North Star Foods fire investigation

Case Number

2009-137 Lead Investigator

Steve Wolf

State Fire Marshal Division Department of Public Safety 444 Cedar Street, Suite 145

St. Paul, MN 55101-5145

Investigation Report Confidentiality: Juvenile: Homicide: Confidential:

Property

Name: North Star Foods

Address: 1279 St. Charles Avenue

City: St. Charles County: Winona State: MN Zip: 55972-

Phone: 507-932-4831 Contact Name: Contact Phone: - -

Property Use Code: 700

Building Name: Food Manufacturing or Processing Use Code: 700 Alarm Type: None Sprinkler: None

Section Name: Use code: Alarm Type: Choose Sprinkler: Choose

Incident Detail Date: 4/17/2009 Time: 1022 Fire Type: Accidential Fire Cause: Undetermined # Injuries: 2

Fire Dept.: St. Charles FDID: 85111 Req. Agency: St. Charlles Fire Department Coop. Agency: St. Charles Police; Lewiston, Altura, Dover, Eyota, Winona, Rochester, Caledonia, Houston, Rollingstone, Hokah, Chatfield, Stewartville, Spring Valley, and Rushford Fire Departments; St. Charles, Plainview and Gold Cross Ambulances;, Olmsted County Emergency Management; State Patrol; State Patrol -Trooper 7; Houston, Olmsted, Wabasha and Winona County Sheriff's Offices; Minnesota Pollution Control Agency

Type of Occupancy: Food Manufacturing and Processing Pre Fire Value: 30 million $ Loss: 50 million

Smoke Detector Performance: Unknown Sprinkler System Performance: None

Occupied: Yes: No:

Disposition Open: Closed: Referred to other agency: Referral Info:

Note: All fields underlined are required upon initial submission of this report. Synopsis The facility was operating when employees noticed smoke coming from around a vent in the checker / raw section. Plant officials were notified immediately and went to that area. The fire was thought to have been above the ceiling and possibly the roof. Employees went to the roof, where they saw open flames. One employee fell partially through the roof and was caught or held by roof membrane. The employee received burns to his leg. The fire quickly spread throughout the ceiling void space. The ensuing fire continued for approximately a day and a half. The town was evacuated at one point due to large amounts of smoke, ammonia hazards, and the potential for an explosion. The facility covered approximately one city block in the heart of downtown. By the time the fire was contained and extinguished, most of the facility was severely damaged or destroyed. Along with the building and facilities, over a million pounds of food was also destroyed.

Owner 1 Check if Occupant:

Last First Middle Fatality DOB Gender

North Star Foods / / Choose Address: 2379 St. Charles Avenue CO: % BAC: Drugs:

City: St. Charles State: MN Zip: 55972-

Phone: 507-932-4831 Contact Name: Brad Arndt, President Contact Phone: 507-259-4318

E-mail: School District #: Country:

Blue indicates required fatality information. DOB is optional unless a fatality.

Owner 2 Check if Occupant:

Last First Middle Fatality DOB Gender

/ / Choose Address: CO: % BAC: Drugs:

City: State: Zip: -

Phone: - - Contact Name: Contact Phone: - -

E-mail: Country:

Blue indicates required fatality information. DOB is optional unless a fatality.

Occupants

Last First Middle DOB Fatality Gender CO BAC Drugs

/ / Choose % / / Choose % / / Choose % / / Choose % / / Choose % / / Choose % / / Choose % / / Choose % / / Choose % / / Choose % Blue indicates required fatality information. DOB is optional unless a fatality.

Other Fatalities – Fire Fighters and Others

Last First Middle DOB Gender FF/Other CO BAC Drugs

/ / Choose Choose % / / Choose Choose % / / Choose Choose % / / Choose Choose % / / Choose Choose % CO, BAC and Drugs only required if fatality is not a Fire Fighter

Insurance Record Insurance Agency: Agent: Phone: - - City:

Insurance Co: Cincinnatti Policy Number: Inception Date: Expiration Date:

Amount of Policy: Building: Contents: Other:

Claim Number: Payable to: Adjuster: Phone:

Remarks:

Narrative Report People North Star Foods; 1279 St. Charles Avenue, St. Charles, MN 55972; 507-932-4831

• President - Brad Arndt, DOB 7/3/1970; 19701 County Road 152 NE, St. Charles; 507-259-4318

• Vice President - Pat Thesing, DOB 12/4/1968; 673 Meadowview Drive, St. Charles; 507-313-9684

