so much effort and time gets put into these animations. check out the bump mapping at 1:30. actually idk if it IS bump mapping, might be just entirely modeled and self-shadowed? gosh!
Wow... Shocking to read of this. I was the operating engineer in that plant up into the late 90's when it was Quantum Chemical and before Lyondell bought it. I have had my hand on that valve. It was a zirconium cast valve and the whole time I was there, we did everything imaginable to NOT touch that one or the one next to it also zirconium. They are right, the plug valves used are a quite old and standard design, although cast of a new and amazing material. As the video played out, I saw the animated guy reach behind the actuator assembly. They got it right that there are studs holding that plug cover plate to the valve body. Those should have never been touched. I have seen that actuator removed in a previous plant outage. It has been sticking to that shaft every time. It has corrosion on the shaft from a tiny amount of leakage through the top shaft seal for years. But all would have been fine had they not touched those 6 stud bolts holding that cap down. For the undergrad below that is trying to learn what these valves (and really most all common valves in use) Try to find a Crane valve book from ancient times.... about the year I was born. Ebay has been my source. I have 4 excellent copies of the 1953 version on my shelf at the moment and one 1960 version. I have given away 7 or 8 of these to some very worthy engineers in the years to guys I thought would use them. Had these guys had one, there are cutaway photos of these and almost all common valves you will come across. Mine are not for sale, as I have at least 2 earmarked for a couple of really good engineers that need them. But the USCSB is right, these valves could be made to be less likely to be opened by accident here. Yes, dying from the reactor contents here would be a particularly bad way to go. Vile stuff in that reactor, along with a LOT of dissolved carbon monoxide in pure form.
Do you think it's possible that the workers had experience with *installing* other actuator designs where the actuator has a mounting plate that is captured by the valve cover bolts? it wouldn't be a correct procedure to remove the valve cover to remove those actuators either, but someone could just think they were supposed to reverse the install procedure.
@@gmaxwell Yes, when I was there, this was a top critical part and ONLY a designated supervisor and his best two mechanics were allowed to touch it. And we avoided touching it at any opportunity. Unfortunately, in todays world of cheapest labor standards, it will be obvious to the experienced plant people that these guys had no idea how that valve was assembled.
@@Jonnyg325 The rule is set up to prevent just this occurrence. It is reoffered to as a "lock out tag out procedure." It takes the whole complex manager to get this rule modified or changed. We looked at this valve to modify it for a locking pin to be added so it could be mechanically prevented from rotating. It was deemed to be impractical due to the Zirconium material. The primary shaft would need to be drilled and a pin made with stops so it would not be able to turn. But zirconium being drilled, was possible ( though highly unlikely) to get hot enough to catch on fire itself. So it was abandoned. My input was that this valve requires so much torque to open and close that we were worried that if someone re-connected the pneumatic air to it even if with a utility hose, the unsuspecting mechanic would likely have enough force to break the pin and activate the valve. It is a difficult thing with plug valves. people struggle with this in many places. The way I dealt with it while there is put in a rule with the supervisors in the plant, that either a supervisor or myself would be standing on deck with this valve if anyone was going to work around it. Many of the mechanics are not intimately familiar with the inner workings of these valves. Only ever had 2 shutdowns while I was there and one did not require this valve to be touched. The other one, we simply removed the orange actuator (it was actually orange in real life in the field) and as always found the coupling to be jammed on. We finally freed it up and got it off, but with at least a full shift trying to make it release. Several times we needed to remind the mechanics NOT to touch any of the 6 bolts holding that cover on.
@@Jonnyg325 The only "Setting" is the removal of the actuator air supply. However the "rules of lock out - tag out" do not allow this method of making certain the valve would not rotate. Seems obvious that it would not move , but the rules push for mechanical stops to be in place to prevent rotation of that shaft. Seems a bit much, but remember those 3 guys up there almost certainly have with them a pipe wrench. That alone would turn the valve to the open position. I understand it would be stupid to do that. But pulling not one but SIX cap bolts is what actually killed them.
It could be worse. We could be in 2018 after Trump defunded them, with people having lost their lives with no lessons learned as even more protections and regulations are being ripped away.
I am a firefighter and these videos are what played a key role in encouraging me to be a firefighter. So many tragedies that are oh so preventable. CSB you do a great job! Keep up the good work and continue to keep workers safe.
They say every "accident" are preventable. I've argued ad nauseum with "teachers" that not all accidents are 100% preventable. It seems "educated" people are taught that nothing happens randomly. I do agree most accidents I've seen are typically preventable (I work in oilfield on rigs) I've seen some wicked incidents but it's annoying to have some person whose never worked a day in their life tell you something elwas preventable, "yeah that catastrophic failure of a brand new rope wire that dropped 95,000lbs was 100% preventable and your fault".. ahh yes thee old "you should have inspected it and noticed it was going to fail" method of avoiding a lawsuit and trying to blame the employees instead of taking responsibility for your purchase of Chinese shit that almost killed 3 people exscuse. Those people got mad when I said "if I was that good at being a psychic I sure as fuck wouldn't be working on rigs". I think "safety" is looked at the wrong way, instead of pointing fingers and blaming the individual, saying their at fault, safety should be looked at from the perspective of teaching people how to recognize risk and how to situate themselves in better positions to avoid injury. If you like "safety" lessons learned videos there's a channel called "Brick Immortar" that does a lot of maritime accidents but also some other stuff that's extremely well put together and gives you the facts and how they could have reacted differently to avoid situations when available, and what people did right. Very interesting channel if you're into this type of "safety" content
@@jlo7770a corp's own safety agency is like hr, ultimately a tool to protect the corporate entity from risk (no matter how well intentioned any inspector might be, the incentive is baked into the structure). that is where a govt agency should come in, literally "the people" making it so the corp isn't grading their own homework. but the way business is prioritized the govt only acts after lives were lost. idk what the solution is but these sorts of accidents shouldnt be happening as often as they do. a buddy of mine is a union electrician and what he tells me about the work and safety culture sounds right, even tho there are still questionable occurrences (chemicals being places they shouldnt be, only recognized after exposure). the real bottom line is that people's lives arent replaceable, but to the economy they are a resource like any other. stay safe✌️
Acetic acid, what makes vinegar. We use 5% for food, canning, and cleaning. It smells and tastes bad enough. I can’t imagine being doused in 100% strength of this stuff.
I've experienced a plug valve replacement where there was about a gallon of this ac in the line left over from clearance and it was warm, not hot, and that was uncomfortable and I was about 3 feet away from it. Bro who lived must be or is counting his days... Hope he lives a long productive life.... Preferably in an office with a settlement under his belt and a work shop in his garage.
There's something about this narrator's voice that just LOCKS IN my attention every time. Outstanding video. Condolences to the workers and their families
@@zyenathalous I just looked at his LinkedIn page and he has a Secret Clearance! That means there are probably, like CIA mishap training videos that he narrates or something...
Very touching tribute to the victims at the end. It was a painful reminder that this wasn't just some unintended industrial process error. These were people, human beings like you or I who, we must accept, would in all likelihood still be with us were it not for a culture of being comfortable with unassessed risk. Requiescat in pace. The CSB's total, unwaivering commitment to ascertaining the true root causes of significant industrial accidents, and to providing industry experts and leaders with recommendations to try to avoid a similar situation from occurring ever again, are both superlatively laudable qualities. It is an example of our government working very well, and I am pleased to support the endeavors of the USCSB as a taxpaying citizen of the United States. Thank you for this video, although I regret the circumstances of its existence.
I can't count how many times I've heard "it's just vinegar, it's never killed anyone" from people working with concentrated acetic acid. Even I'm guilty of being a little complacent around acetic acid compared to other reagents. Thank you, USCSB, for bringing awareness to less "fiery" but still potentially lethal hazards.
I've only worked in small-scale research labs, and I started the video wondering how exactly someone died from getting acetic acid on them. Even concentrated, it's not a "strong" acid, right? And then I see it's > 100,000lbs of heated acetic acid escaping at very high pressure, directed AT the workers in question. The third guy somehow surviving with serious injuries now seems more surprising.
