U.S. Fire Administration/Technical Report Series

Chicken Processing Plant Fires

Hamlet, North Carolina

and

North Little Rock, Arkansas

USFA-TR-057/June/September 1991

U.S. Fire Administration Fire Investigations Program

T

he U.S. Fire Administration develops reports on selected major fires throughout the country. 

The fires usually involve multiple deaths or a large loss of property. But the primary criterion 

for deciding to do a report is whether it will result in significant “lessons learned.” In some 

cases these lessons bring to light new knowledge about fire--the effect of building construction or 

contents, human behavior in fire, etc. In other cases, the lessons are not new but are serious enough 

to highlight once again, with yet another fire tragedy report. In some cases, special reports are developed to discuss events, drills, or new technologies which are of interest to the fire service.

The reports are sent to fire magazines and are distributed at National and Regional fire meetings. The 

International Association of Fire Chiefs assists the USFA in disseminating the findings throughout the 

fire service. On a continuing basis the reports are available on request from the USFA; announcements of their availability are published widely in fire journals and newsletters.

This body of work provides detailed information on the nature of the fire problem for policymakers 

who must decide on allocations of resources between fire and other pressing problems, and within 

the fire service to improve codes and code enforcement, training, public fire education, building 

technology, and other related areas.

The Fire Administration, which has no regulatory authority, sends an experienced fire investigator 

into a community after a major incident only after having conferred with the local fire authorities 

to insure that the assistance and presence of the USFA would be supportive and would in no way 

interfere with any review of the incident they are themselves conducting. The intent is not to arrive 

during the event or even immediately after, but rather after the dust settles, so that a complete and 

objective review of all the important aspects of the incident can be made. Local authorities review 

the USFA’s report while it is in draft. The USFA investigator or team is available to local authorities 

should they wish to request technical assistance for their own investigation.

This report and its recommendations were developed by USFA staff and by TriData Corporation, 

Arlington, Virginia, its staff and consultants, who are under contract to assist the USFA in carrying 

out the Fire Reports Program.

The USFA greatly appreciates the cooperation and information received from Hamlet, North Carolina 

Fire Chief David Fuller and Captain David Knight, State Fire and Rescue Division Deputy Commissioner 

Timothy L. Bradley and Deputy Director Ray Eastman and Special Agent David H. Campbell of the 

State Bureau of Investigation. Thanks also go to officials of Tyson Foods, Inc., Shannon Weathers, 

Mike Edmunds and Mike McAlister.

For additional copies of this report write to the U.S. Fire Administration, 16825 South Seton 

Avenue, Emmitsburg, Maryland 21727. The report is available on the USFA Web site at http://

www.usfa.dhs.gov/

Chicken Processing Plant Fires

Hamlet, North Carolina

and

North Little Rock, Arkansas

Investigated by: Jack Yates

This is Report 057 of the Major Fires Investigation Project conducted

by TriData Corporation under contract EMW-90-C-3338 to the United

States Fire Administration, Federal Emergency Management Agency.

Department of Homeland Security

United States Fire Administration

National Fire Data Center

U.S. Fire Administration

Mission Statement

As an entity of the Federal Emergency 

Management Agency (FEMA), the mission 

of the U.S. Fire Administration (USFA) is to 

reduce life and economic losses due to fire 

and related emergencies, through leadership, advocacy, coordination, and support. We 

serve the Nation independently, in coordination with other Federal agencies, and in partnership with fire protection and emergency 

service communities. With a commitment to 

excellence, we provide public education, training, technology, and data initiatives.

TAbLe oF CoNTeNTS

OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

SUMMARY OF KEY ISSUES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THE BUILDING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

THE FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

FIRE SUPPRESSION AND EMERGENCY MEDICAL SERVICES (EMS). . . . . . . . . . . . . . . . . . . . . . 5

DISASTER PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

STRESS MANAGEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CODE ENFORCEMENT HISTORY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

NORTH LITTLE ROCK, ARKANSAS FIRE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

FIRE PROTECTION EQUIPMENT AND SAFETY PROGRAMS. . . . . . . . . . . . . . . . . . . . . . . . . . . 8

LESSONS LEARNED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Appendix A: Imperial Foods Plant Floor Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Appendix B: Hamlet, North Carolina, Fire Department Incident Report. . . . . 13

Appendix C: Imperial Foods Plant Fire Photographs. . . . . . . . . . . . . . . . . . . . . . . 14

Appendix D: Tyson Foods Safety Policy, Monthly Fire Inspections

Checklist and Other Fire Safety Program Materials. . . . . . . . . . . . . . . . . . . . 35

1

Chicken Processing Plant Fires

Hamlet, North Carolina

(September 3, 1991)

North Little Rock, Arkansas

(June 7, 1991)

Local Contacts: Hamlet, North Carolina Fire

Chief David Fuller

Captain David Knight

Hamlet Fire Department

302 Champlain Street

P.O. Box 1229

Hamlet, North Carolina 28345

Deputy Director Ray Eastman

Special Agent David H. Campbell

Arson Division

North Carolina State Bureau of Investigation

P.O. Box 29500

Raleigh, North Carolina 27626

Timothy L. Bradley - Deputy Commissioner

Fire and Rescue Division

North Carolina Department of Insurance

P.O. Box 26387

Raleigh, North Carolina 27611

North Little Rock, Arkansas Fire

Shannon Weathers - Fire Safety Coordinator Loss 

Control 

Mike Edmunds - Corporate Safety Director

Mike McAlister - Plant Manager – Prospect Farms

Tyson Foods, Inc.

P.O. Box 2020

Springdale, Arkansas 72765-2020 
2 U.S. Fire Administration/Technical Report Series

O

The morning work shift of employees at the Imperial Foods Processing Plant in Hamlet, North 

Carolina, had just begun when a fire occurred, at approximately 8:15 a.m., on September 3, 1991. 

The rapid spread of heavy smoke throughout the structure ultimately resulted in 25 fatalities and 

54 people being injured in varying degrees. Of the people who died, 18 were women and seven 

were men.

