Legionella Pneumophila in an

Ammonia Plant Cooling Tower

An outbreak of Legionella pneumophtta bacterial infection that claimed the lives of 30 people in
Bovenkaspel, The Netherlands in 1999 prompted KemiraAgro Rozenburg to sample its cooling
tower water at regular intervals to determine the presence of Legionella bacteria. Results were
consistently negative until a sudden outbreak was detected in the spring of 2000. Safety measures
were implemented immediately, the cause of the outbreak was discovered, and measures were
subsequently taken to prevent a reoccurrence.

W. D. Verduijn
Kemira Agro Rozenburg B.V., Rozenburg, The Netherlands

Introduction wt. % FeC13 solution).

E
emira is a multinational company with its
headquarters in Helsinki, Finland. Active in
various branches of the chemical industry,
Kemira Agro Oyj is its largest subsidiary and responsi-
ble for about 35% of the turnover.
Kemira Agro Oyj affiliate Kemira Agro Rozenburg
B.V. in Rozenburg, The Netherlands, operated until
recently a 1,700 metric ton per day ammonia plant. The
same site encompassed a 1,200 tpd (100%) nitric acid
plant, a 700 tpd urea plant, a 1,600 tpd CAN plant, a
800 tpd UAN plant, a 60 tpd liquid fertilizer specialties
plant, and a 300 tpd liquid CO2 plant. All these plants
were closed in December 2000 due to overproduction
on the European market.
Kemira continues operation on the Rozenburg site
with a 60 tpd hydrogen peroxide plant and a facility for
the production of 400 tpd water treating chemicals (40
World Record Ammonia Production
Rozenburg's ammonia plant was designed by C.F.
Braun and Co. of Alhambra, CA, now Kellogg Brown
and Root (see Figure 1). Design capacity was 1,350 tpd
(1,500 stpd). The first ammonia was produced in late
1968.
The plant, at that tune owned by Exxon Chemicals,
was opened in 1969 by H.R.H. Prince Bernhard of the
Netherlands (see Figure 2). Kemira took over in 1985.
In the period 1969-1990 the plant produced altogeth-
er 10 million metric tons of ammonia. This turned out
to be an officially recognized world record for a single
train ammonia plant: see Figure 3 (Fertilizer
International, 1990). On October 3, 2000, the 15 mil-
lionth ton was produced. We believe this is a world

AMMONIA TECHNICAL MANUAL 130 2002

 Figure 1. Rozenburg ammonia plant.

Figure 2. H.R.H. The Prince of the Netherlands officially

opens the plant in 1969.

