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> extremely silly process issues None of these were silly. It takes an extraordinary amount of hard work and collective intelligence to fix these issues. >

> extremely silly process issues None of these were silly. It takes an extraordinary amount of hard work and collective intelligence to fix these issues. > failure to label the input pipes for a factory Labels are not the end solution, no one reads labels unless they want something, anyone in IT should know this. (It's a great dark pattern trick) That video was a great example video of "Murphy's law" the engineer principle, not the joke. The problem is the solution, different attachments for different fluids goes against the safety of standardization. I've seen USCSB give advice I would consider incorrect or in question, they suggested locking compound gates. You can be directed to leave them unlocked to allow emergency evacuation in person or by car. I don't know what's better there, but USCSB needed to also address evacuation safety if they make statements like that. This stuff is hard and has to be applied to accidents that have not happened. It's a 'Bullshit jobs' mega-machine. [edit] I have the say the 30 second intro to the "Explosion at the Husky Superior Refinery" https://www.youtube.com/watch?v=sFhkzK7jkKg https://www.youtube.com/watch?v=sFhkzK7jkKg gave me goosebumps.

sclarisse 3y ago
The brain finds amusement when it detects a discrepancy between expectation and result. https://youtu.be/Tflm9mttAAI https://youtu.be/Tflm9mttAAI I think this one especially is simple enough of an error, and the consequences are so disastrous, that it’s reasonable to find it silly.
- aaron695 3y ago
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MichaelZuo 3y ago
> Labels are not the end solution, no one reads labels unless they want something, anyone in IT should know this. (It's a great dark pattern trick) That's pretty solvable in IT, just assign full responsibility for fixing the problem to whoever messes up via ignoring the labels.
- lazide 3y ago
  Hard when ignoring the labels kills them before they can be punitively assigned the task I guess.
  - MichaelZuo 3y ago
    Hence why I said "in IT"? Did you misread my comment? Obviously in a chemical plant this would be futile in a lot of scenarios. And so much more complex proactive measures are the norm.
    - lazide 3y ago
      I guess I did! I thought you were saying it as a way of recommending it outside of IT.
fdhfdjkfhdkj 3y ago
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calgarymicro 3y ago
The USCSB didn't just recommend labels in that case (though that likely would have prevented the incident since it was caused by someone unfamiliar with the facility who might have read them). They also recommended making sure the connectors for the inlets were different so it would be physically impossible for the error to occur. That said, it's quite silly indeed that the inlets for two incompatible chemicals that would release toxic fumes if mixed were 18 inches apart, unlabeled, used the exact same connector, and were locked behind the same gate. I don't think it takes extraordinary collective intelligence to see how this could become a problem. The report for anyone who wants to know more: https://youtu.be/Tflm9mttAAI https://youtu.be/Tflm9mttAAI I don't recall the compound gate thing but I'd appreciate a link if you have one.
- aaron695 3y ago
  > mixed were 18 inches apart, unlabeled, used the exact same connector. They were labeled. Same connector - Standardized connectors are safer. Every chemical can't have a different connecter. If the truck swaps connectors in and out per location you are mostly back to square one. The connectors were locked, that's the differential they choose. Except one wasn't, which is the same issue as the truck swapping connectors. It shouldn't have been possible to have two connectors unlocked at once. > were locked behind the same gate. Multiple gates creates other issues. > 18 inches apart This the problem, multiple gates a distance apart are an issue, but probably the solution. It also allows clear signage on the gate rather than than the 7 characters you can see on the connector label. I count 5 - 7 connections, they can't all be behind a gate, so there is no hard rule. > compound gate thing https://www.youtube.com/watch?v=jh2HWT8gPeY https://www.youtube.com/watch?v=jh2HWT8gPeY They actually want a 'written' policy to stop people coming in. People ram raid gates to get into compounds so they can't be flimsy. In an emergency power could be out and you can be in a car or running while on fire.
  - calgarymicro 3y ago
    > They were labeled Were they? It says they had labels some distance down the pipe, but they weren't labeled at the point where the hoses connected where someone could actually read it. > Every chemical can't have a different connecter. Every chemical doesn't have to have a different connector. Maybe just ones that will cause a dangerous reaction if mixed. > I count 5 - 7 connections, they can't all be behind a gate, so there is no hard rule. Sure. Again, a good rule of thumb would be to separate the ones that could cause rapid death. > They actually want a 'written' policy to stop people coming in. So no fire code issue then.

