Respondent operated a manufacturing, packaging, and distribution facility that is located immediately across the street from a residential neighborhood, less than a half mile from a high school and several businesses, and approximately a mile from US. Routes 5 and 84 and the Connecticut River. At all times relevant to the violations alleged herein, the Facility’s ammonia refrigeration system (“System”) used approximately 9,076 pounds of anhydrous ammonia.
Accordingly, Respondent “stored” and “handled” anhydrous ammonia, which, as indicated is subject to the General Duty Clause.
On August 22, 2023, three duly authorized EPA inspectors and one contract inspector (collectively, the “EPA Inspectors”) conducted an inspection at the Facility (the “Inspection”). The purpose of EPA’s Inspection was to determine whether Respondent was complying with Section 112(r) of the CAA and Sections 302-313 of the Emergency Planning and Community Right-to-Know Act (“EPCRA”). The EPA inspectors toured the Facility’s perimeter, primary ammonia machinery room (“AMR”), outdoor ammonia equipment, and the production building.
During the Inspection, EPA observed numerous potentially dangerous conditions.
COUNT I – FAILURE TO DESIGN AND MAINTAIN A SAFE FACILITY
The instances in which EPA alleges that Respondent failed in its general duty to design and maintain the Facility in a safe manner, taking such steps as are necessary to prevent a release of an extremely hazardous substance, are listed under Conditions 1-8 and 15-21 of Appendix A, which is incorporated by reference into this CAFO. They include, for example, the failure to provide impact protection and adequate supports for piping and other equipment and to address areas of corrosion on piping.
Examples of industry standards associated with each instance in which Respondent failed in its general duty to design and maintain a safe facility (identified in Appendix A) demonstrate that the hazard is recognized by the ammonia refrigeration industry and that the industry has identified a feasible means by which Respondent could have eliminated or reduced the hazard. Further, Appendix A identifies, for each condition, how the failure to address the hazard could lead to or exacerbate a release of anhydrous ammonia and cause harm.
Accordingly, from at least January 15, 2020 through August 13, 2024, EPA alleges that Respondent failed to design and maintain a safe facility, taking such steps as were necessary to prevent a release of an extremely hazardous substance, in violation of the General Duty Clause, Section 112(r)(1) of the CAA, 42 U.S.C. § 7412(r)(1).
COUNT II – FAILURE TO MINIMIZE THE CONSEQUENCES OF ACCIDENTAL RELEASES THAT MIGHT OCCUR
The instances in which EPA alleges that Respondent failed in its general duty to minimize the consequences of a release should one occur are listed under Conditions 9-14 and 15-21 of Appendix A, which is incorporated by reference into this CAFO. They include, for example, the failure to provide adequate ventilation in the ammonia machinery room, lack of an eyewash station in the outdoor ammonia processing area, and inadequate labeling of emergency shutoff valves or the primary (King) valve.
Examples of industry standards associated with each instance in which Respondent failed in its general duty to minimize the consequences of a release (identified in Appendix A) demonstrate that the hazard is recognized by the ammonia refrigeration industry and that the industry has identified a standard means by which Respondent could have eliminated or reduced the hazard. Further, Appendix A identifies, for each condition, how the failure to address the hazard could lead to or exacerbate a release of anhydrous ammonia and cause harm.
Accordingly, from at least January 15, 2020 through August 13, 2024, EPA alleges that Respondent failed to minimize the consequences of an accidental release of an extremely hazardous substance should one occur, in violation of the General Duty Clause, Section 112(r)(1) of the CAA, 42 U.S.C. § 7412(r)(1).
Respondent agrees to pay a civil penalty in the amount of $36,000.
In response to the alleged violations of Section 112(r)(1) of the CAA, 42 U.S.C. § 7412(r)(1), and in settlement of this matter, although not required by 42 U.S.C. § 7412(r)(1) or any other federal, state or local law, Respondent agrees to implement supplemental environmental projects (SEPs), as described below in paragraphs 59 –72 below.
By one year after the effective date of this CAFO, Respondent shall provide a first responder drone and at least 116 firefighter emergency escape system kits to the Local Fire Department, the SEP recipient, to enhance emergency response capabilities, including those for an ammonia release, for local responders and the Regional Hazardous Materials Response Team. The SEPs are more specifically described in Appendix B and incorporated herein by reference.
Respondent shall spend no less than $97,746 on implementing the SEPs. The estimated costs of the SEPs are $55,000 for the Drone SEP and $42,746 for the Emergency Escape Equipment SEP.
