Steam Accidents & Forensic Investigations

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Wayne F. Kirsner, P.E
Principal / Kirsner Consulting Engineering

MS/Physics/1973/Georgia Institute of Technology
BS/Physics/1972/Georgia Institute of Technology
BSME/1980/Georgia Institute of Technology

Professional Engineer/Mechanical/1983

ASHRAE Distinguished Lecturer:
June 2001 through June 2009

Fairbanks Alaska- Feb. 1997 investigating valve explosion.

Steam Investigations & Accidents

For the one-year-old 850 MW, supercritical, coal fired Commanche Unit III Power Station in Pueblo, CO., troubleshot two hydraulic transcient problems --one in the 16" condensate return pipe emptying into the Plant Deareator and another in the 16" Boiler Drains Tank pipe to the 3 psia Condenser Hot Well. While the transients were not severe enough to rupture the XS pipe or put operators in danger, they were forceful enough to knock pipe slips off supports and cause damage to valves and structure that had to be repaired. After doing two seminars for Plant operators, I explained what was happening to the Principle Plant Engineer, why it was happening and, in the case of the Deareator piping, recommended a simple fix which is being implemented.
For the Boiler Drains tank, the damage pattern indicated the Tank was draining below the level of it's outlet pipe and permitting flash steam to enter the discharge line causing waterhammer which racked guides and supports (e.g.,photo at right). The Plant will need to conduct a simple test to rule out the simplist cause--a leaking level control valve in the Line to the Condenser Hot Well--to see if the cause is instead collapse of vapor left in the 200' drain line after the level control valve to the Hot Well closes.
For attorneys defending Hydronics Systems Manufacturer, Engineer, and Architect, investigated steam release at Las Vegas hotel where a technician was severely burned while attempting to start up a new steam-to-hot water-heat exchange assembly. During start-up, 110 psig steam was admitted to a steam line which was already filled with subcooled condensate because the Assembly's steam trap and condensate mover had not been activated when steam was applied to the Assembly during a start-up attempt a month earlier. The condensation-induced waterhammer resulting from the mixing of the 344oF steam with 70oF water blew out a flange gasket spraying the worker with hot water and steam. He died a week later in the Hospital. My November 2010 Report on the cause of the accident led to the immediate settlement of the law suit brought by the family of the worker against the manufacturer, vendor, hotel, engineer and architect.
The position of the nuts on the PRV pilot proved that the start-up technician had indeed applied steam to the Heat Exchange Assembly, contrary to testimony by his boss.

For Minara Mining at Murin Murin Nickel Mining Site in Western Australia, investigated 3250 kPa (465 psi) steam rupture in a 10" schedule 80 pipe feeding slurry to an Autoclave. Submitted Report explaining the cause of the steam release to Minara and Safety Directorate. Assisted in writing and editing Mine Safety Bulletin No. 92 for Government of Western Australia Department of Mines and Petroleum. Dr. Fred Moody worked with me on a ground breaking portion of this investigation to calculate the pipe thrust of the escaping slurry which caused the ruptured pipe to wipe around like an unrestrained fire hose. June- Sep 2010.

Forensic engineer assisting plaintiffs attorney to understand the 2004 steam explosion outside the New Executive Office Building in Washington D.C. which killed two contractors attempting to re-energize steam service to the NEOB after a water main break. Water from the break submerged the steam main serving the building causing increased condensation in the Main and subsequent water hammer in the building. The Contractors received an emergency request to shut the steam feed off in the street. In the morning, when the contractors were attempting to restore steam service to the building , the water hammer repeated in the manhole outside the building where the contractors were opening the valve. The force of the waterhammer blew off the bottom plate of a jury-rigged pipe cap for the drip leg welded in place years ago by an amateur welder. The steam and hot water released from the steam main killed two men in the manhole.

