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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: R. Isaac, M. D., Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY : 1984-07-27
INFORMATION ABOUT DECEASED:
NAME: Vernon Douglas White
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Oil Refinery
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1984-05-11
PLACE OF ACCIDENT: Canadian Oil Co., 309 Cherry St., Toronto
BRIEF CAUSE OF DEATH: Asphyxia due to aspiration of blood; severe
cranio-cerebral and multiple injuries.
BRIEF MANNER OF DEATH: Due to Petro-Chemical explosion.
ACCIDENT DESCRIPTION:
We the Jury find that the deceased came to his death as the
result of an
accidental explosion originating in compartment four of a fuel
tanker
during filling procedure. The cause of the explosion was a static
spark
generated by the pumping of oil, HV-250 from the storage tank
to the
trailer. HV1-250 is a highly viscous, clean oil product, which
carries
an electric charge very easily. In the absence of an explosive
vapour;
however, the loading of HV1-250 will not cause an explosion.
Standard
grounding procedures reduce, but do not eliminate the possibility
of a
static spark.
In this case, the spark ignited gasoline vapours in the compartment,
that either remained or re-entered after flushing. The gasoline
vapours
remained in the tanker as a result of a previous load of gasoline.
The
flushing procedures would remove any remaining liquid, but not
gasoline
vapours. It would also not remove any liquid or vapours in the
voids
between the compartments of the multi-compartment trailer. The
existence of the vapour was not detected by the company's explosimeter
either because it was:
1. not used,
2. it was used improperly, or
3. it was not functioning properly.
The tanker involved was owned in Quebec, leased to an Ontario
(sub)
leasing company and loaned to Canadian Oil Ltd. which re-refines
machine
oil to make HVI 250 (a pine oil with very high flash point which
is
viscous - it is the base of motor oils etc.) inter al. The tanker
had
five compartments separated by double bulk heads with a void
(air space)
between. These air spaces are supposed to be freely draining
but three
had been capped, probably because of leaking. There is evidence
of past
structural damage to the tanker which may have caused leaking.
A small
amount of gasoline or vapour may have been in these voids, due
to the
leaks and sealed there due to capping of the vents.
The tanker had previously carried gasoline. Canadian Oil would
not have
accepted it had they had this information. The octagonal tags
required
to be fixed to spouts of The tanker had probably been removed
- since
the tanker was "empty" (except for fumes) there was
no breach
regulation. The tanker was flushed with about 1 percent load
to clean
it but such a flush would only remove residue on the bottom
of the tanks
and not gasoline vapour. This vapour is heavy and may settle
to the
bottom of the tanks. Steam filling of tankers is the best way
to remove
vapour.
There is doubt whether an explosimenter (volatile hydro carbon
detector)
was used by the deceased. It should have been. The detector
unit in
question was functioning poorly but should have registered some
danger.
Static electricity is generated in the filtering, loading and
piping of
any fluid, especially this type of viscous, poor conductor.
This charge
builds up in the tank as it is filled and is only slowly discharged
through the metal tank which is grounded. A spark from the static
charge ignited gas vapours as they fully neared the top of the
tank.
This caused an explosion and fire, fatally injuring the deceased.
RECOMMENDATIONS ISSUING FROM INQUIRY:
TO CANADIAN OIL COMPANY:
A number of improvements to the operations at Canadian Oil Company
arose
at this inquest. These improvements, however, should be put
in context.
The Company had a reasonable safety record with the Ministry
of Labour.
Management had developed a safety manual for employees. And
actions
were being taken to remedy the static electricity problem.
1. We recommend that tankers used by the company to transport
HVI Products
be dedicated solely to that purpose and absolutely no switchloading
of
that product be allowed.
2. All tankers used by the company should be checked for tags
which
indicate the previous load. Tankers that have been used to transport
Class I products should be sent back to the supplier or customer.
3. The explosimeter procedure for checking for volatile vapours
should be
conducted by two people (i.e. the buddy system) to ensure proper
use and
proper readings.
4. Employees should be regularly tested in the use of the explosimeter
and
any other protective equipment they are expected to use.
5. The company should inform all of its tanker suppliers (as
well as its
customers), in writing, of its policy on switchloading. It should
also
indicate to suppliers that tankers previously used to transport
Class 1
products.
6. The company's policy on switchloading and the procedures
to be used when
loading HVI products should be incorporated into its safety
manual. All
future changes of this importance should be immediately incorporated
in
the safety manual and communicated to the employees (as was
done in this
case).
7. The explosimeter itself should be centrally located and controlled
and
any use of the device be recorded in a log form.
8. The company is encouraged to continue its efforts to reduce
static
electricity in HVI products through research into the addition
of
additives to their products.
9. Maintenance of equipment is a joint responsibility of the
employer and
employee. To meet their responsibility we recommend the company
adopt a
schedule of preventative maintenance on all equipment supplied
to the
employees. Results of the maintenance of each piece of equipment
should
be recorded.
10. Equipment such as the explosimeter should be checked at
least annually
by the manufacturer to ensure it is in good operational order.
