Record Number: 2172 CIS Descriptors: WORK IN SEWERS WATER AND SANITATION SERVICES GASES DROWNING FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. B. Bechard, Coroner PLACE OF INQUIRY: Napanee DATE OF INQUIRY : 1989-03-10 INFORMATION ABOUT DECEASED: NAME: Stephen Way OCCUPATION: Sewer Worker INDUSTRIAL SECTOR: Sewage and Sanitation ACCIDENT INFORMATION: DATE OF FATALITY : 1988-10-02 PLACE OF ACCIDENT: Lift Station located on Highway 41 in Napanee in the area of the donut shop. BRIEF CAUSE OF DEATH: Adult respiratory distress syndrome (diffuse alveolar damage) and bilateral acute bronchopneumonia with septicemia. BRIEF MANNER OF DEATH: Rendered unconscious by gasoline fumes which lead to near drowning. ACCIDENT DESCRIPTION: On the 31st of August 1988 an environmental officer with the Ministry of Environment visited the Napanee Water Pollution Control Plant (Sewage Plant) to do some routine testing. While he was there, he was informed by the plant operators, that they had noticed the smell of gasoline coming from a sewage pumping station near the Napanee Mall. The environmental officer, the next day, contacted the Fuel Safety Branch and arranged for an inspection to be carried out and on September 2nd, a member of the Ministry of Environment and a member of the Fuel Safety Branch attended, found no noticeable smell at the man-hole site and found no discrepancy in the dip records at the nearby gasoline outlet. They left the site with the understanding that, if the sewage workers were to smell the gasoline again, they should contact the member of the Ministry of Environment, so that he could do some sampling. On September 29th, Stephen Way and his work mate went to the pumping station manhole to clean up debris and check on the pumping apparatus. They performed some work, but it was necessary for them to go back the next day because the pumps were not working well. The next day they found the water level in the well had risen considerably and they had to use a pumping truck and the pumps that were in place to lower the water to a level where they could have access to the pumps. Stephen Way went into the well and removed pump number 1, which was brought to the surface, disassembled and cleaned. They then reinstalled the pump, but it did not seem to be working well. The second pump was then removed, disassembled and cleaned. While they were trying to reinstall it, Stephen Way was working in the well without any breathing apparatus. He came back to the surface to say that he could smell some gas. He put on an antiquated piece of equipment which was a mask with a long pipe attached to it and went back in, but could not work with it because of fogging of the face plate. He then came back to the surface, removed the mask, and went down to continue the job. By that time, apparently his nose had become dulled (olfactory fatigue), since he said he could not smell the gasoline very much anymore. Moments later, he became unconscious and fell into the sewage water. His work mate tried to rescue him, but was himself being overcome the the fumes, so he came out of the well and ran to a store for help. He testified that he tried to phone 911, to no avail (there is no 911 service in Napanee). He then asked the attendant in the store to contact the police to report the accident and get help. He went back to the manhole and tried to bring his work mate out, but again was overcome by the fumes. He described well the effects of gasoline intoxication. The Fire Department responded to the emergency call and two firemen with breathing apparatus went down into the well to try and rescue Mr. Way. During their time in the well, both of them noticed a strong smell of gasoline and both of them were somewhat affected by the fumes. One of them, in fact, testified that he fell asleep until his partner shouted at him and woke him up. A rope was attached around the chest of Mr. Way and he was pulled out and the two firemen came back to the surface. Mr. Way and both firemen were taken to the hospital and the firemen recovered, but Mr. Way went on to develop severe early onset pulmonary edema which could not be controlled, and he eventually developed a tension pneumothorax, after he had been transferred to Kingston General, and was being treated in the Intensive Care Unit. The pathology revealed that he had died of fulminant version of Adult Respiratory Distress Syndrome from a combination of chemical pneumonitis and from near drowning in sewage water. The toxicology revealed traces of gasoline in his blood stream and the testimony from the Forensic Centre Toxicologist, was that this was a very significant finding since he had never been able to detect gasoline in the blood stream of victims (in gasoline sniffing deaths for instance) where you would have expected their deaths to be associated with significant exposure to the petroleum products. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. Ensure that steps be taken to try to remove the contaminated soil in the area of the Napanee Mall. 2. Further testing and monitoring of the soil in the area of the Napanee Mall be conducted until the area is declared safe. 3. The air in the lift station on Highway 41 near the Donut Shop be monitored regularly. 4. The Government Ministries work together as a team to ensure effective communications and efficiency where an incident impacts on more than one Ministry. 5. There should be increased accessibility to Ministry Inspectors through a system of paging. 6. Workers should be informed, through their supervisor, which Ministries are available for assistance as pertains to their workplace and the scope of that assistance. 