AMMONIA TECHNICAL MANUAL 131 2002

record as well for a single train ammonia plant. It has
been officially recognized as such by Guinness in
London (see Figure 4), and we challenge the world
ammonia industry herewith to refute and beat it.
As mentioned before, the plant was closed in
December 2000. That tragic event is shown in Figure 5.
Sharing the Experience with AlChE
Both Exxon and Kemira have always been support-
ive of sharing relevant technical and safety experience
with the world ammonia industry. In most cases that
was done via articles presented at the AIChE Symposia
on Safety in Ammonia Plants and Related facilities
(Ruziska, 1972; Osman, 1975; van Eijk,1975;
Verduijn, 1979, 1983, 1993, 1996, 2000; Mertens and
Kolff, 1984; Kolff, 1986; Mertens, 1990; Song et al,
1992).
Rozenburg's Cooling Tower
The cooling water system of the Rozenburg fertilizer
complex is shown in Figure 6.
Some 18,000 m3/h treated cooling water with a tem-
perature of typically 21°C (70°F) is pumped from the
basin of the cooling tower to the various plants on the
site. The ammonia plant takes the majority of the cool-
ing water capacity. The warm cooling water, with a typ-
ical temperature of 38°C (100°F), is subsequently
divided into 9 more or less equal streams. Each of these
warm streams flows via a riser to the top of two of the
18 cooling tower cells that are arranged in two rows of
nine.
Figure 7 shows that each cell is equipped with a dis-
tribution system that takes care of a proper water flow
division across the horizontal surface area of that cell.
The incoming water is directed by main gutters to open
distribution gutters. Further flow division is realized by
means of numerous sprayheads in the bottom of these
distribution gutters. Each sprayhead drops its water on
splash plates. The warm water droplets subsequently
cascade down the wooden tower with timbered and
plastic internals, where they meet the countercurrent
flow of cold air. A small part of each droplet evapo-
rates. The required heat of evaporation cools that
droplet down. The thus cooled cooling water falls into
AMMONIA TECHNICAL MANUAL
a concrete basin which both serves for retaining and
storing the cooled water. The basin is subdivided by
internal partitions into nine compartments. Each of
these compartments can be isolated and drained while
the others are in operation. Finally, the cooled cooling
water is pumped to the process plants again.
The cooling tower is shown in Figure 8.
Chemical Treatment of Cooling Water
(before 1993)
In the early decades of the site, chemical treatment of
the cooling water was as follows:
Sulfuric acid was added to adjust the pH to 6.8-7.0.
The ami was to minimize deposition of calcium car-
bonate scale on the waterside of the cooling water heat
exchangers.
Polyphosphate and zinc chloride were added to min-
imize corrosion of the cooling water heat exchangers.
Chlorine, and later sodium hypochlorite, was added
to counteract the formation of any biological growth
(bacteria, slime and algae) that can cause fouling,
obstruction, or damage in the cooling water system.
A nonoxidizing biocide, finally, was also added to
counteract biological growth.
Chemical Treatment of Cooling Water
(after 1993)
As use of zinc chloride came under environmental
pressure, it was decided to switch to Nalco's All
Organic Program in 1993.
No acid addition
Acid is no longer added. Instead, the treatment pro-
gram leads to a relatively high pH of about 8.9 in the
hot return cooling water; this pH is controlled by the
purge flow.
Corrosion protection
Zinc chloride is no longer added either. Instead, a
mix of various predominantly organic chemicals is
used: Nalco 23210 (a mix of certain chemicals to pre-
132 2002
 K!-X;oki> BOKR
GUINNESS
WORLD RECORDS
i » «.H- V *faTiad. il BiljJ* «il
;ilth dig 1 1 K isioMr I Ir>x1 1 * rMw«

As at 3 October 200Q,
the ammonia plant of
Kemira Agro Rozenburg B. V.
in Rozenburg, Netherlands
produced a world record
15 millions tonnes of ammonia

*&Zv?vfsX£vtïîï:

Figure 3.10 million metric tons of ammonia produced Figure 4.15 million metric tons of ammonia produced
Nov. 14,1990. Oct. 3,2000.

Figure 5. Final shutdown of the ammonia plant on Dec. 18,2000.

AMMONIA TECHNICAL MANUAL 133 2002

 hot return

-38 t L-Q-180 Gcal/h — Q-120

plume

COOLING TOWER HN03 PLANT

9x2-18 cells CAN PLANT
Moke-up water NH3 PLANT UREA PLANT
duty 300 Gcal/h L-C02 PLANT
700 m3/h UTIL PLANT

air • • air * leak *

150 m3/h
-21 °C
118000 m3/M
purge

cooled cooling water

-H-*

pump

Figure 6. Rozenburg's cooling water system.

AMMONIA TECHNICAL MANUAL 134 2002

 to atmosphère

plastic
dropte«
separators

spray head

fffffffftff
fffffffffff > «_ -. • - ^ -
fffffffffff spmnpHn
timbered \fffffffffff
or plastic internals

variable M«t vanes

cold

basin
«tor
slide valve

Figure 7. One of the 18 cooling tower cells.

