One area that is often overlooked or not applied during process hazards analysis (PHA) is a review of previous incidents. This is often not done as the process has no reported incidents in the past five years. We can discuss/challenge that “phenomenon” in a later posting, but I wanted to offer this bit of advice…
If your process has no previous incidents to review, there may be some opportunities to review some other industry-wide incidents. Below are some brief summaries of incidents involving Anhydrous Ammonia. These incidents range from ammonia used in the fertilizer industry to refrigeration processes; therefore some may apply to your process and some may not. They are just meant to be brain ticklers to get team members to ask “can that happen here?”. If your facility handles other HHCs/EHS’s, you can do a quick search of the OSHA database at https://www.osha.gov/pls/imis/accidentsearch.html
On May 31, 2012, Employees #1 through #6 were working for the Smithfield Packing Company, Inc. The narrative did not state their occupations. When an evaporator that had been deactivated was mistakenly activated by a worker, approximately 68.5 pounds (31 kilograms) of ammonia were released on an overhead catwalk. Employees #1 through #6 inhaled the fumes, and they were transported to a hospital. Employee #1 was not hospitalized, but Employees #2 through #6 were. The narrative did not specify whether the inadvertent release of the ammonia was caused by a co-worker or one of the six employees who were injured.
On May 15, 2012, Vibration in a fan motor from incomplete ice removal caused a 1 in. liquid ammonia line to crack releasing ammonia gas to work areas in the potato packing area. Seven employees inhaled ammonia gas. All employees were evacuated; some employees were treated on site. Seven employees were transported to an area hospital, where they were treated and released.
Employee #1 was near a cooling condenser on a truck mounted ammonia refrigeration compressor trailer. The condenser overpressurized and ruptured, consequently, Employee #1 suffered chemical burns from liquid anhydrous ammonia. Employee #1 was hospitalized for the burns due to this accident.
At approximately 2:30 p.m. Employee #1’s coworker, a refrigeration technician, was troubleshooting a compressor shutdown and opened a valve which vented anhydrous ammonia into Engine Room #3. A small fire started after the released liquid ammonia froze and shorted the wiring inside the conduit. The fire flashed in the concentrated ammonia and flared rapidly within the southwest corner of the engine room. The flash fire apparently traveled conduit lines and destroyed almost all electrical wiring in the room. The facility was shut down and evacuated within less than two minutes. Employee #1 was taken to the hospital for observation and treatment, but left the hospital on his own cognizance without treatment after waiting over an hour in triage.
At approximately 10:50 a.m. on March 26, 2010, Employees #1 through #16, mostly working in the Slice Department, were exposed to anhydrous ammonia. Approximately 300 employees were evacuated from the plant. Other employees were decontaminated on-site by the county hazardous material responders. Thirty (30) gallons of anhydrous ammonia, used as a refrigerant, leaked from a fractured back flow regulator, Refrigerating Specialties Co., Model A4A. The liquid ammonia pooled on the roof and then flowed to the storm sewer drain. The storm sewer drain, made of polyvinyl chloride material, was cracked and released ammonia into the Slice Department. Employees #1 through #16 were taken to the hospital and treated with oxygen for breathing, albuterol inhaler for asthma, and eye washing. Employees #1 through #16 were not hospitalized.
At approximately 8:30 p.m. on March 10, 2010, Employee #1 was working for a trucking firm. He had been dispatched to a location ten miles north of Sublette, Kansas, to unload 40,000 lbs. of anhydrous ammonia from the tanker truck he was driving into a storage tank on the site. At the middle section of the tanker truck, Employee #1 bent over to close a 4-inch main valve lever. To do this, he had to extend his right hand above and past a power take-off (PTO) shaft, which was turning at approximately 700 to 750 rpm. A bolt protruding from a universal joint on the turning PTO shaft caught the right wrist of the jacket he was wearing. Employee #1’s right forearm was pulled in and around the shaft three times. When Employee #1 reacted by reaching in with his left hand, his left wrist was shattered. A nearby resident approximately 100 yards away heard a scream, jumped in his truck and drove to the site. The resident cut off Employee #1’s jacket with a pocket knife and, following Employee #1’s directive, shut the truck off. The resident removed Employee #1’s right arm from the shaft, and his wife called for emergency medical services, which were dispatched from Sublette, KS. Employee #1 was transported to Saint Catherine Hospital in Garden City, Kansas, and from there to Via Christi in Wichita, Kansas. On March 12, 2010, Employee #1’s right arm was surgically amputated. On March 28, 2010, he died, due to complications.
