Record Number: 2258 CIS Descriptors: SCALDS DIGESTERS PULP AND PAPER INDUSTRY MATERIAL FAILURE COMMUNICATIONS SAFETY VALVES FAULTY TRAINING FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. M. Puttick, Coroner PLACE OF INQUIRY: Red Rock DATE OF INQUIRY : 1989-10-27 INFORMATION ABOUT DECEASED: NAME: Joseph Paul Real Boudreau OCCUPATION: Labourer INDUSTRIAL SECTOR: Pulp and Paper ACCIDENT INFORMATION: DATE OF FATALITY : 1989-04-21 PLACE OF DEATH: Wellesley Hospital, Toronto BRIEF CAUSE OF DEATH: Almost total body burn with thermal injury to airway, laryngotrachebronchitis & brochopneumonia BRIEF MANNER OF DEATH: Industrial accident: body coated by hot stock and caustic liquor from an erupting digester. ACCIDENT DESCRIPTION Real Boudreau was a twenty-three (23) year old spare man or labourer working in a pulp mill. He had gone up to an old digester control room on the digester charging floor for lunch. Just after he arrived, a digester still full of pressurized hot stock opened prematurely because of a plugged pressure sensing device which gave a falsely low reading. He was extensively and severely burned by steam, hot stock and black liquor, and died of his injuries in hospital 27 1/2 hours later. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. All employees must be trained in Basic First Aid Training. 2. A first aid station capable of addressing any injuries shall be situated on the Digester Charging Floor. 3. Installation of proper safety shower station and eye wash station on the Digester Charging Floor in a location recommended by the Occupational Health & Safety Committee. 4. Exit lights must be in place & exit routes clearly marked. 5. No employee shall be on the Digester Charging Floor under any circumstances during the activation of red flashing lights. 6. Control rooms must be explosion proof with reinforced LEXAN windows. 7. A routine preventative maintenance program shall be put in place. 8. Only authorized personnel to be in any work area. 9. Supervisors must have working knowledge of all job tasks. 10. Mandatory training for all new work procedures. 11. Mandatory refresher courses for employees returning to work after a prolonged absence. 12. Supervisors must ensure that all employees are trained in all routine safety procedures. These procedures must be enforced. 13. All training sessions to be logged and filed for future reference. 14. All safety committees should meet on a regular monthly basis. All ensuing safety concerns are to be reported on a Safety Work Request form. Copies of the Safety Work Request are to go to the department (shift) supervisor and to the Occupational Health & Safety Committee. The Occupational Health & Safety Committee to be empowered to ensure that the necessary changes are carried out or action initiated within one week. In addition, employees meeting dangerous situations during their daily shift will also complete a Safety Work Request form and follow the same procedure. 15. All significant tasks assigned to employees shall be documented and acknowledged. 16. Maintain present staff levels in digester operation. 17. A "user friendly" procedures manual must be created and made available to all operators immediately. Manuals shall be updated on an on-going basis. 18. We recommend that design engineers review the entire digester operation. Employees and management shall have input into the process. The ultimate goal being the implementation of the safest, possible productive system. COMMENTS ON RECOMMENDATIONS BY CORONER: The jury made a number of recommendations to prevent accidents of this nature from happening again and also to generally improve safety procedures in the pulp mill. 1. It was established that there was no routine first aid training for employees and yet clearly they were working in an area where accidents could be expected to happen from time to time. 2. Evidence showed that the first aid station had limited equipment and materials. 3. At the time of the accident, there were no emergency showers or eye wash stations on the digester charging floor. The burned employee was hosed down with a pressurized fire hose. At the time of the inquest, showers were in the process of being installed. 4. When the digester opened prematurely, the deceased, for reasons that are not known, in trying to escape from the hot steam, stock and liquor chose an exit route which took him out onto the digester charging floor where conditions were even worse. 5. These lights come on when the lid of a digester is about to open signifying a potentially dangerous situation. It was known that the deceased came onto the digester charging floor just prior to the accident occurring and that the red flashing lights were on at the time. 6. When the digester lid opened prematurely, a large amount of stock and liquor under high pressure, blasted through a weak area in the wall of the old digester control room where the deceased was sitting. A lexan window which was present at the time, remained intact. The wall of the digester control room has since been reconstructed with concrete. 7. It was felt important to try to anticipate safety problems rather than correct them as they arose. 8. Due to the specialized equipment and procedures in different parts of the mill, it would be dangerous for personnel not familiar with the equipment and procedures to hang around in areas they were not familiar with. 9. The foreman on the shift was not completely familiar with the computer controls of the digester operation and it was felt that in future if problems arose with any aspect of the operation, that personnel should be able to consult with their supervisors in trying to solve those problems. 10. The computer system for controlling the digester operation had been gradually phased in over the previous four or five months. There was concern that unfamiliarity with new procedures could create dangerous situations. 11. These would refresh their knowledge of existing procedures and familiarize them with any new procedures that had been introduced during their absence. 12. This may relate to recommendation number 5. 13. See number 12. 14. Considerable evidence was heard that a similar situation had arisen with another digester approximately six (6) weeks before the fatal accident occurred. In this incident, a faulty pressure reading had given rise to a situation where a digester might have been opened prematurely with disasterous results. For a number of reasons which largely appeared to be communication difficulties, no action was taken. As well, a safety committee had criticized the practice of opening pressure bleed off valves by hand to reduce pressure in the digesters in order to facilitate opening the lids. Again, testimony was heard which cited apparent communication problems. There was much concern expressed about the best way to ensure that action is taken with respect to a potentially dangerous situation. The jury's recommendation tries to ensure that potentially dangerous situations are acted on immediately. 15. At times during the inquest, there appeared to be some disagreement as to whether certain tasks should be performed by digester operators or by instrument mechanics. There also appeared to be some confusion as to which specific tasks during digester operation were handled by the "cook" and which were handled by his helpers. The recommendation appears to be aimed at preventing dangerous situations from arising by avoiding such confusion. 16. Before computer controls were phased in by the company, the digester operation was controlled by three (3) workers at any one time. With the introduction of computer controls, the company hoped that the digester operation could be run by only two (2) workers at any one time. The jury were concerned that this might create a dangerous situation with the two (2) operators now having increased responsibilities during digester operation. No evidence was actually brought forward to establish that having only two (2) operators at any one time would be dangerous. Therefore, it is difficult to say whether this is a reasonable recommendation or not. 17. It was established that the operating manuals for the computer system consisted of a highly technical four inch thick manual from the computer company and also a smaller manual which was condensed from the larger text. It was also clear that none of the digester operators could understand any of the language in these texts. It was also well established that all the operators were trained in the use of the computer system by the pulp mill superintendent and that they were quite satisfied with the level of this training. However, when unforeseen probems arose with the computer control of the digester operation, the operators had difficulty dealing with these problems. A "user friendly" procedures manual with a problem solving approach in it, would be useful for operators to refer to in future if they ran into problems with the operations. 18. Numerous witnesses described inherent problems with the existing pressure sensing devices and also with proposed new systems. It was not established at the inquest which system would be the safest. The jury felt that if all parties involved had input into the design process, that a safer system would be the end result.