Recognized and Generally Accepted Good Engineering Practices
In collaboration with the American National Standards Institute, the International Institute of Ammonia Refrigeration (“IIAR”) has
issued and updates, among others:
- Standard 2: Standard for Safe Design of Closed-Circuit Ammonia Refrigeration Systems (“ANSI/IIAR 2”) (e.g., 2014 version, with Addendum A published in July 2019, and the 2021 version);
- Standard 4: Installation of Closed-Circuit Ammonia Mechanical Refrigeration Systems (“ANSI/IIAR 4”),
- Standard 5: Start-up and Commissioning of Closed Circuit Ammonia Refrigeration Systems (2013 with subsequent edition published on 9/9/2019) (“ANSI/IIAR 5”);
- Standard 6: Standard for Testing, Inspection, and Maintenance of Closed-Circuit Ammonia Refrigeration Systems (“ANSI/IIAR 6”),
- Standard 7: Developing Operating Procedures for Closed-Circuit Ammonia Mechanical Refrigerating Systems (“ANSI/IIAR 7”),
and
- Standard 9: Standard for Minimum System Safety Requirements for Existing Closed-Circuit Ammonia Refrigeration Systems (“ANSI/IIAR 9”), inter alia, along with other applicable standards and guidance.
Bulletins and guidance include, without limitation:
- IIAR Bulletin No. 109, Guidelines for IIAR Minimum Safety Criteria for a Safe Ammonia Refrigeration System (1997, and in effect until 2019 when ANSI/IIAR 6 replaced it) (“IIAR Bull. 109”);
- IIAR Bulletin No. 110, Guidelines for Start-Up, Inspection, and Maintenance of Ammonia Mechanical Refrigerating Systems (1993, most recently updated in 2007, and in effect until 2019 when ANSI/IIAR 6 replaced it) (“IIAR Bull. 110”);
- IIAR Bulletin No. 114, Guidelines for Identification of Ammonia Refrigeration Piping and Components (1991, most recently updated in 2018) (“IIAR Bull. 114”);
- IIAR Bulletin No. 116, Guidelines for Avoiding Component Failure in Industrial Refrigeration Systems Caused by Abnormal Pressure or Shock (1992) (“IIAR Bull. 116”); and
- The Ammonia Refrigeration Management Program (2005, most recently updated in 2019) (“IIAR ARM Program”), which is intended to provide streamlined guidance to systems that have less than 10,000 pounds of ammonia.
Also in collaboration with the American National Standards Institute, the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (“ASHRAE”) has issued (and updates):
- “Standard 15: Safety Standard for Refrigeration Systems.” Addendum A to ASHRAE Standard 15-2016 (published 2018) modifies ASHRAE Standard 15 to defer regulation of ammonia refrigeration systems to ANSI/IIAR 2. Standard 15 and ANSI/IIAR 2 have historically served as additive standards for regulation of ammonia systems, with ASHRAE addressing general design and IIAR addressing ammonia-specific topics.
These standards are consistently relied upon by refrigeration experts and are often incorporated into state building and mechanical codes.
The chart cites to the standards of care that were in effect in 2023, when the inspection occurred.
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 1 The High Pressure Receiver (HPR) was not properly bolted down to the pad it was sitting on. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. | Inadequately mounted machinery can result in detrimental vibration or movement that might make the equipment fail and release ammonia. This equipment was located in an exit area, where snow removal equipment could inadvertently hit the equipment. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide adequate supports to prevent excessive vibration or movement of equipment. See, e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2-2014, Add. A (2019), and ANSI/IIAR 2-2021 §§ 5.11.1 (Supports and anchorage for refrigeration equipment shall be designed in accordance with the building code.), 5.11.5 (Supports and foundations shall be designed to prevent excessive vibration or movement of piping, tubing, and equipment.), 6.2.4 (Machinery shall be mounted in a manner that prevents excessive vibration from being transmitted to the building structure or connected equipment.); ANSI/IIAR 9-2020 §§ 7.2.7.1 (Piping, tubing, and equipment shall be supported to prevent excessive vibration and movement.), 7.3.2.3 (Supports and foundations shall be adequate to prevent movement of the equipment.), 7.3.2.4 (Supports and foundations shall be adequate to prevent excessive vibration of the equipment.). |
| Condition 2 The HPR, adjacent piping, and King Valve in the outdoor ammonia processing area lacked adequate bump protection. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. | Lack of adequate bump protection risks accidental impacts from equipment to system components that can result in an accidental release of ammonia. