@@antonfloor344 but at least we can go forward knowing what not to do. Seems obvious in Hindsight, but in the moment you dont know how stupid some practices are until they turn fatal or just dangerous
the level of detail they include is what makes it feel real and relatable. i work in Aerospace not petroleum but a lot of the lessons are applicable. i got my whole shop hooked on these videos we binged them all haha
I’ve always trusted my instincts when on dangerous jobs. I have told employers I refuse to do a task when it is unsafe. They don’t usually listen and just get someone who only cares about following orders. I have never been fired for it and I have never regret putting my safety and life first. To all the young guys just starting a trade... your safety is important, but only if you speak up about it. Think about what you have to lose at home before you lose it all at work.
The guys undid the wrong bolts. If they'd done the right ones, there would have been no danger. They didn't realize that this one had a different design. It wasn't an issue of them being made to do something they thought was dangerous. The action itself had not been thoroughly vetted by a safety team.
I left a job because of lack of safety awareness. They had an extreme turnover rate for EHS managers (employee safety and health). Any EHS manger that identified safety issues and recommended changes (that usually cost time and money), were quickly run off. After a co-worker was seriously injured during a fire/small explosion due to a machine being set with the wrong parameters due to a fault in the old timing equipment. It was not a fault of any operator. This was clearly evident to all who knew how this process worked. The EHS manager at the time was instructed to find an employee, any employee possible that he could put the blame on. This would keep them from having to update the equipment, and blame it on operater error, and possibly avoid spending a lot of money and downtime. He refused. This was the last straw for him, me, and several others. 2 years after I left, the same incident occured, but this time it caused a much larger fire, and much more damage. There were a few injured. OSHA got involved, and the fines were massive. I have the safety first mentality. To many, that it just a catch phrase. Take it seriously. I have seen way to many accidents that could have easily been prevented if someone had spoken up about a safety issue, or followed proper guidelines.
I am a new engineer at a hydrogen plant with a lot to learn. These videos are such a great resource through sharing of detailed lessons learned. It allows for people like me, who are new and very green in terms of engineering experience, to consider human error possibilities and even prevent poor engineering design choices. I do my best to take all these events to heart to help keep operators and maintenance safe out in the plant. Thank you so much for putting all the time and effort into these videos.
This is a prime example of a case where the old design should have been adequately safe, but required to field personnel to pay attention, which is why the newer design came to be. No matter how much we try, we cannot design everything to be completely fool-proof, because there's always a bigger fool out in the wild. We do however try to make things as user friendly as possible, and the fundamental design lesson from this incident is to not use pressure containing features to support less process critical features. The operational lessons are to select your people for smarts, don't over-stress or over fatigue them, and make it abundantly clear that if a job is not going as smoothly as it should, to stop and call for help... and lay down the law on people who give others a hard time for reaching out for help.
A man once said that anyone working on electrical equipment is expected to be certified in the field, but when it comes to high pressure, the only certification people think they need is a wrench, and this shows it very clearly. The design might've been stupid, but if you can't understand what those 4 bolts are holding in place you shouldn't be touching any high pressure piping.... let alone poisonous gases piping.
Honestly even as an electrician I think that is about the dumbest thing I have ever heard someone doing during maintenance. I don't think you have to be a pipe fitter or an engineer to figure out that that's not how you remove that gear box. Stupidity or not its a shame that people got hurt, especially for those who weren't involved.
I don't think those people were hired out of university. And this is baton rouge we're talking about. Not the location with the highest IQ per square meter.
its probably a combo of errors and misjudgment, maybe the side bolts were seized, stripped, or they just didnt see them. and they thought to themselves, hey they are still 2 bolts holding the valve in a middle, its fine we remove these outer 4 just for a while and then screw everything together. And obviously they didnt want to install the outer ones, just for the time they tried to operate the valve using wrench. Safe work procedures take extra time, and sometimes people in hurry, just think to themselves, i will get way this time. Then the do it a few times, and hey nothing happened, so they continue.
What was not said : 1. Time of day. 2. Environmental conditions. 3. How long on duty. 4. Supervisory pressure. All of these can affect job performance. I've been in situations, hurry-up jobs stacked one atop the other, where I had to force myself to stop and think. Sometimes I had already started to work when the little alarm bell in my head went off. Not excusing these fellows at all for such an obvious oversight, but there may have been external factors in play here.
@@jplandscaping5069 operations are not dead end jobs. Skilled plant operators keep this country running. We can definitely do without more useless entrepreneurs tho.
... It certainly is. But when I think about it, all the equipment, that I ever worked with had a meter close to the flange bolts somewhere - and when you see the pressure indicator, the brain immediatelly tells you not to touch the bolts - and this was not the case in this accident. From my point of view - I would use different style of bolts for all the structural elements, which you are not suposed to touch, when performing a normal maintenance. Also, using some water-proof housing for the gearbox would most definitelly help - the whole problem was created by rusted equipment in the first place...
Yeah if you aren’t smart enough to know you can’t pull the top cap off a pressurized valve then you have no place in maintenance. It amazes me how people with such little knowledge get put in work places like that.
Clearly the worker responsible could have thought this through better; but is that really a good excuse for not updating the design of the valve? Especially when you have a process specifically for that purpose. We aren't going to run out of people failing to use their brains anytime soon. To me, it stands to reason that one would choose the surefire way to eliminate the risk over the one that relies on humans making smart decisions.
I wonder how often they had to do this on either type of valve? You would think since neither type of valve required removal of 4 bolts that should have been a cause for alarm.
I wonder how experienced the workers were. That seems to be an underlying issue. Young and eager workers who weren't properly trained to anticipate this.
Oil executives will always hire men who are too stupid to drool without drowning. Best case they die doing something stupid at work, worst case they are smart enough to hire a lawyer.
Thanks CSB. As a safety professional I find most of these well made and comprehensive video reports to be great visual training aids. They are excellent for stimulating open discussion about a variety of scenarios and for comparing the do's and don'ts of policies and procedures with real world incidents. Keep up the good work.
@@adrianabenefield short answer is family, my dad was a chemical engineer, other family members were contractors. I wanted to weld so I went for it. And you’d be surprised, you can follow all the procedures to the T, but when your material is corroded to sh** and all you want is patch jobs because you’re to cheap to change and update process lines, accidents are bound to happen. The worst experience I’ve had of someone completely skipping safety steps was in Praxair Geismar. Operator didn’t sniff test a formaldehyde tank and a welder went to go doing some work on it and the tank blew up on him, catwalk fell on him. He survived, but seriously messed him up. Probably won’t ever be able to work again. Operator didn’t even get fired, just got moved to another place in the company without process lines.
@@nathanielclause2588 Wow, that’s awful. Definitely not something I’d go into even if i had family that did it, even if you do everything right someone else’s mistake can screw you over. I’ve been binge watching the videos on this channel and even with regulations in place many operations still aren’t safe enough. Glad you’re safe and still kicking, thanks for doing what you do.
A relative of mine died in a sugar cane plant explosion years ago. It was a lesson to me that these people don't give crap about safety, only the bare minimum to keep things running.
