Skip to content

Evergreen Packaging Paper Mill - Fire During Hot Work

Overview

On September 21, 2020, during a planned shutdown at Evergreen Packaging's paper mill in Canton, North Carolina, a fire occurred during maintenance work in connected process vessels in the #2 Fiber line bleaching unit. A portable electric heat gun used to warm resin fell into a five-gallon bucket containing flammable resin inside the upflow tower, and smoke and flames quickly spread to the connected downflow tower, fatally injuring two contractors.

Incident Snapshot

Field Value
Facility / Company Evergreen Packaging
Location Canton, NC
Incident Date 09/21/2020
Investigation Status The CSB's investigation was approved at a public board meeting on September 24, 2021.
Accident Type Fire during hot work
Final Report Release Date 09/24/2021

What Happened

  • On Thursday, September 17, 2020, Evergreen began a mill-wide shutdown, which Evergreen calls a “cold mill outage.”
  • Between 7:00 p.m. and 8:00 p.m. on Sunday, September 20, 2020, the night shift crews for Blastco and Rimcor arrived and began preparing for their shift in the D2 upflow and downflow towers, respectively.
  • By about 8:20 p.m., Blastco had completed permitting and setup and entered the upflow tower.
  • Blastco workers opened a 55-gallon drum of raw resin outside of the vessel, mixed a cobalt promoter and DMA into the drum, filled five-gallon buckets with promoted resin, and then mixed MEKP and DMA into the buckets inside the vessel.
  • Blastco workers applied resin and fiberglass matting to the wall, but cold temperatures caused longer gel times and the lamination patterns slid down the walls before the resin hardened.
  • Sometime after 2:00 a.m. on September 21, 2020, one of the workers went to locate drum warming bands, could not locate them, obtained a heat gun from the Blastco trailer, brought it into the tower, and began using it to warm the resin.
  • At approximately 5:15 a.m., the two Rimcor entrants radioed their foreman outside of the tower to inform him that they had only 10 minutes of abrasive blasting remaining before they would need the scaffolding raised.
  • At roughly the same time, a Blastco employee said they had just finished warming and mixing a bucket of resin inside the upflow tower and needed to pass it to another worker inside the tower applying the resin.
  • The worker looped the heat gun cord around the scaffolding railing, leaving it powered on, repositioned himself, and saw a fire in the bucket.
  • Another Blastco worker stated that the heat gun was inside the bucket.
  • The Blastco crew did not have a fire extinguisher immediately available, and Evergreen did not require Blastco to have one available.
  • Blastco workers exited the upflow tower and attempted to extinguish the fire by covering the bucket with a plastic lid and then placing fiberglass mat on the bucket, but the fire continued.
  • Witnesses stated that at approximately 5:17 a.m., they saw the Blastco workers exit the upflow tower and throw a heat gun on the ground.
  • At 5:18 a.m., the Blastco night foreman notified his Evergreen contact of the fire via cell phone.
  • At approximately 5:20 a.m., the safety office activated the Evergreen site emergency response team (ERT).
  • At 5:22 a.m., the Evergreen employee overseeing the repairs to the D2 towers arrived at the scene and called 911.
  • At 5:24 a.m., a Rimcor worker called Rimcor’s Evergreen contact to notify him that Rimcor had lost contact with the two workers inside the vessel.
  • At approximately 5:25 a.m., the Evergreen ERT began arriving on scene and was informed that two Rimcor workers had not been accounted for in headcounts and were likely still inside the downflow tower.
  • The ERT decided against entering the vessel to attempt rescue.
  • The Evergreen ERT, area fire departments, and emergency responders fought the fire for approximately two hours.

