Fatal Cryogenic Asphyxiation
Foundation Food Group Fatal Liquid Nitrogen Release
Foundation Food Group (now Gold Creek Foods)
📍 Gainesville, GA
Incident: January 28, 2021  •  CSB Report: December 11, 2023
6
Fatalities
Multiple
Injuries
Liquid Nitrogen (N₂)
Chemical Involved
📋 Incident Summary

On January 28, 2021, a liquid nitrogen release at the Foundation Food Group Prepared Foods Division poultry processing plant in Gainesville, Georgia, resulted in 6 worker fatalities and multiple injuries. A flexible hose connected to a liquid nitrogen cryogenic freezer failed, releasing a large quantity of nitrogen into the enclosed facility. The oxygen-deficient atmosphere incapacitated and killed workers who were not aware of the danger or were attempting to rescue colleagues.

The facility had no atmospheric oxygen monitoring system, no audible or visible alarms distinct from the building fire alarm, and no remotely operated emergency isolation valves on the nitrogen supply. Emergency stop (E-stop) switches were located in areas that became immediately inaccessible once the nitrogen began to accumulate. Workers had not been adequately trained on the asphyxiation hazards of inert gases and cryogens.

🔎 Key Findings
Finding 01
No Atmospheric Monitoring
The facility had no oxygen monitors or nitrogen detectors in the cryogenic freezer area, so workers received no warning of the oxygen-deficient atmosphere.
Finding 02
No Audible/Visible Alarms
No alarm system distinct from the standard fire alarm existed to alert workers to an atmospheric hazard — workers could not distinguish a nitrogen emergency.
Finding 03
Inaccessible E-Stop Locations
Emergency shutdown switches for the nitrogen supply were located in or near the release zone, making them impossible to safely actuate during a nitrogen release.
Finding 04
No Emergency Isolation Valves
The nitrogen supply lacked remotely operated emergency isolation valves (ROEIVs) that could be closed from a safe distance to stop a release.
Finding 05
Inadequate Worker Training
Workers were not trained to recognize asphyxiation hazards of inert gases or on proper emergency response actions for a cryogenic nitrogen release.
Finding 06
No PSM for Cryogens
The facility did not apply process safety management principles to the liquid nitrogen freezing process; cryogenic asphyxiant hazards were not addressed in PHAs.
🔍 Root Causes
1
Failure to Recognize Cryogenic Hazards
Neither Foundation Food Group nor the nitrogen supplier (Messer LLC) adequately identified or communicated the life-safety hazards of large-scale indoor liquid nitrogen use.
2
Absence of Engineering Controls
No engineering safeguards — atmospheric monitoring, ROEIVs, or properly located E-stops — were in place to detect or stop the nitrogen release.
3
Inadequate Emergency Preparedness
The emergency action program did not address cryogenic asphyxiant hazards, leaving workers and first responders without procedures for a nitrogen release.
4
Regulatory Gap for Cryogens
OSHA has no specific standard covering cryogenic asphyxiants in food processing; the facility was not covered by the PSM standard, creating a regulatory gap.
☑ CSB Recommendations
→ OSHA
Promulgate a standard specific to cryogenic asphyxiants covering atmospheric monitoring, emergency shutdown, employee training, and PSM elements.
→ OSHA
Update three Regional Emphasis Programs for poultry and food manufacturing to explicitly cover liquid nitrogen freezing hazards.
→ Compressed Gas Association (CGA)
Develop a comprehensive standard for safe use of liquid nitrogen in stationary applications, including atmospheric monitoring and ROEIVs.
→ NFPA
Update NFPA 55 (Compressed Gases and Cryogenic Fluids Code) to require atmospheric monitoring and guidance on ROEIV locations.
→ International Code Council
Update the International Fire Code to require atmospheric monitoring with cryogenic asphyxiants.
→ Messer LLC (Supplier)
Update product stewardship policy to require participation in customer PHAs and verification of proper signage and E-stop locations.
💡 Lessons Learned
Liquid nitrogen and other cryogenic inert gases pose lethal asphyxiation hazards in enclosed spaces — oxygen monitoring and alarms are essential safeguards.
Emergency isolation valves and E-stop switches must be located where they can be safely actuated during a release — not inside the potential hazard zone.
Cryogenic asphyxiant hazards in food processing fall outside OSHA PSM coverage — yet they can be as deadly as covered processes.
Nitrogen suppliers share responsibility for ensuring customers understand and manage asphyxiation hazards through product stewardship.
Process hazard analysis (PHA) must explicitly address cryogenic asphyxiant hazards before startup of new freezing processes.
PSM Element: Process Safety Culture & Continuous Improvement
🔨 Safety Meeting Toolbox Talk
▸Have we conducted a formal PHA that addresses cryogenic asphyxiant hazards for all liquid nitrogen operations?
▸Are atmospheric oxygen monitors installed in all enclosed areas where liquid nitrogen could accumulate?
▸Do emergency shutdown controls for nitrogen supply have audible/visible alarms and are they located outside the hazard zone?
▸Are remotely operated emergency isolation valves installed on all cryogenic supply lines entering enclosed spaces?
▸Are workers trained to immediately evacuate (not rescue) upon activation of atmospheric alarms?
Immediate Action Items
✓Conduct a cryogenic asphyxiant PHA for all indoor liquid nitrogen systems
✓Install fixed oxygen monitors with visible and audible alarms in all cryogenic freezer areas
✓Relocate all E-stops and nitrogen isolation valves outside the potential hazard zone
✓Install ROEIVs on all bulk nitrogen supply lines with remote actuators in safe locations
✓Revise emergency action plan to include nitrogen release response procedures
🔗 PSM Failures Behind This Incident

This incident traced to breakdowns across 1 PSM element (PHA). Each represents a documented gap that process safety documentation and consulting can close before a similar event occurs at your facility.

Process Hazard Analysis (PHA)
A structured PHA or HAZOP study exists to identify exactly these scenarios before they occur. When PHA is absent, superficial, or overdue for revalidation, hazards operate unseen until they kill someone.
Supporting documents in our library →
Process Safety Management Consulting & Document Library
📂
PSM Document Library
32 ready-to-deploy PSM documents covering all 14 OSHA elements — procedures, checklists, and audit templates built for facilities operating under 29 CFR 1910.119.
Browse the Library →
📊
Free PSM Health Score
Find out where your PSM program stands across all 14 OSHA elements. Our free health score surfaces your biggest gaps in under 10 minutes — no account required.
Check Your Score →
📞
Consulting Services
PHA facilitation, PSM program builds, compliance audits, and OSHA inspection support. Transparent flat-fee pricing — no retainer required to get started.
View Pricing →
📋 Explore the full incident library: All 132 CSB Case Studies →