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Ammonia Incident Profile in Brazil
Ammonia Incident Profile in Brazil
Alessandro da Silva
Bitzer Compressores Ltda, Av. Joao Paulo Ablas 777, Cotia, Sao Paulo, Brasil
alessandro.silva@bitzer.com.br
There is a list of ammonia incidents below I prepared by searching in the internet. I collected
information from 2010 to 2013 and put it into a spreadsheet the data. The results were
alarming and seemed immediately applicable to all owners and operators of industrial
refrigeration systems. The data is tracked on the following incident criteria:
The vast majority of “ammonia incidents” as reported in this searching lays blame directly at
the feet of owners and operators for refrigeration system failures and/or negligent
maintenance routines. Many incidents with ammonia leakage happens in the Brazilian Food
Industries due to a lack of technical standards during the refrigeration system design; lack of
skilled technicians on ammonia refrigeration systems; lack of ammonia training courses; lack
of technical schools to provide ammonia training courses; reduced costs of maintenance and
services on ammonia refrigeration systems; lack of personal protective devices; lack of a
process safety management or a risk management program; lack of emergency action plan;
employee training; etc.
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Incident Profile # 01
Incident Title: Ammonia leakage in a Juice Industry
Report Date: 01/16/2013
Incident Description: Ammonia leak in industry leaves 4 intoxicated in Sao Carlos. Agroindustry of juice
was closed by Fire Department for an hour and a half. Incident occurred near to the
chain and took an officer and three inmates to hospital. The leak was reported
around 11.30 p.m. According to firefighters, a company employee handled a safety
valve when the gas began to leak and spread throughout the region. Thirteen men
from the Fire Department, with vehicles of firefighting and rescue, isolated place for
an hour and a half.
Incident Profile # 02
Incident Title: Ammonia liquid receiver explodes in a Food Industry
Report Date: 01/19/2013
Incident Description: On January first, 2013 an ammonia liquid receiver exploded and eight employees
went to the hospital in Sao Jose do Rio Preto. 11 dogs also became ill and were
taken to a veterinary hospital. The ammonia liquid receiver flew two hundred meters
and landed in the median of the highway Washington Luis
Reasons of the Incident: Faulty Design or Fabrication; the liquid receiver had a volumetric capacity for
1,000kg of ammonia.
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Incident Profile # 03
Incident Title: Ammonia leakage in a Cattle Slaughterhouse
Report Date: 01/23/2013
Incident Description: On Wednesday 23rd, around 7a.m. an ammonia leak caused intoxication at JBS
Industry (Cattle Slaughterhouse), located in road MS-276, exit Ivinhema in Nova
Andradina city. According to a worker, at least six people would have felt bad when
in contact with the ammonia, after breakup of tubes that pass through the slaughter
industry. The Fire Department had knowledge about the leak occurred in the
industry, however, as the company security technicians managed to control the
situation, no vehicle was requested on site. For safety, the victims were admitted to
the Regional Hospital, for medical evaluation. Around 9am, with proper
maintenance performed, the company returned to normal operation.
Incident Profile # 04
Incident Title: Ammonia leakage in a Food Industry
Report Date: 02/01/2013
Incident Description: On Saturday 1st, an accident has been registered with ammonia leak at the
company BRF (Brazil Food Industry), located in the neighborhood of Uvaranas in
Ponta Grossa city. The smell nearby factory was intense, but the damage was
considered minor proportions by employees who are part of the Company Fire
Brigade. Laborers working in the area of freezing food had to leave the site. There
were no serious injuries. The leak would have happened due to a service that was
being done by employees from a contracted company. Two men came to inhale the
ammonia and had to be treated in SIATE ambulance with oxygen.
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Incident Profile # 05
Incident Title: Ammonia leakage in a Food Industry
Report Date: 02/07/2013
Incident Description: Five employees of a Food Industry in Barra do Bugres city were intoxicated with an
ammonia leak in the morning on Thursday 7, they had to be taken to the Municipal
Hospital. The ammonia leak was caused by a small crack in a connection of the
evaporator.