Ratus if you don't mind me asking, what caused the plant to explode? I didn't know there was any explosion hazards associated with sugar cane processing
@@pepe6666 Well, maybe they didn't expect some dum-dum to come around and unscrew the bolts holding down the top cap. You have to be able to rely on a certain degree of common sense or companies will soon have to hire shoelace technicians to ensure the workers have tied their shoelaces correctly before coming to work!
A way the older valves could have been modified to make them a bit safer would be to drill a small extra hole through the support bracket base, and the top and topcap faceplates to run a padlock through. That would prevent the removal of the bracket even if the vertical bolts were removed, guiding employees to the try removing the horizontal bolts instead.
The bolts shouldn't be that easy to remove but I honestly don't see how anyone who knows basic mechanics couldn't see that removing those 4 vertical bolts is a really bad idea. You're basically disabling the valve in use.
@@hebber1961 This exactly. I don't mean to be harsh, but jesus, these guys are professionals? That could have been avoided just by stopping for a second and actually thinking what they are doing. Any person without any training can go haphazardly opening random bolts, but what makes someone a professional is that they actually know what they are doing and how to do it safely.
@@azur3125 when you work with assholes bosses and you allow yourself to ingratiate to an unsafe workplace, it’s easy to skip steps mentally because you feel like you are under immense pressure
@@shaneprather6743 It would be better to modify the brackets to attach to a fixed point that does not interact with the process containment functions. It's a given that others have made similar mistakes in the past, which is why the ne design has a different pipe flange with the drilled & tapped hole to attahe the bracket in bosses on the perimeter. I can see why engineers 30 years ago would not expect anyone to be so witless as to miss the horizontal bolts, but clearly fatigued, stressed, or distracted workers did make that mistake.
Many thanks to the CSB for making these videos; they're incredibly well done! Informative, easy to understand, aesthetically pleasing, and even somewhat entertaining. Safety stuff like this is usually pretty boring, the approach they took with these is not only interesting enough to keep my attention, it makes me want to see and learn more.
It is astonishing that they removed the 4 vertical bolts when the 2 horizontal bolts were the most obvious in securing the gearbox housing. The stupidity of what those two workers did is incredible !
My theory: they tried with the side screws first, but these could not be removed because a) the heads were damaged and rusted and had lost their edges, or b) the threads were locked up by corrosion or uneven expansion under heat or gas pressure influence. Assuming this and facing a broken gearbox, the whole old apparatus needed to be replaced anyway, including the bracket, and so they did.
Y'all need to reexamine the video. This is an older model that has the gear box attached not just by those two top bolts but also the four on the bottom.
@@i.robles5785 No watch 3:45 The animation initially shows removing the 4 bolts, but the narrator and diagram indicate you could just remove the horizontal bolts and the gearbox would come off.
So this video shows that the correct tool to turn a valve is a pipe wrench. And that one should use the pipe wrench in any orientation you feel like, as their graphic shows the orientation of the wrench to flip-flop at random.
I saw this and could not believe anyone would dismantle that style valve that way. I've been in industry for 40 years and most of these accidents , experience would solve. I could see this one coming as the video ran. Never touch any pressure systems without a risk analysis of the structure. Knew that in the 1970's.
Ive learned this being an auto mechanic. Its called paying attention to what your doing, and these guys were not. I saw a guy with his new impact gun remove the bolt holding the ac manifold to the compressor, thinking it was a one of the bolts securing the compressor to block. Everything in that shop got covered in PAG oil mist. Probably explosive as well if ignition source were present due to the suspended oil. This is in Alabama though. Dingalings.
I trained many aircraft mechanics and the auto mechanics made good ones because they had to be VERSATILE early on. Industrial mechanics who are noobs don't have to think on their feet like you do wrenching autos or aircraft. If all they do is basic shit they learned slowly on the job they can't cope as well.
I agree with you, but we both know that: "Silence it, work around it, and fuck it." has been all too common in the safety culture on sites in the past, especially with production and start up bonuses. The concept of "If your not sure, stop, ask, confirm." Is relatively new as a philosophy in the processing side of the industry, at least from my perspective. There is a reason many refer to it as the 'wild west' of industry.
Not too far off from the "Little General" store propane explosion. A filling tech opened the transfer bolt after a 'misunderstanding', releasing the contents of the propane tank, which detonated shortly after.
so, they are used to 97% of the site valves and made a mistake on this one. I don't think that it's even reasonable to blame the techs. 3% that you aren't trained for doesn't mean they are in the wrong. And yes, as Johnny Sunday notes, this is very akin to the Little General store.
@@sandiegofun1 the are just a bolt turning crew with little mechanical and critical skills. If they really looked at what they were doing and thought about it they might realize the mistake. The second guy watching should have been more cognizant of what was taking place.
sandiegofun1 screw the percentages and statistics - it has nothing to do with that OR training. These people are professionals who get paid to operate this equipment. There’s a giant pressure bulkhead secured by 4 bolts... they’re playing around with extremely high pressure and flammable chemicals. No one even paused for a second to think about what bolts to remove or what they actually secured? Typical BS in the industry. I’m going to remove the bolts but have no idea what I’m about to touch or what they do and how they work. The people with genuine passion and curiosity are the smarter, more efficient and safer employees.. always.
Dear sir, i am just speechless about your explanation, how so beauty of your animation and experiment,research etc ..thank u so much to whole of your grt team ..
If you are going to be stupid you had better be tough... Thanks for the video, these are much more informative and useful than simply printed media. Well worth the effort to produce them.
I never worked in a refinery but if I saw the way those bolts were bolted up I would come to the conclusion that if I were to remove those 4 bolts the valve would come apart. These guys must have been the stupidest people ever.
Chemical plant fires create some incredibly nasty burns over large areas of the body. Many years ago I knew 2 men with these very bad keloid scars that form after bad burns. Mentioned to my neighbor I knew someone else with such scars: he asked me his name. When I told him he said to say hello from him, that was the person who had pulled him from the fire. Not a big fan of cops, but this hero was exactly that.
I really can't understand this one. Looking at the valve for 2 seconds would tell you that removing those bolts is a very bad idea and would disassemble the top of the valve. What did they think would happen? Pretty obvious really. The animation keeps using the "pipe wrench" incorrectly (backwards) 😁
These incidents always seem to boil down to "Nobody was responsible for ensuring safe practices" and in my experience the reason is always the same...when safety procedures are strictly enforced and adhered to, there are usually few to no incidents. This lack of incidents leads management to presume that such strict protocols must be excessive and thus the long backsliding on safety begins, since doing things at the height of safety is time consuming and thus expensive. The sad fact is managers are seduced into thinking "If nothing has happened so far, everything must be fine". Add in elements like fatigue, inexperience, and poor training and you have a recipe for a disaster cocktail.
