104,543Records 70,659Employers 84,666Hospitalizations 27,563Amputations 2015-01-01 2025-09-30
Safety Incidents OSHA Severe Injury Reports · 2015–2025

OSHA Accident Investigation · Summary #14560031

EYE,LEAK,RESPIRATORY,THROAT,AMMONIA,PURGING,SKIN,UNTRAINED

Event
EYE,LEAK,RESPIRATORY,THROAT,AMMONIA,PURGING,SKIN,UNTRAINED
Linked inspection
No inspection record linked to this accident's victims.
Summary number
14560031
Report ID
112600

Event description

EXPOSED TO AMMONIA GAS FROM LEAKING REFRIGERATION SYSTEM

Investigation abstract

AT APPROXIMATELY 7:20 PM ON AUGUST 29, 1984, EMPLOYEE# 1 STARTED TO PURGE THE OI DEFECTIVE AMMONIA GAS MASKS) ALSO FAILED. SUPERVISORS THEN ACTIVATED THE EVACUA TION PLAN. BEFORE EVACUATION BEGAN, AND DURING EVACUATION, MANY OTHER EMPLOYEES WERE EXPOSED TO THE AMMONIA GAS, WHICH HAD DIFFUSED THOUGHOUT THE PLANT. EVENTUA LLY MUNICIPAL FIREFIGHTERS WITH SCBA'S TURNED OFF THE VALVE. APPROXIMATELY 300 T O 400 POUNDS OF AMMONIA ESCAPED. TWO EMPLOYEES OF MID-ATLANTIC CANNERS ASSOCIATI ON, THREE MUNICIPAL FIREFIGHTERS AND ONE TRUCK DRIVER WHO HAPPENED TO BE IN THE PLANT WERE HOSPITALIZED OVERNIGHT AND RELEASED THE NEXT MORNING. THE OTHER EMPLO YEES WHO WERE SOMEWHAT AFFECTED BY THE AMMONIA EXPOSURE WERE EXAMINED AND RELEAS ED THE NIGHT OF THE ACCIDENT. THERE APPEAR TO BE NO EFFECTS OF THE EXPOSURE TO A NY OF THE EXPOSED EMPLOYEES. L FROM AN AMMONIA GAS REFRIGERATION SYSTEM AT A SOFT DRINK BOTTLING PLANT. IT WA S THE FIRST TIME HE HAD ATTEMPTED THIS PROCEDURE AND HE HAD NOT BEEN PROPERLY TR AINED. HIS PURGING TECHNIQUE WAS FAULTY, CAUSING HIM TO ACCIDENTALLY RELEASE A L ARGE AMOUNT OF ANHYDROUS AMMONIA INTO HIS BREATHING ZONE. HE WAS MOMENTARILY BLI NDED 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 ROO M. SUBSEQUENT ATTEMPTS BY EMPLOYEES ONE THROUGH EIGHT TO RE-ENTER THE ROOM (WITH

Victims (22)

  1. #1 Hospitalized Age 32 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  2. #10 Hospitalized Age 29 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  3. #11 Hospitalized Age 39 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  4. #12 Hospitalized Age 33 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  5. #13 Hospitalized Age 31 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  6. #14 Hospitalized Age 21 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  7. #15 Hospitalized Age 22 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  8. #16 Hospitalized Age 20 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  9. #17 Hospitalized Age 30 F

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  10. #18 Hospitalized Age 40 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  11. #19 Hospitalized Age 40 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  12. #2 Hospitalized Age 38 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  13. #20 Hospitalized Age 50 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    19
    Environmental factor
    7
    Hazardous substance
    0170
    Task assigned
    2

  14. #21 Hospitalized Age 35 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    19
    Environmental factor
    7
    Hazardous substance
    0170
    Task assigned
    2

  15. #22 Hospitalized Age 35 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    19
    Environmental factor
    7
    Hazardous substance
    0170
    Task assigned
    2

  16. #3 Hospitalized Age 53 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  17. #4 Hospitalized Age 30 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  18. #5 Hospitalized Age 22 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  19. #6 Hospitalized Age 32 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  20. #7 Hospitalized Age 28 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  21. #8 Hospitalized Age 31 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

  22. #9 Hospitalized Age 43 M

    Nature of injury
    17
    Part of body
    28
    Event type
    8
    Source
    19
    Occupation code
    999
    Human factor
    18
    Environmental factor
    8
    Hazardous substance
    0170
    Task assigned
    2

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