IIAR

Having enthusiasm LESSON for your work and a desire to accomplish something is good. I have worked with many people in the industrial refrigeration field that are enthusiastic, fun to be around, and even in challenging or stressful situations they have worked through issues in a positive manner.

But I also have seen some instances where enthusiasm quickly overwhelmed the knowledge and training level of facility personnel, which put them and others in an unsafe situation.

In every work environment, a manager’s responsibility is to safeguard that enthusiasm. And while that often means encouragement, it also means cultivating a high level of situational awareness so that the talent of your people can thrive in a safe environment. For this edition of Lessons Learned, I’m going to focus on the dangerous side of enthusiasm.

Several years ago I was involved in the startup of a distribution center that was mostly low temperature storage, using ammonia as the refrigerant. This facility was in a Spanish speaking country in South America, and since I speak only a few words of Spanish, I relied on others who were bi-lingual. As the startup went along, I communicated to the installing contractor and the operators, through an interpreter, about various aspects of the gas powered liquid recirculation refrigeration system and the refrigeration computer control system.

A few days into system start-up, as we arrived at the facility, I could immediately tell from the frenzied activity of the team and that “deer in the head lights” look that something was definitely wrong. We were asked to immediately come to the machine room. When we got to the door of the machine room, we heard that distinctive, loud, sound of pressure being released, similar to a relief valve discharging. At the same instant we saw a white cloud rapidly develop just below a low pressure receiver and float down the walk space between the compressors. The release seemed to last only a few seconds, but it certainly could have been longer – as time perception often gets distorted during an emergency (another lesson learned). Two operators had started to disconnect the relief discharge line from the relief valves on a liquid transfer vessel (LTU).

Having no idea what was happening or how soon this might happen again, we first directed others to ventilate the room. At this point I realized – that in my own enthusiasm to get this system operational – I had neglected to communicate a few very important pieces of information to the operators and others working in and near the ammonia system.

I, or someone else, should have instructed everyone to continually ask themselves: What is this chemical?; What are we doing with it?; and, What can it do to you?

The answer to that last question would have addressed not only the situational awareness that was missing, but how to properly protect yourself, and important steps to consider when a release occurs.

The lesson I learned here was “DO NOT” skip the step of teaching and verifying that all those involved in a project have and know how to use the appropriate personal protective equipment, and have reviewed procedures to follow if a release happens.

As I mentally kicked myself for not being able to speak Spanish and better prepare the operators, I saw two refrigeration operators – with good intentions, but an over-abundance of enthusiasm – that were in the machine room near the release point trying to do something.

One of these men was standing right next to a LTU located directly below the low pressure receiver, and the relief valve that appeared to be releasing was on that LTU. The other person stood within arm’s reach of the first person. The only PPE the man next to the LTU had on was a face shield. The other man didn’t even have that. If the release happened again, the man nearest the LTU could have been seriously injured, or killed.

I stood in a safe location, but was extremely scared of what could happen to those two men if they stayed where they were. Through an interrupter I said those men need to “Get out of there!” It seemed like it took a long time before they finally, and reluctantly, did leave the machine room. Just after they left, a release happened again. These men again wanted to get back in there and stop the leak. We told everyone that “No one” is going back into that machine room until we get some idea of what is happening, make sure there was proper PPE worn, and it is safe to enter.

As the release happened again, and with people no longer in danger, we watched and thought it didn’t look like it was coming from the relief valve on the LTU. Investigating further, we noticed that most of the main relief header running down the middle of the machine room was covered in frost, and one particular line going up through the roof was also frosted.

Why was this vertical relief line frosted? We went up on the roof to see where this line came from and there we found the source of the continuing release. The release source was a roof mounted purger that had its relief connected into the main relief header system. The purger was not functioning properly and was periodically filling up with liquid, building up pressure, then blowing its relief. Each discharge was a small amount of liquid ammonia, which vaporized as it traveled down the relief piping system and blew out the loosened relief discharge piping connection at the LTU.

In this incident, the two operators, in their enthusiasm, had focused on what they thought was the cause of the release. They had rushed in to stop the leak without proper PPE, not understanding what was happening, or even looking for other clues that could have lead them to the real cause. Their enthusiasm nearly cost them their lives.

The lesson that these men and all of us should learn is: if you don’t have the proper training, proper PPE, and do not understand what is or what can happen “DO NOT GO.” Wait until there are trained and knowledgeable people with the proper equipment to safely address the incident. The second lesson is to have training, adequate and knowledgeable leaders on site, and sufficient PPE available and ready to use prior to introducing ammonia into a system, or a portion of a system.

Generally, people are interested in doing their work well and helping, but many times they let their enthusiasm to get something done interfere with taking that essential step of stopping and thinking, “Is what I am about to do safe?; Do I and others have the proper training, PPE, and equipment to handle this situation?” Take time to consider what is happening, or could happen. And if you’re in doubt, ask some other knowledgeable or experienced person to take a look.

Yes, we all have times when there are deadlines we need to meet, but don’t be in such a rush that your enthusiasm to do good work gets in the way of doing your work safely, and most importantly, training others to ask if they are doing their work safely.