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By,CHETHAN.K.NCHETHAN.K.N

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CONTENTSCONTENTS Introduction

Background

Fire

Emergency response

Reactions

Causes for fire

Investigation

Criminal prosecution Prosecution of the owners

Prosecution of Imperial Foods

Recommendations

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INTRODUCTIONINTRODUCTIONThe Hamlet chicken processing plant fire was an industrial fire thattook place in Hamlet, North Carolina, USA at the Imperial Foods chickenprocessing plant on September 3, 1991. The fire was North Carolina's

worst industrial disaster and the third worst American industrial disaster,exceeded only by the 1947 Texas City disaster and the 1911 TriangleShirtwaist Factory fire.

Twenty-five people were killed and 54 injured in the fire, as they weretrapped behind locked fire doors. Due to a lack of inspectors, in 11 yearsof operation, the plant had never received a safety inspection. Investigatorsthought that a single safety inspection might have revealed the problemand easily prevented the disaster.

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BACKGROUNDBACKGROUND

The Imperial Foods building was 11 years old, although the basic structure

dated back to the early 1900s.The building had been used for various food

processing applications and was previously an ice cream f actory.At the time

of the fire it had grown to include a series of adjoining structures totaling30,000 square feet.The f actory was constructed with bricks and metalwork

and was one story high. Imperial's owners usually kept the doors of the

chicken plant padlocked and the windows boarded. This was done to

prevent people from stealing chickens, vandalizing the premises or

committing other petty criminal acts. There had been no safety inspections

by the state due to a lack of inspectors.The poultry inspector had visitedthe site daily and was aware of the various fire violations; one worker has

stated that much of the chicken meat was rotten. The company always had

a poor safety record although it had had no previous f atal accidents.

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Contd«Contd«The Hamlet plant had had three previous non-f atal fires but no action was

taken to prevent recurrence or to unlock the doors.The plant had been hit

by fires before Imperial took over as well, although these, too, were non-

f atal. It had no fire alarm system to warn workers further back in theplant, and there were no sprinklers anywhere in the building.

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FI

REFI

REThere were 90 employees in the f acility at the time of the fire, which began

when a 25 foot (7.6 m) long deep f at fryer vat apparently spontaneouslyignited at around 8:30 AM.This cooker's temperature was controlled bythermostat and was maintained at a constant 375 °F (190 °C), which was

variable by design to 15 °F (8.3 °C) either way.T

he fire spread rapidly,sending workers into a panic so that some suffered trauma injuries during

their rush to escape. Large quantities of smoke were produced by acombination of burning soybean oil and chicken, and melting roof

insulation. The smoke was later found to be hydrocarbon-charged and

therefore had the potential to disable someone within a few breaths. Several

gas lines embedded in the ceiling also caught fire and exploded.

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Contd«Contd«Most of those who escaped who were unharmed worked in the front of the building and got out through the unlocked main entrance, but mostworkers were trapped by a curtain of smoke. Others tried to escapethrough the locked doors by kicking them down, but without success; mostof the survivors from the rear of the building got out via a loading bay.The bay was originally blocked by a tractor-trailer, but three workers wentinto the rear of the truck and pounded on the walls until they were heardby rescuers who moved the vehicle. Others escaped when several workersmanaged to break open a few of the doors, though for many this came toolate.

The injured were sent to several different hospitals for treatment for theirinjuries. One of the deceased worked for an external company and wasresupplying the on-site vending machines; no one even realized he wasinside the plant until the company he worked for reported his truckmissing.

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Contd«Contd«Twenty-five people died and 54 suffered injuries or aftereffects such as

burns, blindness, respiratory disease from smoke inhalation, neurologicaland brain damage, and post traumatic stress disorder.Of the dead, 18 were

female and 7 were male. Many of the survivors either still suffer or diedearly from their injuries, and others have become addicted to their

medications or to alcohol.

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EMERGENCY RESPONSEEMERGENCY RESPONSE

Emergency response was delayed because telephones inside the building

could not be used. The plant owner's son drove to the fire station and

informed them there that the f actory was on fire but neglected to say that

workers were still in the plant. More than 100 medical and emergencyservice personnel attended the scene, some of whom ran from a localhospital, and nearby towns provided emergency evacuation for the injured

via four air ambulances from the local hospital to nearby burns units.

