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.
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.
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
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...
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.
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 ?
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.
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.
@@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 TH-cam 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.
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
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,
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.
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.
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.
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.
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 ?
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.
"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"
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...
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.
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
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
The amount of commenters here that missed the part where ethylene oxide is used to sanitize a wide variety of medical devices makes me lose hope in humanity.
Yea, they're acting as if the gas permanently contaminates the equipment it touches and/or stays on it in dangerous concentrations. Any syringe you get pricked into you has so little of the stuff left on it that it probably can't even be measured anymore. Zero danger.
@@Irrenhaus3 Zero danger? That is exactly what doctors use to say about cigarettes. Population control is in full effect and I will pay 1k if someone can produce a healthy child whose parents were vaccinated!
@@r6racer53 So will you be paying in cash or check then? Because you're talking to a child of vaccinated parents right now. ;-) (Also I'm pretty sure it was tobacco lobbying groups who told you that cigarretes are harmless, not doctors. But I wouldn't know, I never smoked a single one in my life.)
"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.
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.
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.
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?
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.
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.
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
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.
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
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
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.
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.
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.
i assume they were damaged to some degree, since the original chamber walls are just bulge outwards, the forces may have been directed away from the other chambers so it may not be as bad as you think but that's just a random internet person 2 cents.
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.
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.
*THAT* was a terrible design flaw. Safety interlock to prevent opening the main door if internal air reads above LEL. And/or some kind of holding chamber for the gases to go instead of straight into the flame.
Sterigenics doesn't seem to have the best safety track record. I worked for a company that does electrical work in one of their facilities in Georgia and this facility had an explosion that threw a worker 30 feet across the room 3 years ago. Not only is the gas a carcinogen that harms the community but it's very explosive and leaks don't seem to be detected before accidents occur
Because even if you had a flame suppressor, if you're feeding in an explosive mixture, a catalytic system would have either melted instantly or popped the can and a fire almost certainly would have resulted anyway. The cat system is designed to oxidize ppm levels of EtO, not 5% levels in air. The supervisor was a reckless idiot, and the machine builder is criminally negligent to not have a gas level monitor inside the chamber.
another step not mentioned would be that there should be an esdv and online sampling of the gas flow from the unit to the oxidizer in the case that a malfunction of prior stages.
I think it's meant that the end goal or purpose of safety is to preserve life. What is safety for? For fun? For food? For money? For binge watching in the wee hours of the morning? No it's for life ya donut xD
*"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...
How can you not do hazard analysis for explosions when you have a chamber that vents a material that can oxidize its own combustion into a direct flame?
The safety poster in the control room is the best
6:33 the poster was saved
SDChick
Reading and spelling that hard for you?
That made me laugh
Instablaster...
Right?
After watching this video I am now more qualified to operate a sterilization facility than the supervisor who was operating the facility.
I wonder how CSB officials feel about people watching their videos for the sole purpose entertainment
💀
They don't give a f.
You are still learning something
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.
@@sophierobinson2738 Dude, what the fresh hell are you on about?
These are just as good as any Netflix series.
“Safety is for Life” poster survived the explosion 😂😂
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.
Roughly $12 million annual budget, and 47 staff. What do you think?
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
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.
Chernobyl was essentially that also.
"Then the worker opened a valve"
Not to mention, the supervisor giving his special password to the workers was probably a violation of company policy.
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...
The CSB was ahead of it's time! Using TH-cam 13 years ago as a (as far as I can tell) government agency.
I really enjoyed how thorough their investigation, findings, and recommendations were.
I love how there's still people watching and leaving comments here 13 years later
This is a great case study
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.
Reporting in!
@@kilbeam99 just make sure to use the logbook, in case a large blowdown drum backfills and explodes in your aria
not that I want more disasters, but I definitely want more USCSB videos
You say you want more disasters? We gotcha fam
OK, but only if those disasters teach me how to stay alive.
WorkSafeBC also looks like another interesting Channel it was recommended to me recently on my homepage.
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 ?
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.
@@timothylegg that’s the worst. Like really, the neighbors too. At least the employees understand they are taking SOME risk, but the neighbors?
I make ethylene oxide, and we have a tank with hundreds of thousands of gallons in it. If it blows, we’re blowing a 60 mile hole in the ground
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.
Amazing to see the video quality was just as excellent back in the 4:3 days.
If I go somewhere and hear a csb narrator in the background I'm running away!
Sounds good to me!
You know it's an old TH-cam video when the maximum quality is 240p and it looks like a VHS tape.
Pretty sure it was originally a tape
@@hziebicki Yes.
What's amazing is how good of quality 240p looks when it was shot with a 240p camera, vrs compressing a 1080p to 240p
@@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 TH-cam 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.
@@Ryan_Thompson thanks for the analysis, I appreciate it!