GAA is wildly not at all just "vinegar" but people do act like that it isnt a hazardous chemical all the time for some reason. Maybe we should call it ethanoic acid more often so people think it sounds scary again.
I have learned a few things from these videos 1) Don't work or live near a chemical plant. 2) Dont get inside confined spaces. 3) Alarms and warnings need to be carefully selected and implemented to prevent people ignoring them.
no the answer is you should do your maintenance on your own equipement but no you let compagny wash their hand and give it to subcontractors ... th many time it happened in the past the compagny was in fault so they had to pay for their mistake but with subcontractors they pay for the spill ... 100% uscb fault even more if people died there before you gave them the ok to continue this countrywide....
What makes this even more tragic is the acutator was being removed to allow for valve lockout. These workers were killed/injured performing a job that was intended to make another job safer. The risk assessment of repairing the leak was properly done, but the risk assesment of the task needed to complete the required work for that leak repair was lacking. The same as an electrician getting blown up by an arc flash while racking out a disconnect to de-energize something for repair.
What makes it even worse is that the valve actuator did not have to be removed in the first place. Usually, only the power supply to the actuator is interrupted when it is closed, so that it cannot be operated.
@benjaminhampel8640 In my Canadian refinery, we don't even rely on actuated valves for lock out. There's always a manual block valve close by, especially in a location shown in the video, being at the bottom of a vessel.
@@TLarose. There is a video in uscsb that a fatal accident caused by a manual valve, it's very similar to this case. Things need to be foolprof, i worked as a maintenance tecnician in industrial factory, a lot of machinery we only used our thouth to demount and repair things, even the f engeneer didn't know how to do those things...
@@benjaminhampel8640 would that work if the valve was air-to-close though? But I guess the absence of a manual valve there was really alarming, with all the static head of inventory up there. Control valves shouldn't be used for isolation purposes
@@Jason_Hubred When it comes to recreation of the environment the 3D-work is impeccable. Yes, the humanoid movements are a bit awkward and stiff, but everything else is exactly as it should be for clarity. uwu
I love how this channel started as a basic overview of incidents and accidents for companies to review and make sure it doesn’t repeat. To “this is very interesting, everything is well detailed and the animation is satisfying to watch”.
@@hayleyxyzyou should check out Mentor pilot and Green Dot Aviation! Mentor Pilot has great visuals and detailed technical explanations, Green Dot Aviation has good visuals and sometimes even puts sounds like the alarm and voices in
The sheer amount of effort that goes into designing and animating these videos is phenomenal. Every nut, bolt, girder and pipe has to be designed and placed correctly... and then there's the textures, lighting and camera angles. Whoever is funding these videos has deep pockets! I love it! 🤩
One of the workers explained his reasoning for removing the pressure-retaining nuts. He told the CSB they had to remove the interior fasteners because “…it’s all connected. As [the actuator] sits up there, it’s all connected to one another.” This worker did not seem to understand that the interior fasteners were pressure-retaining and should not have been removed.
If it was really necessary to remove the pressure retaining screws to remove the actuator, which I doubt, then the actuator should not have been removed under any circumstances. But that would not have been necessary to secure the valve so that it would not be opened accidentally. Usually you disconnect the power supply to the actuator when it is closed to prevent it from being opened accidentally.
@@benjaminhampel8640 Correct. And as such while I was there, that was the rule. Don't touch that valve. The only time it was, was after the reactor was emptied and depressured and made full of air to be entered. ONLY 1 time as I remember.
@@lpconserv6074 how did you know that? oh, did someone teach you that? well, that expertise costs money and time. and i can just hire people and yell at them to get it done. whatever. insurance will pay. stonks must go up.
@@chillDude_chills If you can find a book, Crane Valves, from 1953, It is 580 pages deep. Learned about it by accident, but at the moment I have 4 of them plus a 1960 version in my office. It shows a cut away of almost every valve you will come across. More than once, I looked up this exact valve prior to our maintenance outages. Granted it was about 10 to 20 years prior to this accident, and the plant was my responsibility to keep running and when down, to keep it safe. Before any serious internet was out there. I was the first plant engineer with a computer on my desk, a ROCKET, mind you. FULL 286 power house. just to give a little context. Full transparency YES I am an old fart these days. But still get calls to Saudi, Bahrain, Malaysia and Singapore to assist in new plant startups. This time when I was there, we had dedicated maintenance guys, experienced typically with at least 5 or more years in the plant.
It’s wild that I’ve been watching this channel for over a decade, since I was in college. And I still watch every update. To this day, I point out when propane tanks are too close to a building
@@JoeRogansForehead An installed propane tank, not the sort you buy for grills. I live in the country, so there are a lot of propane tanks installed outside houses out here.
Here is my theory on why they removed those nuts: On *some* actuators (see page 20 of the report) the actuator is installed by putting a plate under those nuts. You still shouldn't remove them when removing the actuator, there are other nuts for doing that.... but if you had only ever *installed* new systems using that style plate you might think that the correct way to remove the actuator was to reverse the install procedure. This is also consistent with the worker's explanation for their actions.
Yeah, same, after I just saw a CZcams short before this of some family that had a 4th of July firework malfunction that resulted in what is basically a dollar store airstrike 🙄
While I do not work for the chemical industry, these videos serve as a stark reminder to make sure you find procedures, follow them to the letter and ALWAYS be on the lookout for hazards. If there is a procedure or method in place, it usually was written because of incidents like this.
its a common saying i hear whenever i learn about safety practices in industry. "all safety procedures and rules are written in blood" and its true, most if not all rules and regulations came into being BECAUSE of disasters and accidents resulting in injury or death.
Never in my life did I think i'd find myself dropping anything to watch a video from a youtube channel called the "United States Chemical Safety Board" but this channel always smacks. Well done.
These videos are the catalyst behind me deciding to enter into the safety field with a bachelor's degree and I decided to continue to get my masters. I appreciate these videos and the quality is only getting better and better.
Thank you USCSB. As a chemical engineering undergraduate student, these videos help me understand how to be safe in my future career and how to prevent injury to myself and others.
Make sure you learn about PHA’s and HAZOP’s and get into the routine of having them done on any of your processes. It’s important to find a knowledgeable facilitator and even more important to not work for any company unwilling to do this as part of their design review process. I’ve managed many complex chemical projects and always insist on a safety representative being assigned to my project team.
It will never cease to amaze me that videos made by a government body-- for the sake of depicting a bureaucratic issue-- are more interesting than half the other things on CZcams. I don't know if these are mandated to be posted publicly, and youtube was chosen-- or if the ad revenue is the motivator. Either way, I'm thankful they're posted. So much knowledge on display.
Safety is the motivation for publication. The goal is to prevent future accidents. It's the whole point of the UCSB. CZcams is chosen because it's free and popular. They're not trying to make money, they're trying to save lives.
Perceived simplicity of the work.....Just goes to show you that complacency is something that must be guarded against. This is probably the most polished video out of them all. Thanks for honoring those that perished at the end. Sadly regulations are written in blood.
I honestly can't believe that any pipe fitter would do something like this. They are trained to work with this stuff. Very sad. I personally wouldn't have ever thought a procedure would be needed for such a simple task. Just goes to show how you can't trust anyone.
also they are contracting out work instead of training people to work and be on call is cringe. better to have someone who knows the system and its hazards then to get some randome company to ape your shit up
@@Generic_Name_1-1 Any pipe fitter worth their salt would think twice what fastners to loosen, especially on a pressurized system, tripley so when hazadous chemicals are involved. And what about some basic PPE like bunny suits and a full face splash mask.
It's a slow pan. The refinery in the background is moving when the camera slowly pans so that's why I believe it was a slow pan of a parked truck. There's no way they forgot to animate the wheels it has to be intentional..
I think it was a year ago, when i stumbled on a video named delta p, i thought it was just a dumb meme but watched 20 minutes of the danger between different pressures and how you can get stuck. This lead to a 2 day lasting binge watch of every work safety related videos CZcams had to offer.
I belive ucsb deserves more funding for this quality and informative work, that narrator, animation, and script writing are perfect. because of this cchannel I know so so much more about hazards, and stopped my boss from probably dying from hydrogen sulfide exposure from overcharging a huge bank of semi truck batteries, I know what the dangerous smell is from watching one of these videos and going on a Google rabbithole. thank you, only branch of the government I respect!
