This was the exact video that the instructor showed our review class for the Control Systems Principles and Practices exam. We were all stunned. We all looked at each other knowing that we've seen incompetence and unawareness of this magnitude in all of our plants. Most of the time, something stops these problems from getting worse. And then every once in a blue moon these things converge in to a shocking combination of awful. If you think something this bad couldn't possibly happen to your operation, then you're a prime candidate for precisely this sort of disaster.
I believe it's called optimism bias. People tend to think that although there's a probability of something happening, it's not going to happen to _them,_ no, it's going to happen to somebody else, of course. And there's also complacency; they've always been taught to overfill the raffinate splitter slightly to avoid killing the startup by accident. The crews of the Titanic and the Ocean Ranger got complacent with their "unsinkable" vessels, and we know what happened to them.
@@tomfoolery4490 Slightly off topic, but the Titanic was sunk on purpose to kill off most of the major opposition of the Federal Reserve (the privately owned bank that controls our money). It was no accident they had no lifeboats on board.
Yep, CSB should do a Chernobyl video. Whatever country it is, it's all the same. Constant safety violations, and bypassing even exiting procedures. Even when design is not perfect, the first thing that causes accidents like these is when people do some really silly shortcuts.
Thanks for a fantastic video explaining such a complex series of events. I am thoroughly impressed by how the board managed to reconstruct even the early events leading up to the accident given how little was left of the plant. This kind of forensic work is very very hard, and explaining it clearly and concisely in only 6 minutes is exceedingly rare. Brilliant!
In order for something like this to occur, SEVERAL safety checks from many people have to be overlooked, which happened over 3 shift changes. No abnormalities were reported and nobody thought to stop the process and go physically check equipment when the level sensor started alarming. Meeting a schedule or taking shortcuts to save a few minutes is never worth the risk you are assuming. When an ignorant culture exists - this is when terrible accidents happen.
"Silence it, Bypass it, or Fuck it". Right there is the cause of many industrial accidents in all industries. Nobody wants to be the guy who raises the false alarm and costs the company money. Takes a lot of courage to be the one who gives bad and unprofitable news.
And in cases taking dangerous shortcuts in procedure like this, is never good idea. From docudrama of this explosion i remember that this went on for years.
“Nothing reported” did you not pay attention? The indicator was not designed to detect any liquid past a certain level in the drum. The problem starts from the engineering plans and the people who approved this type of plan.
Probably said fuck it, the second high level alarm hasn't gone off, so it can't be that high. Plus the separate level alarm on the blowdown should've gone off too. Two broken alarms. Need to do more safety checks.
I was at school when this happened. There was a big explosion shake in Galveston which knocked down our basket full of basketballs. The school had told us what had happened in 5-10 minutes.
After looking at pictures and setting foot on the grounds of that unit it really gives you the sense of the devastation of this blast. Cooling tower blocking off a unit to the east, contractor trailers to the west near another unit, dome covered tanks in the farm to the south, and 2 units to the north across the street. Now there’s a new unit being built in it’s place.
Improper flow controls is what they probably thought. I think they thought the outflow was open and causing escaping liquid faster then the pumps causing them to add more. Mix of faulty equipment and human error seems like
Well their obvious thought was it was flowing out as it was supposed to, except the out flow valve was shut. So they likely just thought their feed was lower than the outflow.
BP. A Swiss cheese company. The Swiss model is where each gate keeper is human (or is a system component) and flawed. Redundancy for catching problems is built into system of checks , however somehow the system for control is defeated by each gate keeper whereby the critical factor passes through the gatekeeper represented by a gaping hole in a slice of Swiss cheese. Here BP has several if not many pieces swiss cheese lined up in a row where the critical problem escaped duty function of control and passed through each gatekeeper.
