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

Employee #1 and Employee #2 were overcome by ammonia vapors and were hospitalized. Employees #3, #4, #5, and #6 were also exposed to unknown levels of ammonia during the release and were treated at a local hospital.

Employee #1 died of injuries sustained in the ammonia release.

Violation Summary
  Serious Willful Repeat Other Total
Initial Violations 7 17     24
Current Violations 12 9     21
Initial Penalty $31,500 $1,071,000 $0 $0 $1,102,500
Current Penalty $198,000 $450,000 $0 $0 $648,000

 

Violation Items
  # ID Type Standard Issuance Abate Curr$ Init$ Fta$ Contest LastEvent
  1. 01001 Serious 880004 12/20/2007 01/09/2009 $8,000 $4,500 $0 01/14/2008 F – Formal Settlement
  2. 01002A Serious 19100036 B01 12/20/2007 01/09/2009 $8,000 $4,500 $0 01/14/2008 F – Formal Settlement
Deleted 3. 01002B Serious 19100037 A02 12/20/2007 01/09/2009 $0 $0 $0 01/14/2008 F – Formal Settlement
  4. 01003A Serious 19100038 C02 12/20/2007 01/09/2009 $8,000 $4,500 $0 01/14/2008 F – Formal Settlement
Deleted 5. 01003B Serious 19100119 N 12/20/2007 01/09/2009 $0 $0 $0 01/14/2008 F – Formal Settlement
  6. 01004 Serious 19100119 E03 II 12/20/2007 01/09/2009 $8,000 $4,500 $0 01/14/2008 F – Formal Settlement
Deleted 7. 01005 Serious 19100119 H02 VI 12/20/2007 01/09/2009 $0 $4,500 $0 01/14/2008 F – Formal Settlement
  8. 01006 Serious 19100119 M03 12/20/2007 01/09/2009 $8,000 $4,500 $0 01/14/2008 F – Formal Settlement
  9. 01007 Serious 19100134 F01 12/20/2007 01/09/2009 $8,000 $4,500 $0 01/14/2008 F – Formal Settlement
  10. 02001 Serious 19100119 F01 I 12/20/2007 01/09/2009 $25,000 $63,000 $0 01/14/2008 F – Formal Settlement
  11. 02002 Serious 19100119 F03 12/20/2007 01/09/2009 $25,000 $63,000 $0 01/14/2008 F – Formal Settlement
  12. 02003 Serious 19100119 F04 12/20/2007 01/09/2009 $25,000 $63,000 $0 01/14/2008 F – Formal Settlement
  13. 02004 Serious 19100119 G01 I 12/20/2007 01/09/2009 $25,000 $63,000 $0 01/14/2008 F – Formal Settlement
  14. 02005 Serious 19100119 H02 IV 12/20/2007 01/09/2009 $25,000 $63,000 $0 01/14/2008 F – Formal Settlement
Deleted 15. 02006 Willful 19100119 I01 12/20/2007 01/09/2009 $0 $63,000 $0 01/14/2008 F – Formal Settlement
Deleted 16. 02007 Willful 19100119 J06 II 12/20/2007 01/09/2009 $0 $63,000 $0 01/14/2008 F – Formal Settlement
  17. 02008 Serious 19100119 L01 12/20/2007 01/09/2009 $25,000 $63,000 $0 01/14/2008 F – Formal Settlement
  18. 02009 Willful 19100120 Q01 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  19. 02010 Willful 19100120 Q03 III 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  20. 02011 Willful 19100120 Q03 IV 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  21. 02012 Willful 19100120 Q06 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  22. 02013 Willful 19100134 C01 IV 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  23. 02014 Willful 19100147 C04 II 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  24. 02015 Willful 19100147 C07 I 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  25. 02016 Willful 19100147 D04 I 12/20/2007 01/09/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement
  26. 02017 Willful 19100165 B01 12/20/2007 03/15/2009 $50,000 $63,000 $0 01/14/2008 F – Formal Settlement

 

CASE FILE

 

 

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