AMMONIA TECHNICAL MANUAL 135 2002

vent formation of notably inorganic deposits), Nalco
7348 (biodispersant; a "detergent" to prevent slime for-
mation), and Nalco 73136 (polyphosphate, for addi-
tional corrosion protection, if necessary).
Sodium hypochlorite (NaOCI)
This is used to counteract the formation of biological
growth (bacteria, slime, algae), and enhanced by the
addition of Nalco 1338 which contains bromine. Both
are added in the suction of the circulation pumps.
A typical chemical analysis of the makeup water and
the hot return water to the Rozenburg cooling tower in
February 1999 is shown in Figure 9. Note that the tar-
get concentration of free chlorine is 0.1-0.3 ppmwt in
the hot return flow. The use of NaOCI is limited by
Rozenburg's operating permit to a certain quantity per
year.
Cooling Water Bacteria in Genera!
As stated above, addition of sodium hypochlorite to
cooling water is aimed at combating bacterial growth.
Due to the favorable temperature of cooling water, bac-
teria in there namely tend to multiply easily, which is
undesirable from a standpoint of system efficiency
(slime causes heat-transfer reduction of exchangers),
corrosion protection (under slime), and health (possible
infection). There are many types of bacteria present in
cooling water.
Sampling for bacteria in general
The presence of these bacteria is determined by
measuring their overall concentration. This is a practice
that has been in use for decades, and is applied by
every industrial cooling tower operator. This determi-
nation, via a dip slide at 37°C (99°F) on-site, takes
about 2 days. The thus measured concentration is
expressed in colony forming units per milliliter
(cfu/mL). Detection limit is 1,000 cfu/mL; the problem
limit 10,000 to 100,000 cfu/mL.
Typical analysis
The typical analyses of Figure 9 shows a measured
AMMONIA TECHNICAL MANUAL
overall bacteria concentration in cooling water in
February 1999 smaller than the detection limit of
1,000 cfu/mL. That is a typical figure for our cooling
water. In other words: the overall bacteria population as
measurable with the above sampling technique was at
that time well under control.
The Legionella Pneumophila Bacterium
Although'not many people were aware of it in 1999,
cooling water can also contain a bacterium named
Legionella. This bacterium can cause the so-called
Legionnaire's disease, an infection of the lungs that is
a form of pneumonia. There are over 30 different
species of Legionella bacteria. Legionella pneumophi-
la is the most common species that causes the disease.
Infection is caused by inhaling water in the form of an
aerosol contaminated with Legionella pneumophila
bacteria. Legionella pneumophila bacteria exist in 14
different sero-types, of which sero-type 1 is probably
responsible for 80% and sero-type 6 probably respon-
sible for the remaining 20% of the disease cases. The
other sero-types are believed to be far less dangerous.
Symptoms
Incubation time is 2-10 days. Symptoms of the dis-
ease in its initial stage are much like those of the flu.
After one or two days, though, pneumonia-like symp-
toms may appear. Some individuals may only have
flu-like symptoms, while with others the disease can
be fatal.
Who are at risk?
Many people appear to be resistant to the disease.
Some have a lower resistance. The risk of developing
the illness is increased by factors like underlying med-
ical problems (respiratory diseases, diabetes and so
on), heavy smoking, heavy drinking, and age (older
persons are more likely to get the disease).
Pontiac fever
The same bacterium can also cause the flu-like dis-
ease Pontiac fever. Full recovery of Pontiac fever with-
136 2002
 Figure 8. Rozenburg's cooling tower.
make up water hot return (actual) hot return (target)

PH 7.9 8.6 8.8 - 9.0

conductivity (25 °C) uS/cm 670 2060
calcium hardness ppmCaCOS 180 540
free chlorine ppmCl2 - 0.13 0.1-0.3
free bromine ppmBr2 - 0.09
chloride ppmCl 90 380
iron ppmFe 0.05 0.33 <0.5
concentration factor . - 3.0 3.3
bacteria count (37 °C) cfu/ml - <1000 <1000

Figure 9. Typical analysis of the cooling tower.

Figure 10. Dimensions of the cooling tower plume can be substantial.

