Federal investigators released their final report into a deadly nitrogen gas leak that claimed six workers’ lives at a Gainesville-area poultry plant in January 2021.

According to the U.S. Chemical Safety and Hazard Investigation Board (CSB), the horror unleashed in the Foundation Food Group plant was “completely preventable.” It disproportionately affected the North Georgia immigrant community that powers the region’s poultry industry, accounting for five of the victims.

“This is an incredibly damning report,” said Debbie Berkowitz, a former chief of staff at the Occupational Safety and Health Administration (OSHA) and a current fellow at Georgetown University’s Kalmanovitz Initiative for Labor and the Working Poor.

The CSB’s findings released earlier this week confirm that a bent tube in an immersion freezer was the cause of the chemical leak. The compromised tube, likely bent during maintenance, foiled the machine’s control system. This allowed the freezer to fill with an unsafe level of liquid nitrogen, which overflowed and quickly vaporized into a four- to five-foot-high “deadly cloud.” The six victims died by asphyxiation. Three other employees and a first responder were also seriously injured.

The severity of the incident was exacerbated by Foundation Food Group’s inadequate preparedness and safety training, which according to the CSB report resulted in at least 14 employees entering the freezer room or the surrounding area to investigate what had happened or attempt to rescue their colleagues. Investigators also cited the company’s failure to install air monitoring and alarm devices, which could have warned workers about the dangerous vapor cloud and prevented them from entering the freezer room.

“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,” said CSB’s investigator-in-charge Drew Sahli.

According to the 115-page report, Foundation Food Group had allowed the job responsible for safety management to remain vacant for over a year prior to the incident. The company failed to inform, train, drill, or otherwise prepare its employees for a release of liquid nitrogen. There was no personal protective equipment in the plant that would have allowed safe entry into an oxygen-deficient atmosphere.

“These are stunning failures and really just another example how the poultry industry treats the most vulnerable workers in the state of Georgia as expendable,” Berkowitz said. “The company didn’t even label the equipment filled with liquid nitrogen that this was hazardous, even though one of the oldest standards by OSHA has required this since the early 1980s.”

The deficient freezer where the deadly leak began was leased to Foundation Food Group by industrial gas supplier Messer LLC. Following the incident, Foundation Food Group sold its plant to fellow poultry processor Gold Creek Foods, the current owner of the facility. According to CSB, Gold Creek Foods does not use liquid nitrogen freezing in the building where the leak took place.

Back in 2021, OSHA cited Foundation Food Group for 26 violations, including six “willful” violations, for a total of $595,000 in penalties. Messer was cited for six violations totaling $74,000. Relatives of the victims and surviving workers launched wrongful death and personal injury litigation.

The Atlanta Journal-Constitution reached out to Foundation Food Group to seek the company’s response to the CSB report. It will update this story with their comments.

Unlike OSHA, the CSB doesn’t impose fines or penalties. Instead, it specifically investigates workplace chemical accidents and issues recommendations on how to prevent them. Inside meatpacking plants, chemicals such as liquid nitrogen and ammonia are widely used to instantly freeze meat and keep ambient temperatures low, respectively.

“Whenever 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 any regulation requires the organization to do so,” the report authors note.

“Messer welcomes CSB’s thorough and thoughtful recommendations. We will consider their proposals seriously, as we have cooperated with CSB and other investigating authorities since this unfortunate and tragic event. As CSB recognizes in its report, Messer has developed several enhancements and robust customer safety inspection practices since the incident to provide additional layers of protection against the possibility of a liquid nitrogen overflow,” Messer spokeswoman Amy Ficon said in a statement. “We pledge to work with all our customers to assure the safety of their workers, as this type of collaboration is necessary to prevent similar situations in the future. Messer continues to express our sincere sympathy for the families of those workers who lost their lives at the FFG facility.”

Shelly Anand is the executive director of the Sur Legal Collaborative, an immigrant and workers’ rights non-profit based in Atlanta. She described the publication of the CSB report as an important win, but noted there’s more work to be done to hold employers accountable and prevent future worker injury.

“I think it’s very powerful. It’s a result of brave, vulnerable workers being willing to come forward to government officials they don’t know and speak their truth,” she said. “I hope and pray that employers that are not unscrupulous and that have morals take workers safety and health seriously. I just I think this is a very corrupt industry, and we have a lot of work to do.”

The CSB’s recommendations include the following:

  • 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 CSB 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 calling on 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.

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Hundreds turn out at a prayer vigil Saturday, Jan. 30, 2021, to remember the victims of a deadly incident at the Foundation Food Group poultry processing plant in Gainesville, Georgia. (Photo: Vanessa McCray / Vanessa.McCray@ajc.com)

Credit: Vanessa McCray

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Credit: Vanessa McCray

03/02/2021 —Gainesville, Georgia — Flowers, candles, notes and stuffed animals are displayed at a makeshift vigil outside of the Foundation Food Group in Gainesville, Tuesday, February 2, 2021. Six people died while working at the plant, January 28, when a liquid nitrogen line ruptured. Five people died at the scene on Memorial Park Drive, and 12 others were taken to the emergency room at Northeast Georgia Medical Center with injuries, officials said. One of those patients died at the hospital. (Alyssa Pointer / Alyssa.Pointer@ajc.com)

Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com

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Credit: Alyssa Pointer / Alyssa.Pointer@ajc.com