CSB Safety Video: Vinyl Chloride Explosion and Fire

Explosion and Fire at Formosa Plastics Corporation, USA, Illiopolis, Illinois

[@Thenotfunnyperson]

I am sure that that person did not just figure out how to bypass the safety mechanism randomly that day. Probably had to be done before on functioning tanks.

[@CunderThunt87]

When i was a student operator we had an xv that would open to dump regen acid waste when tank level got too high. If the ph was too low, the interlocks wouldn't allow the valve to open. I was shown how to jump the xv to allow the regen waste to be transfered to a pond of sorts(or a disposal well, i can't remember), but was never told why we had to jump it till later.(i believe it was illegal to dump the tank to the pond if the ph was too low for legal environmental reasons...)

[@amelliamendel2227]

The valves get stuck all the time that's why the other one was right there. The failure was having a light on the tank showing it was in use.

[@Satchmoeddie]

@@amelliamendel2227 They should have put a unique air fitting on the upper valve, and kept the adapter up by the control panel, and had a procedure to double check the status of the tank number, and sign out the adapter for use on that specific tank, as well as have had at least status light for the tanks on the lower level.

[@Tindometari]

There are times when bypassing is necessary, or else the bypass wouldn't exist. But bypassing a safety feature should never be done unless you know exactly what you're doing and why you're doing it.

[@cherriberri8373]

@@tripplefives1402 ttee5aat5hvby.mnnjjh9 l x. Can i don't do that uciioo. Bbn h oop 4e

[@opalishmoth8591]

I appreciate how the CSB doesn’t just find the cause is human error and says “well case closed” They acknowledge the fact that people aren’t perfect and human error is inevitable- but steps can be prevent those mistakes from being possible / having catastrophic results

[@carbonwolf3865]

Honestly, this is the same reason I like the NTSB. They approach the situation with a "ok, people aren't perfect, let's be mature and find the reason/reasons why this happend and how to prevent these from happening again in the future." point of view. To me, a blameless culture is an environment that brings growth. Ok, yeah things happen and there should be accountability, but let's have it be done in a way that helps everyone and not just blame/punish people for an accident.

[@javidson7534]

From the operator's perspective, there are two possibilities: it's a jammed valve, or the wrong reactor. He immediately assumed a jammed valve and knew what to do about that, which suggests that this was not the first time he'd had to unjam one. Most critically, he had no way of checking: no radio, no intercom, no gauges at all to tell him what was on the other side of that valve. When you're dealing with a vast tank of a highly toxic, carcinogenic, flammable substance, that kind of setup is insane. Think about the worker's job: you need to get this valve open. Sometimes they stick, and this is how you fix that. Oh, and if - late in the evening, in the middle of a routine task - you turn right instead of left, you and your coworkers will be burned to death. You'll finish your life being boiled in poisonous chemicals, and if you're lucky the resultant explosion will put and end to your suffering. How can you be sure you got the right valve? You can't, they look identical. But you can remember today's tank is number 310, right? Or was it 306? Tell me I'm wrong if, after watching the video and knowing the risks, you'd bet your life on answering that question right.

[@Syclone0044]

javidson Don't worry, half of the comments here are by people who are immune to making mistakes. They boast how only stupid "idiots" would make this mistake. (/sarcasm)

[@medicbabe2ID]

@@Syclone0044 A "mistake" is forgetting paper towels at the grocery store. Dude couldn't remember a 3 digit number from the top of the stairs to the bottom, and five people died horrific deaths including a married couple (did they have littles at home?), an entire plant was leveled, and a community was rocked because of it. "World Class fuck-up" just about covers it here.

[@Rammstein0963]

Indeed, truth is a pen and slip of paper was all that would've been needed to stop this.

[@OnionRingsGaming]

I would have gone to my supervisor and double checked. In a job this dangerous you cant just fucking guess which tank is right.

[@mirandabri834]

Anyone ever heard of worker fatigue?

[@blazzing_fury2425]

To everyone debating, the point the CSB is trying to make is that these things need to be dummy proof. That it was way too easy for the person to bypass the safety measures in place and that addition measures (such as locks) might have prevented this from happening.

[@TauCu]

And people wonder why all of their jobs are going to robots, You get paid to use your brain, And do the work. "The CSB has concluded that SHOVING AN AXE HEAD into a reactor is not listed as an unsafe activity"

[@ianmoseley9910]

Tau However the company already knew this was a risk and had failed to take action to limit or mitigate risk.

[@fuckjewtube69]

The flip side of that is a safety measure has to also be easily bypassed or that in it self can cause a disaster.

[@MDAdams72668]

don't worry soon there will not be any jobs left (because machines don't make mistakes humans do)

[@dd_ranchtexas4501]

M D Adams: "because machines don't make the SAME mistakes humans do" There fixed it for you..............

[@randallflick8015]

For those that hate government and government regulation these videos should serve as a reminder that regulations are usually put in place in response to these kinds of events and the government employees at the CSB and other agencies do a great service to the country

[@Bankable2790]

That’s true. At the same time the government also goes way overboard with regulation in other areas. Check outs “waters of the USA” in which EPA tried to prevent people from doing things like creating ponds on their own property. They were sued and lost.

