OSHA Accident Investigation · Summary #14538276
RESPIRATORY,VAPOR,AMMONIA,GAS LEAK,EVACUATION
Event description
EMPLOYEE OVERCOME BY AMMONIA VAPORS
Investigation abstract
THE BOLTS WHICH SECURE THE BOTTOM PLATE OF A STRAINER IN THE HOT AMMONIA DEFROST AMMONIA. LINE FAILED. CONSEQUENTLY, A RELEASE OF PRESSURIZED AMMONIA OCCURRED. THE LINE WAS LOCATED IN ROOM 260. EMPLOYEE #1, WHO WAS UNAWARE OF THE RELEASE AND THE ONG OING EVACUATION, PROCEEDED TO TAKE AN ELEVATOR FROM THE BASEMENT UP TO THE LEAK AREA. IN THE LEAK AREA, EMPLOYEE #1 WAS EXPOSED TO THE AMMONIA VAPOR AND EXPERIE NCED SEVERE RESPIRATORY DISCOMFORT. HE WAS ABLE TO LEAVE THE AREA UNDER HIS OWN POWER BUT COLLAPSED ONCE HE REACHED THE OUTSIDE OF THE BUILDING. ANOTHER RECENT AMMONIA LEAK AT A NEIGHBORING PLANT RESULTED IN A FATALITY. THESE INSTANCES INDI CATE THAT PROPER PRECAUTIONS ARE NOT BEING TAKEN TO PROTECT THOSE WHO WORK WITH
Victim
-
#1 Hospitalized Age 49 M
- Nature of injury
- 2
- Part of body
- 28
- Event type
- 8
- Source
- 9
- Occupation code
- 999
- Human factor
- 4
- 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.