@@geoffreypiltz271 I noticed that too. I couldn't tell if the truck was "sliding" or if the camera was slowly rotating while panning. I was trying to use the background parallax for clues but I'm still not completely sure lol.
So wait, Turn 2 said they had a crew who was qualified to do the work and then provided a crew who had no training on the work they were supposed to do? Lying about the capabilities of their crew is a clear contributing factor if I've ever seen one.
When I lived in Texas I was shocked at how often people were derisive of safety training. They have a culture of complacency and I feel that was a contributor to this accident as well.
Management needs to stop trying to hide the design of components under the guise of "you don't need to know that, just follow procedure". Nobody should ever be expected to maintain equipment when they don't understand how it works.
I have never worked a job in chemical manufacturing l in my entire life. I could not tell you the first thing about chemical engineering. I am glued to the screen when I watch these videos. I cannot overstate how awesome this channel is and the fact they've been doing it for over a decade now.
So preventable that it's basically a retread of "fire in baton rouge" video. Employees removed a gearbox from a valve and accidentally removed all the pressure-bearing bolts, leading to hydrocarbon release and explosion. I guess that problem from before wasn't really fixed.
I don't work in industry, but I was shocked there was no written or other visual warning indicating what the bolts were. Would seem like an obvious thing to include.
@@Motoko_Urashima Same nuts that hold the valve together were also asked to hold a flange that needed removal, thus forcing an unnecessary valve disassembly through force of bad design.
awww yes my favorite channel that scared the absolute shit outta me because a lot of the time I'm one of those random contractors working on different chemical, refining or geothermal plants. Every time I arrive at a new plant in the back my mind is always the thought I hope I don't end up in one of these videos.
@mobius273 me personally no never. I know what I'm doing, that being said I can only guess for every other contractor working at on site that day. You never know, people sometimes make mistakes unknowingly.
This truck driver and former steel manufacturing/overhead crane operator loves these videos. Seen so many so called “safety videos” in my years. But safety officers should have workers watch THESE videos. They’re great reminders to keep your focus where it belongs in every day situations.
I work in a chemical laboratory and this channel has definitely helped me strongly internalize a culture of safety and danger prevention while I'm at work.
I'm a big fan of good "error culture". Errors happen, and we have to fix the processes and systems to reduce the likelihood of them occurring. I think it's fascinating how these CSB videos rarely, If ever, blame the workers for the accidents. It's very similar to the investigations and recommendations after an aviation mishap. Don't blame the person. Blame and fix the system that allowed the person to commit an error. Thankfully, even the medical sector is finally starting to improve their error culture.
I tried to push this approach through as much as I could in my previous manufacturing job while on the safety committee. Even beyond that, when approached by management to isolate quality issues (since I was often the most knowledgeable of our entire production chain in my dept), I always made sure my answers indicated policy & procedure problems, so long as there was no evidence procedures had not been followed. Most of my direct managers must have appreciated that, because they kept coming back to me for advice/direction on quality/safety investigations. I think it's always important approach problems that way.
I wish this sort of thinking would get applied to car accidents. It's always about liability and incompetence instead of road design, vehicle safety requirements and licensing
That's the key! When writing policy and procedures to be done by thousands of people over millions of collective work years, you have to account for human error. Its guaranteed to happen. Levels of redundancy, thinking past stage one, and never being in a position where any worker is ever one mistake away from injury. When I was a young guy learning to fly, the instructor gave me a piece of flying advice that I apply in many places in my life. "Always be at least 2 mistakes from the ground".
if you blame individual people, especially people who have died, there is no recommendation to be made. it's saying everything can just keep going as normal because all of the problems have been purged. this is the only possible way.
This is some of the best and most informative content on CZcams. Not only with a consistent base level of quality, but a consistently increasing level of animation quality with each subsequent release. The videos are thorough, clearly understandable, and very informative. A lot of big name productions could learn a thing or two from the USCSB, and not just about safety.
I was working down the road when this happened. The amount of first responders that responded was insane. I also done turnarounds in this unit a year prior
I always feel weird when I see a new video notification from USCSB. I'm excited and happy because the work you folks do is fascinating and critical but I also feel bad for being happy because, for USCSB to make a video, there had to be an accident and people may have been hurt or killed. I guess I'm mostly glad that you do the work you do to share the lessons you learn and help make the world safer for all of us. Not all heroes wear capes.
The animations keep getting better and better! I love the work you guys do. As an HSE technician, I love showing your videos for my Confined Space Entry Procedures classes as they’re always so helpful and informative. Thank you!
I think it should be a feature of the actuator assembly. At my plant we always have a manual valve in line with any automatic valve on process fluid piping.
Could you maybe enlighten us why in this case there might have been a need to remove the actuator at all? Can't one just tell the actuator to close the valve?
@@maoiljitschguevara It is probably ironically for safety purposes. If you remove the actuator, it can't accidentally open the valve. So once the valve is closed, it stays closed while they are working on it.
Thank you CSB for your work on detailing and providing insanely clear and concise information in a entertaining and purely informational stance. Your videos over all these years are amazing- and no matter who you are or what you do there's always room for learning.
I have no chemistry or industrial background and do not plan to be employed in those fields, but these videos still are so informative and fascinating to watch and learn from.
Fantastic Production from the team that made this video and Fantastic work to the teams that did the detective work and problem solving to try to prevent this plug valve failure in the future. Shame to hear people were lost.
It's similar to what destroyed Piper Alpha. Maintenance workers removed a pump for servicing but the paperwork was not seen by the next shift. The workers started the pump not knowing it was down for maintenance. The maintenance crew had only put a temporary seal on the pump so it leaked and the whole rig went up.
That's a LOTO issue. This is workers without relevant training or knowledge messing up a task that's routine and low risk when a qualified worker is performing it.
IIRC, half the issue with Piper Alpha was that the idiots on the rig next door refused to stop pumping gas to the flaming rib because "no one told them to stop"
@@MandolinMagi As I understand they were afraid getting fired because they did not had the authority from their greedy bosses to stop pumping as it as usual would cost a lot of money in downtime even they could clearly see the rig was on fire. Money goes way ahead of lives in the buisness world! Its tragic!
Before I started following chemistry, it had never occurred to me that acetic acid could be dangerous - after all, it's in vinegar, and we use that all the time. But, of course, if it's concentrated enough, acetic acid could absolutely be dangerous.
When using certain silicone sealants, the odor is described as 'acetic acid'. Having used it, the fumes do have an intense burning sour smell when inhaled and is considered toxic in accumulated amounts.
And according to the report at www.csb.gov/lyondellbasell-la-porte-fatal-chemical-release-/ , it was at 238 °F. (!) (There was also water and methyl iodide in the mix, but those would have vaporized at that temperature and standard pressure.)
It's worth pointing out that concentrated acetic acid is also flammable, which is obviously not a property of vinegar. It's tempting to compare chemicals to the common products in which we encounter them, but the pure stuff needs to be considered in its own proper context. 10 % (vinegar) and concentrated (glacial) acetic acid have different safety data sheets for a reason!
Chemistry is interesting indeed. A block of sodium is so reactive, it will exothermically break apart water, possibly leading to a hydrogen fire/explosion. Chlorine gas is so reactive, it will kill you if inhaled, and may do so with enough skin contact. Put the two together, and it's one of the more crucial components of our bodies, one we can't live without.
I saw a new USCSB video and exclaimed, "Woo-Hoo! USCSB has a new video!" Then, "I love safety videos... why do I love safety videos? I hope the narrator is the same!" I am an electrician and physical plant mechanic for a civilian government agency, and I'm currently in training this month for my HVAC license. Chemical safety in the lab there is a big deal due to the risk of asphyxiation, frostbite and cold burns, and things that could cause catastrophic failure if done wrong. Thanks, USCSB, for making bangers of safety videos that are compelling and focused on preventing injury and loss of life in the workplace.
These are so incredibly well put together every time i am blown away. Fantastic, educational stuff. Really phenomenol and very cool to make it publically available to help raise public awareness regarding chemical and workplace safety!