Question is- how do you remove the old style gear box? You would have to de-pressurize both sides of the vale, probably a time consuming job. It's always the hurry that kills
@@MikeBarbarossa no really. from the picture, it looks clear that the two bolts on the side would allow one to remove the valve system from the bracket. furthermore, im sure they have set impact wrenchs. takes less than 2 minutes to put the bolts back on
Maybe. I know that the guys work in a sometimes confusing work environment, & mistakes are extremely costly, & extremely easy to make. Remember, they were following all rules & procedures. The men were not necessarily incompetent.
I like your videos, but I'm wondering if I'm the only person who noted that the animation shows the pipe wrench being applied backwards? Obviously your animators have never used a pipe wrench.
"The leg bone's connected to the knee bone..." I guess nobody cares that the bolts removed were actually keeping the top cap on. "Hmm, these bolts go THROUGH the top cap...Oh, well, let's loosen them anyways."
Great content. One small minutia, I scrolled the comments and think the video properly addressed 99% of it, at 7:00 however they mention addressing workers discussing difficulties removing the gearboxes as a potential avenue for disaster mitigation. While this is correct I don't believe this would have mattered as the employees did NOT have difficulties removing the gearboxes, nor did the one who were not properly trained on recognizing the procedure for the old valve have knowledge of their errors. It's basically saying workers would've self-identified hidden future knowledge to forewarn the company. Now the investigation may have revealed former complaints or incidents which would change the above, however it was not mentioned in the video.
Yeah I see what you mean, and def. agree, but I think he misspoke... I think he meant to say the workers' previous troubles actuating the gear boxes, necesitating the removal in the first place... if the company had been well aware of their dysfunction they would have at least had the chance to update all gearboxes to the newer safer design.... still I agree that it's stopping the buck at the workers' feet instead of the company's and management who's job it actually is to ensure worker and general plant safety.
theoreticataly, they could put them back and safely open the valve, but once the bolts were back, they would not be able to put the gearbox back. it is possible to remove GB, open valve and put GB back only with newer model where the gearbox is not connected to the top cap
@@martinpilda - That pipe was pressurized. If they take the 4 bolts going through the bracket, top cap and valve out, there would almost instantly be a leak. Those valves didn't have anything holding them in once those bolts were removed except a little natural cohesion.
@@thomashodis5740 In the video, it showed the valve not leaking until the worker took a wrench to it. Perhaps they could have removed the bolts and the gearbox, reattached the bolts without the box, then turned the valve, removed the bolts again, reattach the gearbox and bolts.
The pipe wrenches are facing the wrong way when used to open the valves. That's not how you orient them. The jaws should face into the direction of travel, not away. You have to wonder at the lack of awareness by the individuals opening the valve not to realize that those bolts held the top cap on. It's obvious when you look at it.
It is unbelievable to me that the workers did not see that the bolts they were removing also held the valve together. Was there no mechanical skills test for prospective mechanics/operators?
0:57 Management of safety is critical to the protection of workers, but sadly it seems that it's often treated mainly as a cost, reducing company profits.
Interesting use of a Ridgid-pattern pipe wrench in several scenes. Correct use is the scene showing worker turning valve stem after bolts removed. Who edited this?
I think it was more people who had to come in early on a day off or something and had to watch this safety video, but I'm gonna leave a like because this is knowledge I didnt know I needed
Sounds like that’s the employer abusing workers, training should happen during normal work hours, bringing people in on their days off is simply the employer being greedy by choosing not to provide training during normal working hours.
The refinery is a ship. The captain is responsible for everything. At the refinery it is management. Hire the first guy that passes the drug test. On the job training, the old guys train the new guys. 3% of the valves different without markings or warnings Worker comp expenses are cheap compared to one day's profits. Particularly TX and LA.
If they had been dealing with the newer versions where you removed the bracket with the gearbox. Then you might be inclined to remove the bracket for the older ones as well. But they obviusly didn't give this much thought. Maybe fixing the gear required the bracket(alignment and so forth). Maybe they've seen it being done that way by others, different being they replaced the 4 bolts. When you are going through the motions its easy to miss the glaring obvious.
You can clearly see it's a right angle bracket that's also bolted from the vertical stroke, why on earth would you not just remove those bolts instead of the ones holding the pressure valve together
Looking at the valve support fixture it looks like on both old and new versions the gearbox can be removed by removing the top bolts completely eliminating the need to touch the top cap.
If this animation is correct, well, I don’t know what to say, except that the workers were ridiculously incompetent. The bolts obviously went thru the entire valve cap assembly. How could you possibly not see what would happen if they were removed?! This is almost like a cartoon where Wile E Coyote saws off the end of a board will sitting in it..
This accident happened because the guys weren't paying attention to how the valve worked, or didn't understand how it worked. Perhaps they also didn't know that isobutane was flammable, or that it would escape if they took the valve apart. There is a limit to how far one can go to combat ignorance.
It's clear why the old design would appear reasonable, as it utilizes existing mounting hardware without requiring the pipes to be changed. Likewise the newer design is also reasonable as it avoids reusing the pressure bolts for the mounting bracket, to avoid confusion on which bolts to remove. Having both sets in the same facility especially with incomplete training is the problem here. If you only knew how to remove the newer design, the older design would be confusing and it would be likely anyone would assume the pressure bolts were the proper ones to remove, if they were not aware of the true function of those bolts and the top plate.
a large percentage of the workers there got their jobs being related or associated to someone else that works for Exxon-no degrees or training before hand
Inspite of safe operating procedures and good written practices, how could a mechanical device provided with single system of connection for both valve and top bracket and how could that worker operate a valve leaving the top bracket open😳 it’s purely stupidity.
What is never made entirely clear in these videos is what the ignition source for so many of these fires are. I am assuming that it's was unclear to the csb as well
Yeah, because the business has no responsibility whatsoever to train workers. Why should employers bother training workers? If they weren’t bad workers then they would already know how to be safe! If a worker gets hurt it means they’re a bad worker that should be let go, which I’m absolutely certain is exactly what happens to everybody that falls into the Exxon meat grinder.
If the purpose was change the pump, the last valve beforer that shoud be was close with an open drain between them , why they ere attemped open the valve? to drain the pipe completely? it was not clear. Can you enswere?
They were not going to replace the pump (as in unbolting the pump and mounting a new one). What they were going to, is to change pump, ergo start up pump2 and shut down pump1. Propably to replace pump1, which would later on warrant draining ANOTHER pipe section not shown in this video. The pipe section shown in video was for pump2, the pump they propably were going to replace, was pump1. This to keep production going, even while doing maintenace. Thats why you have inactive "spare pumps" and similiar, to be able to keep production going, while still being able to safely do maintenace on inactive parts of the plant.
Very interesting how someone could make such a mistake. What could have confused the technicians is the top doesn't get pressure until the valve opens a little, so they thought the bolts were just mounting bolts.
I just don't know how anyone could possibly not realize that those bolts were holding the top plate, which is the lid to an open pipe. That is pure insanity.
I was curious why they took off the whole bracket instead of the 2 bolts holding the gear box to the bracket. Looking at the picture did they think it was too corroded to do so?
I wonder if that was as easy to spot in the actual valve. Seems bloody obvious that that was a bad way to remove the gearbox, especially when you could loosen only 2 bolts to do it right.