• Plant Engineer - Larry Young, DOB 1/6/1947; 17231 County Road 25, Lewiston, MN; 507-421-7519

• Production Manager - Craig Hartman East; 443 Church Avenue, St. Charles; 507-932-5287

• Building Maintenance Manager - Lyle Lawrence

• Plant Manager - Mark Eadz; 507-932-3792

St. Charles Fire Department - Fire Chief-Lyle Peterson

• First Assistant Chief Keith Zanto; 507-421-2596

MN Department of Public Safety, State Fire Marshal Division – Investigators Steve Wolf and Ron Rahman

Whitemore Fire Consultants, Inc – Investigators Robert Whitemore and Doug Noah

Fire Cause Analysis – Investigators Donald Perkins and Hal C. Lyson; 800-726-5939

Cincinnati Insurance – Investigator Carl Duncan

Marshall W. Nelson & Associates, Inc - David Kalscheur; 651-890-0720

• Attorney for Marshall W. Nelson - William Moran, Murnane and Brandt; 651-227-9411

Attorneys - Roger M. Stahl, Wendland Utz; 507-288-5440

• Robert J. Gilbertson, Greene Espel; 612-373-8333

Background At approximately 1330 hours on April 17, 2009, I, Deputy State Fire Marshal Steve Wolf, was notified by local people and the TV news reporting about a major fire burning in downtown St. Charles. I had not yet been requested, but I took it upon myself to self-dispatch. I was just finishing up another fire scene and started towards St. Charles. I notified the State Duty Officer en-route. Also while en-route, I started taking photos from the interstate and could see smoke from about 20 miles away. Due to the size and severity of the fire situation, I also asked for assistance from Deputy State Fire Marshal-Investigator Ron Rahman, who agreed to respond and would be arriving in a couple of hours.

I arrived on scene at approximately 1430 hours and met with St. Charles Assistant Fire Chief Keith Zanto and Law Enforcement personnel. Once on scene I was told the following:

• The alarm time was 1022 hours, with fire department arrival at 1030 hours.

• Upon fire department arrival, smoke was seen coming from the roof and out the main street side.

• Mutual aid was called for from the Lewiston and Altura Fire Departments immediately due to a shortage of manpower.

• Entry was made several times to get to the area where smoke was first seen, but crews were pulled out due to extreme heat and dense smoke. Several attempts were made, but efforts were not showing progress.

• Ammonia discharge was also an issue that compromised firefighting efforts.

• It was some time later that defensive efforts were initiated. The fire was fought from the defensive from there after.

• The fire burned through many parts of the building.

• The fire was difficult to fight due to varying ceiling and roof heights, miles of piping containing natural gas, ammonia, and nitrogen, and electricity.

• A total of 16 fire departments responded to assist. Many other government agencies and support also were on scene to assist.

• The fire destroyed most of the processing plant and office spaces. A large refrigerated/product storage area was saved, but the extent of smoke, heat and or water damage is unknown.

• I didn’t specifically note the weather at the time, although I remember it to be warm and partly cloudy, with little or at least only a slight wind.

• The fire scene was kept secure by the St. Charles Fire Department and all other assisting agencies prior to my arrival.

Additional Background

During one of the follow-up meetings, I was given information about the plant operation and processing in order to better understand the process and timeline of events that may have led up to the fire. I have put this in the order I had received, and not necessarily in chronological or any sequence that makes sense.

• The plant is set up for meat cooking (could be beef, pork, chicken, etc.). It starts out with raw meat mixed with water and spice. It goes out to one of two continuous ovens or stays in raw form. Then it goes to IQF (Individual Quick Freeze) in 2½ pound portions. If it goes in the ovens, it’s linear or circular format or a roll-in and roll-out type of batch oven.

• Smoke was first seen from the IQF checker door.

• A couple of employees went to the roof with extinguishers. Smoke was seen coming out of some vents or exhaust stacks.

• Kaiser out of Keiler, Wisconsin is the contract sanitation services. They clean equipment and hoods and should have maintenance records. A contact person is Rick Moya.

• There is an 8” or 10” diameter vent for exhaust.

• The checker ovens are steam fed.

• The ovens are a circular process belt-steam cooking process. Temperatures reach about 185-190 degrees F.

• The product the goes under a highlighter hood to make “grill marks”. The highlighter is natural gas fed. After the highlighter, the line dumps off to the freezer, etc. The highlighter has a hood and the cooker has a hood. The cooking process uses steam. The highlighting process is similar to a torch or grill.

• The entire process takes about 15-45 minutes depending on the process.

