John C. Brooks: OSHA still needs attention long after tragedy
Regarding the Sept. 2 editorial “Tragic memories”: After 25 years, The News & Observer still doesn’t recognize the facts about the tragic Hamlet fire that resulted in unnecessary loss of life and multiple injuries.
The Imperial Foods chicken processing plant was not registered with the secretary of state’s office as required by law and therefore not in the database available to the Department of Labor for scheduling OSHA inspections. Therefore, no OSHA inspection had ever been made at the plant. Had an OSHA inspection been made, locked doors would not have been cited as OSHA violations because building code violations are not included in OSHA standards.
Locked doors are a violation of the North Carolina Building Code and part of the enforcement responsibility of the local fire department under the jurisdiction of the North Carolina Department of Insurance.
Following the tragedy in Hamlet, the N.C. Department of Labor embarked upon both an inspection of the tragedy and an assessment of what, if any, laws should be inaugurated to hopefully prevent such a tragedy from reoccurring. After a series of public hearings, the Department of Labor adopted the North Carolina Building Code as an OSHA standard so that its inspector could cite locked doors and other building code violations when making inspections.
Upon taking office, Commissioner Harry Payne immediately repealed the new OSHA standards. The Democratic-controlled General Assembly then adopted a law forbidding the Commissioner of Labor from ever adopting the building code as an OSHA standard again. Therefore, should OSHA make an inspection of a facility today and find locked doors, it still cannot cite them as OSHA violations.
However, it can make a referral to the local fire department. There are no such referrals on record during the past 25 years.
Twenty-five years ago, the N.C. Department of Labor’s Occupational Safety and Health Administration’s division was headed by two of the nation’s foremost OSHA administrators – Deputy Commissioner Mike Ragland and Dr. Jim Oppel. The department annually published a report, a copy of which was routinely sent to The News & Observer, showing the work of its OSHA inspectors compared with that of both other state-administered programs and the federally administered programs. This report regularly showed that North Carolina’s program was the most active and extensive in the nation.
Nevertheless, the annual report also demonstrated that North Carolina needed significantly more personnel in OSHA consultation, education and enforcement. The OSHA staff has not even grown proportionately to this state’s population growth. Unfortunately, it takes the occurrence of tragedies before the shortcomings of the state’s OSHA program gets any public attention.
John C. Brooks
N.C. Commissioner of Labor, 1977-93
Raleigh
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September 1, 2016
Hamlet fire anniversary shows the need for safety regulations
Blackened footprints mark the door to the employee lounge where workers tried to kick their way out to escape the fire at Imperial Food Products plant in Hamlet. Witnesses said the doors at the plant were locked, trapping workers inside. JIM BOUNDS (JRB) JIM BOUNDS (JRB)
BY THE EDITORIAL BOARD
Twenty-five years ago Saturday, a hydraulic line in the Imperial Foods poultry processing plant in Hamlet failed, a fire resulted, and 25 innocent workers lost their lives. Another 55 were injured. And it didn’t have to happen. Exit doors were locked from the outside, and so the workers died a horrible, terrifying death.
Outrage was instant, and the owner of the plant got a 20-year prison sentence, of which he served but four years. Fines were levied, And the shoddy nature of North Carolina’s safety laws and lax oversight of such plants were exposed. State Labor Department officials had never inspected the plant; if they had it’s likely those doors would not have been locked.
Yes, there was a federal investigation and some safety steps were taken, but the federal government ultimately took over enforcement, at least to a large degree, of the state’s worker safety laws.
This anniversary of Hamlet is occasion to scrutinize the promises of Republican politicians in North Carolina who have long talked about the oppressive nature of government regulations. In fact, Republicans have set about cutting regulations they say unnecessarily hinder businesses. But the Hamlet anniversary reminds us that not all “regulation” is about the environment or fees or taxes. Much of it has to do with the public’s safety (from food products to fair rides) and with workers’ safety.
As we remember the poor souls who perished unnecessarily in Hamlet in 1991, it is productive to remember that sound regulation might have saved them, just as it can save workers today.
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Hamlet chicken processing plant fire
A view of the front of the plant, taken shortly after the fire. The door to the right is the entrance to the main office.
