On Monday August 14, 1989, high liquid level alarms sounded several times throughout the day in the Engine Room of XXXXXXXX indicating high amounts of liquid ammonia returning from the production area to the engine room. Mr. XXXXXXXX began his shift at 4 pm between 5 pm and 5:15 pm hammering was heard in the “No. 2 XXXX Compressor” (1962) indicating the presence of liquid ammonia in the compressor. Shortly thereafter a pump out valve on the “No. 2 XXXX Compressor” (1962) exploded catastrophically releasing liquid ammonia. A second worker, while injured, managed to escape from the engine room. See details below…
CCOHS Record Number: 2322
CIS Descriptors: SCALDS, TOXIC LIQUIDS, AMMONIA, MEAT INDUSTRY
FATALITY REPORT
REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner’s Jury
INDIVIDUAL PRESIDING: Dr. M. Milton, Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY : 1990-03-28
INFORMATION ABOUT DECEASED:
NAME: XXXXXXXXXXXXXX
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Manufacturing
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1989-08-14
PLACE OF ACCIDENT: XXXXXXXXXXXXXXX
BRIEF CAUSE OF DEATH: Acute tracheobronchitis, with 95% 3rd degree burns, consistent with ammonia burns.
BRIEF MANNER OF DEATH: A pump out valve on the “No. 2 XXXX Compressor” (1962) exploded catastrophically releasing liquid ammonia.
ACCIDENT DESCRIPTION:
The following relates to the accidental death of Mr. XXXXXXXXX: On Monday August 14, 1989, high liquid level alarms sounded several times throughout the day in the Engine Room of XXXXXXXX indicating high amounts of liquid ammonia returning from the production area to the engine room. Mr. XXXXXXXX began his shift at 4 pm between 5 pm and 5:15 pm hammering was heard in the “No. 2 XXXX Compressor” (1962) indicating the presence of liquid ammonia in the compressor. Shortly thereafter a pump out valve on the “No. 2 XXXX Compressor” (1962) exploded catastrophically releasing liquid ammonia. A second worker, while injured, managed to escape from the engine room.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. That all establishments with ammonia refrigeration systems arrange for the installation, if not already present, of an automatic shutdown switch to prevent liquid carry-over into a compressor. And that the location of said switch be determined by precise calculations made by company engineers and representatives of the Ministry of Consumer and Commercial Relations – Pressure Vessels Safety Branch.
2. That all establishments with ammonia refrigeration systems devise and reduce to writing standard procedures, particularly with regard to emergency situations, with the purpose that all operators will react to such situations in a uniform and safe manner. Furthermore, that operators be trained such that they are qualified to act in the manner specified.
3. That all establishments with ammonia refrigeration systems be required to maintain log books on site with sufficient space to allow the detailing of any and all unusual conditions encountered in the operation of the equipment.
4. That all establishments with ammonia refrigeration systems where production variations result in fluctuations in demand for refrigeration devise a system for notification of the engine room operators of the anticipated changes.
5. That in any area or on any shift where only a single Stationary Engineer is on duty, spot checks should be conducted at regular intervals to determine both the operator’s health and welfare and the smooth operation of the equipment.
6. That all owners of ammonia refrigeration facilities be required to obtain a licence to operate, which would be renewed at intervals deemed appropriate by the Ministry of Consumer and Commercial Relations provided they have proof of insurance and inspection, or inspection by the Pressure Vessels Safety Branch.
7. That all establishments with ammonia refrigeration systems provide facilities for deluge showers and eyewash stations both inside the engine room and immediately outside of every exit from the engine room.
8. Insure that any ammonia refrigeration engine room have no less than two safe exits directly to the outside. And that each exit be clear and unobstructed so as not to prevent or deter a quick evacuation of the premises.
9. That training be given to all workers, including contract workers who enter areas where ammonia leaks are possible in the location of emergency facilities, exits, equipment and procedures.
10. All Stationary Engineers working with ammonia refrigeration systems carry on their person a small respirator apparatus, to be used if quick exit is necessary.
11. That the Ministry of Consumer and Commercial Relations, in conjunction with the appropriate industry advisory committee, develop specific checklists for the guidance of those inspecting ammonia refrigeration systems, whether the inspector be employed by the Ministry or by an insurer.
12. That the Ministry of Consumer and Commercial Relations, in conjunction with the appropriate industry advisory committee, study existing legislation, regulations and standards, to determine if the inspection of ammonia refrigeration engine rooms be given to the jurisdiction of one single inspector specifically trained in this field.
13. That the subject matter of the appropriate material to be employed in the manufacture and installation of compressors, valves and fittings for a pressurized ammonia refrigeration system, and specifically whether the standard permitting gray cast iron as opposed to a more ductile iron or steel, be studied by the appropriate government authorities and experts of the private sector.
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