[@anonymousAJ]

The problem is these regulations, even when entirely justified, can never account for the full range of future needs, and the full costs and benefits of different processes. One reaction to events like this is to demand strong regulation. This implies low accountability, since bureaucrats rather than operators become responsible for the decision flow. These bureaucrats are not accountable in any obvious way. The alternative is to have freedom with accountability. The directors of a company that injured workers in an industrial accident should be PERSONALLY liable under general standards that used to make directors liable for all obligations of their business.

[@Bankable2790]

@@anonymousAJ I agree we need to hold the people who made these mistakes personally accountable

[@doctormcboy5009]

i hate goverment regulations on how to live my life not this

[@doctormcboy5009]

@Jordan Rodrigues the racist black lies do matter to you

[@jonathanverret6872]

I love these videos. I love the detailed problem analysis, I love the illustration. I love the dry, bureaucratic narration. God bless the CSB.

[@noodlelynoodle.]

It's like how it's made but for death!

[@Aikisbest]

CSB bless god more like it, but yes, I agree.

[@member5488]

Painting each batch set a different color would've been a big help.

[@ichaukan]

Color coding does help provide an additional mark of identification in any industrial process.

[@tsomeone950]

If u cant remember the number can u remember the colour?

[@zedg7473]

@@tsomeone950 also not everyone sees the same colours, some can't even see ranges of colours due to being colour blind so..

[@MrOpenGL]

@@zedg7473 Paint them with patterns... one batch in zebra, the other with dots, the other with diagonal stripes, etc.

[@andrewallen9993]

It would help if the operator was too stupid to remember a tank number but would not help if the operator was colour blind.

[@matthewstephens8215]

Imagine dying on a shift because another worker was either tired or just didn't pay attention

[@Reality_Based_Fantasy]

or incompetent

[@j-man6001]

that was what happened to my cousin, R.I.P. bro

[@andrewallen9993]

Or stoned again hey?

[@totallyfrozen]

Tired? Probably just day dreaming because the task was “simple”, i.e. rinse out the tank. He put the high pressure hose in the top, he goes down and opens the drain at the bottom. Easy, peasy, lemon squeezy. Except-it’s dangerous! He was moving on autopilot and day dreaming.

[@MarkPalmer1000]

@@totallyfrozen True, the worker was likely very complacent, and using the emergency air supply to open the valves on the reactors was probably just a normal "day at the races," where the shifts were long, hot, and mundane.

[@baruchben-david4196]

You've got to design these things for people at their worst. People may be taking medication that impairs them. Even if no one drinks or drugs on the job, they do get tired, distracted, confused, and otherwise impaired. It should be impossible - or at least extremely difficult and inconvenient - to do things wrong.

[@DrMantisToboggan69]

Make plants "reGard" proof, got it.

[@j-man6001]

Just shows how easy one mistake, becomes a catastrophic tragedy, Bravo to the ones who tried in vain to close it off, may the all be at peace now R.I.P.

[@m8die319]

something similar happened in 1968 in germany (elektrochemisches kombinat bitterfeld/ EKB) in the at the time oldest pvc factory in the world. with 42 deaths and 270 injured people. and it was a worker opening a valve at the wrong moment too, with 4 cubic meters of vinyl chloride being released. autoclaves are kind of scary...

[@VintageTechFan]

Opening the valve was totally deliberate, they wanted to depressurize it to fix a small leak at a manometer .. like they had done many times before.

[@andrewallen9993]

@@VintageTechFan So was using high explosive to clear a blockage in a silo of high explosive, the German workers had done it often before without negative consequences. It was still the act of complete idiots with no brains though.

[@tedmich]

CSB recommended... and companies said: "we'd prefer to maximize profits!"

[@richardbell7678]

After the Westray mine disaster, people were so incensed that it was not possible to charge Westray management with criminal negligence that the Canadian Criminal law code was amended to allow management guilty of egregious safety violations to be charged with criminal offences up to and including negligent homicide. Workers are still killed and injured, but it is more a case of foolproof systems attracting more imaginative fools than easily prevented incidents. One odd, possibly unintended, consequence is that failing to use safety equipment or failing to apply safety training will motivate management to fire a worker, before he gets himself hurt.

[@chasehicks7465]

Time and time again unfortunately...

[@paulgaskins7713]

It’s crazy to think that this is just one of the first of the few thousand videos uploaded in 2007 after videos were no longer limited to only 100 megabytes

[@Blacklab99]

After a lifetime in engineering maintenance and being responsible for people’s safety, I learned one thing. The job was easy, people were the problem, when it came to safety. It is also easy to criticise, in a world where speed, efficiency, costs, profit, job security etc etc, are driven into the minds of workers. The guy who pulled the interlocked system off and lashed another feed onto the valve, probably thought he was doing everyone a favour, sometimes called ‘being conscientious’. I’ve seen this done, albeit not in such a serious situation. Put any safety system in you can think of, and you can bet, someone will try and defeat it. It’s also much easier with hindsight, to criticise and point out failings in any system. There’s no accounting, for the sometimes, illogical workings of the human mind.

[@qbasic16]

Imagine what would happen if a train full of this stuff would derail...