A federal investigation was launched. Owner Emmett Roe received a 20-year prison sentence, of which he served only four years. The company received the highest fine in the history of North Carolina,[3] which was less than the federal minimum. As a result, the federal government took over enforcement of much of North Carolina's worker safety laws.[4] Survivors and victims' families accused the fire service and city of Hamlet of racism, leading to two monuments to the tragedy being erected. The plant was never reopened.
The fire was North Carolina's worst industrial disaster.[5] Higher fatalities occurred in the 1947 Texas City disaster, the 1911 Triangle Shirtwaist Factory fire, and the 1860 Pemberton Mill collapse.[6] Some mining disasters have been worse: 53 miners died in 1925 in North Carolina in the Coal Glen mine disaster.
Contents
Background
The Imperial Foods building was 11 years old, although the basic structure dated back to the early 20th century. The building had been used for food processing applications and had been an ice cream factory.[2] At the time of the fire, it included adjoining structures totaling 30,000 square feet (2,800 m2).[5] The factory was constructed with bricks and metalwork and was one story high.[2] The interior was a "maze of large rooms separated by moveable walls", and both workers and the product moved around the interior from process to process, going from front to rear.[5] Imperial's operators usually kept the doors of the chicken plant padlocked and the windows boarded, to prevent theft, vandalism or other criminal acts.[7] There had been no safety inspections by the state due to a lack of inspectors.[1] The poultry inspector visited the site daily and knew of the fire violations. One worker stated that much of the chicken meat was rotten,[7] and that the reason it was processed into chicken nuggets was to disguise the foul taste. He did not report these violations.[6][7] Some workers were made nervous by the locked doors but did not voice their concerns for fear of losing their jobs.[5]
Another view of the plant from front and side, taken shortly after the
fire, showing the loading facility and giving a good general view of the
building
The Hamlet plant had three previous fires, but no action was taken to prevent recurrence or to unlock the doors.[7] The building had fires before Imperial took over as well, although these, too, were non-fatal.[2] The Imperial plant at Cumming, Georgia, had two major fires, one of which, in 1989, caused $1.2 million worth of damage.[8] The Hamlet plant had no fire alarm system to warn workers farther back in the plant, and there were no sprinklers in the building.[7][9]
An extensive fire was considered unlikely because of a lack of flammable materials throughout the complex, other than packing materials in the rear. There were open spaces between rooms in place of doors to allow for easy access by forklift trucks. The only barriers were curtains of plastic strips between some to hold in refrigerated air. This allowed for rapid spread of smoke and heat in the deadly blaze. The building's previous use as an ice cream production facility meant that the walls and floor were hard, smooth surfaces, which limited the amount of material that was available to absorb heat and smoke during the fire.[2]
An inspection of the floorplan shows that 12 of the victims died of smoke inhalation and several more were injured when they ran into the freezer in a panic rather than to the front of the building.[citation needed]
Fire
A view of the cooker vat where the fire started.
The majority of those who escaped unharmed were workers in the front of the building who left through the unlocked main entrance, but most workers were trapped by a curtain of smoke. Others tried to escape through the locked doors by kicking them down, but without success; most of the survivors from the rear of the building got out through a loading bay. The bay was initially blocked by a tractor-trailer, but three workers went into the rear of the truck and pounded on the walls until they were heard by rescuers who moved the vehicle.[5] Others escaped when several workers managed to break open a few of the doors, though for many this came too late.[3]
The same cooker viewed from further back to give a better view of the
general area. Note the heavy damage to the metal roof girders, testimony
to the extreme heat of the fire.