SUMMARY oF KeY ISSUeS

Issues Comments

Casualties Twenty-five fatalities and 54 people injured in varying degrees.

Building Structure Poultry processing plant of 30,000 square feet with open work areas, sealed concrete slab floor, 

ceramic tile walls, and ceilings of formica-type finish. Interior kept cool.

Origin and Cause The conveyor to a cooker had hydraulic line repaired which burst when brought up to full pressure. 

Hydraulic fluid expelled at 800 to 1,500 psi, ignited by heating gas plumes of a cooking vat.

Fire Spread Immediate and very rapid spread of heavy black smoke throughout the building.

Evacuation Fireball and rapid spread of smoke caused disorderly evacuation attempts. Several exit doors 

locked, drove employees to seek refuge in cooler or seek other exits. Rapid build-up of toxic gases 

killed personnel attempting to escape.

Detection and Alarm Plant Operations Manager found phone line already inoperable, ran to vehicle and drove to fire 

station.

Response Rapid response by combination department and people from immediate community including 

medical personnel who ran from nearby hospital. Search and rescue delayed by heavy smoke and 

heat. Ample mutual aid from neighboring communities, including helicopter transport of victims to 

regional medical facilities.

Code Enforcement During the 11-year operation of the plant, no inspection conducted by North Carolina Occupational 

Safety and Health Administration.

Critical Incident Stress Debriefings provided through Pee Dee Council of Government. Many fire service personnel 

involved in incident knew or were related to the victims

.

A similar type fire occurred at a chicken processing plant in North Little Rock, Arkansas, on June 

7, 1991, but with no fatalities or injuries. Following the description of the Hamlet fire below, 

the North Little Rock fire is summarized along with the factors in the different outcomes of these 

two fires.

THe bUILDING

Imperial Foods occupied a one-story brick and metal structure that over the years had been used for 

various food product operations. Reportedly, the previous operation had been in dairy products. As 

such, the interior work areas had walls, ceilings, and floors conducive for that type of operation. This 

meant that these three surface areas were of materials that could be washed down. The floor was 

a sealed concrete slab, the walls were ceramic tile, and the ceilings were a formica-type finish. The 

total square footage was approximately 30,000. For the layout of the plant see Appendix A.
USFA-TR-057/June/September 1991 3

Imperial Foods operations did not include the slaughter of poultry. Rather, poultry parts were 

shipped to the plant, which prepared and cooked the chicken. The cooked chicken would then be 

distributed to various markets for use in restaurants.

The plant had a total employment of approximately 200 people, with a normal shift having around 

90 employees. Preparation of the poultry products included trimming, marinating, cutting, and 

mixing. The prepared meat would then be cooked, quick-frozen, packed, and prepared for shipping. 

Storage areas varied from large drive-in coolers to quick-freezing units.

The plant layout allowed easy movement of products from one area to another by electrical forklift 

pallet movers. The entryways between the various preparation areas were for the most part open 

while some entrances had a curtain of plastic strips to assist in holding refrigerated air in the rooms. 

The freezers and coolers had standard refrigeration doors.

The preparation areas were for the most part cooled or refrigerated in order to prevent food spoilage. Accordingly, door openings were designed in a manner to seal in the structure, with door seals 

similar to those on a refrigerator. This was necessary to assist in maintaining a constant temperature 

in work areas.

Day to day the contents inside the building did not represent a major fuel load problem. The 

only combustible products were items such as paraffin-coated shipping boxes and wood pallets. 

Therefore, the probability of having an extensive fire was considered remote.

The bulk of the food processing operations was performed in the south three-fourths of the complex. The north one-fourth was predominantly for storage and loading. The main operations areas 

by virtue of their cooled, open rooms did present a problem in that there were no smoke or heat 

barriers between work areas. This meant that in the event of any type of fire, there would be nothing 

to impede the travel of heat and smoke. Furthermore, the predominance of hard, smooth surfaces 

meant there was little available material to absorb heat and smoke.

There were exterior personnel doors throughout the structure. These included the main entrance on 

the east side; the southeast loading and trash compacting dock; doors from the break room and the 

equipment room to the outside; and a door from the packing room which led to the north one-fourth 

of the building complex. However, the locations of some of these exits and their sizes would in all 

probability have excluded them from being considered appropriate as part of an evacuation plan.

THe FIRe

The area identified on the Floor Plan in Appendix A as the processing room is the room where the 

fire incident occurred. This area is centrally located within the building complex. Any incident 

occurring in this area could adversely affect much of the building operations and personnel.

Poultry products that had already gone through the various marinating and mixing procedures were 

taken by conveyor to a cooking vat in the processing room, which contained soybean oil. The oil 

was maintained by a thermostat control at a constant temperature of 375 degrees Fahrenheit plus or 

minus 15 degrees Fahrenheit.

A maintenance worker who survived the fire indicated that the hydraulic line that drove the conveyor 

had developed a leak. The hydraulic line was turned off and drained of fluid. Then the maintenance 

worker disconnected the leaking line and replaced it with a factory prepared line.
4 U.S. Fire Administration/Technical Report Series

The factory prepared line, however, was found to be too long and would have dragged on the floor, 

possibly causing people working in the area to trip. So the maintenance worker reportedly asked for 

and gained permission to cut the factory prepared hydraulic line to an appropriate length, replaced 

the end connector with their own connector, and put the line back in-place. This line has been 

described as a 3/4-inch flex line rated to carry 3,000 psi. Information from plant personnel indicated normal pressure was kept at approximately 800 psi, but it would at times fluctuate as high as 

1,200 to 1,500 psi.

The hydraulic line was brought back to operating pressure. Shortly afterward it separated at the 

repaired connector point. The connector was some four to six feet above floor level with hydraulic 

fluid being expelled at a pressure of 800 to 1,500 psi. It obviously began to splatter off the concrete 

floor. Droplets were bouncing back onto the gas heating plumbs for the cooking vat, which turned 

them into vapor. The vapors then were going directly into the flame. The vapors had a much lower 

flashpoint than the liquid hydraulic fluid and therefore rapidly ignited.

