating that something is wrong, would be dizziness. I have willingly experienced it just for fun (and almost everyone can) by making 2 or 3 deep breaths in a helium-filled balloon. Don't recommend it though, it feels like you've just drunk A LOT of alcohol
Show this to the next goober at your jobsite who snivels about safety.
They should be strapped to a chair and forced to watch this entire channel
@@karenelizabeth1590 Set up like an OSHA carnival games! Can you fish out the duct tape? 1 catch- you gotta hold your breath the whole time!!
Being in a hurry to finish shutdown for production to commence is also a big problem. I've been in a situation that requires me to purge a gas plants ( the gas flare line)with Nitrogen using a Nitrogen Membrane unit before they proceed to hot work on the line. This purging operations have been timed and at the same time a boat have been called for back loading of equipment for demon.
Time was ticking and the hydrocarbon in the vent side is still at 18%. I noticed that it wasn't reducing from that percentage and quickly called on the engineering that marked out the point to purge and points to isolate. They never want to listen as they were emphasizing on the cost of keeping the boat waiting and also for the cost of our Nitrogen equipment spread per day. I requested for the flare line diagram but they refused as they are still in a rush to rap up the shutdown. I have to go through the plant myself and discovered That the lines are have lots of 16inch pipe elevated up to 100ft for all module into a sludge catcher vessel (TANK) with no isolation valves and their vent with ¾ inch valve were kept closed. The only valves to the tanks were PSV and check valve the check valves are in locked open position. I discovered 32 number of this risers with vent valve closed. It was clear they never noticed. I draw a sketch of a P&ID diagram to explain this. This made them relax to rethink of the problems. Finally they pulled out the real p&ID diagram from their system and saw my scetch was similar. The job purging operations was re-planned and it took another 9hrs to reduce LEL to zero.
The cost went up
They missed the boat
It took another 5 days to get the equipment off the platform because of their logistics plans.
This made them pay more for standby.
There would have been a huge explosion if this fault was neglected because of time and money as the hydrocarbon in this lines were reading to infinity on the gas tester when I finally got their vent opened. All 32 vent were opened simultaneously.
This happened in one of the biggest oil and gas company worldwide I will not mention name.
But I work with
BG Technical limited
Though I wasn't given an award but I know I've save lives and facility
And we do our job Best.
I read about 2 guys doing some welding in a large water tank......the Argon killed them when the air was depleted.
We had an N2 asphyxiation incident in a space hardware testing lab I worked in. We had environmental (vacuum) chambers and we purged them with Nitrogen. You were supposed to open the door and go do something else for 15min. He stuck his whole upper body into the chamber immediately and set to work removing the test hardware from the "cold plate". He immediately passed out but fortunately someone was watching.
MARCH 19, 1981: SHUTTLE COLUMBIA had 5 technicians asphyxiated by a nitrogen filled cabin, two died.
It is extremely bizarre, you think you’re breathing, but you aren’t. I had a N2 leak inside an elemental analyzer I was working on...wasn’t even a totally confined space, and it still made me almost pass out.
Wish I could do a request... Really want to see the oxygen generator accident that happened at the orange county waste district. there was also a electrical accident there too.
A roll of duct tape killed two people!!!
Guy who dropped it probably felt bad.
Two guys and a roll of duct tape.
You should read on Aeroperú Flight 603, a piece of tape killed 70 people
Stupidty killed 2 guys
@@Paintotheworld11 Poor safety practices and training killed two guys.
I have been in center and wing tanks on C-130s, 737s and other Boeings. Dealing with Kerosene (Jet A) in truly confined spaces requires you to be alert and aware at all times. Need to have someone you TRUST outside. We always had breather app outside pumping the air. You can't get into an aircraft wearing a scuba tank. just a hose and a mask. Like I said, we are professionals and this is what we do. I worked for some younger guy that was venting a tank on Gen Aviation bird using pressurized air and a venturi setup (this is not Jet A, it is AvGas). I walked into the hangar and immediately fled. Grabbed him and asked, "is this approved"? He said "what do you mean"? I said, "do you realize how much static electricity that compressed air and that venturi are creating"? His face just went pale. I spent the next ten minutes in the parking lot until returning to work. If that aircraft had exploded it would have torn that hangar down. FAE, fuel air explosives can be extremely dangerous, have even been used by the military.