• There is also a general exhaust hood for the room. It is a 24” or 28” diameter vent.

• Food is put on line track at a rate of 6-7,000 pounds per hour on the raw side in-feed, with 5-6,000 pounds coming out on the finished side.

• There are high pressure water knife systems at the end of the conveyor.

• There is a 90-degree turn at the end of the oven and two stacks off of the steam cooking line. There is one stack off of the highlighter. One more stack is toward the end of the line (water knife).

• They are mostly stainless steel make up. Some are round and some are square.

• The steam oven was purchased from Checker Machine in Minneapolis. A contact is Russ Hoyum.

• It was purchased over ten years ago and updated in 2005. There was a change in the exhaust.

• There is slack in the line to adjust the belt tension. It is a chain loop system.

• The highlighter was purchased from Marshall Nelson and Associates. They are out of Minneapolis and Wisconsin.

• The system is less than ten years old (5-6 years). They have had a burner change recently. They went from infrared panels to direct flame. The nozzle or burner system is from Marshall Nelson. That had been updated within the last 2-3 months. Some work had also been done on the highlighter around 0830-0900 that same morning.

• A North Star Foods employee (Brandon --------) would have escorted them in.

• They have to follow USDA guidelines; rubber boots, smock, wash hands, hair net, etc.

• The highlighting system was self-installed, supervised by Marshall Nelson.

• Salsbury Electric from Chatfield would have done the electrical.

• The steam vent was installed by Checker Machine.

• The highlighter was probably mostly installed by Marshall Nelson.

• The knife vent was self-installed (PVC pipe). The knife system was supplied by Flow International, Washington and has been in place for ten plus years.

• On the raw side, there are about 6-7 employees. One person takes meat out of the tank and places it on the belt. Others position meat on the belt. None of these people get to the cook side, per FDA restrictions. There is a wall and the oven separating these areas.

• The cook side has one supervisor. At the end of the oven is one temperature taker (this controls oven speed). Every 5-10 minutes, it is checked and oven speed adjusts.

• Most of the product goes into a 35 pound bag or box.

• There is one utility person who does nothing but watch for USDA regulations.

• In the freezer area, the meat enters at the bottom and goes around and around. It is flash frozen at the top.

• At the end of the conveyor are a dicer and a vibratory conveyor. The meat enters the freezer and a shaker breaks up clumping. It leaves the shaker and goes through a tube and then enters a metal detector. It fills into bags or boxes.

• There are also inspectors who do x-rays etc., which are done before freezing.

• There are about 16-18 total people in that department.

• The schedule is set by the product type.

• The plant was in production at the time the service guy was there.

• People were coming out of the checker room when the smoke was first seen.

• A batch is 1,000 pounds of mixed meat.

• Lyle Lawrence is the Plant Manager. He is also part of the in-plant hazmat team.

• There are no heat or smoke detectors and no sprinklers. There is no video surveillance system.

• Lyle was burned on his hands when he attempted to put on SCBA to try to enter the room. He could not go into the room due to the heat. He may have burned his hands from radiant heat on the lockers or a similar metal surface.

• The building age is not specifically known. The oldest part of the plant is where the fire was first seen. There would have been wooden rafters there.

• There was FRP (fiberglass reinforced plastic) panels for most interior walls and ceiling surfaces. Some of the rooms had stainless steel wainscoting up to about four feet from the floor on the side walls. The ceiling heights were about 10’ -12’. Some were 16’ -18’ in height.

Property Description The structure was a multi-level, food processing plant that encompassed about a 1½ block area. The structure sits on the property in a somewhat angled position due to city streets and an adjacent railroad track. The plant is located in the heart of downtown St. Charles and employs approximately 250 local people. This plant would process raw meat products, including cooking, freezing and storage at a rate of about 5-6,000 pounds of finished product per hour. The Company would process and sell their products according to various vendor contracts.

The exterior of most of the plant is cement block, but both steel siding and wood sheeting is also seen on various parts. An office space at the northeast corner is sided with wood sheeting. Most of the roof structures are flat roofs with the typical rubber membrane and rock material covering. The roof truss systems vary from wooden to metal bar joist construction. The roof system appears to be multi-level due to additions and alterations from the original plant as years went by. The roof also houses several air handling units, a large amount of piping for various applications, and many exhaust or vent stacks.

Exterior Examination The exterior examination was on-going and continued for approximately three days. Photographs were taken on all three days, including during the fire suppression efforts, to some evasive excavation efforts to stop fire spread, some aerial views from the ladder truck and helicopter, and by walking the perimeter and documenting all elevations. It is clear the fire started somewhere near the center of the building and more toward the north end. The fire traveled in basically all directions until it was controlled. The south and southwest corners of the facility show probably the least amount of physical damage. The freezer and warehouse portion in the southwest corner received the least amount of physical damage.

