Batman Jingle bells, Batman smells, Robin laid an egg. Thought you wankers only hung out on mainstream news sites and left-leaning sites. Go find a maga site and push your stupidity there. Maybe enough of them will croak from the virus so they won't be a danger to the U.S.anymore.
Many of the lessons about hazard identification , safety systems and training standards are cyclical and definitely still relevant today Adam :-) I worked in Chlorine manufacture for over 30 years - I've seen Production orientated management , $$$ focussed management and safety focussed management in various waves come and go ... the general trend is that safety focussed management take a few years but eventually you end up with a skilled , happy , knowledgeable workforce ... along comes some new faces at board level and suddenly it's more production ...NOW! ... ... safety systems wither , training becomes a tick the boxes exercise , corners get cut and there's a major incident ... rinse , repeat ...
@@arbee1958 As a mechanic, mechanical engineering student and welder, I know how how important safety standards and protocols. I have to admit, I have watched all of these videos twice over, and I love how easily anyone can find then. Usually videos this old are from a bygone age of youtubers and influencers, I mean think about it, Fred was the largest channel on youtube, people like Shane Dawson and Onision hadn't even created their channels, and the most prevalent videos were of cats doing cute things. Plus, I have a lot of nostalgia for the mid 2000's, being 19 now.
Basically 8/10 of these videos involves the operator "Bypassing" the safety control and subsequently blowing them self up in the process. The lesson here, is to not bypass the safety control.
1st lesson is to make sure that the person with the power to bypass is educated fully from top to bottom with the equipment that they control. It's not the guys fault that that actually did bypass the purging process ...nor the guy who gave the code to authorize it. Perfect example of why recertification should be mandatory every so many yrs. fault goes right to the top of the food chain on this one and shit should roll downhill a just a little bit...2) there should be a checklist in place that should be signed off on after every single step of the checklist when doing all procedures in the plant. Everything should be itemized and part 2 of checklist can not begin until part one was completed by workers and signed off on by a operator in control of the equipment the first task was done on..that's what we did and it is why I said that the place I worked it's virtually impossible for this to happen...every single thing u do in chemical plants like this (and I'm speaking from my own experience close to identical as this) we had to write out a permit for the work being done and you would call the operator on cb of that equipment and have him come to where the work is being done and you physically show him everything you are doing that's on the permit to the smallest details...we would lock any equipment valve's that only I had the key for and everyone else does it too and the operator puts a lock on it...only then will the operator sign the permit and work could begin. Even if this was done.... And I'm sure it was... It still would have happened...this tells you it's lack of retraining and recertification and not procedure itself that's at fault...this is something that they have done many many many times...and should and will continue because time is money...the perfect storm hit dead on which is virtually impossible to detect until after the fact... Which is even more of a reason to make sure that people get retrained/recertified...every year I had a few different things to get recertified to get on the grounds and work...they would not let the person who delivered our checks every week from the check company and we had to send someone to the entrance gate to meet them...16hr OSHA safety training cert is needed and the boss of our company gave the chemical companies we worked for the names of the individuals who have had and passed the OSHA safety course certification and when you pulled up u said your name and the company that you work for... definitely an oversight from the top and I can assure everyone it's impossible for that person responsible for the oversight to do anything similar again cause with that one his safety record it would cost the company that hires him a fortune for workplace insurance to have him on the site. Besides profit...there is nothing more important for chemical companies than having a clean slate with no injuries from workers onsight at the plant...no chance in hell someone else hires him..
@Kinguin quite the contrary, saving money is important, so give training so people don't literally explode your money, you know, facilities have a cost. but probably its insured...
I just watched this video jump from 14 years old to 15 years old in real time. Incredible. Wow. Thank you algorithm gods. CSB videos are among the best of all bureaucracies.
@Unconditional lover we need Love Well, that’s the thing. I guess CSB isn’t actually a bureaucracy. In the exact same way the NTSB makes recommendations to the FAA, the CSB makes recommendations to OSHA, the EPA, etc. They have no enforcement power. So, given their very specific role and purpose, they do a great job. Is their work worth the millions of public dollars they get, though? That’s certainly a conversation to be had.
@@Adam-vj7dn Video from a decent 1080p camera downsampled to 240p will look great for a 240p video, provided the bitrate isn't *also* reduced to the point of introducing obvious artifacts. What you're probably seeing is when a site like RU-vid downsamples a video to 240p, which it does to reduce bandwidth when it thinks the connection is shit, so it uses an ultra low bitrate, and what you see is a bunch of compression artifacts. If I wanted to shoot a 240p video for some weird reason, I'd take a good 1080p camera over a good 240p camera any day, as the higher resolution sensor gives me about 27x more data per pixel when reduced to 240p.
