New Video Highlights Safety Issues That Led to Fatal Fire at Paper Mill in 2020
The U.S. Chemical Safety and Hazard Investigation Board (CSB) has released an 11-minute safety video, titled “Simultaneous Tragedy: Fire at Evergreen Packaging,” outlining the events that led to a fire at a paper mill in Canton, North Carolina, on Sept. 21, 2020. The video discusses safety issues that CSB identified as contributing to the deaths of two contracted workers and features interviews with Katherine Lemos, CSB chairperson, and Drew Sahli, CSB’s lead investigator for the incident.
During a scheduled shutdown, employees of contracting companies Blastco and Rimcor were performing maintenance in two “upflow” and “downflow” towers. The towers were connected by a pipe but considered separate by the contractors and Evergreen Packaging, the paper mill’s owner. The Blastco employees were applying alternating layers of fiberglass matting and resin to replace the surface material inside the upflow tower. The resin hardened more quickly in warmer temperatures, but this work occurred on a particularly cold night. Having difficulty completing their task, the Blastco employees used an electric heat gun to warm the resin, not communicating this decision to Evergreen or the two Rimcor employees working in the connected tower. Around 5 a.m., the heat gun was accidentally dropped into the bucket of resin, which ignited, and fire and smoke quickly spread through the pipe into the downflow tower. The Blastco employees evacuated, but both Rimcor employees were fatally injured.
CSB found that the heat gun was capable of producing temperatures greater than the resin’s flashpoint, but the Blastco employees did not recognize this. According to CSB, Blastco failed to recognize the heat gun’s use in a confined space near flammable resin as a form of hot work. Although Blastco had provided drum heating bands that could have been used to safely heat the resin, these devices had not been identified during pre-job planning, so Blastco employees were not able to locate them before the accident.
Evergreen did not have a simultaneous operations (SIMOPS) program in place to facilitate coordination between contractors, so Blastco and Rimcor employees had limited awareness of each other’s work. According to Sahli, if “Evergreen had a SIMOPS program, it could have foreseen the potential hazards of the two jobs being done at the same time, so close together, and could have put measures in place to prevent fatal injuries to the Rimcor employees.”
CSB also learned that the upflow tower and connecting pipe were constructed from combustible materials, increasing the severity of the fire. The five-gallon bucket of resin did not contain enough fuel to create a fire of the size that occurred during the incident.
As a result of the investigation, CSB recommends for OSHA to release safety information addressing hazards resulting from work inside confined spaces, to require facility owners and operators to ensure coordination between multiple work groups, and to publish a bulletin on flammable materials in confined spaces. More information can be found in CSB’s news release.