Why did the ammonia leak occur?

While the Hod Hefer tragedy could have been a lot worse, if government agencies and consumers do not compel industry to take preventative measures, the next tragedy will certainly be worse.

November 12, 2014 23:16
3 minute read.
Emek Hefer ammonia

Scene of ammonia leak in Emek Hefer. (photo credit: POLICE SPOKESPERSON'S UNIT)


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Last Thursday night a leak of toxic ammonia from the Hod Hefer factory near Netanya resulted in the death of a firefighter. Twenty more were sent to the hospital for emergency care.

Hundreds of citizens and rescue personnel were exposed and dozens suffered from adverse health effects. In response the vice president of the company stated that “it could have been a lot worse.” While this is true, it is clear that the leak should not have happened in the first place. But unfortunately it did – and it wasn’t the first time.

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We live in a small country. The border between residential communities and industrial areas often consists of a fence.

The toxic chemicals that are stored in factories routinely enter residential areas; it occurs on a daily basis at small levels, and multiple times a year in high concentrations that result in death and illness. In the past few months many similar events have happened, including a chemical leak at a factory in Atlit and a fire at a petrochemical factory in Haifa resulting in significant exposures that impact our health.

The obvious questions have already begun to be investigated: Why did the leak occur, why did it take so long to stop, and how did a trained firefighter die as a result? But we need to look beyond this particular incident to fully understand the state of industrial safety in order to prevent these tragedies from happening again.

When industrial accidents occur in Israel there is a tendency to blame a single individual. When three Haifa chemical workers were killed and dozens injured in 2010, the response from the factory managers and the Environmental Protection Ministry was that it was an isolated incident caused by workers who did not follow protocol.

When two children died in Jerusalem last year it was blamed on a pesticide sprayer who did not follow protocol.

And last week, when thousands were evacuated from homes near the Hod Hefer factory and Samir Assli, the firefighter who died, didn’t return home from work, the investigation focuses on the mistake of a lone contractor.

These events do not occur in a bubble.

When industrial accidents happen, even though they are unintended they are not “accidents.” They are often the result of neglect, and occur within the context of a system that blames the workers first while failing to promote a culture of industrial safety and corporate responsibility.

In truth, when these “accidents” happen we are all to blame. The relevant government ministries are to blame for not enforcing current regulations and promoting stricter ones, and corporations and safety managers are to blame for not instituting precautionary measures, promoting a safety culture and incentivizing prevention. The occupational medicine physicians are to blame for not emphasizing to patients the potential clinical consequences of their work and the importance of safety equipment to their health. The public is to blame for not demanding that the companies we buy from ensure the health of their workers and neighboring communities by all means necessary.

As an occupational medicine physician and researcher in occupational epidemiology I have seen the reality on factory floors throughout the world.

Industrial workers need to be incentivized to take safety seriously. Factories have to routinely monitor compliance with safety protocols; if a worker is not compliant, they need to be told they can’t work – before an accident happens.

Too often I’m told by safety managers in Israel that if a worker doesn’t follow safety procedures, then it is his problem.

Really, it is all of our problem.

While the Hod Hefer tragedy could have been a lot worse, if government agencies and consumers do not compel industry to take preventative measures, the next tragedy will certainly be worse.

Eric Amster MD MPH, is an occupational physician, a lecturer at Haifa University School of Public Health and scientist at the Harvard School of Public Health. He is a alumni of the Fulbright exchange of professors and students, which is managed by the United States-Israel Educational Foundation. Shahar Fertig is a Mendeley member in Social Sciences from Haifa.

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