Skip to content

Foundation Food Group Fatal Chemical Release

Overview

On January 28, 2021, a liquid nitrogen release occurred at Foundation Food Group’s Plant 4 in Gainesville, Georgia. Liquid nitrogen overflowed from an immersion freezer, vaporized, and accumulated in a partially enclosed room with no mechanical ventilation. This created an oxygen-deficient atmosphere. The incident fatally injured six employees and seriously injured others. The CSB final report identified failure of the immersion freezer’s liquid level control system, resulting from deformation of the bubbler tube component, as the direct cause.

Incident Snapshot

Field Value
Facility / Company Foundation Food Group (FFG)
Location Gainesville, GA
Incident Date 01/28/2021
Investigation Status CSB final investigation released on 12/11/2023.
Accident Type Liquid nitrogen release
Final Report Release Date 12/11/2023

What Happened

  • At approximately 7:16 a.m., operations on Line 4 commenced.
  • At approximately 8:14 a.m., Line 4 stopped processing chicken so maintenance personnel could troubleshoot the freezer issue.
  • At approximately 8:20 a.m., the Line 4 Packaging Supervisor instructed workers to go on break while maintenance workers attempted to resolve the freezing issue.
  • Likely while workers were on break, the bubbler tube in the immersion freezer became bent, preventing the liquid nitrogen level control system from working properly.
  • The liquid nitrogen level increased in an uncontrolled manner and liquid nitrogen overflowed from the immersion freezer.
  • The released liquid nitrogen vaporized and accumulated in the freezer room, displacing oxygen and creating an oxygen-deficient atmosphere.
  • At approximately 8:40 a.m., Line 4 workers returned from break and noticed a cloud of white fog coming from the freezer room but took no further action.
  • By 9:40 a.m., a Line 4 worker entered the freezer room through an elevated opening and observed a dense white cloud and one maintenance worker lying motionless on the ground.
  • At approximately 9:55 a.m., the Line 1 Packaging Supervisor escorted Line 1 and Line 4 workers from the building and other supervisors began evacuating the rest of the Plant 4 employees.
  • At 10:11 a.m., the Director of Prepared Foods Operations called 911.
  • At 10:18 a.m., Hall County Fire Rescue arrived on scene.
  • At 10:36 a.m., one firefighter activated two of the immersion-spiral freezer’s E-stop buttons.
  • The uncontrolled liquid nitrogen release likely ceased at approximately 10:15 a.m. when the bulk storage tank manually-operated discharge valves outside the building were closed.

Facility and Process Context

  • Foundation Food Group was a poultry processor in Gainesville, Georgia.
  • Plant 4 housed five production lines, Lines 1 through 5.
  • Line 4 processed cooked chicken products and included marination, cooking, a dicer, freezer, and packaging equipment.
  • The Line 4 freezer room had four openings and no mechanical ventilation or HVAC.
  • Below five feet of elevation, the room was nearly fully enclosed.
  • The room was ventilated only by the building’s make-up air system.
  • Messer supplied bulk liquid nitrogen and designed and owned the liquid nitrogen immersion-spiral freezer system leased to and operated by FFG.
  • FFG was responsible for maintaining the equipment site, ensuring compliance with safety and environmental regulations, providing utilities, piping, and connections, providing security, and maintaining freezer equipment per Messer instructions.
  • The majority of the FFG workforce did not speak English as their primary language or were non-English speaking.
  • The Line 4 freezer room was not equipped with HVAC or industrial ventilation.
  • FFG relied on the opening from the adjacent processing room to supply make-up air.
  • The maintenance workers conducted troubleshooting without shutting down the freezer and with the transition box door and immersion freezer lid safety switches intentionally bypassed.

Consequences

  • Six FFG employees were fatally injured. Autopsy results revealed that all six employees asphyxiated.
  • Three FFG employees and one firefighter were seriously injured.
  • Additional employees and emergency responders experienced symptoms of oxygen deprivation, including dizziness, shortness of breath, abdominal pain, fainting, headaches, nausea, and loss of consciousness.
  • At most, approximately 6,300 gallons (approximately 42,400 pounds) of liquid nitrogen released from the Line 4 immersion freezer, though the actual released quantity was likely less.
  • Messer reported business and property losses of roughly $245,000.
  • FFG sued its insurance company for damages of roughly $1.7 million.
  • Line 4 stopped processing chicken at approximately 8:14 a.m.
  • Approximately 130 workers were evacuated from the building.
  • Production was interrupted by the incident.

Key Findings

Immediate Causes

  • The CSB determined the cause of the liquid nitrogen release was the failure of the immersion freezer’s liquid level control system to accurately measure and control the liquid nitrogen level inside the freezer, which resulted from deformation of the system’s bubbler tube component.
  • The bubbler tube was bent, preventing the freezer’s liquid nitrogen level control system from working properly.
  • The liquid nitrogen overflowed from the immersion freezer.