Big Papi the problem with refineries is that engineers are always coming in and out. For all we know the contractor who installed this indicator is probably retired. This is the problem with big companies not tearing their senior engineers well and replacing them with kids with no experience.
j ross not to mention hiring cheap immigrants who can barely speak English to carry out vital maintenance procedures. The kids of employees who fix a leaking pipe or valve with a plastic bread bag, wadded up and shoved into the crack. I’ve seen that bs myself
Super sad but I've worked in plants and factories before and if you have a lax attitude about doing things correctly, people will get hurt and killed. We had a guy who was a stickler for doing things by the book, I'm sure it saved lives over the years.
Final RCA: poor process safety implementation in the original design of the process, very very poor Operational procedures and Operational Integrity culture, poor Maintenance & Integrity procedures... in short.. its BP's culture! A Major accident each couple of years. This accident could've been prevented in at least half-dozen ways. Welldone stupid!!
Mahmood Ali How right you are, the management idiots at BP insist on behaving as if their American plants were designed and built by Britons with British equipment and operators and it keeps on biting them in the backside disaster after disaster.
So, the vapor was ignited by a Diesel pickup truck (?) then you show the pressure wave starting from a high place on the stack. How did the truck ignite from up there? The ignition point would be where the vapor cloud started, IE. the "Seat" of the blast. Unless the truck was in the air it did not happen the way you showed in the blast simulation. Unless that truck was hanging in mid air this is incorrect.
They knew that level indicator at the base of the tower was not working correctly, yet they went ahead with the startup and created a bomb with about 20,000 gal of fuel. Absolutely incredible. Amateurs at work.
Complacency. Happens every day in every industry. Blame whomever you choose but it's always the culture at that work location. Sad but true. Cross checking each other should be a requirement.
this accident happened because of operator's stupid errors of not understanding the process and basic operations of a tower. What board operator introduces feed to a tower and never thinks about letting some product out. Bring the tower up on reflux and check all level indicators and make sure where your levels are before proceeding. This was just dumb on their part.
Total equipment and operator error. As a constructor on petrochem plants we joked about operator hands needing to wear Gerber baby food jar lids on strings around there necks to know which way to turn valves. Faulty valves and equipment were present in every plant I ever worked on. The industry is a total mess of old outdated and jurry rigged equipment. Patches on patches on tanks and towers at every refinery, plant, compressor station.
A redundant alarm is a backup system for another. If the primary level transmitter failed, the secondary would be like, "Hey, the level's over 10 feet! Shut off the feed!" Of course, _it_ failed too, helping make an already bad situation worse.
How can a company fail so hard? It is understandable that safety mechanisms fail - That just happens and this is why you have some kind redundancy. But how can all mechanisms fail? Bad maintenance...
This accident was due to allowing the Three Stooges running the process. How can you feed a column without any drawout? Multiple instrument failures added to the fiasco.
From the people who brought you the Deepwater Horizon, 5 million barrels of oil pollution due to non-functioning and miswired safety systems, and eleven dead.
Look up Alpenrose dairy. I was working days at the water treatment plant. The lazy pothead that could barely tie his own shoes dead headed a sulfuric acid recirculation pump while servicing a ph sensor and the fitting blew up in his face. He dawned no protective gear, and decided to get help when his clothes started melting off. Fun shit. In my OSHA interview all I could say was, "shoulda fired his ads when I told them too".
It's impressive the amount of effort it takes to put all the safety violations, gross negligence and lack of proper procedures into the passive voice. It's like "the events happened" where it's all coincidental instead of causative. I'm sure BP was relieved.
Thanks for keeping up with the times. When everyone was posting 1080p in 2007, USCSB was posting in 240p, at 1/8 of the resolution, or 1/4 of the vertical resolution. Now in 2022, they have much better videos, posting in 1080p, when everyone else is posting in 2160p (4k UHD), which is 4x the resolution, or 2x the vertical resolution. Sorry for the run-on sentences.
A engineered solution will always beat the operator and if done right these systems should eliminate alot of the chances of something going wrong and do this was poor engineering and a bad culture
+Jamie Mcconnachie 1986 (jambo) No, operators need to be trained in instrumentation so they understand how convenient transmitters work. Too often I see them calling us in to investigate a "broken" instrument when all it takes is for us to go out and prove that it's reading correctly. They need to maintain a high index of suspicion always.
