UNSAFE NH3 charging practices causes catastrophic failure of 150-pound NH3 cylinder and a fatality

At approximately 3:15 pm on May 9, 1986, employees started to charge the number 1 line Carbo-Cooler, using a cylinder containing 150 pounds of anhydrous ammonia at 129 psi (room temperature). Employee #1, in an effort to speed the charging process, was running hot water (132 degrees F) over the ammonia cylinder (to raise the internal pressure).  Approximately 15 minutes later the cylinder fails, releasing NH3 into the workplace.  Nine (9) days later, Employee #1 died in a burn unit.

Employee #2 was working on 2 magnetic switches located near the sight glass on the carbo-cooler.

Employee #3 was operating the #1 line filler, approximately 25 feet from the ammonia cylinder.

Employee #4 was painting in aisle #3, approximately 45 feet from the cylinder.

At approximately 3:30 pm the cylinder ruptured, producing a white cloud of ammonia gas.

Employee #1, who was approximately 5 feet from the cylinder, was burned in the eyes and body and admitted to the hospital.

Employee #2 was also admitted to the hospital.

Employees #3 and #4 were both treated and released at the hospital.

Employees reentered the plant at 5 pm.

The anhydrous ammonia cylinder had a 21 inch long split in it, approximately 3 1/2 inches wide at the widest spot.

On Sunday, May 18, 1986, employee #1 died at Loyola University burn center, Chicago, Illinois.