Release Resulted in the Death of Six Workers
Washington D.C. December 11, 2023 – Today the U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final investigation report into a liquid nitrogen release at the Foundation Food Group (FFG) facility in Gainesville, GA, on January 28, 2021, that fatally injured six workers. The CSB’s final report identifies a number of equipment and process failures at the facility and issues a dozen recommendations to various entities, including the current owner of the facility, OSHA, and two standard-setting organizations.
The FFG facility was a poultry processing operation that used liquid nitrogen to quickly freeze prepared poultry food products. The CSB’s final report found 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 allowed the room to fill with an unsafe level of liquid nitrogen that quickly vaporized into a four- to five-foot-high deadly cloud, resulting in the death of six employees by asphyxiation. Three other FFG employees and a firefighter who responded to the incident, were also seriously injured from asphyxiation.
The CSB’s report concluded that the bubbler tube likely was bent during maintenance in the freezer room. The report also determined that the severity of the incident was worsened by FFG’s inadequate emergency preparedness -- which resulted in at least 14 employees entering the freezer room or the surrounding area to investigate the incident or attempt to rescue coworkers -- and FFG’s failure to install air monitoring and alarm devices that could have alerted workers about the hazardous vapor cloud and warned them against entering the freezer room.
The freezer involved in the incident was designed and owned by Messer LLC, which leased it to FFG. After the incident, FFG sold the facility to Gold Creek Foods, which is the current owner of the facility. Gold Creek does not now have liquid nitrogen freezing processes in the building where the incident occurred.
CSB Chairperson Steve Owens said, “This needless and senseless tragedy was completely preventable. 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 CSB’s final report emphasizes five key safety issues:
- Single Point of Failure. The immersion freezer design included a device called a bubbler tube, which was used to measure the liquid nitrogen level inside the freezer. The bubbler tube was likely bent during maintenance activity, rendering it unable to measure and control the freezer’s liquid nitrogen level. As a result, liquid nitrogen overflowed from the freezer and filled the room with vaporized nitrogen.
- Atmospheric Monitoring and Alarm Systems. There is abundant industry guidance on the importance of atmospheric monitoring when the potential for hazardous atmospheres exists. FFG, however, did not install atmospheric monitoring equipment in the freezer room.
- Emergency Preparedness. FFG did not inform, train, equip, drill, or otherwise prepare its workforce for a release of liquid nitrogen. FFG’s workforce lacked knowledge on the hazards of nitrogen, were unable to recognize an oxygen-deficient atmosphere, and lacked any equipment or Personal Protective Equipment (PPE) that would have enabled safe entry into an oxygen-deficient atmosphere.
- Process Safety Management System. FFG had no 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. The company did not evaluate the process hazards associated with the freezer, lacked written procedures and a management of change process, and did not train its workers on the asphyxiation hazards of liquid nitrogen.
- Product Stewardship. Messer owned the liquid nitrogen bulk storage tanks and the Line 4 immersion-spiral freezer and leased the equipment to FFG. At the time of the incident, Messer had institutional knowledge, experience, policies, and practices for effective product stewardship but applied those practices only to the bulk storage tanks and not to the Line 4 freezer process. Throughout its relationship with FFG, Messer identified issues with FFG’s safety practices and nonconformance to industry guidance, but despite FFG’s unsafe practices Messer continued to supply FFG with liquid nitrogen.
Investigator-in-Charge Drew Sahli said, “The CSB’s key safety issues outline the important lessons from this incident. 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.”
The CSB’s twelve safety recommendations are directed toward several entities, including the current facility owner, the manufacturer of the freezer, the Occupational Safety and Health Administration (OSHA), an industry trade association, and two standard-setting organizations.
- The CSB is calling on Gold Creek Foods to proactively engage with local emergency responders to ensure that they are aware of the chemicals being stored onsite at the facility and their potential hazards.
- The CSB is recommending that OSHA issue a national standard to address the hazards arising from the storage, use, and/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.
- The CSB is calling on the Compressed Gas Association and the National Fire Protection Association to improve their guidance on the safe use of cryogenic asphyxiants, including liquid nitrogen, and the International Code Council to update the International Fire Code to require the use of atmospheric monitoring with cryogenic asphyxiants.
Chairperson Steve Owens added, “The CSB’s recommendations are important for preventing incidents involving liquid nitrogen and lessening their severity if they do occur. 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 CSB’s board members are appointed by the President subject to Senate confirmation. The Board does not issue citations or fines but makes safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.
Please visit our website, www.csb.gov. For more information, contact Communications Manager Hillary Cohen at [email protected]