A federal workplace safety investigation into a Jan. 19, 2022, ammonia leak that hospitalized two workers and led to the evacuation of about 50 workers at a Canton poultry processing plant found their employer might have prevented the incident by ensuring required safety standards were followed. OSHA found the uncontrolled temperature and pressure conditions on an ammonia refrigeration system contributed to the release of ammonia. Liquid and vapor ammonia were dispersed in the air and engulfed the emergency exit doors that discharged outside. In addition to the hospitalized workers, one worker was treated on the scene. OSHA issued nine (9) serious citations for inadequately implementing and maintaining the process safety management program for controlling anhydrous ammonia hazards in industrial refrigeration systems. Specifically, the employer failed to:
- Confirm a pre-startup safety review before introducing a highly hazardous chemical into an existing process, and include instructions to address process deviations.
- Train workers on the physical and health hazards of anhydrous ammonia.
- Ensure exit signs were properly illuminated and clearly identified.
- Maintain safe walking and working surfaces.
OSHA has proposed $110,630 in penalties
Here is a breakdown of the citations:
Citation 1 Item 1
Type of Violation: Serious; $9,116
29 CFR 1910.22(d)(1): The employer did not ensure that walking-working surfaces are inspected, regularly and as necessary, and maintained in a safe condition: a) Plant; on or about January 19, 2022 and at times prior to, employees accessing the roof of the Debone engine room were exposed to trip/fall hazards, in that the employer did not ensure that missing platform grates were installed, and broken sections were repaired/replaced.
Citation 1 Item 2
Type of Violation: Serious; $14,502
29 CFR 1910.37(b)(2): Each exit was not clearly visible and marked by a sign reading “Exit”: a) Plant, Fresh Shipping Dock area; on or about January 19, 2022 and at times prior to, employees were exposed to fire and/or anhydrous ammonia hazards, in that the employer did not ensure that the exit door discharging to the battery room was marked by an EXIT sign to minimize delays and exposure during an emergency.
Citation 1 Item 3
Type of Violation: Serious; $14,502
29 CFR 1910.37(b)(6): Each exit sign was not illuminated to a surface value of at least five foot-candles (54 lux) by a reliable light source and be distinctive in color: a) Debone Area, Fresh Shipping Dock area; on or about January 19, 2022 and at times prior to, employees were exposed to fire and/or anhydrous ammonia hazards, in that the employer did not ensure that the exit door on the dockside (discharging towards the stairs) was illuminated and distinctive in color in order to minimize delays and exposure during an emergency.
Citation 1 Item 4
Type of Violation: Serious; $14,502
29 CFR 1910.119(d)(3)(i)(H): Process safety information pertaining to the equipment in the process did not include the safety systems:
a) Plant, Debone Area; on or about January 19, 2022, and at times prior to, employees were exposed to anhydrous ammonia hazards, in that the employer did not document Process Safety Information pertaining to the equipment safety systems such as, but not limited to, ammonia system emergency stop devices and, operational safeties for compressors DSCH3 and DSCH4 including, switches, sensors, detectors, alarms, and related components.
Citation 1 Item 5
Type of Violation: Serious; $14,502
29 CFR 1910.119(d)(3)(ii): The employer did not document that the equipment complies with recognized and generally accepted good engineering practices (RAGAGEP).
a) Plant, Debone Engine Room; on or about January 19, 2022 and at times prior to, the employer failed to document compliance with recognized and generally accepted good engineering practices to protect employees exposed to anhydrous ammonia hazards as specified in ANSI/IIAR 2-2014 Standard for Safe Design of Closed-Circuit Ammonia Refrigeration Systems, Section 16.1.5, Restricted Access to Safety Settings, in that supervisory controls were not implemented to prevent untrained/unauthorized personnel from effecting changes to the Quantum control system and the programmable logic controller (PLC) that could lead to unsafe and uncontrollable conditions.
b) Plant, Debone Engine Room entrance area; on or about January 19, 2022 and at times prior to, the employer failed to document compliance with recognized and generally accepted good engineering practices to protect employees exposed to anhydrous ammonia hazards as specified in ANSI/IIAR 2-2014 Standard for Safe Design of Closed-Circuit Ammonia Refrigeration Systems, Section 7.2.4, which requires “Equipment shall be protected where a risk of physical damage exists. Where equipment containing ammonia is in an area with heavy vehicular traffic during normal operations and risk of impact exists, vehicle barriers or alternative protection shall be provided in accordance with the Fire Code.” The employer did not protect the DHTA/DLTA high-temperature accumulator and piping from vehicles to prevent damage or rupture and loss of containment of 9,145 lb. of anhydrous ammonia.
The alleged violations below have been grouped because they involve similar or related hazards that may increase the potential for injury or illness.
Citation 1 Item 6a
Type of Violation: Serious; $14,502
29 CFR 1910.119(f)(1)(ii)(B): The employer did not develop and implement written operating procedures that provided clear instructions for safely conducting activities involved in each covered process consistent with the process safety information and did not address the steps required to correct or avoid deviation. a) On or about January 19, 2022 and at times prior to, employees were exposed to anhydrous ammonia hazards in that the employer did not develop and implement written operating procedures for the DECD1 and DECD2 evaporative condensers containing clear instructions/warnings for uncontrolled or manual operation.
Citation 1 Item 6b
Type of Violation: Serious
29 CFR 1910.119(i)(2)(ii): Safety, operating, maintenance, and emergency procedures were not adequate: a) On or about January 19, 2022 and at times prior to, employees were exposed to anhydrous ammonia hazards, in that the employer did not confirm through a pre-startup safety review that the written operating procedures for the DECD1 and DECD2 evaporative condensers contained clear instructions/warnings for manual operation.
Citation 1 Item 7
Type of Violation: Serious; $14,502
29 CFR 1910.119(i)(2)(i): Construction and equipment was not in accordance with design specifications:
a) Plant, Debone area; on or about January 19, 2022 and at times prior to, employees were exposed to anhydrous ammonia hazards in that the employer did not perform tests and inspections on emergency stop devices to ensure the equipment was in accordance with design specifications and operable in case of emergency.
b) Plant, Debone area; on or about January 19, 2022 and at times prior to, employees were exposed to anhydrous ammonia hazards in that the employer did not perform tests and inspections on the emergency ventilation equipment to ensure the equipment was in accordance with design specifications and operable in case of emergency.
c) Plant, Debone area; on or about January 19, 2022 and at times prior to, employees were exposed to anhydrous ammonia hazards in that the employer did not perform tests and inspections on the critical limiting devices (operational safeties) for compressors DSCH3 and DHCH4 to ensure the equipment was in accordance with design specifications to prevent worker exposure to an accidental anhydrous ammonia release and damage to equipment.
Citation 1 Item 8
Type of Violation: Serious; $14,502
29 CFR 1910.120(q)(3)(iv): Employees engaged in emergency response and exposed to hazardous substances presenting an inhalation hazard or potential inhalation hazard did not wear positive-pressure self-contained breathing apparatus until such time that the individual in charge of the incident command system determined through the use of air monitoring that a decreased level of respiratory protection would not result in hazardous exposures to employees: a) Plant, Debone area; on or about January 19, 2022, employees were exposed to anhydrous ammonia hazards, in that the employer did not ensure that each emergency responder intending to reach the king valve and emergency stops was protected by a positive pressure self-contained breathing apparatus until air monitoring would indicate that a lower level of respiratory protection would not result in hazardous exposure.
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