Facility and Process Context

  • The Evergreen Packaging paper mill in Canton, North Carolina, produces printing paper and paperboard used to make packaging materials such as cartons and disposable paper cups.
  • The incident occurred in one of Evergreen’s bleaching units, called the #2 Fiber line bleaching unit.
  • The bleaching process occurs in three reaction stages; each stage consists of a pair of process vessels: the upflow tower and the downflow tower, connected at the top by a large diameter pipe called the crossover line.
  • The upflow and downflow towers are designed such that the pulp and bleaching chemicals slowly move through the vessels.
  • The pulp bleaching process is corrosive by design, and the upflow and downflow towers are constructed of corrosion-resistant materials.
  • The #2 Fiber line D2 upflow tower was constructed of fiber-reinforced plastic (FRP) and was approximately 96 feet tall and almost nine feet in diameter.
  • The downflow tower was constructed of a carbon steel shell, lined internally with a urethane membrane covered with fireclay acid brick laid in vinyl ester mortar.
  • The downflow tower was 110 feet tall and roughly 22 feet in diameter.
  • The crossover line was approximately the same diameter as the upflow tower and was also constructed of FRP.
  • Evergreen hired two contractors to make the repairs to the D2 upflow and downflow towers during the shutdown: Universal Blastco (“Blastco”) and Rimcor.
  • Blastco was working in the upflow tower, while Rimcor was working simultaneously in the downflow tower.
  • Blastco’s scope of work for the D2 upflow tower was to repair approximately 30 feet of FRP.
  • Rimcor’s scope of work was to re-line approximately 15 feet of the D2 downflow tower.
  • Blastco used traditional scaffolding built from the ground to the entry manway of the upflow tower, located 23 feet above the ground, and additional scaffolding platforms inside the tower.
  • Rimcor used suspended scaffolding inside the downflow tower.
  • The upflow tower and crossover line were constructed of FRP, a combustible material.

Consequences

  • Fatalities: 2 Rimcor workers [Brett Burgueno, Curtis Butler] were fatally injured.
  • Injuries: The two Blastco workers inside the upflow tower successfully escaped the fire and evacuated the vessel.
  • Environmental Release: Not reported.
  • Facility Damage: Burn damage was found on the inside surface of the vessel’s insulation near the top of the vessel. Physical evidence shows that the FRP upflow tower and crossover line were partly consumed by the fire. Multiple core samples showed significant thermal degradation, and some completely delaminated.
  • Operational Impact: The fire burned for approximately two hours and required response by the Evergreen ERT, area fire departments, and emergency responders.

Key Findings

Immediate Causes

  • The CSB determined the cause of the incident was the failure by Blastco to effectively evaluate the flammable material hazards presented by its work in the upflow tower and implement controls to prevent the introduction of ignition sources to the work area.

Contributing Factors

  • Blastco’s failure to recognize heat guns as a form of hot work that could ignite flammable materials
  • gaps in Evergreen’s training to contractors on forms of hot work
  • poor pre-job planning that allowed Blastco’s work to occur during cold temperatures which were known to make the fiber-reinforced plastic application process difficult
  • a lack of Blastco troubleshooting guidance for safely addressing cold-weather resin performance
  • poor confined space safety practices
  • Blastco’s and Rimcor’s lack of recognition and control of the hazards of the simultaneous operations
  • Evergreen’s failure to ensure coordination and the integrity of pre-planning between the two contract companies
  • inadequate communication between Blastco and Rimcor
  • the lack of immediately available emergency services during the hazardous operation involving flammable materials in a confined space
  • the material of construction of the upflow tower and crossover line, as it was a combustible material that enabled the fire to quickly spread

Organizational and Systemic Factors

  • Evergreen’s internal policies defined hot work as “any activity that could serve as a source of ignition,” while Evergreen’s contractor orientation materials limited the hot work definition to only “burning, cutting, brazing or welding.”
  • Blastco did not have a standalone hot work policy and did not produce documentation showing training related to the acceptable use of heat guns or their qualification as a form of hot work.
  • Evergreen did not have a SIMOPs program in place at the time of the incident to facilitate coordination between parties performing work close together in time and place.
  • Evergreen did not ensure its emergency response team was on standby outside the upflow tower while flammable materials were used inside the confined space.
  • Blastco and Rimcor did not have a shared communication method and had separate entry supervisors.
  • Blastco did not complete required portions of the confined space permit, including designation of an entry supervisor and attendant.
  • Blastco did not directly call the Evergreen emergency phone number listed on the permit when the fire started.

