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- REPORT
CHARACTERISTICS:
DONOR: Alberta Community and Occupational
Health
Occupational Health and Safety Division
JURISDICTION:
ALBERTA
REPORT TITLE: Fatality Investigation Data
Base
INFORMATION ABOUT DECEASED:
NAME: Confidential
SEX: Male AGE: 30
OCCUPATION: roasting, cooking and drying
chemicals and related materials
INDUSTRY:
natural gas
processing plants
Industrial sector: mines, quarries and
oil
ACCIDENT INFORMATION:
DATE OF ACCIDENT:
Confidential
PLACE: RAINBOW LAKE AREA: Grande Prairie
region
NATURE OF INJURY:
poisoning (systemic from toxic
substance)
TYPE OF ACCIDENT:
contact with gases/fumes by
inhalation (lack of oxygen)
SOURCE OF INJURY:
hydrogen
sulphide exposure
ACCIDENT DESCRIPTION:
The deceased
worker began to adjust an injection pump but did not isolate
the
pump (remove the back pressure) according to procedure. He
removed a plug
which allowed natural gas (four to five per cent
H2S), at a pressure of 130psi
(897 KPa), to blow into his face
causing him to lose consciousness. At
approximately 02:50, the
No. 1 operator noticed that the gas alarm light showed
for the
"B" satellite. He radioed to the deceased worker but could not get
a
response. The No.1 operator then radioed to a second worker
(No. 2) and a
third operator (No. 3) and asked them to go to
the "B" satellite to look for
the deceased worker. A few
minutes later, No. 2 operator radioed back to say
he had found
the deceased worker "down" and proceeded to run approximately
100
feet (30m) through the building without respiratory
protection. As he
attempted to lift the deceased worker, the
No. 2 operator was overcome and
collapsed. The No. 3 operator,
who had by this time "masked up", found the two
workers. He
removed the No. 2 operator who was still breathing
and
administered artificial respiration. The No. 2 operator
responded to the
treatment. The No.3 operator re-entered the
building and removed the deceased
worker. Artificial
respiration was administered but the deceased worker did
not
respond to any treatment and was pronounced
dead.
INVESTIGATION:
DATE: 1983-05-31
UNSAFE
ACT(S):
operating without authority, failure to secure or
warn
UNSAFE CONDITION(S):
no unsafe condition
identified
INDIRECT CAUSE(S):
worker's lack of experience or
knowledge
unsafe job procedure
EMPLOYER
ACTION(S):
eliminate unsafe conditions
OHSO
ACTION(S):
issue a requisition or order
approval of new
procedures, equipment, etc
OTHER'S
ACTION(S):
safe-t-gram/bulletin issued by OHSD, magazine
publicity
REGULATION(S): 27076017
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