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Incident Investigation Report I. Incident Description Release Incident Title Type of Release ID Pallet Entrance HCR Door Flange Ammonia Vapor INC-2300 Date of Release Incident Date Investigation Began Date of Report Incident Investigation Team Leader 3/31/2021 3/31/2021 3/31/2021 Ben Schlegelmilch Incident Investigation Team Membership with Company Title and Function Ben Schlegelmilch - Engineering Manager Doug Chitwood - Maint Manager Chuck Wither - Utilities Supervisor Toby Paluck - Safety Supervisor Injuries or Property Damage 2 contractors injured - left on ambulence NAICS Code Chemical Released Quantity Released (lbs.) Reported Ammonia 109 Yes Agency Reported To (Case #) CAL Emergency Management Agency (21-1709) | National Response Center (1301693) | SJC EHS (Eliana Floroido) 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. At 12:40 pm, a smell was detected in the storage freezer around HCR-PE. The ammonia feed was immediately shut off and the system isolated at 12:55 pm. The line was high pressure vapor of 140 psi. At 1:30 pm calls were made to the government agencies regarding the release. 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. 2 contractors from crown painting were removing ice from the ceiling between HCR-PE and HCR-RS. Two pieces of plywood was sitting on top of HCR-PE and the vapor line feeding it. Ice accumulated from the removal on top of the plywood. A hiss was heard and a smell of ammonia occurred at 12:40 pm. When the hiss was heard, the LFC building tech called the 2 contractors down from the lift they were working in. 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. Immediately after the release, the 2 contractors lowered the lift, but it was going too slow. One contractor jumped on to HCR-RS, took off his harness, and then jumped to the ground. The other contractor took off his harness and jumped from the lift to the ground. The lift was approximately 15 ft. in the air. The utility supervisor was already in the area just as the release occurred and called all parties to isolate the leak. A utilities tech went to the roof and closed the valves. The building tech and maintenance supervisors helped the two contractors out of the storage freezer. At 12:45 pm, the warehouse and processing areas were evacuated. At 12:55 pm, the system was isolated. Evacuation of the ammonia if the areas commenced after that. 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. The accumulated weight and the position of the plywood on the flange cause the gasket in the flange to split and create the leak. 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. The contractors were told not to put ice on the plywood. They were also told not to work in the area they did without notifying the utilities supervisor. Basic explanation of the ammonia hazard in the freezer was done. The ice on the plywood was noticed, but not thought to be an issue due to it being small pieces. 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 There is no question regarding work around the covered process. PHA is for work done on the covered process. Were the Standard Operating Procedures properly prepared and were they being followed when the release incident occurred? Yes No No written SOP for work being done close to the covered process. 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 Technicians are trained on the equipment, but contractors aren't trained on the system regarding work around the covered process. 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