CSB Safety Video: Anatomy of a Disaster
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- Опубликовано: 18 сен 2024
- Anatomy of a Disaster tells the story of one of the worst industrial accidents in recent U.S. history--the March 23, 2005, explosion at the BP refinery in Texas City, Texas, which killed 15 workers, injured 180 others, and caused billions of dollars in economic losses. The U.S. Chemical Safety Board, an independent federal agency, investigated the accident. The CSB produced this video in March 2008 based on its comprehensive 341-page public report issued in 2007.
The video includes a nine-minute animation detailing the events leading up to the blast. It features interviews with members of the CSB investigative team who spent two years studying the causes of the accident. Outside safety experts Prof. Trevor Kletz (Texas A&M University and Loughborough University, UK), Prof. Andrew Hopkins (Australian National University), and Mr. Glenn Erwin (United Steelworkers) provide insightful commentary on the significance of the accident to the world's petrochemical industry.
The CSB believes that an understanding of the key findings, recommendations, and lessons from this investigation will help prevent future accidents. To learn more about this and other CSB investigations, please visit CSB.gov.
“Maintenance workers left the scene early to attend to company lunch, celebrating a month without any lost-time injuries”
Love that CSB included this, what a cruel irony
.................... A MONTH lol
Karma was rubbing his hands so fast that it caught fire.
Based on the state of the refinery, one month no fatalities was a friggin miracle 😂
Celebrate no lost time injury? Hold my beer
I wonder if the deaths still do not count as no lost time injuries because they are no longer employees.
Here I sit, a man of 42, just now realizing how much I always wanted to grow up to be a USCSB investigator.
You can still do it !!!
NEVER too late
42 is so young! This could be your calling! I know I would love to be involved with this...
I believe in you!
@@steamedhamlet no it isn’t, please stop😂😂
Yes, totally agree that Management that ignored reports should be imprisoned for manslaughter.
But this is the oil industry in the US, and they're different. They self-regulate
I get that but in my view this was the fault of the workers. Especially union workers. Corporate types will always do this kind of thing. The union members should have been following procedures regardless of the risk of damage to the system and force the hand of BP to update the machinery.
"You broke it"
"No I followed procedure, good luck trying to fire me for it" and hit them with "it'll break again, every time I fill it because I refuse to deviate from procedure"
Then notify OSHA.
The union is as weak as you allow it to be.
Murder not manslaughter.
@@w12ath040211 workers are only one part of the equation. The organization that leads to simple workers to be able to end up in catastrophe scenario is more responsible than the workers. If you want the corporate salary you also have to assume the corporate responsibility
"they can just notify osha"
Yep then they lose their jobs and can't fight back legally against the giant that is BP
A management who is making sure the responsibility is on workers is a management which will always eventually fail
Random factory workers should never be able to be in a position where one of their mistake can end up in billions of dollar of damage. It's on the organization to make sure this doesn't happen. Having your refinery depending on a dude who has been doing 12 hours shift for 30 days in a row is a disaster of an organization and the fault is on BP, not on the workers
Do you really think the workers didn't care about dying on the job and BP is completely innocent here?
The organization that lead to this are the criminals here, not the dudes who had no rest day in a month
@@azerty1933 I don't know what world you're living in. Where I work OSHA does mean something to the company and you cannot be fired because you notified them. In fact it's against the law to do so.
And even if you were afraid of losing your job, that means continue to operate under unsafe conditions putting yourself and others in danger? If you do that you have no balls. The employee has to put their foot down and say no. I've done it before people I work with have done it, if it is a legit concern the company can't retaliate against you.
Professor gave best quote;
If you think safety is expensive, try a accident...
As long as it isn't on the current and short lived executives watch. Thats the problem with switching leadership every 2 years. Nobody knows what's going on. It's a tactic used on purpose so they can claim ignorance when they deem the enivedable happens. Thats their mindset. It's going to happen eventualy so protect yourself from the conciquences by switching executives often
Too big to fail
Bars.
*mic drop*
an*
I wanted to make a reference to the Titan submersible, but the CEO cut corners because he was an idiot, I don't think there was a monetary motivation behind it. I could be wrong tho.
This is why I appreciate the CSB, as well as the NTSB, both of their reports are made so that a person with average intelligence can understand what went wrong, no having to hire an expert to understand the final report.
Thanks bro, didn't realize the NTSB did similar reports. I have a great binge watching session ahead of me thanks to you
Yes ! No legalese jargon used.
Well when you’re making reports for congress, you have to make it very basic for them lol
More than average intelligence I would say limited knowledge about the subject
and great animations. AND THEY POST THEM TO RUclips!
So many red flags in the first few minutes of this vid:
"operators routinely deviated from written procedures"
"second alarm [...] failed to go off"
"lead operator left the refinery early"
"30th day in a row, working a 12-hour shift"
"day shift supervisor arrived [...] more than an hour late"
"board operators and others had received conflicting instructions"
"contrary to BP's own procedures, no experienced supervisor was assigned to replace him"
The list just goes on and on. If their intention was to blow the place they couldn't have done a better job (or worse, depending on your perspective).
Sounds exactly like my trucking company. We are worked 17 hours a day. They misuse ag exempt to extend drivers days by 6 or 7 hours a day. They even blow your phone up at 3am to wake you up knowing you have been off work for only 4 hours on a daily basis. We have had 3 drivers crash rollover and die in the past couple of years. Many offical reports complaints have been filed to the dot and its clear zero investigation has been done by the DOT. our safety laws have zero bite and all bark. None of it is enforced at all
“TCS kills someone in the next 12-18 months”
@@prestonhanson501 agreed, not once in my career have I seen an OSHA rep. Always a day late and a dollar short
@@kevinburgess5066 anouther useless burocracy eating up the wealth and doing nothing. Anouther useless parasight bureaucracy
"His tenth 12-hour shift in a row". Working hour limits are good for more than the health of the worker.
