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Safety Recommendation Details

Safety Recommendation H-04-024
Details
Synopsis: About 11:50 a.m. central daylight time on April 15, 2003, a nonspecification cargo tank used by River Valley exclusively for agricultural purposes as a nurse tank split open after being filled with anhydrous ammonia at River Valley’s nurse tank filling facility near Calamus. About 1,300 gallons of the poisonous and corrosive gas escaped, seriously injuring two nurse tank loaders, one of whom died from his injuries 9 days after the accident. Both loaders suffered more than 50 percent body surface area chemical burns, eye injuries, and inhalation injuries. The Safety Board determined that the probable cause of the accident was inadequate welding and insufficient radiographic inspection during the tank’s manufacture and lack of periodic testing during its service life.
Recommendation: The National Transportation Safety Board makes the following safety recommendation to the River Valley Cooperative: Review manufacturers’ material safety data sheets for anhydrous ammonia, the National Institute for Occupational Safety and Health’s HAZOP of Anhydrous Ammonia Use in Agriculture, and the Emergency Response Guidebook and establish written emergency procedures for employees to follow when an anhydrous ammonia release poses an inhalation hazard.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Highway
Location: Calamus, IA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA03MZ001
Accident Reports: ​Nurse Tank Failure with Release of Hazardous Materials
Report #: HZM-04-01
Accident Date: 4/15/2003
Issue Date: 7/1/2004
Date Closed: 1/31/2005
Addressee(s) and Addressee Status: River Valley Cooperative (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: River Valley Cooperative
Date: 1/31/2005
Response: The Safety Board understands that since the April 15, 2003, accident, the RVC has reviewed the circumstances of the accident with the U.S. Department of Transportation, the Environmental Protection Agency (EPA), the Iowa Department of Agriculture, the Iowa Occupational Safety and Health Administration, and local government authorities. As required by the EPA, the RVC established a risk management program for anhydrous ammonia, which includes information on what to do in the event of a serious release or other emergency actions, and includes instructions on personal safety. The risk management program was audited in December 2003 on site at Calamus and found acceptable by EPA staff. Further, as requested, RVC has reviewed its employee safety training programs, along with a review of the manufacturers' material safety data sheets for anhydrous ammonia, the National Institute for Occupational Safety and Health's HAZOP of Anhydrous Ammonia Use in Agriculture, and the Emergency Response Guidebook. The Safety Board has reviewed the risk management program document and has determined that it meets the intent of the recommendation. We believe that the guidance on immediately evacuating the area in the event of an anhydrous ammonia release, however, could be more conspicuously highlighted and emphasized in the risk management program; we encourage the RVC to make that change. We further note that the RVC annually conducts refresher training for all employees involved in the sale, storage, handling, or distribution of anhydrous ammonia. In this regard, we note your statement that you will continue to stress the importance of immediately evacuating the area in the event of an anhydrous ammonia release to reduce personal exposure to escaping liquid and vapor concentrations. Because the RVC's actions fully address Safety Recommendation H-04-24, it is classified "Closed--Acceptable Action."

From: River Valley Cooperative
To: NTSB
Date: 9/14/2004
Response: Letter Mail Controlled 9/21/2004 1:12:39 PM MC# 2040573 Since its occurrence on April 15, 2003, River Valley Cooperative has had the opportunity to review this incident with the Federal DOT, Federal EPA, Iowa Department of Agriculture, Iowa OSHA, and local government authorities, as well as the NTSB investigation team. Mistakenly, we believed that the NTSB team had gathered documentation of our training and emergency procedures from contacts they had made with the other organizations mentioned above. In particular, we were of the belief that the following information provided to Iowa OSHA officials was available to NTSB for your consideration: a. Safety information b. Requirements for respiratory protection at anhydrous ammonia facilities c. Material Safety Data sheets (MSDSs) d. Emergency response procedures e. Training records Enclosed are copies of this information. You will note that the majority of this information is from the Risk Management Program prepared, as required by the United States Environmental Protection Agency, under the provisions of the Risk Management Planning Process. Specifically you are directed to the section of the Risk Management Program entitled "What should be done in the event of a serious release?" followed by the "Emergency Action Steps" that are to be taken. Step 1 states in part, "The first concern in the event of a serious release is personal safety". You will also note that this is Step 1 in the section entitled "Emergency Action Steps-Minimally Staffed Remote Facilities. This Risk Management Program was audited in December of 2003 on site at Calamus by Region VII EPA officials for U.S. EPA. Specifically, the Risk Management Program for our Calamus site was audited. With minimal revisions, our Risk Management Program was found to be acceptable by EPA staff. River Valley Cooperative consistently, on an annual basis, conducts refresher training for all our employees who are involved in the sale, storage, handling and distribution of anhydrous ammonia. We train our employees to meet or exceed the requirements as set forth in Parts 3.1.1, 11.6.1(1), and 12.4.1 of the American National Standards Institute's (ANSI) "Safety Requirements for the Storage and Handling of Anhydrous Ammonia". In 1997, an anhydrous ammonia safety training program and manual was developed by Agricom, Inc. (a then, wholly-owned subsidiary of the Agribusiness Association of Iowa). River Valley Cooperative was a financial sponsor in the development of this program. The program was developed with direct input by representatives from industry, the Iowa Department of Agriculture and Land Stewardship, the Iowa DOT, insurance companies, and other interested parties. This program has been utilized not only in Iowa but in other states as a model for employee safety training on anhydrous ammonia. Parts of this material have been incorporated into our training programs over the years since 1997. Please find enclosed a copy for your perusal. River Valley Cooperative personnel have always been trained to leave the scene of a release and to minimize their personal exposure. Our emphasis has always been on employee safety. We continue to reinforce this philosophy at each of our safety training events. We will continue to stress the importance of immediately evacuating the area in the event of an anhydrous ammonia release to reduce personal exposure to escaping liquid and vapor concentrations.