Milliard Refrigerated

Services Anhydrous
Ammonia Release
A Case Study
Written By:
Jasmine Monroe
Will Wibberg
Elizabeth Wiggins
Oct. 4th, 2019
Abstract:
This paper analyzes the Milliard Refrigerated Services Accident that occurred in the year
2010 in Theodore, Alabama. Milliard used Anhydrous Ammonia, a common low-temperature
refrigerant, to efficiently cool the variety of freezers located across the plant grounds. On August
23rd, 2010 the plant was beginning start-up after a long period without power. The Ammonia
Refrigerant lines had not been purged after the long period of inactivity, and the normally cold
liquid transitioned to a high-pressure gas. Upon initiating system start-up, safety interlocks were
bypassed by an unqualified operator, allowing cold liquid Anhydrous Ammonia to directly
interact with the warm Anhydrous Ammonia gas. The Anhydrous Ammonia vapor rapidly
condensed, leading to the vacuum-wave hydraulic shock rupture of a 12-inch refrigerant pipe and
the rupture of an internal evaporator manifold. Over 32,000 lbs. of Anhydrous Ammonia escaped
the rupture before the leak was contained, contaminating millions of kilograms of product and
spreading from the plant to reach areas over a quarter mile away. One area subject to exposure
was the staging ground for Oil Spill Cleanup responding to the then-recent BP Oil Spill. Over
800 individuals were at risk of Anhydrous Ammonia exposure, with over 150 individuals
requiring treatment and over 30 needing intensive care. The fallout of this mismanagement of
startup procedures highlights the need for well-defined and robust operating procedures in the
workplace. Also evident is the need for a means to prevent unqualified individuals from
bypassing these procedures and interlocks before a system is ready to enter startup. If operators
had been better educated or required permissions from a qualified supervisor to initiate the
process, this incident may have been avoided.

Introduction:
When lives could be at risk, safety is the most important factor to consider in any
industry. With the chemical industry, special emphasis is required because of greater system
complexity and higher safety risks. A good method for preventing accidents before they happen
is to learn from past mistakes and incidents, especially with chemicals commonly used in
industry such as anhydrous ammonia. On August 10, 2010, such an incident occurred when over
32,000 lbs. of anhydrous ammonia, a commonly used chemical cleaner and refrigerant, was
leaked at a chicken warehouse facility owned by Milliard Refrigerated Services in Theodore,
Alabama. As a result, over 800 individuals were subjected to possible Anhydrous Ammonia
exposure with 152 individuals being treated for symptoms arising from exposure.
Background Information:
Milliard Refrigerated Services was founded in 1963 in Milliard, Nebraska. The company
operates many cold storage facilities throughout the United States, providing both cold storage
and cold transportation to many retail, food service, and food distribution companies. The
specific location in question was Milliard’s Mobile Marine Terminal in Theodore, Alabama. This
facility serves as a hub for Milliard to transition frozen goods onto or off ships for waterborne
transportation.
This facility houses many cold-storage freezers that utilize Anhydrous Ammonia for
efficient refrigeration. Anhydrous Ammonia is desirable for a refrigerant as it can be
implemented as a liquid at temperatures of approximately -40C. This refrigerant is moved
through many heat exchangers to cool inlet air to temperatures below 0C to ensure adequate
refrigeration. Anhydrous Ammonia is hazardous on inhalation or skin-contact, the result of
which is chemical burns and severe irritation leading to death if not removed from the source.
Improper management of this chemical can lead to severe consequences, as seen in the Milliard
Mobile Marine Terminal Incident.