+Daniel Nebdal Blame the unions for that. Workers never wanted 40 hour work weeks, they only used that lie for leverage to get overtime. These insane hours and work schedules, and the resulting worker fatigue, are the results of hour hogs who want to rake in an endless amount of over time pay. That's why not much is said about it in the video, and why they blasted upper management instead, nobody wants to insult the unions, but every loves to bash the top execs.
Which is, of course, why the unions in many western countries has negotiated laws to limit how much overtime it's legal to work (even when the employee claims to want it).
If the unions in the US were somehow much stronger overall than in e.g. Norway, you might still be right ... but I'm not convinced that that's the case.
correction ..... 30th day in a row for 12hr shifts
Seems to me Management is mainly to blame for this accident, Oh give me that shit about overtime, especially during maintenance outages, Lot of Forced Overtime when Undermanned as mentioned!!!
Sounds just like the Power Plant I Retired from, You better learn what YOUR Talking about before opening your MOUTH
Sounds like a MAJOR management Issue and they don't give SHIT ABOUT the WORKER'S well being and only satisfying the Corporate Board
I'm in the oil industry and BP has had a bad safety reputation for decades. They're a bad apple; no one I know was surprised this happened to their refinery. Since the accident, they have moved the contractor buildings back to the accident site location, claiming it was too inconvenient to have them farther away. No lesson learned at all.
How some company could think it's a good idea to risk such stuff is beyond me ... seems like it would be more expensive and detrimental to the business in the long run to have disasters and accidents (which cost billions of dollars!!!) rather than slight occasional setbacks!
I’m not even in the business nor do I follow it closely at all, and even I can list at least 4 incidents where BP screwed up and hurt or killed people. Not the least of which is the oil rig fire and spill in the gulf of deep water horizon.
I think it’s time to send them back to Britain, I mean how many times have they blown up Texas City now? 3 or 4 at least right?
Wow just wow.
"British" tells the whole story. Sending the proles to the grider to support the upper classes.
hell, if i worked for BP i'd quit and find a better company to work for.
BP 3 years later: "Deepwater Horizon"
5 years later, but your point still stands. Federal oversight (OSHA) is big oil's bitch in most states.
Consider this a Texas company offered to stop flow day one BP told out government to stop them because they would damage valve. They finally drop a dome over the valve. They put a dispersant that had been banned thirty years ago. President ordered them to stop BP told him to get lost.
@@ronniewall1481 Wait, someone had a plan to end it a day, and BP told them to get loss because it would damage their already busted valve? Do you have the company name, or something I want to read up on this.
@@mabsalom1
OSHA is horrendously useless.
Not as bad as EPA but...
@@mabsalom1 I was in Houston TX a few years ago and got to speak with some oil people (Houston is overflowing with oil people). I asked about Deepwater Horizon and what they thought of it. To a man they agreed that the fault was squarely with BP because they were doing crap they shouldn't have been doing in order to save money. It's always about the profits, never about safety or people.
When I was in Houston 2 years ago, I met a number of oil workers and executives in the lobby of the motel in which I was staying. The BP disaster in the Gulf came up and these men, to a man, said the same things that are being said in this video - that BP apparently places much higher premium on saving a few cents than in doing the job correctly. The Gulf disaster was caused by stuff that, according to the men telling me the story, should have never been done. It was stuff that they knew better than to try, but BP wanted to save a few bucks.
Edward Hara The whole engineering team that was on that oil rig advised BP about a number of safety issues and concerns on the rig. You know what BP did? They fired all of them and hired a new team of engineers. Guess what happened 10 days later...
pretty00lights Yup. Complete lunacy to save a few bucks.
+pretty00lights
This is what happens when you have shithead old-money business execs with zero engineering perspective managing dangerous projects like this. The first thing they think of to cut is always preventive maintenance, which is a major part of fixed costs. All they see is the bottom line, not the extreme limitations and "looking the other way" required of engineers and supervisors on the ground to keep it up.
BP should be banned from the US and sued into the ground and the top end jailed for life after that godamn mess in the gulf
At a steel plant I used to work at, there was a saying, We don’t have the time to do it right, but we have the time to do it over! Any accident where someone got hurt or killed, the company didn’t fix the problem, just find a way to blame the injured or deceased. Foremen and supervisors, who had been on the jobs for years, were replaced by college graduates, most with associate degrees. They had no clue on how we did our jobs, but they would tell us how we had to do it. Jobs that used to require 3 people were down to 1. Safety rules, that if disobeyed got you 3 days off without pay, were discarded. Safety was a 4 letter word!
The very last line of this documentary says "In 2007, BP accepted the recommendations of the Baker Panel, including a call to become 'a recognized industry leader in process safety management'". In 2010, Deepwater Horizons happened. Kind of says it all.
The way you stop this kind of Corporate BS is to gather the CEO, COO, CFO, the Board of Directors and all executive VPs and chain them near these types of processes, particulary during start-ups. THEN tell them that the plant hasn't had proper maintenance due to budget cuts. They stay in place 24-hours.
Greed in the name of the "stockholders" just to raise earnings a penny or two per share is the cause of S like this and should be criminally prosecuted.
In my opinion in such situations greed should be considered a Malice, causing a criminal prosecution as murder
I like this idea
Nah, that won't make them realize. Instead they'll just stand there with their stupid phones in their hands playing games, tweeting, or doing other things.
Didn't DuPont do this with powder mills?
But that isn't the American way. That's how they do it in countries that know how to use the metric system, have health care, and do recycling.
