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| Record Number: |
2322 |
| CIS Descriptors: |
SCALDS
TOXIC
LIQUIDS
AMMONIA
MEAT
INDUSTRY
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: Dr. M. Milton,
Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY :
1990-03-28
INFORMATION ABOUT DECEASED:
NAME:
Clifford Hoover
OCCUPATION: Unavailable
INDUSTRIAL SECTOR:
Manufacturing
ACCIDENT INFORMATION:
DATE OF ACCIDENT
: 1989-08-14
PLACE OF ACCIDENT: Canada Packers, 2200 St. Clair
Ave. West, Toronto
BRIEF CAUSE OF DEATH: Acute
tracheobronchitis, with 95% 3rd degree burns,
consistent with
ammonia burns.
BRIEF MANNER OF DEATH: A pump out valve on the
"No. 2 York Compressor"
(1962) exploded catastrophically
releasing liquid ammonia.
ACCIDENT DESCRIPTION:
The
following relates to the accidental death of Mr. Clifford
Hoover:
On Monday August 14, 1989, high liquid level alarms
sounded several
times throughout the day in the H.A. Engine
Room of Canada Packers
indicating high amounts of liquid
ammonia returning from the production
area to the engine room.
Mr. Hoover began his shift at 4 pm between 5
pm and 5:15 pm
hammering was heard in the "No. 2 York Compressor"
(1962)
indicating the presence of liquid ammonia in the
compressor.
Shortly thereafter a pump out valve on the "No. 2
York Compressor"
(1962) exploded catastrophically releasing
liquid ammonia. A second
worker, while injured, managed to
escape from the engine room.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
1. That all establishments with ammonia
refrigeration systems arrange for
the installation, if not
already present, of an automatic shutdown
switch to prevent
liquid carry-over into a compressor. And that the
location of
said switch be determined by precise calculations made
by
company engineers and representatives of the Ministry of
Consumer and
Commercial Relations - Pressure Vessels Safety
Branch.
2. That all establishments with ammonia
refrigeration systems devise and
reduce to writing standard
procedures, particularly with regard to
emergency situations,
with the purpose that all operators will react to
such
situations in a uniform and safe manner. Furthermore,
that
operators be trained such that they are qualified to act
in the manner
specified.
3. That all establishments with
ammonia refrigeration systems be required
to maintain log books
on site with sufficient space to allow the
detailing of any and
all unusual conditions encountered in the
operation of the
equipment.
4. That all establishments with ammonia
refrigeration systems where
production variations result in
fluctuations in demand for
refrigeration devise a system for
notification of the engine room
operators of the anticipated
changes.
5. That in any area or on any shift where only a
single Stationary
Engineer is on duty, spot checks should be
conducted at regular
intervals to determine both the operator's
health and welfare and the
smooth operation of the
equipment.
6. That all owners of ammonia refrigeration
facilities be required to
obtain a licence to operate, which
would be renewed at intervals deemed
appropriate by the
Ministry of Consumer and Commercial Relations
provided they
have proof of insurance and inspection, or inspection by
the
Pressure Vessels Safety Branch.
7. That all establishments
with ammonia refrigeration systems provide
facilities for
deluge showers and eyewash stations both inside the
engine room
and immediately outside of every exit from the engine
room.
8. Insure that any ammonia refrigeration engine room
have no less than two
safe exits directly to the outside. And
that each exit be clear and
unobstructed so as not to prevent
or deter a quick evacuation of the
premises.
9. That
training be given to all workers, including contract workers
who
enter areas where ammonia leaks are possible in the
location of
emergency facilities, exits, equipment and
procedures.
10. All Stationary Engineers working with
ammonia refrigeration systems
carry on their person a small
respirator apparatus, to be used if quick
exit is
necessary.
11. That the Ministry of Consumer and Commercial
Relations, in conjunction
with the appropriate industry
advisory committee, develop specific
checklists for the
guidance of those inspecting ammonia refrigeration
systems,
whether the inspector be employed by the Ministry or by
an
insurer.
12. That the Ministry of Consumer and
Commercial Relations, in conjunction
with the appropriate
industry advisory committee, study existing
legislation,
regulations and standards, to determine if the inspection
of
ammonia refrigeration engine rooms be given to the jurisdiction
of
one single inspector specifically trained in this
field.
13. That the subject matter of the appropriate
material to be employed in
the manufacture and installation of
compressors, valves and fittings
for a pressurized ammonia
refrigeration system, and specifically
whether the standard
permitting gray cast iron as opposed to a more
ductile iron or
steel, be studied by the appropriate government
authorities and
experts of the private sector.
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©2004 Canadian Centre for Occupational
Health & Safety 