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December 14, 2023
5 Min Read
The fatal incident occurred due to various reasons, including a bent bubbler tube.Image courtesy of nycshooter / iStock / Getty Images Plus
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:
Single Point of Failure. The immersion freezer design included 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.
“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.
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 federal agency 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 asking 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.
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.
About the Author(s)
Kristen Kazarian has been a writer and editor for more than three decades. She has worked at several consumer magazines and B2B publications in the fields of food and beverage, packaging, processing, women's interest, local news, health and nutrition, fashion and beauty, automotive, and computers.
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