I’m from Texas and to this day BP is probably the most hated company round these parts. I personally knew someone whose business was affected by the massive oil spill in the Gulf. The ecological impact on the seafood industry was tremendous. Even to this day the reputation of Gulf Coast seafood is put into question. The poor guy and his business partner went into massive debt to try and save their business, but the damage was already done. He ended up taking his own life after losing his savings and being unable to recover financially due to the irreparable harm BP caused to so much of the industry.
Damn that’s a tragic story!!
How about having a new policy: A member of the BP board of directors must be present on the facility at every major startup of equipment.
Either things would get a lot safer or youd have a lot of "turnover" of board members.
Like the board of directors know safety policies? They delegate that responsibility way down the food chain.
William K but they would make sure they delegate to competent people, while standing next to the units
Do you think the board member will turn over as he flies through the air?
Depends on whether he/she has overeaten at the self-congratulatory executive luncheon.
I just gotta laugh at how people blindly blame board members for the clear faults of undisciplined, dumb and lazy workers. Safety procedures are as safe as the dumbest and laziest worker carrying them out.
The BoD cannot be there to hold hands of thousands of their workers. As an example: an employee who breaks protocol and leaves an hour early without briefing the next shift; a manager who goes home mid-shift; an employee who sees that the fluid level is 50% higher than desired but does absolutely nothing about it; a manager responsible for deciding where to drain the fluid who fails to decide. Should I go on?
When I was a teenager living in Houston all the men I knew who worked in the oil industry ALWAYS advised me to never work in the refineries. As I completed my BS degree in Chemistry my father (who had worked at Goodyear post WW2) reminded me to stay away from the oil industry. I think it might be too easy to zero in on BP as a worst case actor when in truth the entire region has embraced a general lack of safe practices as far back as anyone can remember. Anyone who has worked in the chemical industry as I have for years (37 for me) can tell you stories all day long about misses, near-misses and accidents that got people killed. When times are tough, men, good men, men of honor will take a job knowing full well he is risking his life every shift. Why is it times are always "tough"?
Times are always tough for the worker when there's money in it for the boss
So long as industry is in the hands of the free market it will never be safe.
life is tough not the times
@@MarxistMedia black lies matter to you
I always wondered why anyone would want to be a coal miner (I don't even like being in an elevator), but when you gotta' take care of yourself and family, you do what you have to.
I don’t know who is in charge of the CSB but these videos are amazing. I would expect something like this to be dry, boring, and not able to hold my attention but I just can’t stop watching.
There’s real drama here. Nothing artificial.
it is because it focuses strictly on the relevant facts in a well delineated narrative, there is so much fluff in most documentatries these days that the technically minded tend to have their eyes glaze over and begin drooling within a few minutes
@@wcatcher5622 ⚠️🤓
@@MrHastygamer Oh no a nerd alert in a chemical safety board video what a shock, It's like I showed up to the club wearing suspenders and my pocket protector, PLEASE DON'T HURT ME MR BULLY HERE TAKE MY LUNCH MONEY 💸💸
Death
I love how well these videos are put together. These are the best safety videos out there. I hope the CSB makes more of them. They're really important so that professionals and the public can both access accurate, meaningful information.
Agreed. Its sad to see the corporations put money before lives
I agree. As a layperson, I always find I understand the issues thoroughly. I'm hope that there are so few more recent videos is because the CSB's recommendations _are_ being implemented. I would love to see follow-up videos made perhaps five years later.
They make good presentations because that's what Safety guys do for a living. They sit at a desk all day, they aren't the one on the factory floor that actually knows and does the job themselves. Then when an actual worker has an accident, the Safety guy steps out of their air conditioned office and plays a game of Shoulda, Coulda, Woulda. Factories have Safety guys, and their job is to burn the employee as negligent; and the government has Safety guys whose job it is to burn the whole company.
@@realkingsport3052 Wow, who peed on your shoes? I guess you never noticed how these "Safety guys" say they recommended that OSHA or other regulating/rule-making agencies upgrade their requirements or standards. I guess you don't think that valve that stuck open, or that corroded pipe that burst, or that alarm that failed to go off, didn't _really_ have anything wrong with it. Tell me, just who do you think IS responsible for these accidents if it's not the employees or the companies or the regulators? Saboteurs? Gremlins? Go clean off your shoes.
@@DalokiMauvais Try and pay attention knucklehead, I'll explain it real slow for you. Front office middle managers at a company make all the decisions, management tells you how to do your job even though they don't really know how because they have never actually done any of the work themselves. Factory workers are the ones who do all the work, but they aren't allowed to make decisions, they just follow orders. Then you have Safety guys, those that work for company and the government, whose job it is to "keep it safe" but 95% of the time that usually means writing up workers for violations. How can you hold people at the bottom responsible for accidents when they literally have no control over the way a company operates? Because its not about "Safety", its all about government control and bureaucracy .
The executives who order the budget cuts probably got a huge bonus for their cost-saving measures.
You know they did. They never learn. People always die.
It's funny cuz they cut 2 critical employees and made the others work over 30 12 hour shifts back to back... After all "why pay two when one will do?"
The lesson learned is that it can still keep making money at expense of others' health or life
I cant stop watching these... I used to work at Abengoa Bioenergy at an Ethanol refinery where things were MUCH worse. I quit after 6 months and an E&I technician died because if poor operator training. Dodged a bullett
This is where a strong union can help workers push back against unsafe conditions.
I spent 7 years of my life at an ethanol chemical refinery. I was a board operator. Safety and doing things correct were always my priority.
Nothing should be asumed and no one's life should be risked.