The photographs taken probably best describe the overall exterior due to the size and complexity of the entire facility. Some of the excavation efforts also have altered the overall exterior appearance, but with the photos taken can recreate each elevation as it was prior to excavating.

Interior Examination The interior exam was limited due to the complexity of the fire scene. Even a couple of days later, some areas were still smoldering, while others had major structural collapse. The fire department had returned several times for areas that had flared up due to concealed areas or void spaces that may have been smoldering yet.

After talking to witnesses about where the fire was first seen, the checker cook room was our main focus and the area of origin. The area of origin was not accessed until a couple of days later. Photographs were taken and electrical circuits were examined for signs of arcing. Extreme care was taken not to damage or alter any evidence, but an initial assessment was needed to determine who may all be involved in the investigation, if anyone would be put on notice, and where the investigation would proceed from here.

Due to the severity and intensity of the fire, there wasn’t a lot of burn patterns immediately recognized. With visuals from the roof or aerial views, the remains of the interior checker room, and with some basic arc mapping, the area of origin was zeroed in on. There is some major structural collapse, with metal I-beams twisted and warped, some sagging and being supported by vertical metal posts, while others have sagged and are resting on the ovens, highlighter, or portions of the production line. Some areas of the underside of the roof show extreme heat and oxidation. There are some areas where the top of the roof can be seen due to collapse. It is difficult to determine at this point which of the holes through the roof are for which vent, and possibly some holes may have been from previous installations that were covered up with ceiling and roof materials and may have nothing to do with actual working intakes or vents for this area. We will need to consult with North Star Foods personnel or other experts, especially in determining where each vent and stack was located, and for what specific purpose and material was each vent system made of.

At this point in the investigation, there is not a lot that can be done without other interested parties present. Photographs are the best documentation until portions of the room and/or roof can be lifted or moved to gain better access. There is no doubt that a more in-depth survey of this room will be needed. The next step may be to remove some of the debris and to actually clean up some of this room or, in fact, the entire room before a better analysis can be made.

Evidence I did not take any evidence from the scene.

Photographs & Diagrams I took photographs of the fire scene and a photo log will be included with this report. Deputy State Fire Marshal Rahman also took photographs of the fire scene and his photo log will also be included with this report. Sketches or partial blueprints were provided by North Star Foods or by Whitemore Fire Consultants and I will include them as seen fit. I will add or modify them to meet my needs.

Photographs have been taken on numerous days and will be labeled as day 1, day 2, etc. or may be labeled according to the date taken. The investigation has taken place over a period of a couple months and I have done my best to sort things out as to time and sequence of events.

Interviews & Investigation Activity The investigation took place over a period of almost two months. The days or activities have been sorted out to the best of my abilities. I had assistance in the investigation from Deputy State Fire Marshal Ron Rahman, who was present on several occasions when I was not. I have included photographs that he supplied and a photo log will be added to this report. Photos are labeled according to the day or date when the activities occurred. Most of the photos are self-explanatory.

Day one consisted of walking the perimeter and taking photos as much as possible without endangering myself due to toxic smoke, ammonia, and/or explosion potentials. I also was available to offer assistance in any way within my abilities to assist the fire department. Investigator Rahman and I coordinated our efforts as best we could to assist in helping to put out the fire without destroying anything deemed as evidence or a potential area of origin site.

At some point during the day, it was determined the fire may not be stopped and was approaching some large anhydrous tanks. It was suggested these tanks could bleve and send huge amounts of anhydrous into the community. The three to five tanks contained about 30,000 pounds of anhydrous ammonia. Aerial devices were set up and reduced to an un-manned operation due to the explosion or bleve potential. I was able to meet up with the State Patrol helicopter and was flown over the fire scene to possibly get a better view of what was burning and to help in developing a strategy to stop the fire from approaching the anhydrous tanks. After the flight, I was able to return to the fire scene and we directed the aerial master streams and again had the nozzles re-manned. I believe this effort was successful, as the fire was slowed and the tanks never were compromised by fire. I was also able to get some aerial views of the overall fire scene to have a better scope of the entire situation. A plant maintenance person also was taken up by State Patrol helicopter and a thermal imager was used to look at the anhydrous tanks. It was determined that those areas were relatively cool now and were no longer a safety concern.

