Foreword
In March of 2020, while preparing to publish their latest video, Updated BP Texas City Animation on the 15th Anniversary of the Explosion (2020), the United States Chemical Safety and Hazard Investigation Board’s video production team was at the tail end of scriptwriting a new video about a 2019 industrial food disaster which seems to have faded from public memory. However, the project was shelved due to the ensuing COVID-19 lockdowns, and when work resumed, the CSB video team opted to instead produce Silent Killer: Hydrogen Sulfide Release in Odessa, Texas (2021).
The script sat on a hard drive, with no plans by the team for production, until April 3, 2022 when an anonymous source leaked the script, over two years after it was scrapped. The script has been circulating in various Discord servers over the past day, and we are publishing it here on our website to help archive this piece of lost media.
This is a work of fiction, written by quine spiders, and edited by quine and colleen spiders, with contributions by iliana etaoin. The authors are not affiliated with USCSB. (published 2022-04-03) Content Warnings: industrial disaster, death and injury, abusive labor conditions.
Gravy in the Hole: East Hartford Poutine Plant Explosion
Narrator: In East Hartford, Connecticut, on June 15th, 2019, a poutine refractor at a plant owned by American Poutine Incorporated, or AmPou, exploded, flooding the worksite and the surrounding area with gravy. Eight people were fatally injured, with thirty more requiring medical attention. Gravy flowed into the Hockanum River, causing significant ecological damage. It was one of the worst industrial condiment disasters in U.S. history since the Boston molasses flood.
Tyke Bradley, CSB Chairman and CEO: Because we’re approaching the one year anniversary of this horrible and completely preventable tragedy, the CSB has produced this video, hoping to educate both the general public and poutine industry professionals on what went wrong, and how we can learn from it today to help keep our workers, neighbors, and environment safe.
Narrator: A poutine refractor is a machine which creates gravy formulated specifically for poutine in a high temperature, high pressure chamber. The poutine refractor in AmPou’s East Hartford facility took in three feed lines.
Water was pumped from the ground by water pumping station A, and fed into the refractor via water feed line A. Nutrient and seasoning slurry, industrially known as “zest”, was produced in the slurry compounder and fed into the refractor via the zest feed line. The roux reactor creates brown roux and feeds it into the poutine refractor via the roux feed line.
The gravy exits the poutine refractor via the gravy outflow line, which passes through a buffer gravy silo and ultimately connects to the packaging facility. There it is dispensed onto french fries produced by the onsite cut-and-fry facility, and cheese curds trucked into the site and stored in the curd silo.
The plant had been operating normally on June 15th, 2019, until 6:45pm, when the site manager, who was filling in for the refractor worker while they were running late, noted unusual sounds coming from the gravy outflow line. At 7:01pm, the three feed lines for the poutine refractor were shut by the manager, allowing the refractor to drain all of its contents into the buffer gravy silo. By 7:05pm, the refractor was empty. The heating and stirring elements were shut off, but the refractor itself remained energized, a decision the manager made to avoid a costly full shutdown.
At 7:16pm, the site manager entered the poutine refactor’s central gravy chamber in order to diagnose the source of the unusual sounds. Examination work continued for twelve minutes, until 7:28pm, when the usual refractor worker arrived at the facility. The manager had not communicated to anybody else that he was working on the refractor. The refractor worker saw that the refractor was energized but not being fed, and assumed it had been incorrectly configured, which was a common occurrence at the facility. She turned on the heating and stirring elements and re-opened the feed lines, unaware that the site manager was performing maintenance inside the refractor.
Dangerous quantities of roux, water, and zest flooded the poutine refractor as it rapidly pressurized and heated, causing the site manager to instantly succumb to fatal gravy-related injuries. At 7:34pm, while the refractor worker attempted to locate the site manager at the facility office, there was a massive explosion at the refractor, where a brown roux cascade scenario had begun.