AMMONIA TECHNICAL MANUAL 137 2002

out antibiotics occurs in two to five days.
Multiplication conditions
Warm stagnant water of a pH between 5 and 9 pro-
vides ideal conditions for growth of the organism.
Multiplication is possible between 20 and 50°C (68 and
122°F), and optimal between 32 and 40°C (90 and
105°F). The presence of rust, scale, slime and algae can
promote that growth (Nalco Bulletin; National Center
for Genome Resources, 1998; Huysmans, 1999).
Standard test for Legionella bacteria
The general alimentary medium used to determine
the overall bacteria concentration in cooling water (see
above) is not suitable for Legionella bacteria: they do
not grow on this medium. Therefore, their isolation and
determination requires a special technique. This tech-
nique, in an outside microbiological laboratory,
involves incubation and produces preliminary results
after 3, 5 and 7 days, followed by a final result after 10
days. The detection limit of the technique for both city
water and cooling water is 25 cfu/L (per liter, not per
milliliter, as in the case of bacteria in general). The
legal safe limit for city water in the Netherlands is 50
cfu/L, irrespective of the Legionella type. There is no
legal safe limit for cooling water in The Netherlands
yet; some suggest 100 cfu/L (Huysmans, 1999), but
the discussion on this subject has not been finalized
yet.
A rapid Legionella test is also available. It is based
on a colorimetric determination of certain chemicals
specific in Legionella bacteria. The test requires 8 h,
(24 h including shipment of the sample to a foreign
laboratory), but its detection limit is only 600 cfu/L in
clean water and only 2,100 cfu/L in turbid water. Also,
this test measures the total of dead and viable
Legionella bacteria, whereas the standard test measures
viable Legionella bacteria only.
Tragedy in Bovenkarspel
In 1999 about 30 people died after attending a flower
fair in Bovenkarspel, The Netherlands. The fair was
AMMONIA TECHNICAL MANUAL
held in February of that year. Cause turned out to be
contamination with the bacterium Legionella pneu-
mophila, reportedly as a result of a whirlpool demon-
stration.
This tragedy urged Kemira Agro Rozenburg to sam-
ple its water systems for the presence of the bacterium.
The necessity was further supported by a Legionella
incident at a neighboring industry, and by an article in
Chemical Engineering during that same period
(Chemical Engineering, 1999; Huysmans, 1999) men-
tioning that at least 14% of the cooling towers in the
U.S. contain the bacterium, that the fatality rate of
infected people is 10-20%, and that 1,000 of the
15,000 infections per year in the U.S. end in death.
Safety Showers Sampled in 1999
One of the first actions was sampling the water in the
safety showers of Kemira Agro Rozenburg for the pres-
ence of Legionella bacteria.
Method of sampling
A sampling method adopted by Nalco was applied,
which requires a defined (1 min. long) water purge
before sampling. The standard sampling test described
above was used. As mentioned before, its detection
limit in city water is 25 cfu/L, whereas 50 cfu/L is the
legal safe limit in city water.
Result
Much to our dismay, we found that those safety
showers located inside buildings showed unacceptably
high concentrations of Legionella of the dangerous two
sero-groups 1 and 6. One of these showers was the lab-
oratory safety shower. We could have predicted that:
the laboratory sometimes is at, and sometimes is above,
room temperature, and the safety shower is seldom or
never used. The measured concentration of sero-groups
1 and 6 together of about 3,000 cfu/L was characterized
as "moderately unsafe", and was also unlawful. The
other (four) safety showers were located inside the
CAN production building. Temperatures there usually
run well over 20°C (68°F), and sometimes up to 40°C
(104°F). Also, these showers are seldom or never used.
138 2002
Only sero-group 6 was found here: the measured con-
centrations at all four places in the CAN building, rang-
ing from 9,000 to 11,000 cfu/L, were characterized as
"moderately to highly unsafe"; of course, they were
also unlawful.
Corrective action
All safety shower water systems running the risk of
(temporary) operation at temperatures over 20°C were
systematically purged and sampled, until the
Legionella bacteria level was below 25 cfu/L. One
shower showed in March 2000 still persistently 125
cfu/L of sero-type 6. All of its many dead end parts
were cut off. Thermal disinfecting (purging at a tem-
perature over 60°C) and chemical disinfecting (I
believe with NaOCl or H2O2) were necessary to get the
Legionella bacteria in this specific shower finally
under control. Other city water systems were investi-
gated as well. Finally, a weekly purging and monthly
sampling program was set up.
Conclusion
Despite their name, safety showers can turn out to be
deadly traps if they are seldom used and located in
environments with temperatures well over 20°C.
Cooling Tower Sampled in 1999 and 2000
The cooling tower water was also sampled in 1999
for the presence of Legionella bacteria. Again, the stan-
dard test described above was used for the determina-
tion of the cfu/liter figure.
Result in 1999
The first sample of cold supply and hot return was
taken March 25, 1999. Measured concentrations of