Manhole Under Renovation Before Accident

For Suncor Energy, Firebag, Canada--Analyzed water hammer in the common Blowdown Header from OTSG's where flashing steam from superheated water and is mixed with subcooled water. (The diagram at right shows six scenarios for how subcooled water flowing into a steam line can either be stable or cause condensation induced waterhammer). Provided report analyzing all foreseeable water hammer susceptibilities in steam plant producing 11,000 kPa steam for SAGD bitumen recovery at the Firebag site in Northern Alberta. Presented 7 hour seminar at Firebag to Operations Managers and Engineers explaining condensation-induced waterhammer and the origin of waterhammer suffered at their Plant. Advised Suncor's engineers on developing equipment modifications and operating procedures to avoid waterhammer scenarios. Diagram at left is from Aya, Yayame, Nariai's "Effect .. Waterhammer Induced by Injection of Subcooled Water...into Steam flow. " IIt served as my model for diagrams drawn for Suncor to explain the different waterhammer scenarios that could take place in their OTSG blowdown line.

Forensic engineer in defense of Spence Valve (who was not responsible for the accident) in law suit resulting from the 2004 BLEVE of a stainless steel tank in a Con Agra Plant in Tennessee. A BLEVE is a Boiling Liquid Expanding Vapor Explosion. Although normally associated with accidents involving flammable liquids like propane, a BLEVE can occur in a pressurized hot water tank in which only hot water and steam are released. A BLEVE occurs when superheated water (at elevated temperature and pressure compared to atmospheric conditions) is released through what may start as a relatively small fracture in the vessel. The explosive power comes from the 1600 times expansion of superheated water as a portion of the superheated water flashes to steam at atmospheric pressure. At right is a photo from another accident. It's believed the atmospheric vent on this Laundry condensate receiver became plugged allowing hot condensate from high pressure traps draining to it to pressurize the tank beyond its 5 psig intermittent rating. Upon cracking, probably at a weld, a BLEVE blew off both heads of the vessel. The resulting loss of containment created a shock wave in the surrounding space which knocked down and injured two workers roughly 20 and 50 feet away as well as denting duct work, cracking sheet rock, and breaking a glass window. (Click on BLEVE to view the tank that was utterly destroyed in the Con Agra Incident and for more about what causes a BLEVE)
Ends Blasted Off 350 Gallon Condensate Receiver Tank

March 2009, for the Washington D.C. Capital Steam System, analyzed ramifications of improperly sloped new buried steam conduits for potential for destructive fluid-structural interaction due to puddled water filling as much as 25% of the pipe depth. The puddle of water retained in the steam pipe was verified by video survey to be 138 long. Calculated magnitude and location of worst case fluid-structural interaction so engineers could evaluate if conduit should be dug up and reinstalled.

For Duke University, investigated steam release accident which resulted in the death of a maintenance mechanic trying to reactivate a Building PRV Station. Briefed management to explain the series of events that led to the accident. Wrote revised start-up procedures which management perfected and issued. Conducted two day seminar for maintenance, safety staff, and management on water hammer in steam systems including what happened in their accident.
Blown out Strainer upstream of 120 psi PRV Station that was being re-energized after a brief shut down for maintenance

For MIT in Cambridge, MA Nov 2008, Investigated 200 psi steam release accident where anchors were jerked from their ceiling mounts allowing a slip-type expansion joint to be yanked apart by a condensation-induced waterhammer. Condensate accumulated in the steam line due to an isolated trap which was hidden from plain view by an unrelated equipment modification. The accumulation apparently sat in a piping depression undetected and undisturbed for more than a year because of near equal steam pressure on either side of the University's looped steam network. The accident was finally initiated by a major pressure upset at the

Slip Yanked from 8" Expansion Joint by Condensation-Induced Waterhammer when anchors broke
University's Power Plant. There were nopersonnel injuries, but extensive property damage . In addition to reconstructing and explaining the cause of the Accident, provided an 8-hour seminar to steam fitters and University's engineers.

Consolidated Edison Company of New York, assisted attorneys in understanding and explaining the cause of a steam explosion which occurred beneath the intersection of 41st and Lexington Ave. Litigation is ongoing. In other work, presented power point explanation of origin of damage resulting from another "loop type" condensation-induced waterhammer incident in New York City. Once again, litigation is ongoing.

For Kent State University, investigated deterioration of underground buried conduit to determine if repeated water hammer events was a possible cause of multiple failures in the HDPE steam conduit system. Found that fluid-structural interaction was unlikely to be the cause of damage and suggested at least one other failure mechanism based on manufacturers installation scheme to allow for expansion.

