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| Record Number: |
2455 |
| CIS Descriptors: |
BURNS
FLOOR LAYING
WATER
HEATERS
FIRE
DATA SHEET
FLAMMABLE
LIQUIDS
CONSTRUCTION INDUSTRY
BUILDING
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. James T. Outred,
Coroner
PLACE OF INQUIRY: Markham
DATE OF INQUIRY :
1991-04-12
INFORMATION ABOUT DECEASED:
NAME: Joseph
Talik
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Renovations
industry
NAME: Miroslaw Butkiewicz
OCCUPATION:
Unavailable
INDUSTRIAL SECTOR: Renovations
industry
ACCIDENT INFORMATION:
DATE OF ACCIDENT :
1990-04-28
PLACE OF ACCIDENT: 73 Summerdale Drive,
Markham
BRIEF CAUSE OF DEATH: Mr. Talik died due to respiratory
failure probably
due to secondary infection. Mr. Butkiewicz
died due to multiple system
failure, 50% surface
burns.
BRIEF MANNER OF DEATH: Due to burns sustained in flash
fire.
ACCIDENT DESCRIPTION:
On April 23, 1990 at
approximately 1:00 p.m., Mr. Butkiewicz was working
with a
floor finishing product on a parquet floor in the basement of
73
Summerdale Drive, Markham, Ontario. During the application,
a buildup
of heavier than air vapours occurred along the floor
level and spread
throughout the basement including the adjacent
furnace room where the
gas-fired water heater was located. The
buildup of vapours continued
until the fumes reached the level
of the lit pilot light of the water
heater which was the most
probable source of ignition. The fire flashed
back to the main
room and engulfed Mr. Talik and his coworker in
flames.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. The
911 system should be implemented in York Region as quickly
as
possible.
2. The first police officer who arrives at
the scene of a fire should be
responsible for the security of
the scene and for seizing any items
which might be required for
a subsequent investigation.
3. If there is any injury
resulted from a fire which requires hospital
treatment, the
Fire Marshal's Office should be informed immediately so
that
any necessary investigation can be started promptly.
4. A
prominent warning label should be displayed on all products
covered by
the WHMIS Regulations that would say an information
sheet is available
that lists precautions to be taken when
using this product. Obtain from
your employer or from the store
where you purchased this product.
9. When interior renovations
in a residential home are being done, a
building permit should
be available promptly, at a minimal fee, and that
no additional
municipal taxes should be incurred until the property
is
resold.
10. The Province of Ontario should upgrade
the qualifications of ambulance
attendants to the level of
paramedics.
COMMENTS ON RECOMMENDATIONS BY
CORONER:
1. I endorse this recommendation as this is the
fourth inquest where it has
been made. Delays may be due to the
need for extensive
preimplementation studies on
feasibility.
2. This also refers to recommendation #3. I
agree. There appeared to be a
delay in investigation by the
Ministry of Labour and fire officials.
This may have occurred
because the fire was very short and the
seriousness of the
injuries was not readily appreciated.
3. See recommendation
#2.
4. This also refers to recommendations #5 and 6. I
agree. It would appear
from the evidence that the workers did
not fully appreciate the inherent
dangers of the materials
being used.
5. See recommendation #4.
6. See
recommendation #4.
7. This also refers to recommendation
#8. I agree. These recommendations
are safety
measures.
8. See recommendation #7.
9. This also
refers to recommendation #10. I do not fully agree with
these
recommendations as I do not feel they would have
prevented this
accident. Additionally, there are cost
implications to these
recommendations which may not be
practical.
10. See recommendation
#9.
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©2004 Canadian Centre for Occupational
Health & Safety 