Legionella bacteria were nil (or rather below the detec-
tion limit of 25 cfu/L). It was concluded that Legionella
bacteria were absent. As from that date, the analyses
were repeated each three months. None of these quar-
terly checks revealed a problem.
AMMONIA TECHNICAL MANUAL
April 2000 event
On March 28, a sample was taken from the cold sup-
ply and hot return of the cooling water during full plant
operation. During the evening of April 4 (after 7 days),
the preliminary analyses results came in: 10,000 cfu/L
of sero-type 1 ! Consternation all over! How could this
happen? Given the high analyses figure, there was no
doubt in our minds that we had a problem. We also
realized that the plume of the cooling tower had been
discharging appreciable flows of aerosol into the
atmosphere containing the dangerous Legionella sero-
type 1 bacteria, and probably was still doing so. It was
not unlikely that employees had inhaled the aerosol:
the discharge point of the cooling tower fans is at a rel-
atively low elevation, and, under certain weather con-
ditions, the dimensions of the plume can be quite con-
siderable (see Figure 10).
Operators inside
The on-site operators that evening were immediately
informed and retracted within the overpressurized main
control room as much as possible. Also, we realized
that, on that same day, the four Northern cells of the
cooling tower were being cleaned; a check revealed
that this work had fortunately just been finalized.
Legionella Crisis: Shutdown all Plants?
All plants?
We seriously considered shutting down the ammonia
plant, as well as the other plants on-site, with the objec-
tive of eliminating the plume of the cooling tower. This
option would also permit us to thoroughly clean and
disinfect the cooling tower and cooling water system.
Some plants?
We also considered shutting down a number of plants
on the site in order to reduce the cooling tower plume
and therefore the risk area.
139 2002
Neither of the two
It was finally decided to not execute any shutdown
for the following reasons. Firstly, the full plume reduc-
ing effect would only be reached after 24 h. Secondly,
operators would have to carry out shutdown work in
the plume. Thirdly, the effect of the Legionella com-
bating actions mentioned below would, we hoped, be
visible within 24 h.
Legionella Combating Actions
Within 2 h from the receipt of above analysis result
of 10,000 cfu/L, the following actions were taken.
Increased purge flow
Firstly, the cooling water purge flow to the cold sea
water canal, normally 150 m3/h, was increased to
1,000 m3/h for a period of 12 h. This was realized
under simultaneous increase of the makeup flow. As
the volume of the circulating cooling water is approxi-
mately 5,600 m3, this was an effective way to rapidly
purge the bacteria out of the system.
More hypochlorite
Hypochlorite solution addition to the system was
increased from the regular 1.5 tpd to the maximum
capability of the system of 4.0 tpd. After the purge flow
had been reduced again to the regular value of 150
m3/h, this resulted in a free chlorine level of 2.0 ppm,
vs. a regular level of 0.1-0.3 ppm (see again Figure 9).
Actions with Respect to Health
Information
Employees were informed the next morning (April 5)
via a bulletin of the situation and its possible risk.
Other personnel that had been on-site during the period
from March 20 were informed as well. Kemira's med-
ical service approached the employees who reported
sick during this period for an additional diagnosis.
AMMONIA TECHNICAL MANUAL
Neighbors
Neighboring companies were informed as well. A
press release was issued to make sure that involved
individuals who possibly had not been informed could
be informed via that message. It was felt that neighbor-
ing communities were not at risk since they were locat-
ed much further away from the cooling tower than 250
meters (275 yards); 250 meters is considered the max-
imum length the plume can reach under the worst cli-
matic conditions.
Restricted area
The Northern wind sent the plume southbound. The
area covered by the plume was fenced off up to 250
meters from the cooling tower, and was declared for-
bidden for personnel. This area included most of the
major plants, including the ammonia plant.
Special filter masks, the so-called P3SL filters, were
brought in for those operators who had to enter the
operating plants from time to time. These special
mouth and nose masks effectively absorb aerosols.
Information to the Authorities
The authorities were informed as well. It was obvi-
ous that the incident, so short a time after the
Bovenkarspel tragedy, caused considerable public
commotion.
First of all, it was emphasized to the authorities that
the surrounding communities were not at risk. Also,
our action plan was discussed with them. Thereafter,
on April 6, a joint press release on the situation was
issued by Kemira and the authorities (see above).
Finally, a member of Rozenburg's management team
appeared that evening together with a representative of
the authorities on local TV to assure the public that
they had nothing to fear. This step effectively eased the
commotion.
We have again concluded that a good relationship
with the authorities and the press is vital in times of cri-
sis.
140 2002
Result of Legionella Combating Actions Standard test April 5

