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REPORT CHARACTERISTICS:
DONOR: B.C. Coroner's Service
JURISDICTION: British Columbia
REPORT TITLE: Judgement of Inquiry
INDIVIDUAL PRESIDING: Michael Olifkey, Coroner
PLACE OF INQUIRY: Burnaby
DATE OF INQUIRY : 1987-11-19
INFORMATION ABOUT DECEASED:
OCCUPATION: Builder, Bricker
INDUSTRIAL SECTOR: Steel Manufacturing
NAME: Confidential
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1987-08-11
PLACE OF ACCIDENT: Richmond
BRIEF CAUSE OF DEATH: Multiorgan failure and sepsis; severe
thermal burns.
BRIEF MANNER OF DEATH: Received burns in propane/oxygen explosion.
ACCIDENT DESCRIPTION:
The deceased was a 54 year old male who was employed by Western
Canada
Steel Limited at Mitchel Island, Richmond, BC. The deceased's
job title
was a builder or bricker. The job requires the worker to remove
bricks
from the bottom of an upright ladle. To accomplish this task,
the
worker would use a jack hammer, a pry bar, and cutting torch
which uses
propane and oxygen. The ladles are approximately 14 feet deep
by 10
feet in diameter at the top and 8 feet in diameter at the bottom.
At approximately 1400 hours August 11, 1987, the deceased proceeded
to
leave his work area for coffee break. He had left all his equipment
previously described at the bottom of the ladle. At approximately
1425
hours August 11, 1987, the deceased returned to the ladle. He
began to
start to light the cutting torch to being his work. At this
time an
explosion occurred, and the deceased was engulfed in flame.
An overhead crane operator observed the deceased on fire inside
the
ladle. The crane operator immediately sounded his emergency
horn and
directed the supervisor and the group leader to the incident
site. Upon
observing the deceased the supervisor and group leader immediately
poured water and extinguished the fire. The Emergency Health
Services
was summoned and attended the incident scene. The deceased was
immediately transported to Vancouver General Hospital Burn Unit.
The
deceased was diagnosed as sustaining burns to 50 percent of
his body.
During his admission to the Intensive Care Unit at Vancouver
General
Hospital, the deceased received two surgical skin grafting procedures.
Despite intensive therapy, the deceased continued to deteriorate.
At
approximately 2035 hours on 3 September 1987, the deceased was
pronounced deceased at Vancouver General Hospital.
My investigation revealed that on August 11, 1987, the deceased
had been
removing steel slag from the inside of a steel and brick ladle
during
the morning. Normal procedure for this type of work is that
a helper
assists the bricker and acts as a safety watch because no one
else in
the area is able to see the worker inside the ladle. The ladle
is on
its side and the knockout plug is removed from the bottom of
the ladle.
This is done to help with ventilation inside the ladle from
burning slag
with oxygen and propane torch. All the bricks are removed from
the
ladle. This is accomplished mostly by the use of a jack hammer
and pry
bar. The work procedure used in this occasion was different.
The
bricker asked that the helper be reassigned because he felt
safe working
alone.
The helper was sent to work elsewhere in the shop area. The
ladle was a
new one that only required the bottom bricks to be removed.
Therefore,
the ladle was set in the upright position instead of on its
side. The
knockout plug was not removed because of the type of work being
done,
only a small portion of the bricks being removed. The cutting
torch was
being used extensively because steel was between the bricks
and was
difficult to remove. The torch is usually removed from the ladle
when
not being used but on this occasion it was left in during the
coffee
break.
The cutting torch was confiscated by the Workers' Compensation
Board and
tested, revealing a leak at the shut off valve and the hose
connection
attachment on the oxygen side. Testing at the Workers' Compensation
Board revealed more than 30 litres per minute could escape from
this
area. Therefore, the accumulation of gas in the ladle was ignited
upon
return and beginning work.
CONCLUSION
I conclude that the deceased came to his death on September
3, 1987 at
Vancouver General Hospital as a result of multiorgan failure
and sepsis
due to severe themal burns due to a propane/oxygen explosion.
I find
this death of the deceased to be accidental, and I have no
recommendations.
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