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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: R. Isaac, M. D.,
Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY :
1984-07-27
INFORMATION ABOUT DECEASED:
NAME: Vernon
Douglas White
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Oil
Refinery
ACCIDENT INFORMATION:
DATE OF ACCIDENT :
1984-05-11
PLACE OF ACCIDENT: Canadian Oil Co., 309 Cherry St.,
Toronto
BRIEF CAUSE OF DEATH: Asphyxia due to aspiration of
blood; severe
cranio-cerebral and multiple injuries.
BRIEF
MANNER OF DEATH: Due to Petro-Chemical explosion.
ACCIDENT
DESCRIPTION:
We the Jury find that the deceased came to his
death as the result of an
accidental explosion originating in
compartment four of a fuel tanker
during filling procedure. The
cause of the explosion was a static spark
generated by the
pumping of oil, HV-250 from the storage tank to the
trailer.
HV1-250 is a highly viscous, clean oil product, which
carries
an electric charge very easily. In the absence of an
explosive vapour;
however, the loading of HV1-250 will not
cause an explosion. Standard
grounding procedures reduce, but
do not eliminate the possibility of a
static spark.
In
this case, the spark ignited gasoline vapours in the
compartment,
that either remained or re-entered after flushing.
The gasoline vapours
remained in the tanker as a result of a
previous load of gasoline. The
flushing procedures would
remove any remaining liquid, but not gasoline
vapours. It would
also not remove any liquid or vapours in the voids
between the
compartments of the multi-compartment trailer. The
existence of
the vapour was not detected by the company's
explosimeter
either because it was:
1. not
used,
2. it was used improperly, or
3. it was not
functioning properly.
The tanker involved was owned in
Quebec, leased to an Ontario (sub)
leasing company and loaned
to Canadian Oil Ltd. which re-refines machine
oil to make HVI
250 (a pine oil with very high flash point which is
viscous -
it is the base of motor oils etc.) inter al. The tanker
had
five compartments separated by double bulk heads with a
void (air space)
between. These air spaces are supposed to be
freely draining but three
had been capped, probably because of
leaking. There is evidence of past
structural damage to the
tanker which may have caused leaking. A small
amount of
gasoline or vapour may have been in these voids, due to
the
leaks and sealed there due to capping of the
vents.
The tanker had previously carried gasoline. Canadian
Oil would not have
accepted it had they had this information.
The octagonal tags required
to be fixed to spouts of The tanker
had probably been removed - since
the tanker was "empty"
(except for fumes) there was no breach
regulation. The tanker
was flushed with about 1 percent load to clean
it but such a
flush would only remove residue on the bottom of the tanks
and
not gasoline vapour. This vapour is heavy and may settle to
the
bottom of the tanks. Steam filling of tankers is the best
way to remove
vapour.
There is doubt whether an
explosimenter (volatile hydro carbon detector)
was used by the
deceased. It should have been. The detector unit in
question
was functioning poorly but should have registered some
danger.
Static electricity is generated in the filtering,
loading and piping of
any fluid, especially this type of
viscous, poor conductor. This charge
builds up in the tank as
it is filled and is only slowly discharged
through the metal
tank which is grounded. A spark from the static
charge ignited
gas vapours as they fully neared the top of the tank.
This
caused an explosion and fire, fatally injuring the
deceased.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
TO CANADIAN OIL COMPANY:
A number of
improvements to the operations at Canadian Oil Company arose
at
this inquest. These improvements, however, should be put in
context.
The Company had a reasonable safety record with the
Ministry of Labour.
Management had developed a safety manual
for employees. And actions
were being taken to remedy the
static electricity problem.
1. We recommend that tankers
used by the company to transport HVI Products
be dedicated
solely to that purpose and absolutely no switchloading of
that
product be allowed.
2. All tankers used by the company
should be checked for tags which
indicate the previous load.
Tankers that have been used to transport
Class I products
should be sent back to the supplier or customer.