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to adequately safeguard ammonia system components to minimize possible accidental damage or rupture due to external sources. See, e.g., ANSI/IIAR 2-2014 and ANSI/IIAR 2- 2014, Add. A (2019) §§ 5.16.1 (Enclosures for ammonia equipment shall be suitable for the installation location and shall be provided with protection from physical and environmental damage as required for the installed location.), 5.17.1 (Guarding or barricading shall be provided for ammonia-containing equipment installed in a location subject to physical damage.), 7.2.4 (Equipment shall be protected where a risk of physical damage exists.), 13.4.2 (Refrigerant piping shall be isolated and supported to prevent damage from vibration, stress, corrosion, and physical impact.); ANSI/IIAR 4-2020 § 4.8.2 (All components and piping shall be installed in such a manner that they are protected from physical and environmental damage in accordance with IIAR 2.); ANSI/IIAR 9- 2020, § 7.2.12.1 (Where ammonia-containing equipment is installed in a location subject to physical damage, guarding or barricading shall be provided.); ANSI/IIAR 2-2021 § 5.15.1 (Enclosures for ammonia equipment shall be suitable for the installation location and shall be provided with protection from physical and environmental damage as required for the installed location.), 7.2.4 (Where ammonia equipment is installed in a location subject to physical damage from powered vehicles normally operating in the area, guarding or barricading shall be provided.). |
| Condition 3 There were signs of surface corrosion on piping associated with | Failure to design and maintain a safe facility taking such | Corrosion can weaken piping and vessels to the point where it fails, causing a release. Risks | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to regularly inspect piping for degradation of the protective coating and corrosion, clean down and repaint areas where corrosion has not yet materially reduced the wall thickness, and measure wall thickness and evaluate the potential for safe |
| the evaporative condenser. | steps as are necessary to prevent releases. | release of ammonia from system components if corrosion continues to point of failure. | further use for areas where corrosion has materially reduced wall thickness. See, e.g., ANSI/IIAR 9-2020 § 5.1 (All equipment and system components shall be inspected, tested, and maintained in accordance with ANSI/IIAR 6 (2019)); ANSI/IIAR 6-2019 §§ 10.1 (calling for annual visual inspection for pitting or surface damage and degradation of protective coating, i.e., paint, on uninsulated pressure vessels), 10.1.1 (Where pitting, surface damage, general corrosion, or a combination thereof, is visually observed on a metal surface of the pressure vessel, deficient areas shall be further evaluated.), 10.1.1.1 (Where such corrosion is suspected to have materially reduced the vessel wall thickness beyond its permitted corrosion allowance, the remaining wall thickness shall be measured using appropriate techniques.), 10.1.1.1.1 (Where such corrosion has not materially reduced the vessel wall thickness beyond its permitted corrosion allowance, the pressure vessel metal surface shall be cleaned and recoated to arrest further deterioration.), 10.1.1.1.2 (Where such corrosion has materially reduced the vessel wall thickness beyond its permitted corrosion allowance, the owner shall proceed in a timely manner with an analysis using specified criteria to determine suitability for continued operation); ANSI/IIAR 2- 2021 §§ 5.10.1 (Piping and equipment surfaces not intended for heat exchange shall be insulated, treated, or otherwise protected to mitigate effects of condensation and excessive frost buildup that interferes with valve operation or creates damage to piping, equipment, or supports.). |
| Condition 4 Ammonia Pipes supporting pipes. | Failure to design and maintain a safe facility taking such steps as are | Lack of adequate piping supports can weaken piping to the point where it fails, causing a release. | The recommended industry practice and standard of care is to provide adequate supports to prevent excessive vibration or movement of piping. See, e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2-2014, Add. A (2019), and ANSI/IIAR 2-2021 §§ 13.4.2 (Refrigerant piping shall be isolated and supported to prevent damage from vibration, stress, corrosion, and physical impact.); ANSI/IIAR 4-2020 § 4.8.2 (All components and piping |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| necessary to prevent releases. | shall be installed in such a manner that they are protected from physical and environmental damage in accordance with IIAR 2.); ANSI/IIAR 9-2020 §§ 7.3.2.2 (Piping supports shall carry the weight of the piping system including contents and insulation; if necessary, provide sway bracing to minimize vibration.), 7.3.2.3 (Supports and foundations shall be adequate to prevent movement of the equipment.). | ||
| Condition 5 The AMR relief valve header was being supported by evaporative condenser process piping. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. | Inadequately mounted machinery can result in detrimental vibration or movement that might make the equipment fail and release ammonia. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to adequately safeguard ammonia system components to minimize possible accidental damage or rupture due to external sources. See, e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2-2014, Add. A (2019), and ANSI/IIAR 2-2021, §§ 13.4.2 (Refrigerant piping shall be isolated and supported to prevent damage from vibration, stress, corrosion, and physical impact.), 13.4.4 (Anchors, their attachment points, and attachment methods shall be designed to support applied loads.); ANSI/IIAR 9-2020 § 7.3.2.2 (Piping supports shall carry the weight of the piping system including contents and insulation.