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 Commented [PR1]: Some inconsistency in the way start-
Refrigerant lines had not been been purged after the long period of inactivity, and the normally up is written through out
ordinarily cold liquid transitioned to a high-pressure gas. Upon initiating system start-up, safety Commented [PR2]: Choose another word, ordinarily is a
interlocks were bypassed by an unqualified operator, allowing cold liquid Anhydrous Ammonia more proper and less used synonym
to directly interact directly with the hotwarm Anhydrous Ammonia gas. The Anhydrous Commented [PR3]: To-infinitive is split by directly
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 Commented [PR4]: Since it is a gas hot is a better
Anhydrous Ammonia escaped the rupture before the leak was contained, contaminating millions adjective

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 oOil sSpill cCleanup, 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 start-up 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 start-up. If operators had been better educated or required permissions from a qualified
supervisor to initiate the process, this incident mightmay have been avoided. Commented [PR5]: Missing a brief discussion to the root
cause of accident and lessons learned

Introduction: Commented [PR6]: Introduction should be a brief

mention in implementations failure in design and other
When lives could be at risk, safety is the most essentialimportant factor to consider in any factors that led to the accident and what resulted from the
accident
industry. With the chemical industry, particularspecial emphasis is required because of greater
Commented [PR7]: Important is often overused, and
system complexity and higher safety risks. A suitablegood method for preventing accidents most is not necessary. Essential does not need a qualifier.
before they happen is to learn from past mistakes and incidents, especially with chemicals
Commented [PR8]: Special can be overused. again
commonly used in industrindustries y such as anhydrous ammonia. On August 10, 2010, such an writing in a passive voice
incident occurred when over 32,000 lbs. of anhydrous ammonia, a commonly used chemical Commented [PR9]: Good is often overused
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 Commented [PR10]: Passive voice
possibllye exposed to Anhydrous Ammonia exposure, with 152 individuals being treated for
symptoms arising from exposure. Commented [PR11]: Passive voice

Commented [PR12]: This section should give a clear

indication of the information in the accident case study,
more description as to the process at Milliard Refrigerated
Services what equipment is used in the process and why this
equipment is necessary for the process.
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. Commented [PR13]: Expand more on company
description, size, and background.
This facility houses many cold-storage freezers that utilize Anhydrous Ammonia for i.e.: when did it become operational? How many workers?
efficient refrigeration. Anhydrous Ammonia is desirable for a refrigerant as it can be be Production capacity? Any changes that occur within the year
of accident?
implementeded as a liquid at temperatures of approximately -40C. This refrigerant is moved
Commented [PR14]: Passive voice
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:
Leading up toBeforePrior 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. During a loss of Commented [PR15]: This is the only date mentioned
power, the The refrigeration process is brought to a halt Tto reduce strain on the system and throughout the report, should consider adding to the
timeline of events possible information leading up to the
prevent an enormouslarge waste of refrigerant. , the refrigeration circulation process was halted. august 23 2010 date and events afterward
The insulated freezers and bulk refrigerant could maintain their temperatures for extended
Commented [PR16]: Sentence should be re-written, the
periods of time. When power was restored, Ooperators began start-up procedures after restoring subordinate phrase does not appear to be modifying the
power.. Reports of minor issues while executing the standard Sstart-Uup oOperating pProcedures subject
resulted in troubleshooting to ensure proper management of all issues. Minor issues were
reported while executing the normal Start-Up Operating Procedures, so troubleshooting ensued Commented [PR17]: Passive voice , large can be
overused
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 Commented [PR18]: Remove tautology

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, purging of the refrigeration lines had not commenced.
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. Commented [PR19]: Needs clear description of normal
daily process tasks
The Anhydrous Ammonia line rupture corresponded to alarms sounding within the plant Possibly compare refrigerant used to other options
due to high Anhydrous Ammonia concentrations. Once the alarms brought the leak to
employees’ attention, evacuation of the facility began without initiating emergency shutdown.
Once the alarms brought the leak to employees’ attention, the facility was then evacuated
without initiating emergency shutdown. Sources of the leak caused alarms; however, a second
rupture occurred in a blast freezer due to an evaporator coil rupturingThe 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 lostt as a
result of the contaminated blast-freezer. 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 Commented [PR20]: Some information has already been
before beingit was contained. The resulting cloud of hazardous vapor traveled over a quarter- repeated in the same context multiple times
mile. The cloud passed through a staging area for oil cleanup from the BP Oil Spill, possibly Commented [PR21]: A timeline starting from what went
exposing over 800 individuals to the hazardous vapor. Over 150 individuals received treatment wrong (equipment or other factors) to facility members
respond (detected or unnoticed?) to accident occurrence to
for anhydrous ammonia exposure resulting from this leak, with over 30 receiving intensive care emergency response
for severe exposure symptoms. Commented [PR22]: Ultimate Results is lacking, appears
only a minimal amount of information to results is included
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 Commented [PR23]: Provide more details in how this
accident affected employees, company, and the community
the system may be starting up after an abnormal shutdown. An unqualified operator cleared
Commented [PR24]: Several suggested changes to
alarms without permission, going against safe operating procedures to save time during start-up.
phrasing to avoid a passive voice
The control system lacked proper checks to bleed off the 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 Commented [PR25]: How were employees affected?
only ones who can approve operations outside of the standard operating procedure. Another How was the public affected?
lesson to be taken away is that the emergency shutdown should be activated if containment of a
hazardous leak cannot begin immediately. if a hazardous leak cannot be contained immediately.
The initiation of an emergency shutdown in the process would likely have dramatically reduced
the volume of released anhydrous ammonia vapor.If emergency shutdown had been initiated in Commented [PR26]: What lessons learned by the
the process, it is likely that the volume of released anhydrous ammonia vapor would have been company, only mentioning hypothetical lessons learned.
dramatically reduced.

Conclusion:
The Anhydrous Ammonia leak that occurred at Milliard Refrigerated Services in
Theodore, Alabama, impacted not only contaminated the storage facility, ruining the 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 start-up and Commented [PR27]: This part needs to summarize the
operating procedures, inadequate personnel training, and mismanaged access to bypass safety root causes and then describes what implementations can
take place to prevent similar accidents from occurring as the
features, such as interlocks. Lessons learned are to thoroughly evaluate start-up procedures and concluding content
mitigate the risk of stored energy sources, such as pressure, to restrict the ability to bypass Conclusion is currently lacking
critical safety feature of the system to authorized personnel, and to adequately enforce training
and proper use of all procedures (i.e., start-up, 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. Commented [PR28]: Some inconsistency with previous
start-up use

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.