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| Record Number: |
2371 |
| CIS Descriptors: |
PHOTOGRAPHY
DISOBEYING SAFETY
INSTRUCTIONS
ASPHYXIA
CONFINED
SPACES
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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. Naiberg,
Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY :
1990-09-06
INFORMATION ABOUT DECEASED:
NAME:
Siegfried Saalfeld
OCCUPATION: Unavailable
INDUSTRIAL
SECTOR: Photography industry
ACCIDENT
INFORMATION:
DATE OF ACCIDENT : 1990-01-05
PLACE OF
ACCIDENT: Kodak Canada Plant, 3500 Eglinton Avenue West,
Toronto
BRIEF CAUSE OF DEATH: Asphyxia due to lack of
oxygen.
BRIEF MANNER OF DEATH: Was overcome by lack of oxygen
and fell back into
a Nitrogen vessel landing on the baffle
plates.
ACCIDENT DESCRIPTION:
From the evidence presented,
it is concluded that Mr. Saalfeld
disregarded the safety
regulations already in place at Kodak. He
removed the access
hatch and entered the Nitrogen vessel to repair the
level
probe, presumably fully aware of the potential danger.
Once
inside, Mr. Saalfeld attempted to re-set the probe, but
was overcome by
the effect of the lack of oxygen. In his effort
to escape from the
vessel, Mr. Saalfeld apparently lost his
footing and fell back into the
vessel landing on the baffle
plates. This accounts for the injuries as
described in the
Pathologist's report.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
1. No work, internal or external, should be
allowed to proceed if the
system is charged with
nitrogen.
2. The access hatch should be equipped with a
safety switch that triggers
an alarm in the control room in the
event of removal (authorized or
unauthorized). This would serve
to inform Kodak of all attempted
entries to the
vessels.
3. Although the response time of the York Fire
Department and Paramedics
is adequate under normal
circumstances, we recommend that, given the
size and staff of
Kodak, an in-house, trained rescue team be organized
to react
immediately to extreme emergencies. This team should
be
equipped with all necessary life saving devices.
4.
Kodak safety personnel should be present when work is being
initiated
to verify that all safety regulations and procedures
are being
followed. Periodic inspections should be subsequently
carried out to
verify compliance.
5. A safety guard rail
should be provided around the upper perimeter of
each
tank.
6. A manual emergency alarm should be provided in any
potentially
dangerous area.
7. Formal safety meetings
should be conducted on a regular basis. These
meetings should
be mandatory for all staff and outside contractors
doing work
at Kodak. The consequences of misconduct should be
understood
by all parties, and enforced by Kodak.
8. Ensure that
clearly visible warning signs are placed in all
strategic
locations.
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©2004 Canadian Centre for Occupational
Health & Safety 