Record Number: 2112
CIS Descriptors: SUPERVISORS
CHEMICAL INDUSTRY
FALLS FROM HEIGHTS

FATALITY REPORT



REPORT CHARACTERISTICS:

DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Dr. Mitchell-Gill, Coroner
PLACE OF INQUIRY: Whitby
DATE OF INQUIRY : 1988-10-26

INFORMATION ABOUT DECEASED:

NAME: Allan Andrews
OCCUPATION: Foreman
INDUSTRIAL SECTOR: Chemical Industry

ACCIDENT INFORMATION:

DATE OF ACCIDENT : 1988-01-12
PLACE OF ACCIDENT: G & R Chemicals
BRIEF CAUSE OF DEATH: Asphyxia.
BRIEF MANNER OF DEATH: Fall into bottom of chemical mixing vat sprayed
with a methylene chloride solution.
ACCIDENT DESCRIPTION:
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 the
above named plant. The vat had been sprayed with methylene chloride
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.

The mixing blades damaged the ladder on which Mr. Andrews was standing,
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
respirator mask. He then lost consciousness himself and another member
of the staff then entered the vat to remove Mr. Andrews and the
laborer, using an air hose to try and combat the fumes. He became
dizzy himself and was just able to climb out as the ambulance arrived.

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
laborer, who were then resuscitated by the ambulance attendants.

Mr. Andrews was deeply unconscious and the laborer was semi-conscious.
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
January 16th 1988 found that death had occurred due to oxygen being
replaced in the atmosphere by chemical fumes.

RECOMMENDATIONS 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
is placed for an ambulance, the fire rescue truck would respond to the
same call.

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
any accident involving hazardous substances.

5. Safety procedures should be stressed at regular safety meetings with
appointed representatives which would include all personnel regardless
of the size of the company.

6. All new employees should immediately be trained in safety and emergency
procedures. Every employee should be given a written copy of safety
and emergency procedures.

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
such.

9. All switches pertaining to machinery and equipment should be clearly
labelled and a lock-out device provided.

10. All safety procedures outlined in the IAPA with respect to hazardous
substances should be in a clearly written format and provided to
company employees.

11. Any missing vat should have a failsafe switch installed on the lid to
prevent its operation while the lid is open.

12. The regulations and rules of IAPA pertaining to companies of 20 or more
employees should be reviewed with a view to including all companies
regardless of size.

13. A list of dangerous substances contained in the IAPA should be expanded
to include methylene chloride, toluene and methanol.

COMMENTS ON 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,
it may have saved a life, as the fire brigade can extract victims that
the ambulance personnel are not equipped for.

2. This is suggested only for industrial accidents.

3. Self explanatory.

4. Self explanatory.

5. This would be a practical way to educate all employees on safety
procedures.

6. Many employees are currently unaware of safety procedures at the plant.

7. Self explanatory.

8. Self explanatory.

9. These are basic safety precautions in industry. At least the labelling
would not be expensive to install and enforce.

10. Self explanatory.

11. This would seem to be an excellent safety device.

12. The chemicals handled by small companies can be just as dangerous as
those handled by larger companies.

13. This should certainly be done.






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