第三组--CSB Safety VideoVinyl Chloride Explosion and Fire

1、100:00:03,429 -> 00:00:06,720I on April 23rd 2004200:00:06,720 -> 00:00:10,030an explosion at the Formosa Plastics corporation facility300:00:10,030 -> 00:00:13,330rocked the small town avaliable us in central Illinois400:00:13,330 -> 00:00:18,250five workers died including a husband and

2、 wife500:00:18,250 -> 00:00:21,330three others were severely injured600:00:21,330 -> 00:00:26,080authorities evacuated approximately 150 residents from the area700:00:26,080 -> 00:00:29,130the incident had serious economic consequences for the surrounding800:00:29,130 -> 00:00:29,740comm

3、unity900:00:29,740 -> 00:00:33,410as the plant did not reopen1000:00:33,410 -> 00:00:37,540the facility which employed 139 workers produced PVC1100:00:37,540 -> 00:00:42,320a common plastic PVC is used to make many different products including credit1200:00:42,320 -> 00:00:42,850cards130

4、0:00:42,850 -> 00:00:46,910clothing pipe siding and flooring1400:00:46,910 -> 00:00:50,070Borden chemical constructed the plant in 19651500:00:50,070 -> 00:00:54,510and Formosa purchased it in 2002 two years before the accident1600:00:54,510 -> 00:00:58,280the CSB investigated the incide

5、nt and issued a report1700:00:58,280 -> 00:01:03,800with findings and recommendations this explosion occurred after a worker opened1800:01:03,800 -> 00:01:08,140a valve on a pressurized reactor full of flammable material1900:01:08,140 -> 00:01:12,620might be tempting this simply blamed the

6、tragedy and human air2000:01:12,620 -> 00:01:17,480however as is often the case the root causes were much deeper2100:01:17,480 -> 00:01:21,850the CSB investigation revealed that better operating practices2200:01:21,850 -> 00:01:25,530and equipment design could have reduced the chances a few

7、 min air that had such2300:01:25,530 -> 00:01:27,420catastrophic consequences2400:01:27,420 -> 00:01:31,100the CSB used physical evidence documents2500:01:31,100 -> 00:01:35,200and the testimony of the few surviving witnesses to reconstruct the accident2600:01:35,200 -> 00:01:42,180the f

8、ollowing computer simulation shows how events likely unfolded2700:01:42,180 -> 00:01:45,780the formosa plant made polyvinyl chloride or PVC2800:01:45,780 -> 00:01:49,930in 24 large vessels called reactors that were ranged2900:01:49,930 -> 00:01:53,340in Group A four inside each vessel3000:0

9、1:53,340 -> 00:01:56,880thousands of pounds of highly flammable toxic3100:01:56,880 -> 00:02:00,369vinyl chloride reacted under heat and pressure3200:02:00,370 -> 00:02:05,760to form PVC an operator controlled the process from a panel3300:02:05,760 -> 00:02:09,530on the upper level when

10、the process was finished3400:02:09,530 -> 00:02:12,760a second operator would walk down the stairs3500:02:12,760 -> 00:02:17,170in open valves on the reactor piping to transfer the product out3600:02:17,170 -> 00:02:21,660after completing the transfer a worker back on the top level3700:02:2

11、1,660 -> 00:02:25,190with then clean out the insider the reactor with a high pressure water3800:02:25,190 -> 00:02:26,000blaster3900:02:26,000 -> 00:02:29,160the worker would then go to the lower level4000:02:29,160 -> 00:02:32,700in open the reactor bottom valve as well as the drain val

12、ve4100:02:32,700 -> 00:02:36,400water indeed onto the floor into a drain4200:02:36,400 -> 00:02:42,230on the evening and the accident and operator started cleaning reactor 3064300:02:42,230 -> 00:02:46,350with the water blaster he then walked downstairs to drain the water4400:02:46,350 ->

13、; 00:02:50,959out love the reactor that he had been cleaning but he made a critical mistake4500:02:50,959 -> 00:02:54,300the CSP concluded that instead of turning left4600:02:54,300 -> 00:02:57,340at the bottom the stairs to get a reactor 3064700:02:57,340 -> 00:03:01,060the operator turn r

14、ight to a different group for reactors4800:03:01,060 -> 00:03:07,209in approached reactor 310 but reactor 310 was not in the cleaning process4900:03:07,209 -> 00:03:11,959it was pressurized in heated in mid cycle making PVC5000:03:11,959 -> 00:03:15,739the operator turn switches to open the

