Accident: Evergreen Packaging Paper Mill - Fire During Hot Work
Location: Location: Canton, NC
Accident Occurred On: 09/21/2020 | Final Report Released On: 09/24/2021
Accident Type: Release
Investigation Status: The CSB's investigation was approved at a public board meeting on September 24, 2021.
On Monday September 21, 2020, a fire occurred at the Evergreen Packaging Mill in Canton, NC. During a scheduled maintenance event, a fire occurred during a repair to a process unit. Two contractors were fatally injured as a result of the incident.
Update all documentation, training, and orientation materials provided to contractors pertaining to hot work to reflect Evergreen Packaging’s internal definition of hot work. The materials should make clear that hot work encompasses any method of work that can serve as a source of ignition.
Develop and implement a formalized and comprehensive Simultaneous Operations (SIMOPs) program addressing planned work occurring close together in time and place to include policies, procedures, hazards reviews, hazards abatement, training, and shared communication methods, to protect employees and contract workers from the hazards posed by simultaneous operations at its facilities. At a minimum, the program should:
• Identify potential simultaneous operations
• Identify potential hazardous interactions
• Evaluate and implement necessary safeguards to allow for safe simultaneous operations
• Ensure coordination, including shared communication methods, between the simultaneous operations
• Include emergency response personnel or services in the planning and coordination of the simultaneous operations.
Develop and implement a policy that requires the involvement of emergency response personnel in planning and coordination of activities involving the use of flammable materials in confined spaces. In the policy, require that emergency response personnel be stationed directly outside the confined space in which flammable materials are used. Ensure that the emergency response personnel are appropriately trained and equipped for confined space entry, confined space rescue and fire response.
Issue a safety information product (such as a letter of interpretation) addressing the analysis and control of hazards that are not pre-existing but which result from work activities inside permit-required confined spaces.
(Superseded by 2021-01-I-TN-R1 from the Wacker report)
Require Owner/Operators to ensure the coordination of simultaneous operations involving multiple work groups, including contractors. Include in the requirement for Owner/Operators to ensure the following activities occur:
• Identification of potential simultaneous operations
• Identification of potential hazardous interactions
• Evaluation and implementation of necessary safeguards to allow for safe simultaneous operations
• Coordination, including shared communication methods, between the simultaneous operations
• Inclusion of emergency response personnel or services in the planning and coordination of the simultaneous operations.
As necessary, seek the regulatory authority to promulgate this requirement.
Update the Universal Blastco hot work policy and employee training program to specifically identify the use of heat guns as hot work. The policy and programs should make clear that hot work encompasses any method of work that can ignite a fire and not just spark- or flame-producing work methods.
Develop a formalized troubleshooting guide and/or standard operating procedure for the usage of resin and fiberglass matting in FRP operations. The procedure should direct employees on acceptable means of addressing cold-weather resin performance.
Develop a policy and standard operating procedures for the proper use of heat guns in FRP operations.