Abstract: "The receiving dock attendant and nine other adjacently exposed workers were sent to emergency rooms for evaluation and were released with only minor injuries. All others employees were unharmed." Employee #1 was the truck driver. He was working for Univar USA. In addition to Employee #1, who was employed by Univar USA, ten other workers were injured in this incident. They were employees of Darigold. It is not known whether a 170 was generated for those workers. As it develops, the employer in this 170 is given as Darigold, when the actual employer was Univar USA. What should I do? == == == == Brief Description: There was a large chlorine release due to pumping of acid into the wrong tank. Company Information: This Darigold facility was recently converted to a milk packaging plant only - no ice cream. Consequently, they reduced their ammonia usage and are no longer a PSM covered process. Darigold purchases their sanitation chemicals through Ecolab. The chemicals are delivery by Univar USA which is a local chemical trucking company. Accident Investigation: At approximately 10:15 a.m. on May 30, 2012, Employee #1 was working as a truck driver for Univar USA. was making a routine delivery of sanitation chemicals to Darigold. These deliveries are made using milk-loading dock #2 (second of two at the facility) and the chemicals are pumped through receiving pipes located on the south wall the loading dock. The pipes lead to three large tanks located in the Clean In- Place (CIP) room located adjacent to the dock. The multi-compartment tanker truck was loaded with two different chemicals; AC-55-5 (nitric and phosphoric acid blend) and AC-103 (sodium hydroxide). The sodium hydroxide was pumped first, without any problems. When Employee #1 hooked up the hose to pump the second delivery, which was acid, he selected the wrong intake pipe. He started pumping the acid into the "CIP Exelerate" sanitizer tank which contained sodium hypochlorite. The mixture started a reaction that generated chlorine gas. He could not see the tank in the CIP room, thus there was a delay in recognizing a problem. By the time the mix-up was identified, approximately 325 gallons of acid was mixed with approximately 1150 gallons of sodium hypochlorite. The Darigold dock attendant evacuated the area to safety. Employee #1, the truck driver, donned a full face APR and shut-off the acid tanker. He then evacuated to safety. The entire milk plant was evacuated. Employee #1, the truck driver, was most severely injured and hospitalized overnight due to inhalation burns. The receiving dock attendant and nine other adjacently exposed workers were sent to emergency rooms for evaluation and were released with only minor injuries. All others employees were unharmed. The chemical reaction continued to generate chlorine until approximately 8:00P.M. that evening. The building and perimeter remained evacuated all evening and the chlorine was controlled by fans blowing into the room until the reaction was stopped and the tank was pumped out. Related Factors: Negative -A chlorine concentration above the IDLH (10 ppm) was formed. The fire department's chlorine meter was pegged out (about measuring range). - Chemical truck deliveries tie up one of the two milk delivery docks. There was an emphasis on limiting milk delivery interruptions, thus Employee #1 was in a hurry to get the delivery done. -The milk receiving attendant at the Darigold Dock was too busy to verify and watch the delivery. -The Bulk Delivery Release Form (BDRF) was not signed by Darigold. -The locks were under the control of Employee #1 - he had the combinations. -The lock combinations on the acid and hypochlorite locks were very similar (3264 for acid and 3266 for sodium hypochlorite). Thus, they could have easily been interchanged. -The Ecolab safety procedure was being used as the overriding standard for this operation. The "2 sets of eyes" unloading concept discussed multiple times in the Ecolab training was not