In sum, the pressurization of the hydraulic fluid combined with the heat was causing an atomizing 

of the fuel which in all probability caused an immediate fireball in and around the failed hydraulic 

line and the heating plumbs.

The ignition of the fuel caused an immediate and very rapid spreading of heavy black smoke throughout the building. Seven workers were trapped between the area of origin and any escapable routes.

Measurement of the system during the investigation after the fire indicated 50 to 55 gallons of 

hydraulic fluid fueled the fire before electrical failure shut the system down. (Investigators stated 

that if the hydraulic system was fully charged and its reservoirs filled to capacity it would have held 

110 gallons of 32 weight ISO hydraulic fluid.)

In addition to the hydraulic fluid, the fire reached a natural gas regulator that in turn failed and 

caused an induction of natural gas to the fire increasing the intensity and buildup of toxic gases.

The fires in both this incident and the North Little Rock incident were centered around the cooking 

vat areas and expanded outward from there. In both incidents, the vats ultimately did ignite in latter stages of the fire, but in the initial stages the vats did not ignite. The vats in both locations have 

a hood-mounted system over them with built-in CO2 heads. But after considerable burning with 

secondary falldown, the oil in both vats did eventually ignite and burn.

Witness reports indicate much of the plant was enveloped in under two minutes. Workers throughout the plant found their visibility eliminated and oxygen quickly consumed. Hydrocarbon-charged 

smoke, particularly as heavy as this, is extremely debilitating to the human body and can disable a 

person with one or two breaths. This was confirmed as autopsies conducted on all of the fatalities 

found that virtually all died of smoke inhalation as opposed to direct flame injury.

Survivors indicate there was no real organization in the plant’s evacuation, and this was confirmed 

by the locations of the bodies. Several employees in the central part of the structure moved to the 

trash compactor/loading dock area near the southeast corner of the building. It was here they found 

one of the personnel doors to the outside locked. A trailer was backed into the loading dock cutting 

off all exiting through this area. One woman became trapped between the compactor seal and the 

building wall while trying to squeeze through an opening. A number of remaining people in this 

area went into a large cooler adjacent to the loading dock, but failed to pull the sealed door shut thus 

allowing smoke infiltration into the cooler. The cooler had the largest single fatality count area with 

12 deceased people being removed from this room along with five injured people.
USFA-TR-057/June/September 1991 5

The second largest fatality area were the seven trapped in the processing room between the fire and 

any escape route. Three additional bodies were found in the trim room area, one of whom was a 

route salesman who had been filling food machines in the break room. The exterior personnel door 

in the break room was the other door locked from the outside.

The people who died in this tragic fire were as follows:

Name Age City

Josephine Barrington 63 Hamlet

Peggy Anderson 50 Hamlet

Mary Lillian Wall 50 Rockingham

Philip R. Dawkins 49 Rockingham

Minnie Mae Thompson 46 Hamlet

Janice Marie Wall Lynch 43 Hamlet

Elizabeth Ann Bellamy 42 Bennettsville, SC

Cynthia S. Wall 41 Rockingham

Josie M. Coulter 40 Rockingham

Bertha Jarrell 40 Rockingham

John Robert Gagnon 39 Hamlet

Rose Marie Gibson Peele 39 Bennettsville, SC

Mary Alice Arnold Quick 38 Hamlet

Fred Barrington, Jr. 37 Rockingham

Martha A. Ratliff 36 Hamlet

Gail V. Campbell 33 Hamlet

Rosie Ann Chambers 31 Ellerbe

Michael Morrison 31 Hamlet

Rose Lynette Wilkins 30 Laurel Hill

Brenda Gail Kelly 28 Rockingham

David Michael Albright 24 Hamlet

Margaret Banks 24 Laurinburg

Donald Bruce Rich 24 Ellerbe

Jeffrey Antonia Webb 24 Hamlet

Cynthia Marie Ratliff 20 Hamlet

FIRe SUPPReSSIoN AND eMeRGeNCY MeDICAL SeRVICeS (eMS)

Upon discovery of the fire, the operations manager of the plant attempted to call the alarm to the fire 

department, but found that phone lines were already inoperable. (Imperial Foods was not equipped 

with pull-station alarms, nor does the town have 9-1-1.) He then ran to this vehicle parked outside 

and drove some three to five blocks to the fire station.

The initial equipment left the station at 8:24 a.m., and was on the scene three minutes later. Fire Chief 

David Fuller indicated the first smoke he observed was grayish-yellow in color. He stated that Hamlet 

has two paid firefighters on-duty at all times with 28 volunteers. Of the 28 volunteers, 22 responded 

to the scene. (See Appendix B for Fire Department Incident Report.) He also stated there is a county 
6 U.S. Fire Administration/Technical Report Series

mutual aid agreement and that Captain Calvin White immediately called for the Rockingham Fire 

Department to stand in at the station. Lieutenant David Knight indicated that upon their arrival on 

the scene they immediately encountered three dead-on-arrivals and 15 to 18 casualties. Their first 

actions were to administer first-aid and attempt victim rescue. Once they had backup companies on 

the scene, the fire was attacked. Extremely heavy volumes of smoke prevented them from pinpointing the seat of the fire in the early stages. AFFF foam was used to extinguish the vats which eventually 

caught fire. Upon seeing the magnitude of the incident, additional mutual aid assistance was called 

in, including the East Rockingham, Cordova, and North Side Fire Departments.

In addition, two EMS units were initially brought in by volunteers with a third unit added later. 

Shortly afterwards, a call was made to the County Sheriff’s Office to call all available EMS units to 

the scene. These consisted of two from Rockingham, three from the county, one from Cordova, one 

from Ellerbe, and one from Hoffman. Also, there were helicopters from Winston-Salem, Chapel Hill, 

Duke, and Charlotte which took patients from the hospital in Hamlet to the various burn units. The 

helicopters did not operate from the scene.

