Lessons Learned from Accidental Ammonia Releases

IRC Research & Technology Forum

May 10-11, 2017

M. Kent Anderson President Emeritus, IIAR

Past Chair, ASTI

Why is ammonia regulated? Are ammonia refrigeration accidents common/significant? Can lessons be learned from accidental releases that will prevent future incidents?

Introduction and Overview

Is this a code and regulatory compliant

ammonia machinery room?

Natural

ventilation!

Is ammonia toxic, highly toxic, hazardous, extremely hazardous? Is ammonia flammable, explosive, reactive? Are chemical safety and security regulations relevant, appropriate and necessary for ammonia?

Why is ammonia regulated?

“It depends on what the definition of “IS” is”! - William Jefferson Clinton

DEFINTIONS ARE CRITICAL! Ammonia may or may not be toxic, highly toxic, hazardous, highly hazardous, a Toxic Industrial Chemical (TIC), a Toxic Inhalation Hazard (TIH), etc. depending on the criteria. Ammonia may or may not be flammable, explosive, etc. depending on the definition and method of test. Generally, ammonia does NOT meet most of the regulatory criteria. Ammonia is regulated because of accidents that caused fatalities and injuries.

The answer is:

REGULATORY HISTORY

Why is ammonia regulated?

Regulatory History

• Major Accidents – Titanic (April 1912)

– Flixborough (June 1974)

– Seveso (July 1976)

– Love Canal (1978)

– Times Beach (1982)

– Bhopal (December 1984)

– West, TX (April 2014)

• Regulations – OSHA (1970)

– RCRA (1976)

– CERCLA (1980)

– SARA Title III / EPCRA (1986)

– Clean Air Act

Amendments (1990)

– Executive Order 13650 (2014)

Ammonia Regulations

• Environmental

– EPCRA / SARA Title III

– Risk Management Program (RMP)

• Safety

– Process Safety Management

– PPE / HAZWOPER / Confined Space / Lock Out – Tag Out

• Transportation

• Homeland Security

– Chemical Facility Anti-Terrorism Standards (CFATS)

– Maritime Transportation Security Act (MTSA)

• The Future????

The Future of Regulation and Emergency Planning

• Critical Infrastructure / Key Resources – Sabotage

– Release

– Theft and Diversion

• “All Hazards Approach”

• Business Continuity / Resiliency

Are ammonia accidents and incidents common? Can ammonia refrigeration accidents cause significant consequences: fatalities, injuries, property damage, off-site consequences, environmental damage, etc.? Are there common/typical incidents that have broad applicability? Can incidents be prevented?

Ammonia accidents and incidents

YES!!!

The answer is:

Significant Ammonia Accidents

• Crete, NE (1969)

- Rail car, 90 Tons, 9 dead, 53 injured

• Potchefstroom, South Africa (1973)

- Storage vessel, 38 Tons, 18 dead, 65 injured

• Hutchinson, KS (1976)

- Pipeline, 350 Tons, 4 dead

• Houston, TX (1976)

- Tanker truck, 19 Tons, 6 dead, 200 injured

Terra Nitrogen

Sioux City, IA

• December 1994

• AN process explosion

• 5,700 Ton release

• 4 dead

Minot, ND

• January 2002

• Rail car derailment

• 5 tank cars ruptured

• 146,700 gal release

• 1 dead, 11 injuries

• 1 car travelled 1,200’

• +74,000 gal released

over the next 6 days

2009 was a bad year for ammonia accidents!

