OSHA Accident Investigation · Summary #14295398
RESPIRATORY,INHALATION,ANHYDROUS AMMONIA,VALVE,GAS LEAK
Event description
EXPOSED TO ANHYDROUS AMMONIA VAPORS
Investigation abstract
AN EMPTY 150 POUND ANMONIA CYLINDER, ONE OF TWO MANIFOLDED TO A WHITEPRINT MACHI ISOLATION VALVE WAS OPENED IS NOT KNOWN. THREE COUNTY EMPLOYEES AND THE DRIVER W ERE TAKEN TO A NEARBY HOSPITAL, EXAMINED AND RELEASED WITHOUT TREATMENT. THE PRO CEDURE HAS BEEN CHANGED TO INCLUDE REMOVING THE YOKE AND CAPPING THE EMPTY CYLIN DER AT THE TIME THE SHIFT IS MADE TO A FULL CYLINDER. CONSIDERATION IS ALSO BEIN G GIVEN TO INSTALLING A CHECK VALVE IN EACH DISCHARGE LINE. THIS WOULD PREVENT B ACKFLOW IN CASE THE ISOLATION VALVE IS ACCIDENTALLY OPENED AFTER THE YOKE HAS BE EN REMOVED. NE, WAS BEING EXCHANGED FOR A FULL ONE. THE DRIVER/DELIVERER, AFTER BEING TOLD W HICH CYLINDER WAS EMPTY, ASSUMED IT WAS READY TO BE REMOVED AND UNSCREWED THE T- HANDLE ON THE CYLINDER YOKE FITTING. AMMONIA MIST WAS UNEXPECTEDLY RELEASED, RES ULTING IN RAPID EXCAVATION OF THE ROOM, EXCEPT FOR THE DRIVER. HE STAYED FOR 15 TO 20 SECONDS TO SCREW DOWN THE YOKE AND STOP THE LEAK, THEN LEFT. THE EMPLOYEE ASSISTING THE DRIVER ASSUMED THAT THE CYLINDER VALVE AND MANIFOLD ISOLATION VALV E WERE CLOSED, AS IS CUSTOMARY. IN FACT, THE DEPARTMENT SUPERVISOR DECLARED THAT HE SHUT BOTH VALVES THE DAY BEFORE, WHEN HE SHIFTED TANKS. WHY AND BY WHOM THE
Victims (4)
-
#1 Hospitalized Age 37 M
- Nature of injury
- 21
- Part of body
- 31
- Event type
- 14
- Source
- 19
- Occupation code
- 307
- Human factor
- 11
- Environmental factor
- 7
- Hazardous substance
- 0170
- Task assigned
- 1
-
#2 Hospitalized Age 32 M
- Nature of injury
- 21
- Part of body
- 31
- Event type
- 14
- Source
- 19
- Occupation code
- 347
- Human factor
- 11
- Environmental factor
- 7
- Hazardous substance
- 0170
- Task assigned
- 1
-
#3 Hospitalized Age 33 M
- Nature of injury
- 21
- Part of body
- 31
- Event type
- 14
- Source
- 19
- Occupation code
- 347
- Human factor
- 11
- Environmental factor
- 7
- Hazardous substance
- 0170
- Task assigned
- 1
-
#4 Hospitalized Age 26 M
- Nature of injury
- 21
- Part of body
- 31
- Event type
- 14
- Source
- 19
- Occupation code
- 805
- Human factor
- 11
- Environmental factor
- 7
- Hazardous substance
- 0170
- Task assigned
- 1
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.