Oops

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Pigeon
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Oops

Post by Pigeon » Tue Mar 10, 2020 1:52 am

Use my password... it’s “PASSWORD,” all caps.


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Royal
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Re: Oops

Post by Royal » Tue Mar 10, 2020 5:08 am

Give me the cliff notes.

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Pigeon
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Re: Oops

Post by Pigeon » Tue Mar 10, 2020 1:46 pm

Healthcare sterilant

As a toxic gas that leaves residue on items it contacts including food and spices, ethylene oxide is a surface disinfectant that is widely used in hospitals and the medical equipment industry to replace steam in the sterilization of heat-sensitive tools and equipment, such as disposable plastic syringes. It is so flammable and extremely explosive that it is used as a main component of thermobaric weapons; therefore, it is commonly handled and shipped as a refrigerated liquid to control its hazardous nature.

Ethylene oxide is one of the most commonly used sterilization methods in the healthcare industry because of its non-damaging effects for delicate instruments and devices that require sterilization, and for its wide range of material compatibility. It is used for instruments that cannot tolerate heat, moisture or abrasive chemicals, such as electronics, optical equipment, paper, rubber and plastics. It was developed in the 1940s as a sterilant by the US military, and its use as a medical sterilant dates to the late 1950s, when the McDonald process was patented for medical devices


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Pigeon
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Re: Oops

Post by Pigeon » Tue Mar 10, 2020 2:06 pm

A company used EO bulk sterilize medical products by loading boxes into large chambers and filling these with EO.

The process is to fill then this hazardous chemical must be removed. A series of air washes is used. About half is first pumped out to a scrubber. Next a flush of several passes of air/nitrogen is used to remove most of the second half of gas that remains into the scrubber. This gets the level below explosive level but harmful traces remain.

Lastly a venting process is used to flow air through the chamber and the EO passed over a flame heating and catalytic process to remove the trace amount.

So

A malfunction cause to operators to empty the chamber and unload the products. Techs check the chamber system by running an empty chamber test which fills it will EO. The system seems to be working so the first empty of EO is done. The techs/operators decide to skip the second wash step as they think the chamber was almost completely emptied. A supervisor gives out the password required to have the system advance pass that step.

When the final catalytic step occurred, too much EO remains and it explodes. The chamber is destroyed, control room windows blown out and the building itself is damaged.

Typical tech support call.

A little knowledge can be dangerous.

I wonder if the password was changed when they rebuilt the place.

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Pigeon
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Re: Oops

Post by Pigeon » Tue Mar 10, 2020 2:17 pm

Process Control Manager v0.9

>flush bypass

Bypassing a process can lead to unexpected results.

A password is required to bypass this process.

Password: holdmybeer

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Pigeon
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Re: Oops

Post by Pigeon » Wed Mar 11, 2020 1:08 am

It seems quite often shutting down alarm systems because they are annoying leads to problems. Who would have thought.

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