You are doing a big job guys. Thank you!
This hurts to watch. Why am I addicted to watching these??
After reading a few comments no mention of who signed off safe work permit without oxygen censored test of a tank. The m maintenance supervisor would be where the buck stops.
When the worker sat on the ledge and his legs broke the plane of entry then he is now considered inside the confined space. Any part of your body is not allowed to break the plane. Something this video should have mentioned
3:53 Why would the permit say nitrogen purge if the scope of the work didn’t include the vessel?
POV: it’s 2023 and you just learned that Alabama is very close to executing someone with nitrogen asphyxiation.
just did.
They managed to do it improperly too
If you took swimming lessons growing up, you may remember "Reach or Throw, Don't Go!"
I think the same applies to confined space rescue without specialized PPE.
That is exactly correct.
I'm a journeyman millwright, there is so much we are not told. These two brothers didn't have to die if they were made aware. In my eyes this is murder. RIP
How is it murder? Their work permit was for OUTSIDE. Even the video said they didn’t want to wait for a confined space permit. They were never supposed to enter.
@@thetowndrunk988 - These investigators must hear dozens of these cowardly "Well technically..." excuses a day. And they crumple them up and throw them in the trash where they belong.
The company put literally zero effort into warning these men that the exposed hole they were working directly over was extremely deadly. And that includes the sniveling pencil-pusher who wrote this permit.
@@CheshireCad considering the people that made this video were the investigators, and acknowledged it both in this video and their report, it’s pretty dumb to say “investigators wad it up and throw it in the trash bin”……
There’s a reason permits are required to enter confined spaces. There’s a reason workers are trained and told not to enter confined spaces without permits. It’s so the company doesn’t have to list every hazard known to mankind. These men knew they were supposed to get a permit to enter, but they entered anyways because they didn’t want to lose the crane…..
@@thetowndrunk988 - The video specifically drew attention to the permit, and the lack of a nitrogen gas warning. So they are explicitly stating that it was relevant to the accident.
The contractors were working *directly above* a hole filled with an invisible, odorless, extremely deadly gas. A gas that could, and did, escape from the hole and contaminate the surrounding area in significant quantities. They could have easily been affected by leaning over the hole, which would not have required a confined space permit.
And yet you're acting like writing "Warning: nitrogen gas in chamber" is some ludicrously unnecessary task. That even doing it "just in case" would somehow make the world worse through the sheer overabundance of caution.
You are pathetically grasping at straws to try and paint this whole scenario as 100% the fault of the victims.
@@CheshireCad nitrogen isn’t a poison. It simply displaces oxygen. It was not deadly above that hole. They were assigned a specific job, and they took it upon themselves to enter the confined space, rather than pulling the proper permit, because they didn’t want to reschedule the crane. It’s their fault, plain and simple. When did personal responsibility take a backseat in this modern society?
It was the duct tape's fault. Recommendation: Redesign of duct tape to be resistant to gravity.
Who put nitrogen in that vessel should have checked that it was cleaned out first. That would have prevented any accident. They were careless.
these videos are really good. sad story but very helpful in preventing these types of things in future.
Why were the workers not equipped with oxygen. Inconceivable negligent on the the workers and employer.. It goes to show you can't trust your employer, most unions give workers the right to refuse UNsafe workplace environment.. If you don't feel safe DON'T DO IT.
Yes.
#1 The work order, while having a provision to indicate Nitrogen Purge, was filled out correctly.
#2 They didn’t even have a atmosphere sensor device.
