Hamlet chicken processing plant fire

Throughout this article, the unqualified term "dollar" and the $ symbol refer to the United States dollar.

The 1991 Hamlet chicken processing plant fire is an industrial disaster that took place at the Imperial Foods chicken processing plant in Hamlet, North Carolina, USA, on September 3, 1991 after a failure in a faulty modification to a hydraulic line. Twenty-five people were killed and fifty-four injured in the fire as they were trapped behind locked fire doors. Due to a lack of inspectors, the plant had never received a safety inspection in eleven years of operation, and it is thought that a single inspection would have easily prevented the tragedy.

A full federal investigation was launched, which resulted in the owner receiving a 20-year prison sentence, and the company received the highest fines ever handed out in the history of North Carolina. However, the investigation also highlighted failings in the authoritative enforcement of existing safety regulations, and resulted in a number of worker safety laws being passed. Accusations of racism were leveled at both the fire service and the city of Hamlet in the aftermath of the fire. The latter dispute, concerning a memorial service organized by the city, resulted in two separate, near-identical monuments being erected. The plant was never reopened.

The fire remains the worst peacetime human-made disaster ever to strike North Carolina, and the second worst American industrial disaster, with only the Triangle Shirtwaist Factory fire being worse.

Background

A view of the front of the plant, taken shortly after the fire. The door to the right is the main office.

The Imperial Foods building was eleven 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 factory. At the time of the fire it had grown to include a series of adjoining structures totaling 30,000 square-feet. The factory was constructed with bricks and metalwork and was a single storey high. 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. Imperial's owners usually kept the doors of the chicken plant padlocked and the windows boarded-up. This was done to prevent people from stealing chickens, vandalizing the premises and/or committing other petty criminal acts — a decision that was to later have fatal consequences. There had been no safety inspections by the state due to a lack of inspectors. However, the poultry inspector had visited the site daily and was aware of the various fire violations as well as the fact that much of the chicken meat was found to be rotten, and that the reason it was processed into chicken nuggets was to disguise the foul taste. However, for unknown reasons, he did not report these violations. Some workers were made nervous by the locked doors but did not voice their concerns for fear of losing their jobs.

The company always had a poor safety record although it had had no previous fatal accidents. It was cited in the 1980s after safety violations in its plant at Moosic, Pennsylvania were discovered. These included poorly marked or blocked emergency exits. The offending factory had been closed by the time of the fire. The factory had three previous non-fatal fires but despite this 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-fatal. Also, the Imperial plant at Cumming, Georgia had two major fires, one of which, in 1989, caused $1.2 million worth of damage. The plant in Hamlet had been hit by fires before Imperial took over as well, although these, too, were non-fatal.

Another view of the plant from front and side, taken at the same time, showing the loading facility and giving a good general view of the building.

This particular plant was also less than ideal. The plant tended to have a workload of one hundred chickens a minute. This high rate of speed created large currents of air which kept temperatures low via the "wind chill" effect. This, combined with refrigerated working conditions, lead to many workers contracting parrot fever, a type of pneumonia. There was also a high rate of repetitive motion injuries and an average of 23% of workers fell seriously ill or were badly injured every year. There were no sprinklers in the building, which also contained a quantity of asbestos and had no fire alarm system to warn workers further back in the plant.

There was a general lack of flammable materials throughout the complex, other than some packing materials towards the rear, and as a result an extensive fire was considered unlikely. As a result there were open spaces between rooms in place of doors to allow for easy access by forklift trucks. The only barrier to any of these was curtains of plastic strips between some to hold in refrigerated air. This allowed for rapid spread of smoke and heat in the deadly blaze. Also, the building's previous use as an ice cream production facility meant that the walls and floor were hard, smooth surfaces, which would severely limit the amount of material that was available to absorb heat and smoke during the fire.

Fire

File:Imperial Foods Cooker 1.png

A view of the cooker vat where the fire started.

There were ninety employees in the facility at the time of the fire, which began when a twenty-five foot long deep fat fryer vat apparently spontaneously ignited at around 8:30 AM. This cooker was temperature controlled via thermostat and was maintained at a constant 375 degrees fahrenheit (190°C), which was variable by design to fifteen degrees fahrenheit either way. The fire spread rapidly, causing trauma-related injuries to some of the survivors as they rushed to escape. Large quantities of thick, acrid smoke were produced by a combination of burning soybean oil and chicken, and melting roof insulation. One worker later described being overtaken by this smoke while running at full speed to the rear of the facility. 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.