BANCO DO NORDESTE REPASSAR ISSO PARA NORDESTE GANHAR MUITO DINHEIRO LANCHONETE VENDAS DE LOJA DA INTERNET MUNDIAL GANHAR MUITO DINHEIRO LANCHONETE DOAR EMPREGO PARA ARARUNA REPASSAR ISSO.
computers can introduce an immense amount of safety. you can have more sensors, better analytics and much faster response and without needing people on the ground to physically intervene in high hazard operations.
Properly designed computers and software s with properly maintained sensors are more reliable than tired lazy incompetent overworked meatbag workers. Computers fly every airliner and jet fighter. If you observe these videos the DESIGN, MAINTENANCE and REPAIR needs of these systems are not taken care of and their design is usually defective. Nothing in this incident was a "computer" problem. Lack of redundant sensors, failure to ensure everything was operational, etc caused the incident along iwth inadequate system understanding. The failed "alarms" were not "computers". If you want to survive in industry you NEED TO KNOW WHAT WORDS MEAN. If you don't you will never understand theory of operation, and failure to understand the system vs. just being a button pusher gets people killed.
This was the exact video that the instructor showed our review class for the Control Systems Principles and Practices exam. We were all stunned. We all looked at each other knowing that we've seen incompetence and unawareness of this magnitude in all of our plants. Most of the time, something stops these problems from getting worse. And then every once in a blue moon these things converge in to a shocking combination of awful.
If you think something this bad couldn't possibly happen to your operation, then you're a prime candidate for precisely this sort of disaster.
I believe it's called optimism bias. People tend to think that although there's a probability of something happening, it's not going to happen to _them,_ no, it's going to happen to somebody else, of course. And there's also complacency; they've always been taught to overfill the raffinate splitter slightly to avoid killing the startup by accident. The crews of the Titanic and the Ocean Ranger got complacent with their "unsinkable" vessels, and we know what happened to them.
@@tomfoolery4490 Slightly off topic, but the Titanic was sunk on purpose to kill off most of the major opposition of the Federal Reserve (the privately owned bank that controls our money). It was no accident they had no lifeboats on board.
@@Luckingsworth, you're right. That is off topic. Way off topic.
@@Luckingsworth oh look, a crazy person!
@@jettmannings7413 Look it up, all major opponents of the Fed were invited to board the Titanic. All of the lifeboats conveniently missing...
"The gauge reads ten feet, but that's as high..."
"Ten feet. That's not great but it's not terrible."
Joshua is delusional... get him to the infirmary.
Yep, CSB should do a Chernobyl video. Whatever country it is, it's all the same. Constant safety violations, and bypassing even exiting procedures. Even when design is not perfect, the first thing that causes accidents like these is when people do some really silly shortcuts.
Thanks for a fantastic video explaining such a complex series of events. I am thoroughly impressed by how the board managed to reconstruct even the early events leading up to the accident given how little was left of the plant.
This kind of forensic work is very very hard, and explaining it clearly and concisely in only 6 minutes is exceedingly rare.
Brilliant!
Johan Strandberg how’s life been since this comment?
Check out the newest one
@@agoniaXdunyahe dead
In order for something like this to occur, SEVERAL safety checks from many people have to be overlooked, which happened over 3 shift changes. No abnormalities were reported and nobody thought to stop the process and go physically check equipment when the level sensor started alarming. Meeting a schedule or taking shortcuts to save a few minutes is never worth the risk you are assuming. When an ignorant culture exists - this is when terrible accidents happen.
"Silence it, Bypass it, or Fuck it". Right there is the cause of many industrial accidents in all industries. Nobody wants to be the guy who raises the false alarm and costs the company money. Takes a lot of courage to be the one who gives bad and unprofitable news.
And in cases taking dangerous shortcuts in procedure like this, is never good idea. From docudrama of this explosion i remember that this went on for years.
“Nothing reported” did you not pay attention? The indicator was not designed to detect any liquid past a certain level in the drum. The problem starts from the engineering plans and the people who approved this type of plan.
