Ammonia Fatality

A Central Valley Winery

Why it is important

• It proves that anhydrous ammonia, in an outdoor release, can be fatal.

• It is not always something you can choose not to breathe

• It shows the futility of the “simple evacuation” policy that many people officially rely on.

• Forget the name of the winery, this could happen to almost anyone

Limitations

• Case occurred September, 2012. • Inspection was done by the Fresno District

office, CSHO now retired. • I reviewed the case, in preparation for appeal

with a Division attorney. • I have not actually been to the site.

Review Material

• Case file, xxxx Winery• Case file, temp agency (victim was a temp)• Police reports, narratives• Closed circuit TV of the release• Photos and information from an ammonia

consultant hired by the family.

Shell/Tube Wine Chiller

Events

• Chiller (shell and tube heat exchanger) froze, plugging tubes with frozen wine;

• Employee went to valve beneath chiller to open hot gas valve (hand wheel) to send warmer NH3 to shell/tube exchanger/chiller.

• Employee opened oil drain valve instead (hand wheel)

• Employee had opened hot gas valve “500 times”.

Human Factors

• Drain valve plug not in place (lost). • Drain valve had identical appearance and feel

to hot gas valve. (Hand wheel, same diameter)• Two valve handles 6-10 inches of each other. • Operator talking to another employee (cell

phone) while opening valve. • End of shift, midnight, dark, tired.

Hand wheels

Valves beneath chiller

Equipment factors

• When opening oil drain valve, the method is to do so gradually, on and off, till done.

• When opening hot gas valve, it is simply opened all the way.

• Employee opened drain valve 2 to 3 full turns, then walked away.

• Plug cleared, employee(s) heard a hiss and ran, yelling for others to evacuate.

Spring loaded (deadman) valve

• Could have prevented it• They had one, but not

always in place.• Connected by a hose,

when draining oil. • Present only during

planned oil draining.

Valve locks(could have prevented it)

Globe valve plug

• Could have prevented it• If it were in place• Screws in to outlet of

manual globe/ball valve.

• These things get lost.•

Environmental Factors

• Closed circuit TV shows cloud forming quickly, hugging the ground (NH3 cold, liquid). It did not rise and dissipate.

• Approx 30 ft away was an L shaped building. • Outdoors, no ceiling, building acted as barrier. • Release formed a cloud in the area against the

inside corner of the L shaped building.

Structural Factors

• There were numerous openings into the building on the inside elbow of the L shaped building.

• Some had a second exit, some were dead ends.

• Victim was in the men’s bathroom at the time of the release, a dead end.

Evidence of Panic

• “Women’s bathroom and supv’s office doors closed but not locked” (victim incapacitated)

• Victim fell face first in hallway. • Unable to self rescue due to lung spasms• “Convulsions” observed by those trying to

help him. (Lung spasms)• Break room had second exit, did not get there.

Safety Program Factors

• Coworkers tried to help, had no respirators• ER had written policy that employees would

not respond in an emergency • No rescue training. {3220(b)(4)}• No SCBA or FFAPR for NH3• No shelter in place training• No escape respirator in bathroom.• No axe to make an exit with.

Witness Statements• “I saw someone’s feet moving” (victim, prone,

on floor in hallway)• “We all tried to get back in there to try to get

him out”• “..couldn’t get in because the ammonia smell

was too strong”

Witness Statements

• “We started to look for masks but none of us could find anything” *

• “After 5 minutes…. The smell got less strong. That’s when we all went inside and got him out”

• “By this time the paramedics were arriving”

*Half masks only (So2?)

Witness Statements

• “We pulled him out in front of the office but the paramedics would not come into the plant, so we carried him out to the driveway.”

• “Joe, Raymond, Mark, Cody and Eduardo tried to save Robert.” “even tried ropes”

• “Ed found a fan“.

Time• “It was 12:10 am. “ (before valve was opened)

(estimate valve opened at 12:15)• “They were working on him” (approx 12:34

am) (he was already gone).• “At approx 1 am . Raymond called, said Robert

didn’t make it. “ • (10 minutes (?) exposure til fatal)• Time before rescue is important.

Evacuation/rescue attempts

• Employees noticed employee missing, returned to area of release.

• Employees saw victim convulsing on the floor of hallway outside bathroom.

• Several attempts were made to rescue employee without respirators, ropes, etc.