After the initial day or two, when the fire concerns were over, the interviews began in the hope of narrowing down or pinpoint a particular area of origin. The interviews were all pretty consistent and quite helpful in determining our room and/or area where the fire occurred.

Interviews were conducted on April 20 and April 22, 2009 at the St. Charles Fire Department meeting room. The interviews were recorded and a court reporter was present to document in paper form. Interviews will be transcribed and will be included with this file. I was able to take some notes from each interview and the following are some highlights from each, with the list of those interviewed.

LYLE LAWRENCE, Facilities Manager, said that:

• He went to check the cook side, saw smoke in the hallway and shut the door.

• He grabbed a 1-½ inch water line and sprayed a water fog.

• He could not get into the room and burned part of his head and right hand, receiving some blisters.

• He had put on SCBA and tried to enter the area where smoke was seen.

• He got the SCBA from the engine room (for anhydrous problems).

• He could not enter due to heat and smoke and burned his hands on the metal surface outside the checker room due to radiant heat.

• He was checked out by the ambulance only; he did not go to the hospital.

MARIA HERRARRA, a Temperature Checker, said that:

• At 1030 hours, she smelled something like plastic burning.

• She hadn’t left the room since 0700, when she started.

• Smoke was seen by the long tube from the oven.

• It is normal for the room to be 95-97 degrees.

• She saw no active fire in the room, only really dark smoke.

BRAD FISCHER, Maintenance Manager, said that:

• He was on break a little before 1000 hours.

• Carlos first notified him about an odor and then seconds later a fire.

• He and other maintenance personnel grabbed extinguishers and went toward the checker room.

• He saw smoke pouring out of the vent north of the highlighter.

• It looked like the fire was on roof, so he went to the roof.

• He fell partially through the roof between the vents of the highlighter and the room vent piping.

• The rubber membrane caught and kept him from going through.

• He ordered everyone off the roof and out of the building.

• He singed the hair on his legs when he dropped through.

• He identified the roof vent stacks and labeled them A, B, C, and D and told me the materials they were made of.

• He stated that Jerry ------- from Marshal Nelson was there that morning. He was making adjustments on the gas train and adjusting the combustion blower and gas valves.

• There is no temperature monitor for the highlighter.

• There are no high limit sensors.

• The gas will shut off if there is a flame out.

• It is still the original exhaust stack.

• The hood and stack were installed about four years ago. North Star Foods and Marshal Nelson installed it.

• K and K Construction built the hood.

• There may be some grease build-up in the vents, but most grease is gone in the oven.

• If ideal, the highlighter flames were blue burning.

• They had some long yellow flames and needed some adjusting. There should be a work order paper for this.

• Al Lane from North Star Foods had called Marshal Nelson to come down. He thought the flames were too yellow and jumping and wanted then recalibrated.

• The gas system was set with a meter.

• He went on to describe the roof vents and blowers and said all four motors in the area of concern had been replaced in the last six months.

• It was 18 inches from the top of the hood above the highlighter to the ceiling.

• He thought there should be a collar around the pipe that went through the ceiling.

ROBERTO RUIZ, a Line Worker, sub-contracted through Global. He said that:

• He has worked there for six years.

• Employees within the room asked if he smelled smoke.

• The supervisor came in and stopped the belt and oven.

• He saw smoke around the pipe at the ceiling. It initially was small, but grew rapidly.

• They were in the room 8 minutes before being evacuated.

• By the time they evacuated, he could not see back into the room.

MIKE HOLZER, Maintenance, said that:

• He has worked there 3-½ years.

• He heard the call from supervisor Carlos about the fire.

• He first went to the checker room area and met the other maintenance guys coming back.

• They mentioned something about the roof, so he grabbed a ladder and put it up on the roof.

• All four of them went to the roof with extinguishers.

• He saw smoke coming from the roof edge and a NY vent.

• He was not sure of the stack identification.

• He did notice the lights were on in the checker room when he arrived and the guys were coming out.

An interview with TRAVIS YOUNG, a private contractor who did work for North Star Foods, was stopped due to a legal notification issue.

TOMMY SCOTT OSBURN, Maintenance, said that:

• He has been there four years.

• He was on break at the time and heard about the fire over the radio from Carlos.

• He described in detail the exhaust stacks and systems on the roof.

• He identified C as the steam oven, B for the highlighter, D for the room air exhaust, and A for the water knife. All four are powered exhausts.

• He first saw smoke out of the oven and highlighter vents.

• He then saw flames out of the room exhaust vent and smoke out of the edge of the roof.