Safety Analysis:
Prior to the accident that occurred on August 23, 2010, the Milliard Mobile Marine Terminal had
suffered a loss of power that lasted for over 7 hours. To reduce strain on the system and prevent a
large waste of refrigerant, the refrigeration circulation process was halted. The insulated freezers
and bulk refrigerant could maintain their temperatures for extended periods of time. When power
was restored, operators began start-up procedures. Minor issues were reported while executing
the normal Start-Up Operating Procedures, so troubleshooting ensued to ensure these issues were
properly managed. During a troubleshooting operation, an operator improperly and without
permission cleared alarms on freezer evaporators. With the alarms cleared, the control system
reset the freezer evaporation system from a “Defrost” state to a “Refrigeration” state. Anhydrous
Ammonia Liquid at a temperature of -40C was allowed to enter the system. Unbeknownst to this
operator, the refrigeration lines had not been purged. The control system contained an error that
had not automatically bled off the residual vapor before initiating the refrigeration process.
Anhydrous Ammonia vapor had built up to high pressures within the refrigeration lines.
Introducing the cold liquid caused a rapid condensation of the high-pressure vapor, creating a
vacuum wave that ruptured a 12” rooftop refrigeration line.
The Anhydrous Ammonia line rupture corresponded to alarms sounding within the plant
due to high Anhydrous Ammonia concentrations. Once the alarms brought the leak to
employees’ attention, the facility was then evacuated without initiating emergency shutdown.
The source of the leak that caused the alarms, however, was a second rupture that had occurred
in a blast freezer due to an evaporator coil rupturing. Manual valves leading to this freezer were
reported closed 4 hours after the leak was detected. Over 3 million kg of frozen chicken and
packing material was contaminated as a result of the contaminated blast-freezer. Concurrently,
over 32,000lbs of Anhydrous Ammonia escaped the rupture of the 12” rooftop refrigeration line
before it was contained. The resulting cloud of hazardous vapor traveled over a quarter mile. The
cloud passed through a staging area for oil cleanup from the BP Oil Spill, possibly exposing over
800 individuals to the hazardous vapor. Over 150 individuals received treatment for anhydrous
ammonia exposure resulting from this leak, with over 30 receiving intensive care for severe
exposure symptoms.
Root causes of this accident can be summarized as the improper implementation of
operating procedures and improper control system coding checks to address situations in which
the system may be starting up after an abnormal shutdown. An unqualified operator cleared
alarms without permission, going against safe operating procedures to save time during start-up.
The control system lacked proper checks to bleed off remaining material before reintroducing
refrigerant into a system after an abrupt shutdown. Attention to either of these root causes, either
through safety checks to ensure a proper individual approves of clearing alarms or fringe-case
testing of code, could have prevented this incident from occurring. From this situation one can
gather the need for proper safety checkpoints to ensure trained and authorized personnel are the
only ones who can approve operations outside of the standard operating procedure. Another
lesson to be taken away is that emergency shutdown should be activated if a hazardous leak
cannot be contained immediately. If emergency shutdown had been initiated in the process, it is
likely that the volume of released anhydrous ammonia vapor would have been dramatically
reduced.

Conclusion:
The Anhydrous Ammonia leak that occurred at Milliard Refrigerated Services in
Theodore, Alabama impacted not only contaminated the storage facility, ruining chicken
product, but also exposed hundreds of lives to the toxic chemical. While the release was due to
pipe rupture from hydraulic shock, root causes were identified to be mismanaged startup and
operating procedures, inadequate personnel training, and mismanaged access to bypass safety
features, such as interlocks. Lessons learned are to thoroughly evaluate startup procedures and
mitigate risk of stored energy sources, such as pressure, to restrict ability to bypass critical safety
feature of system to authorized personnel, and to adequately enforce training and proper use of
all procedures (i.e. startup, operating, and emergency shutdown procedures). Adding measures to
the system that would prevent the root causes of this incident from occurring again would be the
ideal way to reduce the risk of another Anhydrous Ammonia leak of this nature or magnitude.
References:
1. Chemical Safety and Hazard Investigation Board. (2015, January). Millard Refrigerated
Services Ammonia Release. Retrieved from
https://www.csb.gov/millard-refrigerated-services-ammonia-release/

2. Cooling Post. (2015, January 16). Hydraulic shock caused huge ammonia leak. Retrieved
from
https://www.coolingpost.com/world-news/hydraulic-shock-caused-huge-ammonia-leak/

3. United States of America v. Millard Refrigerated Services, LLC. United States District
Court for the Southern District of Alabama.

4. (2015, June 2). Georgia-Based Millard Refrigerated Services to Pay $3 Million Civil
Penalty for Ammonia Release That Sickened Workers Responding to Deepwater Horizon
Oil Spill. Retrieved from https://www.justice.gov/opa/pr/georgia-based-millard-
refrigerated-services-pay-3-million-civil-penalty-ammonia-release

5. Secretary of Labor v. Millard Refrigerated Services. Occupational Safety and Health

Review Commission. 2012.