The world record for a breath hold is 22 min and 22 seconds. Most people can hold their breath for 30 seconds with confidence. The issue is our poor ability to consider everything that could happen. The unexpected is why we follow processes. RIP to those men.
Whoever dropped that roll of tape and didn’t tell anyone has a lot to answer to.
I fired two highly trained technicians who went into an enclosed space without PPE because they wanted to save time. Two months later at a different job one of them died inside a storage tank, again citing proper PPE would take too long to put on. Very sad.
What we really need to know, is did they finally get the tape removed?
There’s stories where, to retrieve one asphyxiated man, six or more others head in, only for them all to die… it’s easy to throw caution to the wind when trying to rescue someone, but you can’t help them if you wind up needing rescue too.
There was a case in Victoria where a man connected his breathing apparatus to a nitrogen line and died.
Meanwhile, my Epson cartridge-less printer has a keyed spout, different for each color...hmmm.
Simple solution.
Its weird to think that something so abundant in the air we breathe can suffocate you if things are a little bit to high or to low
I worked in Underground Facilities for Telcom we had safety DRILLED into us constantly... yet dumbasses often entered confined spaces w/o safety gear
What happened to the usual narrator in this video??
I feel like that guy is the voice of the CSB! I'm struggling to watch this video without him 😢
This was all completely avoidable with proper safety.
There was a contractor fatality back in 2012 at Shell’s Ground Birch gas plant, we did not received enough information but it was related to N2 asphyxiation in a building.
mainly the work permit is the cause of that death not mention the nitrogen and second cause is the shortcut made by the contractor cost them they live and probably due to lock of Knowledge cause of less training … role is role even its take longer time ( do it right or not at all )
I guess im being recommended this in 2024 bc Alabama or someone used it as an execution method for the first time.
that should've been a fresh air job right off the bat wtf happened with ops?? They also shouldve sniffed the reactor prior to work
uuhuhr Nitrogen is odorless and colorless. Sniffing the air would not have helped them, unfortunately.
there is no odor to indicate oxygen deprived areas
nitrogen hasn't got a smell.
I'm assuming that by "sniffed" the OP means tested using the appropriate meters, which should be common practice where inert gases are involved - it certainly was when I worked in the oil and gas industry, both onshore and offshore.
With an analyzer, not your noses nitwits!
Oh my god I was just reading comments in /r/OSHA about cleaning ice off liquid nitrogen lines and people warning it was unsafe due to the risk shocks could rupture the line and flood the area with nitrogen.
Nitrogen is no joke people, regular nitrogen might be lighter than air but when it's that cool it's more dense, and poses an asphyxiation hazard even outdoors. Safety first, know the risks around you.
Somebody out there knows that they were the one that dropped that tape roll and didn't bother to go through with whatever protocol should have been followed to report and remove it. That is a heavy burden to carry.
Apparently not enough to have done the right thing to start with...
The response time of 10 minutes is impressive.
Has the tank no emergency flush opening? Or a emergency ventilation system?
They were probably hypoxic before they went into the reactor. Your brain cells basically start to self destruct once they are deprived of oxygen for 5 to 7 minutes. What an unfortunate accident. RIP.
So did they get the elbow on in time they reserved for the crane or not! Damnit man we have to know!
Nope. It was a crime scene after that.
You can take a deep breath because theres an atmosphere there, just not the right atmosphere so you breathe in but feel like you get no air because there is not enough air in the air
@@Sashazur false
5:16
naughty safety managers get put in the nitro chamber
These older CSB videos are better than the new ones.
What I want to know is why was it still purging if they were gonna put the elbow on? the only time to purge it is to remove to spent catalyst because catalyst combust when exposed to air so they purge it to prevent that but after all the catalyst is remove they should've stopped purging it
maybe leftover?
Another problem too is on Any job site or at Any plant, you'll always have that One foreman or boss that'll chew you out for trying to go through the correct safety procedure just to save time. The, "Wtf just grab the tape and lets go already" type. Not in this case here, but I'm sure its happened.