An ammonia leak occurred in the machinery room of an unoccupied arena. An employee was attempting to add oil to an ammonia compressor when he observed a leak (fill hose was not attached). Approximately 200 lbs ammonia was released.
Qualified person was trained, but with minimal experience in this procedure. No written procedure was available, and an error occurred while executing the procedure. The shut-off valve type (wrench-operated,
mufti-turn, no position indicator) added complexities to the process.
Source: British Columbia Safety Authority
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