UPDATED 8/15/2017 with OSHA Case info: This has now been classified as a “Hot Gas Defrost Valving Error”.
On September 11, 2012, Employee #1, a temporary employee was working as a racker-blender at the [wine company], was exposed to anhydrous ammonia, and died of asphyxia. Employee #1 was found in the west hallway 54 ft from the men’s restroom. Upon further investigation, a cellar supervisor was to clear iced juice in Chiller 13 by performing a “hot gas” procedure. The evaporator’s temperature is raised by opening a bypass valve that equalizes the refrigerant pressure. The cellar supervisor was distracted in conversation with a graveyard shift supervisor and inadvertently opened the dump valve. The dump valve purges excessive oil from the refrigerant system into a barrel of water. The opening of the dump valve instead of the bypass valve caused oil to discharge and liquid ammonia to release forming a gas cloud. The cellar supervisor evacuated the area but left the dump valve open. The gas cloud engulfed the area and was pushed against the building containing two hallways, a men and women’s bathroom, and a break room. The gas cloud formation was captured on a surveillance video, but dissipated within seconds. Approximately one minute before the release, Employee #1 entered the west hallway. It was calculated the refrigerant charge at the facility was 23,640 pounds of anhydrous ammonia.
NOTE: this was a CAL-OSHA case and why they did not issue any PSM citations is unknown- it could be the facility was fully compliant with 5189 – Process Safety Management of Acutely Hazardous Materials. The citations totaled $2,250. Here is what CAL-OSHA cited:
SAFTENG MEMBERS can see CAL-OSHA’s presentation on this fatality case HERE
Here is what CAL-OSHA cited:
| Violation Items | |||||||||||
| # | ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Fta$ | Contest | LastEvent | |
| Deleted | 1. | 01001 | Other | 5144 E04 A | 03/08/2013 | 04/10/2013 | $0 | $185 | $0 | 03/29/2013 | F – Formal Settlement |
| 2. | 01002 | Other | 5192 Q02 A | 03/08/2013 | 04/10/2013 | $375 | $375 | $0 | 03/29/2013 | F – Formal Settlement | |
| 3. | 01003 | Other | 3310 A | 03/08/2013 | 04/10/2013 | $750 | $750 | $0 | 03/29/2013 | F – Formal Settlement | |
| Deleted | 4. | 01004 | Other | 3328 G | 03/08/2013 | 04/10/2013 | $0 | $935 | $0 | 03/29/2013 | F – Formal Settlement |
| 5. | 01005 | Other | 5155 C02 B | 03/08/2013 | 04/10/2013 | $1,125 | $1,125 | $0 | 03/29/2013 | F – Formal Settlement | |
| Deleted | 6. | 02001 | Serious | 3203 A04 | 03/08/2013 | 04/10/2013 | $0 | $9,000 | $0 | 03/29/2013 | F – Formal Settlement |
CLICK HERE for the case file
In September 2012, a worker at a “winery” in CA was killed when he opened a valve on a refrigeration chiller, releasing 284 pounds of anhydrous ammonia. Below is the NRC report from this fatality incident and I have submitted an FOIA to CA-OSHA so that I can obtain their citations and have a better understanding of what happened.
NOTE: From what I know about this incident, it MAKES A CASE for a “car seal” program in the refrigeration industry. Often times the idea of such an administrative program is shunned in the refrigeration industry – but this single incident shows just what can happen when only a mere 5 gallons of NH3 is spilled and the worker is unable to escape the area. We know the worker opened the “wrong valve” from the facility NRC report; a properly applied Car Seal program would/could have indicated to the worker he was at the wrong valve!
NATIONAL RESPONSE CENTER 1-800-424-8802
*** For Public Use ***
Information released to a third party shall comply with any applicable federal and/or state Freedom of Information and Privacy Laws
Incident Report # 1024235
INCIDENT DESCRIPTION
*Report taken at 16:11 on 12-SEP-12
Incident Type: FIXED
Incident Cause: OPERATOR ERROR
Affected Area:
The incident occurred on 11-SEP-12 at 12:15 local time.
