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| Record Number: |
1336 |
| CIS Descriptors: |
SHIPBUILDING INDUSTRY
FLAME
SPREAD
WORK IN CONFINED SPACES
SHOCK
THERMAL
BURNS
OXYGEN
INDEX
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: Dr. Thomas Heringer,
Coroner
PLACE OF INQUIRY: Thunder Bay
DATE OF INQUIRY :
1983-05-27
INFORMATION ABOUT DECEASED:
NAME: Steven
Elsey
OCCUPATION: Unavailable
INDUSTRIAL SECTOR:
Shipbuilding/Manufacturing
NAME: Stanley Humar
OCCUPATION:
Unavailable
INDUSTRIAL SECTOR:
Shipbuilding/Manufacturing
NAME: Gary McDonald
OCCUPATION:
Unavailable
INDUSTRIAL SECTOR:
Shipbuilding/Manufacturing
ACCIDENT
INFORMATION:
DATE OF ACCIDENT : 1983-02-18
PLACE OF
ACCIDENT: N.V. Richelieu, Drydock, Port Arthur Shipbuilding
Co.,
Thunder Bay, Ontario.
BRIEF CAUSE OF DEATH: Shock,
Burns due to fire.
BRIEF MANNER OF DEATH: Oxygen enriched
atmosphere; oxygen enhanced fire.
ACCIDENT
DESCRIPTION:
Three workmen died in an oxygen-enhanced fire in a
large ballast tank
in a ship under repair.
The origin of
the oxygen enrichment was obviously the "burning
lines"/
(Oxygen acetylene lines), however the exact
circumstances of how this
came about were not determined. This
is an Oxygen leak, not acetylene.
The welding, generally
speaking, is done by electrical arc.
RECOMMENDATIONS
ISSUING FROM INQUIRY:
1. A booklet be prepared to include
all pertinent safety regulations and
to be supplied to each
employee.
2. That this booklet be prepared by a joint union
and management
committee.
3. A copy of the Occupational
Health and Safety Act and Regulations be
presented to each
employee.
4. Safety seminars to be presented to all
Supervisory personnel on a
regular basis.
5. Periodic
general informative and demonstrative sessions be held for
all
employees.
6. That educational institutions ensure
that their curriculum include an
explanation of the properties
of oxygen and particularly the dangers of
oxygen use.
7.
That institutions using significant amounts of 02 immediately
advise
their employees of the dangers associated with 02
enrichment.
8. That the Ministry of Labor consider amending
its regulations to more
clearly define the term "confined
space".
9. That the Ministry of Labor, in conjunction with
the shipbuilding
industry and relevant unions consider
developing a set of regulations
which more specifically deal
with the working in a shipyard than do the
present regulations,
with reference to the Canada Shipping Act.
10. That
appropriate government authorities consider legislating
the
minimum size of manholes on vessels to be 24" or
more.
11. Companies and employees must adhere to the
regulations as set out in
the Occupational Health and Safety
Act and regulations.
12. That back flow preventers be
installed on all torches.
13. A means of identification of
burning lines at the manifold and torch
ends.
14. That
mandatory inspections be made of all burning lines and
torches
every thirty days.
15. That a device be made
available for all jobs in remote locations where
clamping the
line may be necessary in emergencies. (e.g. vise grips)
16.
That lines be disconnected from manifold and torch at the end of
each
shift.
COMMENTS ON RECOMMENDATIONS BY
CORONER:
Recommendations 1 to 5 need no further
explanation. Recommendations 6,
7: Educational institutions --
this should include the Community
Colleges, Technical High
Schools, Vocational Schools, Trade Schools,
and Nursing
Schools, Medical Schools -- any institution giving
instruction
on any process in which Oxygen is involved. Recommendation
8:
It was obvious at the Inquest that the workers did not consider
the
huge forepeaks ballast tank (25,000 cu. feet, about three
times the
size of an average house) a confined space. Still,
there was but one
way in or out of this huge space - the small
manhole. Recommendation
9: The Port Arthur Shipbuilding
Company, as I understand it, was
formerly under the aegis of
the Canada Shipping Act, then the Coast
Guard, now the Ontario
Ministry of Labour. (Industrial Safety Act - By
some sort of
agreement, or letter of agreement, the Canada Shipping Act
is
much more specific in its rules and regulations than is
the
Industrial Safety Act of Ontario. Recommendation 10: It
would take a
knowledgeable shipbuilding engineer to comment on
this one. I spoke to
the Captain of the MV John B. Aird
(Shipyards II Inquest pending),
about this, and he mentioned
caution - too large a manhole contributes
to weakness of the
ship under conditions of stress, i.e. high seas.
Recommendation
11: Obvious. Recommendation 12 Being done.
Recommendation 13
Being done. Recommendation 14 Being done.
Recommendation 15
being done. Recommendation 16 See enclosed
report.
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