7. The Ontario Health and Safety Act Section 74(D) be amended to include a note indicating that "adherence to Canadian Standards Association Standard Z-94.4-M 1982 complies with the intent of this section". 8. Compliance letters from the employer to the Ministry of Labour in response to a Ministry order should include pertinent data relating to new equipment for Ministry approval. 9. Ministry of Labour Safety Officers state performance requirements that would meet the intention of the Act when identifying a problem. 10. Encourage CSA to develop standards for safety harnesses and alarms as prescribed in Section 74(D) of the OCHS Act. 11. The Director of Ministry of Consumer and Corporate Relations, Fuel Safety Branch, be directed to institute a testing program to find the most suitable equipment for detecting leakage rather than relying solely on the monitoring of inventory (e.g. soil sampling of area around fuel storage). 12. The installation and modifications of gas tanks be monitored and require certification by the Fuel Safety Branch of the MCCR. 13. More confined space entry courses be required to be made available and ensure that they are all not oriented towards people who are fully literate. 14. Municipal boards should see themselves as employers as described under the OHS Act and therefore the insurers of Section 14 of the Act. 15. Small municipalities should combine resources to obtain a 911 Emergency System. 16. Employers ensure that all steps be taken to minimize the necessity for employees to enter confined spaced - (ie.) lift stations be updated so that no entry is required for maintenance work. (ie.) Fire fighters possess a monitor for testing for unsafe atmosphere that has a remote detection device. 17. Supervisors be responsible for tagging obsolete and unsafe equipment. 18. All modifications or installations of mechanical equipment in a confined space are to be inspected by authorized inspectors. 19. Compulsory safety meetings at regular intervals to include training sessions that incorporate visual aids, demonstrations and hands on experience for all work places where workers are exposed to a potential hazard. 20. That in addition to Section 7(1) that at least one health and safety representative also be required for work places with less than 20. 21. Supervisors are to remain up to date on safety procedures and practices and keep employees informed of courses or materials available. 22. For Ministry of Labour to devise ways of encouraging compliance with the OH and Safety Act. 23. We as a jury commend the efforts of the Napanee Fire Department for their efforts in this unfortunate tragedy. Special commendation goes to Brian Jones and David Peterson. We concur with evidence given that these two men gave Steven Way a chance, if he had a chance of survival. We also found the efficiency and expertise of the medical staff to be unquestioned and commend them also. COMMENTS ON RECOMMENDATIONS BY CORONER: Recommendation No. 1 Comment: This recommendation followed the testimony that, after the investigation to localize the source of the contamination had been completed, some soil had been removed but that a large quantity of soil was likely still in place. The jury thought that it was important both for the municipality and workers who had to deal with sewers that this contamination be dealt with and it is my understanding that the Minister of Environment is issuing an order to that effect. Recommendation No. 2 Comment: This follows up on recommendation no. 1 and requests that the Ministry of Environment remains involved until the contamination has been dealt with properly. Recommendation No. 3 Comment: This also follows from 1 and 2. The jury thought, I believe, that because of the danger to the workers in that lift station and maybe the potential for explosion that this station be monitored on a regular basis until the contamination has been dealt with. Recommendation No. 4 Comment: It was evident from the testimony of areas, ministries personnel that there was difficulty in communication at the field level while some Ministry employees felt quite comfortable communicating with their counterparts in other Ministry, others felt that they had to go right to the top of the branch, in particular the Fuel Safety Branch people, before communicating their results to others. In fact, it is apparent that some of those results were not communicated until the employees were on the stand. Comments were made that this increased the potential for miscommunication and is not an efficient way to handle the investigation of an incident and adds only to the cost of the investigation. Recommendation No. 5 Comment: This relates to the fact that a number of witnesses complained about the difficulty in getting hold of the Inspector for the Fuel Safety Branch. Their system in Kingston is an answering machine in the home of the Regional Manager. The suggestion was made that like members of other Ministries, they should carry a pager where they could be reached at any time and if something was urgent they could respond to it in a more timely fashion than was evident from this incident. Recommendation No. 6 Comment: It was apparent from the testimony at the inquest that the workers at the Sewage and Water Board were not aware from whom they could get advice and help for procedures and equipment in terms of safety in the workplace. Testimony was given that not although the Ministries, in particular the Ministry of Labour, have a regulatory component to their activities they should also have an educational component so that workers and their employers are aware of the safety procedures that relate to their particular workplace and also are aware of the avenues that they can use to ask for advice and get