I’ve been around tons of the 2 types of valves mentioned in this video. It’s pretty obvious which ones you don’t want to go unbolting on a live line and which ones you can. It was either pure stupidity or ignorance as to why the person/s decided to completely unbolt the valve bonnet.
Why not use a stud/nut/bracket/nut combo? It would be cheaper than replacing all the old valves. Or is it that the old valves were so unwieldy/stubborn that a large wheel and worm gearbox couldn't turn them?
I've watched this video multiple times and every time I get stuck on the workers using the pipe wrench backwards. I realize they are not using it on a pipe, but EVERY clip is them using it the wrong way.
It is more interesting because it is a USCSB video animation. So if someone doesn't know how to use a pipe wrench or adjustable wrench properly, how in the hell are they going to know not to remove the four bolts that hold the plate in place? Blind leading the blind.
I hate how they show the pipe wrench being used BACKWARDS. This is a safety video and you guys can't even properly demonstrate basic tool use? On another note, it is called a valve bonnet not a top cap. As a pipefitter, I completely agree that removing the bolts from a valve bonnet that is under pressure is a terribly dangerous practice. Unfortunately I'm not surprised that someone was injured/killed.
i don't know the name of this narrator, but I hope that nobody else will narrate csb videos insteat of him 😋 he gives the videos really special atmosphere hehe
Not sure if I'd like to work with anyone who couldn't identify the hazard of loosening 4 bolts holding down the cap. Even worse would be working for a supervisor who didn't recognize the items that were a possible source of catastrophic failure potential. Who could be in charge of working at a explosive latent plant that would be unfamiliar with it's vavle safety.
There's a reason there are 4 big bolts there. It's not just to hold a bracket for a gearbox. Makes the other thousands of workers who work safely for years look bad, and all the training and safety placards in the world won't stop people who don't understand the equipment they're work on.
Well...if they had been dealing with the newer versions where you removed the bracket with the gearbox. Then you might be inclined to remove the bracket for the older ones as well. But they obviusly didn't give this much thought. Maybe fixing the gear required the bracket(alignment and so forth). Maybe they've seen it being done that way by others, different being they replaced the 4 bolts. When you are going through the motions its easy to miss the glaring obvious.
2:09 I thought it was a excepted practice that if the valve isn’t working you grab a big hammer 🔨 and if the valve still isn’t working you grab a much bigger hammer or use a blow torch to heat the valve up!
That's what I'm talking about! I guess it could be said taking the ol' gas axe to a pressurised valve full of flammable chemicals might be a bad idea. If you were quick about it you would probably be OK.
Наука
Am I the only one who feels like this group actually cares about us because they are willing to animate and educate us about what happens/ed?
information is power
The CSB is like captain hindsight on Southpark.
@@antonfloor344 but at least we can go forward knowing what not to do. Seems obvious in Hindsight, but in the moment you dont know how stupid some practices are until they turn fatal or just dangerous
They even put in the Mechanix gloves at 0:31 lol
the level of detail they include is what makes it feel real and relatable. i work in Aerospace not petroleum but a lot of the lessons are applicable. i got my whole shop hooked on these videos we binged them all haha
I’ve always trusted my instincts when on dangerous jobs. I have told employers I refuse to do a task when it is unsafe. They don’t usually listen and just get someone who only cares about following orders. I have never been fired for it and I have never regret putting my safety and life first. To all the young guys just starting a trade... your safety is important, but only if you speak up about it. Think about what you have to lose at home before you lose it all at work.
Damn well said, wise wise words right here. Right the refuse with no repercussion.
The guys undid the wrong bolts. If they'd done the right ones, there would have been no danger. They didn't realize that this one had a different design. It wasn't an issue of them being made to do something they thought was dangerous. The action itself had not been thoroughly vetted by a safety team.
I left a job because of lack of safety awareness. They had an extreme turnover rate for EHS managers (employee safety and health). Any EHS manger that identified safety issues and recommended changes (that usually cost time and money), were quickly run off. After a co-worker was seriously injured during a fire/small explosion due to a machine being set with the wrong parameters due to a fault in the old timing equipment. It was not a fault of any operator. This was clearly evident to all who knew how this process worked. The EHS manager at the time was instructed to find an employee, any employee possible that he could put the blame on. This would keep them from having to update the equipment, and blame it on operater error, and possibly avoid spending a lot of money and downtime. He refused. This was the last straw for him, me, and several others. 2 years after I left, the same incident occured, but this time it caused a much larger fire, and much more damage. There were a few injured. OSHA got involved, and the fines were massive. I have the safety first mentality. To many, that it just a catch phrase. Take it seriously. I have seen way to many accidents that could have easily been prevented if someone had spoken up about a safety issue, or followed proper guidelines.
@@davealmighty9638 thanks for sharing
@@toomanymarys7355 You'll be in one on these videos soon smartass.
I am a new engineer at a hydrogen plant with a lot to learn. These videos are such a great resource through sharing of detailed lessons learned. It allows for people like me, who are new and very green in terms of engineering experience, to consider human error possibilities and even prevent poor engineering design choices. I do my best to take all these events to heart to help keep operators and maintenance safe out in the plant. Thank you so much for putting all the time and effort into these videos.
This is a prime example of a case where the old design should have been adequately safe, but required to field personnel to pay attention, which is why the newer design came to be.
No matter how much we try, we cannot design everything to be completely fool-proof, because there's always a bigger fool out in the wild.
We do however try to make things as user friendly as possible, and the fundamental design lesson from this incident is to not use pressure containing features to support less process critical features.
The operational lessons are to select your people for smarts, don't over-stress or over fatigue them, and make it abundantly clear that if a job is not going as smoothly as it should, to stop and call for help... and lay down the law on people who give others a hard time for reaching out for help.
H; so reactive !! 😮😮😁
Keep safe dd !!
Engineering: 💪💥💯 !!
A man once said that anyone working on electrical equipment is expected to be certified in the field, but when it comes to high pressure, the only certification people think they need is a wrench, and this shows it very clearly.
The design might've been stupid, but if you can't understand what those 4 bolts are holding in place you shouldn't be touching any high pressure piping.... let alone poisonous gases piping.
Honestly even as an electrician I think that is about the dumbest thing I have ever heard someone doing during maintenance. I don't think you have to be a pipe fitter or an engineer to figure out that that's not how you remove that gear box. Stupidity or not its a shame that people got hurt, especially for those who weren't involved.
I don't think those people were hired out of university. And this is baton rouge we're talking about. Not the location with the highest IQ per square meter.
Agreed, just looking at it, it's so damn clear that they were taking apart the valve with those 4 bolts.
I Agree. It's best to assess the situation before removing any type of bolts
its probably a combo of errors and misjudgment, maybe the side bolts were seized, stripped, or they just didnt see them. and they thought to themselves, hey they are still 2 bolts holding the valve in a middle, its fine we remove these outer 4 just for a while and then screw everything together. And obviously they didnt want to install the outer ones, just for the time they tried to operate the valve using wrench.