Safety is a self defeating program. If the safety department does their job to the best possible level, management eventually gets complacent; "Why do you need to increase your budget? We have not had a serious incident in years." "Sir, the reason we have not had a serious incident in years is because we have built an excellent safety program which must be maintained." "Oh, we'll do that another time. Things are running fine for now- profit this year is most important." all they can see is that big bonus at the end of the year.
Then the safety department falls apart until the next major accident. Management never seems to learn their lesson about maintenance and safety.
Sad cycle
Agreed, it’s one of those positions where if you’re doing a good job, it’s easy to forget why you’re needed to begin with, and if you aren’t then you definitely aren’t needed.
We're there consequences?
Typical example of the extreme short term thinking of many American corporations
@@FF-pi9fq Not only american, but it is indeed something I'd associate with the "capitalist dream", so to speak.
Note to self: if my car ever starts revving for no reason, gtfo and run like hell
The problem is how do you know which way to run? 01-13-2020.
Turn the key off and floor the accellerator . That changed the fuel/air ratio enough you won't get combustion.
@@raymondedge8889 It was a diesel engine. It will simply burn whatever it ingests if it is flammable. It will run away and there's no throttle to limit the intake. This is something that we are taught to watch for in firetrucks around propane leaks. This can also happen if the oil seals on the turbine side of the turbocharger blow out. It will take off on engine oil.
@@raymondedge8889 It was diesel, they have no "throttle". Accelerating just adds fuel.
Just run faraway fast! This happened to Chevron Huntington Beach! If your vehicle is inexplicably accelerating the air is charged with fuel! RUN!!!
When BP has a history of fatalities it's "business as usual" but when I have a history of fatalities it's "he's a serial killer"
Lmao
My Grandpa was in the 1947 Texas City explosion. He was about a half mile or so inland on a scaffold painting a building. the force of the blast knocked him off the scaffold and briefly unconscious.
Simple facts presented in a concise way.
I remember first hearing of this event through the "Seconds From Disaster" series. Found it very difficult to take seriously when there was an overly-dramatized description of the pickup truck where the narrator was talking about the "carburetor system" on the truck and showing close-up footage of the A/C hoses on a random non-diesel engine.
Subscribed here after seeing this video because this is what I was wanting to see all along.
I know right, im a mechanic by trade, i turned my nose up at that explanation, leave it to media,
And it's interesting that NatGeo (creators of "Seconds From Disaster") interviewed one of the CSB members along with some of the survivors and their families, the daughter of two of the victims as well as a TCFD (Texas City Fire Department) firefighter
I HATED how those shows extremely dramatize those scenarios.
I remember you could pick out those shows because they would ALWAYS have post edited sirens, screams, explosions, just a verity of sensational sound effects _along_ with fast editing/cuts.
Sometimes I'd really want to know the information but their presentation of the show into something that looks like it was aimed towards children made me sick.
@mikeysgametime8914 seconds from disaster was an entertaining show but always got most mechanical and architecture aspects WAY wrong lol. They did one about 9/11 and claimed the buildings were tube structures and even had diagrams showing the buildings being hollow tubes when the official blue prints and videos of them being built show they were core structures😂 or the episode where they tried to talk about airplane jet engines and made a huge mistake and said they ran on diesel.
Diesel engines don't have carburetors tho, but as far as the a/c lines go, well that's just plain hilarious 😆
Yet only a couple years later, BP still had not learned it's lesson when the Deepwater Horizon blew up and AGAIN people died!
They learned their lesson: Keep operating like this because there are no financial repercussions that would outweigh the amount of resources that would have been necessary to prevent these things from happening
I think Bp simply doesnt give a fuck
@James Horton Hey how much are BP paying you to shill for them in the comments?
BP was and still is an extremely arrogant company. BP employees can get reprimanded for even mentioning Deepwater Horizon. The company I work at sometimes gets orders directly from BP and their specifications are always messy copy-paste jobs that usually make no sense and are often contradictory. When you ask BP for clarification they'll make every possible effort to avoid giving a direct answer because then they'll have to take responsability.
It's even worse when the order comes via an engineering company. They don't dare to question anything coming from BP, the default answer to any question is "just follow the specs" and more than half the time they don't have a clue what they're talking about. it's a miracle disasters like this don't happen more often.
5:16 - 5:30 clearly demonstrates the kind of sloppy design that causes accidents. For safety critical functions you'll want two out of three (2oo3) functionality where the alarm is sounded when two instruments detect an out of bounds value. You can use two instruments but then 1oo2 voting has to be used but in both cases the system should always fail to a safe state. Whenever I see this sort of thing it's a clear indication that somebody considers profits more important than safety and I'll give them a "Thank you for your hospitality, I'll be leaving right now" speech.
As for 18:15, I have an even better idea: how about we give those managers an office right in the middle of the facility and the let Darwin do his thing.
No lesson to learn, they make billions of $ pay a few fines all is good. To big companies workers are expendable...
Narrator: *mentions BP Oil in the first few seconds of the video*
Well there's your problem. BP was trusted that its learned its lesson for the millionth time.
So let me get this straight... they kept records of employee injury statistics which
did not take into account FATALITIES. Hmm, I wonder who came up with that sneakiness... absolutely disgusting!
How exactly do you keep a set of injury statistics that exclude fatalities (unless you’re considering them separately)? Surely death is the highest form of injury?
Its not them, it's an industry norm..likely calculated as directed by Java.
@@fetchstixRHD strangely, no. I have an electrical contractor business. I sadly had an employee die on the job - he had elected to consume alcohol over lunch break and stumbled into a 600 volt panel. As an employer the liability is determined and paid by the insurance carrier, who naturally used the results of his autopsy to refuse to pay the death benefit. When I expressed concern that his wife and children were going to suffer for it, the carrier explained I was free to pay it myself, though to do so could open me to civil litigation as evidence of fault. When I asked what figure they would have to pay, it was well below the cost for serious injury and even less than moderate injury.
