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| Record Number: |
2595 |
| CIS Descriptors: |
CARBON
MONOXIDE
POISONING
VENTILATION
DATA
SHEET
CONSTRUCTION INDUSTRY
WAREHOUSES
SAFETY AND
HEALTH TRAINING
INTERNAL COMBUSTION
ENGINES
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of the
Coroner's Jury
INDIVIDUAL PRESIDING: Dr. M. Naiberg,
Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY :
1995-02-20
INFORMATION ABOUT DECEASED:
NAME: Jose
Tercas
OCCUPATION: Unavailable
INDUSTRIAL SECTOR:
Construction industry
ACCIDENT INFORMATION:
DATE OF
ACCIDENT : 1993-05-18
PLACE OF ACCIDENT: An enclosed warehouse
(location not stated).
BRIEF CAUSE OF DEATH: Acute Lt. anterior
coronary thrombosis
BRIEF MANNER OF DEATH: Of undetermined
means
ACCIDENT DESCRIPTION:
The deceased and six fellow
workers suffered the symptoms of mild
carbon monoxide poisoning
(levels of approximately 25%) when
gasoline- and
propane-powered machinery (2 forklift trucks, a
mixing machine
and a trowelling machine) was run in an enclosed
warehouse. Mr.
Tercas died of an acute coronary thrombosis. Elevated
levels of
carbon monoxide that affected Mr. Tercas' associates may
have
contributed to his demise.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
1. WE THE JURY RECOMMEND that all medical and
hospital records of an
individual, whose death will be
investigated by a Coroner's jury, be
kept at least until the
investigation is completed. Medical and
hospital records for
other individuals who received treatment at any
hospital as a
result of the same incident involving the death should
also be
retained until after the investigation is completed.
2. WE
THE JURY RECOMMEND that all combustible fossil fuel engine
must
have affixed label stating, "When this engine is operated
in an enclosed
area, adequate ventilation must be present to
avoid carbon monoxide
poisoning", with appropriate WHMIS poison
symbol (skull & crossbones).
3. WE THE JURY RECOMMEND
that carbon monoxide emission levels be
established,
appropriate to the engine size for all propane and
gasoline
powered engines.
All engines should be checked on a regular
basis to ensure
conformation and the results should be recorded
in a maintenance
log, available for inspection at anytime by a
Ministry of Labour
representative. The date of the latest test
should be shown on a
weatherproof tag or label affixed to the
engine. Ultimate
responsibility for conformation would be to
the owner. Frequency of
the test and emission levels should be
determined by the Ministry of
Labour in consultation with the
manufacturer.
4. WE THE JURY RECOMMEND that WHMIS Material
Safety Data Sheets (MSDS),
covering products that discharge
hazardous substances into the air
indicate that when used
indoors, adequate ventilation must be available.
If fans or
exhaust ducts are used, they should be placed so that
the
hazardous substances are drawn or pushed away from the
worker.
5. WE THE JURY RECOMMEND that WHMIS training
include mandatory instruction
regarding proper ventilation for
interior worksites. Particular
attention should be paid to
construction and renovation worksites where
hazardous
substances such as carbon monoxide may be present. A variety
of
diagrams should show how air movement can be improved for
various
conditions. Unsafe working conditions may occur as a
result of propane
or gasoline fossil fuel burning equipment
being used indoors for
temporary operations. If practical we
recommend that equipment powered
by combustible engines not be
used.
6. WE THE JURY RECOMMEND that all regulatory
approvals pertaining to a
building, should be made available
for the future tenants or owners
by a notice attached to the
appropriate records. For equipment requirin
extra air
ventilation, special calculation should be made.
7. WE THE
JURY RECOMMEND that WHMIS training and guides should be
made
available in the languages best understood by the
worker.
All products containing WHMIS controlled substances
imported from
outside Canada should be labeled in accordance
with WHMIS regulations
before being allowed onto a job site.
Accompanying the product must be
a fully completed MSDS that
also conforms to WHMIS regulations.
8. WE THE JURY
RECOMMEND that where combustible engines are operated in
an
enclosed environment, carbon monoxide monitors be used.
9.
WE THE JURY RECOMMEND that equipment rental companies
must
determine if equipment that will produce carbon monoxide
will be
used in an enclosed environment. If yes, a carbon
monoxide monitor
must be offered. If declined, a signed waiver
must be kept by the
rental company for 1 (one) calendar year,
after return of equipment.
10. WE THE JURY RECOMMEND that
supervisors must rigidly follow and implement
a company's
safety policy as well as the requirements of the
Occupationa
Health & Safety Act and WHMIS
regulations.
11. WE THE JURY RECOMMEND that where workers
are working with hazardous
material or equipment producing
carbon monoxide, oxygen should be
made available on the work
site.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1. The
carbon monoxide blood level record on the deceased, on a
blood
sample drawn at the time of his cardiac arrest, was
nowhere to be
found in the hospital chart. The levels on all
the victims, on blood
specimens drawn on admission, were also
not to be found in their
charts. The assays were performed at
the Toronto General hospital,
but these reports were apparently
disposed of after being reported
orally to the first
hospital.
2. The evidence was that 4 internal combustion
engines (2 propane
forklift trucks, a cement mixer and a
flooring troweller) were being
operated in an enclosed
warehouse and equipment area, with poor
ventilation.
3.
The evidence was that there was no permissible or
acceptable
industry standard for C.O. emissions established for
any of the
internal combustion engines. The carbon monoxide
emissions found on
these machines by the investigators greatly
exceeded the values set
out in the specifications reported by
the manufacturer, indicating
the inadequate maintenance of the
engines. The several machines were
all rental machines from an
equipment rental company. There were no
records of regular
maintenance. The M.O.L. does not conduct any
monitoring in this
area.
4,5 The evidence was that WHMIS does not include
information on the
proper ventilation of work sites. There was
evidence that two large
fans were being used, but in such a way
as to cancel out each
other's action, thus hindering rather
than aiding ventilation.
6. The building plans had been
approved on the understanding and
undertaking by the owners
that only battery-driven forklift trucks
be used. Hence,
ventilation requirements adequate for this usage
were
installed. There was concern that this understanding might
be
forgotten, or that a subsequent owner might not be aware of
this
stipulation, since it was not expressly indicated in the
building
plans. Indeed, the propane trucks had been used by the
present
owner.
7. The workers involved in this accident
were mainly Portuguese and
Italian, some with only limited
familiarity with English. The WHMIS
training and guides were
available in English only. The jury
apparently felt this could
make for poor or inadequate instruction
for these
workers.
Some of the flooring materials being used were of
U.S. origin and
their containers bore only the original
labelling. It was the jury's
concern that WHMIS did not
apparently review these products and
affix its own
labels.
8. The evidence was that good C.O. monitors are
readily available in the
market for rent or purchase, but were
not in use at this site.
9. Self-explanatory
10.
There was evidence that there was not close supervision
or
monitoring of the job site with respect to the company's own
stated
safety policy and the OHSC requirement.
11.
Self-explanatory.
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©2004 Canadian Centre for Occupational
Health & Safety 