Rapid test April 5
About 24 h after the start of the Legionella combat-
ing actions, namely on April 5, a rapid Legionella test
as described above was executed to obtain an impres-
sion of the result of these actions. The more sensitive
and accurate standard test would of course have been
preferable, but there was obviously no time to wait 10
days for its result. The rapid test result, available April
6, showed that the Legionella concentration in cooling
water was still "positive". Kemira interpreted that out-
come as 600 cfu/L (which was later found to be a not
fully correct interpretation). Apparently we started to
get the crisis under control!
Hypochlorite dosing
It was therefore decided to reduce the free chlorine
level from the crisis value of 2.0 ppm to a medium
level of 0.5 ppm (the level before the crisis was 0.1-0.3
ppm).
Rapid test April 6
On April 6, another sample was subjected to the rapid
test. The result, on April 7, was that the Legionella con-
centration had dropped to below the detection limit of
the rapid test (usually 600 cfu/L). Apparently, the situ-
ation was under control. That same day, April 7, fenc-
ing was removed and a message was released that
wearing P3SL filters in the area in question was no
longer necessary. We felt the crisis was over.
How wrong we were! Of course, part of the cooling
water sample for the rapid test of April 5 was, as a cross
check, also subjected to the accurate and more sensitive
standard test. The result came in 10 days later: 38,000
cfu/L of the sero-types 1 and 10! Remember that this
sample was taken after cleaning of the four Northern
cells, after one day of increased purge flow, and after
one day of increased hypochlorite addition. We had
therefore to conclude in mid-April that the Legionella
crisis had not been under control at all by the end of
April 5! On the contrary, it reached there its height!
Finally, we confronted the laboratory executing the
rapid test with the big difference between their result
and the result of the standard test. They answered that
the detection limit of the rapid test is a function of the
turbidity of the cooling water, and that the outcome is
an indication only. We therefore also concluded in mid-
April that there is an urgent need for a Legionella
analysis method that is both fast and accurate.
Further Sampling Results
Fortunately, the sample results via the standard
method that arrived in subsequent days showed that the
measures taken had nevertheless led to the desired
result (see Table 1).
After two months, no presence of Legionella bacteria
could be demonstrated anymore with the standard test,
that has a detection level of 25 cfu/L. Note also that the
dangerous sero-type 1 was killed off effectively by the
measures taken. The increased free chlorine level of 0.5
ppm was maintained until June, after which it was
reduced gradually to the target value of 0.3 in

