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| Record Number: |
2740 |
| CIS Descriptors: |
IRON AND STEEL
INDUSTRY
CONFINED SPACES
ASPHYXIA
TOXIC
GASES
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| Donor: |
Office of the Chief
Coroner
|
| Jurisdiction: |
Ontario |
| Report Title: |
Verdict of Coroner's
Jury |
| Individual
Presiding: |
Dr. John Ewen,
Coroner |
| Place of
Inquiry: |
Hamilton |
| Date of
Inquiry: |
1999-10-18 | |
| INFORMATION ABOUT
DECEASED |
| Name: |
Robert LaPolice and John
Hewson |
| Occupation: |
Labourers |
| Industrial
Sector: |
Iron and steel
industry | |
| Date of
Accident: |
1997-01-17 |
| Place of
Accident: |
Dofasco Number Two Melt
Shop, Hamilton |
| Brief Cause of
Death: |
Suffocation |
| Brief Manner of
Death: |
Accidental
|
- Accident Description:
- The morning of January 17,
1997, was bitterly cold in Hamilton. Mr John Hewson, age 31,
and Mr Robert LaPolice, age 26, both employees of Steel Cat
Task Force/Auburn Industries were working at Dofasco Number
Two Melt Shop located on Burlington Street East in Hamilton.
They were assigned to clear out debris at the bottom of the
degasser tank, which is considered to be a confined space.
The tank had been shut down for servicing since January 2,
1997. At about 10:15 a.m., a gas check was conducted on the
air quality inside this three storey structure and the
results showed a safe oxygen level of 20.8 percent oxygen.
The task of moving the debris was only to take a few
minutes. Of note, the lid of the tank had just been removed
a few minutes before the oxygen check was done. As the task
was about to start, the Dofasco supervisor was called away
from the job site. Mr John Hewson was the first to go down
into the tank and Robert LaPolice was to be the safety man.
Shortly after entering the tank, Mr Hewson collapsed and
then Mr LaPolice went in after him and collapsed as
well.
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- Recommendations Issuing From
Inquiry:
1. That the Ontario Solicitor
General amends the Coroners Act in Section 10-(5) to add "or
Industrial Establishments".
Rationale: We, the jury, feel
very strongly that every fatality in the workplace is equally
tragic regardless of whether it occurred at a mining site,
construction site, or industrial establishment. At this inquest
taking place 2 years 10 months after the death of John Hewson and
Robert LaPolice, it was obvious their families are still
experiencing tremendous anguish. A prompt and automatic inquest
would give families the opportunity for closure and the lessons
necessary to prevent similar accidents will be available to the
community in a prompt manner.
2. That the Government of Ontario
completes as soon as possible the review of the Occupational
Health and Safety Act initiated in 1997. The revised act should be
given the highest priority on the legislative
agenda.
RATIONALE: The jury is of the opinion that the
changing characteristics of the modern workplace, with the
increasing use of part-time workers and contract labour requires
the speedy revision of the current Occupational Act. The jury was
made aware through evidence presented that there has been a
significant number of confined space fatalities in North America.
Many of these involved multiple fatalities where would-be rescuers
also lost their lives.
3.
That M.S.A. Canada Inc. maintain a register of all purchases of
their MSA model 360 gas monitor and send to all purchasers a
revised instruction manual when changes are made, together with a
covering letter highlighting the changes in the
manual.
RATIONALE: The jury is of the opinion that this
procedure needs to be established in order to keep all users aware
of current changes.
4.
That the Ministry of Labour considers changing the wording in
section 68(d)(i) of the Confined Space (Regulations for Industrial
Establishments) to read "records the results of each sample
analysis in a permanent record". The Ministry of Labour should
also consider the need for including a definition of the term
"test".
We, the jury heard and saw evidence that
stratification test results were recorded as one result, even
though sample readings were taken at more than one
level.
5. That the
Ministry of Labour add to Confined Spaces (Regulations for
Industrial Establishments) 68(d), the requirement that any person
entering a confined space be competent in the confined space
safety procedures and hazards of the specific confined
space.
6. That the
Ministry of Labour include in section 68(d) a requirement that a
confined space entry permit listing all safety, process,
isolation, and lockout procedures. The permit should testify that
all requirements have been met and signed as complete by the
confined space supervisor. The permit must be attached prominently
to the confined space entrance.
