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| Record Number: |
2189 |
| CIS Descriptors: |
GAS STORAGE TANKS
GAS WELDING AND CUTTING
ERECTION AND DISMANTLING
FLAMMABLE GASES
BURSTING
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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: British Columbia
REPORT TITLE: Judgement of Inquiry
INDIVIDUAL PRESIDING: Chris Ditmas, Coroner
PLACE OF INQUIRY: Victoria
DATE OF INQUIRY : 1989-05-08
INFORMATION ABOUT DECEASED:
NAME: Confidential
OCCUPATION: Welding Cutter
INDUSTRIAL SECTOR: Tank Disposal
ACCIDENT INFORMATION:
DATE OF FATALITY : 1988-11-23
PLACE OF ACCIDENT: 6432 Patricia Bay Hwy, Victoria
BRIEF CAUSE OF DEATH: Multiple traumatic injuries.
BRIEF MANNER OF DEATH: An explosion.
ACCIDENT DESCRIPTION:
The twenty five year old deceased lived with his wife and child
in a
mobile home, on the farm in Saanich, BC where they had both
lived and
worked for some years. They were expecting the birth of their
second
child within days.
As well as farming, the owner had developed a subsidiary business
of
the property that consisted of dismantling and disposing of
used
gasoline storage tanks. On this day, the 23rd of November 1988,
the
deceased was engaged in cutting up two such tanks, the first
of 2000
gallons capacity and the larger one of 5000 gallons.
Soon after mid-day he was seen and spoken to by his foreman
and a
fellow worker, both of whom were on their way to lunch. The
owner also
came by soon after and spoke with him, mentioning it was lunch
time and
noticing that he had only about a foot left to cut of the smaller
tank.
At just before 1214 hrs that day local residents heard a loud
explosion
and Central Saanich Emergency Dispatch received calls from the
public
that there had been an explosion and fire in the area. At first
neither the RCMP helicopter that was dispatched, nor the Central
Saanich Fire or Police departments could locate anything unusual
in the
area they had been searching. It was not until 1246 hours that
Emergency Dispatch received the correct address, though at that
time
they were told that a 100 lb propane bottle had exploded and
there was
no need for the police and ambulance to attend.
At the farm itself, the explosion had drawn the owner and his
foreman
to the yard where the deceased had been working on the tanks.
There
was a smell of propane in the air, but no sign of the deceased
whom
they assumed must have gone to lunch.
It was more than 30 minutes after the explosion, when the foreman,
having failed to find him at his home and noticing that the
end section
of the large tank was missing, stepped up the search for the
missing
worker.
Finally, the mutilated remains of the deceased were discovered
in a
barn more than a hundred feet away, lying on the concrete floor
beneath
a hole in the corrugated iron roof.
In the yard where the explosion occurred were found the remains
of the
cut up smaller tank, together with the bent and buckled eight
foot
diameter end-piece from the larger tank.
A leaking propane cylinder lay on its side, and the steam line
was
still on the ground. The larger tank had been moved from where
it
blocked the driveway before the significance of the explosion
was
understood.
Witness's statements relate that:
1. The deceased had nearly finished cutting up the smaller tank,
with
about a foot to go, when the Foreman and his co-worker left
the yard
for lunch. About the same time he was seen and spoken to by
the owner,
who mentioned it was lunch time and reminded him to replace
the steam
hose in the larger tank before cutting it.
2. A lady who lived in a suite overlooking the yard where the
deceased had
been working was having lunch with a friend. She heard a loud
explosion and saw the glass door of her sitting room disintegrate.
Looking out on the yard she saw no one at first; then the owner
appeared from his house and started to look around.
3. The owner confirmed that the deceased had worked for him
about six
years as a labourer, and that he had cut up a number of tanks
in the
past. He also commented that he had considered letting him go
on a
number of occasions as he had found him to be "accident
prone".
