CSB Safety Video: Ethylene Oxide Explosion

December 2, 2019 posted by

Narrator: On August 19, 2004, an explosion at the
Sterigenics International Facility in Ontario, California injured four workers and caused extensive
damage to the 66,000 square foot facility. The blast occurred when ethylene oxide gas, used
in the sterilization process, ignited and exploded. The U.S. Chemical Safety and Hazard
Investigation Board investigated the accident. Bresland: This was an incident involving a chemical
that is both highly flammable and toxic to humans. It is fortunate that no one was in
the immediate vicinity of the explosion, because it was likely there would have been
more serious injuries and possibly fatalities. McClure: The CSB investigation revealed several
factors that led to the explosion at Sterigenics. This video digest is intended
to graphically show what happened and how such accidents may
be prevented in the future. Narrator: Sterigenics International uses
ethylene oxide to sterilize medical products such as syringes, catheters and bandages
and then ships them to medical suppliers. Products arrive at the plant prepackaged and stacked on
pallets, ready to be sterilized in large steel chambers. The plant contains eight
sterilization chambers, operated and monitored by personnel
using a computer system in the control room. Packaged medical products are added to
the chamber and the doors are sealed. The chamber is then
filled with ethylene oxide, which penetrates the packaging
over a period of several hours, killing any germs and
sterilizing the products inside. After the sterilization phase,
ethylene oxide is removed from the chamber and the packaged products
in several steps. First, about half the gas is pumped from the chamber
to a pollution control device called a scrubber, where it is removed by chemicals. Next, virtually all of the remaining ethylene oxide
is removed in a step called “gas washing.” This involves injecting air and nitrogen into the chamber,
where they mix with the ethylene oxide. This mixture is then pumped
from the chamber to the scrubber. This process is critical to reducing the
concentration of ethylene oxide to below explosive levels and is repeated several times, until there is
only a trace amount of ethylene oxide remaining. This trace amount of
gas is not explosive, but it is toxic and must be removed by
ventilating the chamber before workers can enter. The front door is raised a few inches, which
automatically opens a vent at the rear of the chamber. Air is drawn through the chamber to another
pollution control device called a “catalytic oxidizer.” Once the air enters the catalytic oxidizer,
it is heated as it passes over open flames. Any remaining traces of ethylene oxide are
removed as the air passes over a metal catalyst. After the chamber has been ventilated for several
minutes, operators can safely enter to remove the products. McClure: During the sterilization process, gas washes are key to removing
ethylene oxide and preventing explosions. But on the day of the accident,
this critical step was bypassed. Narrator: On August 19, 2004, the
computer alerted operators to a possible error in the amount of ethylene oxide that
had been injected into Chamber Number 7. Operators in the control room instructed the computer
to abort the sterilization cycle and remove the gas. The system automatically
performed the normal series of gas washes, which removed virtually
all of the ethylene oxide. Finally, the chamber was
ventilated to the oxidizer. Operators then removed the
products from the chamber. Maintenance technicians arrived and
performed tests, which did not reveal any problems. They then ran a test cycle that injected 120
pounds of ethylene oxide into the empty chamber. And again, they could
not identify a problem. As the system performed the first step
of pumping ethylene oxide to the scrubber, the technicians asked the supervisor for
permission to bypass the time-consuming gas washes. The supervisor agreed. All of them incorrectly believed that because there
were no products in the chamber to absorb ethylene oxide, all the gas would be removed in the first step,
making the gas washes unnecessary. They did not realize that about half of the ethylene
oxide originally injected still remained in the chamber. There was no monitoring system to alert
them to this explosive concentration of gas. The supervisor provided a technician with his
special computer password to manually advance the cycle, bypassing the gas washes. A short time later, the front door was raised,
activating the chamber ventilation system. This drew a large amount of
ethylene oxide from the chamber, through the back vent, to the
open flames in the oxidizer. The explosive gas ignited. A flame front traveled back through the ducting,
into the sterilization chamber, igniting the remaining ethylene oxide
and causing a powerful explosion. It destroyed the sterilization chamber, bulging the chamber walls outward,
blowing off both of the two-ton chamber doors, sending one of them 75 feet away,
knocking out this hole in the north wall. The force of the blast caused widespread
structural damage throughout the building. The control room was showered
with flying glass from the windows. Debris, including the computers that control
the process, littered the inside of the room. McClure: While the accident would seem to have been
caused by a single event, bypassing the gas washes, the CSB investigation actually
revealed several causes for the explosion. Narrator: The supervisor with the critical password
did not understand why the gas washes were essential, whether the chamber was
empty of products or not. Next, the sterilization chamber was
not equipped with a gas monitoring system to warn employees of
explosive levels of ethylene oxide. And the company’s process hazard analysis program
never thoroughly evaluated the hazard presented by the oxidizer, despite a history of
oxidizer explosions in the sterilization industry. Narrator: The CSB investigation noted that the control
room had glass windows that were not shatter-resistant. The control room suffered
significant damage in the explosion and all the injuries
occurred to workers inside the room. Selk: If your control facility is located
in an area where an explosion could occur, consider using reinforced window materials
or replacing any windows with video cameras. Another lesson from this incident is
the importance of regular training. Maintenance technicians had last been
trained about the need for the gas washes in 1997, seven years before the incident. The maintenance supervisor, who was
authorized to use a password to skip the gas washes, was hired after 1997 and
never received the training. Selk: So a very important
lesson is, be sure personnel are fully trained on process hazards before
authorizing them to override automatic systems. Narrator: The CSB made several recommendations
to the company, government agencies and others. Bresland: Oxidizers are commonly
used for reducing air pollution. However, they have been the
source of numerous explosions. Our recommendations are
aimed at reducing this hazard. Inside an oxidizer, fuel, air and
an ignition source are all present. There is a serious risk if the
fuel/air mixture is too concentrated. Facilities with oxidizers should
use multiple layers of protection, such as gas monitors, safety interlocks and alarms, to
prevent a single mistake from leading to an explosion. Bresland: The CSB recommended that the
National Fire Protection Association, which creates fire codes
used around the country, require additional safeguards to prevent
explosions at ethylene oxide facilities. Specifically, we recommended the
codes require the use of gas concentration monitoring equipment, alarms and
explosion damage control devices. We also recommended that
Sterigenics install similar safety devices and improve its employee
training and hazard analysis programs. Finally, we recommended that the National
Institute for Occupational Safety and Health or NIOSH work with the ethylene oxide industry to promote
the use of gas monitoring and other safety measures. Bresland: CSB recommendations
are aimed at preventing accidents. If followed, we believe these recommendations will
go a long way towards developing safer workplaces. Bresland: To read the full report on the
CBS’s investigation, visit our website at CSB.gov. Thank you for watching
this CSB Safety Video.


