Record Number: 1286 CIS Descriptors: BITUMEN EXPLOSIONS SHIFT WORK TRANSFER OF LIQUIDS EXPERIENCE FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. C. Robson, Coroner PLACE OF INQUIRY: Toronto DATE OF INQUIRY : 1982-11-19 INFORMATION ABOUT DECEASED: NAME: Norman Barker OCCUPATION: Unavailable INDUSTRIAL SECTOR: Asphalt ACCIDENT INFORMATION: DATE OF ACCIDENT : 1982-06-14 PLACE OF ACCIDENT: McAsphalt Industries Ltd., Sheppard Ave, East Scarboro BRIEF CAUSE OF DEATH: Rupture of aorta with massive bilateral hemothorax. BRIEF MANNER OF DEATH: As a result of an explosion. ACCIDENT DESCRIPTION: From evidence submitted that during a routine measurement of primer (asphalt) contained in a tank and employing a universally accepted dipping method at McAsphalt Industries Ltd., Sheppard Ave. East, Scarboro, Ontario on Monday June 14, 1982 approx 11:00 p.m. Norman Barker, the now deceased came to an accidental death as a result of an explosion. Briefly, Norman Barker died as a result of an explosion at McAsphalt Industries Ltd., Sheppard Avenue, East, Scarborough, on June 14 1982. Barker, aged 24, and Gregory Wuisman, aged 19, were working the afternoon shift on that day, by themselves. Barker had five weeks' experience and Wuisman several months' experience with McAsphalt. Both were competent to carry out the tasks assigned them. One of their tasks was to transfer asphalt primer from one holding tank to another. Before the day shift left, it was ascertained that there was sufficient space in the receiving tank and an overflow could not occur. Towards the end of the shift, doubt arose as to whether the material was flowing correctly. According to the evidence, Barker went to the top of the receiving tank to take a dip reading, but could not read the measure as he had no flashlight. Apparently Wuisman and Barker searched for a flashlight but could not find one. Barker went up the tank again and Wuisman followed him. According to Wuisman, when he reached the third top rung, he saw Barker crouched over the inspection manhole and a blue flame. He started down the ladder, but before he reached the bottom an explosion occurred. Barker was found lying about fifteen feet from the tank and was taken to Scarborough Centenary Hospital where he was pronounced DOA at 1143 hours. Wuisman suffered third degree burns and spent several months in Scarborough General Hospital. There was no evidence as to whether the source of ignition was a match. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. Supervisor to be present on each shift and for the duration of the shift. 2. Regular safety meetings with mandatory attendance of all employees for the express purpose of reviewing all safety measures. 3. Extensive and thorough training of all employees to assure competence of job and duties, with periodic re-fresher courses. 4. Supervisor in attendance must issue flash light to each employee working in any dangerous area during afternoon and all night shifts. COMMENTS ON RECOMMENDATIONS BY CORONER: 1. In my summation, I suggested that this might be an appropriate recommendation. Although Barker and Wuisman were competent to do the job allocated, they did not use sound judgment. They had the option of stopping the operation or telephoning the plant manager for instructions. They did not do so. An experienced supervisor would not have permitted an unsafe procedure to be carried out. 2. Since the accident, this measure has already been taken. Employees not working at the time of the meeting are paid to attend. 3. Evidence indicated that the employees are trained for the job which they have to carry out. This training is carried out on the job. The procedures carried out by temporary summer employees are few and uncomplicated. They are not hazardous if existing safety regulations are observed. Temporary employees do not work for more than a few months in the summer and would not work long enough for refresher courses to be appropriate. The training of full-time employees was not considered at this inquest. 4. I agree with this recommendation. I have one further comment. Safety regulations state that matches and cigarette lighters must not be carried on the person of an employee working in a dangerous area. Lockers are provided for each employee. However, apparently, the Bill of Rights prevents spot checks or searches of employees to be carried out in order to determine that they are observing these safety regulations.