An Unhappy Easter in West Reading: The R. M. Palmer Chocolate Factory Explosion

 

Chocolate Easter bunnies are a minor but long-established part of the holiday, which will be celebrated a week from today. They are well-known enough to be the subject of a long-running shtick in the comic strip "Sally Forth," in which the mother always finds the daughter's chocolate Easter bunny and eats the ears off.  But somebody has to make chocolate Easter bunnies, and one of the prominent suppliers of such is the R. M. Palmer Company of West Reading, Pennsylvania.

 

Around 4:30 P. M. on Friday, Mar. 24, several employees of the 850 or so in the West Reading facility smelled gas.  Patricia Borges, who had worked in the factory for four years, approached a supervisor and asked if they were going to be evacuated.  She says she was told that such a decision would have to be made by someone higher up, and so Borges went back to work.

 

Just prior to 5 P. M., a tremendous explosion demolished much of the two-story brick factory and damaged several nearby buildings.  Surrounded by flames, Borges began to run and fell through the floor into a basement vat of chocolate, which extinguished a fire that had attached itself to her arm.  But her feet were injured by the fall.  As the vat began to fill with water from fire-fighting equipment, she managed to crawl onto the lip of the tank and onto the floor, which was flooding with water.  Dazed, she lost track of time until much later, when she heard noises of rescue workers searching the rubble.  She cried out ,and rescuers pulled her from the building and took her to a hospital, where she is being treated for burns and broken bones in her feet.

 

Seven of her co-workers were killed and about twelve more were injured in the blast, which is under investigation by both state and federal authorities.  A statement on the homepage of the R. M. Palmer Company addressed to "our R. M. Palmer teammates" says "Our thoughts and prayers are with you during this difficult time."  But the rest of the site is unchanged, and presents brightly colored ads for Valentine's Day, Easter, Halloween, and Christmas candy over the company's slogan "Making Candy Fun."

 

Lest we lapse into a bathetic mode, let us note that the same employees would be just as dead or injured had they been making 45-caliber ammunition instead of candy.  Factory workers in any facility have a right to expect that their place of employment will not put them at daily risk of life or limb, and while working in a munitions plant might call that expectation into question, you would think making candy would be a fairly safe way of earning a living.  And most of the time, it is.

 

We will have to await the results of investigations to learn the cause or causes of the explosion, but one thing seems to be pretty clear from Borges' testimony already.  Whoever her supervisor was, he or she made a fatal mistake in not responding to the smell of gas by ordering an immediate shutdown and evacuating the plant.

 

Such a decision is not to be made lightly, of course.  Especially with continuous-process plants, an emergency shutdown entails hazards of its own and a guaranteed cost in lost product, lost time, and other costly issues.  But against these costs must be weighed the imponderable but real chance that a catastrophic accident may be averted, or at least minimized, by a shutdown and evacuation. 

 

Different types of manufacturing have different cultures, including different safety cultures.  The petrochemical industry deals constantly with highly flammable and explosive materials under conditions of temperature and pressure that make an accident almost guaranteed if a leak occurs.  Because of this, they have developed a safety culture that to an outsider seems extreme in its emphases on training, precautions, and rigorous rules that can get an employee fired for violating them even if nothing bad results from the violation.

 

I have no idea what type of safety and training programs were in place at the R. M. Palmer Company.  News reports indicate few recorded violations of OSHA rules in the recent past, but candy manufacturing is not a typically dangerous process.  Gas leaks can occur at any facility where gas is stored or used, however, and procedures should be in place for precautions to be taken in the event of a gas smell.

 

This incident calls to mind an accident at a chicken processing plant in January of 2021 in which a liquid-nitrogen leak asphyxiated six workers who were apparently not informed of the hazards that were involved.  Again, proper training would have at least minimized the number of fatalities, but in the event, the company was fined over a million dollars for OSHA violations.

 

Perhaps it's a fantasy, but wouldn't it be nice if there was some sort of rule that required upper-level managers to don working clothes once every few months and take the place of a sick or absent worker in the factories they supervise?  Some managers have worked their way up from the factory floor, and probably wouldn't benefit that much from returning to their old haunts.  But others would have their eyes opened at the conditions that their employees endure, and I think such a policy might do more for safety and other working conditions than any number of OSHA rules. 

 

Maybe I've mentioned this before, but it's worth saying again.  Back when I was in high school, I attended an Explorer Scout program that met in a telephone exchange building operated by the Bell System.  A plaque was prominently displayed on the wall of the meeting room, and it read "No job is so important and no service is so urgent that we cannot take time to perform our work safely."  The Bell System was far from a perfect organization, but at least it had high aspirations for safety.  And that motto has struck me as being something to keep in mind the next time a safety issue arises and a supervisor has to decide whether to protect workers at some cost.  For all I know, that supervisor may have paid for the bad decision with his or her life.  But the rest of us are still around to learn from it.

 

Sources:  I referred to Associated Press reports on the accident carried at the sites https://apnews.com/article/pennsylvania-chocolate-factory-explosion-survivor-c1c8e8cb8ee585db9cc9277fbb0b88e3 and https://apnews.com/article/pennsylvania-chocolate-factory-explosion-e4b3197a3cfa6d3a93a7519d83a7aa26.  The R. M. Palmer company website is https://rmpalmer.com/. 

 

NOTE TO READERS:  After a reader noted that my RSS feed was apparently not working, and there was no way to request email notifications of new posts, I investigated ways of improving these situations. 

 

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Filling in your email and clicking on the Subscribe link should bring you to a page that will inform you of receiving a confirmation email.  Clicking on the link in that email should sign you up for receiving notifications.  The system is new, so I'm not sure how one goes about unsubscribing, but there should be a way to do that too.  Please notify me of any problems or issues with this system, and thanks to the folks at tekRESCUE of San Marcos for setting it up.