• Lack of SCBA or other FF respirator • Employees helpless

Employer’s Written Statement(in Emergency Response Program)

“XXX Wine Company is not subject to Title 8 CCR § 5192 (q) Hazardous Waste Operations and

Emergency Response because in the event of an emergency response, XXX Wine Company willevacuate their employees from the danger area and will not permit any of their employees to

assist in handling the emergency (see §5192(q)(1)”

Other ER Statements

“ In event of emergency, the plant manager will contact: Fire DepartmentThe plant manager will insure that the entire plant is evacuated.Supervisor will assist anyone who needs help evacuating the building.” (How are you going to do that, with no respirator?)

The “Simple Evacuation” policy: Where did it come from?

• An attorney?• A consultant?• Joe the fireman?• A Hazmat person?• The Ammonia industry?• Our doctor?• It came from OSHA

Feds vs. DOSH (no difference)

5192(q)(1)• Employers who will evacuate

their employees from the danger area when an emergency occurs, and who do not permit any of their employees to assist in handling the emergency, are exempt from the requirements of this subsection if they provide an emergency action plan in accordance with 8 CCR 3220.

29 CFR 1910.120 (q)(1)}

• Employers who will evacuate their employees from the danger area when an emergency occurs, and who do not permit any of their employees to assist in handling the emergency, are exempt from the requirements of this paragraph if they provide an emergency action plan in accordance with 29 CFR 1910.38.

1910.120 (Hazwoper) Preamble

• “an exemption from this paragraph if the employer totally evacuates the facility at the time of the emergency and has an emergency action plan meeting the requirements of 29 CFR 1910.38(a). “…

• (Same as 3220 (b) and includes rescue and medical duties)

Hazwoper Preamble (intent)

• “OSHA will still permit an exemption from this paragraph if the employer totally evacuates the facility at the time of the emergency and has an emergency action plan meeting the requirements of 29 CFR 1910.38(a). “

3220 (b) minimum elements

• (1) Emergency escape procedures and emergency escape route assignments;

• (2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate;

• (3) Procedures to account for all employees after emergency evacuation has been completed;

• (4) Rescue and medical duties for those employees who are to perform them;

Missing EAP Element:

29 CFR 1910.38(c)(5)

• “Procedures to be followed by employees performing rescue or medical duties;”

T8 CCR 3220(b)(4)

• “Rescue and medical duties for those employees who are to perform them;”

“Who are to perform them”

• “Who is to perform rescue duties?”• The answer, with many employers: NO ONE. • “Our employees will not perform rescue. They

will simply evacuate and wait for the fire department. “

• But they will not evacuate if they cannot evacuate.

Another 3220 requirement

• 3220(e)(1) “the employer shall designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees.”

• How are you going to do that with no respirator?

Waiting for Fire Dept

• Takes too much time (ten minutes til death)• Fire department will arrive to find a body. • Paramedics arrived after victim was dead and

refused to enter the building. • In effect this policy statement means: Call the

Coroner. • This policy is a “let them die” policy.

What could be done?

• For dead ends: – Escape SCBA in bathroom,. – An axe mounted on the wall. – Shelter in place training.

• 2 SCBA onsite, near but away from potential exposure location.

• 2 employees/shift trained in SCBA, fit tested. • Practice the Collar drag rescue.

Escape tools

5-10 minute escape air Back door maker

Shelter in place kit

• Things you might need to shelter in place

• Tape vents shut, sinks, overhead

• Stuff wet towels under doors.

• Fill a bag with relatively clean air and seal it.

Nice things to have around

Simple rescue (collar drag)

Applicable Regulations

• It is an IDLH environment {(5144(g)(3)}• It requires 2 SCBA wearers, one inside, one

outside. • It is not a confined space, with difficult access

or egress. • It does not require Two in, Two out (It is not

“interior structural firefighting”.{5144 g4}

Harmful Exposure

• 5140 ..is of such a nature by inhalation as to result in, or have a probability to result in, injury, illness, disease, impairment, or loss of function.

• It is a harmful exposure. • 5141( c) “Harmful exposure” shall be

prevented …..by use of respirators.

Applicable regs, contd.

• 5144(c) Respiratory protective equipment…shall be used to prevent harmful exposures in emergencies

• 5144 c 1 D: Program must include: procedures for .. use of respirators in … reasonably foreseeable emergency situations

“2 in 2 out” is not required

• {5144 (g)(4)} Procedures for interior structural firefighting.

• (A) At least two employees enter the IDLH atmosphere and remain in visual or voice contact with one another at all times;

• (B) At least two employees are located outside the IDLH atmosphere; …

• 2 in 2 out For “interior structural firefighting “ only.

