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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Dr. Robert N. Green, Coroner
PLACE OF INQUIRY: London
DATE OF INQUIRY : 1985-11-08
INFORMATION ABOUT DECEASED:
NAME: Leonard Thistle
OCCUPATION: Maintenance
INDUSTRIAL SECTOR: Service Station
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1985-09-14
PLACE OF ACCIDENT: Unavailable
BRIEF CAUSE OF DEATH: Complications from extensive body burns.
BRIEF MANNER OF DEATH: Gasoline fume ignition fire occurring
in a confined
space, fuel storage tank.
ACCIDENT DESCRIPTION:
The inquest is concerned with the death of Leonard Thistle which
occurred in the critical care unit of Victoria Hospital on the
23rd of
September 1985. This death was a result of extensive body burns
received in a flammable fuel ignition fire in a gasoline storage
tank on
14 September 1985. The deceased was a trained worker in a high
risk
industrial repair occupation, servicing and refitting gasoline
storage
tanks. The high risk of explosion and fire in this occupation
has led
to statutory regulation of safety procedures to be followed
by workers
in this field.
Evidence heard at the inquest was summarized by the presiding
coroner as
follows:
A worker with Heath Engineering, testified that he was assisting
Leonard
Thistle in the cleaing out of a fuel storage tank. He stated
that he
had no formal training or instruction in these cleaning procedures
in
the five weeks he had been doing this job. He described the
procedure
of digging down to underground tanks, cutting an opening in
the steel
top with a water cooled, air driven drill and jig saw, after
evacuating
the tank of fuel and fumes. He explained that an aluminum ladder
was
inserted and cleaning of the tank was done by scrubbing and
scooping out
petroleum sludge with an aluminum shovel into a plastic bucket
and the
bucket lifted up through the opening.
He described the clothing and lighting used on the job. He described
pulling up a five gallon bucket of sludge which caught fire
when passing
close to a very hot lamp, being used to illuminate the tank.
A fire
spread within the tank and he lowered down the ladder; Thistle
climbed
out of the tank with his clothing on fire. A fire extinguisher
was
brought from the gas station to assist in dousing the fire in
Thistle's
clothing. On reflection about this incident, he expressed concern
about
the very hot lamp used and the possibility of wearing fire-proof
clothing on the job.
An area supervisor for Heath engineering with 14 months experience
with
the company, trained on the job. He functioned as a job coordinator
including spot checking on site for safety procedures being
followed
properly. He described the list of safety equipment to be available
and
to be used, including gas masks, hats, explosion proof lamps
and safety
harnesses. He explained that no lights were to be used during
the clean
up operations, that an air supply was a necessary part of the
face mask.
A specialist in internal medicine and intensive care, described
the
extensive surface and airway burns to Leonard Thistle. He explained
the
serious prognosis in this degree of burning. He described an
incident
three days prior to death when Thistle"s ventilator had
become
disconnected from his airway tube for a brief period resulting
in low
oxygen brain damage that may have hastened his death. On questioning
from the jury, he explained that the airway connector has to
regularly
be disconnected for suctioning of the airway and at many times
daily
these connections do become disconnected, but a nurse is always
present
and there is also a beeper warning device that sounds when the
disconnection occurs.
The reason that this disconnection was not noticed for a period
of about
7 minutes was that Thistle was being nursed in a separate room,
isolation for antiseptic procedure. The nurse had gone out of
the room
and the door was closed as part of the isolation procedure.
Apparently
the warning beeper could not be heard outside of the room when
the door
was closed. He stressed that Thistle's chance of survival from
these
extensive body burns was less than 10 percent.
An electrical engineer and owner of Heath Engineering described
his
company's experience in petroleum tank cleaning since 1966 and
his broad
experience in this area. He described the training of Leonard
Thistle
in these cleaning and tank lining procedures. He explained that
Thistle
had trained his associate on the job.
He explained that his written procedures were submitted to the
Ministry
of Labour, and he reviewed this document explaining the process.
Heath
advanced some recommendations regarding improved safety, noting
that a
safety harness is probably ineffective because the rope may
readily burn
and also because of the small entrance hole used in this work
would make
it very difficult to raise an unconscious person by rope and
harness
through the opening. Mr. Heath made some suggestions in regard
to
improved safety including the wearing of fire resistant clothing,
improved training procedures, and improved sludge removal procedures
that would not involve the presence of a worker in the tank.
An engineer with 17 years experience of the Ministry of Labour
as
Regional Engineer, his work often involving a review of hazardous
processes by field inspection for the Health and Safety Branch.
He
explained the regulations for working with hazardous gases in
a confined
space. He examined the job site involved the day after the fire
and
described his findings. The equipment on site was examined including
the pail, light and face mask involved, all showing evidence
of fire
damage.
There was no evidence of a safety harness or lifeline in the
immediate
area of the tank excavation. He concluded that the regulations
had not
been complied with during the cleaning of tank sludge in regard
to no
use of harness and lifeline, no use of airhose to face mask,
an
unsuitable light fixture used within the tank and questionable
tank
entry procedures. He recommended that no worker should be allowed
to
enter a confined space where there is a source of flammable
vapour.
Wayne Beedle, an Industrial Health and Safety Officer with the
Ministry
of Labour gave testimony regarding his investigation into this
industrial death. He described the equipment and clothing worn
by the
deceased at the time of the incident. He noted that the fire
was
limited to the inner layer of Thistle's clothing. He determined
that
the quartz light being used to illuminate the inside of the
tank was the
source of ignition of this fire.
He explained how broad the application of the Industrial Health
and
Safety Act is in application to workers in Ontario. He explained
the
responsibility of the worker, the supervisor, and the industry
in
adapting these broad, vague, general regulations to their particular
work area. In his opinion, it is not practical for government
inspectors to review all the details of all safety related issues
in all
industries. There are local conditions and frequent changes
that must
be addressed and policed by those in each particular industry.
A retired service station inspector now serving as a consultant
in fuel
storage tank installation, maintenance, and safety. He is very
familiar
with underground storage tanks for flammable fuel storage. He
explained
the need for the regulation of this work of lining all tanks.
He
outlined the difficulties in doing this job carefully and safely.
He
stressed the need for a step by step procedure, possibly reviewed
by a
safety officer. Uniform guidelines for the procedures are necessary
as
most workers are not well educated in the hazards involved.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. The jury strongly supports the recommendations of Mr. Wayne
Beedle with
regard to:
i) Ministry of Labour review safety procedures used by firms
involved in
work with tanks of sufficient size to allow access. Such as:
a) size
of entry hole, b) safety training of employees by employers,
c) type of
clothing to be worn, d) equipment to be used in operations,
e) safety
checklist.
ii) The Ministry of Labour, in conjunction with the Technical
Committee of
the Ontario Petroleum Association and other firms involved in
such
related work review practices and procedures on an ongoing basis.
iii) All companies involved in cleaning and repairing tanks
of sufficient
size to allow entry should be licensed.
2. The Ministry should request all firms involved in this type
of work to
immediately review and evaluate their safety precautions with
their
employees.
3. Respirator patients should be monitored at all times either
medical
staff with the patient or through alarms connected to a manual
site.
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