Know Your Incident Timelines


Like a good science fiction plot, any ammonia-related incident has two parallel timelines. Making sure you’re aware of both of them, even before anything happens, can make the difference between public relations and operational horror story, and a good outcome.

Take one incident where the lack of awareness by facility staff led to a lot more chaosthan should have been expected. It was a normal work shift when several employees coming into a process area smelled a very strong, irritating odor.

Several of them knew that the refrigeration department had just a short time earlier been working on the refrigeration system in the area. But they didn’t know, or remember, who to call about the strong smell. Panicking, more than one of them called 911 as they all rapidly exited the area to the outside.

Almost fifteen to twenty minutes later, someone finally remembered to call the facility safety manager, who quickly drove to the site. When he got there, he found several ambulances, fire department engines, police and sheriff department cruisers, and, of course, the media. As the safety manager approached the scene, he also noticed what appeared to be several employees lying on the ground, some seemingly convulsing. In the safety manager’s words, “It was chaos!”

In this particular event, the employees did not remember who was supposed to be called, and what the facility emergency plan was. The safety manager quickly contacted the refrigeration department and began investigating the incident.

It was soon learned that this was not an ammonia release, or even any other kind of release. What the employees had smelled turned out to be a cleaning agent used for sanitation of the process equipment in the area.

Nevertheless, the damage was already done. In a very short time, news of this incident quickly spread through the media. One regulatory agency called the safety manager asking why they had not reported this serious ammonia release. From the quick investigation the safety manager was able to explain there was “not an ammonia release.”

A lesson learned from this event is there are two timelines that should always be considered. One is a timeline that should begin well in advance of any incident. The other timeline begins at the moment of the event. And both are very important to always keep in mind.

The “before event” timeline is concerned with what might be done to prepare employees for any type of incident. This means companies should train all employees on several things, which can include: the emergency plan (action or response); what specific actions should be taken when an event occurs (these may vary depending on the emergency); what the chain of command is and who should be notified within a company; how to properly evacuate all areas in a facility; where a pre-determined gathering point is outside of the facility; what areas within the facility could be used for shelter-in-place; how to identify a chemical; how to perform basic first-aid; and who should talk to the media. Training drills that prepare employees to better respond when an event occurs are essential to the “before event” timeline.

The event described above would have likely unfolded much differently, with less of an impact to the company, if “before event” training had established a reflexive employee response. At the least, employees would not have made several separate 911 calls indicating that there was a large emergency.

In this case, the correct facility personnel would have been contacted, and the facility would have been exited in a safe and organized manner. In the end, the panic experienced by some of the employees was not from a physical effect of a chemical, but a psychological effect that caused “panic attack” symptoms, including minor convulsions.

Meanwhile, the second timeline begins the moment the event occurs. In this scenario, several actions should take place during a very short time period. To illustrate this timeline let’s look at another event of an ammonia release occurring outside of a refrigerated facility and examine some of the approximate times that events occur as the incident unfolds.

In this case, a 150-psig relief valve on a surge drum released. The estimated wind speed was approximately 7 mph, which was normal for the area. But in these few minutes, two minutes to be exact, the wind carried the ammonia over 1000 feet, which was well past the facility property line.

During the first couple of minutes, the ammonia could be smelled outside of the facility property line. There was no plan in place to determine how to rapidly notify or alert the public of what to do if an ammonia release occurred. In this event, it was actually someone outside the facility property that called 911. The 911 dispatcher quickly notified responders, which in this case included members of the fire department and police department. Once the call arrived at the fire department, the responding fire company engine quickly prepared, left the station, and in about seven minutes was on site at the facility. A police unit arrived shortly after that.

Once the fire department arrived, it took a few more minutes for the engine captain to determine what the event was, the status of the facility employees (they were all accounted for and safe), and where to set up exclusion areas.

With the identification and confirmation that this was an ammonia release, the fire captain radioed fire-dispatch to request the hazmat team to respond. It would be over another 30 minutes before the hazmat team arrived. State Patrol (in this particular state, the designated incident commander for hazmat events) was also contacted by the fire department to coordinate what was happening. The local ambulance service also sent an aid unit, which arrived a few minutes after the fire engine.

In the follow-up to the ammonia release, it was stated by the Office of emergency management that whoever owns the chemical is responsible for notifications, including alerting the public of the emergency. This was not new information, but the lesson learned was potentially how little time was available to accomplish the notification of the people and businesses around the facility or in the potentially affected area.

As was found in this event, the ammonia smell went over 1,000 feet in the first few minutes of the release, which meant there was not sufficient time to make phone calls to all potentially affected offsite people or businesses. The proper response would have required a plan to have been developed and coordinated with local agencies on how to rapidly notify the surrounding area. This plan would also involve informing and educating the surrounding population prior to future events.

Another lesson learned was that since this particular facility had an “emergency action plan” and would rely on outside emergency responders, the length of time it would take to have the properly trained and equipped hazmat responders on the scene was well past the first 30 minutes of the event.

Analysis of the event timeline turned out to be an eye-opener for facility personnel, illustrating the importance of close coordination with local emergency responders and possibly a local refrigeration contractor to improve the means and methods of dealing with an ammonia release in a timely, safe, and effective manner.

These two events illustrate lessons that can be learned to improve some of the actions and responses to emergencies. The first event shows the importance of doing proper training in a timeline well in advance of an incident, and that properly trained people should both be able to safely evacuate and be able to communicate to the right people, agencies, and media.

The second incident shows the importance of developing an emergency plan that takes into account the rapid timeline of actions that should occur during an ammonia event. Also the importance of coordinating with local responders in developing an overall action or response plan that will provide the most effective, efficient, and timely actions.

Have you considered the timelines before and during an emergency at your facility?