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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 : 1986-06-23
INFORMATION ABOUT DECEASED:
NAME: Giuseppe Campione
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Construction
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1986-03-26
PLACE OF ACCIDENT: Toronto
BRIEF CAUSE OF DEATH: Extensive burns.
BRIEF MANNER OF DEATH: Propane cylinder fire.
ACCIDENT DESCRIPTION:
We, the jury, find from the evidence submitted, that Guiseppe
Campione
came to his death as a result of burns received in a fire on
the third
floor of a construction site at 40 Sheppard Avenue West on March
26,
1986. On the third floor, a number of unsecured propane cylinders
were
being stored; cylinders that had been emptied and cylinders
awaiting use.
Evidence suggests that immediately prior to the fire, Mr. Campione
heard
one of the propane cylinders overturn and proceeded to walk
over to the
fallen cylinder. We believe that Mr. Campione then bent over
the fallen
propane cylinder which was releasing propane. It appears Mr.
Campione
then walked by an operating propane construction heater and
he caught
fire. Subsequently, the fire spread to the remaining cylinders
which
hampered immediate rescue attempts.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. The propane storage handling and utilization code should
be referenced
in and adopted as part of the regulations to the Ontario Occupational
Health and Safety Act. The propane storage handling and utilization
code should draw attention to relevant provisions of the Occupational
Health and Safety Act.
2. Ministry of Labour Construction inspectors should be empowered
to
enforce all regulations concerning safety in the use and handling
of
propane.
3. Section 19 of the Occupational Health and Safety Act should
be amended
to require that a supplier ensure the intended users of equipment
are
aware of requirements for its safe operation.
4. Section 51 of regulations to the Occupational Health and
Safety Act
(O.H.S.A.) should be clarified to indicate acceptable means
of securing
a cylinder. Additionally, uncertainty concerning the meaning
of
"storage cylinder" should be addressed.
5. Inspectors should ensure that employers comply fully with
section 14.2
of the "O.H.S.A.", which deals with employer responsibility
for safety.
6. The design of propane cylinders should be reviewed to provide
greater
protection against overturning. Relief valves should be redesigned
to
prevent the escape of liquid propane, and as soon as practicable,
only
relief valve seats able to withstand the heat normally associated
with
propane fires should be used.
7. Section 5.14 1h of the Propane Storage, Handling and Utilization
Code
("PSHUC") should be amended to require all construction
heaters to have
excess flow valves (E.F.V.) installed at the connection to the
propane
cylinder.
8. Section 3.5.3. of the "PSHUC" should be amended to
indicate that in the
event of known or suspected leakage, all sources of ignition
in the
vicinity shall be extinguished until the leakage is eliminated.
9. The "PSHUC" should be amended to require labelling
of all cylinders to
warn against fire, explosion and tipping hazards, the form and
wording
of which should be clear to all regardless of language spoken
and be
approved by the director.
10. The "PSHUC" and other similar documents which form
a part of
legislation or regulation should be readily available from such
government sources as the Ontario Government bookstore.
11. Legislation should require that all hoses and appliances
to be
connected to propane cylinders be inspected or checked prior
to rental
or sale. Propane cylinders and valves should be checked for
leakage
after each filling.
12. Trade Unions should ensure that employees working with propane
equipment are provided with regular training in its safe use
and ensure
that appropriate emergency procedures are in place and are communicated
to all workers.
13. A bulletin prepared by the fuel safety branch detailing
all proper
safety and emergency procedures should be distributed periodically
to
all sellers and major users of propane.
14. Prior to each construction heating session, an extensive
information
program should be undertaken by all involved parties to remind
workers
of propane safety and emergency procedures respecting propane.
Such a
program should include audio-video material, brochures and
familiarization with the warning labels.
15. As a specific initiative, a construction safety commercial
to be aired
on network and ethnic television should be prepared highlighting
the
safe use of propane.
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