A chemical leak that killed six workers at a Georgia poultry plant in 2021 resulted from a poorly designed freezer that spilled deadly liquid nitrogen as well as a failure by the plant’s owner to install safety equipment and properly train employees for emergencies, a federal agency has concluded.

“This needless and senseless tragedy was completely preventable,” U.S. Chemical Safety and Hazard Investigation Board Chairman Steve Owens said in a statement accompanying a 116-page report by the agency’s investigators.

A freezer used to instantly freeze chicken at the Foundation Food Group plant in Gainesville, Georgia, overflowed with liquid nitrogen that spilled into the surrounding room on Jan. 28, 2021. On contact with the air, the chemical vaporized into an odorless gas, forming a cloud up to 5 feet (1.5 meters) high.

Two workers who were performing maintenance on the freezer died from asphyxiation, the agency said, and four more were killed as other employees tried to rescue their colleagues. Three additional workers and a firefighter were seriously injured.

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Located roughly 60 miles (100 kilometers) northeast of Atlanta, Gainesville is the hub of Georgia’s $4.3 billion poultry industry.

The Foundation Food Group plant and others in the area rely heavily on a Latino workforce. Five of the workers killed in the 2021 chemical leak were Mexican citizens.

Federal investigators found the freezer had a bent tube, likely damaged during maintenance, that disabled its ability to monitor and regulate liquid nitrogen levels — allowing the chemical to fill and then leak from the freezer. The agency faulted the freezer’s manufacturer, Messer LLC.

“This design was vulnerable to a single point of failure,” the CSB said in its report, released Monday. “Once the tube became bent, there was nothing else to prevent the release of liquid nitrogen.”

The board also blamed the plant’s owner, concluding that Foundation Food Group had poorly prepared its facility and workers for such an emergency.

The freezer room lacked air monitors to shut off the flow of liquid nitrogen and alert employees if oxygen levels dropped to dangerous levels, the report said. And it said employees weren’t trained to respond to a liquid nitrogen leak, as evidenced by a number of workers rushing to the vapor-filled freezer room as if unaware they wouldn’t be able to breathe.

Foundation Food Group did not immediately respond Thursday to an email message seeking comment on the CSB’s findings.

Messer spokesperson Amy Ficon said in a statement that the industrial gas supplier welcomed the federal investigators’ “thorough and thoughtful” recommendations. She said Messer has already improved safety inspection practices to help prevent future liquid nitrogen leaks. The CSB report noted the company has also made safety upgrades to its freezer design.

“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,” Ficon said. “Messer continues to express our sincere sympathy for the families of those workers who lost their lives at the FFG facility.”

The federal safety board doesn’t issue fines or sanctions. Its findings are used to make safety recommendations to policymakers and industry officials.

The U.S. Occupational Safety and Health Administration proposed more than $595,000 in fines against Foundation Food Group for safety violations a few months after the deadly leak. The company contested the penalties and its case is still pending, according to OSHA. Messer ended up paying more than $54,000.

The safety board recommended that OSHA create a national workplace standard for storage and use of liquid nitrogen and other cryogenic asphyxiants, which can displace oxygen and render air unbreathable.

The agency also called for Messer to work directly with customers to ensure they have signs posted warning of potential dangers of liquid nitrogen and emergency shutoff equipment that can be reached safely during a leak.

Foundation Food Group has since sold the Gainesville plant to Gold Creek Foods. The safety board said the new owner doesn’t use liquid nitrogen freezing in the building where the deaths occurred. Still, it called on the company to make sure local emergency responders are aware of what chemicals are stored and any potential hazards.

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