The reason is once you are dead, you won’t accumulate any more medical costs, whereas an injury could require a lifetime of medical care.
gotta love the way that the powers that be interpret statistics... goes all the way through to the govt.
On the other hand, you would not want your death statistics to be obfuscated with injuries. They should be recorded separately, but analyzed and acted upon jointly.
"we found that inspections in the US were largely driven by personal injury statistics" (47:00) in case you were wondering why the obsession with personal injuries rather than the actual risk of disaster
16:39 Two major accidents resulting in 3 fatalities in 2004.
“Yet the same year, the refinery has the lowest recordable injury rate, a statistic that does not include fatalities.”
... are you for real.
This is why you have to be very careful when anyone presents you with statistics. They rarely include the full picture.
I am beginning to Study Safety engineering in Germany and my first "Homework" is to watch this Video XD
Lesson 2: Watch the movie "Zerodays" (STUXnet)
We obviously need a lot more people like you. They should be mandatory at every site.
Good luck, Petsto, and stay safe
It's the US CSB, not the German CSB. Stop stealing from us, you elected Hitler, remember that.
@@ATLTraveler are you okay?
Was anyone else reminded of a fellow co worker when you heard about the supervisor who was a hour late and left before their shift ended? I think every work place has that person employed somewhere and if no one comes to mind then chances are you might be that person. Also I like how the CSB animators included an empty chair in the control room to signify that BP had eliminated that position. Good call.
"A" hour ........
@@dyates6380 that's alot of time to be late. Most places will fire you if you're constantly late and leaving early.
54:10 "In 2007 BP accepted the recommendations of the Baker Panel, including a call to become 'a recognized industry leader in process safety management.'"
And then nothing bad ever happened again for BP. Especially not in 2010. Or 2014. Or 2016.
What happened those years?
@@00bean00 Ugh! RUclips deleted the comment I made, since I linked to articles. Here's a quick re-write.
I wrote that comment about 1 year ago, so I'm not entirely sure what I was referencing, but here's what I've found:
2010: Deep water Horizon. There was also a chemical leak in Texas City, Texas. "In August 2010, the Texas Attorney General charged BP with illegally emitting harmful air pollutants from its Texas City refinery for more than a month. BP has admitted that malfunctioning equipment led to the release of over 530,000 pounds (240,000 kg) of chemicals into the air of Texas City and surrounding areas from 6 April to 16 May 2010."
2014: "One serious near miss was at BP’s huge oil refinery in Whiting, Indiana, in 2014, where failures to record data properly led to $258m in lost production, the report found. Another was at BP’s chemical plant in Hull, UK, where a piece of equipment was not operated correctly, causing damages of $35-45m, while another failure saw critical blueprints that “had gone missing during critical operational activities”." Quoted from a Guardian article about "near-misses". Not quite the same thing as the video was talking about, but I would not call that an "industry leader in process safety management".
2016: I couldn't find anything. I suspect the information might have been covertly removed or buried on Wikipedia over time - it's a thing that does happen when big companies get bad press. Hire an outside contractor to combine dedicated pages into subsections of articles, then reduce that down to sentences, then remove those sentences, over the course of months or years.
It's also possible I was completely mistaken about the 2016 thing. I'd like to think I didn't just grab that out of thin air, but it's possible I was just plain wrong.
Hope that helps!
@@00bean00 Deepwater Horizon in 2010, not sure about the other two
Or 2023.
Mandatory watching for Chemical Engineers
I watch these occasionally, always keeps me on my toes when I go back to work.
This RUclips channel is one of the best on the site. Not even because of the safety learnings but because of the production value and the interesting scenario
So they rebuilt the plant and passed along the cost to us, BP didn't lose a dime, they probably made money on the deal. Someone did.
Rogg32 they probably have life ins policy's on they're employees with them or an "agent" of theirs as the beneficiary so they make money off of death and dismemberment
Rogg32 yep, and this is why laws granting corporations the rights of a person yet zero of the responsibilities must be revoked.
Why would any of these greedy SOBs care if there actions carry no personal consequence.
It’s insanity
@@Justathought81 Not insanity. Calculated GREED. Money in and money out and the human cost is just a part of the variable.
We are no more than cattle to the people that make the bulk of the wealth and thereby control most of world.
Shareholder equity, shareholder equity, shareholder equity. I read the oil companies annual reports and that's all they talk about. Never, never is there any space devoted to employee safety. Other chemical companies are really committed to safety but the oil companies are still in the dark ages. I really admire refinery workers, they're committed, hard-working folks. Management needs to step up and protect them. I've been to this refinery a number of times. As a visitor you watch a brief safety video and are issued a respirator along with PPE you need to bring. The facility is so large and so complex accidents are bound to happen but management must be committed to safety as the most important product made at this facility. It just makes me feel so sad and so mad.
Well yes, sadly that’s what the annual report usually only talks about: financials. CSR reports would talk about safety but sadly those aren’t as widespread and common, or even required.
Publicly owned companies are the spawn of Satan.
Correct. Pursuit of profit above all else caused every incident this channel describes.
I just discovered that the CSB is investigating an explosion that killed three people about 7 miles from my home 2 months ago. Although the resulting concerns about toxic chemicals did not reach as far as my town, I still feel safer knowing these folks are on the job.
BP has a very bad reputation. They have been responsible for so many horrible accidents and they rarely face criminal charges.
you can say they never face criminal charges
They're too big to jail and in the US, the oil industry is self regulating.
