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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 : 1987-01-28
INFORMATION ABOUT
DECEASED:
NAME: Dennis Huntley
OCCUPATION:
Labourer
INDUSTRIAL SECTOR: Transportation
ACCIDENT
INFORMATION:
DATE OF ACCIDENT : 1986-09-18
PLACE OF
ACCIDENT: Provost Cartage Inc., Shawson Drive,
Mississauga
BRIEF CAUSE OF DEATH: Extensive burns, 2nd and 3rd
degree over
approximately 50% of body.
BRIEF MANNER OF
DEATH: As a result of flash fire during a procedure of
cleaning
a tanker with acetone.
ACCIDENT DESCRIPTION:
This 50 year
old labourer had worked for Provost Cartage Company,
since
April 21, 1986. He had been trained by a co-worker in the art
of
cleaning tankers. There were no written directives with
respect to the
washes used for the various tankers, but he had
been taught using the
"hands-on" approach and had been
considered to be capable of doing all
washes, including solvent
washes.
The night that the fire occurred, a tanker that had
been used for
the transport of varnish had been brought in.
Together with a
co-worker, the wash had been almost completed
with acetone, when the
now-deceased found that he had been
splattered with acetone from one of
the hoses, or from the
acetone spilling onto the pump assembly being
used. It was
believed that he disconnected a hose, in order to remove
out of
it, an air-lock. Somehow, there was a flash identified as
coming
from the pump assembly, which then ignited the acetone
vapour in a flash
fire, which resulted in the now deceased
being engulfed in flames,
sustaining more than 65% body burns.
His co-workers acted swiftly and
efficiently in putting out the
fire, extinguishing the flames on his
body, and rendering first
aid.
Investigation revealed that Provost Cartage Company
had not been
given a permit to use acetone in its cleaning
procedures, by the
Mississauga Fire Department. It had been
refused. There was, however,
no follow-up by the Fire
Department. Also, it was found that the
inspector from Labour
Canada reacted mainly to infractions, or
complaints, and had
been unaware of the use of acetone at this terminal,
thinking
that all washes were done with steam and water, or
caustic.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
1. That Labour Canada establish a schedule to
conduct regular and thorough
"Safety Audits" of all firms under
their jurisdiction (priority given to
those dealing with
dangerous substances), and that additional qualified
Labour
Affairs Officers be employed to meet this requirement and
ensure
prompt attention and effective follow-up on all
matters.
2. That Labour Canada assign Labour Affairs
Officers to specialize in
either Part III or Part IV of the
Canada Labour Code so that greater
expertise can be acquired
and closer attention given to Occupational
Health and Safety
matters by personnel responsible for Part IV.
3. Labour
Canada or other government authorities require that
companies
using dangerous substances must advise local Labour
Canada and Fire
Department officials, in writing, of the type
and use of the dangerous
substances, and that approval for such
use be obtained before use is
commenced. Further, that all
equipment used with dangerous substances,
and the work area, be
approved in advance of the use of the dangerous
substances, by
Labour Canada and the appropriate local authorities.
4.
That the City of Mississauga assign additional manpower to
fire
prevention and inspection activities so that regular and
thorough
inspections of established premises are not neglected,
due to the
commitment of existing resources to new development
and high risk
buildings only.
5. That the Government of
Ontario be urged to secure speedy passage of the
proposed Part
4 of the Ontario Fire Code in order to further reduce
the
possibility of similar accidents occuring in the
future.
6. Respecting the Health and Safety Committee at
the Mississauga terminal
of Provost Cartage Inc.:
a)
that the Committee meet at least monthly at a fixed day and
time
with adequate notice provided to all Committee
members;
b) that employee representatives attend meetings
on company time;
c) that an alternate representative attend
meetings on company time;
d) that consultation on a monthly
basis and as may be required by held
with specific persons in
maintenance and washbay areas in order to be
advised of their
concerns and suggestions;
e) That minutes of the meetings
be sent directly to the local Labour
Affairs Officer as well as
the Labour Affairs Officer in Montreal.
7. The Regional
Safety Co-ordinator for Provost Cartage Inc. (Ontario
Region)
be provided with an updated job description providing
for
overall responsibilities for Health and Safety matters
affecting Provost
employees.
This will include
authority:
a) to require that work be stopped where there
is immediate dangers to
health and safety;
b) to
institute and conduct fire drills at least quarterly
in
consultation with the Mississauga Fire Department;
c)
to ensure that safety training sessions are held as
required;
d) to compile a manual for all work areas,
containing written work
procedures and safety-related material
to be updated as required and
made available to employees and
which, for washbay personnel would
include specification sheets
for cleaning materials and their
interaction with all
transported goods;
e) to advise Labour Canada, the
Mississauga Fire Department and other
appropriate authorities
of the type and use of dangerous substances at
the Mississauga
Terminal and other Company facilities under his
jurisdiction
and to secure written approval for the manner in which
such
substances are to be used;
f) to be the person
designated at the Mississauga Terminal and other
Company
facilities under his jurisdiction to be fully knowledgeable
of
all statutory and official requirements pertaining to Health
and Safety
matters and to communicate these requirements to
both management and
employees to ensure effective
compliance.
8. Respecting the washbay area at the
Mississauga Terminal:
a) that an audit of operating
procedures be undertaken as soon as
possible by officials of
the Company, Labour Canada, Mississauga Fire
Department and
other appropriate authorities with a view to ensuring
that
practices, procedures, equipment and materials, safety
and
protective equipment comply with all applicable statutory
requirements;
b) that written cleaning (tank washing)
procedures be prepared and
given to washbay
personnel;
c) that a training program be instituted whereby
washbay personnel,
including new employees upon hiring be
trained in washbay procedures,
proper handling of cleaning
materials and equipment, safety equipment
and protective
clothing required, nature and properties of cleaning
materials
to be handled and emergency procedures.
d) that there be
direct supervision of washbay personnel and operations
on each
shift to ensure compliance with stipulated procedures and
safety
requirements.
9. Without limiting the generality
of the Safety Audit as mentioned in 8a)
above, the Company in
cooperation with Labour Canada, the Mississauga
Fire Department
and other appropriate authorities should address the
concerns
raised during the inquest including:
a) installation of
lower-level ventilation;
b) use of non-ferrous tools and
non-ferrous hose couplings;
c) feasability of permanently
eliminating washing procedures utilizing
acetone or other
flammable liquids;
d) installation of a "closed" pumping
system which does not expose the
operator to solvents in
use;
e) all electrical equipment utilized in the washing
process or located
in the washbay area be approved by CSA or
Ontario Hydro;
f) all equipment used by washbay personnel
be serviced regularly by
qualified personnel;
g) all
tankers and metal equipment and fixtures in the washbay area
be
properly grounded and bonded in accordance with
recommendations set out
in the NFPA recommended practices on
static electricity or other
appropriate standards;
h)
necessity of installing a non-conductive floor surface;
i)
conducting of solvent washes outside the building on a
permanent
basis.
10. In view of the appropriate response
by fellow workers to Mr Huntley's
injuries, the Company be
encouraged to expand its program of providing
first aid
training to employees.
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©2004 Canadian Centre for Occupational
Health & Safety 