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REACTIONSREACTIONS

It was immediately clear that the workers had been trapped by locked fire

doors, which drew much criticism. A spokesman for the company admitted

that "certain doors" in the plant were locked at "certain times" but refused

to say which doors. Clark Staten of the Emergency Response and Research

Institute in Chicago said in response to the blaze: "If the initial reports can

be believed, this is an intolerable set of circumstances that should result in

criminal charges being placed against those responsible for having the fire

doors locked... Our past experience with fires and fire deaths shows that we

must ensure an adequate number of open exits from any occupied

building... It's hard to believe, in today's day and age that any businessowner or manager would be so insensitive to fire safety as to allow this

sort of incident to happen.µ

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CAUSES FOR FIRECAUSES FOR FIRE The fire was caused by f ailure of a hydraulic line which powered a

conveyor belt supplying the cooker vat. When the original line developed

a leak a worker originally replaced it with new line and with new

connections. Later the line, which was too long and created a tripping

hazard, was shortened, but in the process the worker replaced the new

end connector with the old fitting. The line was rated to 3,000 psi (20,700 kPa), while normal operating

pressure never f luctuated higher than 1,500 psi (10,300 kPa). However,when the line with a customized connector was brought up to normaloperating pressure, it separated from the connector at between 800 and

1,500 psi (5,500²10,300 kPa). Hydraulic f luid spattered onto the heating

plumbs for the cooker and immediately vaporized. This vapor then went

directly into the f lame of the gas-fired cooker. The vapor had a relativelylow f lashpoint and erupted into a fireball. The ruptured hydraulic line

went on to pump a total of 50 to 55 US gallons (41²46 imp. gal/189² 208 L) of hydraulic f luid into the fire before electrical f ailure shut it

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INVESTIGATIONINVESTIGATIONAn investigation was immediately launched by state authorities who were

joined one month later by federal colleagues.Investigators found

indentations left on at least one door by people attempting to kick it down.There were concentrations of bodies around fire exits and inside a large

walk-in freezer where panicked workers had sought shelter. Some sourcessay they instead quickly froze to death, in temperatures as low as -28 °F (-33 °C), but the official report states they were killed by smoke infiltration

around the improperly closed door. Twelve deaths occurred in this area,though five people survived in the freezer, albeit with injuries.Timothy

Bradly, North Carolina's Deputy Commissioner of Insurance, said thattechnically "There was not a single door in the plant that met the criteriaof a fire exit.µ

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CRI

MI

NAL PROSECUTI

ONCRI

MI

NAL PROSECUTI

ONProsecution of the ownersProsecution of the owners

Emmett J. Roe, owner of Imperial Foods Products Inc.; his son Brad, who wasoperations manager for the company; and plant manager James N. Hair all

surrendered to f ace prosecution on March 13, 1992. It was Roe senior who hadpersonally ordered the doors to be locked from the outside.He received a prison

sentence of 19 years and 11 months. The sentence is unpopular among manyof the workers and their f amilies who point out that it amounts to less than a

year for each dead person.

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Prosecution of Imperial FoodsProsecution of Imperial Foods

Imperial Foods was fined $808,150 for offenses such as the locked doors

and inadequate emergency lighting. The amount is comparatively smallcompared to federal penalties that can total millions because the state

administers its own safety program.It is thought that were theOccupational Safety and Health Administration responsible the fines wouldhave totaled between $2.8 million and $10 million.Despite this, the fine

was still the highest in the history of North Carolina.

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RECOMMENDATIONSRECOMMENDATIONS

The final report made ten recommendations

Life safety codes must be enforced. Proper enforcement of existing

regulations must occur in future.

Cooking areas must be separately partitioned from other employee workareas. Cooking operations in food processing plants carry a high risk of

fire, and so must be separated from the rest of the building, and from as

many workers as possible.

Building exits in wet-type operations should have double emergencylighting, one positioned above the door and one low to the f loor. Because

the work areas were cooled to comply with food preservation laws,humidity was high, so-called "wet conditions". These conditions cause

particularly heavy smoke, obscuring much high-level emergencylighting.

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Contd«Contd« High-pressure equipment maintenance and repairs must be limited to

f actory-trained personnel and specifications. Maintenance personnelworking on high-pressure machinery, such as the maintenance employee

who conducted the f aulty modification to the hydraulic hose in the plant,must be trained by personnel from the f actory that supplied the

equipment. High-pressure equipment in probable incident areas should have built-in

catastrophic shutdown valves. This would reduce the probability of

accidents in high-risk areas by shutting down machinery should a f aultoccur.

Negative air f low systems in these f acilities could enhance safety by being

modified to also accomplish smoke evacuation. Many similar plants have

this equipment, which is designed to quickly purge the air of toxic fumes

in the event of accidental release of ammonia. The report recommends

modif ying the equipment to also pull heavy smoke away from lower

areas.

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Contd«Contd«State and federal inspectors from various departments should be cross-

trained. Had the food inspector reported the problems he saw, the disaster

may have been prevented despite the lack of other safety inspections. Such

personnel should be trained to recognise major problems and to report

them to the relevant authorities. Establish a ´worry freeµ line of communications for industry employees.

Workers inside the Hamlet plant were afraid to say anything about safetyconditions for fear of being fired. To overcome such problems, states

should establish systems of anonymous reporting of problems by workers.

T

he number of OSHA safety inspectors must be increased. Emergency exit drills must be incorporated into industry policies. This

would allow quick evacuation of premises like the Hamlet chicken plant.

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