Chief Fuller stated that the City of Hamlet did not have its own inspectors and relied on one of the 

county’s three inspectors. The county has an inspector for building codes, another for electrical and 

another for plumbing. These inspectors are primarily for new construction or remodeling. Hamlet 

construction codes reference the Southern Building Code. Chief Fuller stated the local code requires 

“periodic” inspections but do not specify a schedule or frequency.

The original building at Imperial Foods was built in the early 1900’s. Today no one appears to know what 

codes existed when the plant was first built. Chief Fuller indicated there had been several fires in the plant 

over the years, some before Imperial Foods took over the facility. Imperial was operating the plant in 1983 

when one of the previous fires occurred after which a CO2 system and hood over the cooker was installed. 

Subsequently, they were required to install a CO2 system by the county inspector.

Firefighters immediately began a search and rescue operation but were met by considerable heat and 

fire coming from the processing area. They had to withdraw and reposition to initiate their attack on 

the fire through the equipment room which was next to the processing room. The fire was brought 

under control at approximately 10:00 a.m.

Search and rescue efforts continued during the fire suppression with injured people and fatalities 

being located from the first entry at approximately 8:45 a.m., with the final victim being located 

shortly after 12:00 noon. Concern for the integrity of the roof structure prevented earlier discovery 

of victims in the processing room area.

Treatment of casualties was being carried out during the entire incident until all were removed from 

the fireground. Word of the incident’s severity spread through the community quickly, and virtually 

everyone involved with medical care in the area responded to the plant site. The Hamlet Hospital is 

approximately six blocks from Imperial Foods.

Chief Fuller was asked to evaluate the handling of the incident with reference to fire suppression, 

rescue, and EMS to which he indicated he felt there were more than adequate numbers of personnel 

and equipment given the layout of the incident site. As it was, he stated there were minor problems 

of some EMS equipment running over charged hoselines. There was some problem later in the fire 

suppression with air for the self-contained breathing apparatus (SCBA) supply because tanks were 

being used to assist injured victims, as well as supplying fire personnel. Chief Fuller stated the entire 

incident centered around one problem – lack of enforcement of existing codes.
USFA-TR-057/June/September 1991 7

DISASTeR PLAN

Hamlet does have a disaster plan in-place which coincides with the county plan. This fire occurred 

so rapidly and was so serious that all of the resources planned for were immediately brought to the 

scene. Under the plan the mayor is in charge of media relations and this became an enormous task, 

which was handled well even though much greater demands were being made upon them than had 

ever been planned for.

STReSS MANAGeMeNT

The Hamlet Fire Department personnel suffered severe stress and emotional reactions because the 

community was small and the firefighters knew many of the victims. A critical incident stress debriefing was arranged through the Pee Dee Council of Government (Region H). Five counselors were 

brought in and 50 to 60 people attended the counseling sessions.

CoDe eNFoRCeMeNT HISToRY

Much discussion has taken place about the lack of inspections conducted by the North Carolina 

Department of Occupational Safety and Health Administration (OSHA) at the Imperial Food operations. In fact, during the 11-year operation of this plant, North Carolina OSHA had never inspected 

the facility.

NoRTH LITTLe RoCK, ARKANSAS FIRe

During the course of the investigation of the Hamlet, North Carolina, fire, information was received 

that another company had experienced a similar fire at a plant in Arkansas. Further inquiries revealed 

that indeed a similar fire had occurred at a Tyson Foods, Inc., facility in North Little Rock, Arkansas, 

on June 7, 1991, but with dramatically different results.

Tyson Foods, Inc., is the largest producer of poultry products worldwide. Corporate officials strongly 

believe that their safety program is what made the difference between their fire and the Hamlet, 

North Carolina, fire. This company has over the years enacted many proactive fire safety programs.

Their operation and plant type in North Little Rock is similar in product production but larger in 

size than the Hamlet plant. The fire that occurred on June 7, 1991, was in the same plant area as 

the Hamlet fire in that it broke out in the hydraulic system of their cooker (also made by Stein and 

Associates, as was the one in Hamlet).

Unlike the Hamlet fire though, the hydraulic failure occurred within fixed plumbing. A flange type 

nut over time had the threads stripped as a result of vibration and when the threads failed, hydraulic 

fluid was expelled at approximately 800 psi. As with the Hamlet fire, the fluid was immediately in 

an atomization state. This was occurring within the gas heating plume areas and fire ignited. The 

resulting fire created a heavy black smoke and, as seen in Hamlet, virtually coated everything it 

spread to.

The Tyson plant, however, had in-place numerous safety factors that averted disaster. They enforced 

life safety codes to include not only plant design but practiced emergency drills.

Tyson Foods has a fire safety director who has implemented evacuation programs throughout the 

company’s entire operations. These programs involved both hourly personnel and management staff 

in safety committees. They have formed fire brigades and have a program called the Incipient Fire 
8 U.S. Fire Administration/Technical Report Series

Force, which involves all personnel and has a common goal to educate and train all employees in loss 

prevention and to take proper action should an emergency occur.

On June 7, there were 115 people working at the North Little Rock plant with some 12 to 14 people 

in the packaging area above the production room where the fire occurred. The plant design was 

such that the minimal number of people needed to operate the cookers were the only ones in the 

actual ignition area. The cookers were in rooms with 2-hour fire rated walls and ceilings, and the 

cookers were fed by conveyors through small openings. When the worker on the cooker that ignited 

discovered the fire, he first reached for an extinguisher but immediately realized it was spreading 

too fast and sounded the alarm.

Within three minutes, everyone was out of the plant and supervisors immediately identified all 

employees by name to make certain all were accounted for. No injuries of any kind occurred. Upon 

fire equipment arriving at the scene, fire brigade members, wearing hazardous materials protective 

clothing and SCBA equipment, met the firefighters and guided them through the plant to the seat of 

the fire.

