A federal safety board released on Monday its final investigation report into a January 2021 liquid nitrogen leak at a Gainesville poultry plant which killed six workers and seriously injured four others.
The U.S. Chemical Safety and Hazard Investigation Board report comes nearly three years after the Jan. 28, 2021, incident at the former Foundation Food Group facility on Memorial Park Drive in Gainesville.
The report identified a number of equipment and process failures at the facility, and issued a dozen recommendations to various entities, including the current owner of the facility (Gold Creek Foods), OSHA and two standard-setting organizations.
Specifically, the report determined that the liquid nitrogen release was caused by the failure of the liquid nitrogen control system in a freezer room due to a bent “bubbler tube.” The bent tube reportedly allowed the room to fill with an unsafe level of liquid nitrogen which vaporized into a four- to five-foot-high deadly cloud.
The report said the bubbler tube was likely bent during maintenance.
Additionally, the report said the incident was worsened by Foundation Food Group’s “inadequate emergency preparedness.” At least 14 employees entered the freezer room to investigate the incident, which the report said could have been avoid had Foundation Food Group installed air monitoring and alarm devices in its facility.
The freezer involved in the incident was designed and owned by Messer LLC, which leased it to Foundation Food Group. Foundation Food Group sold the facility to Gold Creek Foods following the incident. Gold Greek does not currently use liquid nitrogen processing in the building where the incident occurred.
“This needless and senseless tragedy was completely preventable,” CSB Chairperson Steve Owens said. “Six people died and four others were seriously injured because of a bent tube and FFG’s failure to have critical monitoring equipment and warning alarms and FFG’s failure to adequately train and equip its employees to respond safely to a liquid nitrogen release.”
The final report focused on the following five key safety issues:
- Single Point of Failure – The bubbler tube was unable to measure and control the freezer’s liquid nitrogen level after it was bent.
- Atmospheric Monitoring and Alarm Systems – Foundation Food Group did not install atmospheric monitoring equipment in the freezer room even though there is abundant industry guidance for the installation of the equipment when the potential for hazardous atmospheres exists.
- Emergency Preparedness – FFG did not inform, train, equip, drill or otherwise prepare its workforce for a release of liquid nitrogen. The report also said the facility did not have any equipment for its personnel that would have allowed for safe entry into an oxygen-deficient atmosphere.
- Process Safety Management System – FFG did not have a documented process safety management policy and allowed the job position responsible for safety management to be vacant for more than a year prior to the incident.
- Product Stewardship – Messer, which leased the freezer equipment to FFG, had institutional knowledge, experience, policies and practices for effective product stewardship but applied those practices only to bulk storage tanks and not to the Line 4 freezer process. Messer identified issues with FFG’s safety practices but continued to provide them liquid nitrogen, according to the report.
“The CSB’s key safety issues outline the important lessons from this incident,” Investigator-in-charge Drew Sahli said. “Workers were not aware of the deadly consequences of a liquid nitrogen release – ultimately trying to save their colleagues led to them sacrificing their own lives. This is a known hazard, and better training and communication could have prevented such a tragedy.”
As part of the report, the CSB made several recommendations. Specifically, they called on Gold Creek Foods to proactively engage with local emergency responders to ensure that they are aware of the chemicals being stored onsite and their potential hazards.
They also recommended that OSHA issue a national standard to address the hazards that are possible from the storage, use or handling of cryogenic asphyxiants – which include liquid nitrogen.
“The CSB also is calling on OSHA to specifically cover liquid nitrogen in the agency’s regional emphasis programs for poultry processing and food manufacturing,” a release from the CSB said.
Finally, the CSB called on the Compressed Gas Association and the National Fire Protection Association to improve their guidance on the safe use of cryogenic asphyxiants.
“The CSB’s recommendations are important for preventing incidents involving liquid nitrogen and lessening their severity if they do occur,” Chairperson Steve Owens said. “The hazards of liquid nitrogen must be clearly communicated to workers, and the safety management systems for operations that use liquid nitrogen must be improved.”
The full report can be viewed here.