[@haruhisuzumiya6650]

Acid rain that makes Bhopal look like a tea party

[@carbonwolf3865]

Oh boy, I can't wait to see the NTSB report for the Palestine, Ohio derailment and release

[@fbi8792]

“A worker opened a valve” of course they did

[@octaneartllc]

Simple solution... The operator has a specific key/fob/card for each reactor panel... The operator only works on one at a time... Each is operator and panel is specific to only one reactor... Or should i keep repeating myself??? I used to work in the fluid power and automation industry... Blowing up or getting crushed in a stamp is no fun... Alway be smarter and one step ahead of your environment and process... Having worked is so many facets of industry ive learned some key things... 1. Never stick your fingers where you wouldnt stick you d*%k 2. Your back isnt worth the raise you won't get. 3. dying wont get you paid 4. You dont know, ask 5. Dont work for people who are dumber than you 6.if you dont like your job quit 7. If you cant hold your breath for 15min but you get paid x per hour value your time 8. Respect people that have skills and have put their time in. 9. Question everything 10. Always do it right once... 11. Engineers keep mechanics employed 12. You can loose a second of your life or your life in a second 13. If you retire with all your fingers n toes you werent half bad 14. Love your craft 15. Always do your best to better your best 16. If what your getting paid per hr isnt worth you dying in that moment find a better job 17. If your still reading you should get a job or get back to work... 18. I hope your shitbreak was good. 19. Always shit on company time 20. If you work with your spouse may i be the first to formally welcome you to hell... 21. Dont cut corners 22. Dont fluff spiders 23. Seriously get to work already...

[@Stopthisrightnow560]

😂😂😂😂😂😂😂😂😂😂😂😂😂😂

[@jessvagnar4957]

I see there is a lot of people debating whether this is human error or mechanical. Human Error: The man went to the wrong tube. Mechanical Safety Check: Passed, the pvc reactor could not be opened. Human Error: Without contacting anyone or checking what was wrong he replaced the air ride with one continuously running for emergencies. Bypassing the mechanical safety. While there was only one mechanical safety check on this system it seemed to be extensive. I don't see why more than one mechanical safety check would be needed beside someone ignoring them. I honestly don't think that a second physical safety device would have prevented the worker from bypassing it.

[@Nash1a]

Not saying it wasn't human error. But more safety equipment might prevent a similar accident. Like a big red flashing "IN USE" light might have awoken the worker to his mistake.

[@gloomyblackfur399]

Vinyl chloride is probably the most carcinogenic substance known. A single short-term exposure causes liver damage and likely eventual liver cancer. It should not be so easy for a worker to endanger himself as well as everyone nearby. Plus, workers are often overworked and under undue pressure from management, leading to fatigue and distraction and risk. Mistakes aren't always solely their fault. Redundant safety systems couldn't hurt.

[@gregoyo1862]

Disagree! Safety systems should never be able to be bypassed without authorizations and signed paperwork that asks questions and verifies by MORE THAN ONE PERSON! If someone else was required to be involved in the bypass by way of procedure, the error would have been noticed. Mickey mouse system with mickey mouse regulations in a mickey mouse jurisdiction.

[@Simonstoster]

Jess Vagnar Why is it possible to bypass a critical safety measure simply by switching hoses? What happens if the only valve fails?

[@jessvagnar4957]

+Simonstoster Sorry, this video was quite awhile ago and for some reason the page isn't showing the replies! You asked why it's possible for him to bypass the safety system, because almost no safety systems are inherently true. It's not an issue with the safety system. It's like saying the door had a lock on it and someone broke the lock. On the other hand, if I recall correctly if one valve failed nothing happened. If one valve failed the system would've physically prevented any spillage from misoperation because there were two valves, no? This wasn't a mechanical failure or a safety device failure to me. Yeah a flashing red light could've helped, but he didn't consult the control panel anyways, when would we stop adding safety features?! It reminds me of a certification that I recently got for working near train tracks. There were a dozen deathes over the last decade so they implemented a lot of safety features, a lot of them human dependent. All in all they are spending a serious amount of money in labor and training and in the end really only adding 1 more human dependent safety feature. (There were even deaths that occurred from violations of the safety policies!) We can add lights, more valves, etc. it might've even stopped this accident, but in the end a knowledgeable operator (as he clearly was) will be able to ignorantly override them! I just view it this way for this case, if the situation was clearly a human error is that enough justification for more mechanical safety? If you have a Tesla, and the driver decapitates himself while driving poorly, should Tesla add more safety?

[@ForumArcade]

KZbin was a thing 13 years ago? I'm starting to feel old.

[@VintageTechFan]

I remember how I was on other (most of the time topic specific) video pages .. and then at some point heard about that new site called KZbin.

[@yaboikungpowfuckfinger7697]

I mean, the first KZbin video was uploaded in mid 2005...

[@WaterCrane]

I'm no expert, but if the tanks are grouped in sets of 4, might one way of avoiding misidentification be to paint a coloured ring on the top and bottom of each reactor... a different colour for each group? So if you're working upstairs on the yellow-ringed reactors, go downstairs and find yourself in front of purple-ringed reactors, it is more likely to clue you in that something is amiss instead of similar identification numbers.

