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REPORT
CHARACTERISTICS:
DONOR: B.C. Coroner's
Service
JURISDICTION: British Columbia
REPORT TITLE:
Judgement of Inquiry
INDIVIDUAL PRESIDING: John H. Mooney,
Coroner
PLACE OF INQUIRY: Campbell River
DATE OF INQUIRY :
1987-01-11
INFORMATION ABOUT DECEASED:
OCCUPATION:
Unavailable
INDUSTRIAL SECTOR: Pulp Mill Manufacturing
NAME:
Confidential
ACCIDENT INFORMATION:
DATE OF ACCIDENT
: 1987-08-08
PLACE OF ACCIDENT: Gold River Pulp Mill, Gold
River
BRIEF CAUSE OF DEATH: Shock and sepsis; severe thermal
burns; industrial
sulphur accident.
BRIEF MANNER OF DEATH:
Industrial accident.
ACCIDENT DESCRIPTION:
On August 8, 1987
at approximately 2300 hours a recovery boiler tube
leak at the
Gold River pulp mill, Gold River, BC forced a mill
shutdown.
The deceased was in the process of shutting a valve
beneath a molten
sulphur storage tank, when the bottom cone
section of the tank fell out,
covering him in molten sulphur
and sweeping him off the catwalk platform
to the ground
approximately 12 feet below. The deceased was transported
by
ambulance to Campbell River and air lifted to Vancouver
General
Hospital where he died as a result of his injuries on
the 20th of August
1987.
On the afternoon of August 8, a
steam and recovery operator and a
recaust operator noticed they
had a high white liquor level in the
receiver tank. The
telephoned the chemical plant and spoke about this
with the
deceased. They advised the deceased of the situation and
the
deceased explained that the system would have to be shut
down.
The deceased left the chemical plant control room
immediately and
proceeded to the sulphur storage tank, to shut
down the sulphur
injection system. In doing this the deceased
climbed a 12 to 15 foot
ladder to a catwalk to reach the
conical bottom of the sulphur tank
located directly above the
caustic tank. While the deceased was in the
process of closing
the isolation valve, which stops the flow of sulphur
to the
sulphur standpipe, the bottom cone section of the sulphur
tank
fell away. The entire contents of the tank (110 tons of
151 degrees C
molten sulphur) blew out a 14 1/2 inch hole
created by the tank failure
sweeping the deceased from the base
of the tank off the catwalk and
approximately 12 to 15 feet to
the ground below covering him with molten
sulphur.
The
deceased managed to make his way to the roadway where a
security
guard spotted him and assisted him to the first aid
room. He was
immediately treated and an attempt was made in the
first aid room to
wash off the sulphur which had begun to cake
on his body. The deceased
was then rushed to the Gold River
Health Clinic by Company ambulance.
The accident occurred
as a result of a premature failure of the sulphur
storage tank
caused by rapid corrosion in the cone section of the tank.
This
tank had been in service just over 3 1/2 years prior to
its
failure. The proceeding tank, identical in design and
construction had
lasted 16 years and was removed from service
with the cone section still
intact. It appears that the failure
of the new sulphur storage tank
resulted from very rapid
corrosion of the tank in the cone section
caused by an
accumulation of iron sulphides in the tank bottom.
Testing
following the accident showed the metal at the point of
fracture to be
paper thin. It is believed that the deceased's
pressure on the valve
was sufficient to cause the break to
occur at that time.
Since this accident Workers'
Compensation Board has sent a hazard alert
describing the
incident to all pulp mills in BC and to WCB Officers in
areas
where tanks may be situated. This in fact resulted in the
removal
of a tank from a Prince George pulp mill which had been
suffering the
same fault. The owners of the Gold River pulp
mill, CIP Forest Products
Incorporated, over the years have
carried out a continuous preventative
maintenance testing of
this type of machinery by Industrial
Nondestructive Testing
Ltd. These people were again asked to
investigate the molten
sulphur storage tank failure. Various tests were
conducted and
the results implemented by CIP Incorporated to ensure this
type
of accident does not happen again.
As a result of my
investigation I find this death to be accidental.
As a
result of the quick response and notification by
Workers'
Compensation Board of other potential users, the
ongoing and complete
testing by CIP Incorporated of this tank
and others in the mill, I feel
that everything possible has
been done to prevent a re-occurrence of
this type of
accident.
As a result I can make no
recommendations.
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©2004 Canadian Centre for Occupational
Health & Safety 