Incident Profile # 06
Incident Title: Ammonia leakage in a Beverage Industry
Report Date: 02/13/2013
Incident Description: According to the company (Femsa –Coca Cola) the ammonia leak occurred during
the maintenance routine of a refrigeration system, but the incident was quickly
controlled by late morning on Wednesday 13. Only one person was intoxicated by
ammonia gas and he was taken to the hospital.
Reasons of the Incident: Operator Error or Poor Maintenance / Lack of Personal Protective Equipment
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Incident Profile # 07
Incident Title: Ammonia leakage in a Fish Industry
Report Date: 02/26 /2013
Incident Description: On February 26, 2013, an ammonia leak left many people intoxicated in a fish
company located in Vigia city, northeastern Para. According to the Fire
Department, a rupture of a pipe would be the cause of the leak. Because of the
accident, 40 people who inhaled the gas required medical attention. The incident
dispersed in a pipe about 2 Kg of ammonia on site. According to the company, in
less than 20 minutes was controlled leakage, the site was isolated and all 300
employees were removed from the area.
Reasons of the Incident: Operator Error or Poor Maintenance
Pictures of the Incident:
Establishment Name: Ecomar – Fish Industry
(City ‐ State) Vigia ‐ Para
Fatalities: 0 Injuries: 40
Researching on the Internet: http://g1.globo.com/pa/para/noticia/2013/02/vazamento‐de‐gas‐deixa‐varias‐
pessoas‐intoxicadas‐em‐vigia‐pa.html
Incident Profile # 08
Incident Title: Ammonia leakage in an Ice Plant
Report Date: 02/26/2013
Incident Description: An Ammonia leak occurred in an Ice Plant in Belo Horizonte city and an employee
was intoxicated and need to be taken to the hospital.
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Incident Profile # 09
Incident Title: Ammonia leakage in a Fish Industry
Report Date: 03/04/2013
Incident Description: Ammonia leak in fish industry leaves 8 intoxicated in Araçatuba. According to the
Fire Department one of the ammonia pipelines broke as a result the impact the
company's roof was partially destroyed and reached nearby homes. About 200 kg
of the gas was leaked into the system.
Incident Profile # 10
Incident Title: Ammonia leakage in a Food Industry
Report Date: 03/15/2013
Incident Description: There was a leak of ammonia and seven employees required medical attention.
The local Fire Department was activated and controlled the leak, along with in
company staff.
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Incident Profile # 11
Incident Title: Ammonia leakage in a Food Industry
Report Date: 03/18/2013
Incident Description: On March 18, 2013, 60 employees from Frigorifico Minerva S/A were exposed to
the ammonia toxic effects for 45 minutes which required outpatient care of these
labors, with dizziness, vomiting, burning eyes and difficulty breathing. The leakage
occurred after a problem with a safety relief valve fitted in the ammonia liquid
receiver.
Reasons of the Incident: Safety Valve Issues
Pictures of the Incident:
Establishment Name: Frigorifico Minerva S/A (Food Industry)
(City ‐ State) Araguaina – Tocantins
Fatalities: 0 Injuries: 60
Researching on the Internet: http://www.youtube.com/watch?v=uUBn1dtSYIw
Incident Profile # 12
Incident Title: Ammonia leakage in a Beverage Industry
Report Date: 04/15/2013
Incident Description: The ammonia leak occurred in a refrigeration system and burned a technician who
had to be taken to the hospital.
Reasons of the Incident: Operator Error or Poor Maintenance / Lack of Personal Protective Equipment
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Incident Profile # 13
Incident Title: Ammonia leakage in a Thermostatic Industry
Report Date: 04/19 /2013
Incident Description: According to the Fire Department there was a small ammonia leak in the air
released by safety valves from the refrigeration system (cold room), it was due to
high pressure occurred in a pipe segment. As a formation of cloud ammonia
appeared, water hoses were used to dissolve it and dissipate the smell of the
product. The leak did not actually hurt anyone and there was also no damage to the
environment.