NASA Langley Research Center, March 2008, inspected layout of new 10" HPS line and reported to NASA engineers and safety personal on design flaws/construction errors and areas of concern with new line. Found that steam traps were under-rated for service, traps stations were needed directly up- and downstream of a critical valve station to preclude a waterhammer incident at this location, and expansion joints (or their guides) which were designed to accept axial stress only would be subjected to lateral stresses that did not appear to be accounted for in design. My 2002 report on a similar investigation for NASA LaRC is accessible below. Taught a two-day 8-hour seminar for NASA engineers, mechanics, and supervisors after presenting my report.
University of Massachusetts Expansion Joint Failure, Amherst, MA. February 2008, Investigated and reported on root cause of externally-pressurized expansion joint failure in one of two 20" steam mains from new Central Heating Plant. Found that condensation-induced waterhammer had occurred due to misunderstanding of inverted bucket trap operating characteristics by the start-up engineering company. As a consequence, a "parallel two-phase flow instability" between the two nearly-identical 20" lines allowed 7500 gallons of condensate to accumulate in one 20" line unbeknownst to operators. The condensate was able to accumulate without notice because the system was "looped" and under low-flow conditions so that all steam was readily delivered through one line while the other was blocked with condensate.Advised University on identifying
other expansion joints which may have sustained damage. Dr. Peter Griffith assisted in this investigation. Clogged trap strainer pictured at right s explained below.

Strainer removed from trap assembly draining the low point in the 2000' of 20" Mains. Clogging material is pipe scale loosed from pipe walls as a result of pipe cleaning by the start-up contractor who, afterward, neglected to clean the strainers. While not the cause of this Accident, the pictures speak to the residual pipe scale present in new pipe and the need for strainers to protect trap orifices. This strainer on the lowest elevation trap drained the most liquid and so caught the most crud.

For Trigen-Boston Energy Corp, the district heating company serving the City of Boston, investigated steam release from expansion joint failure in underground steam conduit due to waterhammer event. In Nov. 2007, at direction of Company Legal Counsel, gave slide presentation to VP/General Manager and engineering staff on root cause of event. Dr. Peter Griffith attended the briefing and advised in this investigation. Gave 8-hour seminar for Trigen engineers and supervisors on understanding waterhammer in steam systems.

Expert Witness for Attorney defending Industrial Campus against OSHA Citation and Fine
in case where steam worker was killed during start-up/warmup of a branch steam main. OSHA cited management for violating OSHA's Lock-Out/ Tag-Out Standard CFR 1910.147. My report and affidavit argued that employees' procedures exceeded requirements of OSHA's Lock-Out/ Tag-Out Standard and that the accident was caused by circumstances not included in the Citation or anticipated by the Standard. The Federal Judge upheld this argument among others made by the attorney and dismissed this citation. At right is a photo of the 8" Class 250 cast iron valve which ruptured while being opened to 220 psig steam by the worker. (The valve bypass line has been removed.) My investigation found that the actual root cause of the accident was Shut-down/Start-up Procedures which did not require a drain be opened and LEFT OPEN at the low point in the isolated pipeline. A closed gate valve under full steam pressure leaked steam into the isolated section of line which, over five days, filled the line with condensate. Even though there was a trap in the isolated line section, there was insufficient pressure to discharge condensate from the trap. At start-up, full steam pressure was applied to the water-logged line without noticing the condensate accumulation. When the downstream isolation valve was opened, draining condensate allowed steam to intrude into the subcooled condensate and hammer.

Steam Release Accidents in Chicago, IL Chemical Plant, . Three separate failures in the steam system were investigated at the Plant; two were determined to be caused by water hammer, the third by unrestrained pipe expansion after an anchor was removed but not replaced. The sketch below was used to explain the waterhammer incidents.
My Report explained that the waterhammer incidents were brought on by allowing condensate to accumulate in the steam system due to the practice of isolating and de-energizing steam mains without opening drains or vents to prevent a vacuum from drawing condensate backward from condensate system. While this common denominator could be considered the ultimate cause of both accidents, there were other proximate causes.

For Suncor Energy in Alberta, Canada, investigated transients in bybass/blow-off line from OTSG boilers which caused large expansion loops to deform enough to damage adjacent electrical cable racks and be dislocated from their pipe supports. On a second trip investigated waterhammer explosion in steam discharge line from Steam Generator. Wrote report explaining three different waterhammer scenarios in 11.000 kPa steam line and recommended corrective action. For Oil Sands site, conducted nineteen 6-hour training classes for workers in Ft. McMurray, Alberta. Investigated and explained transients in the two-phase condensate return line being used to lift condensate to a flash tank at oil sands site. (If you think about it, you can't lift condensate in a two phase condensate-return line without transients).

