OSHA Accident Investigation · Summary #1001122

JOHN MORRELL & COMPANY

SIOUX CITY, IA· 1986-03-18T09:30:00

Event: LEAK, TOXIC FUMES, GAS LEAK, AMMONIA, INHALATION, NAUSEA
NAICS: 000000
Inspection type: Accident-driven
Activity number: #101923332
Employer profile: JOHN MORRELL & COMPANY
Summary number: 1001122
Report ID: 751910

Event description

AMMONIA LEAK RESULTED IN AMMONIA EXPOSURE FOR 31 EMPLOYEES

Investigation abstract

ON MARCH 18, 1986, AT APPROXIMATELY 9:30 AM, EMPLOYEES #1-#10 WERE WORKING AT TH TO THE HOSPITAL AND ONCE IN THE HOSPITAL, BUT WAS REVIVED BOTH TIMES. EMPLOYEES #30 AND #31 WERE NOT HOSPITALIZED, BUT VISITED THE COMPANY DOCTOR. THE AMMONIA EXPOSURE WAS CAUSED BY A BROKEN PIPE IN THE COOLER. THE LEAKING AMMONIA WAS CARR IED BY THE PLANT'S VENTILATION SYSTEM TO THE WORK AREAS OF EMPLOYEES #1 - #31. EIR REGULAR JOBS ON THE CUT FLOOR (CONVERSION LINE). THE CUT FLOOR IS LOCATED AP PROXIMATELY 40 FEET AWAY FROM A COOLER IN WHICH AN AMMONIA LEAK HAD OCCURRED THE DAY BEFORE (MARCH 17TH). EMPLOYEES #1 THROUGH #10 BEGAN EXPERIENCING CHEST PAIN S, SHORTNESS OF BREATH AND DIFFICULTY IN BREATHING AND WERE SENT TO THE HOSPITAL . AT 11 AM THE REMAINING EMPLOYEES WERE EVACUATED. MANAGEMENT TOLD EVERYONE TO R ETURN TO WORK AT 12 NOON. AT 12:28 AMBULANCES WERE AGAIN SUMMONED, AND EMPLOYEES #11 THROUGH #29 WERE SENT TO THE HOSPITAL. THESE EMPLOYEES EXPERIENCED THE SAME SYMPTOMS AS EMPLOYEES #1 THROUGH #10. EMPLOYEE #20 STOPPED BREATHING ON THE WAY

Victims (34)

#1 Hospitalized Age 31 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#10 Hospitalized Age 33 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#11 Hospitalized Age 33 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#12 Hospitalized Age 32 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#13 Hospitalized Age 21 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#14 Hospitalized Age 40 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#15 Hospitalized Age 34 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#16 Hospitalized Age 42 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#17 Hospitalized Age 25 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#18 Hospitalized Age 35 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#19 Hospitalized Age 32 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#2 Hospitalized Age 23 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#20 Hospitalized Age 21 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#21 Hospitalized Age 39 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#22 Hospitalized Age 39 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#23 Hospitalized Age 27 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#24 Hospitalized Age 25 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#25 Hospitalized Age 23 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#26 Hospitalized Age 27 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#27 Hospitalized Age 27 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#28 Hospitalized Age 34 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#29 Hospitalized Age 24 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#3 Hospitalized Age 30 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#30 Non-hospitalized injury Age 35 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#31 Hospitalized Age 21 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#4 Hospitalized Age 27 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#5 Hospitalized Age 40 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#6 Hospitalized Age 33 M

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#7 Hospitalized Age 31 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#8 Hospitalized Age 56 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#9 Hospitalized Age 33 F

Nature of injury
21

Part of body
28

Event type
8

Source
9

Occupation code
999

Human factor
1

Environmental factor
7

Hazardous substance
0170

Task assigned
1
#981 Degree 0 Age 0

Nature of injury
0

Part of body
0

Event type
0

Source
0

Occupation code
0

Human factor
0

Environmental factor
0

Task assigned
0
#982 Degree 0 Age 0

Nature of injury
0

Part of body
0

Event type
0

Source
0

Occupation code
0

Human factor
0

Environmental factor
0

Task assigned
0
#983 Degree 0 Age 0

Nature of injury
0

Part of body
0

Event type
0

Source
0

Occupation code
0

Human factor
0

Environmental factor
0

Task assigned
0

Codes shown verbatim from OSHA's accident-investigation database. A human-readable decoder is coming in a future release once the accident_lookup2 dictionary is loaded.