On January 3, 2010, a small amount of ammonia was released when a worker drove a forklift into the support frame of an entry door of a freezer. The entryway was equipped with an air curtain above the door. Five workers employed in this area of the distribution center began feeling eye, throat and lung irritation. All were transported to local hospitals where they were treated and released for exposure to ammonia.
On November 16, 2009, Employee #1, a truck driver, was connecting the truck’s loading arm at an anhydrous ammonia fill station. When he encountered difficulty, another truck driver (Employee #2) assisted. During the transfer of ammonia, product leaked from an improperly-fitted connection. Both employees died from the ammonia exposure.
On October 9, 2009, 18 PotashCorp employees and contract workers were exposed to ammonia during the off-loading of four railcars containing anhydrous ammonia. The coupling on the northern railcar came apart, releasing approximately 8,700 lbs of ammonia. Eleven PotashCorp employees were transported to the hospital but not hospitalized, and seven contract employees were sent to local hospitals, where two were kept overnight for observation.
On June 20, 2009, Employees #1 through #3 were performing maintenance operations on Votator #2 when they broke the seal on the machine, resulting in the release of ammonia vapors and liquid. Employee #1 died of the exposure. Employees #1 and #2 were hospitalized for treatment.
On September 3, 2008, a water flow switch malfunctioned at a Birds Eye Foods facility, causing a pressure increase in an outside ammonia vessel. Ammonia emitted from a pressure relief valve and was drawn into the facility, exposing employees. Employee #1 was hospitalized for treatment and 21 others were treated and released.
At approximately 10:00 a.m. on July 8, 2008, Employee #1 was working at a cold storage facility that specialized in fruit juice concentrates. The company is also involved in fish processing, packaging, and freezing. Employee #1 was hired the day before to help in moving the boxes of fish from the packaging line to pallets. On that particular day, the employer had hired too many temporary workers and some of them were sent out to do other tasks. Employee #1 was one such employee and after working two hours in the fish line, Employee #1 was reassigned to help in the maintenance department. The company’s refrigeration system could not keep up with the automatic defrosting of ice causing it to accumulate on the evaporators over time, making their refrigeration system very inefficient. To resolve this, the employer resorted to having its employees manually “chip” the ice by providing them with hammers. On Employee #1’s second day of work, he continued chipping ice off the same evaporator. Employee #1 was working on the top part of a ladder that was propped against the evaporator. Employee #1 had chipped a big portion of ice and as it fell, it hit and punctured an anhydrous ammonia line. Ammonia vapor was released and caused a severe chemical burn to Employee #1’s eyes, face, neck, hand, and lungs. With his eyes closed, Employee #1 managed to climb down the ladder, crawl over several 55-gallon drums of concentrated juice to exit the freezer room. Once outside of the freezer, other employees secured a water hose and doused him with water. Employee #1 was then taken to a local hospital where he stayed for seven days for burn treatment.
At approximately 7:10 a.m. on June 11, 2008, Operators at the C2 unit (Plant 2) in C building were injecting 60-psi steam at a temperature of approximately 400-degrees Fahrenheit into a precooler, heat exchanger Model Number E300-G, to purge the process of the latex products. Latex was on the tube side and ammonia was on the shell side. The steam was injected into the tubes heating the ammonia on the shell side. The precooler over pressured, rupturing the shell, releasing ammonia into the environment. Employee #1 was found dead beneath the debris in the area of the heat exchanger several hours after the explosion occurred. Five contracted employees were severely exposed to ammonia. Employees #2, #3, #4, and # 6 were hospitalized. Employee #5 received first aid and was released.
On January 15, 2008, Employees #1 through #3, located in a workroom of Jbs Swift & Company, were exposed to anhydrous ammonia. Eighty (80) pounds of anhydrous ammonia, used to operate an Evapco evaporative cooler (hog cooler), leaked from a ruptured drain. All three employees were hospitalized.