Interesting coincidence: BP's own safety engineers predicted a Texas City plant would kill someone, and three days later it did. In 1947, a safety engineer said publicly that he expected a fire or explosion in Texas City, and two days later a freighter full of ammonium nitrate went up and took a good chunk of the city with it.
It's almost like those safety engineers knew what they were on about ;)
Maybe we should stop transporting large amounts of ammonium nitrate, it seems to blow up a lot
Something similar happened to me in stagecraft at my high school, the dance coordinator told all the dancers to stand in the same corner of the second story of the set. I warned her not to do this as the set had not been built to withstand this much weight. Minutes later as I was watching them continue I heard a loud cracking and yelled for everyone to get off. The big fat guy in the corner barely got off before the whole platform collapsed. After that, we reinforced the sh!t out of that thing...
@@JayPersing
What are you going to use to fertilise the crops instead?
Like many other things, ammonium nitrate is fine as long as it's managed correctly.
@jerry2357 I said "large amounts" the operative word being large. If course we need fertilizer but maybe not more than a ton per truck/storage area
The CSB is the best usage of my tax dollars since national parks.
Another splendid documentary and analysis of BP's lousy management culture
This would be hilarious if it weren't so tragic. I couldn't help cracking up at the ridiculousness of the chain of events and the narrator just adds to it
Geez that poor operator! Doing the work of 3 people and topping off having worked 30 days straight of 12 hour days.
Fukushima had a similar problem with a level meter. Only level was lower than the instrument's specification,not higher. Decades after the moonlanding and we can't even build reliable level gauges?
Watch the movie more closely. It states that the operator overfilled the tower beyond the range of the leveltransmitter. At that point you are going beyond the design parameters of that instrument. Its like asking a normal family car to do 200mph, it just doesnt work.
Bottom levels of fractionators or reforming towers are very tricky, even with modern leveltransmitters.
i'm a maintenance engineer for instruments/transmitters in an oil refinery. And the whole picture of budget cuts and poor training is something that still happens to this day unfortunately.
It doesn't matter when someone circumvents the alarm on purpose.
perhaps the level meter should have a wider range to determine overfill
Well, those idiots put their backup generators in the basement right next to the ocean where they are prone to earthquakes and the resulting tsunami waves.
Ultrasonic level sensor: $9.
Aaaaaannnnnd - this is why businesses need oversight. They never do the right thing unless they are forced to.
You are right..Its way cheaper just to build a new plant,,
Ima fan don’t forget that BP execs have been found in bed with government regulators 🤔
If there’s one single thing we’ve learned from History; ITS THAT WE DO NOT LEARN FROM HISTORY!!! Since “government oversight” became a massive thing, especially in the USA, safety and well-being of the workers has become MUCH worse. There’s a REASON that many push hard for LESS government oversight. When you give the government the power to tell people how they’re going to do things it’s a problem. Look at history and do some research. Seriously, not anecdote or what you’ve heard, spend a few minutes and do some reading. Plenty of documentaries with TONS of concrete evidence that before the government decided they need to be in charge of everything that safety was better, injury and accidents occurred less and when they did it wasn’t nearly as catastrophic. Look into it, you’ll be mindfucked. I know I was.
See 46:50.
OSHA may have the power but clearly currently lacks the resources to provide that oversight
I have actually worked at a plant. It’s true sometimes... a lot of companies actually go far beyond what is required. Some of these government agencies give out shit requirements though which degrades the respect in the recommendations.. I remember they once told us we needed recolor our lights in the control room so that color blind people could tell the difference.. I’m sorry but you need to see colors to be an operator in the control room.
BP is a serious habitual offender. I was in the Army and it felt safer than working at BP.
Thanks for your service
Imagine being one of the contract workers and having forgotten something important in your car/truck, and while you’re in the parking lot getting your documents or other items, everything behind you self destructs
"Brought in some raff to unit, to pack raff with"
i am always this one guy at work who points out that something isnt done according to the rules. i let boss kno bout hazards and broken stuff thats a risk. i usually get fired after 3 months. i used to be sad afterwards but with time I learned that they actually save my life.
You should tell other workers and report it too!
You're doing great work !
You put yours and the safety of your coworkers before their profit. And that shows integrity and leadership.
You're fighting the good fight
Yeah you tend to be viewed as a threat.
You would probably do well in a risk assessment/management role. Lots available between industrial and insurance industries. That way, at least you’re getting paid when they ignore you.
@@harate ayo that's the job I'm after
You get fired "usually" after three months but you still get hired somewhere else without any red flags to the HR person? Don't get me wrong, I applaud you IF you actually are the "one guy" who points out deficiencies, but I find it highly suspect when you say you're getting fired for pointing that out. If that is the case, I suspect you'd have a pretty good case for wrongful termination and also a story that most industrial facilities would NOT want to be known for - which is wrongfully firing someone for pointing out safety issues. That's NOT a termination situation. Sounds a bit fishy .........
@@dyates6380 it is pharmacy and i can assure you they like delusional workers who dont give a shit.
Just a ridiculous amount of systematic and human failures. BP should be embarrassed of themselves.
This CSB video is so well done. Very thorough, with expert opinions on all the problems.
Whoa whoa whoa. A ONE HOUR CSB video? Let me get the popcorn and settle in, this should be good.
Joking aside, I love this channel. I have a weird fascination reading about disasters and such. I will read hundreds of pages of NTSB and inquiry reports because I find it all super interesting. If we could only get more people and management of companies handling processes like those shown on this channel to watch and learn from these videos, lives would be saved.
Great video. It has been 10 years since the incident, a good time to review what happened, the lessons learned and what is being done on our workplaces to protect people, environment and assets.
"TCS kills someone in the next 12-18 months" lololol
Talk about being jaded to the problem!
That's almost funny to hear... until you realise that they were being serious, and multiple people actually ended up dying. How can you have that as an item of concerns to start off with?
