Record Number: 1943 FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: M. Naiberg M. D., Coroner PLACE OF INQUIRY: Toronto DATE OF INQUIRY : 1987-09-02 INFORMATION ABOUT DECEASED: NAME: Albert Seabrook OCCUPATION: Unavailable INDUSTRIAL SECTOR: Petroleum, Chemical ACCIDENT INFORMATION: DATE OF ACCIDENT : 1987-06-17 PLACE OF ACCIDENT: 500 Commissioner St., Toronto BRIEF CAUSE OF DEATH: Generalized body burns. BRIEF MANNER OF DEATH: Fire initiated by an electrostatic explosion. ACCIDENT DESCRIPTION: Albert Seabrook died as a result of burns in a fire initiated by an electrostatic explosion. The initial explosion took place in number five compartment when vapours ignited as Mr. Seabrook started to load it with toluene. Although the evidence is not found to be absolutely conclusive, the most probable cause of ignition was static electricity. A freak combination of elements including turbulence in the toluene, possibly a pro static contaminant, and the introduction of an unbonded charge collector, (Mr. Seabrooks, glasses) resulted in the production of a spark sufficient to ignite the vapour. As explained in verdict: - Turbulence in toluene unavoidable result of loading tanker by large bore filling pipe. - Metal rimmed glasses could act as collector of charge from surface of toluene. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. Petrochemical loading facilities should require that persons loading a tank truck remove loose objects in or on their clothing. This must be enforced by the terminal operator (loading supervisor). 2. Petrochemical loading facilities should require that eyeglasses be secured to the head using a head band while loading a tank truck. This must be enforced by the terminal operator (loading supervisor). 3. During loading, there should be a company representative on the ground to supervise and enforce loading procedures. There should be strict adherence to recording unsafe procedures on a company driver's record or reporting unsafe practices of non company drivers. 4. A method for centralized recording of petroleum loading safety violations should be devised in conjunction with licensing under the Dangerous Goods Act. 5. Any driver involved in the loading or unloading of bulk chemicals should be required by a central safety agency of the government or a petroleum industry association to do written tests of procedures and safety. These should be done on a regular basis (1 - 3 years) in association with licensing under the Dangerous Goods Act. 6. There should be an immediate introduction of equipment modifications to ensure that the initial slow loading restrictions for low conductivity products can be controlled. This should be in the form of a mark on the dead-man valve casing to indicate the slow flow point, or better, a pin mechanism which would stop the lever from moving past the slow flow position until the tank is full enough for fast loading; or the use of a velocity metering device to indicate the rate of flow. In the intermediate term (6 - 12 mos.), electronic pre-set meters should be installed on all existing loading facilities to regulate velocity of flow. 7. Petrochemical loading facilities should (within 1 year) introduce modified top loading equipment which will remove the operator from the top of the truck during loading. 8. Loading facilities should have an automatic system to indicate to the driver and the supervisor that the ground has been attached prior to the commencement of loading. A device that prevents loading in the absence of a proper ground should be considered. 9. A system should be instituted to ensure that the grounding device is returned to its proper storage bracket after loading. 10. Grounding clamps should be of a type that can only be attached to a grounding knob on the truck. 11. Government regulators of petrochemical loading facilities should initiate a study of whether bottom loading of volatile chemicals is a safer procedure than modified top loading, and should consider requiring that bottom loading equipment be provided at these facilities. 12. Government regulators of petrochemical industry should promote or require the production of petrochemical tankertrucks with bottom loading as well as top loading equipment. 13. Roofs above petrochemical loading racks should be constructed of fire resistant meterials. 14. Foam houses should be built close to loading racks and on-site personnel be trained to use the equipment. 15. Petrochemical installations should be required to have regular fire drills and simulated fire tests. 16. Safety meetings with all personnel handling bulk petroleum products should be held on a regular basis at which existing safety procedures are reviewed and new problems addressed. 17. A central registry should be set up to record details and findings on all petrochemical accidents. These should be made available to police, fire officials, industry personnel, and interested parties. 18. Terminal operators should have a clear view of the loading racks and surrounding yard. Windows should not be obstructed by furniture or stacks of paper. Specific to the Shell plant on Commissioner St., a pigeonhole unit obstructs the view. COMMENTS ON RECOMMENDATIONS BY CORONER: 1. Evidence introduced that personal effects, e.g. combs, cigarette packets occasionally found in bottom of tanker, presumably having fallen from shirt of jacket breast pocket. 2. Victim's glasses found in bottom of tanker and might have contributed to explosion . Might have slipped from his head. Head band would secure glasses. 3. Occasional unsafe procedures observed among drivers. One company's procedure reorted to require one of its representatives to do all loading. 4. To record all such incidents for safety record of drivers. 5. Evidence introduced that driver given training only when starting job, no refresher training. 6. Slow loading necessary at start of loading to minimize static charge. However, this at present left to guess and discretion of driver-loader. 7. Modified top loading removes driver from top of tanker during actual loading. He is on the ground at some distance. 8. Grounding clamp must be properly affixed to grounding knob on tanker to ground static electricity. 9. Grounding clamp may be left inground or clamped to metal loading dock, short-circuiting warning system. 10. Evidence that clamp can be attached to fender or other part of truck, which might be ineffectual ground. 11. Evidence that bottom loading is a safer procedure for highly volatile chemicals. 12. Evidence of some advantages and even preferability of top loading procedure. 13. Roof of loading dock at this site set ablaze by burning tanker. 14. Foam extinguishers, the preferred method of extinguishing chemical fire. However, evidence introduced that use by company personnel hazardous in large blaze. 18. View of terminal operator at this site was obstructed. Operator not aware of fire until alerted by subsequent explosion, and hence did not activate alarm or shutdown of pumps.