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 6 Ammonia Compressor #2 and associated piping was observed to be vibrating significantly. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. | Detrimental equipment vibration or movement might make the equipment fail and release ammonia. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide adequate supports to prevent excessive vibration or movement of equipment. See, e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2-2014, Add. A, and ANSI/IIAR 2-2021 §§ 5.11.5 (Supports and foundations shall be designed to prevent excessive vibration or movement of piping, tubing, and equipment.), 6.2.4 (Machinery shall be mounted in a manner that prevents excessive vibration from being transmitted to the building structure or connected equipment.), 13.4.2 (Refrigerant piping shall be isolated and supported to prevent damage from vibration, stress, corrosion, and physical impact.); ANSI/IIAR 9-2020 §§ 7.2.7.1 (Piping, tubing, and equipment shall be supported to prevent excessive vibration and movement.), 7.3.2.3 (Supports and foundations shall be adequate to prevent movement of the equipment.), 7.3.2.4 (Supports and foundations shall be adequate to prevent excessive vibration of the equipment.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 7 Lower ammonia piping under high pressure near SV-181NH3 and other piping and valve needs bump protection. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. | Lack of adequate bump protection risks ammonia release from accidental damage to system components. | The recommended industry practice and standard of care is to install guarding or barricading to prevent ammonia piping and equipment from being subject to physical impact. See, e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2- 2014, Add. A (2019) §§ 5.17.1 (Where ammonia-containing equipment is installed in a location subject to physical damage, guarding or barricading shall be provided.), 13.4.2 (Refrigerant piping shall be isolated and supported to prevent damage from vibration, stress, corrosion, and physical impact.), 16.2.2 (visual liquid level indicators . . . shall be designed and specified for installation in a manner that provides protection from physical damage); ANSI/IIAR 4-2020, § 4.8.2 (All components and piping shall be installed in such a manner that they are protected from physical and environmental damage in accordance with IIAR 2.); ANSI/IIAR 9-2020 § 7.2.12.1 (Where ammonia-containing equipment is installed in a location subject to physical damage, guarding or barricading shall be provided.); ANSI/IIAR 2-2021 §§ 5.15.1 (Enclosures for ammonia equipment shall be suitable for the installation location and shall be provided with protection from physical and environmental damage as required for the installed location.), 13.4.2 (same); ANSI/IIAR 2-2014 § 5.16.1 (Enclosures for ammonia equipment shall be suitable for the installation location and shall be provided with protection from physical and environmental damage as required for the installed location.). |
| Condition 8 There were signs of surface corrosion on ammonia piping associated with the heat exchangers on the other two chiller lines. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. | Corrosion can weaken piping and vessels to the point where it fails, causing a release. Risks release of ammonia from system components if corrosion continues to point of failure. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to regularly inspect piping for degradation of the protective coating and corrosion, clean down and repaint areas where corrosion has not yet materially reduced the wall thickness, and measure wall thickness and evaluate the potential for safe further use for areas where corrosion has materially reduced wall thickness. See, e.g., ANSI/IIAR 9-2020 § 5.1 (All equipment and system components shall be inspected, tested, and maintained in accordance with ANSI/IIAR 6 (2019).); ANSI/IIAR 6-2019 §§ 10.1 (calling for annual visual inspection for pitting or surface damage and degradation of protective coating, i.e., paint, on uninsulated pressure vessels), 10.1.1 (Where pitting, surface damage, general corrosion, or a combination thereof, is visually observed on a metal surface of the pressure vessel, deficient areas shall be further evaluated.), 10.1.1.1 (Where such corrosion is suspected to have materially reduced the vessel wall thickness beyond its permitted corrosion allowance, the remaining wall thickness shall be measured using appropriate techniques.), 10.1.1.1.1 (Where such corrosion has not materially reduced the vessel wall thickness beyond its permitted corrosion allowance, the pressure vessel metal surface shall be cleaned and recoated to arrest further deterioration.), 10.1.1.1.2 (Where such corrosion has materially reduced the vessel wall thickness beyond its permitted corrosion allowance, the owner shall proceed in a timely manner with an analysis using specified criteria to determine suitability for continued operation). |
