Re-Learning the Most Important Lessons

Most facility op erators believe that they and – LESSON their employees know what needs to be done in an ammonia release situation. But knowing what needs to be done is very different than knowing you will be able to do what needs to be done when the stress of an event makes reaction time and clear thinking crucial. The need for learning and re-learning of those lessons is a critical discipline. As the following three scenarios illustrate, even the most experienced professionals are not naturally immune to the uncertainty that comes in the first phase of a release.

Scenario 1: He was driving down the highway and suddenly noticed a strong smell. He asked himself, “What is that smell?” As the answer (ammonia) dawned on him, his very next thought was, “The only facility around here is mine! We have an ammonia leak! I know I’m supposed to do something, what was it?”

Scenario 2: The refrigeration operator got an alarm indicating a higher-than-normal ammonia level in the machine room. He hurried to the room and yanked the door open. An extremely strong smell of ammonia hit him and he saw a white cloud, filling most of the machine room. Slamming the door shut, he thought, “Oh man! What do I do now? Who do I call?”

Scenario 3: It was a Saturday evening, so there were few people at the plant. One of the few working noticed sirens in the distance. “I wonder what’s going on?” he thought as the sirens got closer. He went back to his work, but just a few minutes later a fire truck pulled into the plant yard. The fire officer jumped out of the truck, asking, “What’s going on?” The man responded, “Nothing that I know of.” But, the fire officer replied, “We got a call about an ammonia smell from one of your neighbors.” It didn’t take long to find the source of the release – a safety relief valve that was continuing to blow. “What do I do now?” the man thought.

There’s a common thread running through all of the above events – company personnel did not know (or forgot) what to do on the spot when an ammonia release occurred.

Knowing what to do in an ammonia release is important, but even more important is the knowledge that you and your personnel will act in a real event. That confidence is the key to staying in compliance with federal, state and local requirements, and hopefully to keeping everyone safe.

Some might think at first that not remembering what to do when an ammonia release happens is not too bad. After all, it’s an indication of just how well designed, built, and operated most ammonia systems are, that so few experience an ammonia release. Releases are usually small, have little if any effect on company personnel, and rarely affect the surrounding community or environment. Yes, sometimes our industry has larger incident, but those are rare.

Many companies have well-developed and written emergency procedures in place, their employees are routinely trained and local emergency responders know the companies’ capabilities. When an ammonia release does happen, it is an emergency, but properly trained people know what they’re supposed to do. Generally, ammonia-release incidents go fairly smoothly from discovery through termination of the event.

However, I have seen that there are a surprising number of companies that are not adequately informed about what actions they should take in the event of an ammonia release, and their employees aren’t prepared to deal with an emergency. Some of the lessons we can learn from recent releases are:

Lesson 1: A well-maintained contact list is essential.

In all of the releases mentioned above, not knowing who to contact extended the time for appropriate action to occur. In one case the primary company contact could not be reached, and it took valuable time to figure out whom else to notify. In the meantime the ammonia release continued and the ammonia spread off the company’s property.

There should always be a readily accessible, up-to-date list of who to contact in an emergency. And it’s best to have more than one contact on that list. This list can shorten the time between discovery and taking the appropriate actions.

Besides having current contacts within a company, you also should know who to contact in a timely manner at the federal, state and local levels. It may be helpful to have a contractor’s contact information on that list.

Facilities and local emergency crews should be well-prepared for the actions they need to take.

One of the releases mentioned above was large, and even though the facility had an emergency response plan, there was only one person at the facility at the time of the release that was able to respond. When the local responders arrived, they were volunteers with very limited knowledge about ammonia.

Lesson 2: Determine what level of action your company will take in an event. Ideally, a company should have an Emergency Action Plan and an Emergency Response Plan.

Some of the main aspects of an Emergency Action Plan are:

  • notification within the facility on discovery of a release, as well as proper and timely notification to federal, state, and local agencies;
  • notification to businesses, schools, residences and others near your facility;
  • evacuation of and accounting for all persons from affected areas;
  • defensive actions that may reduce the impact and/or spread of the release;
  • coordination with local emergency responders.

An Emergency Response Plan should include everything in the Action Plan, plus:

  • having sufficient personnel onsite or readily available who are trained to deal with an emergency and have sufficient and appropriate personal protective equipment to respond to the release;
  • and having personnel trained on the “Incident Command System.”

An Emergency Response Plan requires more planning, training, and equipment, but may be the better approach for your company, especially when local responders are not adequately prepared to deal with an ammonia release.

Lesson 3: Be sure that emergency drills are done regularly.

Even in the most prepared facilities, this is an area that often needs much more attention than it gets. It can be challenging to find the right time to do emergency drills, but these drills can be lifesaving.

Fortunately in all the above mentioned releases no one was injured.

Drills should be frequent enough that all personnel understand and know what they are supposed to do to remain safe. Learn and practice the actions that may be needed in an emergency. If you practice, you will develop experience and understanding that can help in an emergency even if the emergency is different than a scenario you were trained to deal with. Make emergency drills a priority.

Lesson 4: Know what incident reports must be completed and submitted.

For all of the releases I mentioned above, not knowing which reports to submit where was a common situation. The companies either forgot or didn’t know that reports on releases are required to be submitted. In the United States there should be a follow-up incident report sent to state and local (typically the LEPC) agencies. These follow-up reports may be required within 15 to 30 days after the incident; check with your state to verify the timing.

For any release you should do an incident investigation. This investigation should include at least the following: determine what “really” happened; who and what was impacted by the release; develop appropriate recommendations of actions to take that could change or improve the system, training, procedures, etc. to reduce or eliminate the possibility of a repeat incident.

The results of the investigation should be reviewed with all appropriate personnel to help them learn and be better prepared.

Do you know what to do when an ammonia release happens? Do the other people at your facility know what they are supposed to do? These are lessons we need to learn, and keep re-learning to be prepared to respond well if and when a release happens on our watch.

For additional information and training tools concerning an ammonia release, please refer to the IIAR Series II, “First Thirty Minutes” videos and other safety publications available at