Table 1. Test Results

Sample Taken Rapid Test Result Result Standard Test Result Result Sero-type

Mar. 28, 2000 no yes Apr. 4 10 000 cfu/L 1

Apr. 5, 2000 yes Apr. 7 detected yes Apr. 15 38 000 cfu/L 1 +10
Apr. 6, 2000 yes Apr. 8 not detected yes Apr. 16 2 100 cfu/L 10
Apr. 7, 2000 yes Apr. 8 not detected yes Apr. 17 1 900 cfu/L 8 + 10
Apr. 13, 2000 yes Apr. 23 750 cfu/L 8

AMMONIA TECHNICAL MANUAL 141 2002

December.
Cause of the Outbreak
Initiation date
The first sign of Legionella outbreak was found in
the cooling water sample taken March 28, 2000. The
previous sample analyzed for Legionella was taken
three months earlier, and had shown the regular value
of less than 25 cfu/L. It was therefore likely that the
problem had initiated between January 1 and March 28.
Cell cleaning
Investigation showed also that there was cleaning
work started in the cooling tower on March 20. This
cleaning work is part of a yearly spring program, cov-
ering cleaning all cells successively. The cleaning work
that started March 20 was executed in a few cells in the
middle to northern section of the tower. To that end, the
section in question was isolated from the rest of the
tower and shut down. Cleaning was necessary as slime
and deposits had been building up in the water distri-
bution system of the cooling tower top, giving rise to
water maldistribution across the cell. The cleaning
operation was executed with waterhoses. Access to the
area in question was achieved via the top of the tower
by removing the droplet separators. The slime and
deposits, loosened by the water jet, fall down into the
basin, where they are removed every four years during
a scheduled cooling tower stop. As mentioned before,
this cleaning operation is routine and takes place every
spring.
Hypothesis
Although the free chlorine concentration in the cool-
ing water adequately kills the Legionella bacterium,
some local areas underneath the slime and deposit lay-
ers in the tower top can be shielded off effectively from
the water: Legionella concentrations can therefore eas-
ily develop behind that layer. When removing the lay-
ers with a waterhose, these concentrations come loose
and enter the cooling water, where it takes a while
before the Legionella bacteria are killed by the free
chlorine. During that time, certain quantities of
AMMONIA TECHNICAL MANUAL
Legionella bacteria enter into the atmosphere in aerosol
form via the plume. This hypothesis of the probable
cause is strengthened by the phenomenon of high con-
centration of Legionella bacteria found in the sample
taken on April 5: remember that on this day the four
Northern (windward) cells were cleaned.
Cause
Therefore, we believe that it is highly likely that our
Legionella incident was caused by cooling tower clean-
ing.
Past Cooling Tower Cleanings
Personnel
As mentioned before, the cooling tower was cleaned
tens of times following the above procedure. It is there-
fore very likely that we have had temporary high con-
centrations of Legionella bacteria in the cooling water
before. To the best of our knowledge, that has never
lead to a case of Legionnaire's disease among our per-
sonnel, although we do not rule out that it may have led
to cases of the less severe Pontiac fever.
The cleaning crew is a contractor crew. Although
they enter the cooling tower during cleaning, they do
not come in contact with the plume. However, their
cleaning jets bring other types of aerosols into the ah" in
which Legionella bacteria may be present. The crew
did not wear any protective face mask. As far as we
know, none of the crew members has ever developed
Legionnaire's disease. It was not investigated whether
the crew members are young or belong to other groups
that have a decreased probability of developing
Legionnaire's disease.
Future Cooling Tower Cleanings
Monthly samplings
From last year's incident on, cooling tower water
will be analyzed for the presence of Legionella bacte-
ria monthly (quarterly since March 1999).
142 2002
Controlling actions
At positive results, measures proven to be successful
have to be launched, such as to maximize purge flow
and hypochlorite dosage.
Extra entry permit
The cooling tower will only be entered after making
sure that the Legionella bacterium is not present in the
water. That means that cleaning work can only be start-
ed 10 days after sampling.
Stagnant water
Since stagnant water facilitates the growth of
Legionella, all cooling water pumps will be switched
on a weekly basis.
Procedures for the yearly cleaning operation of our
cooling tower internals during operation have been
updated. New measures are for instance: no more than
two cells per time, extra free chlorine, and full face
fresh air masks for the crew. Finally, the procedures for
integral cleaning of the cooling tower during a site stop
have been updated from a standpoint of avoiding
Legionella contamination; these procedures include
shutdown of the cooling tower, sludge removal from
the basin, and re-startup.
Observations and Conclusions
(1) The ammonia plant of Kemira Agro Rozenburg,
started up late 1968 and shut down permanently in
December 2000, has produced over 15 million metric
tons of ammonia in its lifetime.
(2) We believe that to be a world record for a single
train facility, and challenge the ammonia world to
refute and beat it.
(3) Legionella pneumophila bacteria of sero-types 1
and 6 can easily develop in various water systems in
and around ammonia plants. When inhaled, they can
lead to Legionnaire's disease. The fatality rate of
infected people is 10-20%.
(4) Many people are resistant to the bacterium, but
employees with medical problems (respiratory dis-
eases, diabetes, and so on), heavy smokers or heavy
drinkers, as well as older employees, are at increased
AMMONIA TECHNICAL MANUAL
risk.
(5) Despite their name, safety showers can turn out to
be deadly sources of Legionella contamination if they
are seldom used and located in environments with tem-
peratures well over 20°C (68°F).
(6) In March 2000, Rozenburg's cooling water sud-
denly and unexpectedly showed a serious outbreak of
Legionella bacteria of the dangerous sero-type 1.
(7) The spread was effectively suppressed by a com-
bination of a very high cooling water purge flow and a
substantially increased hypochlorite dosage to the cir-
culating cooling water.
(8) It is likely that the outbreak was caused by the
standard spring cleaning work in the cooling tower. It
has not lead to infections.
(9) A good relationship with authorities and press has
again proven to be vital in times of crisis.
(10) There is an urgent need for a Legionella analy-
sis method that is both fast and accurate. The present
analysis time of 10 days frustrates an adequate deci-
sion-making process.
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144 2002