Chemical Process Safety (PSM/RMP)

“Leak Testing” ammonia refrigeration system fatality

Employee #1 was working for a firm that, as a subcontractor, performed maintenance on commercial food service equipment. He was in the kitchen area of a single-story restaurant, attempting to locate the source of a refrigerant leak in an ice cream storage dipping cabinet. Employee #1 connected a cylinder containing pressurized nitrogen to the dipping…...

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Refrigeration Auto-Purger Overpressure Event – Burns and Eye Surgery

At approximately 9:50 a.m. Employees #1 and #2 worked as mechanical engineering technicians at a food cold storage facility. The two workers were troubleshooting an Auto-Purger. The Auto-Purger removed non-condensable material from the refrigeration system. It was mounted on a wall inside the facility’s anhydrous ammonia compressor room. At the time of the accident, the…...

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Ammonia Refrigeration Double Fatality – Draining Oil

Employees #1 and #2 were draining refrigerant oil from anhydrous ammonia refrigeration system oil traps in fruit cold storage warehouses. They were working approximately 24 feet above floor level on a mobile scissor lift personnel platform (Hyster, V24) using hand tools, including a wrench, a flashlight, and a bucket. The cause of the unexpected ammonia…...

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Line Break gone bad (Contractors and Phosgene)

At 2:30 p.m., Employee #1, Employee #2, and Employee #3 were tasked with dismantling a scaffolding level within a containment dome (identified as PMDI A-3600). During their dismantling work, at approximately 80 feet above the ground, alarms specific to phosgene gas were triggered. The process within this Dome was the manufacturing and using phosgene to…...

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Hazard Mitigation: Distance and Barriers (Hot Work)

A recent accident has me explaining the fundamentals of our profession that so many seem to have lost in the past decades.  You have a hazard; DISTANCE yourself from that hazard If you can not put DISTANCE between you and the hazard, then a BARRIER is necessary Our Hot Work Programs are a perfect example…...

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Pressure Testing gone bad (Hydrostatic Testing Fatality)

At 4:15 p.m. on January 28, 2022, an employee was assisting in hydro-testing a joint of steel pipe (39.5-feet long, 9 5/8 OD, 1580 psi).  While pressurized, the employee walked into the testing area. At the same time, the plug on the pipe failed, leading to the pipe striking the employee. The employee was killed…...

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Line Fire – Pressure Relief Devices (PRD) must discharge to a SAFE location

At 4:51 a.m. on January 15, 2022, Employee #1 and Employee #2 (Millwrights) were assigned to replace a pump in a Methylene Diphenyl Diisocyanate (MDI) Unit at the Di-Chlorination Column at approximately 2:00 a.m. The discharge line for this column discharges about a foot off the ground right next to the pump where the employees…...

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N2 and CO kill contractor maintenance worker and hospitalize another

At 11:30 a.m. on October 15, 2021, Employees #1 and #2, both maintenance contractor employees, were assigned to install a pressure safety valve (PSV) on a flare header in a methylene diphenyl diisocyanate (MDI) unit when they were exposed to nitrogen and carbon monoxide. The installation procedure requires supplied air respirators. The employees were staging…...

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WRONG Chemical – WRONG Container @ Brewery (Chlorine)

At 10:10 a.m. on February 1, 2022, an employee connected the wrong chemical tote, (i.e., Dilac instead of Dibac) to a day tank containing a chlorine solution. The chemical reaction of the two chemicals caused a vapor release. Eight employees sustained unspecified respiratory illnesses, and six were hospitalized for treatment…. Membership Required You must be...

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Paraformaldehyde and Ammonia solution reaction burns two employees

At 8:15 a.m. on February 1, 2022, an employee poured paraformaldehyde into an aqueous ammonia solution inside a vessel. There was a chemical reaction, resulting in an explosion. Two employees suffered chemical burns to their backs and arms, and one of the employees was hospitalized…. Membership Required You must be a member to access this...

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NH3 applicator not at ZES and sprays worker doing maintenance

At 3:10 p.m. on February 2, 2022, an employee, 26, performed maintenance on a Raven AccuFlow System Applicator. The employee began the ammonia bleeding procedure wearing safety glasses and rubber gloves. After approximately 20 to 30 minutes, the employee no longer heard a whistling sound and believed that the system was completely bled out. When…...

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