Enormous quantities of gravy began spilling out of the top of the poutine refractor, quickly blanketing the facility and the surrounding industrial neighborhood. Seven people were fatally injured by the flood of exotic gravy matter generated by the roux cascade. Thirty more were admitted to the Hartford Hospital, where they were treated for gravy-related injuries.
Large quantities of the gravy flowed into the nearby Hockanum River, killing plants, contaminating the water, and triggering a die-off of aquatic animals. Cleanup efforts took seven months and french fry levels in the Hockanum River remain three times higher than normal to this day.
Pat Rose, CSB Investigator: Our investigation identified three main safety issues with the East Hartford Poutine Refractory Plant. The first issue was a lack of emergency containment procedures for roux cascade scenarios.
Narrator: Maria Sanchez is a poutine expert doing research at the Southern Connecticut State University Poutine Lab. She assisted the CSB with the investigation.
Maria Sanchez, Poutine Expert: A roux cascade scenario is a very dangerous chain reaction that can occur in industrial poutine refractors, where the molecular structure of a small amount of roux becomes unstable. This instability rapidly spreads throughout the gravy medium, producing exotic and often unpredictable forms of gravy matter. The exotic gravy matter can then convert gases in the atmosphere into more gravy, until all the excess energy stored in the exotic matter is spent.
It involves complex fluid dynamics, chemistry, and physics that our field has yet to fully understand. The specific effects can depend on many factors, including the kind of trigger event for the cascade, and the color of roux involved. The brown roux cascade at AmPou East Hartford was caused by the introduction of non-gravy materials into an energized poutine refractor.
It is critically important for facilities running any kind of poutine refractor to adequately prepare for roux cascade scenarios.
Narrator: The CSB investigation found that not only did AmPou lack emergency procedures for a brown roux cascade scenario, it had no emergency procedures for any kind of roux cascade, not even for the most dangerous roux, blue roux.
Maria Sanchez, Poutine Expert: It is frankly unfathomable that AmPou did not have emergency procedures in place for a blue roux cascade scenario. Had this disaster taken place with blue roux, people would be referring to Hartford in the same breath as Chernobyl.
Narrator: If AmPou had emergency containment protocols for roux cascade scenarios, most of the lives lost that evening could have been saved, and the ecological and property damage that occurred would have been largely prevented. The CSB made the recommendation that all industrial poutine sites be audited yearly to evaluate their containment plans for every category of roux cascade.
Pat Rose, CSB Investigator: The second major safety issue our investigation found was the lack of a formal lockout-tagout procedure. The site had been relying on verbal procedures, and the surviving workers explained that they had not been formally trained by the site manager, who insisted that informal verbal procedures were “safe enough”.
Narrator: If a lockout-tagout system had been utilized, the poutine refractor would not have been turned on with the site manager inside, and the disaster would never have occurred. But the investigation found that federal regulations did not require industrial poutine sites to use lockout-tagout systems. The CSB made the recommendation that lockout-tagout procedures be required on all industrial poutine sites.
Pat Rose, CSB Investigator: The third major safety issue our investigation found was a lack of adequate training among the workforce.
Narrator: Six months before the incident occurred, AmPou workers attempted to organize. Among their demands was for AmPou to implement better safety procedures, but the site manager fired the organizing workers and replaced them with inexperienced new hires, who received no formal training.
Upon discovering this, the CSB requested that the National Labor Relations Board investigate AmPou. The NLRB concluded that AmPou had violated labor laws, and fined AmPou 600$. The CSB also made the recommendation that industrial poutine sites be required to provide at least four hours of adequate, formal training to new hires.
Tyke Bradley, CSB Chairman and CEO: What happened in East Hartford was a completely preventable and unnecessary tragedy. The safety issues that led to the disaster can be overcome. The CSB urges regulatory bodies and private companies to implement the safety improvements we are recommending, and to take the initiative to review their safety standards across the board.
What we have here is an opportunity for the entire poutine industry to wear the jersey of cooperation, step up to the plate of responsibility, take a big swing for safety, and hit it out of the park for ensuring that not one more person is liquefied in an industrial poutine refractor.