INCIDENT DUE TO THERMAL EXPANSION OF AMMONIA

At approximately 7:10 a.m. on June 11, 2008, Operators at the C2 unit (Plant 2) in C building were injecting 60-psi steam at a temperature of approximately 400-degrees Fahrenheit into a precooler, heat exchanger Model Number E300-G, to purge the process of the latex products. Latex was on the tube side and ammonia was on the shell side. The steam was injected into the tubes heating the ammonia on the shell side. The precooler over pressured, rupturing the shell, releasing ammonia into the environment. Employee #1 was found dead beneath the debris in the area of the heat exchanger several hours after the explosion occurred. Five contracted employees were severely exposed to ammonia. Employees #2, #3, #4, and # 6 were hospitalized. Employee #5 received first aid and was released. 

Source:OSHA.gov