You should get a job narrating... great at pointing out the obvious.
Probably said fuck it, the second high level alarm hasn't gone off, so it can't be that high. Plus the separate level alarm on the blowdown should've gone off too.
Two broken alarms. Need to do more safety checks.
I was at school when this happened. There was a big explosion shake in Galveston which knocked down our basket full of basketballs. The school had told us what had happened in 5-10 minutes.
Yeah right
After looking at pictures and setting foot on the grounds of that unit it really gives you the sense of the devastation of this blast. Cooling tower blocking off a unit to the east, contractor trailers to the west near another unit, dome covered tanks in the farm to the south, and 2 units to the north across the street. Now there’s a new unit being built in it’s place.
NDU is there now. Feels insane being in that unit knowing what happened.
So they continued pumping in the liquid when the reading was dropping... and never stopped to think something might be wrong.
Watch this video which is more detailed from CSB
ruclips.net/video/goSEyGNfiPM/видео.html
Improper flow controls is what they probably thought. I think they thought the outflow was open and causing escaping liquid faster then the pumps causing them to add more. Mix of faulty equipment and human error seems like
Well their obvious thought was it was flowing out as it was supposed to, except the out flow valve was shut. So they likely just thought their feed was lower than the outflow.
Too much going on for not worthy guys
Thats not what happened
BP. A Swiss cheese company.
The Swiss model is where each gate keeper is human (or is a system component) and flawed. Redundancy for catching problems is built into system of checks , however somehow the system for control is defeated by each gate keeper whereby the critical factor passes through the gatekeeper represented by a gaping hole in a slice of Swiss cheese.
Here BP has several if not many pieces swiss cheese lined up in a row where the critical problem escaped duty function of control and passed through each gatekeeper.
Four alarm/indicators not working? So much for PM and safety out of BP.
Big Papi the problem with refineries is that engineers are always coming in and out. For all we know the contractor who installed this indicator is probably retired. This is the problem with big companies not tearing their senior engineers well and replacing them with kids with no experience.
j ross not to mention hiring cheap immigrants who can barely speak English to carry out vital maintenance procedures. The kids of employees who fix a leaking pipe or valve with a plastic bread bag, wadded up and shoved into the crack. I’ve seen that bs myself
Super sad but I've worked in plants and factories before and if you have a lax attitude about doing things correctly, people will get hurt and killed. We had a guy who was a stickler for doing things by the book, I'm sure it saved lives over the years.
A case like this teaches us only one lesson: always keep a couple of senators on your payroll.
Sadly true lol. Corruption is as corruption does
Felt this in Galveston shook our house sadly this or worse will happen again as BP never learns.
These early videos just aren't the same without Sheldon Smith narrating.
Make sure to leave trucks idling, they are great igniters!
Final RCA: poor process safety implementation in the original design of the process, very very poor Operational procedures and Operational Integrity culture, poor Maintenance & Integrity procedures... in short.. its BP's culture! A Major accident each couple of years. This accident could've been prevented in at least half-dozen ways. Welldone stupid!!
Mahmood Ali How right you are, the management idiots at BP insist on behaving as if their American plants were designed and built by Britons with British equipment and operators and it keeps on biting them in the backside disaster after disaster.
Seems like theres quite a few mishaps at BP refinerys.....
12 years ago.. time flies
Does anyone know if those contractors had employer provided life insurance? I hope so, their families would be devastated
They have made a new version of this accident.
So why weren't the gauges checked or fixed so they were working. Or emergency valves operating a lot sooner
I wish this RUclips channel did a review of the PEPCON DISASTERIN NV
OK, thats not good. What does the CSB found? What are your recommendations?
Would a sight glass on every tray be unreasonable?
So, the vapor was ignited by a Diesel pickup truck (?) then you show the pressure wave starting from a high place on the stack. How did the truck ignite from up there? The ignition point would be where the vapor cloud started, IE. the "Seat" of the blast. Unless the truck was in the air it did not happen the way you showed in the blast simulation. Unless that truck was hanging in mid air this is incorrect.
