SIMOPs Failure — Hot Work Fire in Physically Connected Confined Spaces
Evergreen Packaging Paper Mill Hot Work Fire
Evergreen Packaging LLC
📍 Canton, NC
Incident: September 21, 2020  •  CSB Report: September 24, 2021
2
Fatalities
Flammable FRP Resin and Solvents
Chemical Involved
8
CSB Recommendations
📋 Incident Summary

On September 21, 2020, a fire at the Evergreen Packaging paper mill in Canton, North Carolina, killed two Rimcor contractor workers inside a scrubber downflow tower. Universal Blastco workers were simultaneously repairing FRP lining using heat guns and flammable resin inside the adjacent upflow tower. A heat gun dropped into a resin bucket ignited a fire; Blastco workers escaped the upflow tower, but fire and smoke spread through an interconnecting crossover pipe to the downflow tower where the two Rimcor workers were killed.

The CSB found that Evergreen Packaging had treated the two physically connected towers as separate, independent confined spaces with no coordination between the contractor crews — a classic simultaneous operations (SIMOPs) failure. Neither crew knew the other was working in a connected space.

The September 2021 CSB report issued 8 recommendations: 3 to Evergreen Packaging (all closed — facility subsequently closed), 2 to OSHA (closed/superseded), and 3 to Universal Blastco (all closed), focusing on SIMOPs coordination, connected confined space identification, and FRP repair flammable material controls.