I really appreciate the excellent narration in these videos. The gentleman's tone, cadence and precise diction are absolutely perfect for this kind of informational content. Fine work CSB, my condolences to the families of the deceased. Stay safe everyone.
Im an engineer in training that responsible for procedure documentation by communicating with operator. This video motivate me to do the work correctly and make sure things. Thank you
Me and all the USCSB subscriber homies are once again here to learn about workplace safety. As always, the USCSB team has put together an excellent video for us!
USCSB, your videos are ABSOLUTELY INCREDIBLE in detail. Huge kudos to everyone involved; especially the 3D designers and animators. Wow!!! 🔥Thank you for the great knowledge. I was impressed with past videos and didn't think your videos would get any better, but boy have I been proven wrong. Amazing work!
An essential service flies again - even with training in Occupational Health and Safety, and Workplace Hazardous Materials, CSB videos give me a whole new respect for the things that can, will, and do go wrong with chemicals and industrial process.
This is a scary one because I have started disassembling vales myself that I didn't have manuals for myself, albeit on air or hydraulic systems that can't usually kill you. These poor contractors where in a situation where I'm sure they thought their mechanical knowledge could overcome the lack of a valve removal procedure. We can all learn alot of lessons about making sure you know the entire process before starting and not being afraid to stop if there's inadequate materials. RIP to these workers.
These videos are a great source of very useful information. Excellent job. Disassembling an actuator on a plug valve, or any valve, pipe, component, without fully understanding the systems and components is a sign of an untrained workforce.
Definitely wouldn't be a pipefitter doing that job here in Canada, pneumatic actuators and their valves are firmly within the scope of instrument techs.
@@RoamingAdhocrat I'm fairly certain it's on the list - If I remember right they tried to get rid of it during the last administration and they survived by the skin of their teeth.
@@RoamingAdhocratthe fact that congress can’t even get an actual list of all the “agencies” and it’s at 400+ tells me there’s a problem. And I work for the Feds too.(but we are one of the largest non DoD agencies though)
Such a simple thing I can understand why they didnt think all those steps would be necessary. Thank you for taking the time to create these videos. You learn so much more than from just a paper.
It's ridiculous that you would have to remove the actuator on the valve in the first place to close and lock it out. You should be able to close the valve and then deenergize the actuator.
Coming from oil and gas, it's pretty alarming to me that these people were working on a non "blocked-in" valve on the bottom of a full vessel. When possible, it's typical to install control and isolation valves with options to either blind off or manually isolate with secondary valves to make maintenance tasks safe and efficient. This is a failure on the design side first and foremost.
We gather again for the semi annual USCSB subscriber conference
We are all not even remotely in contact with the chemical industry either
@cseblivestreaming hey, who said a government agency cant make superb media for consumption
Honestly i think more government agencies did stuff like this
It's wonderful to see you brethren!
Here.
“Secretary cancel my next meeting, something came up”
Thiojoe what are you doing here?!
Haha I just did the exact same thing! (Just in my brain as I don’t have a real secretary). Everything goes on pause when a USCSB video is released!
hahahahha was just thinking this myself!!
Find you in the strangest places dude.
@@jacob_90s I dunno, safety is safety.
The evolution of USCSB CZcams videos over the past 17 years is like watching the evolution of computer graphics
so much effort and time gets put into these animations. check out the bump mapping at 1:30. actually idk if it IS bump mapping, might be just entirely modeled and self-shadowed? gosh!
@@StarHordernot just that, it's raytraced baby!
Wow... Shocking to read of this. I was the operating engineer in that plant up into the late 90's when it was Quantum Chemical and before Lyondell bought it. I have had my hand on that valve. It was a zirconium cast valve and the whole time I was there, we did everything imaginable to NOT touch that one or the one next to it also zirconium.
They are right, the plug valves used are a quite old and standard design, although cast of a new and amazing material. As the video played out, I saw the animated guy reach behind the actuator assembly. They got it right that there are studs holding that plug cover plate to the valve body. Those should have never been touched. I have seen that actuator removed in a previous plant outage. It has been sticking to that shaft every time. It has corrosion on the shaft from a tiny amount of leakage through the top shaft seal for years.
But all would have been fine had they not touched those 6 stud bolts holding that cap down.
For the undergrad below that is trying to learn what these valves (and really most all common valves in use) Try to find a Crane valve book from ancient times.... about the year I was born. Ebay has been my source. I have 4 excellent copies of the 1953 version on my shelf at the moment and one 1960 version. I have given away 7 or 8 of these to some very worthy engineers in the years to guys I thought would use them. Had these guys had one, there are cutaway photos of these and almost all common valves you will come across. Mine are not for sale, as I have at least 2 earmarked for a couple of really good engineers that need them. But the USCSB is right, these valves could be made to be less likely to be opened by accident here.
Yes, dying from the reactor contents here would be a particularly bad way to go. Vile stuff in that reactor, along with a LOT of dissolved carbon monoxide in pure form.
Do you think it's possible that the workers had experience with *installing* other actuator designs where the actuator has a mounting plate that is captured by the valve cover bolts? it wouldn't be a correct procedure to remove the valve cover to remove those actuators either, but someone could just think they were supposed to reverse the install procedure.
Why does the actuator have to be removed to ensure the valve stays shut, isn't there a setting for it to keep the valve shut without removal?
@@gmaxwell Yes, when I was there, this was a top critical part and ONLY a designated supervisor and his best two mechanics were allowed to touch it. And we avoided touching it at any opportunity.
Unfortunately, in todays world of cheapest labor standards, it will be obvious to the experienced plant people that these guys had no idea how that valve was assembled.
@@Jonnyg325 The rule is set up to prevent just this occurrence. It is reoffered to as a "lock out tag out procedure." It takes the whole complex manager to get this rule modified or changed. We looked at this valve to modify it for a locking pin to be added so it could be mechanically prevented from rotating. It was deemed to be impractical due to the Zirconium material. The primary shaft would need to be drilled and a pin made with stops so it would not be able to turn. But zirconium being drilled, was possible ( though highly unlikely) to get hot enough to catch on fire itself. So it was abandoned. My input was that this valve requires so much torque to open and close that we were worried that if someone re-connected the pneumatic air to it even if with a utility hose, the unsuspecting mechanic would likely have enough force to break the pin and activate the valve. It is a difficult thing with plug valves. people struggle with this in many places.
The way I dealt with it while there is put in a rule with the supervisors in the plant, that either a supervisor or myself would be standing on deck with this valve if anyone was going to work around it. Many of the mechanics are not intimately familiar with the inner workings of these valves. Only ever had 2 shutdowns while I was there and one did not require this valve to be touched. The other one, we simply removed the orange actuator (it was actually orange in real life in the field) and as always found the coupling to be jammed on. We finally freed it up and got it off, but with at least a full shift trying to make it release. Several times we needed to remind the mechanics NOT to touch any of the 6 bolts holding that cover on.
@@Jonnyg325 The only "Setting" is the removal of the actuator air supply. However the "rules of lock out - tag out" do not allow this method of making certain the valve would not rotate. Seems obvious that it would not move , but the rules push for mechanical stops to be in place to prevent rotation of that shaft. Seems a bit much, but remember those 3 guys up there almost certainly have with them a pipe wrench. That alone would turn the valve to the open position. I understand it would be stupid to do that. But pulling not one but SIX cap bolts is what actually killed them.
The duality of man.
A new USCSB video dropped: 😄
A new USCSB video dropped: 😞
kinda sad if one drops because someone was hurt or killed sometimes
or before watching vs after watching
@@soft-confWell, you always know before that something serious enough has happened that they saw the necessity to make a video...
It could be worse. We could be in 2018 after Trump defunded them, with people having lost their lives with no lessons learned as even more protections and regulations are being ripped away.
This is too real for me
I unironically cant wait to learn more about workplace industrial safety
same lmfao
Agreed
You have been touched by the blessed hand🫵🥺🥹🥺🥹🥺🥹🥺🥹🥺🥹🥺🥹🥺🥹🥺🥹🫵
lmfao you wouldn't none of these companies care until an accident happens and then they care for a few months then forget about it
They honestly have the best animations hahah. ive binged all of the XD
I am a firefighter and these videos are what played a key role in encouraging me to be a firefighter. So many tragedies that are oh so preventable. CSB you do a great job! Keep up the good work and continue to keep workers safe.