That view is top down. Thus, you have no perceptive of height.
They knew that level indicator at the base of the tower was not working correctly, yet they went ahead with the startup and created a bomb with about 20,000 gal of fuel. Absolutely incredible. Amateurs at work.
Complacency. Happens every day in every industry. Blame whomever you choose but it's always the culture at that work location. Sad but true. Cross checking each other should be a requirement.
Well written comment. I would say there was a lot more issues than some amateurs at work. We need more people like you in this world!!! Idiot.
Nah BP Texas City is just a shitty company that disregards safety.
the accident happened due to negligence
this accident happened because of operator's stupid errors of not understanding the process and basic operations of a tower. What board operator introduces feed to a tower and never thinks about letting some product out. Bring the tower up on reflux and check all level indicators and make sure where your levels are before proceeding. This was just dumb on their part.
I'm from Texas City. I was in school when this happened. So scary.
Why only stop at 10 feet?! There should have been a line at least every 5-10 feet above the first 10 foot mark!
Total equipment and operator error.
As a constructor on petrochem plants we joked about operator hands needing to wear Gerber baby food jar lids on strings around there necks to know which way to turn valves.
Faulty valves and equipment were present in every plant I ever worked on. The industry is a total mess of old outdated and jurry rigged equipment.
Patches on patches on tanks and towers at every refinery, plant, compressor station.
The narrator in this sounds personally hurt. And I think that's a good thing.
can someone explain to me what a redundant alarm is and its purpose please????
A redundant alarm is a backup system for another. If the primary level transmitter failed, the secondary would be like, "Hey, the level's over 10 feet! Shut off the feed!" Of course, _it_ failed too, helping make an already bad situation worse.
Why is it in all these videos the alarms and safety systems never work
Can you say " Manual dump"? Sorry,forgot these guys do not get out from under conditioned air.
I have question what's the name of the program that make this animation please
CSB Made the animation
Boy, looks like a situation where virtually everyone involved screwed up along the way, leading to this chain of dangerous events.
Bad process ( root problem was comming from design.
How can a company fail so hard? It is understandable that safety mechanisms fail - That just happens and this is why you have some kind redundancy. But how can all mechanisms fail? Bad maintenance...
150 degrees what? Fahrenheit? Celcius?
It makes a big difference.
too bad you cant make a see through tower
Yeah if only polycarbonate or high strength glass existed...
I LOVE THE BRAINS BEHIND REPLACING A FAULTY SWITCH VS COST OF REPLACING HUMAN LIVES KILLED AND A REFINERY. HOPE THEY GOT HEFTY JAIL SENTENCES
This is America, those in charge probably got leave with pay, then huge bonuses for their "bravery."
This accident was due to allowing the Three Stooges running the process. How can you feed a column without any drawout? Multiple instrument failures added to the fiasco.
flare system would have helped them.
If anyone who doesnt know the voice its CSB investigator don holmstrom he lead this investigator
We sure could use some new videos please uscsb
From the people who brought you the Deepwater Horizon, 5 million barrels of oil pollution due to non-functioning and miswired safety systems, and eleven dead.
Yep and it will happen again BP gives no fucks about safety.
Deepwater horizon and this were both operator errors. Blame BP all you want but the good ol boys fucked this up.
It's always a valve isn't it lol
My refinery construction job very very important job.Quality is must
I hope they didn't make the diesel pickup truck owner a scapegoat for leaving his truck running and causing the blast
I wuv the danger and incompetence
More safety video please
Very Helpfull . THX
Look up Alpenrose dairy. I was working days at the water treatment plant. The lazy pothead that could barely tie his own shoes dead headed a sulfuric acid recirculation pump while servicing a ph sensor and the fitting blew up in his face. He dawned no protective gear, and decided to get help when his clothes started melting off. Fun shit. In my OSHA interview all I could say was, "shoulda fired his ads when I told them too".
who els is binging this ?