Safe work procedures take extra time, and sometimes people in hurry, just think to themselves, i will get way this time. Then the do it a few times, and hey nothing happened, so they continue.
What was not said :
1. Time of day.
2. Environmental conditions.
3. How long on duty.
4. Supervisory pressure.
All of these can affect job performance. I've been in situations, hurry-up jobs stacked one atop the other, where I had to force myself to stop and think. Sometimes I had already started to work when the little alarm bell in my head went off. Not excusing these fellows at all for such an obvious oversight, but there may have been external factors in play here.
One thing I've learned in 25 years of working in these types of facilities, is you can get hurt by other people's negligence. : (
That’s why I’m an entrepreneur, working dead end jobs can get you killed not worth it
Free money for family
25 years to learn!?
Good lord nothing happened 😂
@@jplandscaping5069 true story, just don't get complacent and end up being that asshole Boss Man pressuring the guys to rush eh
@@jplandscaping5069 operations are not dead end jobs. Skilled plant operators keep this country running. We can definitely do without more useless entrepreneurs tho.
Removing flange bolts on pressurized equipment is always BAD!!! I can’t see how anyone would think this was a good idea.
... It certainly is. But when I think about it, all the equipment, that I ever worked with had a meter close to the flange bolts somewhere - and when you see the pressure indicator, the brain immediatelly tells you not to touch the bolts - and this was not the case in this accident. From my point of view - I would use different style of bolts for all the structural elements, which you are not suposed to touch, when performing a normal maintenance. Also, using some water-proof housing for the gearbox would most definitelly help - the whole problem was created by rusted equipment in the first place...
I'm amazed it didn't blow before the valve was turned.
Then clearly you don't see too many illiterate people.
@@TheNefastor No shit, the United States is over 99% literate, we have one of the highest literacy rates in the world, what are you on about?
Yeah if you aren’t smart enough to know you can’t pull the top cap off a pressurized valve then you have no place in maintenance. It amazes me how people with such little knowledge get put in work places like that.
Very well done video, feels like "Use your brain before unscrewing everything" though.
Clearly the worker responsible could have thought this through better; but is that really a good excuse for not updating the design of the valve? Especially when you have a process specifically for that purpose. We aren't going to run out of people failing to use their brains anytime soon. To me, it stands to reason that one would choose the surefire way to eliminate the risk over the one that relies on humans making smart decisions.
Agreed. Not replaceing the valves is negilent.
I imagine that this was the very reason most had been replaced. I wonder why that one wasn't.
ikr... how do you not notice this? do you have to warn workers not to stab each other also?
I wonder how often they had to do this on either type of valve?
You would think since neither type of valve required removal of 4 bolts that should have been a cause for alarm.
I wonder how experienced the workers were. That seems to be an underlying issue. Young and eager workers who weren't properly trained to anticipate this.
No procedures are the way to go
Oil executives will always hire men who are too stupid to drool without drowning. Best case they die doing something stupid at work, worst case they are smart enough to hire a lawyer.
@@2asseddog Its not just oil executives.
public schools.
@@2asseddog nah. You don't have any idea how much it costs to hire dumb people, especially in this industry
Thank you for continuing to make these informative videos. I love to see them in my subscriber box.
Thanks CSB. As a safety professional I find most of these well made and comprehensive video reports to be great visual training aids. They are excellent for stimulating open discussion about a variety of scenarios and for comparing the do's and don'ts of policies and procedures with real world incidents. Keep up the good work.
I worked there for a year doing a job on their dock. Nasty and dangerous place. Thank you for your videos
How did you get into that line of work? Sounds horrendous, never heard of a refinery that actually followed safety procedures.
@@adrianabenefield short answer is family, my dad was a chemical engineer, other family members were contractors. I wanted to weld so I went for it. And you’d be surprised, you can follow all the procedures to the T, but when your material is corroded to sh** and all you want is patch jobs because you’re to cheap to change and update process lines, accidents are bound to happen. The worst experience I’ve had of someone completely skipping safety steps was in Praxair Geismar. Operator didn’t sniff test a formaldehyde tank and a welder went to go doing some work on it and the tank blew up on him, catwalk fell on him. He survived, but seriously messed him up. Probably won’t ever be able to work again. Operator didn’t even get fired, just got moved to another place in the company without process lines.
@@nathanielclause2588 Wow, that’s awful. Definitely not something I’d go into even if i had family that did it, even if you do everything right someone else’s mistake can screw you over. I’ve been binge watching the videos on this channel and even with regulations in place many operations still aren’t safe enough. Glad you’re safe and still kicking, thanks for doing what you do.
A relative of mine died in a sugar cane plant explosion years ago. It was a lesson to me that these people don't give crap about safety, only the bare minimum to keep things running.
Ratus if you don't mind me asking, what caused the plant to explode? I didn't know there was any explosion hazards associated with sugar cane processing
Fortunately, CSB has a great video on this topic as well: ruclips.net/video/Jg7mLSG-Yws/видео.html
Ratus oh shut the fuck up with that anti company bullshit
@@DrRichtoffen1 no. ratus is right. this is a massively common theme. if you run things for a profit, cost cutting always appears.
@@pepe6666 Well, maybe they didn't expect some dum-dum to come around and unscrew the bolts holding down the top cap. You have to be able to rely on a certain degree of common sense or companies will soon have to hire shoelace technicians to ensure the workers have tied their shoelaces correctly before coming to work!
A way the older valves could have been modified to make them a bit safer would be to drill a small extra hole through the support bracket base, and the top and topcap faceplates to run a padlock through. That would prevent the removal of the bracket even if the vertical bolts were removed, guiding employees to the try removing the horizontal bolts instead.
It wouldn't provide the clamping force required to keep the top cap in place though, in the event the vertical bolts were removed anyway.
The bolts shouldn't be that easy to remove but I honestly don't see how anyone who knows basic mechanics couldn't see that removing those 4 vertical bolts is a really bad idea. You're basically disabling the valve in use.
@@hebber1961 This exactly. I don't mean to be harsh, but jesus, these guys are professionals? That could have been avoided just by stopping for a second and actually thinking what they are doing. Any person without any training can go haphazardly opening random bolts, but what makes someone a professional is that they actually know what they are doing and how to do it safely.
@@azur3125 when you work with assholes bosses and you allow yourself to ingratiate to an unsafe workplace, it’s easy to skip steps mentally because you feel like you are under immense pressure
@@shaneprather6743 It would be better to modify the brackets to attach to a fixed point that does not interact with the process containment functions.
It's a given that others have made similar mistakes in the past, which is why the ne design has a different pipe flange with the drilled & tapped hole to attahe the bracket in bosses on the perimeter.
I can see why engineers 30 years ago would not expect anyone to be so witless as to miss the horizontal bolts, but clearly fatigued, stressed, or distracted workers did make that mistake.
Many thanks to the CSB for making these videos; they're incredibly well done! Informative, easy to understand, aesthetically pleasing, and even somewhat entertaining. Safety stuff like this is usually pretty boring, the approach they took with these is not only interesting enough to keep my attention, it makes me want to see and learn more.