11. The "company record" filled out during the loading
operation should be
modified to include the recording of:
1. Previous load in trailer.
2. The results given by explosimeter test.
3. Examine drains to insure they have not been capped and no
leaks
exist.
4. A warning showing not to fill in the case that any one or
multiple
of above three are not satisfactory.
INDUSTRY RECOMMENDATIONS:
1. The industry should modify "circle check" procedures
on petroleum
tankers to include a check of void drains on multicompartment
tankers
for "caps".
2. All tankers engaged in carrying petro-chemical products should
maintain
a log of previous loads carried by the tanker.
3. Tankers that have carried a Class 1 product at some time
should be
permanently identified as such. (eg. a sticker on the outside
of the
tank).
4. All rental/lease agreements for tankers should identify what
the most
recent load on that tanker was.
INFORMATION TO INDUSTRY:
1. The IAPA and/or Transportation Safety Association should
be encouraged
to develop training courses for existing petroleum products.
These
courses should include such topics as;
a) the construction of tankers
b) switchloading
c) the purpose and effectiveness of flushing
d) the problem of static electricity
e) advantages/disadvantages of various types of loading (eg.
top and bottom
loading)
f) existing laws and regulations applicable to handling and
transportation
of petro-chemical products
g) pronouncements and notices from authoritative bodies (eg.
Hazard Alerts
from the Ministry of Labour).
2. Existing training programs by private companies should be
renewed and
certified by the IAPA and/or the Transportation Safety Association.
3. New drivers of petroleum tankers should take a certified
safety course,
as described in the above recommendations, prior to obtaining
their
licence to operate.
4. The Minister of Labour issue a "Hazard Alert" immediately
on the dangers
associated with switchloading different classes of petro-chemical
products.
5. We recommend that the Minister of Labour take a pro-active
role in
notifying the Petro-Chemical Industry of the existance of the
static
electricity hazard and the following information to reduce that
hazard.
A) Controlling the road tanker charging rate to both speeds
recommended in
the American Petroleum Institute Bulletin No. 2003, Section
2.4.3. i.e.
seven (7) meters per second and the calculated bulk loading
rate.
B) Ensure that a relaxation period after the final filter is
at least 40
seconds. (Highly refined products require more time than the
30 seconds
normally recommended).
6. We recommended that a copy of these recommendations be forwarded
to the
IAPA and the Transportation Safety Association for their consideration.
RECOMMENDED CHANGES TO LEGISLATION:
1. We recommend closer liason between the Ministries of Transportation,
Labour and Consumer and Commercial Affairs, particularly with
regard to
the coordination of legislation and the exchange of information
related
to the handling and transportation of petroleum products.
2. We further recommend that the Ministry of Consumer and Commercial
Affairs identify the Federal Department responsible for railway
tankers
and work more closely with them on legislation, the exchange
of
information and regulations.
3. We recommend that a copy of our recommendations be forwarded
to the
Federal Department responsible for the development of a new
Hazardous
Products Act for their consideration.
4. We recommend that the following changes be made to the Gasoline
Handling
Act and Gasoline Handling Code January 1983:
A) Section 5, Subsection 11
This subsection should be rewritten to refer to empty tank trucks
and
trailers. It should also be rewritten to apply to tank truck
trailers
and semi trailers and semi trailers carrying liquids of the
same class.
B) Section 5, Subsection 6
The application for a licence to transport or the renewal of
same should
be applicable to specific tanker for a specific time and for
a specific
class of liquid.
In addition, we recommend that the application for a licence
and the
renewal of same be subject to an inspection of the tank trucks,
trailer,
or semi-trailer for road stability and safety.
C) Section 5, Subsection 32
This subsection should be modified to include a specific visual
inspection of the void drains in a multi compartment tanker
to ensure
they are functioning.
D) Section 5, Subsection 46
This subsection should be modified to ensure that tags remain
attached
to the tanker until the class of liquid is changed.
E) Section 10, Subsection 7
The Act should include a definition of the word "vehicle"
in particular
it should be extended to include the supplier of the equipment.
The
word supplier should be defined as in section 19 of the Occupational
Health and Safety Act and Regulations for Industrial Establishments.
5. We recommend that a certificate of fitness accompany the
change of
ownership of a tank truck, trailer or semi-trailer. We believe
that
this recommendation would require a change to the Highway Traffic
Act.
6. As an example of coordination between the Ministries of Transportation
and Consumer and Commercial Affairs we recommend that the inspectors
at
Department of Transport weigh stations include in their inspections
a
review of tank trucks, trailers, and semi-trailers for structural
damage
and open void drains and tanker registration.
7. We recommend that sections 71 through 75 of the Occupational
Health and
Safety Act Regulations for Industrial Establishments be amended
to apply
not only to workers in a confined space but also to workers
with or
testing a confined space.
COMMENTS ON RECOMMENDATIONS BY CORONER:
Reason for each recommendation with brief explanation:
TO CANADIAN OIL:
1. This prevents switchloading, switching the loads with the
possibility of
residue gasoline vapour.
2. Tags identify the class of product. Here the tags were probably
not
present on May 11 and the tanker was empty except for the gasoline
vapour. However, a tag would alert to potential hazard.