7. a) That the Ministry of Labour
immediately establish a working group comprised of representatives
from the Ministry of Labour, Employer's Associations, Labour
Associations, and other interested parties, to review the
Occupational Safety Act with a view to the modernization of the
Act, recognizing the changing nature of the workforce
characterized by the increasing use of part time workers and
contract labour.
b) This review should clarify the definition
of employer and worker so that the responsibility of supervision
and training of the contract worker at the work site would be the
responsibility of the employer.
c) That the Act should require
the employer (customer), and the employer (supplying the worker)
to enter into a legally enforceable agreement defining their
individual responsibilities regarding training and supervision of
contract workers at the work site.
It is our view on the
evidence presented that responsibilities for training and
supervision between Dofasco Inc. and Steel Cat Task Force Inc.,
Auburn Industrial Services was not precisely defined. Similar
situations may exist with other employers who use contract
labour.
8. That the
Ministry of Labour establish and maintain a registry of all
employers with confined spaces in the workplace and immediately
following a fatal or serious accident the Ministry shall notify by
electronic mail, all of these establishments, the pertinent
details of the accident.
9. That the Ministry of Labour reviews the
definition of the phrase "easy egress" contained in Confined
Spaces (Regulations for Industrial Establishments, section
68(a).
10. That the
Ministry of Labour shall revise Regulations 69(h), and 70(g), of
the Conned Spaces (Regulations for Industrial Establishments) to
change from Artificial Respiration to Cardio Pulmonary
Resuscitation.
11. That
the Ministry of Labour change the Engineering Data Sheet, #7-01,
section 5.1.1, to read - workers and supervisors shall be trained
to be competent in 5.1.1 a,b,c., rather than just be
"informed".
12. That the
Ministry of Labour change the Confined Spaces (Regulations for
Industrial Establishments) section 58 to include a requirement
that a personal gas detector be worn by the first entrant into a
confined space.
13. That
the Ministry of Labour following the completion of a major new
installation or process, such as the vacuum degasser tank, inspect
the operation immediately following the start up period. Further,
the Ministry of Labour carries out their inspections in such a
way, that within a specific Industrial Establishment all areas of
operations will be inspected with some frequency.
14. That Steel Cat Task Force, Auburn
Industrial Services, and Dofasco Inc. uses this accident as a case
study for developing training material of Confined Space Entry
hazards, and safe entry procedures.
We, the jury, also
recommend that the Joint Health and Safety Committees of both
Steel Cat Task Force, Auburn Industrial Services and Dofasco Inc.
be involved in the development of this training
material.
With the consent of the Hewson and LaPolice
families the above parties use this accident as a case study and
produce a confined space video for training use at Dofasco Inc.
The workplace, Safety and Insurance Board, the I.A.P.A., Steel Cat
Task Force, Auburn Industrial Services, and Dofasco Inc. could
contribute to the production cost of this video. The video should
be professionally produced and have real impact. It would be a
memorial tribute to John Hewson and Robert LaPolice.
It is
our view based on the evidence presented that this accident covers
the hazards of Confined Space entries, testing procedures, lockout
procedures, and the events that took place. To the jury this
accident is seen as an ideal case study for Confined Space entry
training.
15. That Dofasco
Inc. resolve the apparent philosophical differences between its
safety goal of "zero lost time accidents" and apparently only
doing those things necessary to comply with Confined Spaces
(Regulations for Industrial Establishments). These are minimum
standards.
16. That
Dofasco Inc. resolve with M.S.A. Canada Inc. the differences
between their positions on the need to calibrate the M.S.A. 360 at
the site of testing rather than in the instrument shop, the impact
of severe cold temperatures on the operation of the unit and the
final response time for a reading of approximately 90 seconds,
when using a 25 foot sample line.
We, the jury heard
evidence that there are conflicting views between Dofasco Inc. gas
testers and the recommendations of M.S.A. Canada Inc. These
differences need to be resolved before Dofasco Inc. defines
testing procedures for Confined Space entry.
17. That Dofasco Inc. changes the word
"Employee" to "Worker" in all confined space entry procedures e.g.
Proc.No. LMFCSE012 Degasser Tank.
18. That Dofasco Inc. removes the word
"one" from the line "THIS ENTRY FALLS UNDER LEVEL ONE" on Proc
No:LMFCSE912.
19. That
Dofasco Inc. change the Dofasco Health and Safety Manual, Document
#7-19, section 6.3(b) Role of the Attendant to eliminate the
entire first bullet, and revise the second bullet to read,
"Control the Confined Space site, monitor and protect the Entrants
in a Confined Space for any Level. All attendants must be equipped
with a two-way radio."