Coronado North Island Naval Air Station, San Diego, Sep 2004. Comprehensive Report on 8 in.steam valve rupture in a manhole which blew apart releasing 125 psi steam during an attempt to open the valve. The civilian steam worker opening the valve, received second and third degree burns over 20 to 25 % of his body. Had he not been in the process of evacuating the manhole in response to a loud bang which preceded the rupture, it's doubtful he would have survived the incident. Found that the direct cause of the rupture was condensation induced waterhammer resulting from nucleate boiling of ground water in a manhole 300 feet from the accident site. A heat transfer calculation showed that completely submerged steam piping within the downstream manhole (as had been, on occasion, observed to be the case) would generate enough condensate within the pipe to overcome the capacity of the steam trap in the Manhole and fill the 300 feet of 8" pipe between the two manholes. This is a somewhat rare but recurring problem at the base because of the Environmental Protection's office objection to discharging ground and rain water to the street level by sump pumps and the resultant abandonment of sump pump maintenance and replacement.

Concurrent with accident analysis, taught three half-day sessions for civilian steam fitters on condensation-induced water hammer and briefed supervisors and managers on the systemic causes of the accident.

In another phase, inspected 8 Piers at Naval Station San Diego for steam waterhammer potential and reported on hazards found.

Boiling ground water in Steam Pit

For Motorola, now Freescale Semi-Conductor, in Austin, TX, June 2004, investigated cause of steam rupture which shattered a 10" cast iron strainer releasing steam and condensate into the mechanical room of the Plant. Found that one of two 16" steam mains that made up the "loop system" serving the Plant was completely blocked by condensate resulting in an unstable equilibrium in the system. Closing any of several isolation valves between the East and West 16" mains would again accelerate the slug and repeat the accident. Advised Freescale engineers to immediately locked-out valves. Helped them devise a first-of-its-kind method to defuse the situation without down shutting steam production . Taught two-day training class to workers, supervisors, and engineers on condensation- induced water hammer and what caused their accident.

Ruptured 10" Cast Iron Strainer
For Houston, TX law firm representing industrial concern, investigated cause of steam accident resulting in operator death when a hydraulic shock stripped the nuts from the studs of a valve flange allowing it to separate releasing a spray of scalding water. The release burned the operator to death.
I concluded that the accident was due to condensate which accumulated atop the valve and subsequent water hammer which was initiated by the operator when he attempted to open the valve. The root cause of the water hammer was not operator error, but the improper original design configuration by the engineer of the trap assembly with respect to the valve.
For NASA Langley Research Center, 2002, investigated anchor failures and seized joints in 4900 ft. long Steam Tunnel No.4 carrying 350 psig steam. Found joint misalignment due to deficient 1964 engineering drawing detail resulting in widespread improper anchor installation by the original contractor. (It should be obvious that the arrangement shown at right cannot work). Problems were not due to water hammer as had been postulated. Analyzed system vulnerability to waterhammer as a precaution. Documented root causes of tunnel problems in Report to NASA Engineers August 2002. Click to view Report.
Can you spot the obvious engineering error above made by the original Design Engineer?
For BP Refinery and Chemical Plant in Grangemouth, Scotland, investigated two water hammer incidents one of which fractured an 18 in. steam main (at right, pipe peeled open at a Tee) carrying 200 psig steam. Identified cause related to flooding of a culvert thru which a steam main passed. Briefed British Health and Safety Executive occupational safety engineers after delivering reports to BP Engineers. Conducted training session for sixteen BP engineers on water hammer. The article, "The Danger of Flooded Manholes and Submerged Steam Lines" describes one of the two accidents. The Scottish Health and Safety Directorate used my report to produce their Safety Directive on condensation-induced waterhammer which can be viewed at
"A Wee Bit ah Wa'er Ham-mor"

For Tennessee State Board of Regents, surveyed and analyzed problems in the 6000 ft. underground steam and chilled water utility distribution tunnel at Tennessee State University to determine whether the design engineer or maintenance unit was responsible for chronic problems. The Report identified the root causes of failed anchors, seized expansion joints, blowing valve gaskets, and inoperative traps finding the prime culprits were poor anchor welds and faulty guide installations. Published a “virtual tour” of the tunnel problems with analysis on the Internet for use by all parties involved. Wrote new preventive maintenance schedule, confined space entry program, and detailed start-up procedure for tunnel steam distribution system.
CLICK to take a Virtual Tour of Steam Tunnel Problems!

