I have finally received the investigation information regarding the anhydrous ammonia fatality at a refrigerated seafood warehouse in Boston in March 2016. Sadly these reports do not indicate the cause of the accident and it does not appear that the AHJ used the state’s 527 CMR 33.00: Hazardous Material Process or Processing to enforce the PSM type requirements on this process. The process contained around 6,000 pounds of NH3 at the time of the accident. Below is a “behind the scenes” description of what went on that night and how the first-in engine and ladder companies attempted to rescue the deceased worker using only their bunker gear and SCBA(s). The rescue team could not reach the worker due to the levels of NH3 and the fact that bunker gear is NOT the proper chemical protective clothing for NH3. The BFD ended up utilizing a refrigeration contractor who worked on the process (there was no indication he was not working on the process at the time of the release) to escort them on their 3rd entry in the hopes that he could aid them in finding the valves to isolate the leak. There is a lot of learnings to take from this…
Notified by fire alarm to respond to Fargo and Summer Streets at the request of E-39. Upon arrival Engine 39’s officer and I both agreed that there was a strong odor of ammonia in the area, but we were not at its source. There was a steady wind blowing directly across Summer Street from the direction of the EDIC industrial park. E-39 and L-18 to proceed with me to the North Coast sea food plant to determine if it was the source of the odor. Once at the plant there was no odor and L-18, E-39 and Car 06 proceeded in different directions to locate the ammonia leak. Car 06 proceeded to the XXXXXX sea food plant at XXXXX Channel St. and found several workers evacuating the facility and a very strong presence of ammonia. The person in charge stated that they just noticed there is an ammonia leak” and he and several other employees were heading out to investigate it.
Fire alarm was updated of the new location as were L-18 and E-39 and the incident was upgraded to a level II response. There were no audible alarms sounding at the plant but there was a red strobe flashing and a loud hissing coming from the rear of the building. I was then informed that a maintenance man was missing and was probably still in the building. I requested a tech rescue response, had E-39 hook up to the nearest hydrant, had two members of L-18 and E-39 don one hour bottles and full bunker gear to attempt a rescue and detailed a member to locate the “king valve” to shut off the leak. The companies were able to get the doors open and proceed into the plant to the top of the stairway. At the top of the stairs the leaking ammonia tank and the missing employee were visible, but the members could not enter the second floor due to the high concentration of ammonia. The rescue was aborted when the ammonia started to penetrate the firefighters bunker gear, burning their skin, and driving them down the stairway. All members exited the building and it was determined that protective chemical suits were needed. No king valve was located outside the building to control the leak.
T03- Upon arriving at the incident location I reported to Deputy Chief XXXXXXXXXX who briefed me on current status of the leak and the missing worker. I assisted with the planning and hazmat entries for rescue/recovery of the missing worker as well as mitigation of the leak. The priority mission of the first 3 man entry team was to locate and remove the worker. During this entry they also were going to survey the area for any valves or tanks that may be part of the ongoing leak. Entry Team 1 was able to locate and move the victim to the top of the stairs as they were running low on air they notified the Entry Team Leader that a second 3 man entry would be necessary to recover the victim and bring him outside to be processed through decon. The victim was placed in the Hazard Assessment Field Isolation System inflatable tent. He was deconned and firefighters were assigned to stand by the tent until the medical examiner’s office arrived.
Entry team 3 was comprised of two BFD hazmat techs and a tech from XXXXXX [a refrigeration contractor]. It was determined that it would be easier to find and stop the leak with him as a guide because of his familiarization with the plant layout. Team 3 was able to isolate the leaking tank and then reported to Decon. The leak was found at the bottom of a tank where the pressure reaches 140 PSI.
During this incident air monitoring was conducted continually to ensure a safe working environment. We also worked with Boston Police and gave them updates on the release as regards to the shelter in place plan and the temporary evacuation of the affected area. After the first responders made up their gear and the site we had a meeting with the regulatory agencies that were present and formulated a plan to meet the next morning and after monitoring the area in question they would start the investigative process. Boston Fire Special Ops completed their active role at the site by noon time.
NARRATIVE STATUS
FIRE INVESTIGATION UNIT INCIDENT: 16/0018445
DATE: 3/23/2016
ADDRESS: XXXXXX Channel Street
Report is made that on 3/23/2016 at approximately 1822 hours, the Fire Investigation Unit with Lieutenant XXXXXXXX, Inspectors XXXXXXXXX and XXXXXXXX of the K-6 Unit and Inspector XXXXXXXXXX of the K-7 Unit, along with District Fire Chief XXXXXXXX, K-3, Captain XXXXXXXX, K-3A, Lieutenant XXXXXX, K-5, Lieutenant XXXXXXXXX, K-SA and Boston Police Detective Lieutenant XXXXXXXXX assigned to the FIU were ordered by Fire Alarm to a level 3 Hazardous Materials incident at the above address.
The FIU reported to Deputy Fire Chief XXXXXXXXX of C-6 who directed us to XXXXXX Channel Street, the XXXXX Seafood Company, a 2-story, ammonia-driven refrigerated warehouse approximately 150 feet X 100 feet. This incident was elevated to a level 3 Hazardous Materials Incident when it was suspected that a large ammonia tank was leaking and a worker was missing who was later found expired.
Weather at the time of this incident was cloudy skies, temperature 45F, winds NE 12mph and humidity was 55%.
First arriving Boston Fire Department personnel was District Fire Chief XXXXXX who stated that while investigating the cause of the central station alarm, he encountered a strong ammonia odor and felt tingling and burning sensation to his exposed neck skin. He was also told by [company] Operations Manager, XXXXXXX, that a worker was missing.
The FIU interviewed [company] Operations Manager who stated that he was in his office when told by fellow worker, XXXXXXXXX, that there was a suspected ammonia leak in a back cooler. There was a total of 4 known workers in the building at this time. He suspected a fifth worker, XXXXXXXXX, (deceased) was in the building when he saw his vehicle parked in the rear of the building. Other employees, XXXXXXXX (DOB – and XXXXXX – all smelled ammonia and immediately left the building. The missing worker was temporarily identified as XXXXXXXXX. He was removed by Hazmat team members and referred to BPD. The origin of this leak was the ammonia tank and cause of the leak is undetermined. No further investigation by FIU. BFD digital photos were taken by Inspector XXXXX
Respectfully, submitted,
Lieutenant XXXXXXXXXXXX