Twenty-five people died and 54 suffered injuries or aftereffects such as burns, blindness, respiratory disease from smoke inhalation, neurological damage and post traumatic stress disorder.[1][7] Of the dead, 18 were female and 7 were male.[2] Many still suffer or died early from their injuries, and some are addicted to their medications or to alcohol.[3]
Emergency 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 factory was on fire but did not say that workers were still in the plant.[3] More than 100 medical and emergency service personnel went to the scene,[1] some of whom ran from a local hospital, and nearby towns provided emergency evacuation for the injured via four air ambulances from the local hospital to nearby burns units.[2]The response came under heavy criticism. Fire Chief Fuller, in charge of the emergency response, refused help several times from the Dobbins Heights fire department, five minutes away from the plant. The Dobbins Heights Fire Department was composed of African-American volunteers and most of the workers were also black, and there were allegations of racial prejudice from the Fire Chief. Fuller has defended his decision, saying at the time he refused assistance he did not realize the doors were locked, adding "In a fire like this you need good, seasoned people." Witnesses have also said that there were only two oxygen tanks on site to help smoke-inhalation victims.[7]
Fuller was asked to evaluate the emergency response for investigators. He said he felt there were "more than adequate numbers of personnel and equipment given the layout of the incident site".[2]
Reactions
Floor plan of the factory showing the locations of the origin of the fire and of the killed and injured.
The Imperial processing facility in Cumming, Georgia, was shut down for 24 hours immediately after the fire when an inspection by the Occupational Safety and Health Administration found an inoperative sprinkler system, "improper" fire exits and no evacuation plan.[8] The inspection report stated that the plant posed an "imminent danger" to workers because it lacked an automatic fire extinguisher over the cooker similar to the one installed in the Hamlet plant, which failed to prevent the disaster, but did slow the ignition of oil in the vat.[2][11]
Investigation
The remains of the failed hydraulic line. Note the separated end connector lying on the bench.
The fire was caused by failure 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 fluctuated higher than 1,500 psi (10,300 kPa). When the line with a customized connector was brought up to normal operating pressure, it separated from the connector at between 800 and 1,500 psi (5,500–10,300 kPa). Hydraulic fluid spattered onto the heating lines for the cooker and immediately vaporized. This vapor then went directly into the flame of the gas-fired cooker. The vapor had a relatively low flash point and erupted into a fireball. The ruptured hydraulic line then pumped 50 to 55 US gallons (40–45 imp. gal/190–210 L) of hydraulic fluid into the fire before electrical failure shut it down.[2]
A state-of-the-art automatic carbon dioxide fire extinguisher designed to cope with such fires had been installed over the vat after a non-fatal fire in 1983 at the fire department's request. This prevented the oil itself from igniting until the later stages of the fire.[5][not in citation given][2]
State authorities were also blamed. The state labor commissioner, John C. Brooks, blamed his department's failure to inspect the plant on shortage of money and staff, and blamed the federal government for not enforcing stricter standards.[13]
Recommendations
The final report made ten recommendations. A summary:[2]- Life safety codes must be enforced. Proper enforcement of existing regulations must occur in future.
- Cooking areas must be separately partitioned from other employee work areas. 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 emergency lighting, one positioned above the door and one low to the floor. 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 emergency lighting.
- High-pressure equipment maintenance and repairs must be limited to factory-trained personnel and specifications. Maintenance personnel working on high-pressure machinery, such as the maintenance employee who conducted the faulty modification to the hydraulic hose in the plant, must be trained by personnel from the factory 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 fault occur.
- Negative air flow systems in these facilities 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 modifying the equipment to also pull heavy smoke away from lower areas.
- 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 recognize major problems and to report them to the relevant authorities.
- Establish a “worry free” line of communications for industry employees. Workers inside the Hamlet plant were afraid to say anything about safety conditions for fear of being fired. To overcome such problems, states should establish systems of anonymous reporting of problems by workers.
- The number of OSHA safety inspectors must be increased. The team of inspectors was hugely overburdened at the time of the accident, and the report says that an increase in the number of inspectors is required to solve the problem.
- Emergency exit drills must be incorporated into industry policies. This would allow quick evacuation of premises like the Hamlet chicken plant.
A view of the plant taken from a ladder across the street, showing a
collapsed section of roof directly above the origin of the fire.
