At approximately 9:30 p.m. on June 30, 1993, Employee #1, a cleaning contractor, was cleaning up the “cut floor” at a beef facility in Council Bluffs, IA. The facility maintenance employees were removing an ammonia valve from the refrigerant line in the ceiling and had NOT locked or tagged out the isolation valves on the roof. The valve on the cut floor was removed and taken to the maintenance shop for alteration. The foreman gave workers their evening assignments, then went to the roof and OPENED the isolation valves, sending liquid ammonia through the lines and onto the cut floor.
Employee #1 was overcome and died of ammonia irritation and pulmonary complications.
Employees #2 through #9, who attempted to rescue Employee #1, were sent to the hospital for throat, eye, and skin irritation, treated and released.
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Violation Summary
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|---|---|---|---|---|---|
| Serious | Willful | Repeat | Other | Total | |
| Initial Violations | 12 | 7 | 1 | 20 | |
| Current Violations | 16 | 1 | 17 | ||
| Initial Penalty | $44,400 | $245,000 | $25,000 | $0 | $314,400 |
| Current Penalty | $55,500 | $35,000 | $0 | $0 | $90,500 |
| Violation Items | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| # | ID | Type | Standard | Issuance | Abate | Curr$ | Init$ | Contest | LastEvent |
| 1. | 01001 | Serious | 19100120 Q02 II | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 2. | 01002 | Serious | 19100120 Q03 I | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 3. | 01003A | Serious | 19100120 Q03 III | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 4. | 01003B | Serious | 19100120 Q03 IV | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 5. | 01004A | Serious | 19100120 Q03 V | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 6. | 01004B | Serious | 19100120 Q03 VI | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 7. | 01005 | Serious | 19100120 Q03 VII | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 8. | 01006 | Serious | 19100120 Q04 | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 9. | 01007A | Serious | 19100120 Q06 | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 10. | 01007B | Serious | 19100120 Q06 IB | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 11. | 01007C | Serious | 19100120 Q06 IIA | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 12. | 01007D | Serious | 19100120 Q06 IIB | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 13. | 01007E | Serious | 19100120 Q06 VB | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 14. | 01007F | Serious | 19100120 Q08 II | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 15. | 01008 | Serious | 19100134 A03 | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 16. | 01009 | Serious | 19100134 B02 | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 17. | 01010 | Serious | 19100134 E03 I | 11/10/1993 | 05/19/2000 | $1,850 | $3,700 | 11/22/1993 | Y – State Decision |
| 18. | 01011 | Serious | 19100134 E03 II | 11/10/1993 | 05/19/2000 | $1,850 | $3,700 | 11/22/1993 | Y – State Decision |
| 19. | 01012 | Serious | 19100134 E03 III | 11/10/1993 | 05/19/2000 | $3,700 | $3,700 | 11/22/1993 | Y – State Decision |
| 20. | 02001 | Serious | 19100134 F02 II | 11/10/1993 | 05/19/2000 | $3,700 | $35,000 | 11/22/1993 | Y – State Decision |
| 21. | 02002 | Willful | 19100147 C04 IIB | 11/10/1993 | 05/19/2000 | $0 | $35,000 | 11/22/1993 | Y – State Decision |
| 22. | 02003 | Willful | 19100147 C06 I | 11/10/1993 | 05/19/2000 | $0 | $35,000 | 11/22/1993 | Y – State Decision |
| 23. | 02004 | Willful | 19100147 C09 | 11/10/1993 | 05/19/2000 | $35,000 | $35,000 | 11/22/1993 | Y – State Decision |
| 24. | 02005A | Serious | 19100147 D01 | 11/10/1993 | 05/19/2000 | $3,700 | $35,000 | 11/22/1993 | Y – State Decision |
| 25. | 02005B | Serious | 19100147 D02 | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 26. | 02005C | Serious | 19100147 D03 | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 27. | 02005D | Serious | 19100147 D04 I | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 28. | 02005E | Serious | 19100147 D05 II | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 29. | 02005F | Serious | 19100147 D06 | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 30. | 02006 | Willful | 19100147 F02 I | 11/10/1993 | 05/19/2000 | $0 | $35,000 | 11/22/1993 | Y – State Decision |
| 31. | 02007A | Serious | 19100147 F03 I | 11/10/1993 | 05/19/2000 | $3,700 | $35,000 | 11/22/1993 | Y – State Decision |
| 32. | 02007B | Serious | 19100147 F03 II | 11/10/1993 | 05/19/2000 | $0 | $0 | 11/22/1993 | Y – State Decision |
| 33. | 03001 | Serious | 19100134 E03 | 11/10/1993 | 05/19/2000 | $3,700 | $25,000 | 11/22/1993 | Y – State Decision |