CSB Finds Poultry Plant Negligent in Fatal Nitrogen Release

The Chemical Safety and Hazard Investigation Board (CSB) has released its final report on the 2021 fatal liquid nitrogen release at a poultry processing plant in Gainesville, GA, in January 2021.

The CSB’s final report identified a number of equipment and process failures at the Foundation Food Group (FFG) facility and issued 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 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 have liquid nitrogen freezing processes in the building where the incident occurred.

“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," said CSB Chair Steve Owens.

The CSB’s final report emphasizes five key safety issues:

“The CSB’s key safety issues outline the important lessons from this incident," said Investigator-in-Charge Drew Sahli. "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 12 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.

Owens added that the hazards of liquid nitrogen must be clearly communicated to workers, and safety management systems for operations that use liquid nitrogen must be improved.