Prepared Permit-Required Confined Space Program for Motlow State Community College to meet OSHA's 29CFR1910.146 regulation. Performed testing of manholes for hazardous levels of H2S, CO, CH4 and O2 and trained operators and administrative staff on use of testing and rescue equipment.

Expert engineering consultant to attorney defending Chubb Insurance Co. against a law suit brought by the victim of a chemical accident at a large paper mill in Houston, Texas. Found that accident was due to improper installation rather than material defect in the rubber expansion joint that failed releasing a spray of caustic 220oF white liquor.

1999, 2000, 2001 Faculty member at University of Wisconsin's annual "Boiler Plant Design Course" speaking on steam accidents. Speaker at Kansas City IDEA Steam Distribution Forum on "Understanding Water Hammer."

Investigated cause of steam accident at Metcalf Lumber in Metcalf, Georgia in which a Class 250 cast iron valve exploded killing a worker as he passed by the valve. Accident report found that the water hammer event was due to lack of rudimentary engineering design for the "in-house installed" addition of an additional drying kiln.
Steaming Valve on the night of the Accident (left) and the next day (above)

Authored "Reconstruction of the 1988 Steam Accident in Manhole C-4 at Fort Wainwright, Alaska" for the US Department of Justice, Sept. 1997. Expert Witness defending the Army Corps of Engineers in lawsuit involving accident in which a 10" cast iron valve was fractured by steam water hammer severely scalding two asbestos abatement workers. Arbitration by Federal Judge settled the case in favor of the Corps.

Authored "Investigation of Dec. 1996 Steam Accident at the Sacramento Regional Waste Water Treatment Plant" in which a cast iron trap fractured during steam start-up. Developed and trained operators on new safe start-up procedures for the site to prevent future accidents.

Author of investigative report on cause of valve gasket leaks in steam pits at Wright Patterson AFB, Dayton Ohio. Stress analysis showed leaks were caused by inadequate provision for expansion in design, not bad gaskets as was being charged by the owner.

Author and chief investigator retained by the manufacturer for the report on The Expansion Joint Failures at Le Moyne College in Syracuse, NY in which three flexible-hose type joints catastrophically failed during start-up of the steam system. Report found water hammer was not responsible for failure.

Forensic Analyst retained by the Georgia Department of Human Resources to investigate the cause of a steam accident which resulted in an operator's death at Northwest Georgia Regional Hospital. Authored the report: "Analysis of Conditions and Events which led to the Valve Failure in Steam Pit 3A ...". Retained as the expert witness defending the engineering design firm from the law suit which arose from the accident. Report found that the accident was due to a combination of operator error and the inadvertent disabling of a trap during a building demolition which had taken place years earlier. The magazine article "What Caused the Steam Accident that killed Jack Smith" which appeared in the July 1995 issue of Heating/Piping/Air Conditioning magazine and the Feb. '96 issue of National Engineer was based on this accident.

Engineer for design of new $1.5 million dollar Central Steam Plant for the campus of Northwest Georgia Regional Hospital.

Technical reviewer adjudging validity of energy conservation measures submitted in Technical Analysis Reports (TA's) to the State of Florida's Energy Office to compete for grants through the Department of Energy’s Schools & Hospitals Grant Program. Authored State's Life Cycle Costing methodology to be required in all reports submitted in 1995. Conducted training session for approximately 120 professional engineers seeking certification to write TA Reports in Florida in 1995. Conducted subsequent training session on Life Cycle Costing at DOE Region IV Conference for State Energy Directors from Southeastern States.

Authored 1992 Technical Analysis Report of energy conservation measures for Patterson Hospital in Randolph County, Georgia. Wrote engineering study --Deficiencies in Design and Operation of Chilled Water Plant which analyzed and offered solutions to inadequate CHW distribution in the hospital. In 1993, designed, bid, and oversaw construction of redesigned central chilled water plant for the hospital. Similarly, completed comprehensive lighting retrofit project for the hospital and nursing home. Completed projects reduced Hospital's electric utility bill by 35%. Projects were awarded a $114,000 matching grant through the D.O.E.