20.
That Dofasco Inc.'s "Atmospheric test Results" form 764A be
changed to reflect:
i) Start time of testing
ii) End time
of testing
iii) Record bottom, middle, and top level readings
for each location
iv) The number of sample
points
21. That Dofasco
Inc. assess the complexity of its safety material with a view to
clarification and simplification.
22. That Dofasco Inc. assess the
complexity of its safety material with a view to clarification and
simplification.
23. That
Dofasco Inc. develops written Confined Space Entry Procedures for
each and every identified Confined Space. The procedures should
define hazards, lockout procedures, atmospheric test procedures,
and safety watch requirements.
24 a). That Dofasco Inc. with the
assistance of MSA Instrument Division will develop a training
program for the use of the MSA 350 Carbon Monoxide, Combustible
Gas, and Oxygen alarm model. The training should involve extensive
knowledge of:
i) Reasons? Why do a gas test?
ii)
Information in the Instruction Manual
iii) How the machine
works
iv) Parts, accessories, care and maintenance
v)
Proper method of doing calibrations
vi) Affects of extreme
cold temperatures
vii) How to conduct a proper gas
viii) The
prescribed method of doing a stratification test (3 separate
readings rather than only 1 reading being recorded)
ix) To
become familiar with all of the confined spaces and the necessary
sampling procedures for each conned space
x) Have practical
demonstrations that involve the procedures for the different
confined spaces i.e. LMFCSE012 document.
b). Upon
completion of their training program, all applicants should
participate in a written test pertaining to information presented
in the training sessions and demonstrate their proficiency in
actual field?testing. A probationary period of 3 months with
regular inspections and evaluations by a trainer would help to
ensure that a competent gas tester adheres to the proper standards
and procedures.
c). That Dofasco Inc. ensures that all gas
testers are annually recertified (within 12 months) in all areas
of gas testing. Included in their desertification, an audit of
their abilities in calibrations, analytical techniques and a
meaningful written test.
25. That Dofasco Inc. should develop a
program to familiarize the Hamilton Fire Department with the
Dofasco "roadways". When responding to an emergency call they
should always be met at the gate and led to the
scene.
26. That Dofasco
Fire and Rescue Workers undergo yearly medical and fitness
tests.
27. That a program
be developed by Dofasco Inc. for the Fire and Medical Departments
to train and familiarize the Emergency workers with all areas of
the plant.
28. That
Dofasco Inc. will adopt a procedure to notify their Emergency
Crews before entering any conned space.
We, the jury feel
that it is absolutely necessary that the above departments be
alerted to any confined space entry.
29. That Dofasco Inc. review its overall
safety training program and the materials used to incorporate
general safety training at induction, specific training on the
hazards at different locations within the plant, confined space
entry procedures, O.H.S.A. regulations, and W.H.M.I.S.
requirements. There should be evaluations of the level of
comprehension of participants at each completed stage of the
training and monthly inspections of the workplace by the Joint
Health and Safety Committee. Competence should be continually
assessed in order to obtain proficiency in safety performance by
means of annual recertification. All training sessions and
recertification and the content of those sessions should be
documented. The training should be given to supervision, Dofasco
employees and contract workers.
30. That the Chief Coroner issues a report
on the status of the jury's recommendations by November 10,
2000.
- Comments on Recommendations by
Coroner:
1. That the Ontario Solicitor
General amends the Coroner's Act in Section 10-(5) to add "or
Industrial Establishments". The jury felt strongly that every
fatality in the workplace was equally tragic regardless of whether
it occurred at a mining site, construction site or an industrial
establishment. They felt that a prompt and automatic inquest would
give families the opportunity for closure and the lessons
necessary to prevent similar accidents will be available to the
community in a prompt manner.
2. The jury is of the opinion that the
changing characteristics of the modern workplace, with the
increasing use of part-time workers and contract labour requires
the speedy revision of the current Occupational Act. The jury was
made aware through evidence presented that there has been a
significant number of confined space fatalities in North America.
Many of these involved multiple fatalities where would?be rescuers
also lost their lives.
3.
The jury is of the opinion that this procedure needs to be
established in order to keep all users of the monitor aware of
current changes.
4. No
comments provided.
5. The
jury is of the opinion that the regulations in place now, do not
address the needs of every entrant to be competent in safety
procedures and hazards of confined spaces prior to
entry.