6:35 That ironic safety poster was visible to all the people in the control room. "Safety is for life," except when you're in a hurry or think there's no reason for safety procedures
Safety is the ideal and sometimes just a sign on the wall in places where there is a lack of understanding of how exactly the machinery operates. I've heard a few stories of people whom worked in factories that were told that the "engineers/consultants are too expensive to telephone" and to just hit the buttons. In one of those cases, it involved a propane cure oven door being sent through the wall into the neighboring business.
For everyone who has gotten their undies in a bunch about toxic gas in our medical devices, calm down. For one thing, its chemical properties are what lets it kill off all the bacteria we can't avoid getting on the device, even in a clean room. I design medical devices and one of the most important things we do is figuring out exactly how much ethylene oxide (EO) to use and also testing to make sure there's no EO left after the process is over. There's actually a test called "EO residuals" we have to pass before we can market devices. The test shows any leftover gas is WAY below dangerous limits. So no fear! We've all thought about this!
Exactly, I’m not in the industry but I understand that the same things that make things safe can also harm us if used incorrectly or irresponsibly. These same people are the ones that use bleach for cleaning like water and not paying attention to what chemicals they mix.
I love these videos so much. I love the guy's irish accent, the simple animations, the fact they show you how the chemical plants work. I don't even work in the chemicals industry but these videos just hit a spot for me
Grayfox988 my overhead control office is just like in their video and it’s got lexan polycarbonate so it won’t shatter. We’ve had a couple close calls, just Chem spills and a small blowoff explosion that did no damage
Safety-by-design! No concentration metering before the open flames. No flame arrester in the pipe. No software tags. The venting valve could have also failed. Then this would have occurred too. What was the probability they assigned to this failure mode ?
Normally these videos leave me in awe of how complex these chemical systems are, as well as how crazy it is that we humans can operate them at all. This one, however, didn’t do that. This seems like a really really easy system to understand, I don’t know how someone could make it to supervisor status without even having a small clue what kind of danger they just put themselves in.
About 15 years ago at about 3:30 AM, we get a call for a gas leak in a hospital. On arrival, maintenance met us saying "That alarm is going off" "Take your meters and sniff around". I questioned him if the alarm was in surgery. Well of course it is. An indignant nurse then proceeded to tell us our job, "Just go down there and read that yellow book on the wall" she says. Long story short, an evacuation occurred with a first alarm assignment, the county haz-mat team was called complete with decon lines. All because of marginal training on staff and no monitoring systems in place. BTW it was a false alarm!
The hospital I worked (St. Peter) in had a false alarm every week. We were told to ignore workers concerns when they reported it. The boss claimed it wouldn't hurt you and breathed it to prove it was ok. He died of cancer, although no link can be proven to ETO. The same hospital stored huge amounts of formaldehyde in the early 2000's. When a leak/flood of formaldehyde injured several workers, heads rolled.
Excellent video. We had the same gas leak at our work last week. We didn't know how bad it was until after the issue was resolved. I never realized how much danger we were in.
Would it also be a good idea to make any glass angled, so a potential explosion doesn't put its full force against the glass? Adding wire mesh behind the glass could help reduce the size of debris too
"hey, you know this incredibly explosive gas that needs to be filtered out safely? what if we just, not do multiple steps and send it right to an open fire to save a little bit of time"
We had an ethylene oxide sterilized in a hospital I worked at, it was in an underground vault. There are no hospital based ones left in The UK that I know of.
Very good review of causes. Although they focus on operator training and supervisor bypass, the key element that was missing (IMO) is the LEL detection within the chamber. There should have been no way that a system could be bypassed or advanced until that detector indicated less than 25% of the LEL within the chamber. You absolutely cannot 100% predict human behavior, even given good training.
Mike Badley I agree, in this day & age the technology is there and there isn't many excuses. The only excuse I thought of was that a gas monitor goes through sensors if overdosed with a gas, so the sensor would need to be covered & protected during the UEL stages of gas saturation. Regardless, I do agree with you,
I find these videos as sobering reminders for my career in mechanical engineering as an EIT on why thorough consideration in industrial plumbing systems is of the essence. Fires, explosions, and poisonings have been linked to improper design or cutting corners on safety for the sake of profits. In this situation sensors and alarms as well as blast suppression systems could’ve prevented this explosion. As well as requiring all operators in the control room including the supervisor to put in an override password if a process override is needed instead of just one operator.
explosive limit for ethylene oxide is 3-100% and they didnt have anyone there that knew what they were dealing with or maybe just one guy that no one would listen to so he just watched it unfold, with earplugs.