They say every "accident" are preventable. I've argued ad nauseum with "teachers" that not all accidents are 100% preventable. It seems "educated" people are taught that nothing happens randomly. I do agree most accidents I've seen are typically preventable (I work in oilfield on rigs) I've seen some wicked incidents but it's annoying to have some person whose never worked a day in their life tell you something elwas preventable, "yeah that catastrophic failure of a brand new rope wire that dropped 95,000lbs was 100% preventable and your fault".. ahh yes thee old "you should have inspected it and noticed it was going to fail" method of avoiding a lawsuit and trying to blame the employees instead of taking responsibility for your purchase of Chinese shit that almost killed 3 people exscuse. Those people got mad when I said "if I was that good at being a psychic I sure as fuck wouldn't be working on rigs". I think "safety" is looked at the wrong way, instead of pointing fingers and blaming the individual, saying their at fault, safety should be looked at from the perspective of teaching people how to recognize risk and how to situate themselves in better positions to avoid injury.
If you like "safety" lessons learned videos there's a channel called "Brick Immortar" that does a lot of maritime accidents but also some other stuff that's extremely well put together and gives you the facts and how they could have reacted differently to avoid situations when available, and what people did right. Very interesting channel if you're into this type of "safety" content
respect to you sir
@@jlo7770a corp's own safety agency is like hr, ultimately a tool to protect the corporate entity from risk (no matter how well intentioned any inspector might be, the incentive is baked into the structure). that is where a govt agency should come in, literally "the people" making it so the corp isn't grading their own homework. but the way business is prioritized the govt only acts after lives were lost. idk what the solution is but these sorts of accidents shouldnt be happening as often as they do. a buddy of mine is a union electrician and what he tells me about the work and safety culture sounds right, even tho there are still questionable occurrences (chemicals being places they shouldnt be, only recognized after exposure). the real bottom line is that people's lives arent replaceable, but to the economy they are a resource like any other. stay safe✌️
Amen @@jlo7770
Acetic acid, what makes vinegar.
We use 5% for food, canning, and cleaning.
It smells and tastes bad enough.
I can’t imagine being doused in 100% strength of this stuff.
And HOT to boot.
I've worked with glacial acetic acid and acetic anhydride - the strongest "chip shop" vinegar smell ever! As a brit it just makes me crave chips.
Yeh u was going to say I hate the smell of of vinegar at 2-3% I can't imagine what that would smell like even from 1000's of feet away
I've experienced a plug valve replacement where there was about a gallon of this ac in the line left over from clearance and it was warm, not hot, and that was uncomfortable and I was about 3 feet away from it. Bro who lived must be or is counting his days... Hope he lives a long productive life.... Preferably in an office with a settlement under his belt and a work shop in his garage.
I got a sniff of the 100% stuff in a lab once, it was awful. I couldn't smell anything else for an hour
"How AMERICAN do you want your CG intro bro?"
Yes!
ah yes, the red-tailed hawk. our national bird.
@@voyagerwitch inb4 Americans realise their national bird actually sounds like a seagull
“…Hella.”
I love the new intro.
Babe wake up! The USCSB just uploaded!
and an eagle is screaming in your face!
@@RoamingAdhocratAnd it’s screaming, “AMERICA.”
the new intro is cool
You sure your babe is in your room? 😂
She is with me.
@@batman_2004 Jokes on you I’m single
There's something about this narrator's voice that just LOCKS IN my attention every time. Outstanding video. Condolences to the workers and their families
his name is Sheldon Smith. he's a voice actor, and i totally agree...i could listen to him read a damn grocery list and be totally captivated.
@@BayAreaMotorcycleCommuting He's been their narrator for years. I know he did their Texas City BP video.
He's as good as the Forensic Files guy!
@@zyenathalous I just looked at his LinkedIn page and he has a Secret Clearance! That means there are probably, like CIA mishap training videos that he narrates or something...
Very touching tribute to the victims at the end. It was a painful reminder that this wasn't just some unintended industrial process error. These were people, human beings like you or I who, we must accept, would in all likelihood still be with us were it not for a culture of being comfortable with unassessed risk. Requiescat in pace. The CSB's total, unwaivering commitment to ascertaining the true root causes of significant industrial accidents, and to providing industry experts and leaders with recommendations to try to avoid a similar situation from occurring ever again, are both superlatively laudable qualities. It is an example of our government working very well, and I am pleased to support the endeavors of the USCSB as a taxpaying citizen of the United States. Thank you for this video, although I regret the circumstances of its existence.
I can't count how many times I've heard "it's just vinegar, it's never killed anyone" from people working with concentrated acetic acid. Even I'm guilty of being a little complacent around acetic acid compared to other reagents. Thank you, USCSB, for bringing awareness to less "fiery" but still potentially lethal hazards.
Exactly! Acetic acid is no joke.
I've only worked in small-scale research labs, and I started the video wondering how exactly someone died from getting acetic acid on them. Even concentrated, it's not a "strong" acid, right? And then I see it's > 100,000lbs of heated acetic acid escaping at very high pressure, directed AT the workers in question. The third guy somehow surviving with serious injuries now seems more surprising.
@@freddiepowell8524boiling vinegar at that pressure? Bad news!
GAA is wildly not at all just "vinegar" but people do act like that it isnt a hazardous chemical all the time for some reason. Maybe we should call it ethanoic acid more often so people think it sounds scary again.
In Cambodia, they filled rooms with people and ignited Freon!
I have learned a few things from these videos
1) Don't work or live near a chemical plant.
2) Dont get inside confined spaces.
3) Alarms and warnings need to be carefully selected and implemented to prevent people ignoring them.
4) Greed is usually the fundamental culprit.
no the answer is you should do your maintenance on your own equipement but no you let compagny wash their hand and give it to subcontractors ... th many time it happened in the past the compagny was in fault so they had to pay for their mistake but with subcontractors they pay for the spill ... 100% uscb fault even more if people died there before you gave them the ok to continue this countrywide....
5) Non-union work is shoddy and will lead to rushed deadlines, injuries, and fatalities.
Also, train your people on every facet of maintaining all your equipment. This happened because the workers weren't properly trained.
Replace "chemical plants" and "confined spaces" with "Texas".
What makes this even more tragic is the acutator was being removed to allow for valve lockout. These workers were killed/injured performing a job that was intended to make another job safer. The risk assessment of repairing the leak was properly done, but the risk assesment of the task needed to complete the required work for that leak repair was lacking. The same as an electrician getting blown up by an arc flash while racking out a disconnect to de-energize something for repair.
What makes it even worse is that the valve actuator did not have to be removed in the first place. Usually, only the power supply to the actuator is interrupted when it is closed, so that it cannot be operated.
@benjaminhampel8640 In my Canadian refinery, we don't even rely on actuated valves for lock out. There's always a manual block valve close by, especially in a location shown in the video, being at the bottom of a vessel.
@@TLarose. Of course, if there is an additional manual valve, then you should use it, I agree with you. Apparently it wasn't there in this case.
@@TLarose. There is a video in uscsb that a fatal accident caused by a manual valve, it's very similar to this case. Things need to be foolprof, i worked as a maintenance tecnician in industrial factory, a lot of machinery we only used our thouth to demount and repair things, even the f engeneer didn't know how to do those things...
@@benjaminhampel8640 would that work if the valve was air-to-close though? But I guess the absence of a manual valve there was really alarming, with all the static head of inventory up there. Control valves shouldn't be used for isolation purposes
The USCSB has done the impossible; make safety videos that we truly WANT to watch!
@@Jason_Hubred When it comes to recreation of the environment the 3D-work is impeccable. Yes, the humanoid movements are a bit awkward and stiff, but everything else is exactly as it should be for clarity. uwu
I love how this channel started as a basic overview of incidents and accidents for companies to review and make sure it doesn’t repeat. To “this is very interesting, everything is well detailed and the animation is satisfying to watch”.
