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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: F Demanuele MD,
Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY :
1986-09-03
INFORMATION ABOUT DECEASED:
NAME: Babu
Vadgama
OCCUPATION: Unavailable
INDUSTRIAL SECTOR:
Manufacturing
ACCIDENT INFORMATION:
DATE OF ACCIDENT
: 1986-05-30
PLACE OF ACCIDENT: 22 Carnforth Drive,
Toronto
BRIEF CAUSE OF DEATH: Complications arising from
extensive burns.
BRIEF MANNER OF DEATH: Death as a result of
submersion by accident into a
tank of caustic soda which
occurred at his place of employment, Vacuum
Metallizing
Limited.
ACCIDENT DESCRIPTION:
Babu Vadgama was employed as
a helper in a stripping room of Vacuum
Metallizing Limited.
While he was standing on a platform placing metal
racks in a
1200 gallon capacity vat containing caustic soda
solution
heated to 200 degree F and while he was left alone as
his workmate left
the room temporarily, he accidentally fell
into the vat of caustic soda
from which he immediately
extricated himself.
As a consequence he suffered chemical
burns to 90% of his body
(excluding his head).
In 1974
Mr Vadgama had a malignant tumour of the cerebellum resected
and
treated by radiation and was left with residual weakness on
the left
side of the body, some degree of incoordination,
difficulty with balance
and intention
tremor.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1.
A fundamental change in the actual stripping procedures when using
tanks
of the size used in this case. At present, primitive
means are used to
manually raise and lower racks and to
disentangle lid chains. These
should be changed to a safer
system that keeps workers away from the
caustic tank. A cage
raised and lowered by a hoist on a rail seems to
us a feasible,
low-cost alternative. Refilling and emptying this
proposed cage
can be accomplished off-site, and through its side. The
hinged,
hoistable doors presently installed should be removed and
their
function assumed by a lid on top of the suggested
cage.
2. The required use of face masks and coverall safety
suits in view of the
present danger from splashing.
3.
The testing under simulated emergency conditions of the
cleansing
equipment for accidents in order to acquaint workers
with its location
and operation.
4. An increased
attention on the part of the plant safety committee to
the
establishment of emergency procedures and to the worker's
ability to
follow these procedures.
5. A manadatory
medical examination for prospective workers in situations
as
hazardous as the one in this case, as a means of protection both
for
themselves and their fellow workers.
6. That in the
interests of long term safety, the resources of the Ministry
of
Labour be expanded in order to allow for more thorough and
frequent
inspections. We are also concerned with providing
inspections of a
higher calibre. We were struck by the fact
that the testimony of the
Ministry of Labour official in no way
suggested improvements in the
stripping procedure that would
eliminate the problems that we
have
observed.
COMMENTS ON RECOMMENDATIONS BY
CORONER:
1. Various forms of racks, called spiders,
having complicated awkward
shapes which makes them easily
tangle with each other, have to be placed
and removed manually
by the workers standing beside the edge of the tank
which
reaches below waist level. Problems were described with
the
chains lowering and raising the lids to the tank. One of
the most
frequent hazards is splashing of the corrosive
solution. Workers
leaning over the surface of the tank are
exposed to the toxic fumes
given out of the heated
solution.
5. Mr Vadgama had a history of a serious past
illness which left him with
some degree of disability. The jury
felt that this may have been a
major contributing factor to
this accident. If Mr Vadgama had a
pre-employment physical
examination regarding his suitability for this
dangerous job he
may have been advised to seek another employment.
Experts from
the Ministry of Labour were not clear as to what part of
the
Act would make a pre-employment examination mandatory.
6.
Three contraventions of the Health and Safety Act regulations
were
discovered in the operation of the stripping room after
the accident:
1) the height of the edge of the tank above the
surface of the platform
was 4 1/2 inches shorter than the
height required by the regulation: 2)
there was no eye-wash
basin and deluge shower as required by the act:
and 3) the
surface of the platform needed repair. The jury realized
that
there were deficiencies in the inspection procedures of this
plant
and also recommended that the safety committee should
become more active
in drilling exercises and in education of
safety measures to the workers.
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©2004 Canadian Centre for Occupational
Health & Safety 