Readers of my Incident Alerts may remember this NH3 fatality from September 2012… AMMONIA FATALITY Winery worker dies after ammonia exposure (a worker at a winery has died after being exposed to ammonia – one of the workers accidentally opened a wrong valve and released ammonia into a confined area – the man was one of six workers exposed – the other workers tried to rescue the man but were unable to get to him because of the fumes – he died at the scene – the other employees were treated and released)
Now CAL-OSHA has shared some details not previously released…
Conditions leading to the release:
- No locks or chains on the oil drain valve below chiller/exchanger
- The oil drain will cause a full pressure liquid release if fully opened
- No self-closing valve on the oil drain
- No plug to prevent inadvertent release
- Dark, end of shift, midnight
Missing layers of protection
Accident Events
- Wine froze in tubing, needed hot gas to thaw
- Employee went to open hot gas valve, opened oil drain valve instead, three turns, walked away
- When oil plug cleared, a full pressure liquid ammonia release occurred, formed cloud of concentrated NH3 near ground level, against building and bathroom
- Employee ran and yelled for people to leave
- Employee died exiting bathroom through a cloud
Fatal Circumstances
- Victim fell face first on concrete in hallway
- Unable to self-rescue due to lung spasms, bronchoconstriction
- “Convulsions” observed
- Evacuated employees returned to attempt a rescue. Had no respirators, tried ropes
- Could not get him out until a fan cleared the area of ammonia
They Waited
- Valve opened just after 12:10 am
- Call made (estimate) 12:15
- Paramedics on site gave CPR at 12:34
- Paramedics refused to enter the plant – Employees carried the victim to the parking lot. CPR was administered to the deceased victim.
- Fire Dept (with SCBA) arrived after paramedics, then suited up
- Estimate 30 min before rescue by FD possible
- Estimate victim died in ten minutes
CLICK HERE (pdf) for the 5/2016 presentation where OSHA provided these details