The Gibson Winery Ammonia Fatality: September 21, 2012 The Result of "Let Them Die" Policies and PRofessionalization of Rescue

Abstract

On 2012, a young man was killed when he was trapped in a bathroom during an outdoor ammonia release at a winery in Sanger, California. What killed him was inhalation of anhydrous ammonia vapors. The vapor was released when an oil drain valve was opened instead of a hot gas valve near a shell and tube wine chiller. There were no other layers of protection, such as a valve plug or valve lock, or self closing valve on the oil drain valve at that time. The victim, a long term temporary employee who was the cousin of the man who opened the valve, attempted to escape through the released could of vapor and died in an exterior building hallway. Attempts to rescue the victim were thwarted by the fact that the employer had a formal policy prohibiting rescue by its employees and the resulting lack of any ammonia respirators onsite. The origin of such policies and the need for onsite preparedness is commented upon.