• 5-13-2009, American Cold Storage, Louisville, KT (ammonia refrigeration) – 2 worker fatalities

• 6-20-2009, Mountaire Farms’, Lumber Bridge, NC (ammonia refrigeration) – 1 worker fatality

• 7-15-2009, Tanner Industries, Swansea, SC (transportation) – 1 public fatality

• 11-16-2009, CF Industries, Rosemont, MN (transportation) – 2 driver fatalities

Ammonia Refrigeration Accidents

Recent examples

Refrigeration NH3 Release – 08/2010

Accident /Safety Triangle*

* H. W. Heinrich, “Industrial Accident Prevention”, 1931

Frank E. Bird, Jr., “Practical Loss Control Leadership”, 1985

Accident Indicators

• Lead Indicators –Proactive evaluation

• Lag Indicators –Learn from experience

• Use both –Realistic and reasonable

NH3 Accident Research

Collaboration with CSB

• OSHA database • EPA RMP database` • Federal regulatory search (HSEES/HMIS)

• State regulatory search

OSHA DATA ANALYSIS

Integrated Management Information System (IMIS)

• Fatality and Catastrophe Investigation Summaries (FAT/CAT)

• OSHA 170 form

• https://www.osha.gov/pls/imis/accidentsearch.html

• Search for keyword: “Ammonia”

OSHA Database 1995-2004

• Over 60 inspections into ammonia

incidents

– Over 40 involving ammonia refrigeration

– Less than 10 involving agricultural areas

Ammonia Refrigeration Accident Causes – OSHA (1995-2004)

Equipment Failure

40%

Damaged Piping

9%

Human Error

3%

Maintenance

33%

Over pressurization

2%

Power Failure

2%

Plane Crash

2%

Miscellaneous

9%

Equipment Failure

Damaged Piping

Human Error

Maintenance

Overpressurization

Power Failure

Plane Crash

Miscellaneous

“Top 10” PSM Citations

• Operating Procedures, F(1) - Written procedures

• PHA, E(1) - Appropriate PHA/prioritization

• Mechanical Integrity, J(2) - Written procedures

• Training, G(1) - Initial training

• Contractors, H(2) - Contractor evaluations

• Employee Participation, C(1) - Participation plan

• Process Safety Information, D(3) - Equipment info

• Management of Change, L(1) - Written procedures

• Mechanical Integrity, J(4) - Inspection/testing

• Process Safety Information, D(2) - Technical info

RMP DATA ANALYSIS

RMP DATA ANALYSIS

EPA Risk Management Program (RMP)

• 5-year Accident History (Section 6)

• ORMP*Review data base

• http://www.rtk.net/rmp/search.php

• http://www.toxicrisk.com/search/ (not active)

• EPA Public Reading Rooms

Ammonia

43%

Chlorine

24%

Propane

8%

Flammable

Mixture

5%

Sulfur Dioxide

4%

Other

16% Ammonia

Chlorine

Propane

Flammable

Mixture

Sulfur Dioxide

Other

RMP Database

Top 5 Chemicals

RMP Database 1994-2013

• 7,619 RMP covered facilities with reportable ammonia inventory (9,400 – 2004)

• Over 2,000 incidents involving ammonia (57%)

(1,200 – 2004)

• Over 1,200 Ammonia refrigeration incidents

(600 in 2004)