Nearly $1 Million In Fines Proposed for Deadly Liquid-Nitrogen Accident

 

Last January 28, workers at the Gainesville, Georgia chicken-packing plant operated by Foundation Foods began to show up for work.  Several workers were assigned positions in the below-ground-level freezing room on Production Line 4, one of several in the large plant.  Not too long before, the old ammonia-refrigerant freezing system had been replaced with a new liquid-nitrogen (LN2) system.

 

On the face of it, liquid nitrogen is a safer chemical than ammonia, which is both toxic and explosive.  Nitrogen makes up 78% of the atmosphere, and while liquid nitrogen can cause painful burns, as long as it is confined to locations inaccessible to workers, no direct harm from it can result.  However, breathing nitrogen gas cannot support life.

 

The freezing stage itself was in a separate freezing room, and consisted of an immersion freezing line in which the chicken pieces were immersed in liquid nitrogen at around -321 F, followed by a spiral freezing chamber where the gaseous nitrogen boiling away from the liquid surrounded the pieces as they spiraled upward on a conveyor belt. 

 

Just after the shift started, Line 4 had a problem, and three maintenance workers entered the freezing room.  What they apparently didn't know was that the malfunction had filled the entire room with evaporated liquid nitrogen, displacing most of the oxygen in the room.  The workers immediately passed out and died shortly thereafter.  Two more workers entered the room and died, and a sixth was sufficiently overcome that he died on the way to the hospital.  The release of liquid nitrogen created a condensation fog that made escape difficult, and at least twelve other workers were injured enough to require hospital care. 

 

Both the U. S. Chemical Safety Board (CSB) and the Occupational Health and Safety Administration (OSHA) began investigations of the accident.  In February, the CCB issued some preliminary updates, and on July 23, OSHA announced its intention to assess Foundation Food Group Inc. (the plant operator), Messer LLC (the LN2  supplier), Packers Sanitation Services Inc. (the cleaning and sanitation service provider) and FS Group Inc. (the equipment and mechanical servicing provider) a total of nearly $1 million in fines.

 

OSHA found 26 violations committed by Foundation Food Group.  The agency discovered that the workers at the plant had received no training or warnings about the hazards of LN2 and safety precautions they should observe.  There were no written lockout procedures dealing with how maintenance should be performed.  While the following is reading between the lines, something like this accident could have occurred if someone had shut off the LN2 supply to the system while leaving an LN2 valve or joint open in the freezing room, and then someone else came along and opened the shut valve, not knowing it would kill six co-workers. 

 

Lockout procedures are vital for work on hazardous equipment of all kinds, ranging from conveyor belts to high-voltage power systems.  If equipment is being worked on, a typical lockout procedure specifies brightly-colored tags that must be placed on critical controls in a way that will prevent the control from being operated.  Evidently, nothing like this was done.

 

Another standard safety measure is to train everyone who has a reason to work inside a confined space where hazardous gases (such as pure nitrogen) can accumulate.  Ideally, an oxygen monitor or some way to indicate a problem with the air inside the room should have been operating, but at least the workers should have been made aware of the possible danger.  That way they might not have simply walked into the room to their certain deaths. 

 

If a person strays into an area where there is no oxygen but the air pressure and other conditions seem normal, there is usually no time to react, turn around, or do anything except pass out and drop.  I once saw a dashcam video taken from a state trooper's car.  The trooper had stopped to investigate an accident involving a liquid-ammonia truck.  The gas had been released invisibly, and you can watch as the trooper walks toward the truck and then falls as if shot through the heart, and eventually dies.  Even the miserable coal miners of nineteenth-century England were able to bring a canary into the mine with them to give advance warning of "black-damp"—air without enough oxygen to breathe.  But canaries wouldn't be allowed by the microbiologists who rule meat-packing plants—too unsanitary.

 

While there was probably some mechanical malfunction that caused the initial release of nitrogen, the fatalities could have been avoided with better communication among all the parties involved.  The factory operators needed to give instructions in their employees' native language (Spanish) about the hazards of working around LN2.  The LN2 supplier needed to communicate with the factory operators and maintenance workers concerning the delivery and transmission of their product.  And the maintenance and supervisory personnel in charge of fixing Line 4 needed much better lockout and safety procedures, which were signally lacking in this tragic case.

 

Vigilance is perhaps not taught that much in business schools.  It sounds like an old-fashioned, rather static virtue, somewhat passé when compared with flashier virtues like competitiveness and enterprise.  But clearly, whatever safety procedures and safety officers were in place in the Gainesville plant on last Jan. 28 were sadly inadequate to prevent a tragedy that didn't have to happen.  Not everybody enjoys going around their place of business imagining what could go wrong and how to keep it from happening.  But that's the main job description for those charged with the safety of workers, and it's a job that looks like a loss on a company's balance sheet until something like the LN2 accident happens.  Then it's a lost opportunity, and the beginning of something much worse. 

 

Sources:  OSHA's press release on the fines assessed so far regarding this accident can be found at https://www.osha.gov/news/newsreleases/national/07232021.  Some preliminary findings of the CSB are at https://www.csb.gov/third-csb-update-on-poultry-plant-incident/.  I also referred to a news article at https://www.npr.org/2021/07/23/1019784347/six-poultry-workers-died-from-a-nitrogen-leak-osha-has-issued-1-million-in-fines.  I previously blogged on this topic on Feb. 1, 2021 at https://engineeringethicsblog.blogspot.com/2021/02/six-die-from-liquid-nitrogen-accident.html.