There is a difference between a technician and an engineer. This shows.
CSB is getting real tired of saying TRAIN YOUR WORKERS!
How the hell is their no gas monitoring system in the chamber? That’s almost unbelievable!
As the Soviets would say "It's cheaper"
CSB videos are magical
@Nicholas Olesen me too! I think we're honorary CSB inspectors when we finish them all
Wow the early seasons of CSB sure look primitive compared to the animations in 2020!
but it still get the points across perfectly
This made me seriously consider using reinforced window materials for my control facility.
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
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,
sensors go bad, having overrides is standard
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!
Good thing it was a false alarm or you'd just be a poorly animated worker dude in these horror training flims
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.
@@radsdad1 Holy mackerel, Then why are you required to wear badges or personal alarms?
@@Wa3ypx No badges or personal alarms were worn.
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.
6:34 it’s ironic that there’s a “safety is for life” poster in this damaged control room.
Safety means nothing to them. The APPEARANCE of safety means everything.
It's almost as if banal empty slogans don't actually fix anything.
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.
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.
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 ?
And Windows looking over a hazardous area.
Im facinated by failure analysis and seeing stuff blow up!
While a huge sign in the control room reads "Saftey is for life"
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.
6:33, poster on the wall: “Safety is for life”
A true hidden gem
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.
Including an open flame in a process that uses C2H4O or any potentially explosive material is simply asking for disaster.
"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"
Use the super secret password 🔑
Or just use nitrogen gas to do the initial flushes, and only introduce the oxidizer near the flames so the flashback has no oxygen to feed upon.?
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.
Dihydrogen oxide can be dangerous in large amounts too.
@@fallinginthed33p And don't forget it is laced with over 100 ppm of deuterium oxide...😉
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...
that's nice, i'm still not getting jabbed or tested. sugma.
@@johnsmith-sp6yl that’s fine, we all suffer the consequences for our own actions
Huge "Safety is Life" poster in the control room
another example that safety regulations are written in blood
Sterigenic is taking quite a beating these days, look up their facility in Willowbrook, IL and the National Air Toxics Assessment
A back burn preventer should have been present as well.
No redundancy.
Layers of protection
I’m surprised Plainly Difficult didn’t do a video on this. Then again the USCSB knocked it out of the park with this video.
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.
I learned a lot by reading CSB reports
This is crazy to me. This is like emptying a gasoline tank, ventilating it, then inspecting the inside with lighter. Why?
it would have been fine if it had actually been ventilated
"safety is life" on the wall in the control room... smh
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
Love the saftey is for life poster. Your killing me smallz 😂😂😂😂
Too good
Nah man. Safety is love. 😂
A rare video, with actual information and good ideas.
I replaced my facility's control windows with video cameras/monitors for this very reason. Glass kills!
But now you can't stand up there with your hands behind your back and judge the peons below with an intense glare.
You can't put on a price on that.
@@gantmj that just means he gets to sit in front of video feed screens menacingly with his fingertips touching like some villain mastermind
gantmj 😂😂😂😂😂😂😂😂😂
Josh Lyle yes... watching the workers labor like insects in a hive... unable to see beyond the nest...
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
I take it neither the supervisor of the employees involved took college chemistry. My jaw dropped when the supervisor approved this.
I have no reason to watch these so WHY am I binging all of them
Binge watching so i can fear
The amount of commenters here that missed the part where ethylene oxide is used to sanitize a wide variety of medical devices makes me lose hope in humanity.
Yea, they're acting as if the gas permanently contaminates the equipment it touches and/or stays on it in dangerous concentrations. Any syringe you get pricked into you has so little of the stuff left on it that it probably can't even be measured anymore. Zero danger.
@@Irrenhaus3 Zero danger? That is exactly what doctors use to say about cigarettes. Population control is in full effect and I will pay 1k if someone can produce a healthy child whose parents were vaccinated!
@@r6racer53 So will you be paying in cash or check then? Because you're talking to a child of vaccinated parents right now. ;-)
(Also I'm pretty sure it was tobacco lobbying groups who told you that cigarretes are harmless, not doctors. But I wouldn't know, I never smoked a single one in my life.)
@@r6racer53 Pay their child? Cuz that'd be me. I accept paypal, venmo and checks
@@r6racer53 where’s my money bro
"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).
nobody died. just injuries and damges
@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.
6:34 "Safety is for life" poster, LOOOLLL
Binge watching at 2am
I’m addicted to these vids
Same
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.
A simple flame arrestor b4 the thermal oxidizer would be nice...
Agreed
Special password: boom
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.
Company: *negligently skips on safety features for extra cash.*
CSB: *eyes glowing* It's free real-estate!
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?
Hospitals are phasing this stuff out for a reason. It’s dangerous and the sterile process takes forever
Imagine being the guy who said "hear goes nothin" before pushing the boom button
This is why government overwatch is important because the private industry will never follow the rules if they don't have to.
