At around 2:45 p.m. a fire broke out on the chiller of a production line at an animal feed plant. The employees put the fire out with extinguishers. Two of them inhaled smoke and were taken to hospital. They were released that same evening. The fire was out when the firefighters arrived. They used thermography to look for potential hot spots. The two other production lines were restarted that day. The line involved in the fire started was started back up after the weekend.

The first batch was manufactured without any problem. On the day of the accident, however, feed did not easily pass through the pellet mill’s die while the second batch was being made. The mill showed signs of wear that should have been reported so that it could be replaced. Many jams occurred that morning, requiring a restart each time. Steam was added to make it easier for the feed to pass through the pellet mill’s die. The temperature of the pellets exiting the mill was between 60 and 80 °C. Despite being cooled, red-hot feed reached the chiller, igniting the fire. The facility’s technicians did not inform the operator about the problems they were encountering and the isolation valve was not used to interrupt the supply from the pellet to the chiller. In addition, visual inspections were performed but failed to detect the red-hot feed.

The operator took the following measures:

• it trained its employees in fire safety (already scheduled and conducted on 26 September);
• it changed the feed’s formulation so that it enters the pellet mill’s die more easily;
• it replaced the fire extinguishers used during the fire.

Other actions are planned:

• establish a procedure for changing the die and informing the production manager as soon as the slightest malfunction is found;
• provide all new technicians with more in-depth training in operating the pellet mill;
• monitor the amount sent through the die (to be done by the shift supervisor);
• remind employees of what to do the event of a fire.