• The roof was getting soft, so they retreated to the edge of the roof.

• He went to shut off the main gas valve.

• The fire department was arriving as he was returning with tools to shut off the gas.

• He identified the B vent as stainless steel and the A vent as PVC pipe.

• He reported flames from the D vent coming from under the vent cap (room exhaust).

• The B vent motor was burned, but the A vent motor was the same color as new.

CARLOS GALDARNEZ, a Cook superintendent, said that:

• He has been there six years.

• His duties are to observe the operation and monitor the workers.

• He noted a burning smell around 1000-1015 hours.

• An employee first saw smoke by the highlighter exhaust. It was coming from the caulking around the vent. It was yellowish-colored and small.

• There were no flames in the room.

• Evelio Rosalino, a line worker, told him about the smell.

• He didn’t recognize the smell; it was similar to burning plastic.

• He thought the temperature in the room was warmer than normal. It is usually in the low 70s.

• The room temperature was showing 105 degrees. The room sensor was above the highlighter hood.

• He had not experienced heat like that before.

• He had called maintenance about the heat about 40 seconds to 1 minute before he saw smoke.

• He knew maintenance was coming.

• They were cooking chicken strips that day. They average about 45 minutes from raw to freezer.

• They are in his area 17-18 minutes for cooking and highlighting.

• Within the room are three (3) fans and five (5) lights.

• There is about 2 feet of clearance from the top of the highlighter to the ceiling.

• The PVC pipe and vent were for the water knife and room air.

• Roberto Ruiz was another employee in the room visually inspecting the product for bones.

Additional Notes It should also be noted that I had met with David Kalscheur, a representative from Marshall W. Nelson and Associates, Inc., and served a subpoena asking for work orders and records of service work done and any correspondence between North Star Foods that I felt necessary in researching this case. I was put in touch with their legal counsel, Attorney Bill Moran, and was told they needed some time to assemble the paperwork as it may have covered a period of years. He asked if he could look at the paperwork first, make copies and then get them to me in a timely manner. After consultation with my supervisor, it was agreed to give them the time they needed to assemble the records. I was not able to return to Marshal W. Nelson & Associates in Eagan MN due to a new fire investigation involving an explosion and injuries and asked if the materials could

be mailed to me. I received the information a couple of days later. Among the packet are photographs taken the day of the fire when the service technician was there and communications including emails, work orders, notes on phone conversations about changes, updates and progress at North Star Foods. I have included the paperwork with my file, but due to legal issues will not be able to share this information with others.

It should be noted that on May 11 through May 14, 2009, Deputy State Fire Marshal Rahman was present during the clearing of debris in the checker cook area. I was unable to attend due to a prior training commitment and would return again when things picked up. Investigator Rahman spent four days digging and sifting through debris within the above-mentioned room, along with a small number of other investigators and/or insurance company representatives. There were really no photos taken by Rahman due to the nature of the dig. Many others were on hand and photos can be requested from them.

Conclusion Based upon my investigation of the fire scene and after talking to fire department officials, company workers, and other interested parties, it is my opinion the fire originated within the ceiling space of the checker cook line. More specifically, the fire originated at the exhaust chimney for the highlighter within the checker cook portion of that line. It is my opinion that the exhaust stack was originally placed in position and was working properly for the existing equipment. After numerous attempts by both company workers and vendor/service technical people, a newer system was installed two months prior to the fire. They were in the beginning stages and were, in my opinion, still tweaking the system to get the desired effects on the product line.

Since the application and use of a new burner type, it is my opinion (as well as that of others) that there was a potential for more heat to develop within the room itself, within the vent hood, or the exhaust stack. Fresh air intake and exhaust vents were installed for make-up air within the room at some point, but still had little effect on the highlighter hood. It is my opinion that heat built up to the point where it heated the exhaust stack which, in turn, ignited caulking, wood, rubber roof membrane, or Styrofoam insulation. It appears that the exhaust vent may not have been large enough or adequate for the heat produced or there was a situation involving a failure of an exhaust blower or motor on these powered vents.

The fact that a service technician was present prior to the fire and had made adjustments to the system is significant in itself, but one cannot overlook the possibility this fire could have smoldered for some time prior to being noticed. If the flame was out of adjustment and had been burning for two hours prior to service work being done, could the service work have caused a problem or did the service work remedy a situation that already had caused a problem? It is possible the service work done may have fixed the burner situation, causing a better flame and reducing excessive heat build-up and the outcome of the correction may have gone unnoticed due to the fire.