The initial response came from Station 4 of the North Little Rock Fire Department. Backup came 

from the North Little Rock central station and also from the Little Rock Fire Department.

They were on the scene for approximately 9-1/2 hours. There were a total of 23 fire service personnel who responded with a total of six engines, one piece of aerial equipment, and three other types 

of vehicles.

As with the Hamlet fire, heavy, black smoke quickly permeated the entire facility. The firewalls surrounding the cookers no doubt gave the people evacuating more lead time – this was part of their 

pre-fire planning in that the cookers were designed to be isolated as much as possible from the 

remainder of the plant. In addition, Tyson allows absolutely no combustible materials such as wood 

pallets or paraffin-coated cardboard boxes inside the cooker rooms.

These types of operations are viewed as a wet industry for the most part. Accordingly, much of the 

facilities are not sprinklered. Tyson’s safety personnel did not feel that sprinklers would have contributed to the prevention of loss of life due to the nature of the hydraulic-fluid-fueled fire. They do, 

however, have sprinkler protection in all areas that are non-wet operations.

Damages to the structure amounted to approximately 8 million dollars and the plant was down for 

13 weeks. The additional loss in production, wages, cleanup, etc., was approximately 4 million dollars making the total loss approximately 12 million dollars. But upon getting back to production, the 

remodeling of the plant eliminated certain inefficiencies and implemented numerous safety features 

beyond what they already had. The plant currently has 215 employees, which is slightly less than the 

work force at the time of the fire.

FIRe PRoTeCTIoN eQUIPMeNT AND SAFeTY PRoGRAMS

The plant now has shut off valves designed for each cooker. These valves have four functions in that 

they are calibrated to the hydraulic fluid velocity or flow of what each cooker needs or uses. Should 

there be 1) a sudden free flow of fluid; 2) a drop in line pressure; or 3) an electrical failure, the valve 

will shut the hydraulics down. It is also tied into the CO2

 system. In addition, they have mandated 

that if a system is installed by an outside manufacturer, then training must come from the manufacturer on maintenance of the item.
USFA-TR-057/June/September 1991 9

In addition to the shut off valves, Tyson had remote hydraulic shut down switches installed at strategic locations throughout the plant and next to pull alarms. Any one of these emergency switches 

being activated immediately shuts down ALL hydraulics in the plant.

Emergency lights were in-place above all exits. At the time this report was prepared, Tyson officials 

were considering adding a second emergency light lower to the floor as an extra assist should there 

be a sudden induction of wet, heavy smoke, as experienced at the June 7 fire.

They already had negative air flow pressure systems for ammonia releases, which are activated by 

sensors. They indicate rapid heat rise sensors could be added to exhaust heat and/or smoke.

Tyson Foods requires that each of their facilities have a minimum of two fire drills a year; most of 

their plants do it on a quarterly or monthly basis. When a drill is conducted, production is affected 

and some food products may have to be discarded to meet United States Department of Agriculture 

(USDA) inspections. Even so, Tyson Foods makes this mandatory. They have a formal safety policy, 

and, in addition, each plant has a required Monthly Fire Inspection Checklist they must submit to 

corporate headquarters. (See Appendix D.) The checklist covers many areas and must be signed off 

by the Fire Brigade Chief and Facility Manager. This type of checking helps them to detect deficiencies before they develop into problems. This was recently demonstrated in one of their Texas plants 

when a monthly checklist noted a drop in water pressure to their sprinkler system. Upon further 

inspection, they found that the city had changed their water usage classification and dropped their 

flow and pressure. Without a monthly checklist, this might not have been detected for months or 

until an emergency occurred.

Tyson Foods has a daily inspection of CO2 systems. Also, they use permits that must be issued before 

any operation such as cutting and welding takes place. They also have lock-out, tag-out procedures 

that, simply stated, means before any repaired system is put back to use it is tested. Had they discovered the failed flange nut at the North Little Rock plant before the fire, they would have replaced the 

failed area, brought it back to operating pressure, and made sure it would hold before turning gas 

back on to the heating plumbs.

Tyson Foods has incentive/reward programs to encourage all personnel to be on the lookout for 

added safety ideas. The incentive bonuses are based on paperwork turned in in a timely manner, site 

visitations/inspections, and their participation in documented safety training. Tyson’s has installed 

within their break rooms suggestion boxes for any complaints or suggested improvements. These 

are checked daily and responded to by the management staff of that facility.

Tyson Foods has Crisis Management Manuals in-place at each of their facilities. Plant management 

is totally familiar with each phase of those manuals and they, in turn, disseminate the information 

to each employee. Tyson Foods officials feel their emphasis on life safety also leads to protection of 

property and continuity of operations.

As a matter of coincidence, the last thing stated by one of the Tyson safety officers was that the rules 

and safety codes to protect personnel and property are already written and in existence, but for them 

to be effective they must be enforced. This was one of the final statements of Chief Fuller at the 

Hamlet Fire Department as well.
10 U.S. Fire Administration/Technical Report Series

LeSSoNS LeARNeD

1. Life safety codes must be enforced.

Life safety codes cover a broad range of topics but the main goals to be achieved are to 1) plan 

building layouts/construction to reduce hazards and have available the proper number of exits; 

2) provide detection and adequate suppression equipment where needed; and 3) train and 

educate personnel in loss prevention and the proper action to take in the event of emergencies. 

The blatant problem of having exit doors locked on a continuous basis is clearly one that must 

be addressed by enforcement officials. Enforcement is an essential as the code requirements 

themselves. Enforcement can be by State or local officials. And in some cases, as with Tyson 

Foods, industry itself takes its own initiatives in both code enforcement and proactive fire safety 

programs in its plants.

2. Cooking areas must be separately partitioned from other employee work areas.

Any time there is a food processing plant cooking operation, with moving parts and high pressure equipment, the risk factor is greatly increased that a fire will occur at some time. As such, it 

is imperative that the cooker operations be partitioned off from the remainder of the building, 

and workers, as much as possible. The rebuilt Tyson plant designed their cookers to be inside 

2-hour fire-rated walls with openings for incoming and outgoing food. Safety doors were 

installed and the minimal number of needed employees was all that were inside the cooker 

room. In addition, absolutely no combustible products were allowed inside the room.

