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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Dr. C. McIlveen, Coroner
PLACE OF INQUIRY: Whitby
DATE OF INQUIRY : 1986-06-11
INFORMATION ABOUT DECEASED:
NAME: Donald Wright
OCCUPATION: Equipment operator.
INDUSTRIAL SECTOR: Drainage Construction
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1985-10-17
PLACE OF ACCIDENT: 6th Concession and Simcoe Street
BRIEF CAUSE OF DEATH: Asphyxiation due to carbon monoxide
BRIEF MANNER OF DEATH: Gas fire explosion.
ACCIDENT DESCRIPTION:
The above death occurred from an explosion of a main line of
Trans
Canada Pipeline which was inadvertently hit by a trench digger
operated
by the late Donald Wright. The resultant hole in the pipe released
gas
under pressure, ignited and the resulting explosion instantly
incinerated Mr. Wright and severely burned three men working
for the
drainage company, plus an employee of Trans Canada Pipe who
was present
to locate and stake the two buried pipelines.
The evidence at the inquest clearly indicates that the Trans
Canada Pipe
locator had staked one line which he thought was the North Line.
He so
indicated to the deceased. The deceased put stakes approximately
30
feet north of Trans Canada stakes which were supposed to be
his safety
margin.
Mr. Burkholder, the Trans Canada Pipe employee and pipe locator
was
continuing to search for the other line and was having difficulty
finding it. Mr. Burkholder still felt he had the north line
staked when
the explosion occurred. The stakes that the deceased put in
the ground
as a safety margin to stop digging were right on top of the
north pipe
line.
The evidence clearly indicated that this was a human error.
Mr.
Burkholder found a line and assumed it was the north line. Mr.
Wright
took the assumption of it being the north line as gospel and
did not
wait for the other line to be found and staked.
Mr. Wright and Mr. Burkholder had worked together before many
times.
Each respected the other. Both were well trained and had a great
deal
of experience in their jobs. Human error on both parties caused
this
terrible tragedy.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. No work to start on site until all utilities are identified
with
coloured stakes and if necessary, daylight utilities.
2. Add training course for operator's licence to dig around
all utilities.
3. Utility markers should be properly tagged and maintained
at fence lines
and roadways.
4. Upgrade gas line inspectors' training courses and equipment
used.
5. One call system for all utilities before any digging.
6. Penalty should be imposed on all unauthorized diggings or
crossings on
gas or other utilities.
7. Better communication between contractors and utility company.
8. Stakes should be a standard minimum height and some kind
of colour code
- example - 4 foot gas lines.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1. If this would have been done this accident would not have
happened.
Talking to farm drainage people, they feel recommendations should
read:
No work on easement until all utilities are identified. Stakes
put in
too early may be subject to vandalism and create problems.
2. This was not a problem with this inquest, but the witness
from Union Gas
stated some of the problems encountered with inadequate training.
It
could be part of their training for an "A" license.
3. This would have been beneficial in this case. Had the pipeline
been
marked at the fence line, Mr. Burkholder probably would not
have
mistaken the south for the north line.
4. No witness had any derogatory remarks about the ability of
inspector in
this case. However, we were told of disadvantages of the metrotech
locator. It was pointed out that if adequate personnel and adequate
time is taken, it is a satisfactory piece of equipment.
5. This was a recommendation suggested by Ontario Farm Drainage
Association
that the appropriate Ministry in the province should investigate
the
miss dig program in Michigan. Apparently on many occasions,
difficulty
is encountered getting the proper people to the site to locate
facilities.
6. It was pointed out at the inquest that although penalties
are in the
legislation they are never applied.
7. This one call system would help this problem. Apparently
in some
utilities, ie. Bell Telephone, it is a problem to find the department
looking after buried cables.
8. In this case locator did not have adequate number of stakes
and borrowed
some from contractor. However, it was not a mistake in stakes
that
caused the accident. It was shown how coloured stakes could
instantly
be identified if each utility were different, that is Bell Telephone,
Union Gas, Consumers Gas and Trans Canada Pipeline.
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