[@anonymousAJ]

Yep, or just paint the area around each group a different color, don't have to put paint on the machines

[@MarcusMussawar]

just a warning light red no drain green drain

[@mbvoelker8448]

Exactly. Make it easy to see where you are.

[@vejet]

3:35 Unbelievable... why would you not check the reason it wasn't working before using an air hose meant only for emergencies to bypass a critic safety feature at a chemical plant. This incident reminds me of a trespasser I killed last year. He walked around the crossing gates at a level crossing as the train I was operating approached it at 90mph bypassing/ignoring an obvious safety feature. The unfortunate tragedy here is that 3 others also died with him. How could they hire someone so incompetent or unwilling to follow the simplest of safety rules?? It just boggles the mind.

[@jessvagnar4957]

+Rain Machika Dang, sorry you had to go through that. There was a man at a work place I'm familiar with and he was inside the machinery trying to fix something electrical behind the gears. They didn't disable the machinery, or even turn off the electricity. One man was on the gang way while the younger smaller man shimmied inside the machine. He fixed it and was slowly ground to death as the coworker watched being able to do nothing. They didn't turn off the machine, they didn't have emergency radios or communication to the floor or control room. The young mans family settled for an undisclosed sum. I feel sorry for the people who had to clean him out of the machine.

[@mspeir]

The fact that there was an emergency airline nearby explains this clearly. Why would you need to open a pressurized vessel of hot, explosive chemicals in an emergency? The "emergency" airline was there in case the primary air supply was lost. I'd chalk this up to poor safety training and a culture of lax safety practices. There is a good possibility that the worker was uninformed of the exact dangers involved or those dangers were downplayed. Add in the existence of an airline designed for this purpose and this accident is no surprise.

[@vejet]

Thanks mate and damn... what a horrible way to go.

[@gregoyo1862]

pressurized systems or hazardous materials should NEVER be contained by a single isolation, NEVER. Valves leak it was a mickey mouse system that was doomed to failure by design. and pass. US chemical plants have little or no regulation. A plant like that would never be allowed in modern juristictions. Redud ndancies should always be built in.

[@km5405]

harsh but true ... he deliberately bypassed a safety interlock. he basically murdered 3 people and himself with his stupidity. ... and sure its sad if someone gets killed by a train ... but if he was playing chicken with a train he had it coming.

[@veronly2]

I used to live in Niantic IL which is the town over from illiopolis this plant was long gone before I moved there. They leveled this place

[@adamflyshotmail]

Disasters like these are why Im a just leave kind of person. "oh the deadly chemical alarm is going off? I should go."

[@tumblevveed3586]

I wonder how clearly the tanks and control panels were labeled with tank numbers. If the labels/numbers were worn off, painted over, pealing,etc, it may not have been obvious which tank he was at. Makes me wonder about the worker who bypassed it. Maybe he put in too many hours and was fatigued, multitasking working more than one job at a time, distractions, miscommunications, pushed too hard or in a hurry to get the job done.

[@1978garfield]

When Formosa took over from Borden the first thing they did was cut staff and go to longer shifts. I also heard they deferred maintenance as much as possible. Makes you wonder if that emergency air workaround was required sometimes to make the equipment work.

[@googleplex7097]

even the way the stair way was setup, i can see how it could be disoreinting if youre tired, or distracted. The stairway should probaby been placed on 1 end instead of straight down the middle. You get what im saying? youre zigzagging back and forth from left to right as you move down and suddenly when you reach the bottom I can imagine how you might think " yea it was to my left" and hell maybe it was to your left but your left up stairs might be different from the left down stairs.

[@NiceMuslimLady]

@@googleplex7097 There may not have been space for that.

[@MrGrace]

Right. It definitely sounds like the worker was very familiar with the equipment, even though he made that tragic error.

[@Bankable2790]

@@googleplex7097 right exactly.

[@macsawesomeplace]

I always wonder what goes through people's head when they think it's ok to just bypass safety features without any diagnostic procedures to figure out what tripped the safety mechanism to begin with.

[@Stopthisrightnow560]

Methinks it'd have to be a regular occurrence; malfunctioning safety alarm, nothing wrong, keeps happening, still nothing wrong. Why on the 1000th time would you check when 999 times beforehand there was no problem? For me, I like to check safety instructions because I don't like dying in a blazing inferno.

[@jasonmckinney5710]

How do I apply to be a hindsight narrator?

[@maplebacon1]

Who's here from the East Palastine Ohio fiasco. Absolutely horrible.

[@railfandepotproductions]

You mean derailment

[@carbonwolf3865]

​@@railfandepotproductionsit can be a fiasco and still be a derailment

[@groveroark9443]

Thank you God for letting me be smart enough to be working in that worse conditions and not hurt nobody I threw out my career

[@mbvoelker8448]

The obvious thing to me is that if you have a number of identical units where some of them might be in safe states and others in hazardous states that the units should be painted different colors. If you were working on Green C up top you're not likely to mess with something if you find yourself looking at the purple group downstairs. Not foolproof, of course, but an easily achieved layer of extra safety.

