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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 14560031 - Exposed To Ammonia Gas From Leaking Refrigeration System

Accident: 14560031 -- Report ID: 0112600 -- Event Date: 08/29/1984
InspectionOpen DateSICEstablishment Name
1063203211/02/19822086Mid Atlantic Canners Assn Co
AT APPROXIMATELY 7:20 PM ON AUGUST 29, 1984, EMPLOYEE# 1 STARTED TO PURGE THE OIL FROM AN AMMONIA GAS REFRIGERATION SYSTEM AT A SOFT DRINK BOTTLING PLANT. IT WAS THE FIRST TIME HE HAD ATTEMPTED THIS PROCEDURE AND HE HAD NOT BEEN PROPERLY TRAINED. HIS PURGING TECHNIQUE WAS FAULTY, CAUSING HIM TO ACCIDENTALLY RELEASE A LARGE AMOUNT OF ANHYDROUS AMMONIA INTO HIS BREATHING ZONE. HE WAS MOMENTARILY BLINDED AND UNABLE TO LOCATE THE VALVE TO TURN OFF THE AMMONIA, WHICH WAS NOW BEING RELEASED AT GREAT SPEED FROM THE REFRIGERATION SYSTEM. WITH HIS EYES, SKIN, AND THROAT STINGING HE WAS FORCED TO ABANDON THE ATTEMPT. HE CRAWLED OUT OF THE ROOM. SUBSEQUENT ATTEMPTS BY EMPLOYEES ONE THROUGH EIGHT TO RE-ENTER THE ROOM (WITH DEFECTIVE AMMONIA GAS MASKS) ALSO FAILED. SUPERVISORS THEN ACTIVATED THE EVACUATION PLAN. BEFORE EVACUATION BEGAN, AND DURING EVACUATION, MANY OTHER EMPLOYEES WERE EXPOSED TO THE AMMONIA GAS, WHICH HAD DIFFUSED THOUGHOUT THE PLANT. EVENTUALLY MUNICIPAL FIREFIGHTERS WITH SCBA'S TURNED OFF THE VALVE. APPROXIMATELY 300 TO 400 POUNDS OF AMMONIA ESCAPED. TWO EMPLOYEES OF MID-ATLANTIC CANNERS ASSOCIATION, THREE MUNICIPAL FIREFIGHTERS AND ONE TRUCK DRIVER WHO HAPPENED TO BE IN THE PLANT WERE HOSPITALIZED OVERNIGHT AND RELEASED THE NEXT MORNING. THE OTHER EMPLOYEES WHO WERE SOMEWHAT AFFECTED BY THE AMMONIA EXPOSURE WERE EXAMINED AND RELEASED THE NIGHT OF THE ACCIDENT. THERE APPEAR TO BE NO EFFECTS OF THE EXPOSURE TO ANY OF THE EXPOSED EMPLOYEES.
Keywords: eye, leak, respiratory, throat, ammonia, purging, skin, untrained
Employee # Inspection Age Sex Degree Nature Occupation
1 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
2 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
3 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
4 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
5 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
6 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
7 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
8 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
9 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
10 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
11 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
12 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
13 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
14 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
15 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
16 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
17 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
18 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
19 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
20 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
21 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported
22 10632032 Hospitalized injury Poisoning(Systemic) Occupation not reported

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