100 Replies to “CSB Safety Video: Ethylene Oxide Explosion”

  1. KingHalbatorix says:

    6:33 more like safety is a lie

  2. Nexfero says:

    Use nichrome wire for catalytic heating instead of an open flame

  3. Steven says:

    it's a shame all the CSB can do is suggest and recommend

  4. tellucas says:

    Control rooms everywhere need to be able to withstand a major incident and have a self contained air supply so operaters dont loose control of the rest of the plant and have a larger release.

  5. Keith Purdue says:

    You can't fix stupid.

  6. Javier Madrigal says:

    Dumb ass

  7. Linas Kvedaras says:

    I would never trust that valve to not open for some unforeseen reason even while doing everything by the book.

  8. Jason Brooks says:

    Lol.. idiots..

  9. Nullpointer says:

    Seriously though? The vent leading directly into an open flame? Can't see how that could ever go wrong (like not removing most of the explosive gas first)

  10. Matt Mccoy says:

    Bunch of dumb fuckers

  11. Paleo Man says:

    Ethylene oxide is the primary ingredient in thermobaric bombs ie fuel-air explosives.
    These are the bombs they used on the hajis in the Tora-Bora caves.

  12. Mike Bennett says:

    Love the saftey is for life poster. Your killing me smallz 😂😂😂😂

  13. Lawrence Patrick says:

    What was sterilized ?

  14. TheWingedPotato says:

    "Ey bawws? Wazza passwurd to skip da gas scrubby tingy? It take too long"

    "Your right, the password is Ya Dun Goofed"

  15. hahagotcha!!!! says:

    Morons……the supervisor definitely lost his job over this.

  16. 1bad540i says:

    Days without an accident: 0.0

  17. Big Thunder says:


  18. mercoid says:

    Baaa haaaa haa heeee!