This teaches us :
1- Unionize your workplace
2- Request the strict application of safety and security guidelines (better risk being fired than set on fire)
3- Report any and all transgressions to the appropriate authorities
4- Cuts to security and safety because of "productivity " or "speed" or "budget" should be met with a strike.
5- Your employers put profit over YOUR life. So don't put THEIR profit over yours.
6- Unionize your workplace, I'm serious, these vultures will try and get away with anything, they have emergency funds MADE for lawsuits, fines, accidental deaths, etc.
7-Vote for political parties that support workers, NOT corporations
CSB does very good work. I just wish more people who work in hazardous situations would watch these and think about the hazards and how to avoid them wherever they are. An explosion in a tank manufacturing operation in Ottawa Canada has killed 6 people. January 13, 2022. It happens too often.
This is so damning to BP being able to carry on as a legitimate business operator. That the US government would ever continue to grant permits to such an entity shows how deep our own corruption is.
Its all about the money baby! Lives of people mean nothing if they can continue to earn money.
The shareholders are part of the problem, as they don't care how the company makes money, only that it does.
Shareholders even being a thing that exists is a problem, with widespread detrimental effects to civilization itself.
Mutual funds... Hundreds of companies, they don't care
Most of the shareholders don’t know they’re shareholders. They buy some fund that has stocks in whole groups of companies. For instance, if you buy into the S&P 500, you own stock in 500 companies. Do you know which ones? There are lots of those types of investments...
BP pays dividends quarterly to its shareholders.
I know this as a shareholder (I inherited them, didnt spend money on them, I enjoy the free money tbh)
You're probably a shareholder if you have any sort of retirement account.
these videos are so insightful. am a chemical engineering final year student majoring in process control and design. these videos give me that industry mentality and advancement in studies of processes. SUPER LOVE THEM CSB is the best.
I know it's been 10 years since this happened. I also found out that 2 people were scalded to death 6 months before the big explosion
Deplorable! And the suits pay fines-NEVER jailed!!!
As if I didn't hate BP enough already! I avoid this company like the plague. Never will they get my business.
I do the same, and so should everyone. Maybe then, they'll get the message.
BP sure likes disasters, explosions, and killing/injuring their workers. 16:32 seriously?
Statistically, a business that has never had an accident is the most likely to have an accident in the near future. Since accidents don't occur often, the fact that this company has had a few recently means that, statistically, they are likely to go years and years without any more occuring.
@@realkingsport3052 Ah yes the vegas method, 23 IS DUE BABY!
This company’s on fireeeeeeeeeeee
I understand Congress has cut the funding for the CSB in the 2018 budget. It would be disastrous if the excellent work done by the CSB were jeopardised.
I understand Congress has cut the funding for the CSB ok so i didnt know about this so prehaps you could explain to me why they had to?
@@firefox5926 Can't let people's lives get in the way of all that money, can we?
Mike G all government agencies get funding based on the year before and any new or upcoming expenses that are foreseen. What ends up happening is they justify their budget not based on need, but based on previous years budget. Often they go on spending spree at year end so they can prove they needed all the money they were given. It’s healthy for these agencies to have budget cuts to reduce waste spending and boost efficiency. You can then reinvest in more efficient agencies in the years to come. It’s a good thing.
@@firefox5926 Actually CSB's funding was 11 million Dollars (www.safetyandhealthmagazine.com/articles/17160-senate-joins-house-in-approving-budget-for-csb), meaning it stayed the same (as far as I know). But of course the Trump administration wants CSB gone, just like NASA, NOAA and what have you.
@@blawson3603
Yes and that is why trump needs to end up like JFK to make America great again
Known survivors:
David Crow, Construction Engineer (suffered broken legs as well as having his back broken in 6 locations)
Alyssa Dean, Office Manager (suffered broken back, gallbladder had to be removed, burns to 20% of her body)
Known casualties:
James Rowe, Department Superintendent
Linda Rowe
I cannot get enough of these CSB videos. You get to almost taste and smell the situation! Amzing stuff. 100% factual?....count me in!
I'd rather not taste and smell the situation... It's making me light-headed XD...
I must say that BP didn't even use Lagging indicators for safety considerations boggles my mind. I work at a pizza place and even we use Lagging indicators of Burns, Cuts, and even someone making a pizza the wrong way to tell us what we need to change to increase safety or Efficiency. If we can do this at a 1Million dollar Pizza shop, Then a multi-Billion dollar corporation can do the same for a Multi-Million dollar Facility.
The most ironic lunch ever
What's awful is I heard the USCSB budget was proposed to be eliminated. It's no wonder oil companies hate it.
People think these safety cut into costs too much, but the reality is they cost far less than having a failure. If the government wants to eliminate these to boost production, they’re gonna have a bad time. Just look to the 1890s industrial practices and accidents. Sinclair’s “The Jungle” shows why these safety measures are desperately needed.
these innspectors aren't interested in keeping people save all they are interested in is generating revenue for obummer.
@@realkingsport3052 One Big Ass Mistake America.
@Kissalude CSB is an advisory board that has no ability to do anything except make recommendations and these videos. It's pretty useless, and though I like these videos, it's a waste of taxpayer money.
@@TiberianFiend It is absolutely NOT a waste of tax money. It raises awareness not only in the industry but among citisens.
The reason for this and many other accidents can be expressed thus: - Busimess (money) vs Employee Training and Safety = Business wins, every time.
Ok let say in takes 30 mins to fill the tower at 9 feet. So if the liquid is still flowing after 45 mins then where is the liquid going ?
When you got 1 person operating 3 functions and no senior management on duty!!!
Goooooood question!