sclarisse 3y ago

The brain finds amusement when it detects a discrepancy between expectation and result. https://youtu.be/Tflm9mttAAI https://youtu.be/Tflm9mttAAI I think this one especially is simple enough of an error, and the consequences are so disastrous, that it’s reasonable to find it silly.

aaron695 3y ago
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MichaelZuo 3y ago

> Labels are not the end solution, no one reads labels unless they want something, anyone in IT should know this. (It's a great dark pattern trick) That's pretty solvable in IT, just assign full responsibility for fixing the problem to whoever messes up via ignoring the labels.

lazide 3y ago
Hard when ignoring the labels kills them before they can be punitively assigned the task I guess.
- MichaelZuo 3y ago
  Hence why I said "in IT"? Did you misread my comment? Obviously in a chemical plant this would be futile in a lot of scenarios. And so much more complex proactive measures are the norm.
  - lazide 3y ago
    I guess I did! I thought you were saying it as a way of recommending it outside of IT.

fdhfdjkfhdkj 3y ago

[dead]

calgarymicro 3y ago

The USCSB didn't just recommend labels in that case (though that likely would have prevented the incident since it was caused by someone unfamiliar with the facility who might have read them). They also recommended making sure the connectors for the inlets were different so it would be physically impossible for the error to occur. That said, it's quite silly indeed that the inlets for two incompatible chemicals that would release toxic fumes if mixed were 18 inches apart, unlabeled, used the exact same connector, and were locked behind the same gate. I don't think it takes extraordinary collective intelligence to see how this could become a problem. The report for anyone who wants to know more: https://youtu.be/Tflm9mttAAI https://youtu.be/Tflm9mttAAI I don't recall the compound gate thing but I'd appreciate a link if you have one.

aaron695 3y ago
> mixed were 18 inches apart, unlabeled, used the exact same connector. They were labeled. Same connector - Standardized connectors are safer. Every chemical can't have a different connecter. If the truck swaps connectors in and out per location you are mostly back to square one. The connectors were locked, that's the differential they choose. Except one wasn't, which is the same issue as the truck swapping connectors. It shouldn't have been possible to have two connectors unlocked at once. > were locked behind the same gate. Multiple gates creates other issues. > 18 inches apart This the problem, multiple gates a distance apart are an issue, but probably the solution. It also allows clear signage on the gate rather than than the 7 characters you can see on the connector label. I count 5 - 7 connections, they can't all be behind a gate, so there is no hard rule. > compound gate thing https://www.youtube.com/watch?v=jh2HWT8gPeY https://www.youtube.com/watch?v=jh2HWT8gPeY They actually want a 'written' policy to stop people coming in. People ram raid gates to get into compounds so they can't be flimsy. In an emergency power could be out and you can be in a car or running while on fire.
- calgarymicro 3y ago
  > They were labeled Were they? It says they had labels some distance down the pipe, but they weren't labeled at the point where the hoses connected where someone could actually read it. > Every chemical can't have a different connecter. Every chemical doesn't have to have a different connector. Maybe just ones that will cause a dangerous reaction if mixed. > I count 5 - 7 connections, they can't all be behind a gate, so there is no hard rule. Sure. Again, a good rule of thumb would be to separate the ones that could cause rapid death. > They actually want a 'written' policy to stop people coming in. So no fire code issue then.