Sometimes I erupt about one minute from the top of my blowdown stack
Too soon bro
This was a very interesting explanation of an incident that should have never happened, there would have been hell to pay as a result,
Check out the newer one on CSB CHANNEL
the guy doing the audio is for sure from philly or baltimore. probably baltimore. brutal midatlantic accent.
Saw this in a safety video
This video is now older than half the people commenting 😆
The video is only 9. NINE days older than me 😭😭
It's impressive the amount of effort it takes to put all the safety violations, gross negligence and lack of proper procedures into the passive voice. It's like "the events happened" where it's all coincidental instead of causative. I'm sure BP was relieved.
Human error is NOT an accident!! Just saying!
Thanks for keeping up with the times. When everyone was posting 1080p in 2007, USCSB was posting in 240p, at 1/8 of the resolution, or 1/4 of the vertical resolution. Now in 2022, they have much better videos, posting in 1080p, when everyone else is posting in 2160p (4k UHD), which is 4x the resolution, or 2x the vertical resolution. Sorry for the run-on sentences.
Check out the newest version
frank sent me
Wheres sexy mcman voice?
138 ft ≠ 20 x 10. Not even approximately lmao
SEUS GALPÃO SEM INDÚSTRIAS VOU MOSTRAR O NOSSO GRUPO ARARUNA PB. ..VITAL COSTA.
BP again. Terrible company. Board of directors should be drawn and quartered.
O MY GOD!!!!ALL THAT TIME AND NOT CHECKING THE SAFETY GADGETS?????????WHY,WHY,WHY,WHY NOT???????????
There is a newer, much higher definition updated version of this on the CSB page.
ruclips.net/video/goSEyGNfiPM/видео.html
BP TERRIBLE SAFETY RECORD
CHAMADAS PARA AS FM DO BRASIL PUBLICAÇÃO LANCHONETE GANHAR MUITO DINHEIRO.
always a comedy of errors fueled by complacency. again and again
😃😃☠️☠️☠️😃
its funny cause csb stands for cool story bro
A engineered solution will always beat the operator and if done right these systems should eliminate alot of the chances of something going wrong and do this was poor engineering and a bad culture
poor people and bad machine work
Much better updated version
ruclips.net/video/goSEyGNfiPM/видео.html
Fachenglisch 4-President
First: Why would you build a tower over 138 feet high if it’s only meant to hold 10 ft of liquid?
Second: BP sucks
it shout be old school no computers
+Jamie Mcconnachie 1986 (jambo) No, operators need to be trained in instrumentation so they understand how convenient transmitters work. Too often I see them calling us in to investigate a "broken" instrument when all it takes is for us to go out and prove that it's reading correctly. They need to maintain a high index of suspicion always.
BANCO DO NORDESTE REPASSAR ISSO PARA NORDESTE GANHAR MUITO DINHEIRO LANCHONETE VENDAS DE LOJA DA INTERNET MUNDIAL GANHAR MUITO DINHEIRO LANCHONETE DOAR EMPREGO PARA ARARUNA REPASSAR ISSO.
computers can introduce an immense amount of safety. you can have more sensors, better analytics and much faster response and without needing people on the ground to physically intervene in high hazard operations.
Properly designed computers and software s with properly maintained sensors are more reliable than tired lazy incompetent overworked meatbag workers. Computers fly every airliner and jet fighter. If you observe these videos the DESIGN, MAINTENANCE and REPAIR needs of these systems are not taken care of and their design is usually defective.
Nothing in this incident was a "computer" problem. Lack of redundant sensors, failure to ensure everything was operational, etc caused the incident along iwth inadequate system understanding.
The failed "alarms" were not "computers". If you want to survive in industry you NEED TO KNOW WHAT WORDS MEAN. If you don't you will never understand theory of operation, and failure to understand the system vs. just being a button pusher gets people killed.
Because a human looking at a non functioning indicator is better than a computer doing the same thing.
There are much better videos available about this incident
And the only reason they exist is because the USCSB and other agencies did the unfathomably complicated legwork of investigating this catastrophe.
15years old and only that many views.
The newer updated one from CSB is doing a lot better