Re-designed and supervised replacement of steam traps and attendant condensate piping including removal of asbestos in steam pits on the campus of the 15 building Fulton-Dekalb Hospital Complex, 1985. 

Project Engineer and Project Manager for 1985 design of $500,000 Waste-to-Energy Incineration Plant and waste heat boiler at 915 bed Grady Memorial Hospital. Authored $385,000 grant request for this project received from D.O.E..

Investigated underground leaks from hot water piping systems serving six of eight buildings which received new HVAC systems at Brook Run Mental Health Facility. Identified manufacturing defect in pipe joints.

In association with JND Sterling, co-authored feasibility study of energy conservation measures in prototypical existing NASA Office Building at the Johnson Space Center in Houston, Texas. This study added a fourth volume to the three volume set previously accomplished for NASA. Project Director and primary author for the $144,000 Energy Conservation Analysis of Existing Buildings and the two volume set: New Building Energy Design Guidelines for the NASA Johnson Space Center in Houston, Texas. 

Project Manager for evaluation of all Mechanical, Electrical, Plumbing, and Fire Protection Systems in the 42 story First Atlanta Bank Tower and 8 story Bank Annex.

Project Manager and co-author for $200,000 energy study conducted in five largest mental hospitals and institutions operated by the State of Georgia. Five million dollars worth of energy saving measures were identified of which about $1 million worth were selected for implementation. Head mechanical engineer on design of two largest projects:

For the Georgia Forestry Commission, co-authored "Wood Energy Feasibility Study for Northwest Georgia Regional Hospital" to replace fossil fuel steam boilers with wood fired boiler. This report was submitted to the Department of Energy through the State Office of Energy Resources and received a 50% matching grant to fund the $1/4 million project.

Retained by the International Engineering Support Group of Coca Cola to advise on the feasibility of a programmed $5 million cogeneration plant for their Heightstown, New Jersey plant. Based largely a re-evaluation and correction of a computer study performed by the recommending consulting engineer on the project, the project was canceled after Mr. Kirsner demonstrated that the project had a negative net cash flow.

At NASA Johnson Space Center, analyzed impending purchase of two 2,000 ton steam turbine driven chillers designed by NASA's consulting engineers. Recommended alternative chiller selection based on predicted first cost savings of $300,000 and annual savings of $230,000 per year. NASA accepted recommendation, canceled procurement action, and re-designed the Chiller Plant addition based on Mr. Kirsner's recommendation.

July 2009, Expert for Spence Engineering (who was not responsible for this Accident) in law suit arrising from the BLEVE of the stainless steel tank shown at right. For a hot water Bleve to occur: (1) the tank must be pressurized so water can be superheated with respect to atmospheric pressure, (2) there must be steam atop the water in the vessel, and (3) the vessel must suffer a steam release through a crack, hole, or perhaps a safety valve relieving. Thus, the tank must generally be pressurized beyond it's rating, or in a weakened condition.

The water inside this 304 SS tank non-ASME which was tested to 100 psi by the manufacturer, was inadvertently heated to a temperature approaching 288oF by uncontrolled application of 41 psig steam to water passing through a heat exchanger. (An inoperative control convinced us the temperature controls must have been bypassed). A small water leak at a pump seal allowed water to leak out of the closed system without being made-up by the tank's water regulating valve. That's because the pressure in the tank exceeded the setting of the regulator. Thus steam filled the void left by the leaking water.

Stress Corrosion Cracking concealed by insulation severely weakened the tank so it could not withstand the vapor pressure of the hot water. We believe a crack developed near the top of the tank which released steam so that a rapid pressure drop initiated the the BLEVE which proceeded to blow the tank apart causing an instantaneous total loss of containment. The superheated water in the tank, upon release, partially flashed to steam immediately releasing expanding vapor which created a shock wave in the air of the surrounding space. A nearby worker was knocked to the floor and badly scalded by the hot water entrained in the steam blasted from the tank. The 75 psig safety relief valve provided atop the tank never actuated.

Remains of 90 gallon non-ASME SS Tank blown apart by BLEVE.
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