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| Donor: |
Office of the Chief
Coroner
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| Jurisdiction: |
Ontario |
| Report Title: |
Verdict of Coroner's
Jury |
| Individual
Presiding: |
Dr. C. Eisener,
Coroner |
| Place of
Inquiry: |
Dryden |
| Date of
Inquiry: |
2003-06-16 | |
| INFORMATION ABOUT
DECEASED |
| Name: |
Bryian (Bryan) E.
Smith |
| Occupation: |
Driller |
| Industrial
Sector: |
Quarrying/gravel pits
industry | |
| Date of
Accident: |
2001-04-02 |
| Place of
Accident: |
Nelson Granite Quarry,
Docker Township |
| Brief Cause of
Death: |
Explosion with multiple
lethal injuries, including decapitation |
| Brief Manner of
Death: |
Accidental |
- Accident Description:
- Mr. Bryan Smith was an
employee of the Nelson Granite Quarry. On April 2, 2001, Mr.
Smith was employed in his occupation. A few days prior to
April 2, 2001, holes had been drilled in the granite rock at
the quarry with a large drill. The next step of the
operation would normally have been to put explosive charges
into these drill holes in order to break the block of rock
free. However, as sometimes happens in the spring of the
year, ground water had seeped into the cracks and frozen. It
was necessary to clean the ice out of these holes in order
for the blasting to proceed. Mr. Smith was engaged in
removing the ice from the holes. This was done by using a
device designed to generate steam. The device is attached to
a hose through which the steam could be directed into the
holes to melt the ice. An explosion occurred resulting in
the total disruption of the steam vessel into two parts. The
top portion of the steam vessel went through the air as a
projectile, landing some 200 meters from the site of the
explosion. During the explosion, Mr. Smith was killed, in
all likelihood by being struck by the top portion of the
steaming device. Reconstruction of the accident scene
appeared to indicate that he was working over the device
when the explosion occurred.
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- Recommendations Issuing From
Inquiry:
1. Boiler Pressure Vessels Act
should be reworded regarding the definition of a low pressure
boiler to provide clarity. Chapter B9(l) specifically excludes
boilers that are capable of a gas or vapor pressure over 15
pounds.
2. Designs for
shop built, low pressure boilers should be submitted to an
engineer for approval. Usage instructions or cautions should be
provided with the approval of the engineer. Regular (yearly)
inspections should be conducted by the appropriate authority, to
ensure design is adhered to. Inspectors should be instructed to
watch for such devices on site with the purpose of instructing in
dangers and bringing equipment up to standards, i.e. adding
pressure release valves or pressure gauges.
3. Maintenance and modifications of all
equipment should be done only by qualified
personnel.
4. "Lock out'
procedures should be followed on equipment that is intended to
remain inoperable.
5.
Tiger torches should be required to have safety features so that
they cannot be left unattended, or so that they turn off the flow
of propane when the flames goes out, i.e. spring triggers or
thermal couplers.
6.
Public education and awareness regarding the danger potential of
low-pressure steam vessels should be increased.
7. Clear lines of authority should be
established at the scene of an accident. Any persons arriving on
the scene should be informed of who is in charge at any given
time.
8. Any authority or
agency called to the scene of a fatal accident should always file
a complete report, even if it is discovered that they have no
jurisdiction.
- Comments on Recommendations by
Coroner:
1. The Jury heard evidence that
steam generating vessels are exempt from the Act providing
a)
they have less than 30 square feet of heating surface, b) they
have a capacity of less than 1.5 cubic feet, and c) they are
intended to be used at a pressure of less than 15 psi. Under that
definition, the steam generating device in question at this
inquest was exempt from the Act. It was noted, however, that by
closing a simple gate valve, that the appliance could generate
pressures far in excess of 15 psi, and that this in fact may have
happened. The Jury felt that if a vessel could generate pressures
over 15 psi, regardless of the intent, it should be covered by the
provisions of the Boiler Pressure Vessels Act. This could be
accomplished by changing the wording of Chapter B9(1) from the
word 'intended' to the words "capable of".
2. The Jury heard evidence that this was
indeed a home built vessel and that home built
vessels such as
this are endemic in the North, anywhere where water pipes freeze.
The jury heard evidence that there were literally hundreds, or
perhaps thousands, of these vessels across the North, used by
plumbers, camp operators and owners, etc., for the purpose of
thawing water lines, steam cleaning applications, etc. As noted
above, these vessels are exempt from the Boiler Pressure Vessel
Act, and indeed are not covered by any act of legislation. While
some of these vessels may be well built, well engineered, well
designed and very safe, there is little doubt there are others
that are not. The Jury felt that public safety would be increased
by having any such vessel built to specification and plans drawn
up by an engineer, with usage instructions and cautions in the use
of the vessel provided by the engineer who designed the
vessel.