Failed Safeguards or Barrier Breakdowns

  • Blastco did not recognize the ignition hazard presented by the heat gun.
  • Blastco did not inform Evergreen or Rimcor of the heat gun’s use.
  • Blastco did not take adequate action to prevent the introduction of ignition sources into a confined space containing flammable liquids.
  • Blastco did not terminate the confined space entry when a new hazard, the heat gun, was introduced into the space.
  • Blastco did not effectively evaluate the flammable material hazards presented by its work in the upflow tower.
  • Evergreen did not ensure coordination between the two contract crews.
  • Evergreen did not ensure its emergency response team was on standby outside the upflow tower while flammable materials were used inside the confined space.
  • Blastco did not have fire extinguishing equipment immediately available.
  • Blastco and Rimcor did not effectively coordinate simultaneous entry operations.
  • Blastco and Rimcor workers did not communicate with each other prior to the fire.
  • Blastco and Rimcor did not have a shared communication method (e.g., radios).
  • Blastco and Rimcor had separate entry supervisors.
  • Blastco’s confined space permit left blank the sections prompting about hot work permits and did not designate an entry supervisor or attendant.
  • Blastco’s confined space permit did not document the hazards of the space, such as the presence of the flammable resin.
  • The ventilation fan was turned off at some point during the night shift.
  • Evergreen’s contractor safety handbook and site orientation program did not reflect Evergreen’s internal definition of hot work.
  • Evergreen did not require Blastco to have a fire extinguisher immediately available.

Recommendations

  1. 2008-01-I-CO-R2 | Recipient: OSHA | Status: Previously Issued Recommendation Reiterated in This Report | Summary: Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces that includes actionable guidance regarding: the importance of implementing a hierarchy of controls to address hazards in a confined space that first seeks to eliminate hazards or substitute with a less hazardous material(s) or method(s); the necessity of establishing a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy of permit required confined spaces; the need to comprehensively control all potential ignition sources and continuously monitor the confined space at appropriate locations and elevations when work activities involve the use of flammable materials or where flammable atmospheres may be created; the importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health (IDLH) that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment; the requirement that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Such spaces need to be monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.
  2. 2020-07-I-NC-R1 | Recipient: OSHA | Status: Closed – Acceptable Action | Summary: 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.
  3. 2020-07-I-NC-R2 | Recipient: Occupational Safety and Health Administration | Status: Closed – Reconsidered/Superseded (Superseded by 2021-01-I-TN-R1) | Summary: 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.
  4. 2020-07-I-NC-R3 | Recipient: Evergreen Packaging | Status: Closed – No Longer Applicable | Summary: 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.
  5. 2020-07-I-NC-R4 | Recipient: Evergreen Packaging | Status: Closed – No Longer Applicable | Summary: 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.
  6. 2020-07-I-NC-R5 | Recipient: Evergreen Packaging | Status: Closed – No Longer Applicable | Summary: 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.
  7. 2020-07-I-NC-R6 | Recipient: Universal Blastco | Status: Closed – Acceptable Action | Summary: 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.
  8. 2020-07-I-NC-R7 | Recipient: Universal Blastco | Status: Closed – Acceptable Action | Summary: 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.
  9. 2020-07-I-NC-R8 | Recipient: Universal Blastco | Status: Closed – Acceptable Action | Summary: Develop a policy and standard operating procedures for the proper use of heat guns in FRP operations.

Key Engineering Lessons

  • Heat guns and other heating tools can be ignition sources and must be controlled as hot work when used near flammable resins.
  • When work in a confined space can create a new hazard, the hazard must be evaluated and controls must be updated before continuing the entry.
  • Simultaneous operations in connected process vessels require explicit coordination, shared communication, and hazard review.
  • Combustible vessel construction materials can significantly increase fire spread severity once ignition occurs.
  • Emergency response capability should be planned and positioned for immediate response when flammable materials are used in confined spaces.

Source Notes

  • Priority 1 final report used as primary authority for incident facts, causes, and recommendations.
  • Priority 3 recommendation status summaries used to update recommendation statuses and later closure information.
  • Priority 4 supporting documents were not used to override Priority 1 where conflicts existed.
  • Official terminology such as 'hot work', 'SIMOPs', 'confined space', and 'FRP' was preserved from the source documents.

Similar Incidents

Incidents sharing the same equipment, root causes, or hazard types.

Same Root Cause

← View in Knowledge Graph