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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: J. D. Lovering M. D., Coroner
PLACE OF INQUIRY: Toronto
DATE OF INQUIRY : 1985-02-15
INFORMATION ABOUT DECEASED:
NAME: Rosa Delgiudice
OCCUPATION: Textile Processing
INDUSTRIAL SECTOR: Manufacturing
ACCIDENT INFORMATION:
DATE OF FATALITY : 1984-12-30
PLACE OF ACCIDENT: Unavailable
BRIEF CAUSE OF DEATH: Toxaemia of burns of skin and trachea
and candidiasis
of myocardium.
BRIEF MANNER OF DEATH: As a result of fire and explosion due
to volatile
chemical being used close to heated oven while cleaning conveyor
belt.
ACCIDENT DESCRIPTION:
She was working on a conveyor belt that was involved in making
purses
and billfolds. After one day's production it was necessary to
clean the
belt. A very volatile cleaner was used in very close proximity
to a
heat source when the cleaner ignited and exploded. Mrs. Delguidice
was
badly burned and died on December 30, 1984 as a result of the
accident.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. Fire and safety training sessions should be carried out once
per year to
keep workers aware of hazards in their work place and where
the safety
committee is introduced.
Fire Department Inspectors and Ministry of Labour Inspectors
should
visit the plant annually. Inspection reports should be passed
on to the
president of the company, the safety committee and the union
to ensure
prompt followup of infractions.
Inspectors should have discretionay power to stop work and/or
lay
charges where unsafe practices are still carried out on followup
visits,
within 30 days, and that details of the charge be available
to
newspapers and the media.
Consideration should be given to increasing the minimum size
of safety
committees in large plants. Safety committees in factories which
have
separately supervised areas of more than 20 workers should have
a
representative from each area.
The safety committee should receive copies of all safety information
concerning materials and equipment used in the work place. Workers
should be made aware of this material and its contents.
2. If safety features are not built into equipment, relevant
warnings
should be labelled clearly on that equipment.
3. Solvents should be labelled with, or accompanied by, more
detailed
information, modelled after label attached to this copy: flammability
dangers, leak procedures, problems with physical contact, first
aid
procedures and major uses of the solvents. Additional content
identification stickers should be attached to small safety cans.
4. Improved communications between people down the chain of
command. There
should be an onus on managers and supervisors to be sure that
employees
can demonstrate verbally or by their actions, knowledge of safety
procedures and equipment related to their work. A supervisor
giving
instructions must be sure that the instructions are understood
and that
the instructions are consistently followed.
5. Clearly written instructions should be made available to
the work area
describing any new manufacturing procedures, including preparation,
clean up and safety considerations.
6. A fire smothering blanket should be available to areas where
flammable
solvents are used.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1. Cooper Canada and supervisory staff may have been lax in
safety
training. Employees were not aware of existence of a safety
committee.
Fire inspectors and Ministry of Labour inspectors did not follow
up on
infractions noted in previous inspections. It became evident
to the
jury that the safety committee played no role in any of the
proceedings.
The reason the union (the safety committee representatives in
court)
gave for this was that there was not enough people on the safety
for a
plant of this size. Communications obviously needed improvement
at
Cooper Canada. In all cases, whether safety information came
from
equipment suppliers or material suppliers no safety information
was
passed on to the workers.
2. The manufacturer has a responsibility to give warnings. Safety
features
were omitted.
3. The labelling of the Hallmark 88 can was not clearly marked.
We feel
the labels should be improved.
4. At Cooper, assumptions were made that instructions were understood.
In
fact, the important safety instructions were not passed on,
improper
procedures were carried out for months and the engineer who
set up the
procedure never double checked to see that his instructions
were
followed.
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