Further, the Jury heard evidence that this vessel,
at the time of the accident, was very different than when it had
originally been constructed about 15 years previously. The vessel
had originally been constructed with both a pressure relief valve
and a pressure gauge on it. Over the subsequent years, both of
these safety features had been removed. These changes to the
vessel had likely been made by the quarry workers in the field
without the knowledge or assistance of qualified mechanics or the
quarry management. The vessel originally had a handle on a gate
valve to allow one to close the valve during transportation and
storage of the vessel. The handle had been removed to prevent the
gate valve from being closed. It was used in such a condition for
several years. Unfortunately, someone (perhaps the deceased)
nonetheless found a way to close the valve, presumably to assist
in transporting of the steam device. It would appear that the gate
valve had been closed by the use of a nut and a wrench.
It
was noted during the inquest that many of the employees of the
granite quarry are used to working independently - i.e. performing
simple maintenance on their equipment without the knowledge or
assistance of qualified mechanics or of the quarry management. It
would appear that all of these modifications that I have mentioned
were done under such circumstances. Yearly inspections would help
to make sure that these vessels were maintained in a proper
condition, safe for the purpose for which they were
intended.
It was also noted during the inquest that the
original design specifications of the particular steamer were not,
perhaps, as stringent as they could have been. One witness stated
that the discharge pipes should have been larger, and more than
one witness indicated that the original safety relief valve was
set at about 70 psi (it was a standard water heater pressure
relief valve) and that a valve should have been properly sized and
set to release at a lower pressure. Presumably these possible
deficiencies would not have occurred had the vessel been designed
by an professional engineer.
3. Please see paragraphs
above.
4. During the
inquest, the Jury heard evidence of the lock Out Procedures Used
by Nelson
Granite, which are somewhat above and beyond what
they were several years ago, including wheel chalks on all moving
equipment, lock out tags, removing keys, etc. The Jury were
impressed by the safety standards of Nelson Granite in this
regard. I note, however, that the steamer tank with the gate valve
closed was not in a safe operable condition and that there was no
safety lockout procedure for this particular vessel in that it was
the intention of the management that the gate valve on this
particular vessel never be closed.
5. The Jury heard evidence that when the
steam device was filled with a normal five gallons
of water, it
would take several minutes of heating the boiler with a propane
burning "Tiger Torch" for the water to be sufficiently heated to
produce steam. During this time is was possible that "flame outs"
could occur where a gust of wind would blow out the flame, leaving
unburned propane to accumulate in the vicinity. Apparently tiger
torches are not designed to be left unattended for this reason;
nonetheless, they sometimes are. The Jury heard evidence that
there are torches available that have thermal coupler devices so
that if the flame goes out, the flow of propane is decreased or
ceases. I believe the Jury are also aware of such simple devices
as butane cigarette lighters, etc., where if one's finger is
removed from the "trigger" the flow of fuel ceases. I believe the
Jury's recommendations speak to the fact that a propane device
such as a tiger torch, if left unattended, is very hazardous, and
that one of the safety features mentioned should be integral in
propane devices such as tiger torches, to mitigate this
hazard.
6. The Jury heard
evidence that these low pressure steam vessels were very common.
The
Jury heard evidence that these vessels, under some
circumstances, can be extremely dangerous. The Jury believes that
the dangers presented by these vessels are probably not
appreciated adequately by the operators of the
vessels.
7. The Jury heard
evidence from one witness who stated that the scene was chaotic
and that
there did not appear to be any clear line of authority
as to who was in charge. This was refuted by
another witness
(O.P.P.) Ident officer, who was quite sure of the lines of
authority and who was in
charge. I note that there were many
agencies present, including Fire Marshall's Office, the Technical
Standards and Safety Authority, Municipal First Response Team, the
O.P.P. Identification Unit from Kenora as well as the O.P.P.
Dryden Detachment, the Ministry of Labour, and the investigating
coroner. I can certainly appreciate that the scene may have
appeared disorganized to some observers, although I do not believe
this to be the case.
8.
The Jury heard evidence that both the Fire Marshal and the
Technical Standard and Safety Authority were in attendance at the
scene, however, neither of these agencies filed a report. The Jury
heard evidence from one witness stating that both of these
agencies performed an initial investigation, sufficient to
determine that they did not have jurisdiction in this
investigation, and thus both of the agencies left without
completing their investigations or filing a report.
It was
stated by another witness that there appeared to be a conflict of
personality between the personnel involved with these agencies,
and this witness speculated that the personnel involved in these
agencies may have left the scene prematurely, and not completed a
report over this issue.
The Jury felt that if an agency
were to attend the scene it should file a report, even if the
agency did not have jurisdiction. It is recognized that this would
not help prevent future deaths under similar
circumstances, but
would clarify things for anyone reviewing the investigations later
on.
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©2004 Canadian Centre for Occupational
Health & Safety 