| |
|
-
REPORT CHARACTERISTICS:
DONOR: B.C. Coroner's Service
JURISDICTION: British Columbia
REPORT TITLE: Judgement of Inquiry
INDIVIDUAL PRESIDING: Robert J. Graham, Coroner
PLACE OF INQUIRY: Kamloops
DATE OF INQUIRY : 1984-08-27
INFORMATION ABOUT DECEASED:
OCCUPATION: Maintenance Worker
INDUSTRIAL SECTOR: Health Care Institution
NAME: Confidential
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1984-03-29
PLACE OF ACCIDENT: Overlander Hospital, Kamloops
BRIEF CAUSE OF DEATH: Carbon Monoxide Poisoning, Smoke Inhalation.
BRIEF MANNER OF DEATH: Industrial fire.
ACCIDENT DESCRIPTION:
The deceased died in an industrial fire at his workplace, Overlander
Extended Care Hospital, in Kamloops, on March 29, 1984 about
9:30 a.m.
The fire occurred in a paint storage area in a workshop behind
the
hospital and was caused directly from a flammable liquid being
accidentally spilled onto an open element electrical heater,
flashing on
contact.
He was a maintenance employee of the hospital and was repairing
a broken
hand held hair dryer in the boiler room area of the hospital
on the
morning of March 29, 1984. The housing of the hair dryer was
observed
to be held together with an epoxy type of glue. For some reason,
he
left this job and went to the workshop area located in a separate
building East of the hospital. A co-worker was also in the workshop
and
was called over to the paint storage area, an enclosed room
measuring
approximately 2.1 x 3.9 meters, by the deceased.
The deceased asked the co-worker to assist in locating some
acetone. He
did not specify why he required this solvent, but it can be
presumed
from his fastidious nature that he was intending to remove epoxy
from
his hands or clothing. The co-worker did not know of any acetone
in the
paint storage room, but knew of an unmarked one gallon container
of an
unknown substance stored under the counter. The deceased unscrewed
the
lid and tipped the can over to pour the substance onto his hand.
The
bottom of the can slipped off the counter and hit the floor,
splashing
the liquid from it spout. Both men jumped backward, the deceased
into
the back of the room, the co-worker out the doorway. The co-worker
also
pulled the door partially closed to contain the splashed liquid.
The
incident occurred directly in front of a small, portable, electrical
heater used in the area.
Within seconds, a flash fire erupted, followed by a muffled
explosion
which blew the door shut. The burning liquid flowed under the
door,
spreading the fire. The co-worker attempted to open the door,
but the
supply of fresh oxygen caused a further flash and sent thick
smoke into
the rest of the work building.
It is of judicial interest to remark on the actions of the co-worker
following his attempt to rescue the deceased. During his attempt,
he
sustained a minor burn to one hand from the hot door knob, and
singed
some hair on his head. A further explosion occurred within the
paint
room, and the building filled with smoke. The co-worker noted
that the
exterior of the paint room door was on fire and that the fire
was
spreading. He could get no verbal response from the deceased,
and a
second attempt to enter the paint room was foiled when the door
would
not yield even when kicked. He then became dizzy and disoriented
and
had to crawl out of the building.
He went to the hospital nursing station, but in his disorientation
could
not remember why. He subsequently turned in the alarm and took
a garden
hose out to the rear of the hospital. The hose was too short
to be used
in fire fighting, so he kept nearby parked cars wet until the
fire
department arrived. During the fire fighting, the co-worker
could
remember no details, and his initial statement to the police
was later
changed as he spoke to other investigators from the Workers'
Compensation Board and the Fire Commissioner's Office. A second
statement was given to the police, under interrogation, on May
02, 1984
and was consistent with those given to the other investigative
agencies.
He received proper legal advice not to subject himself to a
polygraph
examination.
Although the co-worker's inability to recall details at the
time of the
incident and later to remember them have resulted in suspicions
of foul
play, his conduct is in keeping with Carbon Monoxide Poisoning.
It is
reasonable to conclude that, like the deceased, he inhaled vast
quantities of Carbon Monoxide just from his proximity to the
fire and
smoke. His memory recall improved later in the evening, and
again after
a night's sleep, and he provided a voluntary statement to the
Workers'
Compensation Board. This, and subsequent statements, have been
consistent with the findings. The co-worker probably has performed
a
heroic act in a vain cause.
An autopsy on the charred remains of the deceased confirmed
that he was
alive at the time of the flash fire, and that he died of Carbon
Monoxide
Poisoning and smoke inhalation. The autopsy also ruled out any
pre-mortem injurious trauma and pre-existing disease conditions
which
may have otherwise contributed to his death. Positive identification
has been confirmed through a comparison of the upper dental
plate. This
Inquiry rules the death to be result of an accidental fire at
his
workplace.
RECOMMENDATIONS ISSUING FROM INQUIRY:
This Inquiry recommends that the Administrator of Overlander
Extended
Care Hospital, 953 Southill, Kamloops, B.C., in co-operation
with the
local Fire Inspector, conduct a thorough inspection of all hospital
buildings to ensure that all flammable liquids and solvents
are stored
in areas approved by existing standards, specifically as to
labelling,
ventilation, heating and firewall protection.
|
|
|