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| Record Number: |
2112 |
| CIS Descriptors: |
SUPERVISORS
CHEMICAL
INDUSTRY
FALLS FROM
HEIGHTS
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: Dr. Mitchell-Gill,
Coroner
PLACE OF INQUIRY: Whitby
DATE OF INQUIRY :
1988-10-26
INFORMATION ABOUT DECEASED:
NAME: Allan
Andrews
OCCUPATION: Foreman
INDUSTRIAL SECTOR: Chemical
Industry
ACCIDENT INFORMATION:
DATE OF ACCIDENT :
1988-01-12
PLACE OF ACCIDENT: G & R Chemicals
BRIEF
CAUSE OF DEATH: Asphyxia.
BRIEF MANNER OF DEATH: Fall into
bottom of chemical mixing vat sprayed
with a methylene chloride
solution.
ACCIDENT DESCRIPTION:
On January 12, 1988, at
about 7:30 am, Mr. Allan Andrews, the foreman
at G & R
Chemicals, had placed a wooden ladder in a mixing vat at
the
above named plant. The vat had been sprayed with methylene
chloride
the night before to clean it. He called to a laborer,
who worked at
the plant, but was not familiar with the
equipment, to start an extract
fan. The laborer inadvertently
pressed the wrong switch and started
the blades of the mixing
vat rather than the extract fan. This started
a series of
disasters which resulted in the death of Mr. Andrews.
The
mixing blades damaged the ladder on which Mr. Andrews was
standing,
resulting in him falling into the vat. The laborer
tried to extricate
him from the vat, but he was already
semiconscious and fell down to the
bottom of the vat. At this
time the staff were asked for help by the
laborer, who went
into the vat to rescue Mr. Andrews, wearing a
respirator mask.
He then lost consciousness himself and another member
of the
staff then entered the vat to remove Mr. Andrews and
the
laborer, using an air hose to try and combat the fumes. He
became
dizzy himself and was just able to climb out as the
ambulance arrived.
They were unable to enter the vat and
had to wait some five minutes for
the fire brigade to arrive
with their self-contained respirator units,
which enabled them
to enter the vat and extricate Mr. Andrews and the
laborer, who
were then resuscitated by the ambulance attendants.
Mr.
Andrews was deeply unconscious and the laborer was
semi-conscious.
The two men were taken to Oshawa General
Hospital and subsequently to
Toronto General Hospital on the
same day, January 12th 1988. The
laborer made an uneventful
recovery, but Mr Andrews was declared brain
dead two days later
on January 14th at 6 pm. Autopsy carried out on
January 16th
1988 found that death had occurred due to oxygen being
replaced
in the atmosphere by chemical fumes.
RECOMMENDATIONS
ISSUING FROM INQUIRY:
1. A 911 emergency system be
implemented for the Region of Durham.
2. In the interim, a
tiered system should be in place so that when a call
is placed
for an ambulance, the fire rescue truck would respond to
the
same call.
3. All businesses handling hazardous
substances as listed in the IAPA
should be listed with the fire
department on a central registry.
4. All companies should
have written procedures to follow in the event of
any accident
involving hazardous substances.
5. Safety procedures should
be stressed at regular safety meetings with
appointed
representatives which would include all personnel regardless
of
the size of the company.
6. All new employees should
immediately be trained in safety and emergency
procedures.
Every employee should be given a written copy of safety
and
emergency procedures.
7. Written data base sheets should be
posted in plain view, listing all
hazardous substances handled
by the company.
8. First Aid equipment should be readily
available and clearly marked as
such.
9. All switches
pertaining to machinery and equipment should be
clearly
labelled and a lock-out device provided.
10. All
safety procedures outlined in the IAPA with respect to
hazardous
substances should be in a clearly written format and
provided to
company employees.
11. Any missing vat
should have a failsafe switch installed on the lid to
prevent
its operation while the lid is open.
12. The regulations
and rules of IAPA pertaining to companies of 20 or
more
employees should be reviewed with a view to including all
companies
regardless of size.
13. A list of dangerous
substances contained in the IAPA should be expanded
to include
methylene chloride, toluene and methanol.
COMMENTS ON
RECOMMENDATIONS BY CORONER:
1. This system should be in
place at least for industrial accidents. If
the fire brigade
had been contacted at the same time as the ambulance,
it may
have saved a life, as the fire brigade can extract victims
that
the ambulance personnel are not equipped for.
2.
This is suggested only for industrial accidents.
3. Self
explanatory.
4. Self explanatory.
5. This would be a
practical way to educate all employees on
safety
procedures.
6. Many employees are currently
unaware of safety procedures at the plant.
7. Self
explanatory.
8. Self explanatory.
9. These are basic
safety precautions in industry. At least the labelling
would
not be expensive to install and enforce.
10. Self
explanatory.
11. This would seem to be an excellent safety
device.
12. The chemicals handled by small companies can be
just as dangerous as
those handled by larger
companies.
13. This should certainly be
done.
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©2004 Canadian Centre for Occupational
Health & Safety 