[@jimmyshrimbe9361]

Yeah let’s bypass the safety feature without checking why it’s happening. Great idea.....

[@fetchstixRHD]

As stupid as it sounds watching now and as easy as it should be to avoid right after watching this, I’d imagine the guy would have been in a state of doing the motions and kind of being in autopilot, so may not have thought fully about what he was doing. I’d assume that if it was required to get someone else to work with you if the valve didn’t open before bypassing it, that might have mitigated the incident as then there would be a “fresh” person and they’d want to make sure you’re doing everything correctly.

[@1978garfield]

@@fetchstixRHD Indicators on the bottom for pressure and temp might have helped. He was supposed to be draining a depressurized tank. If the standard procedure had been to check the temp and pressure before opening a valve, hopefully he would have caught it.

[@animula6908]

I bet a million dollars youve done it yourself more than once in your life.

[@jimmyshrimbe9361]

@@animula6908 and I bet you're fun to be around...

[@animula6908]

@@jimmyshrimbe9361 I am, but only because I’m bypassing safety features occasionally myself.

[@dantheemokid1]

My dad was in this explosion he survived I still. remember that night too my sister woke me and my mom up and ask is my dad was working that night

[@paulspomer16]

Oh really?

[@MRblazedBEANS]

And he survivied?

[@hornitorrincoperezoso2189]

It really does come down to good training and safety culture combined with good individual judgement. No matter how complex the engineered safeguards are, there will be a way around them. One way is to run enough drills or dry-runs of different ops that they become second nature to the operators and they instantly notice if something isn't right, but then you run the risk of complacency. Or you can have the operators analyze each situation individually, but then they are more likely to make mistakes. Train people and have a good culture and empower operators to stop work when something doesn't feel right.

[@Tadesan]

And competent engineering. That's so rare. Why operators jobs are so hard and dangerous.

[@Intrafacial86]

“Damnit Jim, when I said ‘for emergencies only’ I didn’t mean for when you want to _CREATE_ an emergency!”

[@craftpaint1644]

"I didn't know, I didn't see, I didn't think," these are three common causes of problems.

[@sammygirlie345]

I don't or never worked with chemicals or lived in USA but I find these videos fascinating

[@sebastiannielsen]

I would have added a second interlock: A button or similiar, that is only depressed by the cleaning adaptor, not the lid of the normal tank operation. This button then controls the air supply to the second valve. Since there was 2 valves, then only one of them could be bypassed at one time, which would saved this disaster from happening, while still allowing bypass of malfunctioning safety equipment.

[@mitchellbliss3828]

Jeeeeesus every single part and position of that entire facility looks & sounds like an extremely dangerous job!!!

[@bigpapi3636]

I've worked for several chemical companies over a 40 year career and it's interesting how some take safety very seriously and others don't. But it's difficult to imagine an operator bypassing the air interlock on the reactor valve even in a stringent safety review. It did happen though and it seems like it could have been avoided by better training and tamper-proof connections as USCSB indicated in the review.

[@toryknotts8026]

About the deceased workers who tried to slow it, were they as dumb as the guy who caused this mess or were they misguided

[@ronobrien5726]

it might have been easily prevented by using color coding on the tanks on upper and lower levels as well as on the controls panels, and entry doors to the reactor rooms. then you would know i.e. "I am working on the red reactor vessel, red control panels behind the red doors".

[@NopeVS]

I've been watching this video for years, and it's amazing how one can always learn from it - thanks CSB. today's question - 3:52 What in hell do you need a "Emergency Air" air hose for? It was never supposed to be available/provided in the area. Something is not working as it should? Call maintenance and go get a coffee. Management is responsible for not making it clear. Only emergency air you need is a SCBA!!!!

[@brendanwilliams7291]

Perhaps the reactors should have been fitted with warning lights or gauges so that workers would know whether or not the reactors were under pressure or not. Perhaps that was an oversight when they were built and installed.

[@danieljudah8992]

I am back here as vinyl chloride is released during a train derailment in Ohio.

[@Tindometari]

Here's a solve for the 'turn to the wrong reactor' hazard: color-code the reactors by group. This is a cheap way to give a visual reminder.

[@stanmnews]

It usually takes people _dying_ for any significant changes to happen, and this is not only within the chemicals industry but across all aspects of society

[@ccsmith2937]

Very sad. Easily prevented when you had 2 near misses just months before.

[@bahn2452]

I'm curious what kind of training was given to the crews that cleaned the reactors.

[@Squick99]

Probably included, "see this line that says "emergency only." Only use it in an emergency Jethro, or you'll blow us all up!"

[@chamonix4658]

@Kinguin 100% this on his first day he was probably shown by another guy 'well your not meant to do this but these valves jam all the time so I use this air hose to just open em up quick, saves stopping production'

[@commissary4196]

Some of it looks like facility level from goldeneye

[@toryknotts8026]

Why wasn't there a sign at the landing of the stairs that had a arrow saying tanks ABC are to the right while tanks XYZ are to the left, like at hotels

[@REXXSEVEN]

that would make sense

[@methylethyldeth]

It seems that there was also a lack of training. Great video!

[@gregoyo1862]

complete lack of modern interlock systems...mickey mouse! Company should be shut down!