  19. travis miller says:

    Maybe require some kind of flashback arrestor on that oxidizer input, in addition to a gas concentration monitoring equipment?

  20. Anon Ymus says:

    This is a metaphor for people not wearing seatbelts because they are inconvenient

  21. Ron Wolpa says:

    What kind of company Sterigenic is : a supervisor who never received training , a team who does not understand the process. How about to hire the Three Stooges to run the plant ?

  22. oron61 says:

    Is this cheaper than Cobalt 60?

  23. John Nelson says:

    Sterigenic is taking quite a beating these days, look up their facility in Willowbrook, IL and the National Air Toxics Assessment

  24. Philip Guhl says:

    Complacency is typically the result of corporate cost cutting initiatives. Less training, less maintenance, etc. As long as nothing goes wrong, the executives look like heroes.

  25. blackhawk says:

    Just inept. No common sense/understanding of the equipment or gas.
    They deserved that.
    How do you train someone to have common sense? Or to be interested in what's around them?
    You can't.
    Those cambers also should have had blow out panels to direct the force of an explosion away from people.
    A fail on do many levels, only dumb luck saved them from themselves.

  26. blackhawk says:

    A back burn preventer should have been present as well.
    No redundancy.

  27. rialbb says:

    202,000 th.

  28. fr89k says:

    Seriously: A technician who does not know how the system works? This is super useless… Also: You can never pump all the gas out of something. A technician should know that. The closer you get to a real vacuum, the harder it gets to actually decrease the pressure further. Creating such a vacuum is super difficult. For that reason, chambers, pipes, etc. like these are being gas washed and not pumped down to a full vacuum…

  29. David Marino says:

    Who the fuck gives thumbs down to a video like this ?!?!?!?

  30. Stephen Bridges says:

    How was this hazard not discussed during the PHA? It's The critical scenario. Why did the operators not know the importance of the gas washing safeguard? If your Safeguards can be bypassed anytime someone feels they aren't required , you CANT COUNT THOSE SAFEGUARDS as effective protection layers. Good video either way, we need more people knowledge sharing and going over at least the KNOWN hazards so we don't all have to make the same mistakes.

  31. remote5555 says:

    How stupid can you be with one head .the supervisor needs his ass fuking.the technician should have known better .thick stupid bastards.

  32. JM Kupihea says:

    Stephen Selk will take none of your nonsense

  33. Kevin Tate says:

    First big one…. Override of system.
    Second….. Not fully understanding the process….
    Third….a simple lel meter inside the room, box……
    4…… Oxygen meter inside…
    5…a check valve at the vent line intersection……
    Training training I have seen such shortfalls in training over the years when companies will hire off the street and not train to a level of knowing exactly what is going on.
    Back in 2008 I was offered a job at a plant in Colorado and after I took a tour I decided right before I was to start to not take it. The entire plant setup was wrong. The systems in place were wrong. I got a bad feeling and some months later there was a explosion and a person died.
    To top it off not to long ago 2 men got burned bad there.
    A lot of people do not understand that you have to respect these chemicals or it will get you.
    The training shortfalls need to stop as well.
    I have been in this field for over 20 years and now more than ever it is hurry hurry hurry! Then safety safety safety. But when it comes down to it to stop for safety you will hear about it because they are not making money.
    One time during a cleanup for maint shutdown plant manager tells me to keep cleaning a reactor when ammonia type vapors were in a building. The operators told me and I shut down the cleaning. Plant manager comes over tells the operators to move the contractors out and for them to stay in. I refused to continue until all were out. He told me again to start and I pushed the keyboard forward got up and walked out to do something else. I got in trouble but there is no way in hell I am going to put someone in that position. Of course me as well as other operators contacted corporate and something was said but not to hard. Department of labor came in and interviewed operators and they got fined big time and then it became a very hostile workplace between management and operations. Needless to say I got out of there. They did wrong and when they got caught it was taken out on us.

  34. Rubble Johnstone says:

    John Bresland a proper Ulsterman.

  35. jed-henry Witkowski says:

    A sup not really knowing what's up… Shocker.

  36. memberwhen says:

    Top notch videos

  37. jeffsfleet says:

    Flying 2,000 lb door 75 feet? Whoa.

  38. Steve Maas says:

    The chamber door flew 30 feet through a wall and another 30 feet into the outside wall.

