Record Number: 1240 CIS Descriptors: HEAD INJURIES EXPLOSIONS FIRED PRESSURE VESSELS FOOD INDUSTRY PREVENTIVE MAINTENANCE UNSAFE PRACTICES FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. R.D. MacKinlay, Coroner PLACE OF INQUIRY: St. Catharines DATE OF INQUIRY : 1982-06-24 INFORMATION ABOUT DECEASED: NAME: Herman Veldmeyer OCCUPATION: Stationary engineer INDUSTRIAL SECTOR: Food industry ACCIDENT INFORMATION: DATE OF ACCIDENT : 1981-10-01 PLACE OF ACCIDENT: Arkell Foods Limited BRIEF CAUSE OF DEATH: Skull fracture, brain laceration. BRIEF MANNER OF DEATH: Result of explosion. ACCIDENT DESCRIPTION: This man was killed when one of the boilers at Arkell Foods Limited, which was being converted to light oil fuel as a back-up to natural gas, exploded resulting in the main door blowing off and striking the deceased on the head and fracturing his skull. The boiler had originally been fired by heavy bunker oil but during the early summer of 1981 it was converted to natural gas. Then, because there may sometimes be a shortage of natural gas, a light oil burner was being added and this would be an alternate fuel. The witnesses indicated that the maintenance of the furnace and boiler was poor and that the cause of the explosion was due to the safety features being eliminated from the firing cycle of the furnace by the stationary engineer, Mr. Veldmeyer, and this was necessary because of the poor maintenance. The poor maintenance resulted in the fuel vapors not being eliminated from the combustion chamber before ignition of the pilot light. The pilot light ignited the gaseous light oil vapors and caused the explosion. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. The stationary engineer in charge of the boiler room set up a maintenance schedule and a qualified supervisor in turn check that the maintenance schedule is maintained in proper order to manufacturer specification. 2. Two switches be installed with a "lighting system" indicating proper opening and closing of "damper on control board". 3. All stationary engineers of boiler rooms be equipped with proper procedures set out by the Energy Act pertaining to types of boilers in their use. 4. At the "head" and "back" of each boiler, a sign indicating "Danger - No Standing". 5. The supplier of fuel place a seal on "Air Proving Switch" prior to operating and not be removed unless by fuel supplier. 6. At no time any fuel be flowed through any project until properly inspected with "Stamp of Approval" prior to full operation by fuel supplier. 7. A permanent ventilation opening meets standard specifications. 8. A "Government Inspection" be made after any new installation or conversion prior to operating to ensure all standard government specifications are met. COMMENTS ON RECOMMENDATIONS BY CORONER: The jury also learned of the inspections performed on this type of operation and found that no one had inspected the combustion chamber other than the stationary engineer. The stationary engineer kept a log of the operation of the boiler and burner indicating the inspection done each day but it was apparent that it was written but not done. The log book was countersigned each day by the owner of the company but he trusted the stationary engineer and never checked on the actual maintenance. 1. The jury felt that a proper maintenance schedule should be written and filled out everyday, signed by the stationary engineer, and inspected and signed by his supervisor would prevent the deteriorated state of the exploded boiler. 2. The damper controls the amount of air entering the fan for the burner and if it is at the closed position insufficient air can enter to eliminate the fuel vapors. The jury felt that there should be indicators on the operating panel showing the open and closed position of the damper. 3. Self-explanatory. 4. Boilers are built so that the back and/or front will blow off rather than have the whole boiler explode. 5. The Air Proving Switch is a safety feature preventing ignition of the pilot flame if there has not been a proper flow of air to remove the volatile vapor from the previous burn. This switch can be adjusted with a screwdriver and someone had adjusted it to the point that a small air pressure was sufficient to cause a contact and allow the ignition of the pilot light. 6. The jury was informed that a fuel supplier is supposed to inspect any new installation of equipment using their fuel, but they would not inspect the equipment unless the installer notifies them of the installation of a new piece of equipment. 7. The jury was informed that the boiler room at Arkell Foods Limited was dependant on its ventilation of air leading in around the closed door and windows. The regulations require a one square foot permanent opening for each 15 horsepower (hsp). The Arkell Foods Limited boilers generated 400 horsepower. 8. Self-explanatory. This would require a considerable increase in the number of fuel supply inspectors and I think the jury realized this.