Criminal prosecution
Prosecution of the owners
Emmett J. Roe, owner of Imperial Foods Products Inc.; his son Brad, who was operations manager for the company; and plant manager James N. Hair surrendered on March 13, 1992, and were charged with non-negligent manslaughter.[14] There was no trial. On September 15, 1992, owner Emmett Roe pleaded guilty to 25 counts of involuntary manslaughter. No one else was found guilty. Emmett Roe had personally ordered the doors to be locked from the outside.[5][15] He received a prison sentence of 19 years and 11 months.[7][15][16] The sentence was unpopular among many of the workers and their families who point out that it amounts to less than a year for each dead person.[15] Roe became eligible for parole in March 1994, and was released just under four years into his sentence.[3][15]Prosecution of Imperial Foods
Imperial Foods was fined US$808,150 for offenses such as the locked doors and inadequate emergency lighting. The amount is smaller than potential federal penalties as the state administers its own safety program.[5] The fine was still the highest in the history of North Carolina.[3]References as a textbook example
The disaster and subsequent prosecution have been used in books such as Essential Criminology (1998, Henry, Stuart; Mark M. Lanier) and Political Crime in Contemporary America: a Critical Approach (1993, Aulette, J.R. & Michaelowski, R.), the latter having an entire chapter devoted to the incident entitled "Fire in Hamlet: a Case Study of State-Corporate Crime".[17]Aftermath
The factory was permanently closed, with the loss of 215 jobs.[15] Within two years of the accident insurance companies and the North Carolina business lobby together introduced legislation limiting the compensation available to injured workers and relatives of killed workers.[7] Insurance companies had originally agreed to pay $16.1 million to the injured and the families of the deceased.[18] Some of the workers became activists as a result, to fight what they see as "bureaucratic injustice". They had originally hired John Coale, an attorney who had worked on the Bhopal disaster, but he could not legally practice in North Carolina.[7]On January 9, 1992, U.S. Labor Secretary Lynn Martin told North Carolina state officials they had a deadline of 90 days to improve enforcement of job safety and health regulations or federal agencies would take over.[19] The North Carolina General Assembly passed 14 new worker safety laws as a result,[3] including provision of a system whereby workers could report violations without fear of job loss. The inspector corps was increased from 60 to 114.[6]
Two separate monuments were erected due to a dispute. Many of the workers and their families wanted Jesse Jackson to speak in the city's memorial effort. Mayor Abbie Covington did not want Jackson involved and was backed up by many other local authority figures. One group of the survivors held their own service which included Jackson. Both services unveiled near-identical monuments, which are situated just 50 yards (46 m) from each other.[3]
Because of the town's small size, many firefighters knew some or all of the victims, and have suffered psychological problems. More than fifty attended counseling sessions afterward.[2] A memorial service was held in 2000, though by then many survivors had died, mostly as a result of complications from their injuries. The burned-out shell of the factory was bulldozed by the state in 2001 after it was declared "a public health nuisance" because of the psychological effects it had on the victims, many of whom still lived within sight of the structure.[3] A small memorial park sits on site today, with no trace left of the original strucure.
References in popular culture
Jello Biafra and Mojo Nixon wrote a song about this incident called "Hamlet Chicken Plant Disaster". It is included in their album Prairie Home Invasion. The disaster is the subject of a documentary film titled Hamlet: The Untold Tragedy. A 20-minute version titled Hamlet: Out of the Ashes is currently on tour.[7] A book on the subject, A Southern Tragedy, in Crimson and Yellow, was written by Lawrence Naumoff. Although it follows a fictional character, much of it is based on the fire.[20] The tragedy is also the subject of Cloud Journal (2008), a book of elegiac sonnets by North Carolina poet David Rigsbee. An earlier version by the same author appeared as Sonnets to Hamlet in 2004. [21]See also
- Iroquois Theatre Fire : a 1903 fire that prompted the fire code to improve safety.
- Collinwood School Fire: a 1908 fire that resulted in efforts to change doors on public buildings in America so that they opened outward, and mandatory "panic bar" latches on all doors in schools.
- Triangle Shirtwaist Factory fire: a 1911 factory fire which resulted in extensive changes to safety and workers’ compensation laws.
- Cocoanut Grove fire: a 1942 fire resulting in bans on flammable decorations and new safety standards for fire doors.
- Our Lady of the Angels School Fire: a 1958 fire resulting in worldwide fire safety improvements in many buildings, particularly schools.
- Beverly Hills Supper Club fire: a 1977 fire which led to an overhaul of fire code enforcement.
References
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