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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Doctor Aikenhead, Coroner
PLACE OF INQUIRY: Milton
DATE OF INQUIRY : 1985-05-14
INFORMATION ABOUT DECEASED:
NAME: Terry Grant
OCCUPATION: Apprentice Mechanic
INDUSTRIAL SECTOR: Transportation
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1985-03-13
PLACE OF ACCIDENT: 245 Bronte Street, Milton
BRIEF CAUSE OF DEATH: Multiple skull fractures and extensive
third degree
burns.
BRIEF MANNER OF DEATH: By means of an explosion involving a
45 gallon drum
of methyl hydrate (concentrated windshield washer anit-freeze)
located
in the vicinity of his work area.
ACCIDENT DESCRIPTION:
The deceased was an apprentice mechanic employed part-time with
Sandstone Transport, 245 Bronte Street, Milton. On the evening
of March
13th, 1985 he died as a result of an explosion of a drum containing
methyl hydrate concentrate. Circumstantial evidence would indicate
that
he was most likely welding on top of the drum. The drum exploded,
hurtling him into the side of a nearby tractor trailer resulting
in a
skull fracture and extensive third degree burns which were instantly
fatal.
Subsequent investigation revealed that the workers in the garage
were
unaware of the extremely explosive nature of methyl hydrate.
The drum
was labelled as being toxic but not flammable or explosive.
Investigation by the Fire Marshal's department revealed that
there was
no law requiring suppliers of this material to industry to clearly
demarcate the volatile explosive nature of the contents. In
addition,
there appeared to be confusion as to who was responsible for
safety
inspection and implementation of the fire code regulations.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. There should be a distinct, standardized, national label
for all
containers of flammable or potentially explosive chemicals,
attached
separately from any commercial identifications.
2. Apparent confusion regarding the current areas of responsibility
among
government safety agencies must be clarified. In particular,
a high
priority should be given to the application and enforcement
of existing
laws, regulations and labour codes with respect to the storage
and use
of dangerous chemicals in the workplace.
3. There should be increased public awareness of the hazards
of dangerous
chemicals commonly used in the work place and by consumers generally.
4. Employers should be encouraged to formulate and enforce internal
safety
standards specific to their plant operations.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1. This recommendation stemmed from the absence of any conspicuous
symbol
on the drum involved in the explosion. Further investigation
revealed
that there were no regulations or laws requiring suppliers of
methyl
hydrate to label the drums as being explosive. Pending legislation
under the Transportation of Dangerous Goods Act to come into
effect in
July, 1985 stipulates that such containers must be labelled
as being
flammable or combustible.
The jury's recommendation feels that this legislation will be
satisfied
only if a conspicuous large sized logo indicating the explosive
nature
of the container is affixed to the container in such a manner
that it
can be easily recognized as being explosive or flammable. Great
benefit
would derive from a Canada wide symbol such as a triangle with
flame
inside or other distinctive logo which would be recognized by
all to
warn of the explosive dangerous contents of containers.
2. In this particular case, the safety regulations were under
the
jurisdiction of the Canada Department of Labour. The Canada
Department
of Labour were unaware that this company was under their jurisdiction.
Previously, up to July, 1983 the transport company was under
the
jurisdiction of the Provincial Department of Labour Occupational
Health
and Safety Division. When the transport company acquired an
extra-provincial license to operate their transport trailers
across
inter-provincial license to operate their transport trailers
across
inter-provincial borders, the safety supervision of the plant
fell under
the Canadian Department of Labour.
There apparently exists no mechanism whereby this transfer of
authority
was communicated from one Department of Labour to the other.
During the
trial it became evident that the Canada Department of Labour
did not
have sufficient staffing to do regular safety inspections of
such plants
and that they function only as an investigator of safety violations
communicated to them. The storage of the methyl hydrate and
several
other features of the case were clearly contraventions of sections
of
the Canada Labour Code, however, without personnel to enforce
these
regulations, they became meaningless.
In addition, at the inquest it became evident that there existed
confusion about the implementation of recommendations of the
Ontario
Fire Code. The local by-laws documented sections of the Ontario
Fire
Code which were clearly not enforced at this particular transport
garage. Once again, there was no regular inspection procedure
enforced
by the local fire department. Representatives of the Ontario
Fire
Marshal's Department also communicated that there was some confusion
about which set of rules applied within the province in view
of an
apparent duplication between the Canada Fire Code and the Ontario
Fire
Code Regulations.
3. This recommendation was apropos in view of the fact that
the employees
and mangerial staff of Sandstone Transport were clearly unaware
of the
explosive nature of methyl hydrate. The chemical company, the
supplier
of the chemicals fielding chemical did not label the drums as
being
explosive although they did have a data sheet which explained
this but
they did not supply this to the buyer of the methyl hydrate
unless
requested. Representatives of the Canada Department of Labour
stated
they had sent an alert to the workplace in Ontario concerning
the
hazards of methyl hydrate. Measures would appear to be indicated
to
educate the public that there exists dangerous chemicals such
as methyl
hydrate which are widely used for windshield washer antifreeze
which
under the right conditions become very explosive.
4. In a small plant or garage such as this there were safety
meetings
conducted, however, these were directed and attended mostly
by truck
drivers. The ignorance of the explosive nature of methyl hydrate
would
appear fairly common amongst garages. If there were some integration
with Canada Labour or Ontario Labour Department officials with
safety
committees or safety officers, possibly this tragedy could have
been
averted.
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