  39. ComputingAsh47 says:

    I love how every video is caused by 1 to many dumb asses that don't know their job or how to do it. Or why they are doing what they are doing. When you pay people 12$ an hour tho.. what can you expect… some high school drop out that is as smart as a box of rocks that doesn't understand his job, just how to perform what he once saw someone else do.. sad.
    edit: I hope the dumb supervisor in that tower was killed and anyone else in there that approved of his dumb decision.

  40. El Chulito GA says:

    6:34 it’s ironic that there’s a “safety is for life” poster in this damaged control room.

  41. quaztron says:

    At least ONE gas wash would be essential. And no catalytic oxidizer should ever use an open flame, just in case.

  42. Onion Rings says:

    Its always a poorly trained idiot

  43. Wa3ypx says:

    The supervisor didn't understand "why"

  44. ocsrc says:

    This is why you need oversight from an outside government supervisor who is there at all times and who must sign off on what the workers are doing

    When it comes to making money they will bypass safety steps and cut corners to save time every single opportunity

    I've been watching these videos today seeing how many people have died because the company was trying to save money and time is money

  45. 〉〉cerebral_malfunction says:

    "ontario, california"
    did i just have a stroke?

  46. Nathan Anderson says:

    common sense and sense of humor ect ect are needed thats why people need to be smart on what they are doing

  47. Sebastian Nielsen says:

    I personally think – why use dangerous chemicals at all? Aren't there safer alternatives to do that type of sterilization?

  48. UltraGamma25 says:

    Tell big Government to fund CSB!

  49. cbmira01yt says:

    4:35 "Supervisor provided the technician with a special password…"
    "Yeah dude, type in this special password: GoodbyeBlueMonday Got it?"

  50. cbmira01yt says:

    I've seen a number of these CSB videos, explosions caused by ethylene oxide, gasoline vapors, iron dust, sugar dust, and so on..
    How is it these criminal enterprises always manage to assemble and detonate something like a thermobaric bomb?

  51. sparkyy0007 says:

    A simple flame arrestor b4 the thermal oxidizer would be nice…

  52. Scott Crabtree says:

    You know even old Oil Furnaces have an "Eye" as I like to call it. It seems putting one in this system as a safety, would be a good idea. Except it working in reverse, when it senses a flame, it shuts down valves on both ends.

  53. Nelson Baietti says:

    "IN ONTARIO…" my jaw drops I have a look on my face as if I saw my mom fighting on the racoon war against the chipmunks "…CALIFORNIA" and then a very strange feeling of relief for some absurd reason washes it away
    Ontario, California… goddammit…

  54. Tig Dogsbody says:

    Q, is that you?

  55. Mr MEMé says:

    "Safety is For Life" ¡¡¡¡

  56. Suzanne Hartmann says:

    How many other shortcuts were they taking? How many products left that facility truly sterile?

  57. stephen melton says:

    Upon further investigation CSB found the special password was……password.

  58. ThomasHaberkorn says:


  59. Advocatus Diaboli says:

    Seriously, they had one job.
    But they didn't even know how their system works? It took us what, less than 5 minutes to learn? And they were working there on a daily basis, doing nothing else but operating these chambers – yet they didn't know exactly how these chambers actually work?
    What a pathetic display.

  60. Reggie R2 says:

    Damn blew the 2 ton doors 75ft away?!

  61. Grayfox988 says:

    This made me seriously consider using reinforced window materials for my control facility.

  62. Sam Labo says:

    This chem has serious handling protocol, toxic and explosive and it's well, oxides everything.
    They can break it down, like flourine breaks O3

  63. chaz zeiler says:

    These assholes sound like mindless robots. You don’t need a generalization every 30 fucking seconds about dangerous it is. We get the fucking point…

  64. Kyusoath says:

    do you ever do anything about these companies? any ceos executed/in prison?

  65. TheDewaltBoy says:

    Well god damnit thats why you don't give out your password to anyone!

  66. Dr Rice says:

    6:33 "safety is for life"

  67. Klaa2 says:

    Corporations will always do the right thing on their own, they don't need to be regulated or monitored !