[@km5405]

deliberately bypassing a safety interlock is beyond poor training - that's inexcusable and plain stupidity.

[@steves1015]

How is it that the waste water from the cleaning of the tank was allowed to just dump onto the floor and into a drain, right next to a worker? Considering vinyl chloride is hazardous and carcinogenic, then the amounts that would be present in washing water would be dangerous for the workers, especially if it is performed repeatedly over time. Even if this accident hadn’t happened, the lack of concern for employee health is astounding!

[@paulsanchez4197]

Well, it’s purged with N2 before it’s allowed to have any access to atmosphere.

[@JamesFox1]

Just A little FYI = Although crude oil is a source of raw material (feedstock) for making plastics, it is not the major source of feedstock for plastics production in the United States. Plastics are produced from natural gas, feedstocks derived from natural gas processing, and feedstocks derived from crude oil refining And Then there`s THIS = Vinyl chloride is used primarily to make polyvinyl chloride (PVC), a hard plastic resin used to make a variety of plastic products, including pipes, wire and cable coatings, and packaging materials. (PVC is not a known or suspected carcinogen.) Vinyl chloride is also produced as a combustion product in tobacco smoke / Tobacco Smoke / Nicotine Is An OIL , Not " OIL " but " AN OIL "

[@I_SuperHiro_I]

So…..the KZbin algorithm isn’t random after all….

[@TripleDDDD]

well, never googled vinyl chloride before either

[@CommieGIR]

If someone bypasses a safety device or interlock, they override safety features built into the plant. It was human error.

[@Nash1a]

So was turning left when he should have turned right. Warning or status lights as the bottom of the reactor should have told the worker he was as the wrong vessel.

[@SirDeanosity]

I see this as using the end justifies the means philosophy. No different than using a 3 prong to 2 prong adapter to make a machine work that wouldn't work when plugged into the provided 3 prong outlet! I was called to fix a machine I had designed and got a shock when I touched it!!! I promptly destroyed the plug adapter and had a word with the person who added the adapter to the plug. I found a wire touching the metal structure of the machine and when repaired it work as designed.

[@thelol1759]

Sure, but failure to minimize potential for human error is in an of itself a process deficiency.

[@derekwall200]

all thanks to a mix up and not reading any pressure gauges on the vessel in question

[@llary]

@@Nash1a they did. He had to physically hook up an air line to the pneumatic valve actuator to force the valve open.

[@llary]

Honestly I think this was a rare occasion when safety procedures and equipment were more than adequate but one dumbass went above and beyond to screw up. The only way to prevent the operator doing this would be to lock all the pneumatic actuators and lines inside a metal box, but then there would be no way to open or close them in an emergency like a sudden power failure. I have had to rip into coworkers who do dumb shit like this (unscrewing safety guards designed to stop hands getting mangled in machinery). And it's not like management gets any benefit out of this, just pure laziness from the worker because it's the fastest way to get a boring maintenance job finished.

[@TauCu]

Exactly, No Engineer has ever managed to outsmart an idiot.

[@vaporisedair4919]

It was ok but far from perfect. Local Gauges could have helped, also a status panel to indicate the reactor status on the bottom of the panel. Finally why didn’t they look for an ESD button and run away instead of looking to close individual valves? The final valve drain valve was a pneumatic valve and should close once the emergency shutdown would initiate.

[@Rammstein0963]

Here's one better, the tanks were CLEARLY MARKED...wth didn't dumbass memorize it write down which tank he was working?

[@yaboikungpowfuckfinger7697]

No offense, but did you even watch the video? Studies found the safety measures in place were prone to misuse, and there were no gauges or indicators to show the tank he was servicing was actually in operation. The fact that making a left turn instead of a right turn, and forgetting whether the number was 310 or 306, and not having any sort of indication of operation. There could’ve been jams in pervious servicing instances and what the worker did had to be done. Guy could’ve been pulling a double shift, my cousin has had to do that many times, he works on the manufacturing floor at a Nissan plant. He’s told me countless stories of guys calling in ‘sick’ at the last minute and someone having to cover their shift and they fuck up. This ‘dumbass’ did not go above and beyond to screw up... This guy made a simple series of errors that literally any person could make. Watch the video again, if you even did the first time, from 6:06

[@xXDESTINYMBXx]

@@Rammstein0963 they are in the video, but were they as clearly in reality?

[@WadcaWymiaru]

I believe the proper emergency sink o overflow would prevent the spill and explosion. If room was isolated, they could displace the air with something inert like nitrogen.

[@brendanwilliams7291]

How much vinyl chloride could have been present in the reactor when the explosion happened I wonder? Well, if you ask me, I would say that there was a lot.

[@jakedee4117]

In any other circumstance I might think that a worker who made that sort of mistake was suicidal or deliberately trying to sabotage the plant. But death by hot plastic goo ! Not even the most screwed up guy would wish for that.

[@johnthefisherman69]

I live in Cancer alley (along the Mississippi River in South Louisiana) I often wonder how the area I live in is habitable.