3. Building exits in wet type operations should have double emergency lighting, one positioned above the door and one low to the floor.

A fast developing, heaving smoke was present in both of these fires. The work areas are kept cool 

according to USDA regulations for food preservation, so the relative humidity is high. These are 

described as wet operations. When heat-charged smoke is injected into this cool, damp air, it 

banks down more quickly than normal. People are taught from an early age that in the event of 

fire they should get as close to the floor as possible to maximize safe evacuation. Heavy smoke 

such as was experienced in these incidents obscures the upper lights at the emergency exits. 

Additional emergency lights in protective cages near floor level would assist personnel in locating exits. Consideration might also be given to having strobe lights as part of the emergency 

lighting system. 

4. High pressure equipment maintenance and repairs must be limited to factory trained personnel and specifications.

Operations such as these plants have extensive hydraulic systems. They operate at considerable 

pressures and, as in these two cases, are integral parts of cooking processes. Moving parts and 

high pressures will naturally increase the likelihood of failure. Maintenance must be a constant 

ongoing process. For maximum safety, maintenance personnel must be trained by the factory 

representatives. If any parts are replaced, they must conform to factory specifications or not be 

used. If a maintenance division alters any part of the high pressure system, their alterations must 

meet or exceed factory specifications.

5. High pressure equipment in probable incident areas should have built-in catastrophic shut 

down valves.
USFA-TR-057/June/September 1991 11

Inlying valves have been designed that are sensitive to multiple functions for high pressure 

hydraulic equipment. These valves are calibrated to the prescribed hydraulic fluid velocity or 

flow of the equipment needed. The valves will automatically shut down fluid flow if there is 1) 

a sudden free flow; 2) a drop in line pressure; or 3) an electrical failure. In addition, these valves 

can be linked to the CO2 fire suppression systems.

6. Negative air flow systems in these facilities could enhance safety by being modified to also 

accomplish smoke evacuation.

Many plants similar to those in the Hamlet and North Little Rock fires have negative air flow 

systems in the event of an accidental ammonia release. These are activated by sensors and can 

purge the area of toxic fumes very quickly. If, in addition to the gas sensor, a rapid rise heat 

sensor was added, these systems could pull the heavy, wet smoke away from the lower levels in 

the event of a fire.

7. State and Federal inspectors from various departments should be cross-trained.

Much has been said about the lack of inspections done prior to the Imperial Foods tragedy. The 

State OSHA inspector force was small in numbers and simply could not cover all of the industry. 

Yet there were USDA inspectors frequently present because of their responsibilities over the food 

processing industry. While it may not be possible to teach USDA personnel all aspects of an 

OSHA inspector’s responsibilities, certainly they could be encouraged to recognize major problems while carrying on their assigned duties and alert the State OSHA office or other appropriate 

authorities including plant management.

8. Establish a “worry free” line of communications for industry employees.

Although it has not been acknowledged firsthand and was told only through the media, reports 

have surfaced that workers inside the Hamlet Plant were afraid to say anything about safety 

conditions due to fear of being fired. In order to eliminate this type of possible problem, communications with plant management or regulatory authorities should be established. States may 

wish to establish agencies/systems such as a known agency/address to write to or an 800 phone 

number. The identity of the individual reporting deficiencies could then be protected.

9. The number of OSHA safety inspectors must be increased.

As with many governmental departments, OSHA has had their budgets cut and funds have been 

directed to other areas. The tragedy of the Hamlet fire demonstrates vividly why cuts should not 

take place within the area of code inspections and enforcement. In North Carolina (and in other 

States as well), the number of staff should be based on the number of inspectable properties and 

time it takes to meet inspection schedules.

10. Emergency exit drills must be incorporated into industry policies.

The posting of emergency routes and exits throughout a structure simply will not suffice. The 

actual practice of the routes and exits must be done. The exit drills include a system to number 

and identify employees in order to make certain that everyone has been evacuated. The drills 

should be conducted often enough that employees will be constantly aware of emergency procedures. The actual practice of drills paid off for Tysons Food as they had all 115 employees out 

of the building within three minutes and all were accounted for, through a system of employee 

identification.
12

APPeNDIx A

Imperial Foods Plant Floor Plan
13

APPeNDIx b

Hamlet, North Carolina, Fire Department Incident Report
14

APPeNDIx C

Imperial Foods Plant Fire Photographs

Photo by Jack Yates 

View of the south end, the southeast corner, and the front (east side) of the Imperial Foods building.
USFA-TR-057/June/September 1991 15 Photo by Jack Yates The compactor area and one of the exit doors that was locked.

Appendix C (continued)
16 U.S. Fire Administration/Technical Report Series

Photo by Jack Yates 

The loading dock area and sealed doors next to the compactor. The pads around the doors are designed to form a seal when 

the trailer backs into this dock.

Appendix C (continued)
USFA-TR-057/June/September 1991 17 Photo by Jack Yates The front of the main building. The door just right of center is to the front office area.

Appendix C (continued)
18 U.S. Fire Administration/Technical Report Series

Photo by Jack Yates 

A view from an aerial ladder from the east looking southwest. Some roof damage is visible at the extreme right.

Appendix C (continued)
USFA-TR-057/June/September 1991 19 Photo by Jack Yates Another view from the aerial ladder from the east looking west, shows the portion of the roof collapsed over the area of origin.