🔎 Key Findings
Finding 01
Two Connected Towers Treated as Independent Confined Spaces
Evergreen Packaging permitted simultaneous contractor work in two scrubber towers connected by a crossover pipe, treating them as independent confined spaces — without recognizing that fire, smoke, and toxic atmosphere could propagate between them.
Finding 02
No SIMOPs Coordination Between Blastco and Rimcor Crews
There was no coordination between the Universal Blastco crew working with flammable FRP resin in the upflow tower and the Rimcor crew in the connected downflow tower — neither was aware of the other's activities or the shared hazard pathway.
Finding 03
Heat Gun Dropped into Resin Bucket — Fire Propagated Through Crossover Pipe
A Blastco worker dropped a heat gun into a bucket of flammable FRP resin, igniting a fire. Fire and smoke traveled through the interconnecting crossover pipe into the downflow tower where Rimcor workers were located.
Finding 04
Rimcor Workers Had No Warning and No Clear Escape Route
Rimcor workers had no warning of the fire in the adjacent tower and no escape route that did not pass through the fire-affected crossover pipe — both were killed by fire and smoke inhalation.
Finding 05
Flammable FRP Resin Used Without Adequate Ignition Source Controls
Heat guns were used in direct proximity to flammable FRP resin and solvents without engineering controls or physical separation sufficient to prevent ignition from accidental contact.
🔍 Root Causes
1
SIMOPs Hazard Not Recognized — Connected Spaces Treated as Independent
Evergreen Packaging's confined space and hot work permit systems had no systematic process for identifying connected, non-independent spaces — the shared atmosphere and fire propagation pathway between the two towers was never recognized as a hazard requiring coordination.
2
No Simultaneous Operations Coordination Protocol
The facility had no formal SIMOPs coordination protocol requiring contractors working in physically connected spaces to coordinate work schedules, communicate active hazards, and share emergency response information.
3
Flammable Material Controls for FRP Repair Inadequate
Hot work permits and work procedures did not establish adequate controls to prevent ignition of flammable FRP resin from heat gun operations in a confined space — the dropped heat gun ignition was a foreseeable failure mode not addressed by existing controls.
☑ CSB Recommendations
→ Evergreen Packaging (3, Closed-No Longer Applicable)
Develop and implement a SIMOPs identification and coordination protocol for all confined space entries and hot work, identifying physically connected spaces and requiring coordination between all crews working in connected areas.
→ Evergreen Packaging
Revise confined space entry procedures to require identification of all openings, interconnections, and pathways that could allow fire, smoke, or toxic atmosphere to propagate from adjacent or connected spaces.
→ Evergreen Packaging
Establish written flammable material controls for FRP repair operations in confined spaces, including physical separation of heat sources from resin and solvent containers.
→ OSHA (2, closed or superseded)
Update confined space entry regulations (29 CFR 1910.146) to explicitly require identification of atmospheric and fire propagation pathways between physically connected permit-required confined spaces before entry.
→ OSHA
Issue a Safety and Health Information Bulletin on connected confined space fire propagation hazard and SIMOPs coordination requirements to pulp, paper, and chemical manufacturing industries.
→ Universal Blastco (3, all closed)
Develop written FRP repair procedures for confined space work requiring physical separation of heat sources from flammable resin containers and pre-job identification of connected or adjacent occupied spaces.
→ Universal Blastco
Establish a SIMOPs coordination protocol requiring supervisors to identify and coordinate with any other contractor working in physically connected or adjacent spaces before beginning FRP repair.
→ Universal Blastco
Provide task-specific confined space FRP repair training including identification of fire propagation hazards in connected spaces and emergency response procedures.
💡 Lessons Learned
Physically connected confined spaces are not independent — they share atmospheres, fire pathways, and hazard exposure. Any confined space entry program must identify connections between adjacent spaces before entry is permitted.
SIMOPs failures kill workers. When two contractor crews work simultaneously in connected spaces without coordination, each crew is unknowingly exposed to hazards created by the other. Facility owners bear responsibility for managing SIMOPs conflicts.
A dropped tool — a heat gun falling into a bucket of resin — was the immediate ignition trigger. Engineering controls preventing accidental ignition (secondary containment, tool tethering, physical separation) are essential when flammable materials are used near ignition sources in confined spaces.
Workers in the downflow tower had no warning and no escape route not blocked by fire. Emergency egress from confined spaces must account for fire and smoke propagation pathways from connected spaces.
Contractor coordination failures are a recurring theme in process safety incidents. Facility owners must take responsibility for identifying where multiple contractors work in proximity and enforcing SIMOPs coordination.
CON: ContractorsHWP: Hot Work PermitSOP: Operating Procedures
🔨 Safety Meeting Toolbox Talk
►Before you enter a confined space, how do you identify whether adjacent or connected spaces are occupied or have active work occurring that could create a hazard in your space?
►Does your facility have a formal SIMOPs coordination process identifying conflicts before work begins — or is coordination left to individual supervisors to negotiate informally?
►If a fire started in a connected confined space while you were working in an adjacent space, would you have a safe escape route and an alarm alerting you to evacuate?
►When multiple contractors work in the same area or connected areas, who is responsible for coordinating their work activities and managing simultaneous operation hazards?
►Have you ever entered a confined space and discovered another crew was working in a connected space that you did not know about? What did you do?
Immediate Action Items
✓Review your confined space entry procedure to confirm it requires identification of all physical connections, openings, and pathways to adjacent or connected spaces before a permit is issued.
✓Map the physically connected confined spaces at your facility — identify vessel systems, scrubbers, towers, and piping that share atmospheres or have fire propagation pathways between them.
✓Develop a SIMOPs coordination checklist for work involving multiple contractors in adjacent or connected confined spaces, requiring supervisor sign-off before work begins.
✓Audit your last five confined space entry permits to verify that connected space occupancy and adjacent work activity were evaluated as part of the permitting process.
✓Brief your confined space attendants and entrants on the Evergreen Packaging incident — ask them to identify connected spaces at your facility where a fire in one space could affect workers in an adjacent space.
🔗 PSM Failures Behind This Incident

This incident traced to breakdowns across 3 PSM elements (CON · HOW · SOP). Each represents a documented gap that process safety documentation and consulting can close before a similar event occurs at your facility.

Contractor Safety Management
Contractor workers must be held to the same PSM standard as employees. When contractor safety oversight fails, knowledge and compliance gaps follow contract workers onto your site.
Supporting documents in our library →
Hot Work Permits
Unauthorized or poorly controlled ignition sources near flammable atmospheres are entirely preventable. A rigorous hot work permit system with pre-job atmospheric testing closes this pathway.
Supporting documents in our library →
Operating Procedures (SOPs)
Operators cannot reliably hold safe operating limits without clear, current, enforced procedures. Deviation from acceptable operating conditions — a root cause here — is a direct consequence of SOP failure.
Supporting documents in our library →
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