| Condition 9 The emergency safety shower in the outdoor ammonia processing | Failure to minimize the consequences of releases | Makes it difficult for emergency responders and workers to wash off this corrosive, toxic | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide at least one easily accessible eyewash/safety shower unit in each machinery room and one easily accessible eyewash/safety shower unit outside each machinery room. See, e.g., ANSI/IIAR 2-2014 and ANSI/IIAR 2-2014, Add. A (2019) §§ |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| area lacked an accompanying emergency eyewash station. | which do occur. | chemical in the event of exposure. | 6.7.1 (requiring a minimum of two eyewash/safety shower units—one located inside the AMR, and one located outside the AMR), 6.7.3 (Emergency eyewash/safety shower unit installations shall comply with ANSI/ISEA Z358.1.); ANSI/ISEA Z358.1 (2009) § 5.4.2 (It is the installer’s responsibility to ensure that emergency eyewashes shall be in accessible locations that require no more than 10 seconds to reach. The eyewash shall be located on the same level as the hazard and the path of travel shall be free of obstructions that may inhibit its immediate use.); ANSI/IIAR 9-2020 § 7.3.7.1 (Each machinery room shall have access to a minimum of two eyewash/safety shower units, one located inside the machinery room and one located outside of the machinery room, each meeting the requirements in Section 7.3.7.3.); ANSI/IIAR 2-2021 § 6.7.2 (A minimum of one eyewash/safety shower unit shall be located outside the machinery room and shall be no further than 55 ft. From the outside of the machinery room door.), Appendix A.6.7.1 (In some scenarios, personnel may need to exit the machinery room after the initial use of the units installed inside the machinery room due to an on-going emergency situation. To account for these scenarios, Section 6.7.3 specifies that at least one eyewash/safety shower unit be installed outside a machinery room door. Additional eyewash/safety showers might be required based on a process hazard analysis and/or hazard review.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 10 There was no emergency safety shower/eyewash station outside the primary AMR egress door. | Failure to minimize the consequences of releases which do occur. | Makes it difficult for emergency responders and workers to wash off this corrosive, toxic chemical in the event of exposure. | The recommended industry practice and standard of care is to provide at least one easily accessible eyewash/safety shower unit in each machinery room and one easily accessible eyewash/safety shower unit outside each machinery room. See, e.g., ANSI/IIAR 2-2014 and ANSI/IIAR 2-2014, Add. A (2019) §§ 6.7.1 (A minimum of one eyewash/safety shower unit shall be located outside of the machinery room. Eyewash/safety shower units shall meet the requirements in Section 6.7.3.), 6.7.3 (Emergency eyewash/safety shower unit installations shall comply with ANSI/ISEA Z358.1.); ANSI/IIAR 2-2021 § 6.7.2 (A minimum of one eyewash/safety shower unit shall be located outside the machinery room and shall be no further than 55 ft. From the outside of the machinery room door.), Appendix A.6.7.1 (In some scenarios, personnel may need to exit the machinery room after the initial use of the units installed inside the machinery room due to an on-going emergency situation. To account for these scenarios, Section 6.7.3 specifies that at least one eyewash/safety shower unit be installed outside a machinery room door. Additional eyewash/safety showers might be required based on a process hazard analysis and/or hazard review.). |
| Condition 11 The Piping and Instrumentation Diagram (P&ID) on the door did not have the critical emergency shutoff valves clearly identified. | Failure to minimize the consequences of releases which do occur. | Being able to quickly identify the location of emergency shutdown valves on a system diagram allows operators and responders to more quickly execute emergency shutdown procedures. Releases are less likely, and their consequences less severe, when this information is available. | The recommended industry practice and standard of care is to clearly identify the critical emergency shutoff valves at the valve itself and in the system schematic drawings. See e.g., ANSI/IIAR 5-2019 § 5.3.1 (All system documentation from the planning, design, and installation phases of the project shall be assembled and readily available.), Appendix A.5.3.1 (System design documents, including those for equipment, provide the information necessary to safely and successfully startup and an ammonia refrigeration system. System design documents may include but are not limited to system specifications, performance specifications, P&IDs, as- built installation drawings, safety systems, regulatory documents, standard operating procedures (SOPs), refrigeration equipment lists, valve lists, relief valve data and relief system design basis, and manufacturer’s instruction manuals. P&IDs and flow diagrams should be a system schematic showing every system component.); ANSI/IIAR 2- 2014, Add. A (2019) and ANSI/IIAR 2-2021 § 5.14.4 (Valves required for emergency shutdown of the system shall be clearly and uniquely identified at the valve itself and in the system schematic drawings); ANSI/IIAR 9-2020 § 7.2.9.3 (same); ANSI/IIAR 2-2014 § 5.14.2 (Refrigeration machinery shall be provided with labels.); ANSI/IIAR 2- 2014, Add. A (2019) § 5.14.3 (same); ANSI/IIAR 2-2021 § § 5.14.3 (Refrigeration equipment shall be uniquely labeled in a manner that is consistent with system documentation.); ANSI/IIAR 6-2019, Table 11.1.6, item h (calling for regular inspection to ensure that system emergency shut-off valves are clearly and uniquely identified at each valve and in the system schematic diagram). |