15、 reactor bottom valve5100:03:15,739 -> 00:03:19,530in the drain valve5200:03:19,530 -> 00:03:23,520the drain valve opened but the reactor bottomed out remained shut5300:03:23,520 -> 00:03:27,330an interlock block the air supply the valves actuator5400:03:27,330 -> 00:03:31,560it was desi

16、gned to do this as a safety measure when the reactor was under5500:03:31,560 -> 00:03:32,170pressure5600:03:32,170 -> 00:03:36,690to prevent an accidental release but instead of checking to see why this5700:03:36,690 -> 00:03:37,890valve would not open5800:03:37,890 -> 00:03:42,920the op

17、erator decided to bypass the interlock he disconnected the existing5900:03:42,920 -> 00:03:44,600valve air supply hearst6000:03:44,600 -> 00:03:48,560in reach for one with the continuous air supply met for use6100:03:48,560 -> 00:03:54,110only in emergencies he connected this hose to the va

18、lve it opened6200:03:54,110 -> 00:03:59,230suddenly the highly flammable vinyl chloride mixture began rushing out onto6300:03:59,230 -> 00:03:59,910the floor6400:03:59,910 -> 00:04:03,410producing a loud rumbling noise that sounded to witnesses6500:04:03,410 -> 00:04:07,579like a jet eng

19、ine workers smelled vinyl chloride6600:04:07,580 -> 00:04:13,510in the vapors triggered an alarm the shift supervisor rushed toward the6700:04:13,510 -> 00:04:14,410reactors6800:04:14,410 -> 00:04:19,639very sorry actor 310 Springbok law right onto the floor6900:04:19,639 -> 00:04:23,090

20、where there is already a funny mixture a foot-and-a-half deep7000:04:23,090 -> 00:04:26,500believing he could stop the release7100:04:26,500 -> 00:04:30,979the supervisor race to the upper level and told operators to open blouse7200:04:30,979 -> 00:04:35,560which would relieve pressure in t

21、he reactor the supervisor and one operator7300:04:35,560 -> 00:04:37,789then tried to get to the lower level 3 and7400:04:37,789 -> 00:04:41,789interior stairwell but were stopped by the overwhelming odor in the final7500:04:41,789 -> 00:04:42,719chloride vapor7600:04:42,720 -> 00:04:47,

22、789the operator remain on the upper level the supervisor headed down to the lower7700:04:47,789 -> 00:04:48,560level on7800:04:48,560 -> 00:04:51,150exterior stairwell7900:04:51,150 -> 00:04:54,720just then the vinyl chloride ignited and exploded violently8000:04:54,720 -> 00:05:01,720wi

23、tnesses reported three or four additional explosions8100:05:02,210 -> 00:05:06,299for workers were killed immediately the two operators who had been working at8200:05:06,300 -> 00:05:07,530the top of the reactor8300:05:07,530 -> 00:05:11,620into operators who had been on the lower level inc

24、luding one who apparently8400:05:11,620 -> 00:05:13,680opened the reactor bottomed out of8500:05:13,680 -> 00:05:16,720a fifth operator who was seriously burned8600:05:16,720 -> 00:05:20,000died two weeks later two other workers8700:05:20,000 -> 00:05:23,230in the supervisor who had been

25、 in the exterior stairwell8800:05:23,230 -> 00:05:26,479were seriously injured8900:05:26,479 -> 00:05:30,550the force of the explosions destroyed much of the plant including laboratory9000:05:30,550 -> 00:05:35,130in the safety and engineering offices it blew off the reactor building roof91

26、00:05:35,130 -> 00:05:38,880knock down walls damaged metal frames and piping9200:05:38,880 -> 00:05:42,750in lifted the reinforced concrete floors on the upper levels at the plant9300:05:42,750 -> 00:05:48,389the CSB investigation found that systems and procedures put in place by both9400:0

27、5:48,389 -> 00:05:49,490Borden chemical9500:05:49,490 -> 00:05:53,650enfermo sir were insufficient to minimize the potential for human error9600:05:53,650 -> 00:05:57,930from OC did not adequately train in drill its employees9700:05:57,930 -> 00:06:02,300to immediately evacuate in the ca

28、se of a major release of hazardous chemicals9800:06:02,300 -> 00:06:05,729such an evacuation would have saved lives9900:06:05,729 -> 00:06:08,940one way to minimize human error10000:06:08,940 -> 00:06:12,680the CS be found would have been to install additional locks10100:06:12,680 -> 00:

29、06:15,990or other devices to prevent critical valves from being opened10200:06:15,990 -> 00:06:19,400when the reactor was under pressure overriding the10300:06:19,400 -> 00:06:24,080only safety interlock was all too easy to do by simply attaching the emergency10400:06:24,080 -> 00:06:24,690

30、air hose10500:06:24,690 -> 00:06:27,180that hung nearby10600:06:27,180 -> 00:06:30,389although the reactors were clearly numbered they were grouped into similar10700:06:30,389 -> 00:06:31,509sets before10800:06:31,509 -> 00:06:36,430increasing the chance that an operator might go to the

31、wrong reactor10900:06:36,430 -> 00:06:39,169there were no gauges indicators were warning lights11000:06:39,169 -> 00:06:42,870to inform operators on the lower level the reactor was processing vinyl11100:06:42,870 -> 00:06:44,319chloride11200:06:44,319 -> 00:06:47,930and those operators d

32、id not carry radios were have an intercom11300:06:47,930 -> 00:06:51,710so they were unable to quickly check on the reactor status with operators at11400:06:51,710 -> 00:06:52,500controls11500:06:52,500 -> 00:06:54,589upstairs11600:06:54,589 -> 00:06:59,889in 1992 Borden chemical the pre

33、vious owner avaliable as planned conducted a11700:06:59,889 -> 00:07:01,529process hazard analysis11800:07:01,529 -> 00:07:05,379which stated that the interlock on the reactor bottom valve was susceptible11900:07:05,379 -> 00:07:08,679to misuse additional safeguards were recommended12000:07

34、:08,679 -> 00:07:11,440but never adopted12100:07:11,440 -> 00:07:16,719another hazard analysis in 1999 again identified severe consequences12200:07:16,720 -> 00:07:19,750if someone opened the bottom valve on an operating reactor12300:07:19,750 -> 00:07:24,729but the analysis incorrectly

35、concluded that the existing safety interlock12400:07:24,729 -> 00:07:29,050was sufficient to prevent a serious incident companies need to thoroughly12500:07:29,050 -> 00:07:31,190investigate near-miss incidents12600:07:31,190 -> 00:07:34,900uncover any underlying trends are safety weaknesse

36、s12700:07:34,900 -> 00:07:39,090for most experienced several previous reactor incidents12800:07:39,090 -> 00:07:43,000that taken together could have pointed to the potential for catastrophic12900:07:43,000 -> 00:07:46,740consequences from human errors13000:07:46,740 -> 00:07:52,230in 200

37、3 an operator it for most his baton rouge louisiana PBC plant13100:07:52,230 -> 00:07:55,780open the bottom valve on the wrong reactor releasing13200:07:55,780 -> 00:08:01,490eight thousand pounds %uh vinyl chloride to the atmosphere in February 200413300:08:01,490 -> 00:08:06,210an operato

38、r at Heliopolis plant bypassed a reactor bottom valve in Iraq13400:08:06,210 -> 00:08:10,230resulting in another significant happen spirit release a final chloride13500:08:10,230 -> 00:08:14,320for motor then recognize that additional controls were needed13600:08:14,320 -> 00:08:19,219but d

39、id not quickly enough to implement improvements13700:08:19,220 -> 00:08:23,169the explosion occurred two months later13800:08:23,169 -> 00:08:25,909when a large chemical release like this occurs13900:08:25,910 -> 00:08:29,870employees need to get out of harm's way as quickly as possible

40、14000:08:29,870 -> 00:08:33,570companies need to train and roll their employees to evacuate14100:08:33,570 -> 00:08:39,909instinctively in this case to operators remained on the upper level14200:08:39,909 -> 00:08:44,910trying in vain to slow the release they and others who remained in the

41、area14300:08:44,910 -> 00:08:49,150died in the explosion their lives would have been saved had evacuated14400:08:49,150 -> 00:08:50,400immediately14500:08:50,400 -> 00:08:55,480the CSB identified many ways that the companies involved14600:08:55,480 -> 00:09:01,310could have avoided this

42、tragedy to prevent future accidents the CSB made14700:09:01,310 -> 00:09:03,560several safety recommendations14800:09:03,560 -> 00:09:07,370to the company the EPA the leading14900:09:07,370 -> 00:09:12,270industry Association and others the CSP15000:09:12,270 -> 00:09:17,480recommended da