Ammonia is THE #1: RMP/PSM/CFATS Covered Chemical

Chemical for RMP 5-year Accident History

RMP Ammonia Incidents by Ammonia End Use

1994-2004

643

367

136

76

Refrigerant Use

Agricultural Use

Chemical Use

Miscellaneous

RMP Ammonia Incidents by NAICS Industrial Classification

1994-2004

0

100

200

300

400

500

600

FoodManufacturing

Wholesaler Trade ChemicalManufacturing

RefrigeratedWarehouse

Miscellaneous

RMP AMMONIA RELEASES TOP 10 LIST – By Amount

Quantity (lbs) NAICS Release Date

109,040 31152 Mar-27-1999

75,000 311611 Jan-21-1997

40,000 (aqua) 48422 Apr-18-2003

33,000 311612 Nov-17-2003

32,110 49312 Aug-23-2010

30,000 31161 Jan-30-1995

27,677 (aqua) 31193 Apr-11-2003

27,000 311615 Dec-19-1995

24,000 311813 Jul-30-1996

21,660 311611 Feb-02-2014

21,000 49312 Aug-3-2004

20,080 311615 Nov-03-1997

20,000 311612 Jul-26-1998

RMP AMMONIA RELEASES TOP 10 LIST – By NAICS

NAICS Code NAICS Description # Releases %

311615 Poultry Processing 185 14.8%

49312 Refrigerated Warehousing and Storage 184 14.7%

311612 Meat Processed from Carcasses 95 7.6%

311611 Animal (except Poultry) Slaughtering 94 7.5%

311411

Frozen Fruit, Juice, and Vegetable

Manufacturing 75 6.0%

311511 Fluid Milk Manufacturing 59 4.7%

31152

Ice Cream and Frozen Dessert

Manufacturing 56 4.5%

31141 Frozen Food Manufacturing 31 2.5%

31151

Dairy Product (except Frozen)

Manufacturing 30 2.4%

1,253 Total Releases

RMP Ammonia Refrigeration Release Sources (1994-2013)

1,253 Total Releases

437

332

375

102 66 54 56

23

0

100

200

300

400

500

Valve Piping Other

Release

Source

Process

Vessel

Pump Storage

Vessel

Joint Transfer

Hose

RMP Ammonia Refrigeration Reasons for Release (1994-2013)

688

371

243 184 183

133 73 70

35 30 30 11 0

100

200

300

400

500

600

700

800

1,253 Total Releases

Ammonia Refrigeration RMP Incident Fatalities (1994 – 2013)

0

4

8

12

16

20

Worker Deaths* Responder Deaths Public Deaths

16

1 1

Ammonia Refrigeration RMP Incident Injuries (1994-2013)

0

250

500

750

1,000

1,250

1,500

Worker Injuries Responder Injuries Public Injuries

1,369

11 84

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

0 1000 2000 3000 4000 5000 6000 7000

Co

nc

en

tra

tio

n (

pp

m)

Distance from source (yards)

ALOHA Concentration vs. Distance 60 min release, 20% flash, Gaussian, worst conditions

10,000 lbs = 2,000 lbs flash gas / 60 min (33.3 lb/min)

1,000 lbs = 200 lbs flash gas / 60 min (3.33 lb/min)

100 lbs = 20 lbs flash gas / 60 min (0.33 lb/min)

100,000 lbs = 20,000 lbs flash gas / 60 min (333.3 lb/min)

1/2 IDLH

Model not accurate

below ~ 50 yards

RMP Ammonia Releases Off-Site Consequences

Total Ammonia Refrigeration Incidents = 1,253

(644 in 2004)

Total Incidents with an Off-site Impact = 122 (19%)

• Avg Inventory = ~50,000 lbs

• Avg Release = 3,314 lbs (6.6%)

• Avg Length of Release = 119 minutes

• Avg Release rate = 27.8 lbs/minute

HIGH-RISK SYSTEM COMPONENTS

Defrost condensate return lines

Oil transfer or drain lines

Hot gas pressurization or heating lines

Pump-out, vent or equalization lines

Oil pots

Pumper drums

Other

SOME COMPARISONS

RMP Incidents / Facility By Chemical

12% 13%

19%

46% 50%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Butane Ammonia Chlorine Phosgene HF

Average Injury/Fatality per Incident by Chemical

0.8

1.1

1.3 1.3

1.6

0.0 0.0 0.0

0.2 0.1

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

Ammonia Chlorine HF Butane Phosgene

Worker Injury

Worker Death

RMP Data Ammonia Refrigeration Incidents

1994-2013

32

69

87

95

107

70

58 52

68

57 53

61

49

84

62

71

64

47 42

22

0

20

40

60

80

100

120

1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Conclusions

• Ammonia has highest # of incidents; highest # of covered facilities (RMP) – Other chemicals have a higher incident rate and

greater impact per incident

• 60 percent of ammonia incidents = ammonia refrigeration – Much industry guidance and state/local regulation

• Most ammonia accidents are preventable!!!!!