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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Dr. D. P. Fitzgerald, Coroner
PLACE OF INQUIRY: Stratford
DATE OF INQUIRY : 1986-01-22
INFORMATION ABOUT DECEASED:
NAME: Daniel A. O'Keefe
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Unavailable
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1985-08-29
PLACE OF ACCIDENT: Unavailable
BRIEF CAUSE OF DEATH: Pulmonary complications and sepsis due
to extensive
cutaneous burns.
BRIEF MANNER OF DEATH: Explosion and fire by a static electric
spark
possibly caused from a missing ground clamp.
ACCIDENT DESCRIPTION:
The above deceased and Rob Harmer were adding aluminum powder
to
polyethylene plastic when an explosion occurred. They were both
severely burned. O'Keefe died 30 days later.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. In the handling of high risk chemicals, existing safety procedures
should be more specific and strictly enforced.
2. Workers should be made more aware of potential hazards, possible
causes
of such hazards and be given a better understanding of the equipment
they are working with. This information should be relayed on
a more
personal level of communication rather than the mere passing
of
bulletins.
3. While working with combustible materials more effective protective
clothing should be mandatory.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1. Aluminum powder is highly explosive in contact with a spark
and oxygen.
During the inquest it came out that safety measures were mentioned
several times, and the workers probably ignored them.
2. During the evidence it was demonstrated that the workers
were
knowledgeable, and were reminded of this (See 1. above).
3. The workers' clothes were completely burned. This recommendation
seems
a reasonable one.
1. and 2. do not seem to me to be particularly relevant, when
reviewing
the evidence brought out at the inquest.
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