3. The
explosimeter procedure for checking for volatile vapours should
be
conducted by two people (i.e. the buddy system) to ensure
proper use and
proper readings.
4. Employees should be
regularly tested in the use of the explosimeter and
any other
protective equipment they are expected to use.
5. The
company should inform all of its tanker suppliers (as well as
its
customers), in writing, of its policy on switchloading. It
should also
indicate to suppliers that tankers previously used
to transport Class 1
products.
6. The company's policy
on switchloading and the procedures to be used when
loading HVI
products should be incorporated into its safety manual.
All
future changes of this importance should be immediately
incorporated in
the safety manual and communicated to the
employees (as was done in this
case).
7. The
explosimeter itself should be centrally located and controlled
and
any use of the device be recorded in a log form.
8.
The company is encouraged to continue its efforts to reduce
static
electricity in HVI products through research into the
addition of
additives to their products.
9. Maintenance
of equipment is a joint responsibility of the employer
and
employee. To meet their responsibility we recommend the
company adopt a
schedule of preventative maintenance on all
equipment supplied to the
employees. Results of the maintenance
of each piece of equipment should
be recorded.
10.
Equipment such as the explosimeter should be checked at least
annually
by the manufacturer to ensure it is in good
operational order.
11. The "company record" filled out
during the loading operation should be
modified to include the
recording of:
1. Previous load in trailer.
2. The
results given by explosimeter test.
3. Examine drains to
insure they have not been capped and no leaks
exist.
4.
A warning showing not to fill in the case that any one or
multiple
of above three are not satisfactory.
INDUSTRY
RECOMMENDATIONS:
1. The industry should modify "circle
check" procedures on petroleum
tankers to include a check of
void drains on multicompartment tankers
for "caps".
2.
All tankers engaged in carrying petro-chemical products should
maintain
a log of previous loads carried by the
tanker.
3. Tankers that have carried a Class 1 product at
some time should be
permanently identified as such. (eg. a
sticker on the outside of the
tank).
4. All rental/lease
agreements for tankers should identify what the most
recent
load on that tanker was.
INFORMATION TO INDUSTRY:
1.
The IAPA and/or Transportation Safety Association should be
encouraged
to develop training courses for existing petroleum
products. These
courses should include such topics
as;
a) the construction of tankers
b)
switchloading
c) the purpose and effectiveness of
flushing
d) the problem of static electricity
e)
advantages/disadvantages of various types of loading (eg. top and
bottom
loading)
f) existing laws and regulations
applicable to handling and transportation
of petro-chemical
products
g) pronouncements and notices from authoritative
bodies (eg. Hazard Alerts
from the Ministry of
Labour).
2. Existing training programs by private companies
should be renewed and
certified by the IAPA and/or the
Transportation Safety Association.
3. New drivers of
petroleum tankers should take a certified safety course,
as
described in the above recommendations, prior to obtaining
their
licence to operate.
4. The Minister of Labour
issue a "Hazard Alert" immediately on the dangers
associated
with switchloading different classes of
petro-chemical
products.
5. We recommend that the
Minister of Labour take a pro-active role in
notifying the
Petro-Chemical Industry of the existance of the
static
electricity hazard and the following information to
reduce that hazard.
A) Controlling the road tanker charging
rate to both speeds recommended in
the American Petroleum
Institute Bulletin No. 2003, Section 2.4.3. i.e.
seven (7)
meters per second and the calculated bulk loading rate.
B)
Ensure that a relaxation period after the final filter is at least
40
seconds. (Highly refined products require more time than the
30 seconds
normally recommended).
6. We recommended that
a copy of these recommendations be forwarded to the
IAPA and
the Transportation Safety Association for their
consideration.
RECOMMENDED CHANGES TO
LEGISLATION:
1. We recommend closer liason between the
Ministries of Transportation,
Labour and Consumer and
Commercial Affairs, particularly with regard to
the
coordination of legislation and the exchange of information
related
to the handling and transportation of petroleum
products.