6. The jury is of
the opinion that a formal checklist in the form of a confined
space entry permit would certify that all necessary pre-entry
safety requirements have been met with the signature of the
confined space supervisor. The posting of this permit will testify
to the safety of the confined space.
7. No comments provided.
8. The present system of conveying Hazard
Alert's to employers only when an inspection occurs is in the
Jury's view, inadequate. The Ministry of Labour's Web Site would
only be accessed by an employer already aware of the accident.
These two approaches do not alert all employers promptly
enough.
9. The jury is of
the opinion that a bottom side mounted door or manhead provides
far safer egress than a ladder or wall-mounted rungs. A
side-mounted door or manhead eliminates the risk of falls and
provides easier access for rescue or First Aid
treatment.
10. The jury is
of the opinion that the requirements for Cardio Pulmonary
Resuscitation will provide superior life-saving
results.
11. The jury is
of the opinion that the requirement of training is not adequately
addressed by the present requirement that "Workers and Supervisors
shall be informed".
12.
The jury is of the opinion that had a personal monitor been in
use, then the first entrant, John Hewson, would have been alerted
to the low oxygen hazard. The jury heard evidence that at a level
of 18.5% oxygen, an alarm would sound on such a device. The jury
also heard evidence that at 18.5% oxygen a person would not
experience confusion and would still be capable of exiting the
confined space safely. The jury further heard evidence from the
Pathologist that at an 8.5% oxygen death would occur within two
minutes and any rescue attempt would be too late.
13. The evidence indicates that there had
not been any inspection of the vacuum degasser tank operations and
lockout procedures since its installation in 1988.
14. No comments provided.
15. It is our understanding from the
evidence presented that Dofasco Inc.'s safety goal was "zero lost
time accidents" and yet frequently Dofasco Inc. stressed that
actions complied with Confined Spaces (Regulations for Industrial
Establishments). However, the Ministry of Labour testified that
these regulations are minimum standards.
16. No comments provided.
17. It is the jury's opinion that this
change will further clarify the definition of "employee" to
include the use of contract workers.
18. It is the jury's opinion that the
automatic inclusion of the word "one" leads a person to
automatically assume that the degasser tank is always a level one,
or section 68.
19. The
jury is of the opinion that an attendant acting as a safety watch
is necessary for any entry into a confined space. The attendant
should be equipped with a two-way radio for immediate rescue
procedures.
20. The
evidence indicates to us that it is necessary to include all test
results accurately and to ensure that all sample points are
recorded.
21. The evidence
indicates to the jury that a live argon line will always present a
potential hazard when the degasser tank is taken out of
service.
22. During the
inquest the jury reviewed a total of 5 separate exhibits of
training material.
i) Dofasco Job Safe Practices, Steelmaking
No.2 Melt Shop Labour, JSP 32, Revised January 1993.
ii)
ProcNo:LMFCSE012 Degasser Tank, issue date March 19, 1998, revised
September 3, 1999.
iii) Dofasco Health and Safety Manual
Document Number 7-19, Program Standards/Confined Space Entry Issue
Date September 30, 1996, Revised May 7, 1999.
iv) Dofasco
Contractor's Safety Handbook, January 1989.
v) Dofasco Standard
Operating Procedures, Designation Number P-SM-7491-32, Steelmaking
Lockout Procedures, Issued December 23, 1993, Revised May 26,
1997.
It is the opinion of the jury that so many different
sources of safety material would be confusing to employees. We
recommend that Dofasco Inc. simplify its safety material to avoid
misunderstandings.
23.
The jury heard evidence that there were a number of Confined
Spaces in the plant and we feel that entry procedures for all
confined spaces should be developed.
24. The jury heard evidence that this is
the most critical of the whole process and there is no room for
error. Any person who is a gas tester must be properly trained by
quality instructors to perform this duty with the highest level of
competence.
25. In our
view with this procedure in place outside responders will get to
the emergency directly and will not waste time getting lost on
Dofasco property.
26. In
the opinion of the jury all rescue workers should be physically
able to conduct a rescue proficiently.
27. The jury was made aware that
previously some of the rescue workers were not familiar with the
degasser tank area.
28. No
comments provided.
29. The
jury heard evidence that some workers did not receive training on
all sections of safe operating procedures. There were not complete
records on training sessions or their contents. There were not
clear assessments of comprehension.
30. No comments provided.
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©2004 Canadian Centre for Occupational
Health & Safety 