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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: A. E. Jones M. D. ,
Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY :
1985-11-28
INFORMATION ABOUT DECEASED:
NAME: Antonio
Giordano
OCCUPATION: Gas construction
INDUSTRIAL SECTOR: Gas
utilities
ACCIDENT INFORMATION:
DATE OF ACCIDENT :
1985-10-02
PLACE OF ACCIDENT: Etobicoke
BRIEF CAUSE OF
DEATH: Asphyxiation due to lack of oxygen.
BRIEF MANNER OF
DEATH: Result of being trapped in an underground concrete
vault
in which air was displaced by natural gas leaking from a
pipe
during a valve change. The occurrence took place on
October 2, 1985, at
a Consumers Gas regulator station located
at the intersection of Kipling
Ave. and North Queen
Street.
ACCIDENT DESCRIPTION:
The deceased descended into an
underground vault containing Consumer's
Gas regulators and
valves. He was going to change a 3/4 inch gate valve
which was
connected to a pressure monitoring device. On his own,
he
decided that he would unscrew the old valve and screw in the
new one
without turning the gas off. In the process, the
escaping gas displaced
the air and he asphyxiated and
collapsed.
Subsequently the rescue operation was delayed
because the gas could not
be turned off due to problems with
one of the shut off valves. The
opening into the vault was
small and descending down into the pit with
oxygen and rescue
equipment was very difficult, as well as pulling out
the
deceased and his associate who is still in hospital in
a
semi-comatosed state.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
SAFETY AND AWARENESS EDUCATION:
1) A
certified safety awareness and educational program,
mandatory
attendance required.
2) The regulations of the
Occupational Health and Safety Act and the
Consumers Gas Safety
Awareness Manual should be made standard minimal
knowledge and
should be tested periodically.
3) Legislation should be
introduced to ensure cyclic and repetitive
awareness programs
should be made mandatory and should be included in
the Ontario
Energy Act.
4) Consumers Gas should provide a news bulletin
to all employees outlining
the details of this incident along
with the specifics of the dangers of
natural gas when an
individual is in a confined space.
PROCEDURES:
1)
Work of this nature must be pre-planned and a plan of operations
for
each individual job.
2) If not already present,
Legislation should be introduced so that
Consumers Gas is
informed before any construction is to be performed
within the
vicinity of any Consumers Gas regulator stations and
or
vaults.
3) An inspection should be performed after
such work.
4) A Procedure Manual should be provided for
every employee.
DOCUMENTATION:
An operations manual
should be available describing each individual
regulator
station about the type of station it is in respect to
the
number of feeds and cut off valves, etc.
PHYSICAL
ASPECTS:
1) TAGS should be installed on cutoff valves
determining the maximum number
of turns required to fully close
or open the valve.
2) Irregardless if procedures were
followed fully, we recommend that air
respirators and lifelines
be made available at every work site
for
emergencies.
COMMENTS ON RECOMMENDATIONS BY
CORONER:
SAFETY AWARENESS AND EDUCATION:
During the
inquest evidence suggested that there were enough rules
and
regulations in existence both in the Consumer's Gas "Safety
Awareness
Manual" and the Occupational Health and Safety Act.
Work personnel were
not familiar with these rules. Thus
education of an ongoing nature was
suggested. News bulletin to
impress upon work crew the dangers of
natural
gas.
PROCEDURES:
1. If the job had been approached
with a specific plan, the gas might have
been turned
off.
2. Sidewalk construction pinched a copper pipe
monitoring pressure at the
regulator station.
3.
Inspection of gas lines in area after road or sidewalk or
other
construction over gas lines.
4. "Safety Awareness"
and job procedural manuals should be
provided.
DOCUMENTATION:
A manual at the regulator
station to describe the station, shut off
valves, gas lines in
and out and direction of gas flow.
PHYSICAL
ASPECTS:
1. Tag shut off valves because in this instance
the person shutting the gas
off was not aware of how many turns
of the valve it would take.
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