Contributing Factors

  • Messer’s design of the freezer allowed the failure of a single level measurement device to result in an uncontrolled loss of containment of liquid nitrogen.
  • FFG’s inadequate emergency preparedness resulted in at least 14 employees responding to the release by entering the freezer room or surrounding area to investigate or attempt rescue.
  • The absence of atmospheric monitoring and alarm devices that could have alerted workers to the hazardous atmosphere and warned them against entering.
  • The freezer room lacked mechanical ventilation.
  • The Line 4 freezer room was nearly fully enclosed below five feet of elevation.
  • The placement of the Line 4 immersion-spiral freezer E-stop buttons required a responding employee or person not otherwise in the freezer room to enter an oxygen-deficient atmosphere during a release to activate an E-stop.
  • The transition box door and freezer lid safety switches had been defeated.
  • Messer did not detect a manufacturing defect: a missing clamp intended to secure the bubbler tube to the freezer.
  • Messer’s Quality Control procedures and practices were ineffective in ensuring the two support clamps on the bubbler tube were in place.

Organizational and Systemic Factors

  • FFG had no documented process safety management policy.
  • FFG allowed the job position responsible for safety management to be vacant for more than a year prior to the incident.
  • FFG did not evaluate the process hazards associated with the freezer.
  • FFG lacked written procedures and a management of change process.
  • FFG did not train its workers on the asphyxiation hazards of liquid nitrogen.
  • FFG did not inform, train, equip, drill, or otherwise prepare its workforce for a release of liquid nitrogen.
  • FFG did not proactively interact with local emergency responders prior to the incident, despite relying upon them to respond to emergencies at its facility.
  • FFG did not install atmospheric monitoring equipment in the freezer room.
  • FFG did not have a system, plan, or program to train and verify employee competency for operating the liquid nitrogen freezer and working with or near hazardous liquid nitrogen.
  • FFG lacked an effective process safety management system to identify, evaluate, and control the hazards of the liquid nitrogen process.
  • Messer applied effective product stewardship practices only to the bulk storage tanks and not to the Line 4 freezer process.
  • Messer continued to supply FFG with liquid nitrogen despite FFG’s unsafe practices.
  • A lack of regulatory coverage for liquid nitrogen and cryogenic asphyxiants allowed FFG to elect not to implement process safety practices that could have prevented the incident.

Failed Safeguards or Barrier Breakdowns

  • The bubbler tube was the sole input to both the level control loop and the high-level safety interlock.
  • The high-level safety interlock was defeated when the bubbler tube was bent.
  • FFG did not install atmospheric monitoring equipment in the freezer room.
  • FFG did not equip the Line 4 freezer room with an atmospheric monitoring system that would continuously monitor for a breathable atmosphere and notify personnel by alarms to evacuate the area if unsafe.
  • The Line 4 immersion-spiral freezer E-stop buttons were all located within the freezer room.
  • FFG had no employees equipped for or trained in emergency response.
  • FFG’s EAP did not mention liquid nitrogen and contained no guidance on how, whether, or when to respond to a liquid nitrogen release.
  • Neither FFG nor Messer provided warning signage for the asphyxiation hazard in the Line 4 freezer room.
  • The liquid nitrogen warning labels were stored within a folder inside the freezer HMI and were never affixed to the freezer.
  • Messer’s Quality Control procedures and practices were ineffective in ensuring that the two support clamps on the bubbler tube were in place.
  • The transition box door and freezer lid safety switches had been tampered with such that they were defeated.
  • The freezer room was not equipped with a mechanical ventilation system.