At this point in the investigation, nothing has been determined on the exact cause or any potential for any liability issues. It is yet to be determined if any of the blower motors or exhaust removal equipment were working properly and were also installed properly. If the problem is truly about the exhaust vent pipe, is there someone clearly responsible or is it something that was noticed and intended to be fixed, but time, money and circumstances got in the way of making necessary or anticipated changes. Determination will now be left up to insurance companies, technical experts and attorneys and may likely be resolved through civil proceedings. If any follow-up meetings or scheduled investigative sessions are held, I will be advised. Nothing has been scheduled as of this date that I am aware of.

It is my opinion the fire originated within the ceiling space and was allowed to develop undetected due to the concealed space, building materials, and interior room finishes. By the time the fire or smoke was noticed and due to the nature of the building materials, the fire spread rapidly. Because of the heavy amounts of smoke, heat, toxic gases, and also the potential for the release of anhydrous ammonia, firefighting efforts were not very successful in stopping the fire spread before a huge amount of damage had been done. Also, due to the physical location of the fire being in the roof / ceiling space at the middle of the plant, the fire originated in about the worst place it could have as far as accessibility. It should also be noted that, in my opinion, if not for the fire department and mutual aid efforts, there could have been catastrophic events and numerous persons could have been injured or killed.

It is therefore my intention to call the cause of the fire accidental, with the exact cause for the fire being undetermined. I cannot make an exact determination due to the many possibilities that have yet to be ruled in or out. It is my intention to close this file at this time pending the receipt of any further information. Respectfully submitted,

Steven L. Wolf Deputy State Fire Marshal – Investigator

Date Submitted: 7/29/2009

Attachments

1. Photo Log (day 1, 2, and 3)

2. Photo Log (photos taken by DSFM Ron Rahman)

3. Sketch or blueprints (numerous)

4. Subpoena to Marshall W. Nelson & Associates

5. Business cards

Photo Log Case No. 2009-137

Day 1

79. Smoke plume from interstate






85. Smoke plume-road into town

86. Smoke plume-road into town

87. Northwest elevation



90. Northeast elevation



93. East elevation


95. North Star Foods-company sign

96. North elevation

97. West elevation

98. West elevation

99. West elevation

100. West elevation-shipping dock

101. South elevation

102. Southeast elevation





107. North elevation

















124. Southwest elevation



























151. East--evacuation of residents






157. Southeast exterior


159. North elevation-nitrogen tanks

160. Off site-incident command site

161. From Trooper 7--Aerial view

162. Aerial view

163. Aerial view

164. Aerial view

165. Aerial view

166. Aerial view

167. Aerial view

168. Aerial view





173. Trooper 7

174. Trooper 7



177. Northwest elevation-nitrogen tanks

178. Frozen piping and valves

179. Aerial ladder

180. North interior

181. North interior-fat tank


183. North elevation-excavator pulling wall

184. Excavator

185. Excavator

186. Excavator

187. Exterior light and camera

188. North elevation-wall pulled

189. North elevation-excavator removing wall panels

190. Removing wall panels

191. Northeast corner-fire

192. North elevation-wall panel removed

193. North elevation-electric wire / cable being pulled

194. North elevation-second panel being removed

195. Second panel being removed

196. Second panel being removed

197. Panel removed

198. Northeast corner-fire now in entire second floor


200. Southeast exterior-aerial



203. West elevation

204. West elevation-excavation

205. Excavation

206. West interior-side door

207. West elevation-excavation started

208. West elevation-excavation




Day 2

1. Aerial view-North side



4. Aerial view-Northeast side


6. Aerial view-North-area of origin


8. Aerial view-North side-area of origin


10. Aerial view-fire extinguishers on roof



13. Aerial view-Northwest side

14. Aerial view-Northwest side


16. North interior-checker raw



19. North interior

20. North interior

21. North interior

22. North interior

23. North interior-checker cook




27. North interior-electrical arcing


29. North interior-highlighter


31. North interior-ceiling

32. North interior

33. North interior

34. North interior


36. North interior

37. North interior

38. North interior-water knife

39. Northeast interior


41. North interior-collapse

42. North roof-from inside out

43. Highlighter

44. North interior-roof collapse

45. North interior-electrical / gas controls

46. North interior-inside steam oven

47. North interior

48. North interior

49. North interior

50. North interior



Day 3

1. Aerial view-North roof











12. North interior-checker cook-arc mapped

13. North interior-checker cook-arc mapped


15. Arc

16. Arc









25. North interior-checker cook-light fixture-arc mapped

26. Light fixture-arc



29. North interior-another light fixture

The following photos were taken by Ron Rahman on 4-19-09 and are marked St. Charles, Ron along with each photo.