[@birdn4t0r7]

The fact that there were 2 incidents in 2 months that involved an operator bypassing the safety interlock means that bypassing safety mechanisms was something they had to do routinely. Manual overrides of safety features should never be part of daily operations unless you work in the emergency room or something, where "daily operations" are non-routine by their very nature, because that basically nullifies the protection against human error that the interlock was supposed to provide.

[@km5405]

they did take errors into account ... I think the guy missed the briefing on not making multiple errors in succession and bypassing a safety interlock on his own without talking or phoning his supervisor first. the take that evacuation training is important is a good takeaway though.

[@robertjenkins6132]

The content is good, but wow, I'm glad you upped the bitrate since the old days. 240p. A person in the 90s could watch this with a dial-up modem (if the signals could time travel). Well, that's probably an exaggeration. Dial-up modems were _really_ slow.

[@vaderdudenator1]

Is the second Formosa video on this channel?

[@derekwall200]

it's frightening to see how a simple mix up (and human error) can cause an explosion of this magnitude. AND WASN'T THIS FACTORY TORN DOWN AFTER THE BLAST?

[@dougschmitii6165]

I think it said in the beginning that it wasn't rebuilt in that town. It sounded like it wasn't worth rebuilding because of the extent of destruction that the blast caused

[@freeman2399]

Where can I buy the CSB robots that are featured in the video?

[@thejasonknightfiascoband5099]

Try the Dollar Tree

[@Whompaah1]

I was reported by a wood carving artist that stopped the dialog of over 350 operators discussing the situation. It deleted all of our conversations that were part of an open dialog of actual operators. It's sad 350 people's lives and comments erased because he didn't understand.

[@haruhisuzumiya6650]

Vinyl chloride when burned can produce phosgene

[@mbvoelker8448]

I'm amazed at all the perfect people in this comments thread who have never walked into the living room when they meant to go to the kitchen, made the turn toward their jobsite when they meant to go to the grocery store, picked up pliers instead of a wrench, or otherwise become momentarily disoriented. Perhaps this info is in the written report, but I'd like to know how many hours the employee had worked that day, that week, and that month. I'd like to know if there was a full crew or if they were short-handed. If he was tackling a normal workload or if he was trying to make up for some earlier loss of productivity. If he was having stress at home and even if his feet and back hurt so that climbing those stairs to check the number seemed like one thing too many. Safety systems aren't for well-rested workers under light demands at the start of their shift in perfect conditions. Safety systems are for the fatigued and stressed-out workers who are trying to catch up from a bad week when their kids are sick, the neighbor's dog got loose and dumped the trash cans on pick up day, and they're grumbling about their feet hurting from going up and down those stupid stairs over and over because the idiot who designed the plant didn't put a control for the drain on the top.

[@samschannel531]

Yikes. Isn’t vinyl chloride a really nasty carcinogen too?

[@ChadBod]

Omg am within a 20 mile radius of Ground Zero. Of a spill of from the Railroadrailroad..Am from Ohio. This will just happen in my town .

[@haruhisuzumiya6650]

It's toxic

[@noahater5785]

i can probably imagine the explosion must have caused an incredibly violent chain reaction that blew up other nearby reactors making PVC, intensifying the explosion that already occured due to reactor 310 exploding, essentially completely levelling the building. Multiple highly pressurized reactors producing flammable liquid exploding caused by one reactor exploding due to operator error is basically a massive cluster bomb.

[@Cypher791]

The valves are downstairs but there’s no gauge there.. that’s maybe all it would have taken to prevent this..

[@juicebox22a]

Is there no cross checking? Or these people are complacent as hell. Ill just bypass a safety interlock designed to prevent an disaster before lunch..... And another thing, these workers wait around way to long. Someone sounds the alarm or radios evacuate, I'm gone.

[@doc.voltold4232]

I have been working 5 years in a lead acid battery company.. The daily word is "bypass" one day someone is gonna die there, I'm sure of it

[@kefpull6676]

basically in all videos summary: 1: follow most strict guidances by nafta osha etc 2: dont allow people to disable safety things 3: information about xyz chemical, zyx pressure/capacity in xzy vessel 4: redundancy 5: maintenance 6: human small braincell count

[@Justsomeoneyoucouldhaveknown]

The controls should have been centrally located and on the same floor. Cameras could have been used to remotely view pipes and valves. The drain should have been a closed separate system that won't operate if it detected anything other than water

[@blackhawkorg]

This plant was obsolete and probably not in EPA compliance, which is why Borden sold it rather than do an expensive overhaul on it. The one moron killed himself with his ineptness. There should have been pressure/temp gauge at that lower station as well. The others failed to... run!!!

[@Reginald-rr1gh]

What is so incomprehensible to me is the MONUMENTAL incompetence of the people running that place. Mis-identification of which reactor he was on was a human error. Deliberately bypassing a safety interlock and bumbling ahead in the face of uncertainty (especially in a hazardous chemical plant environment) is absolutely inexcusable. The fact that the plant management allowed such incompetence in operating the plant reveals a culture that has no awareness of safety. This was demonstrated by another explosion at another Formosa plastics plant in Texas the next year.

[@archerbob6847]

It's easy for them to say in hindsight that they should have evacuated instead of trying to contain or prevent a catastrophe

[@cvtt3194]

Imagine being so high that you accidently blow up a whole plant. Bruh.

