[HN Gopher] Anatomy of a Catastrophic Boiler Accident (1997)
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Anatomy of a Catastrophic Boiler Accident (1997)
Author : zetalyrae
Score : 30 points
Date : 2021-09-07 20:05 UTC (2 hours ago)
(HTM) web link (www.nationalboard.org)
(TXT) w3m dump (www.nationalboard.org)
| trhway wrote:
| Anatomy of a Russian accident - sub-specced metal used for steam
| pipes on nuclear cruiser Peter the Great. The pipe ruptured, 5
| killed.
| omegaworks wrote:
| >It is especially important in today's environment of cost-
| cutting and increased profit margins that safety not be
| sacrificed.
|
| Was there ever a time where the environment was not one of cost
| cutting and increased profit margins?
| jrockway wrote:
| I think there are two challenges here:
|
| 1) Safety systems work so well that people get complacent.
| "Approval of the fasteners is required, so I'm not going to get
| out a flashlight and mirror and double check."
|
| 2) At one point, many failure modes were totally unknown.
| Someone discovers them for the first time. You can have a
| comprehensive safety program that's well funded and always
| performed correctly, but if there is a failure mode that nobody
| knows about, it's as likely to happen to you as it is to
| someone else.
|
| And hey, at least people give safety lip service. Nobody ever
| posts signs that says "cost cutting is our #1 priority", they
| always say that safety is their #1 priority. Their heart's in
| the right place at the very least ;)
| Animats wrote:
| Wrong bolts. That matters.
|
| In the private sector in the US, there's The Hartford Steam
| Boiler Inspection and Insurance Company, established in 1866.
| They were the first company to insure steam boilers, and they
| still do. They inspect them before insuring them, and re-inspect
| at random times thereafter.
|
| They've been trying to expand this approach into "cyber
| insurance", but with limited success. They will insure the
| cooling and power systems for your data center, though. They know
| how to inspect those.
| jey wrote:
| If you enjoyed this, you might also enjoy the US Chemical Safety
| Board's YouTube channel, where they analyze major industrial
| accidents and their root causes:
| https://www.youtube.com/user/USCSB/videos?view=0&sort=p&flow...
| jeroenhd wrote:
| The twitter account @swiftonsecurity linked me to these videos
| once and I've been watching every single one of them ever
| since. It's very interesting to see how a set of complex
| systems can disastrously fail because of a small mistake two
| days earlier or because of some basic human error that anyone
| could make.
| s5300 wrote:
| We've almost come to full scale nuclear war, I think more
| than once, due to failure of singular computer chips in a
| known failure state.
|
| Functioning modern society/things in general just working
| (for those of us living in developed countries) is incredibly
| fragile and regulations are often still taken completely for
| granted.
| barbegal wrote:
| The official report has more details
| https://www.jag.navy.mil/library/investigations/IWO%2520JIMA...
|
| The accident is an example of the rare cases where the tolerance
| for error is tiny to prevent catastrophic consequences. Usually
| systems are designed with multiple lines of defense but this is
| not possible with a steam valve. The process to ensure that the
| correct fastenings were used was not in place. Ideally in these
| cases engineers should use poka yoke where the device can't be
| assembled incorrectly e.g. using an unusual thread size or
| marking all low strength fasteners in an obvious way to indicate
| low strength
| khazhoux wrote:
| Ha, I looked up "poka yoke", and found this Medium article:
|
| https://medium.com/@bhavyamangla/error-proofing-poka-yoke-fo...
|
| but the jigsaw pieces with the words "Poka" "Yoke" can be
| connected in seven incorrect ways :-)
| weaksauce wrote:
| having done some steam work before... that's the one thing that
| terrifies me in industrial settings. so much pressure and heat
| with little margin for error. having worked with the people
| that install things like that is no comfort at all.
| [deleted]
| quickthrowman wrote:
| I'm not sure what you have against union pipefitters, they're
| probably one of the highest skill building trades. They're
| generally at the top of prevailing wage scale, they do clean
| looking work, and pipefitting is still pretty much
| exclusively union labor.
|
| I'm on the commercial side, so maybe industrial is different?
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