| Condition 12 | Failure to minimize the consequences of releases | The king valve can be used to quickly shut off flow of ammonia from the ammonia | The recommended industry practice and standard of care is for critical valves to be clearly identified. See e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2- 2014, Add. A (2019), and ANSI/IIAR 2-2021 § 5.14.4 (Emergency shut down valves must be clearly and uniquely identified at the valve itself.); |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| The HPR’s King Valve signs were faded and partially painted over. | which do occur. | receiver to the rest of the system. Any impediment to its use can lengthen the time of a release, endangering workers, emergency responders, and people off site. | ANSI/lIAR 9-2020, § 7.2.9.3 (same); ANSI/lIAR 6-2019, Table 11.1.6, item h (calling for regular inspection of system emergency shut-off valves to ensure they are clearly and uniquely identified at each valve). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 13 The HPR’s King Valves were not clearly marked which one was the primary valve. | Failure to minimize the consequences of releases which do occur. | Labeling the King valve allows responding personnel the ability to easily identify the valve associated with the storage of ammonia in the system. The use of this valve provides responders a means of isolated a large quantity of ammonia during a release situation. In the event of a release, being able to access critical valves is necessary for emergency response. | The recommended industry practice and standard of care is to ensure critical valves are well labeled at the valve itself. See, e.g., ANSI/IIAR 2- 2014 and ANSI/IIAR 2-2014, (Add. A) § 5.14.3 (Refrigeration machinery shall be provided with labels.); ANSI/IIAR 2-2014, ANSI/IIAR 2-2014, Add. A (2019), and ANSI/IIAR 2-2021 § 5.14.4 (Emergency shut down valves must be clearly and uniquely identified at the valve itself.); ANSI/lIAR 9- 2020, § 7.2.9.3 (same); ANSI/lIAR 6-2019, Table 11.1.6, item h (calling for regular inspection to ensure that system emergency shut-off valves are clearly and uniquely identified at each valve). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 14 The High-Pressure Relief (HPR) valve header near the top of the evaporative condenser was equipped with a rain hat which would force ammonia relief discharge downward in the event of a release. | Failure to minimize the consequences of releases which do occur. | Failing to remove permanent, fixed rain caps may limit the vertical flow of ammonia during a release and may allow the spraying of ammonia on persons in the vicinity. | The recommended industry practice and standard of care for ammonia refrigeration systems is to not limit the vertical flow of ammonia during a release and to avoid spraying ammonia on persons in the vicinity. See, e.g., ANSI/IIAR 2-2014, ANSI/IIAR 2-2014, Add. A (2019), and ANSI/IIAR 2- 2021 § 15.5.1.5 (The termination of the discharge shall be directed upward and arranged to avoid spraying ammonia on persons in vicinity.), Appendix A.15.5.1.5 (re. acceptable designs for limiting rain and snow incursions, including a “double 45 degree” diffuser, a “bull’s horn” diffuser, a “self-closing flapper cap,” or a “sock hood cover.”). |
| Condition 15 The placement of the make-up air intake vent is near the top of the wall and not at ground-level which may inhibit proper ventilation to the AMR. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | Without adequate ventilation, vapors are more likely to build up to levels that are significant inhalation and dermal hazards or that risk causing fire or explosion. Also, where emergency ventilation function is hampered, the buildup of dangerous levels of toxic/flammable vapors in a machinery room can delay the entry of emergency response personnel to shut off the system, resulting in a prolonged release. | The recommended industry practice and standard of care is for machinery room exhaust to discharge vertically upward and for make-up air intakes to be positioned to draw uncontaminated outdoor air. See, e.g., ANSI/IIAR 2-2014 and ANSI/IIAR 2-2014, Add. A (2019) § 6.14.5.4 (Intakes for make-up air shall be positioned to draw uncontaminated outdoor air.); ANSI/IIAR 2-2014, Add. A (2019) and ANSI/IIAR 2-2021 §§ 6.14.3.4 (Machinery room exhaust shall discharge vertically upward with a minimum discharge velocity of 2,500 ft/min (762 m/min) at the required emergency ventilation flow rate.), 6.14.5.1 (Outdoor make-up air shall be provided to replace air being exhausted.), 6.14.5.2 (Make-up air supply locations in the machinery room shall be positioned to prevent short circuiting of the make-up air directly to the exhaust.); ANSI/IIAR 2-2014 §§ 6.14.3.5 (Machinery room exhaust shall discharge vertically upward with a minimum discharge velocity of 2,500 ft/min (762 m/min) at the required emergency ventilation flow rate.), 6.14.5.1 (same), 6.14.5.2 (same); ANSI/IIAR 9-2020 § 7.3.14.3 (Intakes for make-up air shall draw uncontaminated outdoor air.). |