[@brendanwilliams7291]

There should have been a notice on the emergency air hose to state that under no circumstances, should it have been misused, that workman had not been paying any attention to what he was doing, a little carelessness was enough to cause a massive explosion.

[@sadokbarbouche9427]

it doesn't tell you when their under pressure no big ass light or sign a Guage??? or was the guy that oblivious

[@NameNotAlreadyTaken2]

Should reupload this video at better than the 240p setting. KZbin has mulched it.

[@conoba]

I bet they rebuild in china. With same safety .

[@HobbyOrganist]

After collecting millions from the insurance they had on the plant, they don't care- they're insured, the insurance pays off the lawsuits and the losses, it was an OLD plant that was probably soon on the way out anyway, the explosion did that for them and they collected a big insurance check. It's the same way Penski and other truck rental outfits around this low train bridge don't care when every month one of their trucks is totalled when a driver hits the low bridge and sheers the roof off the truck- the city gets easy traffic fines, the cleanup and hazmat people get the business cleaning the mess, the rental truck Co gets a brand new truck, that's how they replace their fleet for free.

[@TheMattc999]

MainsOnTheOhmsRange Nah, they won't use a mechanical secondary safety device in China....

[@Syclone0044]

Victorian Sculptures You must be referring to KZbin's famous 11foot8 bridge. You don't think their insurance company is going to raise their rates after consistent, monthly claims for total vehicle loss due to the same cause every time?!

[@devtrash]

you could stop consuming pvc

[@Phyx1u5]

no offense to this guy but I definitely prefer the raspy old dude narrating. gets the feels going.

[@46bovine]

My opinion, the companies that owned the plant didn't want to spend the $$$$ to upgrade safety procedures or equipment. It's cheaper to allow the insurance to pay out to the accident victims survivors and offer phoney apologies than it is to do the right, safer, thing. Am I being too cynical?

[@vanguard2688]

Should have been a lockout procedure in place during maintenance

[@jayclark5912]

Good God! Bypassing a safety interlock. Crazy.

[@johnnyjoevazquez]

Ohio brought me here..

[@news_internationale2035]

Can anybody explain why so many PVC and type 5 processed plastics sold to the general public have been spontaneously melting into a grease recently?

[@guscarter3291]

People doing routine jobs on a regular basis are always going to make a mistake sooner or later simple as that procedures have to be in place to prevent it got to make it impossible unless it's a deliberate act safety is the first concern

[@rikgto9351]

From my perspective (which I admit is limited) there seems to be a type of “peer pressure” to get jobs finished and moved on to the next task, at least in some organizations. Anyone asking questions or stopping work is seen as a prima-donna and that leads to bad decisions. For all the top level propaganda of safety, at the working level safety unfortunately is not always given top priority. The safety lists become just another check list in these cases.

[@luiytheninja3655]

Attention to Detail. If you don't know with 100% certainty, or have forgotten in the time it took you go down the stairs, check again, write it down, whatever you gotta do. That being said, we are human and are prone to error, more systems should have been in place to prevent an accidental release, AND IF a Accidental release occurred, The operators should have had radios. I know of job sites dealing with a whole lot less dangerous shit that use radios. As someone mentioned below if you are a supervisor, team lead, manager, or whatever somewhere in a manufacturing job or environment or somewhere that works in hazardous conditions or environments, make sure your processes and equipment are 100% dummy proof, if you bring something up to upper management, and they say something about money or not rn, or whatever, find another job. No job is worth your life, or families well being.

[@volvo09]

Poor worker who opened that valve.... Damn.

[@dxb526]

Natural selection.

[@nameless-user]

Wouldn't LOTO tags prevent this?

[@freakyflow]

Yup alot of companies When it boils down to supervisors And lead hands They cut corners of safety to keep production going My view This worker was tired Or had something else on his mind to head to the wrong tank The first problem should of alerted him of using the wrong tank But instead of thinking that his mind was now on how to by pass it to work This should of been a supervisor level to see the problem And fix it By going up and seeing which tank was being flushed followed by knowing the worker is trying to release the wrong tank Safety mode should been set on all tanks till the one was set right...

[@shekalinay]

Exactly why visual signage is necessary and why two person verification is needed before overriding systems. So sad.

[@SuperAgentman007]

4:16 The supervisor saw Homer scratching his head saying what now?

[@stevensonDonnie]

It is sad that one error by someone who did not check the reactor number, did not re check when it would not open and took the time to reconnect another line, caused the loss of 139 jobs, probably good paying jobs, with benefits. The economic damage to that small community must have been great.

[@neilpuckett359]

Plant was closed did they demolish and clear the site?

[@noahater5785]

it was already demolished by the explosion, at least on the bright side they didn't need to hire demolition crew, the demolition took care of itself 😂

[@SuperAgentman007]

0:53 but they were using a 1905 Rulebook in the factory the same book the Titanic builders used and you know what happen then. You see The accident usually happen when they use an old outdated Rule book is the company that cheap that they couldn’t buy a new up dated book!

[@fatboyzracing3178]

Why does the CSB lady sound like Roseanne Barr?