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Notification of order after investigation of ammonia leak – Naturkraft AS

An investigation of the incident on 30 May 2013 when two employees in Naturkraft’s gas-fired power station at Kårstø were exposed to ammonia solution has identified serious breaches of the regulations. The PSA has now notified the company of an order.


A leak of ammonia solution (ammonium hydroxide) occurred on 30 May 2013 during maintenance in Naturkraft’s gas-fired power station at Kårstø north of Stavanger.

During work to replace a valve on the filling line to an ammonia tank, ammonia solution (ammonium hydroxide) began to spurt out when the flange was broken.

One person suffered corrosive injuries to their skin and eyes, while another breathed in ammonia vapour and suffered minor bruising to their arms and feet.

The PSA resolved on 3 June 2013 to conduct its own investigation of this incident.

In the PSA’s view, this incident had a substantial potential. Under different circumstances, it could have resulted in very serious personal injuries and, in the worst case, the loss of human life.

The investigation has identified serious breaches of the regulations.

On the basis of the findings made by the investigation, the PSA hereby gives notice of the following order to Naturkraft AS:

Pursuant to section 69 of the framework regulations on administrative decisions, see sections 10 of the framework regulations on prudent activities, 6 of the management regulations on management of health, safety and the environment, 17 of the management regulations on risk analyses and emergency preparedness assessments, and 50 of the technical and operational regulations on competence, Naturkraft AS is ordered to review its routines for conducting risk assessments and educating personnel, identify improvement measures and implement these by 1 December 2013. See chapter 5 of the investigation report.

The PSA must be informed when the order has been carried out.


Explanation of the terms “order” and “notification of order”
An order is an administrative decision made pursuant to the regulations. Before the PSA issues an order, it usually submits a notification of order to the companies involved.

A notification of order is neither a measure nor a warning of sanctions, but part of the PSA’s administrative process in accordance with the established rules of procedure. The notification is just a first step before an administrative decision is made.

An order is a powerful preventive measure and legally binding on the recipient.