Ammonia gas and highly concentrated ammonia liquids spurted out from a flare piping in the southeast corner of the plant after the flare was extinguished.

Proximate causes:
• Inadequate tools, equipment & vehicles (Mal-function of Ammonia compressor);
• Inadequate training/knowledge transfer
• Lack of communication (hazards identification and communication)
• Lack of work rules/policies/ standards/procedures

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Millenium Post