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| Record Number: |
2231 |
| CIS Descriptors: |
UNSAFE
PRACTICES
TITANIUM
ASPHYXIA
ASPHYXIANTS
WELDING
AND
CUTTING
CONTAINERS
ARGON
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: British Columbia
REPORT TITLE: Verdict
of Coroner's Inquest
INDIVIDUAL PRESIDING: Dr. G. D. Tilley,
Coroner
PLACE OF INQUIRY: Burnaby
DATE OF INQUIRY :
1989-08-21
INFORMATION ABOUT DECEASED:
NAME:
Confidential
OCCUPATION: Apprentice Welder
INDUSTRIAL
SECTOR: Metal Manufacturing
ACCIDENT
INFORMATION:
DATE OF ACCIDENT : 1989-03-09
PLACE OF
ACCIDENT: 1575 Kingsway, Port Coquitlam
BRIEF CAUSE OF DEATH:
Asphyxiation; inhalation of argon gas.
BRIEF MANNER OF DEATH:
Inhalation of argon gas.
ACCIDENT DESCRIPTION:
Ellett Copper
and Brass, 1575 Kingsway Avenue, Port Coquitlam, B.C. is
a part
of a group of firms registered as Ellwood Properties
Ltd.
Ellett Copper and Brass is involved with the construction
of aluminum,
stainless steel, and titanium tanks and vessels.
The titanium tanks
measure approximately 22 meters in length
and 1.2 meters in diameter.
The vessel has three circular
openings at the top with one small
opening on its end. Titanium
is a reactive metal. To complete a sound
weld the entire puddle
and bead must be kept under a blanket of inert
gas (Argon)
until cooled to a temperature of 800 degrees F. Argon gas
is
heavier than air and will settle in low areas. If open it
will
disperse. It is an asphyxiant and in a confined space, if
inhaled, it
may cause loss of consciousness and sudden
death.
The deceased was a 21 year old, employed as an
apprentice welder with
Ellett Copper and Brass. At the time of
the incident Mr. Bartel was
completing the final welds of his
first titanium tank.
At approximately 0630 hours, March 9,
1989, the deceased arrived at
work. He was observed by
co-workers to be more quiet than usual,
generally "not feeling
well" and coughing up phlegm. At approximately
0700 hours
Stephen started work. He spent approximately 25 minutes
setting
up to weld a 25 millimeter nozzle located at the bottom of
the
tank. The 25 millimeter nozzle and a 100 millimeter nozzle
were
blanked with masking tape from the previous day to prevent
loss of
Argon, shielding gas loss during weld inside the tank.
Plastic was
wrapped around the outside surface of the tank
nozzles when welding is
performed inside. The 100 millimeter
nozzle had been welded the
previous day, March 8,
1989.
At approximately 0745 hours, March 9, 1989, the
Foreman, passed by the
tank and observed no abnormalities at
this time. The Foreman continued
on believing the work was
progressing normally.
At approximately 0730 hours, the
deceased requested a co-worker Welder
to assist him by checking
the outside surface of the nozzle. An
effective purge. The
deceased was at this time welding inside the tank
and had
completed about one half of the work on the 25
millimeter
nozzle. The welder checked Stephen's weld, discussed
it briefly and
proceeded away from the tank shortly
after.
At approximately 0805 hours, March 9, 1989, the
Foreman returned to the
tank and checked inside the tank.
Stephen was discovered lying
unconscious on the bottom of the
tank. The Foreman immediately
requested the assistance of an
employee and the Welder and removed the
deceased from the tank.
The First Aid Attendant was immediately
summoned and performed
cardiopulmonary resuscitation, commencing
approximately four
minutes after discovery.
At 0810 hours, March 9, 1989, the
First Aid Attendant, attended the
incident scene and assisted
with CPR.
At 0815 hours, March 9, 1989, the Port Coquitlam
Fire Department,
Emergency Response Crew arrived and
assisted.
At 0836 hours, the Emergency Health Services
arrived at the incident
scene and began resuscitation efforts.
Resuscitation was continued
approximately one hour without
response and then was discontinued. The
deceased was
transported to the Royal Columbian Hospital where he
was
pronounced dead on arrival by a
doctor.
RECOMMENDATIONS ISSUING FROM INQUIRY:
To:
Workers' Compensation Board
Chairman
Richmond,
B.C.
We the jury make the following
recommendations:
1. Implement the recommendations contained
in the report in relation to
the death of the deceased dated 30
March 1989.
2. Write, publish and circulate to all
employers involved with the
manufacture/repair/maintenance of
closed or confined vessels a "Safe
Practices Manual".
3.
Enforce the existing Workers' Compensation Board regulation in
relation
to safe practices in dealing with closed or confined
vessels.
4. Remind all employers in industries dealing with
closed or confined
vessels that they must inform and educate
all employees involved with
those vessels of the related
Workers' Compensation Board regulations.
5. That a data
sheet library of the properties and safe handling of
toxic
gases be available from the Workers' Compensation Board
for employers
and employees upon request.
COMMENTS ON
RECOMMENDATIONS BY CORONER:
The jury put forth five
recommendations and took into consideration
that Ellett Copper
and Brass have incorporated several new safety
measures to
ensure that there would not be a recurrence of
this
incident.
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Health & Safety 