Same reason I loved watching Air Crash Investigation as a kid
@@hayleyxyzyou should check out Mentor pilot and Green Dot Aviation! Mentor Pilot has great visuals and detailed technical explanations, Green Dot Aviation has good visuals and sometimes even puts sounds like the alarm and voices in
Video Budget: $500,000
They aren't accidents unless you drop glass expecting it not to shatter and call that an accident
@@Xinthoseworker salary: 12,000
The quality animations and soothing narrator makes these fun to watch. But god damn, death by acetic acid is a horrible way to go
And it was a recurrent thing!!!
Pickled alive. Absolutely terrible.
Why are we allowing this dangerous substance to be added to our food??
@@Jump-n-smash...vinegar is dilute acetic acid lmao
@@Jump-n-smash Wait till you learn about the substance dihydrogen monoxide. ☠
The sheer amount of effort that goes into designing and animating these videos is phenomenal. Every nut, bolt, girder and pipe has to be designed and placed correctly... and then there's the textures, lighting and camera angles. Whoever is funding these videos has deep pockets! I love it! 🤩
They’re federally funded. They get almost $15 million per year.
One of the workers explained his reasoning for removing the pressure-retaining nuts. He told the CSB they had to
remove the interior fasteners because “…it’s all connected. As [the actuator] sits up there, it’s all connected to one another.” This
worker did not seem to understand that the interior fasteners were pressure-retaining and should not have been removed.
If it was really necessary to remove the pressure retaining screws to remove the actuator, which I doubt, then the actuator should not have been removed under any circumstances. But that would not have been necessary to secure the valve so that it would not be opened accidentally. Usually you disconnect the power supply to the actuator when it is closed to prevent it from being opened accidentally.
@@benjaminhampel8640 Correct. And as such while I was there, that was the rule. Don't touch that valve. The only time it was, was after the reactor was emptied and depressured and made full of air to be entered. ONLY 1 time as I remember.
@@lpconserv6074 how did you know that? oh, did someone teach you that? well, that expertise costs money and time. and i can just hire people and yell at them to get it done. whatever. insurance will pay. stonks must go up.
@@chillDude_chills If you can find a book, Crane Valves, from 1953, It is 580 pages deep. Learned about it by accident, but at the moment I have 4 of them plus a 1960 version in my office. It shows a cut away of almost every valve you will come across. More than once, I looked up this exact valve prior to our maintenance outages. Granted it was about 10 to 20 years prior to this accident, and the plant was my responsibility to keep running and when down, to keep it safe. Before any serious internet was out there.
I was the first plant engineer with a computer on my desk, a ROCKET, mind you. FULL 286 power house. just to give a little context. Full transparency YES I am an old fart these days. But still get calls to Saudi, Bahrain, Malaysia and Singapore to assist in new plant startups. This time when I was there, we had dedicated maintenance guys, experienced typically with at least 5 or more years in the plant.
It’s wild that I’ve been watching this channel for over a decade, since I was in college. And I still watch every update. To this day, I point out when propane tanks are too close to a building
Now come they sell propane tanks at gas stations right outside ? They are as close to the building as you can get
@@JoeRogansForehead An installed propane tank, not the sort you buy for grills. I live in the country, so there are a lot of propane tanks installed outside houses out here.
Same
Then this channel is doing its job
Which incident was that from?
Thank you, USCSB
Thank YoUSCSB
Also whoever animates these videos deserves a raise. The level of detail and realism for a workplace accident video is spectacular.
Here is my theory on why they removed those nuts: On *some* actuators (see page 20 of the report) the actuator is installed by putting a plate under those nuts. You still shouldn't remove them when removing the actuator, there are other nuts for doing that.... but if you had only ever *installed* new systems using that style plate you might think that the correct way to remove the actuator was to reverse the install procedure. This is also consistent with the worker's explanation for their actions.
my pupils audibly dilated when i got this notification
Audible? Like a camera aperture?
Bruh the people at USCSB must be entertained by our comments, shame they dont respond though
Yeah, same, after I just saw a CZcams short before this of some family that had a 4th of July firework malfunction that resulted in what is basically a dollar store airstrike 🙄
You should probably get that checked out...
HAHAHHAHhahahha
While I do not work for the chemical industry, these videos serve as a stark reminder to make sure you find procedures, follow them to the letter and ALWAYS be on the lookout for hazards. If there is a procedure or method in place, it usually was written because of incidents like this.
The scary part is, they did follow procedure. New procedures are being written directly because of this.
2:39 According to the video, there wasn’t a procedure on how to remove the actuator.
i would bet good money no one on that crew spoke english
Even office jo8s need to pay attention to safety. For example, carpal tunnel syndrome, or 8ack injury from improperly lifting a 8ox of paper alone.
its a common saying i hear whenever i learn about safety practices in industry. "all safety procedures and rules are written in blood" and its true, most if not all rules and regulations came into being BECAUSE of disasters and accidents resulting in injury or death.
Never in my life did I think i'd find myself dropping anything to watch a video from a youtube channel called the "United States Chemical Safety Board" but this channel always smacks. Well done.
These videos are the catalyst behind me deciding to enter into the safety field with a bachelor's degree and I decided to continue to get my masters.
I appreciate these videos and the quality is only getting better and better.
Thank you USCSB. As a chemical engineering undergraduate student, these videos help me understand how to be safe in my future career and how to prevent injury to myself and others.
1. Never hose cowworkers down with acetic acid
2. HF leaks are fun for everyone, with two capital letters.
Make sure you learn about PHA’s and HAZOP’s and get into the routine of having them done on any of your processes. It’s important to find a knowledgeable facilitator and even more important to not work for any company unwilling to do this as part of their design review process. I’ve managed many complex chemical projects and always insist on a safety representative being assigned to my project team.
no1. there is always time to be safer. never let schedules pressure you.
Be careful of those presure-retaining screws. Don't unscrew them!
Sheldon Smith delivers yet once again.
Best narrator in the universe
His voice sounds a little more strained in this video though. I hope he's alright.
@@lackedpuppet9022 he's been doing this since at least 1986. I'd expect he will be retiring at some point soon.
@@JKH079 I knew he was late in his career. It'll be sad to see somebody of his stature with such significant talent go.
When Sheldon retires, they should get Bill Kurtis to do the narrations!
Im not even in America, and yet I still watch these
Workplace safety applies no matter where you are.
It will never cease to amaze me that videos made by a government body-- for the sake of depicting a bureaucratic issue-- are more interesting than half the other things on CZcams.
I don't know if these are mandated to be posted publicly, and youtube was chosen-- or if the ad revenue is the motivator. Either way, I'm thankful they're posted. So much knowledge on display.
Safety is the motivation for publication. The goal is to prevent future accidents. It's the whole point of the UCSB. CZcams is chosen because it's free and popular. They're not trying to make money, they're trying to save lives.
Perceived simplicity of the work.....Just goes to show you that complacency is something that must be guarded against.
This is probably the most polished video out of them all. Thanks for honoring those that perished at the end. Sadly regulations are written in blood.
Airline industry did it, no one will because it costs too much. They pretend
I honestly can't believe that any pipe fitter would do something like this. They are trained to work with this stuff. Very sad. I personally wouldn't have ever thought a procedure would be needed for such a simple task. Just goes to show how you can't trust anyone.
also they are contracting out work instead of training people to work and be on call is cringe. better to have someone who knows the system and its hazards then to get some randome company to ape your shit up
@crissd8283 the video literally said they weren't trained to remove the actuator....
@@Generic_Name_1-1 Any pipe fitter worth their salt would think twice what fastners to loosen, especially on a pressurized system, tripley so when hazadous chemicals are involved.
And what about some basic PPE like bunny suits and a full face splash mask.
The best damn 3D animations our federal government can provide
The tire moving on the truck were not in the budget. But Im not complaining - new video!
@@gaveintothedarkness Every time they showed it I was just thinking "is is backing up or is this just a slow pan??"
It's a slow pan. The refinery in the background is moving when the camera slowly pans so that's why I believe it was a slow pan of a parked truck. There's no way they forgot to animate the wheels it has to be intentional..
I think it was a year ago, when i stumbled on a video named delta p, i thought it was just a dumb meme but watched 20 minutes of the danger between different pressures and how you can get stuck. This lead to a 2 day lasting binge watch of every work safety related videos CZcams had to offer.