3:00 You shouldn’t be taking things apart if you are blind to the big picture...
It is astonishing that they removed the 4 vertical bolts when the 2 horizontal bolts were the most obvious in securing the gearbox housing. The stupidity of what those two workers did is incredible !
That's what I was thinking! The horizontal bolts! Lack of attention to detail can get you killed!
My theory: they tried with the side screws first, but these could not be removed because a) the heads were damaged and rusted and had lost their edges, or b) the threads were locked up by corrosion or uneven expansion under heat or gas pressure influence. Assuming this and facing a broken gearbox, the whole old apparatus needed to be replaced anyway, including the bracket, and so they did.
Right. Hindsight is always 20/20.
Y'all need to reexamine the video. This is an older model that has the gear box attached not just by those two top bolts but also the four on the bottom.
@@i.robles5785 No watch 3:45
The animation initially shows removing the 4 bolts, but the narrator and diagram indicate you could just remove the horizontal bolts and the gearbox would come off.
So this video shows that the correct tool to turn a valve is a pipe wrench.
And that one should use the pipe wrench in any orientation you feel like, as their graphic shows the orientation of the wrench to flip-flop at random.
Its things you dont wanta see
no one cares, its not torqueing a pipe its just opening a valve. if it works it works
I worked at this plant for a long time as a contractor this doesn't surprise me at all😐
I saw this and could not believe anyone would dismantle that style valve that way. I've been in industry for 40 years and most of these accidents , experience would solve. I could see this one coming as the video ran. Never touch any pressure systems without a risk analysis of the structure. Knew that in the 1970's.
Ive learned this being an auto mechanic. Its called paying attention to what your doing, and these guys were not. I saw a guy with his new impact gun remove the bolt holding the ac manifold to the compressor, thinking it was a one of the bolts securing the compressor to block. Everything in that shop got covered in PAG oil mist. Probably explosive as well if ignition source were present due to the suspended oil.
This is in Alabama though. Dingalings.
I trained many aircraft mechanics and the auto mechanics made good ones because they had to be VERSATILE early on. Industrial mechanics who are noobs don't have to think on their feet like you do wrenching autos or aircraft. If all they do is basic shit they learned slowly on the job they can't cope as well.
I agree with you, but we both know that: "Silence it, work around it, and fuck it." has been all too common in the safety culture on sites in the past, especially with production and start up bonuses.
The concept of "If your not sure, stop, ask, confirm." Is relatively new as a philosophy in the processing side of the industry, at least from my perspective. There is a reason many refer to it as the 'wild west' of industry.
I barely know my ass from an allen wrench, and even I realized where this was going as soon as those four bolts got mentioned.
Not everybody is experienced like you.
Low number of headline making incidents lets people be careless.
So, they saw a pressurized plate held by 4 bolts, and they decided to remove the 4 screws and pressurize the system?
Im blow away by how someone could be this stupid if you remove any bolts should be reinstalled before opening the valve
Not too far off from the "Little General" store propane explosion. A filling tech opened the transfer bolt after a 'misunderstanding', releasing the contents of the propane tank, which detonated shortly after.
so, they are used to 97% of the site valves and made a mistake on this one. I don't think that it's even reasonable to blame the techs. 3% that you aren't trained for doesn't mean they are in the wrong. And yes, as Johnny Sunday notes, this is very akin to the Little General store.
@@sandiegofun1 the are just a bolt turning crew with little mechanical and critical skills. If they really looked at what they were doing and thought about it they might realize the mistake. The second guy watching should have been more cognizant of what was taking place.
sandiegofun1 screw the percentages and statistics - it has nothing to do with that OR training. These people are professionals who get paid to operate this equipment. There’s a giant pressure bulkhead secured by 4 bolts... they’re playing around with extremely high pressure and flammable chemicals. No one even paused for a second to think about what bolts to remove or what they actually secured? Typical BS in the industry. I’m going to remove the bolts but have no idea what I’m about to touch or what they do and how they work. The people with genuine passion and curiosity are the smarter, more efficient and safer employees.. always.
Dear sir, i am just speechless about your explanation, how so beauty of your animation and experiment,research etc ..thank u so much to whole of your grt team ..
If you are going to be stupid you had better be tough... Thanks for the video, these are much more informative and useful than simply printed media. Well worth the effort to produce them.
I never worked in a refinery but if I saw the way those bolts were bolted up I would come to the conclusion that if I were to remove those 4 bolts the valve would come apart. These guys must have been the stupidest people ever.
I can't stop watching these videos, so informative and great concise animation that effectively helps the viewers visualize what took place.
Too
Chemical plant fires create some incredibly nasty burns over large areas of the body. Many years ago I knew 2 men with these very bad keloid scars that form after bad burns. Mentioned to my neighbor I knew someone else with such scars: he asked me his name. When I told him he said to say hello from him, that was the person who had pulled him from the fire. Not a big fan of cops, but this hero was exactly that.
I really can't understand this one. Looking at the valve for 2 seconds would tell you that removing those bolts is a very bad idea and would disassemble the top of the valve. What did they think would happen? Pretty obvious really.
The animation keeps using the "pipe wrench" incorrectly (backwards) 😁
I'd have to agree. maybe these guys weren't trained to look at the maintenance work they were doing as part of a whole system?
In hindsight
These incidents always seem to boil down to "Nobody was responsible for ensuring safe practices" and in my experience the reason is always the same...when safety procedures are strictly enforced and adhered to, there are usually few to no incidents. This lack of incidents leads management to presume that such strict protocols must be excessive and thus the long backsliding on safety begins, since doing things at the height of safety is time consuming and thus expensive. The sad fact is managers are seduced into thinking "If nothing has happened so far, everything must be fine". Add in elements like fatigue, inexperience, and poor training and you have a recipe for a disaster cocktail.
couldn't have said it better
Paradox of prevention.
02:14, 02:50 wrench is incorrect, this could result in slippage and causing injury, or spark and igniting
How To spot a good video:
1. Subtiles
2. Narator
3. Quality animation
4. New knowledge
BEST CONTENT
I can't believe that the workers didn't understand how a plug valve is assembled, and remove the bolts that obviously holds the thing together.
Ah yes, the oh so complex piece of machinery , the gearbox
gearboxes do get pretty complicated, a lot of them are works of art inside
I love USCSB videos - you guys deserve more funding.
Did anyone see the 2 bolts at the top of the bracket that would let the valve come off freely without taking off the 4 bolts for the top cap??!!
Yeah already in the first seconds.
use nonstandard bults or color them differently when they holding pressure.. u should not be able to open pressurized containers by mistake!
Agree! (just a simple preventive measure). Would save lives!
I blame the stupid gearbox for allowing human error
Question is- how do you remove the old style gear box? You would have to de-pressurize both sides of the vale, probably a time consuming job. It's always the hurry that kills
@@MikeBarbarossa no really. from the picture, it looks clear that the two bolts on the side would allow one to remove the valve system from the bracket. furthermore, im sure they have set impact wrenchs. takes less than 2 minutes to put the bolts back on
To be fair to the company, if someone is this incompetent, they shouldn't be allowed to operate a wrench.
