Animation of 2018 Ethylene Release and Fire at Kuraray America in Pasadena, Texas

A CSB animation about the 2018 ethylene release and fire that injured 23 workers at the Kuraray America, Inc. EVAL plant in Pasadena, Texas.

[ThioJoe]

Imagine going about your job and you hear the USCSB narrator start describing what you’re doing 😳

[kraggman]

The animations on this channel never disappoint. Being a chemical worker for over 40 years i can appreciate the time and effort put into these videos.

[ohwingman]

I spent about 20 years working in refineries, process plants, chemical plants, and pulp mills and I never ceased to be amazed at how poorly many of the plants were maintained and the lack of documentation on changes that had been made in the plants. On the first shutdown I ever worked in a refinery we were given very explicit instructions as to how we were to operate and what to do if things were not as they were supposed to be. Our very first job was to remove some small drain valves on piping assemblies.
My partner and I went to the first valve which was on a boiler feed water line. The line was tagged as drained and and safed out ready but when we cracked the valve to see if there was anything in it it began to flow water. We let it run for a couple of minutes but soon it became clear that something was wrong as the flow showed no signs of stopping. We shut the valve down and called for a plant operator who came over to check things out. He cracked the valve as we had and again, after a few minutes, shut it off. He radioed to the control booth and asked for a status on that line and was told that it was drained and ready for repairs. Fortunately the operator smelled a rat and he called the operator for the boiler bank that the line fed and asked for a status. That operator told him that they had needed feed water the night before so it had been put back into service and was still in service. All of the lock out tag out (LOTO) tags were immediately removed and we were told to go on to the next job.
A few days later we were going to grind some valves off a process line with a grinder and I noticed that the instrumentation shack immediately beside us was actually sitting over what appeared to be a drainage sump. I stopped my partner and we again called for an operator. The operator came and we showed him what we had found. He had been there a number of years and had never noticed this sump and there was no indication of it in any of the drawings he had seen. He called for a gas sniffer to be brought out to test the sumps contents. The needle went off the scale and we were told not to do anything but wait. Soon a more senior operator came and he had never seen this sump before and another test was run with the same results. That sump was extremely explosive and no work should be being done within 75 feet as per plant rules. It was a big cluster fu*k and soon became bigger when a team of operators was sent out to investigate all of the similar instrumentation shacks within the plant. There were about twenty more in the plant and three others were sitting over sumps, all of which were flammable/explosive. Seems at sometime in the past that an engineer had decided that they could save money by using the curb top of the sumps as shack foundations instead of pouring new slabs.
The lesson I learned was don't believe anything that you are told and to check your work area for anything that didn't seem right. These type of over looked problems were fairly common and it was up to you to safe your work area out before proceeding. DO NOT BELIEVE WHAT YOU ARE TOLD! Often it is pure BS.
The fact that the second shift operator assumed that the reactor in question was designed for the same pressure as the other three. So my first question would be why was there not a notice posted on the reactors controls pointing this out and why had the software used to control the plant not amended to reflect this fact? In addition, why was the line outlet horizontal and not vertical so it could be safely bled off and who in the engineering department made the decision to run it that way? I can give you the answer to both these questions and it's quite simple. Someone in management decided that it was too costly to make those simple changes so it never got done. Far too many of these plants have a bonus system in place where the manager gets a bonus based on keeping costs down so safety is frequently ignored because those additional steps might cost bonus money.
I know of one plant where at the time of construction completion the engineering firm wanted $5, 000, 000 to provide a complete set of up to date drawings for the plant. The plant owner, a major oil company, refused to pay and decided to operate with what they had. When commissioning and startup was being done, a fire broke out that destroyed that entire operations unit. When they checked the twin unit, they found the same flaw that had promoted the fire and subsequent explosions. During construction, a 42" gas letdown regulator on a 3" gas line had been changed from cast steel to zinc diecast. This regulator was suspended directly above a drainage sump. There was a small valve leaking on a condensate line that had not been properly drained after hydro testing and it had frozen and cracked wide open. The leaking condensate went into the sump and traveled along until it met with a source of ignition in the form of a Herman Nelson heater. When the condensate caught fire, it was traveling fast enough that it kept going along the sump until it terminated directly under the regulator. The heat from the fire was enough to melt the zinc housing and the three inch gas line blew up causing more damage and soon the fire could not be stopped. So by saving a couple of thousand dollars and not having accurate drawings a $50, 000, 000 unit went up in smoke and had to be completely rebuilt from the ground up. Today those sumps are filled in and the regulators have been replaced with steel units. Bottom line, they saved $5, 000, 000 so they could spend $50, 000, 000 to fix the problem. I wonder if the managers and engineers got a bonus that

[Kerotana]

Holy heck, the USCSB cannot stop posting, I love how informative these always are.

[mphRagnarok]

The quality of the video, writing, narration, and animation are absolutely perfect.

[tay-ai]

Are we just being spoiled now?
Thanks for another great animation! You guys make the most captivating and interesting safety videos.
The work you are doing is important and I appreciate the effort you put into these animations for us.

[Roddy]

The most critical and dangerous times of a processing unit are always during shutting down and restart procedures.

[Katojana]

Can we all please stop a moment and appreciate the hard work those 3D modellers and animators have to do to give us these insights?? They are amazing

[Christopher_TG]

As soon as the narrator mentioned that the reactor had a lower pressure tolerance than the others, I immediately went "I know where this is going..."

Sure enough...

[themightiestofbooshes]

Thank you, Chemical Safety Board, for putting this up on the wider Internet for us to learn from. I hope all of us are as diligent as you all are in helping to prevent workplace disasters.

[CharlesVanNoland]

The new operator not knowing the max pressure could've been solved/prevented by just showing the max pressure right on the pressure readout.

[derb_]

This is next level animation! The fly through at the start showing that the entire plant had been modelled is unreal!

[nicobettio]

It's a quiet week at work for me (I work in a refinery), but I never waste my working hours so I'm watching some videos frome this great channel to learn something new. Thanks for your videos, they are very well crafted and educational.

[markarca]

0:54 - For those who are using the Metric system,
740 psi = 51 bars or 50.3 atmospheres
1, 150 psi = 79.2 bars or 78.2 atmospheres

[ThePizzaGoblin]

Man, the animation team has gotten really good. I remember how basic some of the earliest videos were. Now look at them. Got swoops through ladders, cross sections, volumetric fire. Great stuff

[finnamabob]

Kudos to whoever did those particle simulations on the fire ignition. looks great

[ethhack]

As excited as I always am for your next posts, I always know they come at a cost and someone has to be the example.

I've been integrating these into my safety meetings. Even though most of them do not directly relate to our job functions, the concept and lessons are the same. Great work!

[thanoscube]

USCSB continues to produce some of the most well thought out and designed reviews of hazards or accidents in the industry. And let me say, This was no exception, wow! Continue the excellent work USCSB.

[LanceCampeau]

Its always frustrating to think that these excellent & informative presentations (which save lives) always come at high tragic cost.

God bless all those adversely affected.

[kisaragi-hiu]

The "pressure" graphic that pops in as the narrator mentions pressure and folds to the side to make space is absolutely amazing. Normally the text would be squished, or the full text would never be displayed, or the gauge would take up unnecessary space. It's just… incredible.