Failed energy isolation during process opening and poor communications results in fatal NH3 release

NOTE: this occurred in 2007 – I just missed it in my research and just now posting it.

At a meat product processing plant Employee #1 and Employee #2 were working on the production floor near a section of piping that had been removed the prior day during the rerouting of an ammonia refrigerant line.

The accident happened when the plant coordinator and two maintenance supervisors tried to move ammonia from a high-pressure receiver into an intercooler through a, pump line but a section of piping from the pump line – which was hooked to a meat mixer – was under construction and had been removed.  Due to communication failures about the line rerouting, the plant refrigeration coordinator was unaware of the “changes” to the piping.  When the refrigerant line stop-valve was opened for the transfer, ammonia was released inside the production area.

Initial Penalty =  $1,102,500

Current Penalty = $648,000

Willful = 11

Serious = 15

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