Incident Profile # 14
Incident Title: Ammonia leakage in a Food Industry
Report Date: 04/28/2013
Incident Description: On April 28, 2013 about forty families had to leave their houses due to ammonia
leak in a food industry. According to the Fire Department, the ammonia refrigeration
system is used to cool the milk pasteurization process and the leakage occurred
after a problem with a safety relief valve fitted in the ammonia liquid receiver.
Roughly 300 Kg of ammonia was released to atmosphere.
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Incident Profile # 15
Incident Title: Ammonia leakage in a Food Industry
Report Date: 05/13/2013
Incident Description: The company staff said that the ammonia leakage was minimal and it was due to a
mechanical failure on refrigeration system
Incident Profile # 16
Incident Title: Ammonia leakage in a Refrigerated Warehouse
Report Date: 05/23/2013
Incident Description: The Fire Department had much work to contain an ammonia leak in the Bacacheri
neighborhood in Curitiba city. The leak occurred in a refrigerated warehouse that
uses ammonia as refrigerant for cold rooms. The leak did not actually hurt anyone
and there was also no damage to the environment.
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Incident Profile # 17
Incident Title: Ammonia leakage in Beverage Industry
Report Date: 05/26/2013
Incident Description: An ammonia leak on the premises of AmBev, a beverage industry, located in
Jacarei city, would have caused the intoxication of four employees. According to the
director of the Food Union of Sao Jose dos Campos, the leak occurred in the early
hours on Sunday 26 during maintenance in the plant ammonia pipeline of a
refrigeration system. "The accident happened in the transportation of ammonia
storage tanks to the truck," said union representative.
Incident Profile # 18
Incident Title: Ammonia leakage in a Food Industry
Report Date: January /2012
Incident Description: Brazilian Justice condemns the Company Minerva S/A in Araraquara to pay R$
200,000 for ammonia leak. Punitive damages are due to lack of security features.
The irregularities were identified from the occurrence of an ammonia leak recorded
in January 2012, which hit one of the workers
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Incident Profile # 19
Incident Title: Ammonia leakage in a Food Industry (Poultry Slaughterhouse)
Report Date: 01/30/2012
Incident Description: Four employees of a poultry slaughterhouse were intoxicated by ammonia leak in
the city of Nova Aliança. According to an official of the industry, the ammonia
leakage would have occurred in a cooling room in the afternoon of Monday 30.
Incident Profile # 20
Incident Title: Ammonia leakage in an Ice Plant
Report Date: 05/01/2012
Incident Description: An ammonia leak in refrigeration system of an ice plant forced authorities to isolate
for nearly three hours in an area Cairu Avenue, in the north of Porto Alegre. At
least one person got sick and had to receive medical care but she was well.
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Incident Profile # 21
Incident Title: Ammonia leakage in a Refrigerated Warehouse
Report Date: 05/28/2012
Incident Description: The ammonia leak occurred in a refrigerated warehouse called Marfrig in Nova
Santa Rita, in the metropolitan region of Porto Alegre, it was considered an average
accident severity by the State Foundation of Environmental Protection (Fepam).
The accident was isolated and occurred during a maintenance routine on
refrigeration system. A cloud of 30 cubic meters of ammonia spread through the air
and 11 intoxicated people with ammonia gas need to be taken to the hospital.
Incident Profile # 22
Incident Title: Ammonia leakage in a Refrigerated Warehouse
Report Date: 05/29/2012
Incident Description: A Refrigerated Warehouse in Sao Gabriel do Oeste, located 133 km from Campo
Grande city presented an ammonia leak on Tuesday 29. The Fire Department was
called to check the incident. According to refrigerated warehouse manager the
ammonia leak was due to pipework ruptured and no one was intoxicated with
ammonia gas.