Yeah but competent workers cost more. Training ain't free.
Maybe. I know that the guys work in a sometimes confusing work environment, & mistakes are extremely costly, & extremely easy to make. Remember, they were following all rules & procedures. The men were not necessarily incompetent.
@Graham
By assigning blame to workers, NOTHING will change.
The company is at fault, THAT will drive change
The company hired them, or worse indirectly them, correct? Fair's fair and a spade is a spade.
@David Parry You are an IDIOT.
why didn't they leave the four bolts on the main valve and remove gear box at the correct to removal safe side on that flange connection?
Could also be rust. "Hey those two are stuck but if remove those four we can be done before lunch"
Seroster, they WERE done before lunch, but not in the way you are thinking...
They were well done by lunch.
@betatalk357 no and no
@@Serostern what's for lunch? barbecue
I like your videos, but I'm wondering if I'm the only person who noted that the animation shows the pipe wrench being applied backwards? Obviously your animators have never used a pipe wrench.
haha imagine that, a computer junkie never having used a pipe wrench =) =P
I find it fascinating how so so many of these incidents occur because of sheer stupidity and incompetence.
Nice. I searched for this explanation to remove the Gearbox correctly. Thank you.
"The leg bone's connected to the knee bone..."
I guess nobody cares that the bolts removed were actually keeping the top cap on.
"Hmm, these bolts go THROUGH the top cap...Oh, well, let's loosen them anyways."
Common sense doesn't exist in USA
@@walterbrunswick common sense, so rare, it should be considered a super power.
@@ScumfuckMcDoucheface that's one way to put it😅
Complacency breeds idiocy. Also the ideology of "is it stupid if it works" goes a long way.
Great content. One small minutia, I scrolled the comments and think the video properly addressed 99% of it, at 7:00 however they mention addressing workers discussing difficulties removing the gearboxes as a potential avenue for disaster mitigation. While this is correct I don't believe this would have mattered as the employees did NOT have difficulties removing the gearboxes, nor did the one who were not properly trained on recognizing the procedure for the old valve have knowledge of their errors.
It's basically saying workers would've self-identified hidden future knowledge to forewarn the company. Now the investigation may have revealed former complaints or incidents which would change the above, however it was not mentioned in the video.
Yeah I see what you mean, and def. agree, but I think he misspoke... I think he meant to say the workers' previous troubles actuating the gear boxes, necesitating the removal in the first place... if the company had been well aware of their dysfunction they would have at least had the chance to update all gearboxes to the newer safer design.... still I agree that it's stopping the buck at the workers' feet instead of the company's and management who's job it actually is to ensure worker and general plant safety.
So if they would of put the bolts back before opening the valve this would of never happened?
No they should have only removed the top side bolts on the left only. As this would have left the bracket on and removed the gear box.
theoreticataly, they could put them back and safely open the valve, but once the bolts were back, they would not be able to put the gearbox back. it is possible to remove GB, open valve and put GB back only with newer model where the gearbox is not connected to the top cap
@@martinpilda - That pipe was pressurized. If they take the 4 bolts going through the bracket, top cap and valve out, there would almost instantly be a leak. Those valves didn't have anything holding them in once those bolts were removed except a little natural cohesion.
@@thomashodis5740 In the video, it showed the valve not leaking until the worker took a wrench to it. Perhaps they could have removed the bolts and the gearbox, reattached the bolts without the box, then turned the valve, removed the bolts again, reattach the gearbox and bolts.
@@Misha-dr9rh - the entire valve body is held in place by those bolts. If you remove those bolts there is nothing holding it in place
Y’all’s videos are great!!!!
The pipe wrenches are facing the wrong way when used to open the valves. That's not how you orient them. The jaws should face into the direction of travel, not away.
You have to wonder at the lack of awareness by the individuals opening the valve not to realize that those bolts held the top cap on. It's obvious when you look at it.
It is unbelievable to me that the workers did not see that the bolts they were removing also held the valve together. Was there no mechanical skills test for prospective mechanics/operators?
Very informative
Sheldon is a good narrator,
0:57 Management of safety is critical to the protection of workers, but sadly it seems that it's often treated mainly as a cost, reducing company profits.
Interesting use of a Ridgid-pattern pipe wrench in several scenes. Correct use is the scene showing worker turning valve stem after bolts removed. Who edited this?
13 refinery owners did not like this video.
I think it was more people who had to come in early on a day off or something and had to watch this safety video, but I'm gonna leave a like because this is knowledge I didnt know I needed
Sounds like that’s the employer abusing workers, training should happen during normal work hours, bringing people in on their days off is simply the employer being greedy by choosing not to provide training during normal working hours.
StCreed more likely 36 senior operators that have and still do this dumb crap still, just hasn’t caught up with them yet.
The refinery is a ship. The captain is responsible for everything. At the refinery it is management.
Hire the first guy that passes the drug test.
On the job training, the old guys train the new guys.
3% of the valves different without markings or warnings
Worker comp expenses are cheap compared to one day's profits. Particularly TX and LA.
The animation shows to pipe wrench being used backwards in all but one scene
Yeah it's pretty sad. This is a safety video and its showing improper basic tool use. This is a recipe for busted knuckles and trips to the hospital.
It would probably work since it's being used on something that's square, but nonetheless incorrect
Are you proud of that observation? I'm sure your medal for being smart will show up any day now.
Oh man that bothered me too
It gives me shivers that there are SO many more such dudes maintain dangerous equipment while having no idea what they do....
If they had been dealing with the newer versions where you removed the bracket with the gearbox.
Then you might be inclined to remove the bracket for the older ones as well.
But they obviusly didn't give this much thought.
Maybe fixing the gear required the bracket(alignment and so forth).
Maybe they've seen it being done that way by others, different being they replaced the 4 bolts.
When you are going through the motions its easy to miss the glaring obvious.
You can clearly see it's a right angle bracket that's also bolted from the vertical stroke, why on earth would you not just remove those bolts instead of the ones holding the pressure valve together
Are there any procedure plans for repair
Looking at the valve support fixture it looks like on both old and new versions the gearbox can be removed by removing the top bolts completely eliminating the need to touch the top cap.
isnt this a repost? or a different incident?
andrew campbell This is the full final report. The other video was an initial report and didn't go into root causes.
Take this funny:
ruclips.net/video/kCW4sJWpmaQ/видео.html
the background music lowkey bumps
If this animation is correct, well, I don’t know what to say, except that the workers were ridiculously incompetent.
The bolts obviously went thru the entire valve cap assembly. How could you possibly not see what would happen if they were removed?!
This is almost like a cartoon where Wile E Coyote saws off the end of a board will sitting in it..
Thank you!
This accident happened because the guys weren't paying attention to how the valve worked, or didn't understand how it worked. Perhaps they also didn't know that isobutane was flammable, or that it would escape if they took the valve apart. There is a limit to how far one can go to combat ignorance.
Ive been watching these for 10 years jeez
Alike watching these videos because I work in the industry and it makes me more aware of dangers and of human habits
How do you not see that removing the 4 bolts is not a good idea?
