Stable Until It Wasn't

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Ten years ago today a man went to work filling a trailer with a gas everybody in the plant considered harmless. It was harmless — right up until a pump ran a few degrees too hot. Here’s what nitrous oxide taught us about the gap between “inert” and “safe,” and why the rulebook had a hole exactly where Jesse Folmar was standing.

It was a Sunday morning at the Airgas nitrous oxide plant in Cantonment, just north of Pensacola. Jesse Folmar, 32, was the only Airgas operator on site. His job that day was routine: pump liquid nitrous oxide out of a storage tank and into a transport trailer for shipment. Airgas ran one of only four plants in the country making nitrous oxide — the “laughing gas” hospitals use as an anesthetic, dentists use on nervous patients, and food companies use in whipped-cream chargers. Handled normally, it just sits there. Stable. Boring.

Then the pump overheated.

Nitrous oxide (N₂O) has a dark side almost nobody outside the trade thinks about: heat it past a certain point and it doesn’t just get hot — it decomposes, tearing itself apart into nitrogen and oxygen and dumping enormous energy in a fraction of a second. The CSB found that the transfer pump heated the gas above its safe limit and triggered exactly that runaway decomposition. The reaction ripped from the pump into the trailer and the trailer blew. The blast threw large metal fragments hundreds of feet, flattened the manufacturing area, and killed Jesse Folmar. The plant never made nitrous oxide again.

The CSB’s root-cause findings read like a checklist of things nobody did:

Here’s the part that should stop every safety leader cold. When OSHA showed up, they couldn’t cite Airgas under the big process-safety rule — 29 CFR 1910.119, Process Safety Management — because nitrous oxide isn’t on the PSM list of highly hazardous chemicals. The rule that requires you to do a Management of Change before you install new equipment — 1910.119(l) — simply didn’t apply. So OSHA reached for the tool it uses when there’s no specific standard: Section 5(a)(1) of the OSH Act, the General Duty Clause — the requirement to keep a workplace “free from recognized hazards.” Airgas paid a $12,000 penalty. That’s the whole price a federal fine put on the gap.

Translation to the floor: “Not on the list” does not mean “not dangerous.” A chemical can be perfectly legal to handle with zero PSM paperwork and still decompose hard enough to throw shrapnel across a parking lot. If you run a process that isn’t covered by 1910.119, the smart move is to borrow its bones anyway — do the Management of Change, do the hazard analysis, question every pump and interlock — because the physics doesn’t check whether your chemical made OSHA’s list. The person closest to that pump saw the heat risk first. The system just never gave anyone a place to raise it.

The Full EHS Picture. Most incidents are Environmental, Health, and Safety at once — but this one is honestly weighted toward the S, and it’s worth saying so plainly rather than inventing the rest. (E) Nitrous oxide decomposes into nitrogen and oxygen — ordinary air — so the blast produced no toxic cloud and no documented offsite spill; it was contained to the unit. The environmental footprint is subtler: N₂O is itself a potent greenhouse gas (roughly 270 times the warming punch of CO₂ over a century) and, per NOAA, the single largest ozone-depleting substance now emitted, so every venting and every lost inventory of it carries a climate cost long after the fire’s out. (H) The acute health toll was one life — Jesse Folmar — killed by blast and fragmentation, not by exposure; there’s no verified record of community illness afterward. (S) The safety failure is the whole story: a “safe,” unregulated gas, a hot pump, a bypassed interlock, and no Management of Change to catch any of it. One honest line to tie it together: the same missing safety system that killed a worker is the kind of gap that, with a different chemical, poisons a creek and sickens a town — Cantonment got the narrowest version of that lesson, and a family still paid full price.

Primary source: U.S. Chemical Safety Board, final report on the August 28, 2016 Airgas Cantonment nitrous oxide explosion (csb.gov); OSHA citation reporting via WEAR-TV.

Decommissioning is not “winding down” — it’s a live process. On August 13, the CSB released an investigation update on the April 22, 2026 hydrogen sulfide release at the Catalyst Refiners (Ames Goldsmith) facility in Institute, West Virginia. During decommissioning, workers pumped two incompatible process chemicals and then nitric acid into the same wastewater tank — with no written disposal procedure. A fog formed, an operator passed out, a supervisor went down, and two employees who came to help were overcome and died. Responders detected H₂S and ordered a one-mile shelter-in-place; 18 people went to the hospital. The CSB noted respirator use had been dropped after production stopped, and no personal gas monitors were in use. So what: the day you decide to shut a unit down is the day your hazard analysis has to get sharper, not looser. Incompatible-chemical mixing and confined vapor spaces don’t care that the plant is “closing.” Keep the monitors on and the procedures written until the last drum is gone.

Heat season is peaking while the federal heat rule sits stalled. As of late August 2026 OSHA’s proposed Heat Injury and Illness Prevention standard — the one with the heat-index 80°F “initial” and 90°F “high-heat” triggers, mandatory rest, water, shade, and acclimatization — still isn’t final, with no target date on the regulatory agenda. Meanwhile OSHA keeps enforcing heat under the General Duty Clause and its Heat National Emphasis Program. So what: don’t wait for the rule. The 80°/90°F triggers, a written plan, and a real acclimatization schedule for new and returning workers are defensible, cheap, and they work — and they’re exactly what an inspector will measure you against under 5(a)(1) today.

A crew was transferring a “non-hazardous, inert” cleaning fluid between totes on a warm afternoon — a job so routine nobody wrote it down. The pump they grabbed was the closest one, not the right one, and it ran hotter than the fluid liked. An operator noticed the tote getting warm and a faint chemical smell and — this is the win — stopped, backed everyone off, and called it in instead of pushing to finish the batch. Turned out the “inert” fluid had an incompatibility nobody had flagged, and the warm pump was nudging it toward a reaction. No one was hurt. No blame here: the operator did everything right, and the real gap was upstream — a task treated as too simple to need a procedure, and a pump nobody had matched to the chemical. Error is normal; the system’s job is to make the safe move the easy move. This crew’s instinct closed a hole the paperwork left open.

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Pick one process on your floor that isn’t covered by PSM — a gas or chemical that’s “not on the list.” Before your next shift change, ask the one operator who runs it most: “If you could change one thing about how we move or store this, what would it be?” Then run that answer through a five-minute Management of Change, even though no rule requires you to. That’s the review Cantonment never got.

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Please stay Safe & Hydrated!!!