3. Two people serve as a check on each other to assure that
a routine test
is completed.
4. The meter must be fully inserted into a tank; gas vapour
may settle to
the bottom and form a layer.
5. The company wouldn't accept tankers which had previously
carried
gasoline (Class I). This would give supplies written notice.
This
tanker was inappropriate for the use.
6. This is being done.
7. Record keeping helps to assure that the test is in fact done.
8. Additives would reduce static build-up, however; testing
is being done
to see if additives would interfere with the use of the oil.
9. This is self evident but a good policy to stress. The explosimeter
was
not used too often, had corroded and had been repaired and some
of the
batteries had been removed. Thus it was not functioning up to
standards.
10. Routine servicing.
11. This recommendation is directed to increasing transfer of
information
(prior load) insuring that the explosimeter test is done, insuring
that
inspection for capped vents on voids is done (this can be awkward
because they are located under vents in the tank) and warning
of danger.
TO INDUSTRY:
1. Circle checks are done by drivers prior to leaving with a
load. They
usually relate to mechanical fitness but capping indicates that
a leak
exists between compartments. Load carrying with a capped vehicle
is
illegal ((Gas Handling Act Reg. 5((11)) and very unsafe.
2. This is another check so that switch loading does not occur
and to warn
subsequent drivers of prior dangers (especially gasoline fumes).
3. Another form of warning, at a worker level and inspector
level.
4. Yet another form of warning - Administrative level.
TO INDUSTRY:
Drivers take a written and practical exam to get a licence to
drive
these heavy tankers but there is no uniform educational course.
Many
drivers do not know the dangers of switch loading, static electricity,
or capping vents on voids or that flushing will not remove gasoline
fumes. One of our officers did a survey; most drivers/loaders
do not
inspect for caps. All training is by the private companies and
"on the
job". Small companies may not afford such courses.
3. This might go to Ministry of Transport too - as part of licensing.
4. This is one way of getting information to the workers.
5. A) See exhibit 28 for part of the bulletin.
This Ministry of Labour (Occupational Health) has lines of communication
to workers and industries. The Ministry of Consumer and Commercial
Relations could also send out this information under the Gasoline
Handling Act.
Relaxation period is the time for liquid to flow through the
pipes after
being filtered. A longer period allows for better dissipation
of static
electricity charge built up during filtering. The charge is
"safe"
while in a pipe because there is no oxygen and no spark or ignition
source. Once liquid leaves the pipe, oxygen and a spark may
be
available.
6. Self explanatory.
7. See exhibit 36. These are two Canadian (trucking) trade publications.
I would send this information to all Canadian Trade Publications
that
can be identified. (and possibly to American ones as well).
LEGISLATION:
1. Labour (Occupational Health), Ministry of Consumer and Commercial
Relations (Gasoline Handling Act) and Transport (HTA) must work
together
because this industry crosses all three.
2. Railways and railway loading (possibly other areas) are in
the Federal
sphere. Send copies please to the railways and the railway regulating
agencies as well as Dominion Government. Try Department of Energy,
Mines and Resources.(?)
3. A new Federal Hazardous Products Act is being developed which
will cover
some areas of this inquest.
4. A)5(11) Now refers only to trailers carrying liquids-an empty
trailer
may have gasoline vapours. It also refers to trailers carrying
only
different classes of hydrocarbon liquids. Little danger would
exist if
vents were capped where only the same class of hydrocarbon is
carried,
but in the future different classes may again be carried. A
cap is put
on to prevent leaking and leaking indicates structural unsoundness.
B) Licences are now issued to an individual or company to use
a
designated tanker. As a further check, add a designation of
the class
of liquid which can be carried. This will prevent switching
of the load
(switch loading). The licences are time limited. Relicensing
is done
by proper application and fee payment only. Relicensing should
involve
a check on mechanical fitness, including whether the vents on
the voids
have been capped. The life of a tanker is said to be 10-15 years.
C) An inspection (part of the vehicle check) is implied in Reg.
5(32)
when it refers to operations. The jury wants this one item very
specifically referred to. The section now talks about leaks.
Capping
indicates a leak has occurred.
D) Taps should stay on until the class of liquid is changed.
The
regulation now says tags must be on only while the liquid is
contained
in the trailer. But even after liquid is drained, fumes can
remain.
This is an added warning.
E) More specificity. Issue: Does reg. 10(7) apply to this trailer?
Is a trailer a "vehicle" or is the cab only a "vehicle"?
F) Here there was an owner, a leasor, an operator, and an employee.
They should all be included. The concept of supplier and user
is
broader and catches all.
5. Self evident. Compare with transferring of ownership of a
car which
requires such a certificate.
6. This could easily be delegated by the Ministry of Consumer
and
Commercial Relations to the inspectors of the Ministry of Transportation
who have a chance to spot check vehicles. Currently Transport
does not
look for capping of vents on voids. Alternatively (but less
efficiently) the highway inspection stations could be used by
Gasoline
Handling Act inspectors.
7. This accident did not involve a worker in a confined space
but the
vapour was in a confined space when it exploded and the worker
was just
above the space.
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