DONOR: Office of the Chief
REPORT TITLE: Verdict of
INDIVIDUAL PRESIDING: Dr. Mitchell-Gill,
PLACE OF INQUIRY: Whitby
DATE OF INQUIRY :
INFORMATION ABOUT DECEASED:
INDUSTRIAL SECTOR: Chemical
DATE OF ACCIDENT :
PLACE OF ACCIDENT: G & R Chemicals
CAUSE OF DEATH: Asphyxia.
BRIEF MANNER OF DEATH: Fall into
bottom of chemical mixing vat sprayed
with a methylene chloride
On January 12, 1988, at
about 7:30 am, Mr. Allan Andrews, the foreman
at G & R
Chemicals, had placed a wooden ladder in a mixing vat at
above named plant. The vat had been sprayed with methylene
the night before to clean it. He called to a laborer,
who worked at
the plant, but was not familiar with the
equipment, to start an extract
fan. The laborer inadvertently
pressed the wrong switch and started
the blades of the mixing
vat rather than the extract fan. This started
a series of
disasters which resulted in the death of Mr. Andrews.
mixing blades damaged the ladder on which Mr. Andrews was
resulting in him falling into the vat. The laborer
tried to extricate
him from the vat, but he was already
semiconscious and fell down to the
bottom of the vat. At this
time the staff were asked for help by the
laborer, who went
into the vat to rescue Mr. Andrews, wearing a
He then lost consciousness himself and another member
staff then entered the vat to remove Mr. Andrews and
laborer, using an air hose to try and combat the fumes. He
dizzy himself and was just able to climb out as the
They were unable to enter the vat and
had to wait some five minutes for
the fire brigade to arrive
with their self-contained respirator units,
which enabled them
to enter the vat and extricate Mr. Andrews and the
were then resuscitated by the ambulance attendants.
Andrews was deeply unconscious and the laborer was
The two men were taken to Oshawa General
Hospital and subsequently to
Toronto General Hospital on the
same day, January 12th 1988. The
laborer made an uneventful
recovery, but Mr Andrews was declared brain
dead two days later
on January 14th at 6 pm. Autopsy carried out on
1988 found that death had occurred due to oxygen being
in the atmosphere by chemical fumes.
ISSUING FROM INQUIRY:
1. A 911 emergency system be
implemented for the Region of Durham.
2. In the interim, a
tiered system should be in place so that when a call
for an ambulance, the fire rescue truck would respond to
3. All businesses handling hazardous
substances as listed in the IAPA
should be listed with the fire
department on a central registry.
4. All companies should
have written procedures to follow in the event of
involving hazardous substances.
5. Safety procedures should
be stressed at regular safety meetings with
representatives which would include all personnel regardless
the size of the company.
6. All new employees should
immediately be trained in safety and emergency
Every employee should be given a written copy of safety
7. Written data base sheets should be
posted in plain view, listing all
hazardous substances handled
by the company.
8. First Aid equipment should be readily
available and clearly marked as
9. All switches
pertaining to machinery and equipment should be
labelled and a lock-out device provided.
safety procedures outlined in the IAPA with respect to
substances should be in a clearly written format and
11. Any missing vat
should have a failsafe switch installed on the lid to
its operation while the lid is open.
12. The regulations
and rules of IAPA pertaining to companies of 20 or
employees should be reviewed with a view to including all
regardless of size.
13. A list of dangerous
substances contained in the IAPA should be expanded
methylene chloride, toluene and methanol.
RECOMMENDATIONS BY CORONER:
1. This system should be in
place at least for industrial accidents. If
the fire brigade
had been contacted at the same time as the ambulance,
have saved a life, as the fire brigade can extract victims
the ambulance personnel are not equipped for.
This is suggested only for industrial accidents.
4. Self explanatory.
5. This would be a
practical way to educate all employees on
6. Many employees are currently
unaware of safety procedures at the plant.
8. Self explanatory.
9. These are basic
safety precautions in industry. At least the labelling
not be expensive to install and enforce.
11. This would seem to be an excellent safety
12. The chemicals handled by small companies can be
just as dangerous as
those handled by larger
13. This should certainly be