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.

Those who were able to escape unharmed worked in the front of the building and escaped through the unlocked main entrance, but most workers were trapped by a curtain of smoke. Workers attempted to escape through the locked doors by kicking them down, but without success. Most of the survivors escaped via a loading bay. The bay was originally blocked by a tractor-trailer truck 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. Others were able to escape when several workers managed to break open a few of the doors, although for many the open doors came too late. The injured were sent to several different hospitals for treatment for their injuries. One of the deceased worked for an external company and was resupplying the on-site vending machines; no-one even realized he was inside the plant until the company he worked for reported his truck as missing.

Casualties were high, with twenty-five fatalities; in addition, fifty-four people received injuries such as severe burns, blindness, respiratory disease from smoke inhalation, neurological and brain damage, and post traumatic stress disorder. Of the fatally injured, eighteen were female and seven were male. Many of the survivors either died early deaths from their injuries or still suffer the effects, and others have become addicted to their medication or to alcohol.

Emergency response

Floor plan of the factory showing the locations of the origin of the fire and of the killed and injured.

The emergency response was slow to start because the telephones inside the building could not be used, so the owner's son drove down to the fire station and informed them there that the factory was on fire but neglected to say that workers were still in the plant. Over 100 medical and emergency service personnel attended the scene, some of whom ran from a local hospital, and nearby towns provided emergency evacuation for the wounded via four helicopters from the local hospital to nearby burns units, although they did not attend the scene itself. The emergency response has come under heavy criticism in the aftermath of the blaze. Fire Chief Fuller, who was in charge of the emergency response, refused help several times from nearby Dobbins Heights fire department, located just five minutes drive away. Dobbins Heights fire department was comprised of African-American volunteers, and there have been allegations that there was racial prejudice on the part of the Fire Chief, especially since the workers, being black, were also of an ethnic minority. However, 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, hopelessly inadequate for the large number of casualties.

For the purposes of the investigation, Fuller was asked to evaluate the emergency response. He told investigators that he felt there were "more than adequate numbers of personnel and equipment given the layout of the incident site."

Reactions

A view of the plant taken from an aerial ladder across the street, showing a collapsed section of roof directly above the origin of the fire.

It was immediately clear that the workers had been trapped by locked fire doors, garnering much controversy. A spokesman for the company admitted that "certain doors" in the plant were locked at "certain times" but refused to elaborate on 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 business owner or manager would be so insensitive to fire safety as to allow this sort of incident to happen."

The Imperial processing facility in Cumming, Georgia was shut down for 24 hours immediately after the fire, when a resulting inspection by the Occupational Safety and Health Administration found an inoperative sprinkler system, "improper" fire exits and a total lack of any kind of evacuation plan. Imperial Foods were told 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 prevent the oil in the vat from catching fire.

Investigation

An investigation was immediately launched by state investigators who were joined one month later by federal ones. Investigators found indentations left on at least one door by people attempting to kick it down. They also discovered concentrations of bodies around fire exits. There was also a concentration inside a large walk in freezer where panicked workers had sought shelter. Some sources say they instead quickly froze to death, in temperatures as low as minus 28 degrees Celsius (-18.4 °F). However, the official report into the fire states that they were in fact killed by smoke infiltration around the door, which hadn't been shut properly. A total of twelve fatalities occurred in this area, but five people did survive in the freezer, albeit with injuries. The investigation concluded that the high number of deaths and injuries were caused by the locked fire doors; doors that weren't locked were blocked by parked vehicles. Timothy Bradly, then North Carolina's Deputy Commissioner of Insurance, said that technically "There was not a single door in the plant that met the criteria of a fire exit."

