August, 2010

This is a repeating event

201023AugAll DayMillard Refrigerated Services Toxic Release 2010Millard Refrigerated Services Theodore (US-AL) Origin: CSB Lessons:Emergency Preparedness,Process Knowledge,Risk Assessment,Stakeholder EngagementIndustry:WarehouseCountry:United StatesLanguage:ENLoC:Deficiency

Summary

On August 23, 2010, at the Millard Refrigerated Services facility in Theodore, Alabama, hydraulic shock caused a roof-mounted 12-inch suction pipe to catastrophically fail leading to the release of more than 32,000 pounds of anhydrous ammonia. The hydraulic shock was enabled during the restart of the plant’s ammonia refrigeration system following a 7-hour power outage. In addition to the catastrophic failure of roof-mounted piping, the pressure developed by the hydraulic shock event also caused an evaporator coil inside the facility to rupture.

The ammonia cloud released from the roofmounted pipe and travelled 0.25 miles across the river adjacent to the plant. Downwind of the ammonia release were crew members on the ships docked at Millard and over 800 contractors working outdoors at a clean-up site for the Deepwater Horizon oil spill. One Millard employee sustained injuries after briefly losing consciousness from ammonia inhalation. Nine ship crew members and 143 of the offsite contractors downwind reported exposure. Of the exposed victims, 32 required hospitalization, and 4 were placed in intensive care.

KEY ISSUES:
• REFRIGERATION SYSTEM DESIGN
• REFRIGERATION SYSTEM OPERATION
• RESPONDING TO AN AMMONIA RELEASE

ROOT CAUSES:
• Likely a result of condensation-induced shock, vapor-propelled liquid, or a combination of both.


Image credit: CSB

Origin

CSBUS Chemical Safety Board

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