October 22, 2019

To Authors of CaseStudyGroup19,

cc. Dr. Douglas K. Ludlow (Editor of BSRJ)

This review is an effort to provide constructive feedback for the CaseStudy25 report. Any
feedback provided will be based on what the reviewer believes is meant by rubric point
distribution descriptions. Areas of concern followed by sections of productive comments will act
as the reviewer thoughts to improve the report. Suggested changes are marked on the
CaseStudy19 report through track changes.
Technical Journal Format
Overall the abstract provides a good description of accident case study but could provide more
details in accident root cause and lessons learned. Missing a brief discussion to the root cause of
accident and lessons learned.
Organization of the body material in each section appears to be out of place some improvements
are needed. Sections below will mention material that should have been used elsewhere if need
be. The Background and Safety Analysis sections of the report are not well organized.
The references used should be in the same format and should be in alphabetical order. Also the
references need to be referenced in the body of the report, to be clear where all information was
taken from.
Background
Introduction should be a brief discussion of implementation failure in design and other factors
that led to the accident and what resulted from the accident. Should begin with a brief discussion
of Milliard Refrigerated Services, what the company produces, the process they use, and why
coolant is needed. Some short description of the facility should include the corporation owners,
year established, all activities involved at the facility. The flow of paragraph should summarize
what changes occurred over the years of operation along with other contributing factors that
ultimately led to the resulting accident.
Process description is lacking, there is little mentioning of process involved in Milliard
Refrigerated Services in the background information. Description should detail the facility set
up, where were these refrigeration units located, how were so many people exposed. There
should be more detail as to how the refrigerant is used other than what is briefly said in
background information. A lot of the information that could be used to describe the process is
used in the safety analysis section.
Safety Analysis
Case study accident timeline is clear steps describing the events leading up to the accident.
Accident timeline should follow the sequential accident model, which orders: hazard exposure,
hazard perception, detection, decision, accident occurrence, and resulting impact. A time
duration from accident to a fully controlled situation is not mentioned entirely. A timeline
starting from what went wrong (equipment or other factors) to facility members respond
(detected or unnoticed?) to accident occurrence to emergency response. Why was only a single
inexperienced operator the only one to respond? Is purging of the refrigeration lines commonly
performed after an unexpected shutdown or power loss? Not clear if senior operators would have
been aware of purging the lines to avoid the issue.
Ultimate results should include injuries and fatalities count, facility and corporation lost in
assets, releases of chemical to the environment, impact towards neighboring community, and
fines and penalties. Provide more details in how this accident affected employees, company, and
the community. Were there more safety devices and training introduced into the process? The
process mentions many times how much Anhydrous Ammonia was released but it is not clear
how much of this was into the environment, how far did the vapor reach? Where any safety
measures put in place for containment of the vapor?
The root cause of the accident has limited description in analysis of primary cause for accident.
Main body should begin by listing all cumulative elements that lead to the resulting accident
(implementations failure for the hierarchy of control). Elements to mention include problems
with the management framework, improper safety culture due to lack of training for new and
existing workers, ineffective engineering control for potential hazard, and failure implementation
of emergency protocols.
The lessons learned seem to be missing almost entirely from the case study. The main body of
this content should reflect on the contents mentioned in the root cause section. Proper
engineering design codes, administrative housekeeping, general maintenance, and other
correlated actions that would otherwise remove the causality of the accident. What lessons
learned by the company, only mentioning hypothetical lessons learned and should include
changes so this incident does not occur again. The closing statements of the case study should be
made in the form what lessons were learned to act as a proper conclusion.