Video: Key Safety Issues of Fatal Fog Incident

On January 28, 2021, there was a liquid nitrogen release at a food processing facility in Gainesville, Georgia.

The facility used liquid nitrogen to quickly freeze prepared poultry food products. The Chemical Safety and Hazard Investigation Board’s (CSB’s) Final Report found that the release was caused by a bent tube in a liquid nitrogen control system. The bent tube allowed the room to fill with an unsafe level of liquid nitrogen that quickly vaporized into a deadly cloud.

At least 14 employees entered the room or the surrounding area to investigate the incident or attempt to rescue coworkers. Six employees were fatally injured. Three more employees and a firefighter were seriously injured.

CSB Video: Fatal Fog

See US CSB’s Final Report.

Five Key Lessons for Industry

1. Single Point of Failure

“…the failure of a single component resulted in six fatalities. Companies must ensure that processes and equipment handling hazardous chemicals are robust so that one failure does not result in a catastrophic incident.”

2. Atmospheric Monitoring and Alarm Systems

“Without atmospheric monitoring, an oxygen-deficient atmosphere cannot be reliably detected. Many of the responding…employees likely had no idea they were walking into a hazardous atmosphere. Facilities that handle hazardous gases or cryogenic asphyxiants like liquid nitrogen should have a functioning atmospheric monitoring and alarm system based on a properly conducted risk assessment.”

3. Emergency Preparedness

“Companies handling hazardous materials have an obligation to train and inform their employees. What made the situation worse at [the site] was that many of the company’s employees didn’t know that the site used liquid nitrogen, didn’t know that liquid nitrogen could create a hazardous atmosphere, and didn’t know how to respond to a release.”

4. Process Safety Management Systems

“Companies of any size and risk profile can adapt process safety management principles to their operations so that hazards introduced by the process, equipment, and facility are properly identified and controlled. If [the company] had implemented key process safety management elements, this incident may have been prevented.”

“Food manufacturers are not immune from chemical hazards and process safety risks. When an organization introduces a hazardous chemical into its process, it should implement robust process safety management practices to effectively control the risks regardless of whether a regulation requires it. If [the company] had an effective process safety management system, this incident could have been prevented.

But the CSB also believes there is a need for a specific enforceable regulation of cryogenic asphyxiants such as liquid nitrogen so that companies are required to act where [the company] did not.”

5. Product Stewardship

“Large industrial gas suppliers…are often much more knowledgeable about the hazards of their products than their customers are. As was the case between [the supplier and the food processor], and despite [the supplier’s] knowledge of [the food processor’s] unsafe business practices, [the supplier] continued its business relationship with [the food processor]. Like the company, the supplier had multiple opportunities to prevent this incident.”