I belive ucsb deserves more funding for this quality and informative work, that narrator, animation, and script writing are perfect.
because of this cchannel I know so so much more about hazards, and stopped my boss from probably dying from hydrogen sulfide exposure from overcharging a huge bank of semi truck batteries, I know what the dangerous smell is from watching one of these videos and going on a Google rabbithole.
thank you, only branch of the government I respect!
This content is just so amazingly well done. From the script to the animation. Love it.
Concise and useful.
Can't wait til a CSB video features an industrial elevator misconfiguration and you're giving the grave intro at 0:44
Weird seeing you here. I’m used to watching your other videos. Small world.
🔑🛠
@@62Cristoforo oh heck yeah, nice to see you here, too 👋😁
@@Palabrota hahaha absolutely
Unexpected crossover of interests here.
Your animations keep getting better and better. Props to the animators
But the truck wheels don't rotate!
@@geoffreypiltz271 I noticed that too. I couldn't tell if the truck was "sliding" or if the camera was slowly rotating while panning. I was trying to use the background parallax for clues but I'm still not completely sure lol.
@geoffreypiltz271 the truck wasn't moving.
So wait, Turn 2 said they had a crew who was qualified to do the work and then provided a crew who had no training on the work they were supposed to do? Lying about the capabilities of their crew is a clear contributing factor if I've ever seen one.
When I lived in Texas I was shocked at how often people were derisive of safety training. They have a culture of complacency and I feel that was a contributor to this accident as well.
Yeah, and the rich company owners sleep well at night
Almost every outsourcing contractor company out there: (looks awkwardly away)
Bingo. This is a classic case of "The Audacity" killing again.
"Qualified to do the work" = has a pulse and a BAC less than .08
I've been retired two years, yet I still watch these whenever they come out. Better safety training than the formal training we had every quarter.
Management needs to stop trying to hide the design of components under the guise of "you don't need to know that, just follow procedure". Nobody should ever be expected to maintain equipment when they don't understand how it works.
They didn't even have a procedure. This was easily preventable.
New CSB video LETS GOO!!!!
I have never worked a job in chemical manufacturing l in my entire life. I could not tell you the first thing about chemical engineering. I am glued to the screen when I watch these videos. I cannot overstate how awesome this channel is and the fact they've been doing it for over a decade now.
One of the best narrators anywhere. Period. Just as good as the narrator for PBS Front Line.
@@Jason_Hubredforensic files?
Probably one of the most preventable incidents covered by this channel. That said, condolences to the families of the two workers.
Slap some red paint on the bolts and this never has to happen again.
So preventable that it's basically a retread of "fire in baton rouge" video. Employees removed a gearbox from a valve and accidentally removed all the pressure-bearing bolts, leading to hydrocarbon release and explosion.
I guess that problem from before wasn't really fixed.
I don't work in industry, but I was shocked there was no written or other visual warning indicating what the bolts were. Would seem like an obvious thing to include.
This one is the stupidest we've seen
@@Motoko_Urashima Same nuts that hold the valve together were also asked to hold a flange that needed removal, thus forcing an unnecessary valve disassembly through force of bad design.
awww yes my favorite channel that scared the absolute shit outta me because a lot of the time I'm one of those random contractors working on different chemical, refining or geothermal plants. Every time I arrive at a new plant in the back my mind is always the thought I hope I don't end up in one of these videos.
that's probably ideal
Good policy to have. Here's to you never being the subject of one of these videos.
If you ever pull up to the site and hear "Worker 1 arrived on site at 7:56am", maybe call in sick for the rest of the day :D
Do they routinely make you do jobs you haven't been properly trained for?
@mobius273 me personally no never. I know what I'm doing, that being said I can only guess for every other contractor working at on site that day. You never know, people sometimes make mistakes unknowingly.
This truck driver and former steel manufacturing/overhead crane operator loves these videos. Seen so many so called “safety videos” in my years. But safety officers should have workers watch THESE videos. They’re great reminders to keep your focus where it belongs in every day situations.
I work in a chemical laboratory and this channel has definitely helped me strongly internalize a culture of safety and danger prevention while I'm at work.
When I see a notification saying USCSB, I know I'm in for a treat.
I'm a big fan of good "error culture". Errors happen, and we have to fix the processes and systems to reduce the likelihood of them occurring.
I think it's fascinating how these CSB videos rarely, If ever, blame the workers for the accidents. It's very similar to the investigations and recommendations after an aviation mishap. Don't blame the person. Blame and fix the system that allowed the person to commit an error.
Thankfully, even the medical sector is finally starting to improve their error culture.
I tried to push this approach through as much as I could in my previous manufacturing job while on the safety committee. Even beyond that, when approached by management to isolate quality issues (since I was often the most knowledgeable of our entire production chain in my dept), I always made sure my answers indicated policy & procedure problems, so long as there was no evidence procedures had not been followed.
Most of my direct managers must have appreciated that, because they kept coming back to me for advice/direction on quality/safety investigations. I think it's always important approach problems that way.
I wish this sort of thinking would get applied to car accidents. It's always about liability and incompetence instead of road design, vehicle safety requirements and licensing
That's the key!
When writing policy and procedures to be done by thousands of people over millions of collective work years, you have to account for human error. Its guaranteed to happen. Levels of redundancy, thinking past stage one, and never being in a position where any worker is ever one mistake away from injury.
When I was a young guy learning to fly, the instructor gave me a piece of flying advice that I apply in many places in my life. "Always be at least 2 mistakes from the ground".
if you blame individual people, especially people who have died, there is no recommendation to be made. it's saying everything can just keep going as normal because all of the problems have been purged. this is the only possible way.
Sadly, the federal court here in Switzerland allowed access to the medical Critical Incident Reporting System for law enforcement.
This is some of the best and most informative content on CZcams. Not only with a consistent base level of quality, but a consistently increasing level of animation quality with each subsequent release. The videos are thorough, clearly understandable, and very informative. A lot of big name productions could learn a thing or two from the USCSB, and not just about safety.
I was working down the road when this happened. The amount of first responders that responded was insane. I also done turnarounds in this unit a year prior
The in memoriam at the end is a nice touch.
I always feel weird when I see a new video notification from USCSB. I'm excited and happy because the work you folks do is fascinating and critical but I also feel bad for being happy because, for USCSB to make a video, there had to be an accident and people may have been hurt or killed. I guess I'm mostly glad that you do the work you do to share the lessons you learn and help make the world safer for all of us. Not all heroes wear capes.
The best video production yet. Thanks for honoring those men. We appreciate your reporting.
The animations keep getting better and better! I love the work you guys do. As an HSE technician, I love showing your videos for my Confined Space Entry Procedures classes as they’re always so helpful and informative. Thank you!
I think they missed one - design plug valves so that they do not need their actuators removed in order to lock them in the closed position.
I think it should be a feature of the actuator assembly.
At my plant we always have a manual valve in line with any automatic valve on process fluid piping.
Could you maybe enlighten us why in this case there might have been a need to remove the actuator at all? Can't one just tell the actuator to close the valve?
@@maoiljitschguevara It is probably ironically for safety purposes. If you remove the actuator, it can't accidentally open the valve. So once the valve is closed, it stays closed while they are working on it.
Or close and lock the air supply powering the actuator.
That eagle intro is awesome
The eagle intro is the best use of American tax dollars that I've ever seen. 10/10
I agree, in fact I’m now thinking we need to raise the defense budget post haste!
Oh the USA
Never change this aspect to you.
It’s hilarious.
Hopefully we are laughing with you on this
As a European I love it, when you Americans are unapologetically american.
what's funny is that's not what an eagle sounds like
Babe wake up, new USCSB video just dropped.
Thank you CSB for your work on detailing and providing insanely clear and concise information in a entertaining and purely informational stance. Your videos over all these years are amazing- and no matter who you are or what you do there's always room for learning.
I have no chemistry or industrial background and do not plan to be employed in those fields, but these videos still are so informative and fascinating to watch and learn from.
Fantastic Production from the team that made this video and Fantastic work to the teams that did the detective work and problem solving to try to prevent this plug valve failure in the future. Shame to hear people were lost.