| Condition 16 One of the emergency ventilation switches and the ammonia system emergency | Failure to design and maintain a safe facility taking such steps as are | Creates risk of harm to workers and emergency responders who cannot quickly shut down or properly | The recommended industry practice and standard of care is for ammonia refrigeration systems of this size is to provide clearly identified emergency stop and emergency ventilation switches immediately outside the machinery room with override capability. See, e.g., ANSI/IIAR 2-2014 and ANSI/IIAR 2-2014, Add. A (2019) §§ 6.12.1 (A clearly identified emergency shut-off switch with a tamper-resistant cover shall |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| stop actuation button outside of the boiler room entrance required keys to operate which were not immediately accessible in case of emergency. The metal cabinet had a free wire inside of the cabinet without labeling or indication of use or function. | necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | ventilate machinery room without having required keys, which could be misplaced. The delay could also contribute to a longer ammonia release time, increasing risks to workers, emergency responders, and to people off-site and the environment. | be located outside and adjacent to the designated principal machinery room door. The switch shall provide off-only control of refrigerant compressors, refrigerant pumps, and normally closed automatic refrigerant valves located in the machinery room. The function of the switch shall be clearly marked by signage near the controls.), 6.12.2 (A clearly identified control switch for emergency ventilation with a tamper- resistant cover shall be located outside the machinery room and adjacent to the designated principal machinery room door. The switch shall provide “ON/AUTO” override capability for emergency ventilation. The function of the switch shall be clearly marked by signage near the controls.); ANSI/IIAR 2-2021 §§ 6.12.1 (same), 6.12.2 (same, in addition to: The switch shall be readily operable.); ANSI/IIAR 9-2020 §§ 7.3.11.1 (same), 7.3.11.2 (same); NFPA 1-2018 § 53.2.3.3.6 (Keys necessary for operation of ventilation systems shall be located in a single approved location.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 17 There were no Ammonia audible/visible alarms located nearby the emergency station outside the boiler room. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | A lack of ammonia audible/visual alarms can delay a swift, safe emergency response and increase risks to workers, emergency responders, and people off-site, further exacerbating the consequences of a release. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide well labeled audible and visual alarms inside and immediately outside each entrance to the machinery room. See, e.g., ANSI/IIAR 2-2014, ANSI/lIAR 2-2014, Add. A (2019), and ANSI/IIAR 2-2021 §§ 6.15.2 (Requirements for machinery room: alarm signage shall be provided in accordance with Section 17.6), 7.2.3 (Requirements for nonmachinary room spaces: Level 1 detection and alarm shall be provided in accordance with Section 17.7.1. The detection and alarm system shall comply with Chapter 17.), 17.5 (The audible alarms providing notification shall provide a sound pressure level of 15 decibels (dBA) above the average ambient sound level and 5 dBA above the maximum sound level of the area in which it is installed.); NFPA 1-2012 § 53.2.3.1.2 (Audible and visual alarms shall be located inside the machinery room and outside each entrance to the room.); IIAR 9- 2020 § 7.3.12 (Audible and visual alarms shall be provided inside the room. Additional audible and visual alarms shall be located outside of each entrance to the machinery room.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 18 Multiple entry doors from the outside of the Facility were not labeled with appropriate National Fire Protection Agency (NFPA) diamonds to provide warning. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | A lack of signs about the hazards posed by chemicals in a space increases the chance of inadvertent exposure to ammonia releases and could frustrate effort to react quickly and properly during an ammonia release. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to display NFPA 704 diamonds for ammonia hazard identification on each door to the machinery room. See e.g., ANSI/IIAR 2-2014, ANSI/lIAR 2-2014, Add. A (2019) and ANSI/IIAR 2- 2021 § 6.15.1 (A NFPA 704 placard shall be provided…on or next to all doors through which a person can enter the machinery room.); ANSI/lIAR 9-2020, § 7.2.9.1 (Buildings and facilities with refrigeration systems shall be provided with placards in accordance with NFPA 704.); NFPA 1-2018, § 53.2.4.1 (Refrigeration units or systems shall be provided with approved hazard identification signs in accordance with NFPA 704, among other information.); NFPA 704-6 (2022) § 4.3 (As a minimum, signs shall be posted at the following locations: (1) Two exterior walls or enclosures containing a means of access to a building or facility, (2) Each access to a room or area, (3) Each principal means of access to an exterior storage area.