Final CSB report Pressure Vessel Explosion at Loy-Lange Box Company 2

[FacEngrPE]

thread794-428207
The final report from the U.S. Chemical Safety and Hazard Investigation Board regarding the Pressure vessel explosion / BLEVE non April 3, 2017 has been published (July 29, 2022) at this link and attached below.

https://www.csb.gov/loy-lange-box-company-pressure-vessel-explosion-/

It seems like this is a classic case of many holes in the Swiss Cheese like layers of protection aligning to result in the event.

 

[3DDave]

Complacency and acceptance of a gradually worsening condition is at the heart of many disasters. No surprise, complacency is often propelled by monetary considerations.

It's a shame Saint Louis forgot the boiler codes were developed, in part, due to so many boiler explosions killing crews and passengers on the riverboats that were key to the city's development and were likely seen from the city riverbanks.

 

[GD2]

Some Operators tries to shortcut safety. The incident also greatly reflects the City of St. Louis Regulator's failure and a sad state of affaires.

GDD
Canada

 

[MJCronin]

First: I do not understand what this means:

"It seems like this is a classic case of many holes in the Swiss Cheese like layers of protection aligning to result in the event"

Second: There were no "layers of protection" ....

IMHO, incompetent people made incompetent repairs on a old, high-energy vessel, of marginal design.. they violated the State and Local Laws there was massive property loss and people died

It's not "a shame" or "a sad situation" when organizations do not follow the laws and put incompetent people in positions of authority.

This is willfull Negligence ....and a violation of the law ... the boiler should have been registered and periodically inspected

The Loy Lange Box Company should be sued into oblivion .....

MJCronin
Sr. Process Engineer

 

[FacEngrPE]

MJCronin, I make the assumption that the legal environment is a layer of protection, but in this case the hole(s) in that layer make it ineffective.

Source

https://safeche.engin.umich.edu/tutorials/swiss-cheese-model/

I completely agree that there are many sins here. The flaws in the St Louis boiler and pressure vessel safety program are also highly at fault, and still not fixed.

 

[weldstan]

I cannot understand why a full head replacement wasn't done. Much easier to do than the making a partial head and fitting to the remaining (still corroded) head section.

 

[MJCronin]

FacEngrPE, ... You have shown me an isometric diagram of red exploding bullets penetrating yellow swiss cheese ...

You state: "the legal environment is a layer of protection"

You speak a different type of english than I do ....

You seem to speak a type of english where words and phrases have an approximate and never fully defined meaning ..

Let's just call your mutation "MBA english" for the time being ...

You have also understood each and every word that I have inserted into this post ....

MJCronin
Sr. Process Engineer

 

[hacksaw]

Business as usual, a sickening read nonetheless.

Makes you appreciate the work by those involved in developing the Boiler and Pressure Vessel Codes.

 

[FacEngrPE]

MJ - I have lived in a world where most everything has to be explained to MBA's. It is inevitable that their spin on the English language would contaminate my version. I appreciate your comments.

 

[MortenA]

@MJCronin

IMO the mandatory inspection _is_ a layor of protection - and it failed! Is the layor too weak? Obviously - but were the taxpayers of St. Louis, Missouri happy with this program? Most likely, "yes" until that fatefull day - and you might still get a "nay" to allocate more fund to this program even after the event - because stuff like inspection programs are not very sexy.

--- Best regards, Morten Andersen

 

[akpipelineengr]

CSB posted a video of this incident:

[URL unfurl="true"]https://www.youtube.com/watch?v=rGVbGNdx7g0[/url]