Mark Henderson the damage to the companies facility is probably higher than any profit they would have made by poor safety standards.
@@stevensonDonnie corporations will never do the right thing unless they're forced to.
Government can't even follow its own rules.
Because the goverment is so great isn't it? They never do anything wrong, right?
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.
Damn blew the 2 ton doors 75ft away?!
6:34 “Safety is for life” that’s rich
So let me get this straight - someone designed a container for an explosive carcinogen, then attached a catalytic component with OPEN FLAMES?
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.
Makes sense to me
@@REXXSEVEN - Even if they did, you know that inevitably some knucklehead would de-activate it.
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.
@JimDickenson: yea, I noticed that too. It was the first thing I thought of when watching the animation.
That's great! A supervisor unfamiliar with the dangerous system he's supervising ...
Wonder how much that decision saved on the bottom line
Not very much considering the plant was blown up........
About one day training on the specific of the substances they are using and the computer control system.
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.
Lemuel Haring I can think of lots of reasons why this is needed. This circumstance was definitely not one of them..
@@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.
Safety is for Life
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
Typical that they did the same job every freaking day without knowing what and why they did what they did
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.
@christianne1985 Actually that supervisor is clearly overqualified for president.
christianne1985
Wow. I hope your life is bigger than politics. Your comment had nothing at all to do with the video.
@@totallyfrozen life is politics.
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
They missed the point of gas washing.
They thought if there are no products inside then it s not necessary.
John Bresland knows how to throw one hellava disappointed look. You don't want any of that.
OK, but why not recommend a backfire protection in the oxidizer?
Probably because the oxidiser is a bad idea to begin with. Open flame near toxic gas.... nope.
Sounds like more training, gas monitoring and safety glass should be required from now on.
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
Password: 1234
Hahaha propably true
Password: Safety1!
Shh
U forget the 5
The control room windows were not shatter resistant. Have none of them seen the day after tomorrow the movie.
These videos just draw you in
A: why comments so new
b: it's always nice seeing a very old YT video
sorted by new first by default
6:33 "safety is for life"
🤔🙄😥😑
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.
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.
"Sterigenics"
Sounds about as corporate as it gets
“We-make-money-from-risky-chemical-reactions-igenics”
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.
i assume other adjacent chambers were also badly damaged by the shockwave from the blast?
i assume they were damaged to some degree, since the original chamber walls are just bulge outwards, the forces may have been directed away from the other chambers so it may not be as bad as you think but that's just a random internet person 2 cents.
Love the CSB videos but just not as good without the newer narrator.
True
The biggest doh of all is why there was no flame arrestor on the oxidizer
I never knew a flame arrestor was a thing. Interesting! Are they used commonly in industry?
@@bendoy4555 They are, sir. And they're made custom for each application.
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.
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 am loving these videos they are interesting af
This is my 5th .
*THAT* was a terrible design flaw.
Safety interlock to prevent opening the main door if internal air reads above LEL.
And/or some kind of holding chamber for the gases to go instead of straight into the flame.
You gotta understand what you are doing and why before you start taking shortcuts
You are right on Dawn...
Sterigenics doesn't seem to have the best safety track record. I worked for a company that does electrical work in one of their facilities in Georgia and this facility had an explosion that threw a worker 30 feet across the room 3 years ago. Not only is the gas a carcinogen that harms the community but it's very explosive and leaks don't seem to be detected before accidents occur
Why does the oxidizer not have a flame suppressor. Something like sheets of gauze for example in the airflow to prevent flame propagation ?
Because even if you had a flame suppressor, if you're feeding in an explosive mixture, a catalytic system would have either melted instantly or popped the can and a fire almost certainly would have resulted anyway. The cat system is designed to oxidize ppm levels of EtO, not 5% levels in air. The supervisor was a reckless idiot, and the machine builder is criminally negligent to not have a gas level monitor inside the chamber.
another step not mentioned would be that there should be an esdv and online sampling of the gas flow from the unit to the oxidizer in the case that a malfunction of prior stages.
or check valves
Yes, it is a bloody crazy design flaw if you ask me, it needs at least two flashback arrestors in the pipe.
If that doesn't give you concerns, idk what will. Lots of untrained careless people out there in charge of many hazardous materials.
First red flag. Explosive gas and open flames.
"Safety is for Life"
Yeah, but do you care how long the life is for?
I think it's meant that the end goal or purpose of safety is to preserve life.
What is safety for? For fun? For food? For money? For binge watching in the wee hours of the morning?
No it's for life ya donut xD
*"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...
How can you not do hazard analysis for explosions when you have a chamber that vents a material that can oxidize its own combustion into a direct flame?
Well... if you don't do it, you'll sleep better :)