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Incident Investigation Report I. Incident Description Release Incident Title Type of Release ID HPR Leak Ammonia INC-2315 Date of Release Incident Date Investigation Began Date of Report Incident Investigation Team Leader 04/13/2021 04/13/2021 04/13/2021 Kevin Pelletier Incident Investigation Team Membership with Company Title and Function Kevin Pelletier - Martin Brower General Manager Casey Hays - Martin Brower Quality Manager Dennis Silva - Martin Brower Compliance Manager Joe Diniz - Martin Brower Human Resource Manager Injuries or Property Damage None NAICS Code Chemical Released Quantity Released (lbs.)Reported 49312 Ammonia 13 No 1.1 Location, Rate, Time and Duration Please include specific descriptions of impacts on and or offsite affected by the incident, when the incident was first detected or reported, and how long it lasted. Location: Roof of ammonia room Release Qty (rate/duration): Qty:13Lbs / Rate:0.84 / duration:15 minutes 1.2 Circumstances Leading up to Incident Briefly describe the operating conditions just prior to the incident including loads, pressures, weather, equipment status, etc. Note who was in charge and whether or not there were any abnormal circumstances or early indications of a problem. Tom Prokes arrived for a regular inspection. The wind direction was the reason ammonia was detected. 1.3 Events and Actions as Incident Unfolded Provide a chronology of events including who discovered the incident, how it was reported, how it was responded to, and how and when it was brought under control. Tech: THOMAS G PROKES, Date: 4/13/21 1:52 PM - The condenser was cleaned today. Upon restart, found the top sight glass was leaking a small amount of ammonia vapor to V1. Attempted to isolate the column and the bottom valve has an issue, it will not close. Something is broken internally. Will need to step back and develop a plan to repair this. Will get the ball rolling on this right away. No evacuation needed. 1.4 Assessment of Root Cause Outline the Team's consensus view of the underlying cause of the incident. If there are multiple hypotheses that cannot be ruled out, they should also be included. This should be the condition or event which started the sequence of events which resulted in the near-miss or actual incident. Gasket deteriorated and needs replacement. 1.5 Assessment of Additional Contributing Causes List conditions, actions, or events which contributed to the seriousness of the incident or which should have, but did not, mitigate the effects of the root cause. Comment specifically on the following preventive elements of the PSM standard. Incident was less serious than it could have been due to good inspection and maintenance practices. Was the design of the system, including materials of construction, adequate?Yes No Was the management system in place adequate and functioning effectively to prevent an unintentional release?Yes No Did the Process Hazard Analysis adequately address the root causes of the release incident?Yes No Were the Standard Operating Procedures properly prepared and were they being followed when the release incident occurred? Yes No Was the training received by the operators involved adequate with current records in place to verify that training had been received and understood? Yes No Was a preventive maintenance program deficiency a contributing factor in this release?Yes No Was a pre_startup review deficiency a contributing factor in this release?Yes No Was a management of change deficiency a contributing factor in this release?Yes No Was the emergency response staffing, procedures, and/or training a contributing factor to injuries or property loss in this release? Yes No