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| Record Number: |
825 |
| CIS Descriptors: |
CHEMICAL BURNS
HYDROFLUORIC
ACID
CORROSION
INSPECTION
PIPES AND
FITTINGS
FIRST-AID TRAINING
FIRST-AID
ORGANIZATION
EMERGENCY SHOWERS
PETROCHEMICAL
INDUSTRY
PETROLEUM
REFINING
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REPORT
CHARACTERISTICS:
DONOR: Office of the Chief
Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of
Coroner's Jury
INDIVIDUAL PRESIDING: Dr. K. Flynn,
Coroner
PLACE OF INQUIRY: Brampton
DATE OF INQUIRY :
1979-08-08
INFORMATION ABOUT DECEASED:
NAME: Abdul
Mirza
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Petroleum
refining industry
ACCIDENT INFORMATION:
DATE OF
FATALITY : 1979-05-21
PLACE OF FATALITY: Hamilton General
Hospital
BRIEF CAUSE OF DEATH: Severe hypocalcaemia due to
fluoride toxicity.
BRIEF MANNER OF DEATH: Received acid burns
to his face.
ACCIDENT DESCRIPTION:
While attempting to
remove an end plug from a pipe containing 100%
concentration
enhydrous hydrofluoric acid under pressure, he
applied
sufficient pressure with a wrench to cause a sudden
rupture of a pipe
which was severely corroded by acid. The
resultant release of acid
under pressure caused the victim's
protective hat face shield to fall
off and he received acid
burns to his face. He failed to reach a safety
shower
immediately and also did not remain under a shower for
sufficient
length of time, with the result that severe tissue
damage resulted to
the face and absorption of fluoride occurred
into his body through this
area. Inhalation of acid vapour may
also have occurred. Cardiac arrest
occurred several times in
hospital due to depletion of calcium and
magnesium levels in
the blood and attempts to correct this situation
were
unsuccessful.
RECOMMENDATIONS ISSUING FROM
INQUIRY:
Medical care
1. Hospitals and ambulance
units in any area to be made aware by industries
of the risk of
hazardous substances and their treatment in event
of
accident.
2. Flip files to be maintained in emergency
departments of hospitals
containing above information, to
include names and phone numbers of
industrial physicians and to
be regularly reported.
3. Emergency room physicians be
provided with full details of industrial
accidents including
time, treatment given, and person to contact, to
accompany
treatment kit in ambulance.
4. Physicians involved in care
of this victim ensure that details of the
case be disseminated
in popular medical literature.
Occupational
safety
5. An immediate survey and ongoing inspection of all
acid-bearing equipment
at Gulf Oil refinery to assess state of
corrosion and warn workers of
damaged areas.
6. Joint
management/worker program to alert other users of HF Acid
to
circumstances of this accident. It is incumbent upon both
management
and workers to improve communication with the
intention of maintaining
safe working conditions.
7.
Safety regulations as already laid down to be prominently
displayed at
Gulf Oil.
8. All employees to prove
knowledge of relevant safety regulations within
one month of
commencing employment.
9. Protective clothing regulations
to be enforced.
10. Regular accident drills similar to fire
drills, be carried out
routinely.
11. Pipes containing
acid to be identified.
12. Shower locations to be
prominently posted with suitable lighting,
fluorescent paint
etc., and be no further than six meters from any acid
work
area.
13. Daily check of shower alarms, radio telephones
and stock of neutralizing
solutions.
14. Medical officer
or plant nurse to be a member of the safety committee.
15.
Control room to be staffed whenever work of any kind is being
performed,
at all times and on all shifts.
16. Safety
regulations in operators' manual to be placed at the beginning
of
the book.
17. Complete written and verbal
communication of shift changeover to be
maintained in
duplicate.
Occupational health
18. Every employee to
prove to medical department that he knows how to
respond to
acid exposure to himself and others.
19. Protocol on first
aid be displayed prominently at key locations.
20. Supplies
of HF neutralizing lotion be kept at key locations checked
and
replenished by safety personnel.
21. Wallet cards
similar to that used by Allied Chemical to be issued to
every
employee, and to include name and phone number of
physician
contact.
22. Medical officers in refinery and
manufacturing industries to pool their
knowledge and
standardize treatment methods.
23. Ministry of Labour,
Occupational Health Branch to supervise health and
safety
procedures in industrial areas and assist coordination
with
medical facilities.
24. Treatment kit available 24
hours a day to accompany victim to
the
hospital.
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©2004 Canadian Centre for Occupational
Health & Safety 