Simultaneous Tragedy: Fire at Evergreen Packaging

Summary

The tragic incident at Evergreen Packaging's Canton, NC paper mill in September 2020 highlights key safety failures, including hot work hazards, confined space safety, and inadequate pre-job planning. Two contractors were fatally injured when a heat gun caused a fire in a confined space, spreading quickly to another tower. The CSB's investigation revealed critical lapses in hazard identification, safety procedures, and communication between contractors. Recommendations focus on improving safety training, pre-job planning, and coordination between workers, particularly when simultaneous operations (SIMOPS) are involved, to prevent similar incidents in the future.

Takeaways

• 😀 The Evergreen Packaging incident involved the deaths of two contractors due to a fire caused by a heat gun falling into flammable resin.
• 😀 Hot work safety was a major issue, as the heat gun was not recognized as an ignition source, failing to trigger the proper safety protocols.
• 😀 Proper pre-job planning could have prevented the incident, as safer alternatives like drum heating bands were available but not identified or prepared for use.
• 😀 The up-flow and down-flow towers were both permit-required confined spaces, but the fire spread due to the failure to coordinate safety efforts between contractors.
• 😀 The incident highlights the importance of recognizing non-flame and non-spark-producing tools (like heat guns) as hot work hazards.
• 😀 Effective pre-job planning is critical to ensure workers are properly prepared for unexpected conditions, such as cold weather affecting the resin.
• 😀 The use of combustible materials, like fiberglass-reinforced plastic (FRP) in confined spaces, significantly worsened the fire and contributed to the fatalities.
• 😀 SIMOPS (Simultaneous Operations) safety programs should be implemented to better manage the risks associated with multiple contractors working close together in time and space.
• 😀 Contractors must communicate their actions, such as using a heat gun, to all involved parties, ensuring that all safety risks are assessed and mitigated.
• 😀 The CSB made several recommendations, including improved hot work training, enhanced pre-job planning, better confined space safety protocols, and stricter regulations on combustible materials in confined spaces.

Q & A

What incident occurred at Evergreen Packaging on September 21, 2020?

Two contract workers at Evergreen Packaging in Canton, North Carolina, were fatally injured by a fire that erupted in a confined space. The fire was caused when a heat gun fell into a bucket of flammable resin.

What safety issues were identified by the CSB during its investigation of the incident?

The CSB identified four key safety issues: hot work safety, pre-job planning, confined space safety, and the use of combustible materials in the construction of the vessels.

Why did the use of a heat gun pose a significant risk at Evergreen Packaging?

The heat gun could produce temperatures exceeding the flashpoint and auto-ignition temperatures of the resin. As a result, it should have been recognized as a hot work hazard and treated with proper safety precautions.

What was the mistake made by the Blastco workers regarding the heat gun?

The Blastco workers failed to recognize the heat gun as a potential ignition source. They did not treat its use as hot work, and they did not inform Evergreen or Rimcor about its use, resulting in the fire.

What could Blastco have done differently to avoid the incident?

Blastco could have used a safer alternative, like the drum heating bands they had available, which could have warmed the resin without creating a fire hazard. Proper pre-job planning could have identified and staged the necessary equipment.

How did the lack of pre-job planning contribute to the incident?

The Blastco workers were unprepared for the cold weather and had no plan to safely address the issue of resin hardening too slowly. They resorted to using a heat gun, which ultimately caused the fire.

What is the significance of the confined space safety issue identified in the investigation?

The up-flow and down-flow towers were permit-required confined spaces. The CSB found that Blastco did not recognize the introduction of the heat gun as a condition that required terminating the confined space entry, which violated safety protocols.

What is SIMOPS, and how could it have prevented the incident?

SIMOPS (simultaneous operations) refers to work activities occurring close together in time and place that may interfere with each other, increasing risks. A SIMOPS program could have coordinated the work between Blastco and Rimcor, preventing the incident.

How did the construction materials in the vessels contribute to the severity of the fire?

The up-flow tower and the crossover pipe were made of fiberglass-reinforced plastic (FRP), a combustible material. When the heat gun caused the resin to ignite, the FRP contributed to the rapid spread of smoke and flames to the down-flow tower, leading to the fatalities.

What recommendations did the CSB make to improve safety following the incident?

The CSB recommended that OSHA issue safety information addressing hazards arising from work activities in confined spaces, require coordination of simultaneous operations, and address the risks of using flammable materials in confined spaces.