Systems like that should have a timer/flow counter system that shut off the flow automatically at a certain point until it’s been checked and confirmed by a worker and is manually restarted
@@roadwolf2 Yes, there are many safety systems that could have circumvented this disaster, even their _own_ had it been maintained, though their budget for process safety was $0.00!
Boss: How's the safety meal event going
Supervisor: I got Greg by himself doing his 30th 12 hour shift managing multiple systems on new software, a one line shift report log, and no supervisor cause I'm leaving early. Also I put in a request a month ago to address the numerous alarm systems that don't work, but Greg can eye ball it for now.
Boss: Seems legit
I’m a traveling union worker and took a call to work at BP. After watching this video someone is not showing up and going to take a call elsewhere!
I've had work orders to fix my burned out streetlight closed 3 times, and here I am 3 months later and it's still out, having left notes in the provided note field on the last 2 reports that "the previous order was closed without the light being fixed".
I guess I can be less annoyed after watching this.
Even when these accidents have been caused by employees to me it seems its almost always because upper management override the safety to save a buck.
I watched all 55 minutes, very educational and anybody in the industry must watch this.
I'm a machinist and I still enjoyed it
These CSB videos are addictive!
Challenger, GO at throttle up! Another classic case of what happens when “previous deviations become accepted as normal”.
Every place I’ve ever worked I’ve heard “we’ve always done it this way”.
That phrase sickens me lol. In the military and now in manufacturing
Am addicted to this channel, I can't explain why.
Rip to the 15 lost.
Gutting the company and prosecuting individual board members alongside the company as a whole would be a helpful outcome. Those BP boardmembers will think twice if they're gonna risk being forced into personal bankruptcy.
More to the point, things will change when shareholders have to bite the losses resulting from lack of attention to safety. When fines for safety violations become painful enough to cut profits and damage the share price, then you'll see shareholders start getting safety-focussed.
3:06 The thing people who say "that will never happen to me" almost never realise is that everyone else thinks this, too. When something only happens to someone else, you're someone else's someone else.
If you wrote a novel using the same chain of mistakes as the novel's plot, no one would believe it. Incredible that so many mistakes could be made in less than 24 hours.
All of the deaths, injuries, and damage could have been avoided by installing a simple level gauge.
As Prof. Dr. Tom Sowell once noted, "Nothing could be more dangerous and more stupid than having peoples making decisions and pay no price for being wrong". 2021/08/08. Ontario, Canada.
This is an excellent example why corporations should be able to donate limitless amounts of money to political campaigns. That way, companies like BP can throw the next election and soon, we'll all be slaves to a corporation that doens't care about the safety of its employess.
This comment has aged like a fine wine
If they can donate an infinite amount to the party which was not changed by either the law or court case, then what has changed? Nothing.
@@Knirin It seems as if you've failed to comprehend the OP. It's also ten years old! Obviously you're another victim of the orange imbecile's crude brainwashing. You can't remove an entirely valid party which has legally won an election. However, before he began his extended tantrum over this loss, the barely literate conman would've liked to see us all as slaves to corporations, yourself included.
"paralyzed from the cost-cutting' - what a gentle way of saying nobody gave a damn in this game of hot potato
Outstanding job on this video. Informative and it is very thought provoking as well. I can relate as I retired from a similar environment last December and although we didn't handle anything as dangerous as in this video, we did have chemicals and valves that had to be monitored. Luckily, even with cuts, our company was actually very good about adhering to safety protocols, and if anything were to come up that we as board operators weren't sure about, we either had an engineer a phone call away or we were able to abort the job until someone could advise us. What a horrible accident this was. My condolences to anyone who was affected by it.
Whatever they’re paying the narrator, they should quadruple it. He’s perfect.
I found a remote login with no username or password that allowed workers at an oil refinery to monitor a near identical setup remotely. If I wanted to, I could have messed with the controls and I possibly could have caused a major disaster like Texas City. Instead I anonymously reported it to their IT department. Took a long time for them to change it, even so.
My God.
You said, to monitor
No CEO's were injured in the making of this incident. Only those budgeted as "disposable".
Rest in Peace, all the souls lost at Texas City. 🇺🇸
When a person works 12 hour shifts for 30 days straight mistakes are going to happen.
BP Bremerton had pipes bends that were as thin as paper due to flow scours...an accident waiting to happen...then it happened!
The measurement for the height of the liquid reminds me of the save gas initiative that ultimately gave us the 85mph speedometer on all vehicles back in the day....Blue lights come on...You pull over...He puts on his troopers hat and walks briskly up..Sir do you know how fast you were going. No sir I don't. Why's that !? My speedometer only goes to 85.
Also the "55" numbers in red. Foolishness.
One operator was left to run three units, that is insane. If he would have been able to focus on the ISOM unit, he likely would have noticed the discrepancy between liquid entering, and exiting the tower.
on another note, am I crazy for thinking one of the first steps in a situation where you think something might be wrong would be to reduce or cut off liquid flow?
The level indicator says nine feet, not great, not terrible.
You don’t need more OSHA or more “recommendations”.. you need to hold those in leadership personally criminally liable for deaths and injury- the rest will take care of it itself.
I am just glad that my jobs have had far lower stakes, because the same problems exist with management.
I remember when the rotisserie caught fire because we were always too busy to clean it. unfortunately, the charred birds could not be served with fire-extinguisher powder on them
Any business site that has so many fatalities as BP's in Texas, over such a long period, should be forcibly nationalized by the government or shutdown. The upper management should be imprisoned.
But then here in the US, and especially Texas, people would begin screaming "socialism" at that idea and start running around all panicky.
"If you think safety is expensive, try an accident". I'm going to use this line on a client next time they balk at a price.
R.I.P. Trevor Kletz