Recommendations

  1. 2021-03-I-GA-R1 | Recipient: Gold Creek Foods | Status: Closed – Acceptable Action | Summary: Include in the emergency action program provisions for proactively interacting with and informing local emergency response resources of all emergencies at the former FFG Plant 4 facility to which Gold Creek expects them to respond.
  2. 2021-03-I-GA-R2 | Recipient: Messer LLC | Status: Open – Acceptable Response or Alternate Response | Summary: Update the company product stewardship policy to include participation by Messer in customers’ process hazard analyses (PHAs), require verification that proper signage is displayed on and/or near equipment, and require a facility and/or equipment siting review to ensure emergency shutoff devices, including E-stops, are located such that they can be safely actuated during a release of liquid nitrogen.
  3. 2021-03-I-GA-R3 | Recipient: Messer LLC | Status: Open – Acceptable Response or Alternate Response | Summary: Create an informational product that provides Messer customers with information on the safety issues described in this report and recommend that customers develop and implement effective safety management systems to control asphyxiation hazards from inert gases based on CGA P-86, CGA P-12, CGA P-18, and CGA P-76.
  4. 2021-03-I-GA-R4 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Update the Region 4 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes and encourage process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.
  5. 2021-03-I-GA-R5 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Update the Region 5 Regional Emphasis Program for Food Manufacturing Industry to explicitly cover liquid nitrogen freezing processes and encourage process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.
  6. 2021-03-I-GA-R6 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Update the Region 6 Poultry Processing Facilities Regional Emphasis Program to explicitly cover liquid nitrogen freezing processes and encourage process safety management practices, atmospheric monitoring, employee training and hazard awareness, and emergency preparedness and response.
  7. 2021-03-I-GA-R7 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Promulgate a standard specific to cryogenic asphyxiants that addresses design, construction, and installation of process equipment; atmospheric monitoring indoors; emergency shutdown systems; employee training and hazard awareness; an emergency action plan; and process safety management elements such as process hazard analysis, management of change, and procedures.
  8. 2021-03-I-GA-R8 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Develop and publish a Guidance Document for process safety management practices applicable to processes handling compressed gases and cryogenic asphyxiants, including the practices highlighted in the report.
  9. 2021-03-I-GA-R9 | Recipient: Compressed Gas Association (CGA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Develop a comprehensive standard for the safe storage, handling, and use of liquid nitrogen in stationary applications, including requirements for atmospheric monitoring devices, visible and audible alarm indication distinct from the building’s fire alarm system, room and emergency ventilation systems, and emergency shutdown devices including E-stops.
  10. 2021-03-I-GA-R10 | Recipient: Compressed Gas Association (CGA) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Update P-76 Hazards of Oxygen-Deficient Atmospheres to require atmospheric monitoring systems for processes capable of producing oxygen-deficient atmospheres, visible and audible alarm indication distinct from a building’s fire alarm system and at a continuously attended location, remotely operated emergency isolation valves (ROEIVs), and guidance on the adequate safe location of emergency stop devices.
  11. 2021-03-I-GA-R11 | Recipient: National Fire Protection Association (NFPA) | Status: Open – Acceptable Response or Alternate Response | Summary: Update NFPA 55 Compressed Gases and Cryogenic Fluids Code to require atmospheric monitoring with cryogenic asphyxiants and include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs).
  12. 2021-03-I-GA-R12 | Recipient: International Code Council (ICC) | Status: Open – Awaiting Response or Evaluation/Approval of Response | Summary: Update the International Fire Code to require atmospheric monitoring with cryogenic asphyxiants and include guidance on the adequate safe location of manual shutoff valves and devices such as emergency push buttons used to activate remotely operated emergency isolation valves (ROEIVs) in cryogenic fluid service.

Key Engineering Lessons

  • A single level-measurement device should not be the sole input to both level control and high-level safety interlock functions where loss of containment can create an oxygen-deficient atmosphere.
  • Emergency shutdown devices should be located so they can be safely actuated without requiring entry into the hazardous atmosphere they are intended to mitigate.
  • Indoor processes capable of producing oxygen-deficient atmospheres require atmospheric monitoring and alarm systems that alert workers before entry.
  • Mechanical ventilation is an important safeguard in rooms where released liquid nitrogen can accumulate.
  • Safety interlocks and door switches must not be defeated or bypassed during troubleshooting or maintenance.
  • Warning signage and warning labels must be installed where workers can see them, not stored inside equipment enclosures.
  • Product stewardship and equipment design should account for the full customer process, not only bulk storage equipment.

Source Notes

  • Priority 1 final report facts were used to resolve conflicts over cause, sequence, and recommendations.
  • Priority 3 recommendation status summaries were used to confirm recommendation status and wording where consistent with the final report.
  • Priority 4 supporting documents were used only for details explicitly stated there and not contradicted by the final report.
  • The final report states the CSB final investigation was released on 12/11/2023.
  • The incident involved liquid nitrogen at Foundation Food Group’s Plant 4 in Gainesville, Georgia.

Similar Incidents

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

Same Equipment

Same Root Cause

  • CTA Acoustics Dust Explosion and Fire — Shared failure mode: Communication Failure · Control System Failure · Design Deficiency · Maintenance Error · Procedural Failure · Training Deficiency
  • Bio-Lab Lake Charles Chemical Fire and Release — Shared failure mode: Design Deficiency · Emergency Response Failure · Maintenance Error · Procedural Failure · Training Deficiency
  • Watson Grinding Fatal Explosion and Fire — Shared failure mode: Control System Failure · Design Deficiency · Emergency Response Failure · Maintenance Error · Procedural Failure · Training Deficiency
  • Sodium Hydrosulfide: Preventing Harm — Shared failure mode: Communication Failure · Design Deficiency · Emergency Response Failure · Maintenance Error · Procedural Failure · Training Deficiency
  • DPC Enterprises Festus Chlorine Release — Shared failure mode: Communication Failure · Design Deficiency · Emergency Response Failure · Maintenance Error · Procedural Failure · Training Deficiency

Same Hazard

← View in Knowledge Graph