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 which supplied the cooker vat. The original line had developed a leak, so it was replaced by a maintenance worker. The line it was to be replaced with was a mass produced factory line and was longer than was necessary, causing it to snake across the floor in a fashion that was determined to pose a hazard of tripping. The worker therefore requested and received permission to cut the line down to the required size. He did so, and then replaced the factory end connector with the original end connector from the failed line, before recoupling the line to the conveyor. The line was rated to 3,000 psi, while normal operating pressure never fluctuated higher than 1,500 psi. However, when the line with a customized connector was brought up to normal operating pressure, the line separated from this end connector at somewhere between 800 and 1,500 psi and hydraulic fluid was forced out at this pressure at an elevation of four to six feet above the concrete floor. This fluid spattered onto the heating plumbs for the cooker and was immediately vaporized. This vapor then went directly into the flame of the gas-fired cooker. The vapor had a relatively low flashpoint and erupted into a fireball. The ruptured hydraulic line went on to pump a total of fifty to fifty-five US gallons of hydraulic fluid into the fire before electrical failure shut it down.

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.

Some of the blame was also laid upon the authorities. The state Labor Secretary at the time, John Brooks, blamed his department's failure to inspect the plant on shortage of money and staff, but also blamed Federal government for not enforcing stricter standards.

Recommendations

The final report into the fire made a total of ten recommendations. A quick summary of each point is included below.

• 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 shut down valves. This would reduce the probability of accidents occurring 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 recognise 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 due to fear of being fired. To overcome such problems, states should establish systems of anonymous reporting by workers of problems within their places of work.

• 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 the number of inspectors requires increasing to solve the problem.

• Emergency exit drills must be incorporated into industry policies. This would allow for quick evacuation of premises like the Hamlet chicken plant.

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 all surrendered to face prosecution on March 13 1992 and were charged with non-negligent manslaughter. There was no trial. Instead on September 15, 1992 owner Roe senior pleaded guilty to 25 counts of involuntary manslaughter while his son and another man went free as part of a plea bargain agreement. It was Roe who had personally ordered the doors to be locked from the outside. He received a prison sentence of approximately 19 years and 11 months, although the exact amount is disputed between various sources. The sentence is unpopular among many of the workers and their families who point out that it amounts to less than a year for each dead person. He first became eligible for parole in March 1994, and was ultimately released just under four years into his sentence, another fact unpopular with victims of the disaster.

Prosecution of Imperial Foods

Imperial Foods themselves, as a company, although not strictly speaking prosecuted, were fined a total of $808,150 over the incident for offenses such as the locked doors and inadequate emergency lighting. The amount is comparatively small compared to federal penalties that can total millions because the state administers its own safety program. It is thought that were the Occupational Safety and Health Administration responsible the fines would have totaled between $2.8 million and $10 million. Despite this, the fine was still the highest in the history of North Carolina.

References as a textbook example

The disaster and subsequent prosecution have been used as textbook cases 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".

Aftermath

After the fire the factory was permanently closed, with the loss of 215 jobs. Within two years of the accident insurance companies and the North Carolina business lobby collaboratively introduced legislation to severely limit the compensation available to injured workers and the relatives of the deceased. Insurance companies had originally agreed to pay $16.1 million to the injured and the families of the deceased. 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.

On January 9, 1992, then Labor Secretary Lynn Martin told North Carolina state officials that they had a deadline of 90 days to improve enforcement of job safety and health regulations or federal agencies would take over. The North Carolina General Assembly passed a number of new worker safety laws as a result.

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. But then mayor Abbie Covington did not want him involved and was backed up by many other local authority figures. The argument is often seen as being discriminatory on the grounds of race or class. The result was that a group of the survivors held their own service, separate to that provided by the authorities, which included Jackson. Both services unveiled near-identical monuments, which are situated just 50 yards (46 metres) from each other.

Many firefighters also suffered psychological problems after the fire as due to the small size of the community many of the firefighters knew some or all of the victims. Fifty to sixty of them attended counseling sessions as a result.

A memorial service was held in 2000 but by then many survivors had passed away, mostly due to complications from their injuries. The burned-out shell of the factory remained for many years but was eventually bulldozed by the state in 2001 after they declared it "a public health nuisance" due to the psychological impact it had on the victims, many of whom still lived within sight of the structure.

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 entitled Hamlet: The Untold Tragedy. Although the project is currently looking for funds for completion a 20-minute version entitled Hamlet: Out of the Ashes is currently on tour.
• 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.

See also

• Collinwood School Fire: a 1908 fire that resulted in a national effort to change doors at public buildings 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 1941 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 improvments in many builidngs, particularly schools.
• Beverly Hills Supper Club fire: a 1977 fire which led to an overhaul of fire code enforcement and a ban on aluminum wiring.