Appendix C (continued)
20 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

Another view from the aerial ladder from the east looking northwest, shows the remainder of the building area.
USFA-TR-057/June/September 1991 21

Appendix C (continued)

Photo by Jack Yates 

A view from the aerial ladder from the west side of the building looking to the southeast. The break room roof 

is in the forefront.
22 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

A view from the aerial ladder from the west side looking to the northeast. The roof collapse can be seen on the right, 

refrigeration compressor equipment is seen on the ground in the lower left.
USFA-TR-057/June/September 1991 23

Appendix C (continued)

Photo by Jack Yates 

The trash and loading dock area. It was into this compactor area that several people tried to escape only to find the door to 

the outside locked. Upon coming back out of this area, they went through the large doors at the right which ultimately led 

to the large walk-in cooler where the largest fatality count was found. View is from the east toward the west southwest.
24 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

View showing the trim roof as seen from the west center looking to the southeast. This view is looking toward the door to 

the cooler where the highest fatality count was located.
USFA-TR-057/June/September 1991 25

Appendix C (continued)

Photo by Jack Yates 

Inside the marinating and cutting room; no direct flame impingement actually entered into this area. 

View is from the east to the west.
26 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

The cooler door, which was at the south end of the building, where the highest fatality count was found.
USFA-TR-057/June/September 1991 27

Appendix C (continued)

Photo by Jack Yates 

The west wall in the west portion of the cooler. Numerous handprints were found where people were trying to 

find escape routes.
28 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

The trim room area showing the north end of the room and also a door leading to the break room area.
USFA-TR-057/June/September 1991 29

Appendix C (continued)

Photo by Jack Yates 

The east half of the break room, view taken from the southwest toward the northeast.
30 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

A close-up view of the north door to the break room. Note the footprints and padlock in-place where the door was kicked; 

it was eventually opened for the escape of some personnel.
USFA-TR-057/June/September 1991 31

Appendix C (continued)

Photo by Jack Yates 

The remains of the hydraulic line that had been cut by the maintenance worker for the repair process that took place 

just preceding the fire.
32 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

The west side of the cooking vat. View taken from the north to the south.
USFA-TR-057/June/September 1991 33

Appendix C (continued)

Photo by Jack Yates 

The area of origin viewed from the southeast to the northwest.
34 U.S. Fire Administration/Technical Report Series

Appendix C (continued)

Photo by Jack Yates 

Damage to the steel girders and roof supports over the area of origin.
35

APPeNDIx D

Tyson Foods Safety Policy, Monthly Fire Inspections 

Checklist and Other Fire Safety Program Materials

TYSON FOODS INC.

SAFETY POLICY

INCIPIENT FIRE FORCE

Description: corporate Safety Policy relative to a Fire

Force and Fire Protection within the Tyson

organization.

Scope: This policy covers ALL Tyson facilities.

Individual Plant Requirements:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

An Incipient Fire Force will be established at

all Tyson facilities.

Emergency Action and Fire Prevention Plans will be

prepared at each facility and copies submitted to

Loss Control.

Exit drills will be conducted at least

semi-annually or when Evacuation plans are revised.

Alarm systems will be installed per Section

1910.165 of OSHA.

The Fire Force will conduct quarterly training

sessions.

Records will be kept as to training sessions, alarm

tests, sprinkler tests, and fire hazard

inventores. i

All fires will be reported to Loss Control as soon

as practicable and a follow-up written report made.

Fire extinguishers will be inspected monthly and

records kept.

Each facility will obtain and install an adequate

number of fire extinguishers and hose stations as

required.

Monthly fire inspections will be conducted and

copies of those inspections will be forwarded to

loss Control not later than the 30th of each month.

Approved: Date:
36 U.S. Fire Administration/Technical Report Series

INTRODUCTION

As Tyson Foods continues to expand and change, fire protection

becomes more complex and difficult. New processes and products

bring new fire hazards. Processing equipment and facilities have

become even larger and more expensive. Their loss has a greater

impact on production and the bottom line. Greater values are

concentrated in single buildings. Products are stored higher and

higher in warehouses. More and more personnel are concentrated and

exposed to greater hazards.

Fire detection and prevention equipment is hard pressed to keep

pace with the new hazards. As a result, the risk of very large

losses is increased-- losses which can threaten the entire plant or

event the entire business organization. Maintaining these risks

within reasonable bounds is a major challenge to management.

Good fire protection doesn't just happen, it is the result of

corporate policies and related fire prevention programs. Good

organization, with responsibilities clearly assigned and specific

duties spelled out, will result in implementation of effective

programs.

The two primary ways to manage fire risks are to prevent fires and

to limit or control their size.

An effective program receives its driving force and continuing

motivation from top management, but strong interest extending down

through various levels of management and supervision to the

individual employee is needed for the program to succeed.

The objectives of a satisfactory fire prevention and control

program can be stated very simply:

1. To plan and construct low hazard buildings, processes,

and equipment.

2. To provide adequate fire Control and Suppression

equipment where needed.

3. To educate and train employees in loss prevention and

proper action in emergencies.

In planning new facilities decisions made during the planning

stages largely determine the degree of fire risk the facility will

present after it is built. The important considerations are in the

following areas:

1. Safety to life

2. Protection of property

3. Continuity of operations

Appendix D (continued)
USFA-TR-057/June/September 1991 37

CUTTING & WELDING

PERMIT

Applies Only to Area Specified Below

Date

Building Floor

Nature of the job

The above locatlon has been examined. The precautions checked below have been

taken to prevent fire. Permission is granted for this work

Permit expires:

Date Time

Signed Fire Safely Supervisor

Time started Time finished

FINAL CHECKUP

Work area and all adjacent areas to which sparks and heal might have spread (such as

floors above and below and on opposite side of walls) were Inspected for at least 30

minutes after the work was completed and were found fire safe.

Signed

After signing, return permit to person who issued it.

PRECAUTIONS

The Department supervisor or his appointee should inspect the proposed work area

and check precautions taken to prevent fire.

Sprinklers in service.

Cutting and weiding equipment in good repair.

PRECAUTIONS WITHIN 35 FEET OF WORK

Floors swept clean of combustibles.

Combustible floors wet down, covered with dark sand or metal or fireproof sheets.

No combustible materials or flammable liquids.

Combustibles and flammable liquids protected with fireproof tarpaulins or metal

shields.