assistance. This was apparent in particular with the question of the compliance to an order issued by the Ministry of Labour in April 1988, where on the face of it it would appear that the people at the workplace were under the impression that they had complied with the order when in fact they hadn't. Recommendation No. 7 Comment: Section 74(d) of the Occupational Health and Safety Act reads relating to entry in confine space as follows;... "The worker entering is using a suitable breathing apparatus and a safety harness etc..." The testimony centered on the fact that the Act requires the worker to use a suitable breathing apparatus but does not define the word suitable and reference was made to CSA standard number Z-94.4-M 1982. This standard defines the different types of breathing apparatus that are suitable for different types of working environments. The jury's intention is that this standard be added to the act as a definition of the word suitable. This is not a new procedure since section 84, 85 and 86 of the Act uses this type of notation to define a type of protective equipment. For example, section 84: "Where a worker is exposed to the hazard of a head injury he shall wear a head protection appropriate in the circumstances." Note: Adherence to the Canadian Standards Association standard Z-94.4-M 1977 complies with the intent of this section. It seems that the people who drafted the Act made use of Canadian Standard in later sections of the Act and it would make compliance with the Act much simpler if this was added to section 74(d). Recommendation No. 8 Comment: Testimony at the inquest showed that the current procedure for the Ministry of Labour following the issuance of order does not involve a reinspection of the premises to verify that the equipment or the procedures that have been put in place are satisfactory. In fact it relies on a letter of compliance from the employers stating that they have complied with order as given to them by the Minister of Labour inspectors. The jury thought that if this letter of compliance was to include pertinent data relating to new equipment or updated equipment acquired in order to achieve compliance it would help the safety inspectors of the Ministry of Labour to decide whether in fact the orders have been complied with. Recommendation No. 9 Comment: This recommendation relates to the form in which those compliance orders are issued and compared in fact the way a compliance order in April was drafted as opposed to a compliance order drafted in November. The November one stated much more clearly the requirements that were expected to be achieved in order to meet the intention of the Act to correct the problem identified by the inspector. Recommendation No. 10 Comment: The section 74(d) of the Health and Safety Act talks not only of suitable breathing apparatus but also of safety harnesses and alarm systems to attract attention. The jury wondered if the CSA could not develop standards for these pieces of safety equipment so that some kind of general consensus as to what is appropriate then becomes accepted across the industry. This would make compliance with the Health and Safety Act easier because the requirements would be clearer. Recommendation No. 11 Comment: This recommendation evolved from numerous testimonies which pointed to the inadequacy of the present methods utilized by the Fuel Safety Branch for the detection of leakage from a fuel storage place. In particular, the jury pointed out that sampling of the soil around the installations on a prospective manner might be an appropriate method to bring about early detection of fuel loss. This technique was used to delineate the location of the soil contamination in this present case. Recommendation No. 12 Comment: This recommendation stems from the fact that there was, at one point in the testimony, evidence entered that it is possible for operators of fuel storage facilities to perform modifications to their plant without notifying the Fuel Safety Branch. It would seem that the branch relies on voluntary reporting from these people to be kept up to date as to the different storage specifications. The jury believed that before a modified installation could be put back in service, that a certification be acquired from the branch. Recommendation No. 13 Comment: This recommendation followed testimony that there was only approximately 70-80 spaces in Ministry of Labour courses concerning safe confine space entry procedures available yearly in Ontario with a potential market of approximately 10,000 workers who should be instructed in those techniques. The second aspect of the recommendation was that a number of workers that are involved in that field have trouble with reading and written work. It was felt that those courses should be tailored so that these people could be instructed properly and be able to demonstrate their understanding of the principles and techniques of confine space entry without necessarily being fully literate. Recommendation No. 14 Comment: The evidence indicated that the board appointed by the municipalities did not really insure a proper supervision but relied on his hired supervisor to see that section 14 of the Act be complied with. I think it has to do with municipal boards such as the Water and Pollution Control Board which are formed of counsel appointees and generally work as volunteers on those boards. I do not feel that they are really in charge or at least take a back seat position to the hired managers and as such can be giving the appearance that they are not discharging their responsibility under the Act. Recommendation No. 15 Comment: This recommendation stems from two factors, first the evidence