Is Hazwoper required?

• Is it emergency response?

• Would a rescue activity by employees meet the definition of emergency response?

• Must they be given Hazwoper training?

• An arguable point.

• The release is not just an incidental release.

• Find a course that is specific to ammonia and rescue.

What kind of Hazwoper training?

• 24 hours Haz Mat Technician training required for those who “respond to releases……for the purpose of stopping the release.”

• Don’t try to stop the release. Wait for the fire department on that. Just rescue and evacuate

• First Responder, Operations Level (FRO):

First Responder Ops Level

• First Responder, Operations Level (FRO): • These people “respond to releases……for the

purpose of protecting nearby persons, from the effects of the release”

• “They are trained to respond in a defensive fashion without actually trying to stop the release.”

Is it emergency response or EAP?

• It is not an effort to stop the release.• It is not an effort to “handle” the emergency. • It is a rescue. An evacuation. • Rescue, evacuate and then wait. • 8 hours Hazwoper plus SCBA training.

Emergency response definition{5192 a 3}

Is a response• from outside the immediate release area • by employees or by other designated responders

(i.e., mutual aid groups, local fire departments, etc.)

• to an occurrence which results, or is likely to result, in an uncontrolled release,

• which may cause high levels of exposure to toxic substances, …..

Definition of emergency response, contd.

• Responses to incidental releases of hazardous substances where the substance can be absorbed, neutralized, or otherwise controlledat the time of release -by employees in the immediate release area, or by maintenance personnel are not considered to be emergency responses within the scope of this standard.

The key word is controlled.

Incidental Release?

• An incidental release is one that does not cause a health or safety hazard to employees and does not need to be cleaned up immediately to prevent death or serious injury to employees. {5192 a 3}

• An uncontrolled anhydrous ammonia release can cause death or serious injury.

.

A possible interpretation

• 5192 (q)(1) exception does not apply unless EAP is in accord with 3220.

• EAP (8 CCR 3220) (for acutely hazardous releases) must include rescue procedures.

• ER must evacuate and rescue, if necessary, then wait for fire department to “handle” the release .

• Employer is responsible for evacuating/rescuing its employees before Fire Department comes.

Is Anhydrous Ammonia a Serious hazard?

Some haz-com training. says:• “Ammonia has a built in safety factor. You

can’t stand to breathe it”. • Sometimes there isn’t much of a choice. • When you do breath a concentrated amount,

your lungs spasm and you cannot control your breathing.

Manual of Pharmacology, W. E.Dixon

• Irritation of the nasal mucous membrane with such irritant substances as ammonia … may produce….

• 1. sneezing, coughing; • 2. closure of the glottis; • 3. arrest or slowing of the respiration; • 4. cardiac inhibition; • 5. vaso-constriction; • 6. bronchial constriction.• (anosmia) = loss of sense of smell

Bronchoconstriction

• the constriction of the airways in the lungsdue to the tightening of surrounding smooth muscle, with consequent coughing, wheezing, and shortness of breath.

• Built in Safety factor?• How many seconds do you have after one big

whiff?

Suggestions: Breathing air for rescue

• Have 2 emergency SCBA onsite ready to use. • Monthly inspections, 90% full• Fit test and train two people on each shift one

to don the SCBA and perform rescue, other wait outside

• Drag the victim out (collar drag). • Practice dragging someone on a regular basis.

What Does IIAR say?

“ Every machinery room shall have a self contained breathing apparatus located outside of, but close to, the exit door. A second, backup, self contained breathing apparatus shall also be provided. {IIAR Bulletin 109 10/97}

Is this required by the PSM std?

• Is IIAR a recognized and generally accepted good engineering practice?

• Are these two SCBAs, located just outside the the machinery room considered “equipment”? Are they a “safety system”?

Equipment, safety systems

• 5189 (d)(3)(B): The employer shall document that the equipment complies with the criteria established in subsection (d)(3)(A) in accordance with recognized and generally accepted good engineering practices.”

• (d)(3)(A) includes: “information pertaining to equipment in the process”

• (d)(3)(A)8. includes “Safety systems (such as interlocks, detection and suppression systems, etc.);

Liability

• The purpose of an employer’s emergency action plan is to save lives.

• All employees must be evacuated or the exception in 5192 (q)(1) does not apply.

• A legal disclaimer of liability is a wall of tissue paper. Does nothing to save lives.

• When is liability the highest?• When someone dies.