At approximately 4:45 p.m. on January 9, 2008, Employee #1 and coworkers were engaged in insulation work on a large anhydrous ammonia tank. The tank had been nearly emptied before work was allowed to begin. The employees were repositioning an adjustable scaffold for work the next day when a pressure relief cap was opened, releasing ammonia vapors. Employee #1 was transported to the hospital for treatment of superficial eye and lung burns; he was released the next day. Two other coworkers were sent to the hospital for observation.
On December 27, 2007, Employee #1, a refrigeration maintenance employee, was attempting to return a solenoid valve to an autorun position. He turned the wrong valve, which released ammonia into the work area. Approximately 18 pounds of ammonia was released. The plant was evacuated to contain the release. Eighteen employees were taken to the hospital and treated; one employee was kept overnight for observation.
At 2:00 p.m. on August 6, 2007, employees of the Coffeyville Resources Nitrogen Fertilizer, LLC, and Coffeyville Resources Refining & Marketing, LLC, were exposed to anhydrous ammonia when there was a 7,100-gallon anhydrous ammonia release. The alarm system could not be activated from the control room. Manual activation at the pole delayed the alarm activation. Forty-one employees were transported to the local hospital for treatment. There were no fatalities.
On July 30, 2007, Employee #1 was operating an excavator during the demolition of a cold storage facility. He was grabbing one of the pipes with the excavator and pulling it away from the building when it sprayed ammonia into the cab of the excavator. Employee #1 suffered chemical burns to his face, upper torso, lungs, and respiratory system. He was transported to the hospital, where he was admitted for treatment.
On June 7, 2007, an ammonia explosion occurred. The explosion was due to a failure of an anhydrous ammonia compressor. Two employees were injured in the explosion. Employee #1 was treated at an area hospital and released. Employee #2 was admitted to the hospital for treatment.
On January 29, 2007, Employee #1 was sprayed with anhydrous ammonia at River Garden Farms Company, an agricultural company that cultivated crops. Employee #1 was working as a farm mechanic removing an anhydrous ammonia tank and application rig from a John Deere tractor in the yard of the farm. Employee #1 cut through a hose between the tank and the applicator with a knife. Employee #2 was standing behind Employee #1. When Employee #1 cut the hose, both employees were sprayed with corrosive anhydrous ammonia on the head and chest. After being sprayed, the operations manager helped Employees #1 and #2 irrigate their eyes. They then got in a truck and drove to Woodland Memorial Hospital. Employee #1 was taken to UC Davis Medical Center’s Burn Unit and remained in the hospital for over a month with eye and lung injuries. Employee #2 had his eyes irrigated and was released after four hours. Employee #1 returned to work in two weeks.
At approximately 11:45 p.m. on December 27, 2006, Employee #1, #2 and #3 were working with bacon curing ovens. A pressure relief valve in the ammonia-based cooling system failed, causing a release. All three employees were exposed and taken to a local hospital, where they were treated for respiratory problems and released the same day. Employee #4 was sent back into this area, after evacuation, to operate the bacon curing ovens. Employee #4 required medical treatment the following day.
On October 31, 2006, two employees were performing maintenance on an ammonia line when the line ruptured. Employee #1 was transported to a hospital and was pronounced dead at 2:08 p.m. Employee #2 suffered chemical burns from contact with liquid ammonia and was taken to the hospital for treatment. Employee #3, a first responder, was also treated at the hospital for post event respiratory symptoms. Employees #2 and #3 were not hospitalized.
On June 28, 2006, anhydrous ammonia was released from a pressure relief valve on the F3 Kathabar dehumidifier and refrigeration unit. The anhydrous ammonia was piped from the pressure relief valve to the roof where it was released. The anhydrous ammonia collected outside of the building housing the F3 Kathabar unit, in the B and C Fermentation Tank Corridor. Employee #1, a mechanic, was exposed to the anhydrous ammonia while he was working on a scaffold in the corridor. Employee #1 experienced damage to his respiratory system as a result of the exposure and was hospitalized. Employee #2, an insulator, was briefly exposed to the anhydrous ammonia when he entered the B & C Fermentation Tank Corridor to help Employee #1. Employee #2 was observed and given minor treatment at the hospital, but he was not hospitalized.