that the worker at the surface at the time of the accident, went into a neighboring store and tried to contact the Emergency Services by dialing 911 in an area where the 911 service is not available. The second reason why I feel this recommendation was made, was that during my summation to the jury I suggested to them that it could consider the fact that small municipalities like Napanee do not have a large manpower in particular personnel department and I felt that the jury could recommend that these municipalities could get together with neighboring municipalities to provide services to their employees in particular in the field of safety in the workplace training officers or safety officers etc., that each individual municipality could not provide on its own. I referred to the example of the Kingston area where the 10 municipalities got together to provide a 911 service for the whole region. I have a feeling that the jury interpreted these remarks as indicative that the Napanee region should consider 911. Not that I disagree with that. Recommendation No. 16 Comment: This recommendation stems from the facts of the accident and that the installation of the pumps had not been made in such a way that the employees could repair and maintain those pumps without getting down into the sewer. The design of the pumps by the manufacturers is such that it is possible to service and repair those pumps without having to enter the pumping station and the jury felt that the employer should have seen to it that at the time of installation, the pumps should have been installed in such a way as to comply with the manufacturers recommended installation. The jury, no doubt, responded to witnesses' comments that this type of confine space installation was likely not unique to Napanee and that there should be some general awareness that it is possible for the employers in this field to provide their employees with safe working conditions. Also the monitoring for unsafe atmosphere using a snorkel type breather on the monitoring device so that the men would not have to enter the confine space before knowing what the atmosphere is on the way down and at the bottom. Recommendation No. 17 Comment: This stems from the fact that both the breathing apparatus and the gas detection device that were at the sewage plant were not usable but had not been tagged as such and had not been removed from circulation so that there were considered by the employees to be appropriate equipment. Recommendation No. 18 Comment: This recommendation stems from the fact that at some point in early 1988, damage to the wiring in one of the pumps in the sewer well had occurred and was repaired in an amateurish fashion by the use of twisted wire and MAR connectors and electrical tape. These modifications were looked at by the Canadian Standard Association experts and judged to be very dangerous because they allowed a major leak of current to the point that in the environment where the pump was immersed, there would be enough current leakage that if somebody was to touch the pump with the bare skin he would get a severe shock if not a life threatening shock. The testimony showed that this modification had been made without being reported officially to the management and without being approved by an electrical inspector. Recommendation No. 19 Comment: It was apparent from the testimony that what was considered safety meetings at the sewage and water treatment plants were the morning get-togethers for job assignments that the men and manager had. The jury thought that this was not satisfactory, that there should be proper meetings, in particular with the type of work being done both at the water and at the sewage plant that a dedicated safety meeting at regular intervals with training refreshers sessions and demonstrations were necessary and that this type of approach to safety in the workplace should be regulated not only in the case of Napanee but in any type of work where there is potential hazard. Recommendation No. 20 Comment: Section 1 of the Act states that "Where a number of workers at a project regularly exceeds 20 the constructor shall cause the workers to select at least one Health and Safety representative from amongst the workers on the project who does not exercise managerial function." The jury came up with this recommendation because it was obvious that at this particular place of employment there was nobody in charge of safety that there was no safety meetings held in an organized fashion and the in-training of the employees was pretty much left to chance. I think the jury wanted to indicate with this recommendation that the number 20 should be done away with and that when there is a construction project there should be one Health and Safety representative from the workers. Recommendation No. 21 Comment: I think this represents the response of jury to testimony that the supervisor was not up to date on procedures and practices and did not in fact keep his employees up to date in safety procedures and practices. Recommendation No. 22 Comment: This stems from the fact that testimony showed that the methods commonly in use now with the Ministry of Labour in relation to the Occupational Health and Safety Act are more in the realm of inspection and orders requiring compliance. The jury though that the Ministry should also adopt an educative stance in regard to the dissemination of information to encourage compliance with the Act. Recommendation No. 23 Comment: The jury's commendation for the efforts of the firemen in attempting to rescue Mr. Way was well taken but at the same time, I believe we were very near to having a double or even a triple tragedy in this particular accident.