Record Number: 2063 CIS Descriptors: INSTALLATION OF PIPE SYSTEMS MANUFACTURING INDUSTRIES BURSTING FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. C. R. Meyer, Coroner PLACE OF INQUIRY: Frontenac County DATE OF INQUIRY : 1988-05-25 INFORMATION ABOUT DECEASED: NAME: Egan B. Holterman OCCUPATION: Pipefitter INDUSTRIAL SECTOR: Metal Manufacturing ACCIDENT INFORMATION: DATE OF FATALITY : 1987-12-07 PLACE OF ACCIDENT: Kingston Alcan Works North Plant BRIEF CAUSE OF DEATH: Exsanguination; ruptured aorta; multiple internal injuries; laceration of the liver and spleen. BRIEF MANNER OF DEATH: Explosion: hit by eight inch pipe in the chest. ACCIDENT DESCRIPTION: Kingston Alcan Works was comprised of several plants. The plants of concern to us in the present investigation are the North plant and the South plant. Closure of the South plant took place in April 1987. These plants were connected by a pipe line which carried compressed air from the North plant to the South plant. It is an above ground, eight inch aluminum pipe line which is under pressure 90 to 100 pounds per square inch of compressed air. The 7th day of December 1987 this line was still live even though the South plant was closed, because it was necessary that new boilers and air compressors had to be installed in the North plant. They were finally commissioned on November 1, 1987. On Thursday, December 3, 1987, Mr. James Latimer, the Contractor Engineer at Alcan, decided the eight inch pipe line was no longer needed. He advised Mr. Walter Hodgins, the Central Maintenance foreman, that he could shut off the compressed air supply to the South plant complex. This could be done safely by: 1) Shutting off the compressed air supply to the line by closing the valve at the North plant. 2) Bleed off the air which was locked in the eight inch line. 3) Separate the pipes and install the cap. It was decided that the person who should do the job would be Egan Holterman. Egon Holterman, 51 year old pipefitter, had worked for Alcan for approximately twelve years. It was felt that he would have as much knowledge about the workings of the pipe lines as anyone in the Kingston plant. Shortly after 2:00 pm on December 7, 1986, Mr Frank Maloney, a Stationary Engineer at Alcan, met Mr. Holterman in the North plant to assist him with the job. Mr. Maloney used a ladder to climb to the shut off valve just outside the North plant. The valve was hard to turn because it had been in the open position for a long time. Mr. Holterman and Maloney then proceeded to the area of the pipe line where the blank was to be installed. Mr. Holterman sprayed WD-40 on the flange bolts which held the pipes together and at which joint the blank was to be inserted. He then moved to the next joint, which was one side of the expansion joint, which in this pipe line is shaped like a U. He loosened the nuts and bolts on the flange but nothing happened. Mr. Maloney reached to get a hammer from the tools, and as he did so, there was a loud explosion. As a result of this explosion Egon Holterman was struck by the eight inch pipe in the chest. He was rushed to the hospital, and died on the OR table. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. This jury agrees with the recommendations submitted by management, Union and Department of Labour as stated in Exhibit 5 and would recommend immediate implementation. 2. Appoint an in-plant safety coordinator to ensure that safety procedures are followed at all times. Such procedures to include proper job-related safety requirements. 3. We also recommend colour-coding as to content, of all piping systems in conjunction with recommendation no. 5, page. 5. Alcan Recommendations Recommendations to change equipment, safety rules and operating procedures all aimed at reducing or eliminating the possibility of repeating this accident were submitted both by members of the accident investigating committee and by other innovative, safety conscious Alcan employees. These recommendations are as follows: 1. Communicate to all tradesmen the hazards of stored energy particularly those associated with compressed gases. Dupont and Alcan Oswego will be contacted for safety programs concentrating on stored energy. 2. Re emphasize the requirement for pre job assessments, which have the objective of identifying and thereby avoiding safety hazards, on all non routine work assignments. The supervisor must be present for the start of the work to ensure compliance with the pre job assessment and then must periodically monitor work progress. 3. Rewrite the Alcan Kingston Works Maintenance Department safety rules to emphasize the safety precautions associated with stored energy be it compressed air, steam, or hydraulic systems with accumulators. The existing safety rules concentrate on electrical disconnects which must be locked out before starting most maintenance projects. 4. Provide a standard practice for working on compressed air and steam piping systems. The standard practice must stress the need to properly relieve the stored energy in piping systems. 5. Install valves for relieving pressure adjacent to the isolating valves in the compressed air piping system. This would allow the compressed air supply to be shut off and the pressure then relieved at the same location without having to follow the pipeline to find a suitable relieving valve. 6. Design and fabricate portable guards to support the piping on either side of a Victaulic coupling should the compressed air piping need to be disassembled in future. Piping supports/guards will be required for both eight inch and six inch piping. The accident investigation also revealed several deficiencies that while they were not a factor in this accident could lead to future safety problems if not corrected. Recommendations to correct these safety concerns are as follows: 1. Implement a strict safety procedure for the proper locking out and tagging of piping system valves. This procedure must include not only valves closed for safety reasons but also valves that must be left open for safety reasons such as valves opened to relieve pressure. 2. Prepare specifications for new valves to include provisions for proper lockout. Most gate and globe valves can only be locked by wrapping chain around the valve body and through the handle. 3. Change the main isolating valves in the compressed air piping system from butterfly to gate valves. Any movement of a closed quarter turn butterfly valve handle will result in some leakage. 4. Install a compressed air dryer in North Plant to minimize the buildup of ice in the compressed air piping thereby reducing the possibility of maintenance being required on the compressed air piping. 5. Identify all compressed air and steam piping as to contents and direction of flow. COMMENTS ON RECOMMENDATIONS BY CORONER: An inquest was held concerning this industrial death. The verdict of the Coroner's Jury was the Egon B. Holterman's death was accidental. The jury made three recommendations. Recommendation No. 1: As a result of this death there was, over and above the Coroner's investigation, and investigation by the Department of Labour, Alcan's own internal investigation, and an investigation by the union representing the employees of Alcan. Recommendations in Exhibit 5 were the combined efforts of Labour and management. The Jury really did not feel that they could suggest anything better, and recommended that Exhibit 5 be accepted as a recommendation in its totality. (See attached Exhibit 5.) I might add that the recommendations listed, some six numbered, are self-explanatory. Recommendation No. 2 I might add here that Alcan already has an in-plant safety coordinator. However, the Jury felt that there would probably be small plants who would be handling compressed air who did not have in-plant safety coordinators. They, therefore, made Recommendation 2. Recommendation No. 3 The Jury simply felt that the colour-coding system might help identify lines in different locations as the their content. As author of the above, I certainly feel that if the recommendations proposed by this Coroner's Jury were followed there would be no repeat of this particular type of accident.