Ethylene oxide is pretty nasty stuff with a very wide flammability range, pretty much any concentration more than about 3% will burn and pretty violently. At least one source states it is used as fuel in thermobaric weapons (i.e. fuel-air explosives).That would explain why the flashback and explosion was so powerful and violent
It is very metaphorical of how spouting and hanging slogans mean nothing in themselves only practical application does. A message to all the"awareness" campaigns and empty shouting in politics.
Besides being a bit too simple, that seems like a great password. It's very ominous so that anyone considering using it might think twice about what they're doing.
What kind of company Sterigenic is : a supervisor who never received training , a team who does not understand the process. How about to hire the Three Stooges to run the plant ?
How was this hazard not discussed during the PHA? It's The critical scenario. Why did the operators not know the importance of the gas washing safeguard? If your Safeguards can be bypassed anytime someone feels they aren't required , you CANT COUNT THOSE SAFEGUARDS as effective protection layers. Good video either way, we need more people knowledge sharing and going over at least the KNOWN hazards so we don't all have to make the same mistakes.
"All of them incorrectly believed that because there were no products in the chamber to absorb ethylene oxide, all the gas would be removed in the first step, making the gas washes unnecessary". Yes, why did they believe that? Laziness and making assumptions almost got them all killed. (Time consuming washes).
@christianne1985 What happened? Did your democratic boyfriend almost die in the explosion? How about instead of answering my question, you get off your phone and cook me some dinner like you're supposed to.
Tells you a lot about this company when a guy can get hired and become a supervisor in under 7 years without training and without even understanding the job.
Okay, for the "this stuff's in covid swabs!" people. A few molecules remaining inside the swab packaging won't hurt you. It's a gas. It doesn't form a layer that remains behind like spray paint. It's pumped in, it does it's job, it's pumped out, the tiny remainder left over filters out of the packaging over time leaving only possibly a stray molecule here and there, possibly not even enough to detect with the most advanced lab machines. This stuff's probably been used to sterilize all swabs and tongue depressors you've ever encountered in a doctor's office, unless you're old enough to predate this method entirely. You probably do more damage to your body every time you drink a bottle of beer or a can of soda, eat a hot dog, or get a sun burn. If you freaked out over every thing that's in any product that's dangerous in certain amounts you wouldn't be able to eat or drink ANYTHING. Not even water. I'm not saying nothing's dangerous, but learn how it actually works instead of freaking out over conspiracy theories and lies. You need to know what's actually dangerous or possibly dangerous. I'll give you some hints: if you want modern stuff to avoid, try carpets, mattresses, cushions, scented soaps and shampoos, and antibacterial hand soaps, for starters. Not that I avoid most of those, they're everywhere so it's not worth the effort, although not all hand soaps are antibacterial so I do okay on that one. But really. Potatoes contain "scary and dangerous" stuff that's perfectly safe as long as you aren't eating green or sprouted potatoes or enough to kill you anyway. Apples contain more formaldehyde than a vaccine. All this antivax or covid conspiracy stuff is just silly. If you're going to freak about it you may as well fear every food, drink, and other product you come in contact with because they're no safer, and in many cases less.
Uh, I just binge watch these videos for Entertainment, and ran into COVID crazies? What a world are we living in where safety education videos are abused by people who want to preach unsafety...
Thats bad, it also amazes me that they had no kind of sensors or alarm system in place that could detect explosive levels of ethylene oxide before they went to open the door which released the air that was in the chamber to the other section that had the open flame.
It‘s interesting that no flashback prevention was engineered into the feed to catalytic unit. Flashback prevention has been around for a long time. Also without any sensors for explosive gas concentration, the automated system is running as a simple state machine without any input as to the level of hazard in the chambers.
Ignorant statement. Every single failure occurs due to lack of proper regulatory authority by the government. The government has no bearing on these situations at all. This company had a very good system in place that should ha e never failed. It would be like saying my balloon design was bad because someone could use a knife to poke a hole through it. This company, regardless of any government, will certainly never make this mi$$$stake again. All that the CSB does is provide an external 3rd party audit of the situation free from bias to determine what steps should be taken to make the system even more idiot proof. And then relay that information and make it available to all companies so that they can avoid the same issues in the future. Please never forget millions of companies do these types of procedures incident-free trillions of times a year across the globe.
The really worrying thing about this is that ethylene oxide is well known for having an extremely wide explosive range (3-100%, IIRC) - how could the people working in the plant not know this?