  68. MACK DIESEL says:

    I often wonder what the password was to all these CSB videos where they use a password to override the safety measures then kaboom

  69. James Douglas says:

    Very serious considering this chemical is a known carcinogen and has been recently linked to increased cancer cases in a neighborhood near me from a company releasing it into the air at apparently legal limits ,I’m outraged by not surprised that these companies can fuck with our health without any repercussions

  70. Gingo Studios says:

    I replaced my facility's control windows with video cameras/monitors for this very reason. Glass kills!

  71. WineScrounger says:

    Isn’t ethylene oxide the filler in thermobaric weapons?

  72. mplewp says:

    ever heard of Gellingen gas disaster in Belgium / or the fire works explosion in Enschede NL . now those where some real explosions xD

  73. MrPLC999 says:

    Classic case of ignorant employee who insists that safety requirements can be ignored, which is exactly how the Chernobyl disaster occurred.

  74. Ryan MacFarlane says:

    After watching this video I am now more qualified to operate a sterilization facility than the supervisor who was operating the facility.

  75. John Smith says:

    "All of them incorrectly believed that because there were no products in the chamber to absorb ethylene oxide, all the gas would be removed in the first step, making the gas washes unnecessary".
    Yes, why did they believe that?
    Laziness and making assumptions almost got them all killed. (Time consuming washes).

  76. Matt Schnorf says:

    I like the other narrator better

  77. 19MAD95 says:

    Sweet I live next to one of these plants. Fucking sweet can’t wait to die

  78. POStOLFRONT says:

    This supervisor was a SUPER IDIOT!! this is what happens when you hire idiot burger flippers to do scientific jobs to save money on wages!!

  79. Mark Henderson says:

    This is why government overwatch is important because the private industry will never follow the rules if they don't have to.

  80. Those Fabulous Chartier Boys says:

    The password was "BOOM".

  81. travis eastlick says:

    Apparently their safety team wasDemocratic. To be Democratic you must throw away and ignore all facts and only go by what you feel and apparently they felt they were safe doing it the way they were.

  82. flat eman says:

    There where many strange handshakes and everything seems normal again

  83. Neil Legacy says:

    All that for sterilization of medical products don’t make sense as soon as someone put hands on the objects its contaminated again.And hits air.

  84. Richard NZ says:

    looks like the building is not made to vent explosive pressure – if your brainy enough you could work out how much free space is open to be used as a explosion risk zone ?area and then work out pounds per square inch the building will need to withstand if the worse case happens – make the roof as a hinge doors open etc etc – if space is available a burst wall could be designed in to vent into a secondary area away from people – you have 3 walls stronger than the fourth creating path of lest resistance

  85. rtrThanos Ezekyle Abaddon says:

    USCSB videos are the best murder-pr0n. You haven’t seen a cruel or unusual death unless you seen a USCSB video!

  86. idkYeyeDo says:

    someone got fired..

  87. Pepper Talks says:

    The system seems safe enough. It’s the humans that are the dangerous element.

  88. Giancarlo Eiras says:

    How the hell is their no gas monitoring system in the chamber? That’s almost unbelievable!

  89. Justin Silvers says:

    That's what happens when you cut corners and skip steps. Steps are there for a reason.

  90. Nevermind says:

    Control room workers instantly turned into living hamburger patties.

  91. John Ross says:

    So many outrageously bad decisions. Why was the glass breakable why was even possible to advance the system has skip a step? Why did the system not have a way to detect how much gas was left?

  92. painmagnet1 says:

    Idiots from the top down. Most of these catastrophes are caused by managers and engineers. I see it all the time in the industry I work in as a millwright. If I relied on the salaried guys for my safety, I'd be dead a hundred times over.

  93. seri katil says:

    Fire the supervisor and those who trained the supervisor

  94. Pqrst Zxerty says:

    Always do a risk assessment and every month read it, update it, talk to your team about it, if in any doubt aways get someone else to do it so they get the blame and you are not involved, as you were in the toilet or or lunch or outside having a smoke.

  95. A true meme master says:

    This is like letting a virus use java

  96. The Farmacy Seeds Network says:

    Man… this was dumb X dumb x dumb = 4 injuries.

  97. Arod Rodriguez says:

    Hindsight is 20/20

  98. 301speed says:

    The safety poster in the control room is the best

  99. KELLI2L2 says:

    What would a world without ALL these toxic chemicals and substances be like❓❓❓

  100. Sir Bob says:

    Training, safety, & maintenance cost money. Nuff said ?

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