Thank you for all the care and effort you put into these videos.
No clue how I ended up watching these videos, but it's been years and I still get excited when a new USCSB video comes out!
It's similar to what destroyed Piper Alpha. Maintenance workers removed a pump for servicing but the paperwork was not seen by the next shift. The workers started the pump not knowing it was down for maintenance. The maintenance crew had only put a temporary seal on the pump so it leaked and the whole rig went up.
That's a LOTO issue. This is workers without relevant training or knowledge messing up a task that's routine and low risk when a qualified worker is performing it.
IIRC, half the issue with Piper Alpha was that the idiots on the rig next door refused to stop pumping gas to the flaming rib because "no one told them to stop"
@@MandolinMagi I hadn't heard that but it makes sense considering the company.
@@MandolinMagi As I understand they were afraid getting fired because they did not had the authority from their greedy bosses to stop pumping as it as usual would cost a lot of money in downtime even they could clearly see the rig was on fire. Money goes way ahead of lives in the buisness world! Its tragic!
Before I started following chemistry, it had never occurred to me that acetic acid could be dangerous - after all, it's in vinegar, and we use that all the time. But, of course, if it's concentrated enough, acetic acid could absolutely be dangerous.
When using certain silicone sealants, the odor is described as 'acetic acid'. Having used it, the fumes do have an intense burning sour smell when inhaled and is considered toxic in accumulated amounts.
And according to the report at www.csb.gov/lyondellbasell-la-porte-fatal-chemical-release-/ , it was at 238 °F. (!) (There was also water and methyl iodide in the mix, but those would have vaporized at that temperature and standard pressure.)
It's worth pointing out that concentrated acetic acid is also flammable, which is obviously not a property of vinegar. It's tempting to compare chemicals to the common products in which we encounter them, but the pure stuff needs to be considered in its own proper context. 10 % (vinegar) and concentrated (glacial) acetic acid have different safety data sheets for a reason!
Chemistry is interesting indeed.
A block of sodium is so reactive, it will exothermically break apart water, possibly leading to a hydrogen fire/explosion.
Chlorine gas is so reactive, it will kill you if inhaled, and may do so with enough skin contact.
Put the two together, and it's one of the more crucial components of our bodies, one we can't live without.
All chemicals are dangerous. Acetic acid can easily cause chemical burns, and acid vapors are hazardous.
I saw a new USCSB video and exclaimed, "Woo-Hoo! USCSB has a new video!" Then, "I love safety videos... why do I love safety videos? I hope the narrator is the same!"
I am an electrician and physical plant mechanic for a civilian government agency, and I'm currently in training this month for my HVAC license. Chemical safety in the lab there is a big deal due to the risk of asphyxiation, frostbite and cold burns, and things that could cause catastrophic failure if done wrong. Thanks, USCSB, for making bangers of safety videos that are compelling and focused on preventing injury and loss of life in the workplace.
Another great video. I don't work in industrial, but these videos show that safety isn't a number one priority.
The intro is becoming too powerful
Though if they want to be accurate they should use an actual bald eagle call.
It used to be comically M.U.R.I.C.A. They cut 90-95% of the original anniversary intro, which being a filthy foreigner I nearly died to.
Fun fact: the sound the bald eagle makes is not a bald eagle sound
*These USCSB videos are 10x better than anything coming out of Hollywood right now..*
These are so incredibly well put together every time i am blown away. Fantastic, educational stuff. Really phenomenol and very cool to make it publically available to help raise public awareness regarding chemical and workplace safety!
I really appreciate the excellent narration in these videos. The gentleman's tone, cadence and precise diction are absolutely perfect for this kind of informational content. Fine work CSB, my condolences to the families of the deceased. Stay safe everyone.
I see USCSB upload. I watch immediately.
Its like watching the old history channel stuff, where you actually learn something.
I miss those days so much... I frequently think about how much I miss the old History and Discovery channel.
Im an engineer in training that responsible for procedure documentation by communicating with operator. This video motivate me to do the work correctly and make sure things. Thank you
Hope your job is in your native tongue, because your English is a long way from "procedure documentation" quality.
Me and all the USCSB subscriber homies are once again here to learn about workplace safety. As always, the USCSB team has put together an excellent video for us!
USCSB, your videos are ABSOLUTELY INCREDIBLE in detail. Huge kudos to everyone involved; especially the 3D designers and animators. Wow!!! 🔥Thank you for the great knowledge. I was impressed with past videos and didn't think your videos would get any better, but boy have I been proven wrong. Amazing work!
An essential service flies again - even with training in Occupational Health and Safety, and Workplace Hazardous Materials, CSB videos give me a whole new respect for the things that can, will, and do go wrong with chemicals and industrial process.
These videos are so great. Such a gem.
My absolute favorite channel of all time. Great work guys.
First the new USCSB Intro goes hard! Anyone else notice the USCSB investigator's last name was Schrader, seems he specializes in valves..
😂
Must run in the family 😂
He was Presta'n to service as soon as the accident occurred.
This is a scary one because I have started disassembling vales myself that I didn't have manuals for myself, albeit on air or hydraulic systems that can't usually kill you. These poor contractors where in a situation where I'm sure they thought their mechanical knowledge could overcome the lack of a valve removal procedure. We can all learn alot of lessons about making sure you know the entire process before starting and not being afraid to stop if there's inadequate materials. RIP to these workers.
These videos are a great source of very useful information. Excellent job. Disassembling an actuator on a plug valve, or any valve, pipe, component, without fully understanding the systems and components is a sign of an untrained workforce.
Definitely wouldn't be a pipefitter doing that job here in Canada, pneumatic actuators and their valves are firmly within the scope of instrument techs.
My lord, why am I so unreasonably excited to immediately watch these?!
At the beggining i thought the guy was about to scream WTF is a kilometeeeer !
Though now SVG is doing us dirty this year and we've been getting WTF IS A MILEEEEE'd
How many pounds is that
Fun fact - the metric system is the official system of units and measurements for the US government. States just chose not to implement them.
I'm never more patriotic than when the USCSB posts and I hear that eagle cry.
what are the odds Project 2025 have the USCSB on their hitlist
@@RoamingAdhocrat I'm fairly certain it's on the list - If I remember right they tried to get rid of it during the last administration and they survived by the skin of their teeth.
I'm not even American and I still shed a single tear
@@RoamingAdhocrat considering the supreme court wants to go after OSHA, very likely.
@@RoamingAdhocratthe fact that congress can’t even get an actual list of all the “agencies” and it’s at 400+ tells me there’s a problem. And I work for the Feds too.(but we are one of the largest non DoD agencies though)
I should be asleep right now, and yet i find myself watching “CSB safety videos”.
It's so nice to see how CSB videos quality is improving with every upload. Keep it up !
USCSB when does the new merch drop? 🔥🔥🔥
Yessirrrr
i would unironically wear a uscsb shirt
Hey if USPS sell merch, I don't see why USCSB should do the same!
As soon as the merch is recovered from the chemical spill :*(
unironically I'd probably wear a USCSB hat with that eagle from the intro on it.
genuinely one of my favorite youtube channels thanks so much for providing these to the greater public outside of their intended one
the improvement in quality surprises me each time, this time its practically the same as real life, amazing work
your animations just keep getting better!
Such a simple thing I can understand why they didnt think all those steps would be necessary. Thank you for taking the time to create these videos. You learn so much more than from just a paper.
Wow, the 3d renders are even crisper. looks visually stunning!
so glad to have found my people equally excited to see yet another video after such a long hiatus.
These just keep getting better and better quality… amazing production
USCSB back with another banger video
Figuratively this time. Previous videos have been bigger bangers... ;w;
It's ridiculous that you would have to remove the actuator on the valve in the first place to close and lock it out. You should be able to close the valve and then deenergize the actuator.
It's always a joy when these are posted
Coming from oil and gas, it's pretty alarming to me that these people were working on a non "blocked-in" valve on the bottom of a full vessel. When possible, it's typical to install control and isolation valves with options to either blind off or manually isolate with secondary valves to make maintenance tasks safe and efficient. This is a failure on the design side first and foremost.