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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: M. Milton M.D.,
Coroner
PLACE OF INQUIRY: 15 Grosvenor Street, Toronto
DATE
OF INQUIRY : 1986-02-12
INFORMATION ABOUT
DECEASED:
NAME: Gerome Juman
OCCUPATION: Packaging
batcher
INDUSTRIAL SECTOR: Manufacturing,
Packaging
ACCIDENT INFORMATION:
DATE OF ACCIDENT :
1985-11-21
PLACE OF ACCIDENT: Unavailable
BRIEF CAUSE OF
DEATH: Trichloroethane poisoning.
BRIEF MANNER OF DEATH:
Preventable accidental inhalation of trichloroethane
when
cleaning a vat at 3L Custom Packagers/Langstaff Laboratories
at
approximately 4:30 p.m. on November 21, 1985.
ACCIDENT
DESCRIPTION:
This 24 year old man had been working for
Langstaff Laboratories Limited
for about ten months, first as a
general labourer, and then as a
"Batcher", meaning that he
could work in preparation of materials for
packaging, such as
Freon-11, etc. On November 21st around 1500 or 1600
hours, he
was requested to clean out the smaller of two vats, one
five
feet diameter, five feet deep, using
1,1,1-Trichloroethane.
He was last seen by three employees,
separately, at different times, at
the vat cleaning it out,
standing on a ladder and wearing a "3-M"
dust/fume/mist
respirator 9920, rubber gloves, work boots. All the
employees
left work between 1630 and 1800 hours, and he was not
seen
leaving, and there was no "buddy system" in place. He did
not return
home from work that night, and his wife telephoned a
relative who also
worked at Langstaff and requested him to look
for him. He was found
lying on his back at the bottom of the
vat, no ladder inside.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
1. Instructions for the use of all safety
equipment should be clearly
posted.
2. There should be
some type of covering, possibly gridwork, that would
cover the
top of a vat. The spacing of the gridwork should be open
enough
to prevent the entry of a person, but would not obstruct
the
normal operations of the vat.
3. Written
instructions for vat entry should be on or near the vat.
They
should always be legible.
4. All personnel should
be trained on safety equipment and artificial
resuscitation, on
joining the company.
5. The safety procedures should be
reviewed by all employees at least every
ninety days.
6.
The "buddy system" should be used when a hazardous task is
assigned to
an employee.
7. The Occupational Health and
Safety Branch of the Minsitry of Labour
should perform annual
inspections of all industries employing
hazardous
chemicals.
8. The definitions of "fumes" and
"vapours" should be made more
understandable to the layman.
These definitions should be included in
all instructions and
regulatory literature.
9. Management should take every
precaution that proper apparatus is used
when performing a
hazardous duty.
10. There should be platforms encircling
elevated vats.
11. There should be a removable ladder,
hooked over the rim, to be used
inside the vat when a cleaning
or repairing task is to be performed.
12. There should be
further investigation of 3L custom packagers by
the
Occupational Health and Safety Branch of the Ministry of
Labour.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1.
Evidence had indicated that such instructions had not been posted,
and
the jury wished to stress that each employee was to be made
more aware
of proper operation of the equipment, in case of
accidents (being,
chemical spills, etc.).
2. This
recommendation was made because the enquiry did not reveal
how
Gerome ended up in the bottom of the vat. They wished
this
recommendation to be followed, to prevent someone from
accidentally
entering the vat (such as a fall when working
inside). Also, the jury
felt that if the covering should be
off, if would be obvious that
someone was in the vat.
5.
To be sure that procedures for safety are not forgotten.
6.
To ensure that supervisory personnel take the responsibility of
safe
completion of hazardous tasks.
8. The employees
were very hazy on the definitions of mist, vapour,
fumes,
gases, etc.
9. The jury believed that Juman ought
to have been using a proper air-flow
respiratory.
10.
The jury recommended this so that there would be more stability
than a
ladder would provide.
11. We do not know how
Gerome ended up in the vat, but evidence showed that
even if he
had climbed in, in order to mop up some solvent, the
fumes
would have laid him out very swiftly, but he might have
had time to
climb out had there been a ladder
inside.
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