2. We further recommend that the Ministry of
Consumer and Commercial
Affairs identify the Federal Department
responsible for railway tankers
and work more closely with them
on legislation, the exchange of
information and
regulations.
3. We recommend that a copy of our
recommendations be forwarded to the
Federal Department
responsible for the development of a new Hazardous
Products Act
for their consideration.
4. We recommend that the following
changes be made to the Gasoline Handling
Act and Gasoline
Handling Code January 1983:
A) Section 5, Subsection
11
This subsection should be rewritten to refer to empty
tank trucks and
trailers. It should also be rewritten to apply
to tank truck trailers
and semi trailers and semi trailers
carrying liquids of the same class.
B) Section 5,
Subsection 6
The application for a licence to transport or
the renewal of same should
be applicable to specific tanker for
a specific time and for a specific
class of liquid.
In
addition, we recommend that the application for a licence and
the
renewal of same be subject to an inspection of the tank
trucks, trailer,
or semi-trailer for road stability and
safety.
C) Section 5, Subsection 32
This subsection
should be modified to include a specific visual
inspection of
the void drains in a multi compartment tanker to ensure
they
are functioning.
D) Section 5, Subsection 46
This
subsection should be modified to ensure that tags remain
attached
to the tanker until the class of liquid is
changed.
E) Section 10, Subsection 7
The Act should
include a definition of the word "vehicle" in particular
it
should be extended to include the supplier of the equipment.
The
word supplier should be defined as in section 19 of the
Occupational
Health and Safety Act and Regulations for
Industrial Establishments.
5. We recommend that a
certificate of fitness accompany the change of
ownership of a
tank truck, trailer or semi-trailer. We believe that
this
recommendation would require a change to the Highway Traffic
Act.
6. As an example of coordination between the
Ministries of Transportation
and Consumer and Commercial
Affairs we recommend that the inspectors at
Department of
Transport weigh stations include in their inspections a
review
of tank trucks, trailers, and semi-trailers for structural
damage
and open void drains and tanker registration.
7.
We recommend that sections 71 through 75 of the Occupational
Health and
Safety Act Regulations for Industrial Establishments
be amended to apply
not only to workers in a confined space but
also to workers with or
testing a confined
space.
COMMENTS ON RECOMMENDATIONS BY
CORONER:
Reason for each recommendation with brief
explanation:
TO CANADIAN OIL:
1. This prevents
switchloading, switching the loads with the possibility
of
residue gasoline vapour.
2. Tags identify the class
of product. Here the tags were probably not
present on May 11
and the tanker was empty except for the gasoline
vapour.
However, a tag would alert to potential hazard.
3. Two
people serve as a check on each other to assure that a routine
test
is completed.
4. The meter must be fully inserted
into a tank; gas vapour may settle to
the bottom and form a
layer.
5. The company wouldn't accept tankers which had
previously carried
gasoline (Class I). This would give supplies
written notice. This
tanker was inappropriate for the
use.
6. This is being done.
7. Record keeping helps
to assure that the test is in fact done.
8. Additives would
reduce static build-up, however; testing is being done
to see
if additives would interfere with the use of the oil.
9.
This is self evident but a good policy to stress. The explosimeter
was
not used too often, had corroded and had been repaired and
some of the
batteries had been removed. Thus it was not
functioning up to standards.
10. Routine
servicing.
11. This recommendation is directed to
increasing transfer of information
(prior load) insuring that
the explosimeter test is done, insuring that
inspection for
capped vents on voids is done (this can be awkward
because they
are located under vents in the tank) and warning of
danger.
TO INDUSTRY:
1. Circle checks are done by
drivers prior to leaving with a load. They
usually relate to
mechanical fitness but capping indicates that a leak
exists
between compartments. Load carrying with a capped vehicle
is
illegal ((Gas Handling Act Reg. 5((11)) and very
unsafe.
2. This is another check so that switch loading
does not occur and to warn
subsequent drivers of prior dangers
(especially gasoline fumes).