Complacency is typically the result of corporate cost cutting initiatives. Less training, less maintenance, etc. As long as nothing goes wrong, the executives look like heroes.
did it not occur to them that an open flame in a chamber used to remove explosive chemicals could be a hazard...? the extent of my chemistry knowledge is 10th grade chem but even i know that's dangerous
Not only a flame arrestor, but also redundant flammable sensors upstream that safely isolates the catalytic oxidizer while halting any more venting until the problem can be sorted out. I would guess that a 3 way valve bypass into the scrubber while isolating the remaining chambers, and gas wash injection into the piping would also be in order. It's sad to see that they relied on humans, never making mistakes, or equipment /software never malfunctioning to avoid an explosion.
How come there is an option to skip the gas washing when it is clear that you wil get an explosion when the gas cycle is skipped once the treatment gas has entered? Like once gas entered the chamber its a definite BOOM if not properly washed. This is not just an operation problem. It was a design problem too.
@@alexjackson936 Then please do mention them, do not just make a statement claiming supperior intelect and not back it up. Also why even state that you can think of a reason if you do not provide one? What is the reason? Think about it
@@lemuelharing4137 There should always be a way to override the procedure or skip steps. Ironically, it's part of safety. It's a requirement that any step could be stopped mid-procedure (e.g. emergency stop) or skipped in this instance. Was it poor judgement to skip the ventilation step? Obviously. It caused the explosion after all, but that's why it requires the manual override and supervisor's password to confirm. The supervisor and technician were poorly trained and did not know the "science behind the methods" leading them to believe something that wasn't true. An unfortunate event.
@@anonypersona3189 Wrote a long message, batery went out, not going to rewrite. In short though, you are correct and it makes sence, could have been designed better regarding how the system runs with bypasses, rather all to scrubber than back vent with flame, cost? Extra design time, coding and accomodation of scrubber treatment rate or volume storage. But a lot of exstra design for all single shutdowns, could just train people on what happens under the assumption that training is done sufficiently for many years. It was a trade between time and increased risk of accident. Was a reasonable trade im my oppionion. Human life loss still bad. I need to design these processes. Its an tradeoff between exponential design time increases and creating a fool proof system. How safe should something be? 99%? 99.99%? 99.999999%? If your system blows up at 99.999 safety due to the greed of others, its resembles a moral predicament. Its morally easier for me to design systems for the military and the intent to kill than a system that is ment for civil use and prevention of human harm under any circumstance(worldly or concience/stentient input). Tradeoffs in a world of appliece science, statistics and the infinite scalling cost of pure science or progress towards it. Its not a qaulatative question but a quantative one that is not be required to be asked nor answered. But it is asked. An always moving line to keep track off. Thats the summary
@@lemuelharing4137 Yeah, I do agree that there should have been some more redundancy in the safety systems. Like the narrator mentioned, there should have at least been a sensor alarm to note that there was still flammable levels of gas within the system that could combust when it went to the burn chamber. That definitely seemed to be a huge oversight on the designer's side of thinking. Even if all of the procedures went according to plan, I know I would definitely want to have a sensor in place for that.
Sterigenics Holland In the period of 2006 - 2008 Sterigenics Holland in Zoetermeer polluted the air of the city of Zoetermeer with more than 139 ton Ethylene Oxide
I work in a sterilization plant. This happened almost 2 decades ago, this is impossible to cause now. There are a ton of regulations to this work and more are added all the time and we have to follow them closely
Partly software failure. The software should have explained the risks and consequences of bypassing the safety step, as part of the bypass process. Authoring that information should have been a key step in designing the safety bypass.
Seems like they expected the user to understand the process and why it should not be skipped. I agree with you that warning flags would be idea in the software.
Why does a MAINTENANCE supervisor have the authority to override an Operations function? In my former business, it was the Operations supervisor's line manager (who did understand the process) who had to authorise any deviation from normal operations, and that only after a full risk assessment had been carried out.
Everything these days comes with pages full of tiny print explaining every safety issue in carefully worded lawyer-proof detail. Nobody reads that either.
*"IN ONTARIO..."* _my jaw drops I have a look on my face as if I saw my mom fighting on the racoon war against the chipmunks_ *"...CALIFORNIA"* _and then a very strange feeling of relief for some absurd reason washes it away_ Ontario, California... goddammit...
I have watched them for years for that very purpose, or for that monotone voice as a bit of Melatonin, just before a city block gets leveled & several poor bastards meet an untimely & horrific death..
I wonder if the tech was a private contractor with a flat rate or hourly as a employee of the company. If its hourly this guy had no reason to deviate from protocol . He's getting paid by the hour
If he's a nice employee, and his deviation saves the company money and time and makes them more efficient, then he has a reason. Not ever employee is selfish.
i like how this video was uploaded over a decade ago yet most of the comments are from just this past year. also, the video was lacking the usual piano background music.
I’d say the safety system tried very hard, almost perfectly designed not to poison people. With threat of self destruct if people insist on entering the room full of angry gas.