History:
On 1st March 1978 a similar fatality occurred in South Burnaby
BC when
a used gasoline storage tank that was being cut up for scrap
exploded
and killed the operator.
The Coroner's inquest that followed made recommendations to
the WCB
regarding a requirement for regulations governing the transportation
and disposal of such tanks. Subsequently IH & S Regulations
#72.301
and #8.18 concerning testing procedures and written work procedures
respectively, were issued.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. To: WCB
6951 Westminster Highway
Richmond BC
Copy to:
WCB
320 Cook Street
Victoria BC
V8V 4W1
That a) Up-dated written work and testing procedures be formulated
and
distributed to any work-places engaged in the dismantling and
disposal of used petroleum storage tanks, or any similar items.
b) WCB publish a Hazard Alert Bulletin.
c) Follow-up inspections be initiated to ensure compliance with
regulations.
COMMENTS ON RECOMMENDATIONS BY CORONER:
Conclusions:
1. The most probable sequence of events are determined to be
as follows:
On the morning of November 23rd, 1988, the deceased was given
the job
of cutting up two used petroleum storage tanks, one of 2000
gallons
capacity and the other of 5000 gallons, both situated in the
yard in
front of the work shop.
Having started up the steam generating boiler he proceeded to
steam out
first the smaller tank and then the larger one. While steaming
the
larger tank, he and another worker moved the smaller tank further
away
to a safer distance for cutting. Then he placed the steam hose
back in
the smaller tank and started work on one end with a propane
and oxygen
cutting torch.
Having cut out one end the deceased transferred the steam hose
back to
the larger tank and continued to work on the other end. Soon
after,
his co-worker noticed a small fire start in the sludge and debris
lying
at the bottom of the tank. He stopped the deceased cutting further
while the two of them replaced the steam hose back in the smaller
tank
so as to extinguish the fire.
The deceased cut out the second end and then went on to make
the first
of two longitudinal cuts down the sides of the tank, all the
while
leaving the steam hose inside. Having completed one side he
was about
to start the other when the foreman noticed that the steam hose
was
still running in the now partially collapsed tank and removed
it,
turning off the steam.
Just after mid-day the foreman and his fellow worker both spoke
to the
deceased on their way to lunch, and very soon afterwards the
owner also
mentioned that it was lunch time, and reminded the deceased
to replace
the steam hose in the larger tank before working on it. All
three
remembered that the deceased had about one foot left to cut
on the
smaller tank when they left him alone in the yard at lunch time.
There
is also evidence that he then finished cutting the side of the
smaller tank, after which he cut two holes in the pieces to
assist with
lifting.
Thereafter it appears that the deceased started to cut the end
of the
larger tank without replacing the steam hose, which was still
found to
be switched off after the explosion, and assuring that the tank
had
been rendered safe for cutting. As soon as the flame of his
torch
penetrated the steel wall of the tank, the vapour contents exploded
and
blew out the end which in turn propelled the deceased at least
131 feet
through the air.
Following the explosion the owner and foreman had both assumed
that it
was a propane tank hooked to the cutting torch that had exploded.
They
also presumed that the deceased was absent at lunch. It was
some
thirty minutes before they realised that the tank had itself
exploded,
and that the deceased must have been involved.
2. Toxicological evidence indicating that the victim's liver
contained a
level of 0.26% Ethyl Alcohol was due to post mortem contamination
of
the organ and not to the imbibing of alcohol. This is substantiated
by
the absence of any traces of Ethyl Alcohol in the brain tissue,
and the
microbiological cultures subsequently developed.
3. It is evident that practices and procedures as required by
WCB
regulations were not being followed in this location.
Specifically, Testing Procedures - IH & S Reg #72.301, and
written work
procedures - IH & S #8.18, were not applied or available.
Further, the deceased did not follow even those instructions
given to
him, to re-insert the steam hose for a sufficient time prior
to cutting
the larger tank.
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