Affected Medium: AIR
____________________________________________________________________________
SUSPECTED RESPONSIBLE PARTY
Organization: GIBSON WINE CO
SANGER, CA 93657
Type of Organization: PRIVATE ENTERPRISE
____________________________________________________________________________
INCIDENT LOCATION
1720 ACADMEY AVE County: FRESNO
City: SANGER State: CA Zip: 93657
____________________________________________________________________________
RELEASED MATERIAL(S)
CHRIS Code: AMA Official Material Name: AMMONIA, ANHYDROUS
Also Known As:
Qty Released: 284 POUND(S)
________________________________________________________________________
DESCRIPTION OF INCIDENT
CALLER IS REPORTING A RELEASE OF 284 POUNDS OF ANHYDROUS AMMONIA FROM A VALVE DUE TO AN EMPLOYEE OPENING THE WRONG VALVE AT THE FACILITY ON A CHILLER.
____________________________________________________________________________
INCIDENT DETAILS
Package: N/A
Building ID:
Type of Fixed Object: OTHER
Power Generating Facility: UNKNOWN
Generating Capacity:
Type of Fuel:
NPDES:
NPDES Compliance: UNKNOWN
____________________________________________________________________________
DAMAGES
Fire Involved: NO Fire Extinguished: UNKNOWN
INJURIES: NO Hospitalized: Empl/Crew: Passenger:
FATALITIES: YES Empl/Crew: Passenger: Occupant:
EVACUATIONS: YES Who Evacuated: EVERYONE Radius/Area:
Damages: NO
Length of Direction of
Closure Type Description of Closure Closure Closure
Air: N
Major Artery:
Road: N
Waterway: N
Track: N
Passengers Transferred: NO
Environmental Impact: UNKNOWN
Media Interest: NONE Community Impact due to Material:
____________________________________________________________________________
REMEDIAL ACTIONS
INVESTIGATION UNDERWAY
Release Secured: YES
Release Rate:
Estimated Release Duration: 5 MINUTE
____________________________________________________________________________
WEATHER
Weather: CLEAR, ºF
____________________________________________________________________________
ADDITIONAL AGENCIES NOTIFIED
Federal: 911, OSHA
State/Local:
State/Local On Scene:
State Agency Number:
____________________________________________________________________________
NOTIFICATIONS BY NRC
CA U.S. ATTORNEY’S OFFICE NORTH (MAIN OFFICE) 12-SEP-12 16:16
USCG ICC (ICC ONI) 12-SEP-12 16:16
CHEM SAFETY AND HAZARD INVEST BOARD (MAIN OFFICE) 12-SEP-12 16:24
CHEM SAFETY AND HAZARD INVEST BOARD (CSB AUTOMATIC NOTIFICATIONS) 12-SEP-12 16:16
DOT CRISIS MANAGEMENT CENTER (MAIN OFFICE) 12-SEP-12 16:16
EPA HQ EMERGENCY OPERATIONS CENTER (MAIN OFFICE) 12-SEP-12 16:16
EPA OEM (MAIN OFFICE) 12-SEP-12 16:20
U.S. EPA IX (MAIN OFFICE) 12-SEP-12 16:22
FEMA REGION 09 (SITUATION AWARENESS UNIT) 12-SEP-12 16:16
USCG NATIONAL COMMAND CENTER (MAIN OFFICE) 12-SEP-12 16:20
NATIONAL INFRASTRUCTURE COORD CTR (MAIN OFFICE) 12-SEP-12 16:16
NOAA RPTS FOR CA (MAIN OFFICE) 12-SEP-12 16:16
NATIONAL RESPONSE CENTER HQ (MAIN OFFICE) 12-SEP-12 16:21
NTSB PIPELINE (MAIN OFFICE) 12-SEP-12 16:16
OCCUPATIONAL SAFETY & HEALTH ADMIN (MAIN OFFICE) 12-SEP-12 16:23
CA STATE EMERGENCY SERVICES (MAIN OFFICE) 12-SEP-12 16:16
STATE TERRORISM & THREAT ASSESS CTR (COMMAND CENTER SACRAMENTO) 12-SEP-12 16:16
CITY OF YUMA EMERGENCY MANAGEMENT (COMMAND CENTER) 12-SEP-12 16:16
____________________________________________________________________________
ADDITIONAL INFORMATION
___________________________________________________________________________
*** END INCIDENT REPORT # 1024235 ***