All wall and floor openings covered.

Fireproof tarpaullns suspended beneath work to collect sparks.

WORK ON WALLS OR CEILINGS

Construction noncombustible and without combustible coverlng or Insulation.

Combustibles moved away from opposite side.

WORK ON ENCLOSED EQUIPMENT

Tanks, containers. ducts. dust collectors, etc.)

Equipment cleaned of all combustibles.

Containers purged of flammable vapors.

Inlets 6 outlets locked out &plugged.

FIRE WATCH

To be provided during and for 30 minutes after operation. recheck after 2 hours.

Supplied wlth extinguishers or small hose.

Trained In use of equipment and In sounding alarm.

Signed

Appendix D (continued)
38 U.S. Fire Administration/Technical Report Series

TYSON FOODS, INC.

MONTHLY FIRE INSPECTION CHECKLIST

Facility Date

1. Fire Extinguishers

a. Was each Unit examined?

b. Were all Refills completed?

C. Were Units easily Accessible?

d. Condition of Units:

2. Smoking Regulations

a. List "Smoking" Areas

b. Non - Smoking Areas Posted?

C. Regulations Enforced?

3. Volatile and Combustible Materials

a. Were these Materials Needed where found?

b. Are Materials Safely Stored and Handled?

C. Are Safety Containers used and in good condition?

d. Any stored under Stairwells?

e. Any Excessive Amounts?

Appendix D (continued)
USFA-TR-057/June/September 1991 39

4. Fire Drills

a. Date Held.

b. Was Drill Expected?

C. Number of Persons in Drill.

d. Was signal clear to all persons?

COMMENTS:

5. Hose Stations

a. Was a Hose attached to each outlet?

b. Was a Nozzle attached to each Hose?

c. Is Hose Properly Racked?

d. What Condition are the hoses in?

e. Date Tested.

6. Sprinkler Systems

a.

b.

c.

d.

e.

f.

g.

h.

i.

Valves Open?

Stand Pipes Inspected?

Sprinkler Heads Un-obstructed?

Sprinkler Heads Painted?

Sprinkler Heads or Piping Corroded?

Sprinkler Heads loaded with Dirt?

Sprinklers obstructed by New Partitions?

New Section requiring Sprinklers?

Flow Test Conducted?

water pressure pressure w/ drain valve open

Appendix D (continued)
40 U.S. Fire Administration/Technical Report Series

7.

8.

9.

City Water:

a. Is City Water in Commission?

b. Gage Pressure.

Steam Piping

a. Are all pipes and coils one inch clear

of wood work and supported safely?

b. Ducting of Exhaust in safe condition?

Wiring and Electrical Equipment:

a. Are all panel boards, switch and fuse

cabinets clean?

b. Are all outlet box covers in place?

c. Are all fuse and switch box covers

in place?

d. Is there any temporary wiring?

If so comment on Location:

10. Housekeeping

a. List Locations where housekeeping was not satisfactory:

b. Will these be cleaned up?

11. Detection Systems

a. Heat Detectors in operable condition?

b. Smoke Alarms in operable condition?

Appendix D (continued)
USFA-TR-057/June/September 1991 41

12.

13.

14.

15.

16.

Manual Fire Alarms

a. Are stations un-obstructed?

b. Are stations operational?

Vent Hood Systems

a. Semi-Annual Inspections completed?

b. Are they clear of grease accumulation?

Exits

a. Are there an ample number?

b. Continuously lighted and/or visible?

C. Are doors opened easily?

d. Are doors unlocked?

e. Are doors un-obstructed?

f. Has emergency lighting been tested?

g- Are there at least two Remote Exits?

Building Exterior

a. Are stated Fire Lanes un-obstructed?

b. Are Fire Hydrants easily accessible?

C. Are sprinkler valves in open position?

d. Are Fire Exits blocked?

Inspections:

a. Are end-of-work-day Inspections being done?

17. Fire Brigade Training

a. Are monthly training sessions being conducted?

Appendix D (continued)
42 U.S. Fire Administration/Technical Report Series

18. Construction Areas

a. Check for Fire Hazards.

b. Check for Block Exits of Fire Lanes.

Comments:

I HEREBY, CERTIFY THAT I HAVE INSPECTED THE ABOVE LISTED

ITEMS AS SHOWN BY THE COMMENTS THERON.

(*TO BE COMPLETED BY THE 20TH OF THE EACH MONTH)

Fire Brigade Chief

Facility Manager

Date

Date

Appendix D (continued)
USFA-TR-057/June/September 1991 43

Tyson Fire Safety

(Fry Department)

The following is a list of controls in place at virtually all locations with fry operations.

Hydraulic line interlock valve installation should be completed company-wide within 2 weeks.

Supervisor training on fire extinguisher operation is being updated -

1. Fryer Suppression System -

2.

3.

4.

5.

6.

7.

8.

9.

I0.

11.

12.

13.

14.

15.

16.

200 lb. Co2 Automatic Extinguishing System, 3 minute discharge.

Fryer Gas-line Interlock- Electronically shuts off natural gas supply in the event of a fire.

Fryer Hydraulic line interlock -

Shuts off hydraulic fluid flow in the event of a ruptured line.

(These are currently being installed).

Quarterly Suppression System Maintenance.

Available, strategically located portable fire extinguishers.

Supervisors Trained to use Extinguishers.

Automatic Fire Alarm Systems - * not installed in all locations.

Fire Retardant Room Construction.

Exits located for quick access.

Exit Instructions Communicated and Posted.

Exits maintained clear, unlocked and adequately marked.

Plant Fire Force Team (Fire Brigade) -on site- Regular Training and monthly meetings.

Emergency Response Equipment (Respirators, Chemical Suits, etc.) on site.

Written “Crisis Management” Plan - on site.

Routine Inspections - In house.

Local Fire Department Inspection/Consultation.

13

Appendix D (continued)
44 U.S. Fire Administration/Technical Report Series

Appendix D (continued)