3. Another form of warning, at
a worker level and inspector level.
4. Yet another form of
warning - Administrative level.
TO INDUSTRY:
Drivers
take a written and practical exam to get a licence to
drive
these heavy tankers but there is no uniform educational
course. Many
drivers do not know the dangers of switch loading,
static electricity,
or capping vents on voids or that flushing
will not remove gasoline
fumes. One of our officers did a
survey; most drivers/loaders do not
inspect for caps. All
training is by the private companies and "on the
job". Small
companies may not afford such courses.
3. This might go to
Ministry of Transport too - as part of licensing.
4. This
is one way of getting information to the workers.
5. A) See
exhibit 28 for part of the bulletin.
This Ministry of
Labour (Occupational Health) has lines of communication
to
workers and industries. The Ministry of Consumer and
Commercial
Relations could also send out this information under
the Gasoline
Handling Act.
Relaxation period is the time
for liquid to flow through the pipes after
being filtered. A
longer period allows for better dissipation of
static
electricity charge built up during filtering. The charge
is "safe"
while in a pipe because there is no oxygen and no
spark or ignition
source. Once liquid leaves the pipe, oxygen
and a spark may be
available.
6. Self
explanatory.
7. See exhibit 36. These are two Canadian
(trucking) trade publications.
I would send this information to
all Canadian Trade Publications that
can be identified. (and
possibly to American ones as well).
LEGISLATION:
1.
Labour (Occupational Health), Ministry of Consumer and
Commercial
Relations (Gasoline Handling Act) and Transport
(HTA) must work together
because this industry crosses all
three.
2. Railways and railway loading (possibly other
areas) are in the Federal
sphere. Send copies please to the
railways and the railway regulating
agencies as well as
Dominion Government. Try Department of Energy,
Mines and
Resources.(?)
3. A new Federal Hazardous Products Act is
being developed which will cover
some areas of this
inquest.
4. A)5(11) Now refers only to trailers carrying
liquids-an empty trailer
may have gasoline vapours. It also
refers to trailers carrying only
different classes of
hydrocarbon liquids. Little danger would exist if
vents were
capped where only the same class of hydrocarbon is carried,
but
in the future different classes may again be carried. A cap is
put
on to prevent leaking and leaking indicates structural
unsoundness.
B) Licences are now issued to an individual or
company to use a
designated tanker. As a further check, add a
designation of the class
of liquid which can be carried. This
will prevent switching of the load
(switch loading). The
licences are time limited. Relicensing is done
by proper
application and fee payment only. Relicensing should involve
a
check on mechanical fitness, including whether the vents on the
voids
have been capped. The life of a tanker is said to be
10-15 years.
C) An inspection (part of the vehicle check)
is implied in Reg. 5(32)
when it refers to operations. The jury
wants this one item very
specifically referred to. The section
now talks about leaks. Capping
indicates a leak has
occurred.
D) Taps should stay on until the class of liquid
is changed. The
regulation now says tags must be on only while
the liquid is contained
in the trailer. But even after liquid
is drained, fumes can remain.
This is an added
warning.
E) More specificity. Issue: Does reg. 10(7) apply
to this trailer?
Is a trailer a "vehicle" or is the cab only a
"vehicle"?
F) Here there was an owner, a leasor, an
operator, and an employee.
They should all be included. The
concept of supplier and user is
broader and catches
all.
5. Self evident. Compare with transferring of
ownership of a car which
requires such a certificate.
6.
This could easily be delegated by the Ministry of Consumer
and
Commercial Relations to the inspectors of the Ministry of
Transportation
who have a chance to spot check vehicles.
Currently Transport does not
look for capping of vents on
voids. Alternatively (but less
efficiently) the highway
inspection stations could be used by Gasoline
Handling Act
inspectors.
7. This accident did not involve a worker in a
confined space but the
vapour was in a confined space when it
exploded and the worker was just
above the
space.
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