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Incident Profile # 23
Incident Title: Ammonia leakage in a Poultry Slaughterhouse
Report Date: 07/04/2012
Incident Description: The leak occurred on Wednesday 4 and started in the machine room of a poultry
slaughterhouse with 800 employees located in Para de Minas city. Noticing a strong
smell of ammonia an employee attempted to close a service valve from refrigeration
system. The pipework broke and ammonia spread rapidly by plant. Forty-seven
employees were intoxicated and they were taken to two hospitals to receive
medical care but all of them were well.
Incident Profile # 24
Incident Title: Ammonia leakage in a Food Industry
Report Date: 08/14/2012
Incident Description: Thirty-three people were hospitalized after an ammonia leak at BRF food industry
late on Tuesday 14, in the Nova Mutum located 269 km from Cuiaba city. According
to the Fire Department, after finding the gas leak the place was emptied. BRF
reported that the ammonia leak was caused by a failure in refrigeration system of a
freezing tunnel.
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Incident Profile # 25
Incident Title: Ammonia leakage in a Cattle Slaughterhouse
Report Date: 09/17/2012
Incident Description: The Navirai Fire Department was asked this morning to attend an ammonia leak
from a refrigeration system at JBS industry located in Navirai city.
Incident Profile # 26
Incident Title: Ammonia leakage in a Poultry Slaughterhouse
Report Date: 10/24 /2012
Incident Description: According to the Fire Department, 40 Kg of ammonia leaked from a refrigeration
system (cold room) of a poultry slaughterhouse in Uberlandia city. This accident
happened due to operator error when he was closing a service valve of the system.
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Incident Profile # 27
Incident Title: Ammonia leakage in a Refrigerated Warehouse
Report Date: 03/09/2011
Incident Description: The leak occurred on Wednesday 9 around 6:15 a.m. and roughly 2000 Kg of
ammonia gas leaked from the refrigeration system to the atmosphere. The
ammonia leak occurred through a main solenoid valve fitted in the liquid line that
supplied the cold room evaporators. There was no information about the victims
Reasons of the Incident: and the location was isolated.
Incident Profile # 28
Incident Title: Ammonia leakage in a Cattle Slaughterhouse
Report Date: 03/15/2011
Incident Description: An ammonia leak was recorded on the morning of March 15 in the Boi Bravo (Cattle
Slaughterhouse), located in Uberaba city. Only one person was suspected of
having inhaled the substance and he was taken to the hospital to receive medical
care. The ammonia leak occurred when the refrigeration technicians were testing a
new refrigeration system that was expanded and two new service valves presented
ammonia leak.
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Incident Profile # 29
Incident Title: Ammonia leakage in a Food Industry
Report Date: 04/05/2011
Incident Description: An ammonia leak occurred at around 01:40 p.m on Tuesday 5, in Mairipora city in
Sao Paulo. According to the Fire Department, this incident happened in a food
industry. Nine women employees, including a pregnant woman, were intoxicated.
They were taken to the hospital and were under observation.
Incident Profile # 30
Incident Title: Ammonia leakage in an Ice Plant
Report Date: 07/08/2011
Incident Description: An Ammonia leak occurred in an Ice Plant and scared neighborhood in Fortaleza
city.
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Incident Profile # 31
Incident Title: Ammonia leakage in a Food Industry
Report Date: 09/12/2011
Incident Description: The ammonia leak began in the machine room due to the automatic activation of a
safety valve fitted on refrigeration system. The toxic gas spread rapidly by some
sectors of the company reaching 10 people who worked at the site and had to be
taken to the hospital.
