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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: Dr. John Strathearn,
Coroner
PLACE OF INQUIRY: Oakville
DATE OF INQUIRY :
1987-09-10
INFORMATION ABOUT DECEASED:
NAME: Martin
Baikie
OCCUPATION: Maintenance
INDUSTRIAL SECTOR: Petroleum,
Chemical
ACCIDENT INFORMATION:
DATE OF ACCIDENT :
1987-04-03
PLACE OF ACCIDENT: Petro Canada Refinery -
Oakville
BRIEF CAUSE OF DEATH: Extensive third degree
burns.
BRIEF MANNER OF DEATH: While completing removal of 14
inch pipe-hydro
carbon material was released from an 8 inch
connecting pipe. A flash
fire ensued, source of ignition
unknown. Mr. Baikie died as a result of
this fire.
ACCIDENT
DESCRIPTION:
The No. 1 Catalytic Cracker Unit at Petro Canada
Refinery, Oakville, was
undergoing a routine general
maintenance procedure referred to as a
"turnaround". The
turnaround involves preparation by Petro Canada
employees
followed by the issuance of work permits for specific
jobs
which are then performed by Catalytic Maintenance Inc. who
are under
contract to Petro Canada.
RECOMMENDATIONS
ISSUING FROM INQUIRY:
1. All pipes that are not used in the
normal course of operations should be
blanked at both
ends.
2. (1) When a cold work permit is issued in a
turnaround with instructions
to "blank per list", no other work
is authorized other than the work
described in the approved
blank list. Deviations from published blank
lists must be
approved by either the area process supervisor or
operations
engineer.
(2) The term "General Maintenance" and other
vague instructions should
not be permitted. Permits must be
more specific and restricted to a
specific area.
(3) In
order to control the two hour validity limit - permit should
be
surrendered and signed.
(4) No permit should be
issued by operations or received by performing
authority unless
absolutely complete.
(5) When promoting an employee to the
rank of "signing authority",
management must assure themselves
that the person invovled has adequate
experience, job knowledge
and can comprehend all written instructions.
(6) All rules
regarding permits as outlined in the standing
instructions
should be followed - See exhibit 24.
3. All employees
working at Petro Canada's Trafalgar refinery must have
access
to and be familiar with the standing instructions.
4. A
blank list should have a schematic diagram, showing the position
of
every blank covered in the list. This list and schematic
should be
updated at the end of every turnaround.
5. (1)
Petro Canada's Safety Checklist shall be given to all
contractors'
and sub-contractors' personnel to ensure their
full understanding of the
refinery's safety regulations and
permit systems.
(2) Catalytic maintenance should have
representation at all Petro
Canada safety meetings.
6.
All interconnecting lines between operating and turnaround units
must be
depressured, blanked and gas freed. This activity must
be completed
prior to release to maintenance.
7. Where
work overlaps two shifts, the operating authority should
review
the work done and discuss the status with the incoming
shift.
8. Post shutdown meeting between all co-ordinators
and supervisors to
evaluate shutdown and recommend improvements
in work and safety
procedures.
COMMENTS ON
RECOMMENDATIONS BY CORONER:
Evidence indicated that
everyone at Petro Canada felt that the 8 inch
connecting pipe
had been cleansed of any petroleum product, and in fact
had not
been used for over a year. The accident would not have
occurred
had this 8 inch pipe been capped or sealed at both
ends. This led to
Recommendation No. 1.
The permits
issued for the specific job involved in this inquest, proved
to
be improper in several ways:
a) the pipes which were to be
blanked in this operation are contained in a
"blank list". The
8 inch pipe was not included in this list. This led
to
Recommendation No. 2(1).
b) a permit was issued indicating
"General Maintenance", and was thought to
be too vague. This
led to Recommendation No. 2(2).
c) The removal of the pipe
involved was delayed from the evening shift to
the night shift
because a crane was not available, and a new permit
should have
been issued to the nightshift. This led to Recommendation
No.
2(3).
d) One of the permits presented in evidence was
incomplete in that it had
not had appropriate checkmarks
inserted indicating that the involved
pipes were clear of
petroleum products. This led to Recommendation
No.
2(4).
e) Evidence from one of the witnesses,
indicated that the permit had not
been completely read or
apparently understood by him, leading to
Recommendation No.
2(5).
f) Rules indicated in Petro Canada's Standing
Instructions had not been
followed, which led to Recommendation
No. 2(6).
Evidence from some witnesses indicated they were
not familiar with the
standing instructions, leading to
Recommendation No. 3.
The crucial disconnection of the 8
inch pipe was made below a valve
because this connection was
more accessible. Had the connection been
made above or beyond
the valve, the petroleum product might not have
escaped. It was
felt that a schematic diagram in addition to the
printed "blank
list" would be desirable, leading to Recommendation No.
4.
Petro Canada's safety checklist was apparently not
followed or known to
some of the contractors' employees,
leading to Recommendation No. 5(1).
Catalytic maintenance
people were not apparently represented at all
meetings, or
completely familiar with many safety procedures at Petro
Canada
or in attendance at these meetings on a regular basis leading
to
Recommendation No. 5(2).
Recommendation No. 6 refers
to the same 8 inch interconnecting pipe
which was not in use
and is similar to Recommendation No. 1.
As in
Recommendation No. 2(3), this particular job extended into
two
shifts and, in addition to a new permit, adequate verbal
communication
should also have occurred, leading to
Recommendation No. 7. Evidence
suggested that this accident
might have been prevented by a meeting to
discuss what had
taken place in the turnaround, leading to
Recommendation No.
8.
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Health & Safety 