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 19 There was no label describing the function of an orange visual strobe next to the ammonia audible/visual alarm. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | Properly identifying ammonia alarms allows employees and responders the ability to determine what chemical is being released and helps distinguish between an ammonia release and a fire. Enabling a quick response protects workers, emergency responders, and the public from a larger release. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide well-labeled audible and visual alarms. See, e.g., ANSI/IIAR 2-2014 and ANSI/IIAR 2-2014, Add. A (2019) §§ 6.13.1 Machinery rooms shall be provided with ammonia detection and alarm in accordance with Sections 17.2–17.6.), 17.6 Ammonia leak detection alarms shall be identified by signage adjacent to visual and audible alarm devices.), Appendix A.6.13.2.2 (Visual alarms can be provided by strobes or other distinctive visual signaling devices.); ANSI/lIAR 2-2021 §§ 6.15.2 (Alarm signage shall be provided in accordance with Section 17.6.), 17.6 (same), Appendix A.6.13.2.2 (same); ANSI/lIAR 9-2020 §§ 7.2.9.1.2 (The meaning of each alarm shall be clearly marked by signage near the visual and audible alarms.), 7.3.12.6 (Ammonia leak detection alarms shall be identified by signage adjacent to visual and audible alarm devices.). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 20 The door from the Chemical Storage area into the AMR only had an emergency shut down button. There was no emergency air ventilation override switch. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | In the event of a release, workers and emergency responders need to be able to quickly identify and access emergency control switches without entering the room, which could contain dangerous levels of vapors. Timely use of these switches can reduce the duration and severity of an accidental release. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide and label emergency ventilation switches immediately outside the machinery room. See, e.g., ANSI/lIAR 2-2014, ANSI/lIAR 2-2014, Add. A (2019), and ANSI/lIAR 2-2021 § 6.12.2 (A clearly identified control switch for emergency ventilation with a tamper-resistant cover shall be located outside the machinery room and adjacent to the designated principal machinery room door unless the continuous ventilation operates at a rate at or above that required for emergency ventilation. The switch shall provide “ON/AUTO” override capability for emergency ventilation. The function of the switch shall be clearly marked by signage near the controls.); ANSI/lIAR 9-2020 § 7.3.11.2 (same); NFPA 1-2018, § 53.2.3.3.1 (requiring emergency ventilation switch right outside machinery room door). |
| Alleged Hazards/Dangerous Condition | GDC Violation | How Condition Could Lead to or Exacerbate the Consequences of a Release, Causing Harm | Examples of Industry Standards of Care, Showing that (1) Hazard is Recognized by Owner/Operator’s Industry, and (2) There are Way(s) to Eliminate or Reduce the Hazard |
| Condition 21 Areas housing elevated ammonia piping in the production area of the facility were not equipped with accompanying ammonia detectors and audible/visual alarms to provide detection of ammonia leaks at the elevation at which release may occur. | Failure to design and maintain a safe facility taking such steps as are necessary to prevent releases. Failure to minimize the consequences of releases which do occur. | Ammonia alarms provide early warning that a release is taking place, enabling quick response and protecting workers, emergency responders, and the public from a larger release. It is essential for detectors to be properly placed, maintained, calibrated, set at the proper set-points, and connected to alarms and other safety systems so that they can fulfill their function. | The recommended industry practice and standard of care for ammonia refrigeration systems of this size is to provide ammonia detectors and audible/visual alarms detectors in areas where refrigerant from a leak is likely to concentrate. See, e.g., ANSI/IIAR 9-2020 § 7.3.12.1 (Audible and visual alarms shall be provided inside the room. Additional audible and visual alarms shall be located outside of each entrance to the machinery room.); ANSI/lIAR 2-2014, ANSI/lIAR 2-2014, Add. A (2019), and ANSI/IIAR 2-2021 §§ 7.2.3 (Requirements for nonmachinary room spaces: Level 1 detection and alarm shall be provided in accordance with Section 17.7.1. The detection and alarm system shall comply with Chapter 17.), 17.5 (The audible alarms providing notification shall provide a sound pressure level of 15 decibels (dBA) above the average ambient sound level and 5 dBA above the maximum sound level of the area in which it is installed.); ANSI/IIAR 2-2008, Add. B (2012) § 13.2.2.1 (The detectors shall be located in an area where refrigerant from a leak is likely to concentrate.). |