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| Record Number: |
2609 |
| CIS Descriptors: |
BUILDING
INDUSTRY
CONSTRUCTION INDUSTRY
CONSTRUCTION WORK
WORK
IN CONFINED SPACES
CONFINED
SPACES
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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. R.I. Merritt,
Coroner
PLACE OF INQUIRY: Welland
DATE OF INQUIRY :
1995-05-01
INFORMATION ABOUT DECEASED:
NAME: David
Poulsen
OCCUPATION: Unavailable
INDUSTRIAL SECTOR:
Construction industry
ACCIDENT INFORMATION:
DATE OF
ACCIDENT : 1992-11-14
PLACE OF ACCIDENT: Water Tower, l77 #20
Highway, Pelham
BRIEF CAUSE OF DEATH: Stenosing,
atherosclerotic coronary disease with
early myocardial ischemia
and terminal cardiac arrest.
BRIEF MANNER OF DEATH: Natural
causes with contributing factor of
physical exertion resulting
from climbing a 75' ladder.
ACCIDENT
DESCRIPTION:
Unavailable.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
1. We recommend that it shall be the
responsibility of both the owner
and the constructor to
determine whether a given structure is a
confined space in a
given application.
2. We recommend that all points of
ingress to a confined space, whether
temporary or permanent
shall be clearly and obviously demarcated by
means of signs
with appropriate warnings.
3. Under the Occupational Health
and Safety Act and regulations for
construction projects in the
area of confined spaces.
Section 61 - 4 In addition, the
worker outside shall have a means
of emergency communications
with them (example cellular telephone,
radio, alarm)
4.
Section 61 - 5 In addition, the worker outside shall have with
them,
an emergency supply of oxygen.
5. Section 62 - 3
In addition, the worker outside shall have a means of
emergency
communications with them (example cellular telephone,
radio,
alarm)
6. Section 62 - 4 In addition, the worker
outside shall have with them,
an emergency supply of
oxygen.
7. Under Occupational Health and Safety Act and
WHMIS regulation, all
suppliers of materials safety data sheets
shall, under Section I of the
MSDS provide a substantially
complete identification of chemical
compounds comprising the
product along with their relative
concentration. By
substantially complete we mean all compounds present
at
concentrations of greater than or equal to 1.0% by
weight.
Proprietary or trade secret additives of a non
hazardous nature need
not be identified but if they are omitted
it should be clearly and
obviously noted that MSDS is not
substantially complete. A means of
contact in such cases must
be provided to the user to obtain further
information regarding
compatibility with respect to the users
application.
The
identification should be introduced as necessary at the
next
renewal date of the MSDS.
8. Field investigations
by the Ministry of Labor (Ontario) which
include circumstances
involving chemicals, gases, vapors or fumes shall
provide
technical support in the form of a professional chemist
or
chemical engineer. In addition to general advice, said
professional
shall particularly provide assurance of meaningful
and valid test and
analytical procedure.
COMMENTS ON
RECOMMENDATIONS BY CORONER:
1. Recommendations one to six
had to do with confined space problems.
Section 60 of the
Occupational Health and Safety Act and Regulations
for
Construction Projects establishes the Ministry of Labours
position
although definitions area somewhat vague. Policies and
procedures for
the Regional Municipality of Niagara contain six
pages of policy with
reference to "Confined Space".
The
constructor (Landmark), the painting contractor (Atlas) and
the
inspecting firm (Misco) considered whether this contract
involved a
confined space and decided it was not a confined
space because of three
doors of entry, four vents that may be
opened for ventilation and the
natural ventilation that takes
place by means of a ten inch permanent
pipe from the ground to
the top of the tank. These three companies have
had
approximately 50 years experience in over 150 tanks of this
type
(most tanks are of standard construction) and have never
considered a
water tank a confined space.
Four days
after the death, the Ministry of Labour Inspector declared
a
confined space.
Extensive testimony revealed problems
of interpretation and
communication. A constructor reports to
an office in Toronto if a job
site is over $50,000.00. Due to
communication problems many times the
job is started and even
finished before the local office hears of the
activity.
Staffing for Ministry of Labour is restricted by personnel
that
it is impossible for every job site to be visited by an
inspector.
The first recommendation establishes a procedure
whereby someone other
than the constructor is involved in
establishing before work begins
whether it is or is not a
confined space. Recommendations 2, 3, 4, 5 &
6 are safety
recommendations if it is declared a confined space to
ensure
availability of increased communication, first aid
equipment
including oxygen, and improved instructions by
accurate signage.
7. Recommendation seven had to deal with
the paint. The Material
Safety Data Sheet from the paint
supplier contained a description of the
contents. The toxic
part of such paint are the vinyls which are usually
Xylene or
Toluene. As a rule the vinyls constitute about 40% of
the
weight. The above sheet had no mention to toluene being
present.
Toluene was found in the blood of the deceased,
toluene was found in the
air testing done by the Ministry of
Labour on November 16, 1992. Toluene
was also found in air
testing by the Ministry of Labour on November 27,
1992 when the
Ministry of Labour conducted a simulated test using the
same
paint. It was obvious to the inquest that the Material
Safety
Date Sheet was in error. The company providing the paint
was invited to
attend the Preinquest Meeting and would have
been given standing but did
not respond. The WHMIS is
administered by the Federal Government and
its relationship to
the Provincial Ministry of Labour was
questioned.
Recommendation was made to attempt to ensure an
accurate Material Safety
Data Sheet.
8. Recommendation
eight was made with the hope that in the future
investigations
of deaths involving materials with complicated chemical
and
physical properties that the Ministry of Labour has
more
professional expertise available to assist them in their
role.
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©2004 Canadian Centre for Occupational
Health & Safety 