Record Number: 2064 CIS Descriptors: BLOWPIPES BURSTING CLOTHING CONTAMINATION FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: R. Seaver M.D., Coroner PLACE OF INQUIRY: Toronto DATE OF INQUIRY : 1988-05-27 INFORMATION ABOUT DECEASED: NAME: Ernest Caissie OCCUPATION: Torchcutter INDUSTRIAL SECTOR: Unavailable ACCIDENT INFORMATION: DATE OF ACCIDENT : 1988-01-13 PLACE OF ACCIDENT: Unavailable BRIEF CAUSE OF DEATH: Acute confluent bronchopneumonia; sepsis complicating extensive burns; blast injury to lungs. BRIEF MANNER OF DEATH: An explosion occurred, throwing gasoline on to his clothing and parts of his body, resulting in burns to approximately 75 percent of his body. ACCIDENT DESCRIPTION: This 33 year old man (Date of Birth - December 22, 1954) was employed by Mostel Metal Company of Canada, 371 Comstock Road, Scarborough, at the time of an explosion on January 13, 1988. He had worked for the company as a torch cutter, and had worked for them for about thirteen months. On the morning of January 13, 1988 the deceased and another torch cutter were cutting what appeared to be a large open container, in half, when there was an explosion. Both men were knocked several feet to the ground, and their clothing was on fire. Mr. Caissie was unable to put out the fire on his clothing. Other workers got fire extinguishers to put out the burnt clothing. The Fire Department and Ambulance were called at the same time. Mr. Caissie was treated at the scene for extensive burns and transferred to Scarborough General Hospital. He had third degree burns to about 75 percent of his body. He also had burns and damage to his upper respiratory tract and required a tracheostomy. He was treated in the intensive care unit. He later underwent operations to remove burned tissue (L) forearm and hand amputation and (R) finger amputations. He remained stable for a time, then started to deteriorate due to ongoing sepsis, and infection resistant to antibiotic therapy. He was pronounced dead, February 7, 1988 at 11:30 hours. Autopsy showed death due to acute bronchopneumonia and sepsis, burns to body, and blast injury to lungs. Following the explosion, the Fire Marshall's office, and Ministry of Labour and Metropolitan Toronto Police investigated at the scene. It was not until the container was closely examined, that a false bottom was noted. This had contained some explosive vapor, later proven to have been gasoline. The container appeared to have been a home-made dip tank used for cleaning metal parts. At the time of the accident, there had been a strong wind blowing from the West and the temperature was about -10 degrees C. Mr. Caissie had flammable clothing wired on and was unable to remove it. There was not a full fire extinguisher close at hand. There was a company policy in place that no closed containers were to be cut. Mostel Metals deals in scrap metal. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. Every open container which is to be cut by heat-generating equipment should be visually inspected by at least two workers for possible trapped volatiles before cutting. 2. It should be mandatory that all industrial sites be equipped with a sufficient number of fire extinguishers, such number to be determined by the Fire Marshall, and the Ministry of Labour for each industrial classification. 3. All employees in an industrial plant should have training in the use of fire extinguishers and other fire-fighting equipment from the local Fire Dept. 4. Fire extinguishers should be accessible to all employees using torch cutting equipment, and welding and similar flame-generating equipment; and be placed within 3 metres of the operation. 5. Companies possessing fire extinguishers should designate specific employees to make weekly inspection of the condition of all fire extinguishers, and a log book should be kept and maintained recording dates and condition of equipment. 6. It should be mandatory that all employees using flame-cutting or welding or other equipment which could result in sudden burns, wear fire-retardant protective clothing; suitable for summer use, and suitable for winter use. 7. Every hazardous working area should be equipped with an alarm station to alert the central administrative office that an emergency has occurred. 8. At least one employee in each working discipline (or field) should receive an approved course in First Aid training, repeated every 3 years. 9. The Ministry of Labour should increase its outside inspection staff to allow inspections of industrial establishments on a random basis at least twice yearly. 10. One of the required items of the Ministry of Labour inspections should be a review of the fire extinguishers and of the company log book, as indicated in Section 25 of the Ministry's regulations. 11. It should be mandatory that the Ministry of Labour make available all files in its possession pertaining to past inspections and reports on the company where an accident leading to death has occurred, to investigating officers of other agencies. 12. It should be mandatory that the company make available to the investigating officers its records on past industrial accidents safety committee records and signed logs of internal safety inspections including fire equipment inspections. 13. The gathering of evidence should include statistical data from the Workers' Compensation Board regarding claim history, of the particular industry in which the company is involved, and the performance of that company relative to that industry's average. COMMENTS ON RECOMMENDATIONS BY CORONER: 1. Explanation: This container had been inspected by other workers prior to the cutting, but they had all been at some distance. It was not until after the explosion and close inspection that the sealed bottom was noted. The jury though if the workers had examined the box themselves, they might have seen that there was a false bottom and would not have cut it. 2. Explanation: There had been several fire extinguishers close at hand, but they were all empty. The men had to go some distance to get a full one. The jury thought that the authorities should specify the numbers of fire extinguishers required for a particular type of work, and where they should be located. 3. Explanation: The clothing kept re-igniting after being put out by the fire extinguisher. The Fire Department pointed out that the heat of the clothing would cause re-ignition. The men should have kept using the extinguisher for a longer period of time. It was also noted that the workers had never been shown how to use a fire extinguisher correctly. 4. Explanation: The jury thought if the fire extinguisher had been close at hand, it would have been full and much valuable time would not be lost looking for one. 5. Explanation: The jury thought that some one employee should be responsible to check on and see that the fire extinguishers be refilled and in good working condition at all times. This would also ensure that they were refilled at regular intervals. 6. Explanation: It was noted during the inquest that in the hot summer that the men did not always wear the protective clothing provided by the company. It was also noted that lighter summer weight was available on the market. The jury thought if it were mandatory to provide light weight clothing, that the men would wear it. 7. Explanation: This was an attempt by the jury to reduce response time by fellow workers and administrative personnel in calling fire, ambulance, and police assistance. Co-workers would be able to stay at the scene and provide more immediate help. 8. Explanation: This was to assure that adequate workers had up-to-date first aid training all the time. 9. Explanation: The Ministry of Labour requires more staff to inspect industries on a frequent basis. Also, these inspections should be on a random and unannounced basis. 10. Explanation: Since having full operational fire extinguishers was so important in a scrap metal industry, the jury thought that there should be a special notation of the inspection of both the actual extinguishers and the company's log book. 12. Explanation: These two recommendations came as a result of evidence at the inquest. The labour inspectors had been very helpful and cooperative during the investigations and the inquest. Evidence revealed that there had been other fires in the cutting yard at Mostel Metals. There had been no serious injuries. The jury thought that such information should be made available to the coroner and the investigating police officer. Such information might be essential in determining the need for an inquest or laying criminal charges. 13. Explanation: Such information would help the jury make more specific recommendations to the particular industry. This available information would be of assistance to the Ministry of Labour when inspecting industries and making specific recommendations. COMMENTS: Explanation: Everyone was very impressed with the speed that the various Emergency Personnel responded to this tragic accident and their actions at the scene, and care given to Mr. Caissie.