Incident Profile # 32
Incident Title: Ammonia leakage in a Cattle Slaughterhouse
Report Date: 10/17 /2011
Incident Description: The ammonia leak occurred on the afternoon on Monday 17 at the Matadouro
Municipal (Cattle Slaughterhouse), located in Juiz de Fora, Minas Gerais, the
technicians concluded that the incident was caused by a compressor mechanical
failure. According to the director of the company, the report points out that the gas
leaked through compressor shaft seal. The leak caused the immediate evacuation
of the building where worked about 200 employees. The strong smell of the product
caused nausea and dizziness in some workers. Some surrounding residents fled
their homes and waited in open areas until the gas has dissipated.
Reasons of the Incident: Faulty Design or Fabrication (compressor shaft seal failed)
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Incident Profile # 33
Incident Title: Fire in a food factory (poultry slaughterhouse) with Ammonia leakage
Report Date: 10/20/2011
Incident Description: Company officials said that fire started in the sausage packaging sector. According
to the Fire Department, there was ammonia leak through of a cold room. The Fire
Department also reported that no one was injured in the accident or suffered
poisoning, because when the fire started all 200 sector employees were having
dinner.
Incident Profile # 34
Incident Title: Ammonia leakage in a Food Industry
Report Date: 11/30/2011
Incident Description: Twelve people were poisoned by ammonia leaked that occurred in a refrigeration
system from Palmali Food Industry this morning, in Maringa city. All patients were
taken to the Santa Rita Hospital. According to the firefighters the ammonia leak
occurred due to a ruptured welding on pipeline, made the day before.
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Incident Profile # 35
Incident Title: Ammonia leakage in Refrigerated Warehouse
Report Date: 06/29/2010
Incident Description: An ammonia leak occurred on refrigerated warehouse from Citrosuco in Santos
harbor, near the Channel 4, it mobilized the Environmental Company of the Sao
Paulo State (Cetesb). The incident occurred during maintenance of a refrigeration
system, which uses ammonia as a refrigerant in the juice cooling. During the
operation one of the service valve failed, releasing the ammonia into the
atmosphere.
Incident Profile # 36
Incident Title: Ammonia leakage in a Food Industry
Report Date: 10/8/2010
Incident Description: Four employees were servicing on refrigeration system of a cold room when one of
the ammonia pipework burst. One technician (called MR) and another coworker
was less than a meter away from the spill, about four meters from the ground. The
ammonia has spread locally very quickly and reached two other workers who were
on the ground. MR was directly hit by gas and was the one who had more injuries
and he couldn’t leave the cold room alone. The other three employees left the
scene and returned then using masks to save their colleague MR. After spending
69 days in the Hospital MR died on Saturday 16, 2010
Reasons of the Incident: Operator Error or Poor Maintenance / Lack of Personal Protective Equipment
Pictures of the Incident:
Establishment Name: Tramonto Alimentos S.A (Food Industry)
(City - State) Morro Grande – Santa Catarina
Fatalities: 1 Injuries: 3
Researching on the http://zonaderisco.blogspot.com.br/2010/10/vazamento-de-amonia-em-
Internet: agroindustria.html
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Incident Profile # 37
Incident Title: Ammonia leakage in a Poultry Slaughterhouse
Report Date: 11/17 /2010
Incident Description: Ammonia leak at a poultry slaughterhouse takes dozens of employees to hospitals
The ammonia gas leak in a refrigeration system from company Averama in
Umuarama city left 40 workers hospitalized. The ammonia leak occurred in the cold
room due to a rupture of a pipeline. Throughout the company were 400 employees
who had to leave hurriedly. Another 200 people worked in the administrative and
also had to leave their workplaces.
Incident Profile # 38
Incident Title: Ammonia leakage in a Cattle Slaughterhouse
Report Date: 12/13/2010
Incident Description: Ammonia leak occurred on Monday 6th in a Cattle Slaughterhouse in Terenos city,
may have triggered reactions in at least 60 employees. The problem was noticed
during the slaughter of five heads, an official reported. Tiles were removed to
improve air circulation, but the smell was strong. The pipeline was changed to
repair the leak.
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