On October 4, 2005, Employee #1 was working as a refrigeration mechanic. An ammonia system valve in freezer Number 7 was being turned, when the bonnet came loose with the wheel, releasing approximately 100 to 200 lbs of ammonia. Employee #1 was 35 feet up without fall protection, and he had to slide down racking to escape. He gave notification to shut the system down and summoned the city’s hazard materials team. The plant and the surrounding businesses were evacuated without incident. Employee #1 sustained first and second-degree chemical burns on his left hand. He was not hospitalized. This was not the first time that the bonnet of that Hansen 1.25 in. shut off valve had come off when the valve was turned. This type of valve is now made with a bolt to prevent the bonnet from turning.
On March 21, 2005, Employee #1, a maintenance worker, was performing routine preventive maintenance on an ammonia refrigeration system. He intended to drain oil from the system, but due to confusion, he attached his ratchet wrench to an ammonia fitting. The escaping ammonia caused chemical burns to Employee #1’s right hand and forearm, and his lungs were irritated. He was hospitalized.
On March 15, 2004, Employee #1 and 40 coworkers had to evacuate the plant due to an Ammonia release that resulted from a power failure. Employee #1 along with the other employees, was standing at the designated staging area when Employee #1 fell forward bleeding from the mouth. Employee #1 was killed.
At 11:30 a.m. on February 12, 2004, Employees #1, #2, #3, #4, #5, #6, #7, and #8 were working at a meatpacking plant in Sioux Falls, South Dakota. A liquid ammonia line outside one of the packing plant buildings ruptured and ammonia was released to the atmosphere. Approximately 1,700 employees at the plant were evacuated, with 75 employees taken to hospitals. Employees #1 through #8 were admitted to hospitals, with six of the eight employees being released the same day. The remaining two employees were hospitalized, with one employee staying one night and another employee staying two nights.
At approximately 10:00 a.m. on November 4, 2003, Employee #1 was filling a nurse tank from the bulk anhydrous ammonia tank at the ammonia plant. After the nurse tank was full, Employee #1 disconnected the hoses from the nurse tank and was exposed to anhydrous ammonia. The exposure resulted in burn injuries to his face, neck, chest, and one eye, and injuries to his respiratory tract. Employee #1 drove to the fertilizer plant a few blocks away and was taken immediately to a local hospital and transferred to a regional burn center. Employee #1 died of complications due to chemical inhalation a few weeks later. There were no witnesses to the incident. A company official visited the site approximately 15 minutes after the incident and found goggles and gloves on the ground, the riser liquid and vapor valves closed, and the nurse tank vapor valve open. The company official also found the vapor hose end valve connected to the nurse tank and open, the nurse tank liquid fill valve closed and the liquid hose end valve open and lying on the ground. It appeared that Employee #1 was exposed to the ammonia remaining in the liquid hose between the riser valve and the hose end valve. The exposure appeared to have occurred either because Employee #1 did not close the hose end valve before disconnecting the hose from the nurse tank, or because the safety catch did not engage when the valve was closed, and the valve handle was bumped, causing the valve to open. There was evidence that Employee #1 applied snow to the injured areas. The required water supply had approximately one inch of ice on the surface.
On August 4, 2003, an employee was performing maintenance on an ammonia service valve. The valve had been isolated and the pipeline drained. A small amount of residual ammonia left in the pipeline splashed on the employee when he worked the valve. He suffered burns to his face but was not hospitalized. Anhydrous ammonia was released when Employee #1 pulled a nurse tank away while the fill hoses were still connected.
On April 30, 2003, Employee #1 and a coworker filled an anhydrous ammonia nurse tank to be transported to farm fields. After filling the nurse tank, Employee #1 was hooking the tank to a pickup truck for transport when the tank ruptured along a weld seam on the bottom front side. Liquid ammonia was released through the approximate 40-in. split. The ammonia formed a cloud and a rapidly expanding, boiling-liquid blast enveloped Employee #1. The coworker assisted Employee #1 to and into a water tank. The Employee #1 died 1.5 weeks later from chemical burns.