1. Looking east at the compressed gas area of the plant.

2. Left of prior photo looking at building of origin with two open doors after collapsed area.

3. Left of prior photo showing destruction to the north.

4. South of photo #1 showing undamaged area.

5. Large refrigerated storage building in background and drive.

6. South end of the refrigerated storage building and the dock area.

7. Looking northwest at the complex showing fire damage to the right rear.

8. Left of prior photo.

9. Remainder of the east side of the building.

10. Northeast corner of the building.

11. Different angle.

12. Looking west along the north end of the complex.

13. Inside the structure from the door in photo #11 looking at destruction.

14. Suspended tank.

15. Above prior photo showing piping above.


17. Another tank.


19. Ice formed on another tank.


21. Pump.

22. Piping above pump.

23. Motors and pumps.

24. Strobe did not work.


26. Above prior photo showing piping.

27. More tanks.

28. Piping above tanks.

29. Large pump.

30. Piping above.

31. Left of photo #29.

32. Above prior photo.

33. Looking through double doors into destroyed area.

34. Right of the double doors.

35. Left of the double doors.

36. Looking through large door opening at destruction.

37. Stainless steel containers.

38. Above prior photo showing piping and collapse.

39. Looking west along south wall of collapsed room.


41. Right of prior photo.

42. Looking into partially collapsed area to the north.

43. Exterior northeast corner looking south.

44. West section of north wall.

45. Right of prior photo showing balance of north wall.

46. Looking into east opening of north wall at damage.

47. Close view shows plastic covering over stainless steel containers.

48. Looking into opening west of photo 46 at metal racks of food.

49. Closer view.

50. Right of photo #48.


52. Closer view of plastic covered cardboard containers.

53. Northwest corner of the complex.

54. Right of complex showing office area.

55. Looking northeast at collapsed office area.


57. Right of prior photo looking at west wall and building of origin.

58. Natural gas piping and regulator.

59. Close view.

60. North opening of building of origin.

61. Suspended furnace in northeast corner.

62. Roof and metal frame warped.

63. South opening.

64. Heat damage and warping on roof and metal frame.


66. Collapsed building south of building of origin.

67. Closer view of motor and stainless steel item.






73. Aluminum and fiberglass ladder in photo #71 in relatively good condition.

74. Paint still on pump.

75. Left of photo #71.

76. Electrical component.

77. Pressurized tank south of fire area.

78. Room right of pressurized tank.

79. Closer view.

80. Looking north at west end of refrigerated building showing fire damage.



83. Left o f photo #80 showing collapse and stacked steel from backhoe.


85. Different angle of west end of refrigerated building.

86. Barrels of product outside of refrigerated building.

87. Backhoe tracks through collapsed area.


89. Looking into northwest quadrant of refrigerated building.






95. Product stacked on metal shelving inside refrigerated building.


97. Right of photo #95 showing stacked product.


99. Looking east along the north wall showing stacked product.



102. Underside of roof damage.



105. Insulation destruction on underside of roof.

106. Heat patterns on west wall of refrigerated building.

107. Below prior photo.

108. Looking out doorway of photo #89.

109. Looking into another doorway to refrigerated building east of the southwest corner.

110. Product inside.


112. More product.

113. Looking down on building of origin.

114. Overview of collapsed area.

115. Collapsed roof over area of origin.






121. Looking east of photo #119.

122. Burned metal duct.

123. Fire extinguisher on roof.

124. Fire extinguishers on roof.

125. Overview of fire extinguishers adjacent to area of origin.

126. Another extinguisher on roof.

127. Collapsed area.

128. Looking into building of origin.

129. Chicken preparation machines.

130. Stainless steel tub for raw chicken.

131. Looking east.



134. Looking toward oven area.

135. West end of primary oven.


137. Looking into a machine.

138. Walkway to east partially obstructed.

139. Partial concrete wall at control area.

140. Heat damage on machine.

141. Closer view.

142. Opening through roof.

143. Electrical controls.

144. Controls and piping.

145. Continuation.

146. Exposed electrical wiring traveling to horizontal box.

147. Close view of wires.

148. Looking into rotary steam oven.

149. Underside of roof and frame.

150. Pump, gauges and piping.

151. Below prior photo.

152. Roof damage above photo #150.





157. Door to steam oven bulged and detached over walkway.

158. More stainless steel containers.

159. Raw chicken conveying system.



End of Photo Inventory

North Star Foods fire investigation

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