It's clear why the old design would appear reasonable, as it utilizes existing mounting hardware without requiring the pipes to be changed. Likewise the newer design is also reasonable as it avoids reusing the pressure bolts for the mounting bracket, to avoid confusion on which bolts to remove.
Having both sets in the same facility especially with incomplete training is the problem here. If you only knew how to remove the newer design, the older design would be confusing and it would be likely anyone would assume the pressure bolts were the proper ones to remove, if they were not aware of the true function of those bolts and the top plate.
valve specific written instructions should have been there and given to the workers. lack of proper communication and guidance.
Please study the recent accident at DSM resins in Augusta Georgia
a large percentage of the workers there got their jobs being related or associated to someone else that works for Exxon-no degrees or training before hand
Truth
True and sad
Inspite of safe operating procedures and good written practices, how could a mechanical device provided with single system of connection for both valve and top bracket and how could that worker operate a valve leaving the top bracket open😳 it’s purely stupidity.
@David Parry 2:23 pause it. Look at the highlighted bottom. It is still held down by a bolt on the far right.
This place is old man, most of this stuff is from the 50s
What is never made entirely clear in these videos is what the ignition source for so many of these fires are. I am assuming that it's was unclear to the csb as well
Whomever would do this has no business handling a wrench. Good job, Darwin.
Yeah, because the business has no responsibility whatsoever to train workers. Why should employers bother training workers? If they weren’t bad workers then they would already know how to be safe! If a worker gets hurt it means they’re a bad worker that should be let go, which I’m absolutely certain is exactly what happens to everybody that falls into the Exxon meat grinder.
Why didn't they bolt the valve back after removal of gearbox but before wrenching the axle? Just some common sense!
Agreed, even the most basic mechanic should be able to look at that and see it's going to be a problem.
If the purpose was change the pump, the last valve beforer that shoud be was close with an open drain between them , why they ere attemped open the valve? to drain the pipe completely? it was not clear. Can you enswere?
They were not going to replace the pump (as in unbolting the pump and mounting a new one).
What they were going to, is to change pump, ergo start up pump2 and shut down pump1. Propably to replace pump1, which would later on warrant draining ANOTHER pipe section not shown in this video. The pipe section shown in video was for pump2, the pump they propably were going to replace, was pump1.
This to keep production going, even while doing maintenace. Thats why you have inactive "spare pumps" and similiar, to be able to keep production going, while still being able to safely do maintenace on inactive parts of the plant.
Very interesting how someone could make such a mistake. What could have confused the technicians is the top doesn't get pressure until the valve opens a little, so they thought the bolts were just mounting bolts.
A good insight.
I just don't know how anyone could possibly not realize that those bolts were holding the top plate, which is the lid to an open pipe.
That is pure insanity.
Same guy that uses a pipe wrench backwards. Maybe?
I was curious why they took off the whole bracket instead of the 2 bolts holding the gear box to the bracket. Looking at the picture did they think it was too corroded to do so?
Or did they want to be able to rotate the wrench through 360 degrees?
The bolts should have been re installed after the support bracket was removed.
I'm not a plant operator, just a pipe fitter.
I wonder if that was as easy to spot in the actual valve.
Seems bloody obvious that that was a bad way to remove the gearbox, especially when you could loosen only 2 bolts to do it right.
I think there's a picture of the valve at 5:55
I’ve been around tons of the 2 types of valves mentioned in this video. It’s pretty obvious which ones you don’t want to go unbolting on a live line and which ones you can. It was either pure stupidity or ignorance as to why the person/s decided to completely unbolt the valve bonnet.
These videos and the CSB are like the embodiment of hindsight lol. And hindsight is 20/20 dont we all know
All of the sudden, everyone in the comments section is an expert on gear operated plug valves.
Thanks for this information
Why not use a stud/nut/bracket/nut combo? It would be cheaper than replacing all the old valves. Or is it that the old valves were so unwieldy/stubborn that a large wheel and worm gearbox couldn't turn them?
I've watched this video multiple times and every time I get stuck on the workers using the pipe wrench backwards. I realize they are not using it on a pipe, but EVERY clip is them using it the wrong way.
It is more interesting because it is a USCSB video animation. So if someone doesn't know how to use a pipe wrench or adjustable wrench properly, how in the hell are they going to know not to remove the four bolts that hold the plate in place? Blind leading the blind.
doesnt really matter its just opening a valve, wrench works either way. they just removed the wrong bolts
Had another fire today 2/12/2020. Didn’t learn anything it seems.
Did I miss something or why didn't they use the wheel to turn off the valve???
They said the gearbox was malfunctioning. The wheel engages the gears to turn the valve.
I hate how they show the pipe wrench being used BACKWARDS. This is a safety video and you guys can't even properly demonstrate basic tool use? On another note, it is called a valve bonnet not a top cap. As a pipefitter, I completely agree that removing the bolts from a valve bonnet that is under pressure is a terribly dangerous practice. Unfortunately I'm not surprised that someone was injured/killed.
I MISSED YOU GUYS
These vids are better than true crime drama!
i don't know the name of this narrator, but I hope that nobody else will narrate csb videos insteat of him 😋 he gives the videos really special atmosphere hehe
Two of the contractors settled 16 hours ago as of the writing of this post, i.e 2019-11-04.
Not sure if I'd like to work with anyone who couldn't identify the hazard of loosening 4 bolts holding down the cap. Even worse would be working for a supervisor who didn't recognize the items that were a possible source of catastrophic failure potential. Who could be in charge of working at a explosive latent plant that would be unfamiliar with it's vavle safety.
There's a reason there are 4 big bolts there. It's not just to hold a bracket for a gearbox. Makes the other thousands of workers who work safely for years look bad, and all the training and safety placards in the world won't stop people who don't understand the equipment they're work on.
Why is there no spectacle blinds usptream of that vavle?
why not keep the gearbox working?
ThomasHaberkorn ayy here’s a smart guy
Good point. Swapping in a new gearbox would have solved it. (Granted if they have any or get it fixed)
How can you not see what bolts to remove? Holy smokes.
genuine question
why didnt they just remove the 2 side bolts holding on the gearbox to the bracket and leave the bracket installed?
Well...if they had been dealing with the newer versions where you removed the bracket with the gearbox.
Then you might be inclined to remove the bracket for the older ones as well.
But they obviusly didn't give this much thought.
Maybe fixing the gear required the bracket(alignment and so forth).
Maybe they've seen it being done that way by others, different being they replaced the 4 bolts.
When you are going through the motions its easy to miss the glaring obvious.
2:09 I thought it was a excepted practice that if the valve isn’t working you grab a big hammer 🔨 and if the valve still isn’t working you grab a much bigger hammer or use a blow torch to heat the valve up!
That's what I'm talking about!
I guess it could be said taking the ol' gas axe to a pressurised valve full of flammable chemicals might be a bad idea.
If you were quick about it you would probably be OK.
I take it you were in Army/military . Regards brother :)
As a Custodian, I think that my employer should show these videos before every shift.