[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)
 
web link (www.nationalboard.org)
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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