Ammonia Evaporator not LOTO’ed leading to 68 pound release and 4 hospitilizations

On May 31, 2012, Employees #1 through #6 were working 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 coworker or one of the six employees who were injured.  Here is a breakdown of the OSHA citations:

NOTE:  Rare Emergency Alarm citations using 1910.165,  but this was a PSM covered facility.

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