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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of Coroner's Jury
INDIVIDUAL PRESIDING: Dr P. C. Noble, Coroner
PLACE OF INQUIRY: Whitby
DATE OF INQUIRY : 1987-03-23
INFORMATION ABOUT DECEASED:
NAME: William Puddister
OCCUPATION: Unavailable
INDUSTRIAL SECTOR: Metal Manufacturing
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1985-05-21
PLACE OF ACCIDENT: Lasco Steel Company, Whitby
BRIEF CAUSE OF DEATH: 1. Traumatic laceration of (L)subclavian
artery. 2.
Subarachnoid hemorrhage. 3. Shot-like wounds.
BRIEF MANNER OF DEATH: An explosion causing debris and pieces
of slag to be
projected outward towards Mr William Puddister who was standing
approximately ten feet away from the point of explosion.
ACCIDENT DESCRIPTION:
Furnace at Lasco Steel was shut down for May 20th holiday when
a
number of scheduled repairs were to be made. 1. Replace #9 cooler
panel. 2. Repair leak on bezzle ring and 3. Repair mast lines.
On
repairing the crack of the bezzle ring the crack travelled towards
the
interior wall causing a major leak. Several attempts were then
made by
the welder on duty to correct the leak. Evidence shows that
the bezzle
ring was drained before each welding attempt but not blown dry
and inlet
and outlet hoses were not disconnected. Between each welding
attempt
the water was turned on to check for leaks.
Prior to the start of the 0800-1600 hour shift on May 20th,
the
decision was made to stop repair of the bezzle ring, move the
welder to
another job, and to operate the furnace with the bezzle ring
in a 'dry'
condition. At this time the bezzle ring was again drained, not
blown
out or hoses disconnected with drain plugs left in place. The
balance
of the other repairs were then completed at this time, i.e.
number 9
cooling panel removed and replaced and mast line repaired.
Communication throughout the procedures by the numerous individuals
involved appears to be highly inadequate. The lack of written
reports
and documentation is evident.
On May 21st at about 0010 hours, when the supervisor refired
the
furnace, he assumed the bezzle ring was being run in a dry condition.
The furnace was operated without incident for the 2400-0800
hour shift.
At shift change (0800-1600) May 21st no one was made aware of
any
existing problems. Everyone assumed that C furnace was being
operated
with a dry bezzle ring. At approximately 1000 hours on May 21st
1985
while the furnace was being tapped, an explosion occurred in
the
northwest bezzle ring causing debris and pieces of slag to be
projected
outward towards Mr William Puddister who was standing approximately
ten
feet away from the point of explosion beside the tapping station.
Mr
William Puddister was at this time hit by several pieces of
flying
debris.
Explanatory note: A belly ring around a furnace, that normally
carried cooling water was shut off with no venting to the atmosphere.
After ten hours of operation, as the furnace was tipped and
perhaps
because of vibration, water in the vertical channels leading
to this
belly ring, released their water running down to a hotspot in
the
furnace to an area where a one inch protrusion extended into
the belly
ring. The water was turned to super-heated steam causing an
explosion,
ripping the belly ring apart. Slag on the outside of this belly
ring
was projected towards the victim causing the injuries.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. Communication:
A. That all supervisors concerned with a specific area give
written
documentation to incoming supervisors regarding all shift activities.
In some cases, the use of a tape recorder might be an appropriate
tool.
B. Communicating the completeness or incompleteness of a job
assignment
- we recommend the use of a red tag (four by six inches for
example)
and/or a padlock system showing what work is being done and
by whom so
that accountability for a particular job exists. The red tag
and/or
lock are not removed until inspected by the appropriate supervisor.
C. Use of check lists to be monitored by two people, signed
and kept on
file for reference and proof of communication for not less than
three
years.
D. We recommend the use of a clearly defined and written Procedure
manual. This manual should include at least the following procedures:
I. A procedure for the draining and capping off of all water
coolant
systems.
II. A procedure for the handling of a water leak on a water
cooled
chamber.
III. A procedure for the restarting of a furnace including in
the
procedure the use of a start-up check list by two appropriate
personnel.
This manual to be accessible to all personnel and to be reviewed
and
updated on a regular basis with not more than a lapse of two
years.
2. Safety:
A. We recommend that each furnace be equipped with a deflector
plate so
that any falling debris will slide to the floor and be cleaned
on a
regular basis. We also recommend that the furnace, being taken
apart
for sceduled maintenance every two weeks, have its entire surrounding
area cleaned up at that time.
B. Each employee be given a safety talk for five minutes every
month by
his supervisor. This talk should be recorded, signed by the
employee
and kept on file.
C. That a safety committee, made of both company and union
representatives, meet monthly and review records of safety talks,
and
tour at least one supervisor's area of responsibility to make
sure all
safety requirements are adhered to.
D. That the union personnel and company management review the
responsibilities of a job classification so that an employee,
where
safety is concerned, is totally responsible for his job related
actions.
E. Also, that the consecutive hours worked by an individual
be
carefully monitored to ensure job productivity, as well as safety.
F. We strongly suggest that the company, along with the safety
committee, investigate, as soon as possible, the use of protective
clothing for the covering of chest and neck area. This material
should
be of denser material with a greater impact resistance.
G. Also, that each supervisor's area be manned with trained
first aid
personnel on each shift (ie. St. John's Ambulance) and have
appropriate
first aid materials readily available nearby.
H. We recommend that the company investigate the area of hot
spots
discussed during the inquest and take corrective action where
appropriate (ie. addition of refractory materials).
I. We recommend all repairs of potentially dangerous situations
be
dealth with immediately and not left to scheduled repairs.
3. Welding:
We recommend that all welding adhere to the Canadian Welding
Bureau of
Standards and to be inspected by qualified personnel.
4. Procedures in place:
We, as a jury, commend Lasco for the changes already made:
I. Use of check lists.
II. Installation of pressure relief valves.
III. Increase screening at tapping station.
IV. The eventual elimination, in the near future, of the use
of a
bezzle ring.
And all other safety features they have incorporated. We also
urge them
to continue this practice in the future.
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