Record Number: 2434 CIS Descriptors: EXPLOSIONS WORK IN CONFINED SPACES STORAGE TANKS SANDBLASTING BURNS CARBON MONOXIDE POISONING FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. D.M.S. Gabrielle, Coroner PLACE OF INQUIRY: Whitby DATE OF INQUIRY : 1991-02-01 INFORMATION ABOUT DECEASED: NAME: Windel Daley OCCUPATION: Unavailable INDUSTRIAL SECTOR: Unavailable ACCIDENT INFORMATION: DATE OF ACCIDENT : 1990-04-25 PLACE OF ACCIDENT: Olco Station, Bayly Street, Pickering BRIEF CAUSE OF DEATH: Carbon monoxide poisoning - extensive burns to body. BRIEF MANNER OF DEATH: Accidental explosion in a confined area caused when a volatile substance in the interior of a petroleum storage tank was ignited by a spark from the breaking of contact wires that were acting as a switch for a sandblasting machine. ACCIDENT DESCRIPTION: Mr. Windel Daley had recently been promoted to a foreman at the company and was given his first job which was to process for petroleum storage tanks for the Olco Station located on Bayly Street in Pickering, Ontario. Apparently, this job went without problems and two of the tanks had been processed and closed. The last two tanks were open and clean. One of the tanks had already been sandblasted and on the day in question the last tank was to be sandblasted. Apparently, Mr. Daley took a reading of both the oxygen content and volatile gases content of this tank since it had been cleaned on the previous day; he then proceeded to enter the tank to perform the sandblasting necessary. Apparently, a sump pipe leading into the tank was still present and this needed to be removed before sandblasting could proceed. This pipe was removed by Mr. Daley and being held in a vertical position was handed out to his coworkers that were outside the tank. Testimony given at the inquest indicated that this pipe with its connections would still hold gasoline and it is obvious by the results that occurred a portion of this gasoline must have been spilt at the time this pipe was removed. Testimony given by an expert witness from the Ministry indicated that for the size of the tank, at least 1.6 litres of gasoline needed to have been spilt into the tank for the explosion and fire to have occurred. Testimony given indicates that the equipment being used by Mr. Daley for sandblasting the inside of the tank was powered by an electrical cord attached to an extension cord. Apparently, throughout the company, these pieces of equipment were under the control of a single flowthrough switch that was attached around the waist of the worker. Apparently this is contrary to the employers' own safety manual which requires a deadman switch not a flowthrough switch. Evidence was given at the inquest that the switches tended to fill with sand during the sandblasting and therefore become non-functional. Evidence was presented at the inquest by the experts from the Ministry that on this particular occasion, there was no switch but simply two pieces of wire that were being used as a contact switch and that they were simply wound together when the worker wanted the equipment to work and pulled apart when he wanted the equipment to stop. Testimony from an electrical engineer from the Fire Marshall's Office indicated that the energy and spark that resulted when the wires were touched together was insufficient to ignite the volatile gases but that when the two pieces of wire came apart the arc of electrical charge was sufficient to ignite the petroleum products in the gasoline storage tank. It is surmised that Mr. Daley attempted to form this connection, the wires must have parted and caused an arc that was sufficient to ignite the gasoline and cause the resultant explosion and fire that resulted in Mr. Daley's death. These pieces of wire could have come apart easily as Mr. Daley was wearing gloves and was holding onto the sandblasting equipment which would have caused some vibration. Testimony given from the coworkers at the site indicated that when the sandblaster was turned on they heard a surge of the power followed by the explosion almost immediately thereafter. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. The jury strongly supports the recommendations of Mr. Bibeau to provide a constant air monitoring system with an alarm system in order to assure a safe atmosphere is maintained. 2. Workers in a confined space shall wear a full body harness at all times. 3. The firefighters assure their personal safety before entering a confined space. 4. Two 24"x24" manholes be cut into a storage tank before proceeding with entry to assure one clear egress. 5. Pneumatic deadman switch be used on all sandblasting equipment. 6. New foreman/tack representative should have a period of direct supervision until he is competent in his new position to allow the adjustment from taking to giving orders. 7. Constant follow-up by supervision should be maintained to ensure company policies and all pertinent safety regulations be strictly adhered to. Supervisors safety checklist should be implemented for onsite visits and be included to the safety talks with employees, e.g. only safety approved clothing, breathing apparatus, and equipment should be used in confined areas. 8. Although companies have the fortitude to devise proper training manuals, it is up to them to enforce that the procedures are followed properly without contradiction and not assume that it has been automatically read and absorbed. Follow-up is a necessity, as safety is an ongoing process. COMMENTS ON RECOMMENDATIONS BY CORONER: All underground petroleum storage tanks are required by law for environmental reasons to be adequately sealed against corrosion or replaced. Heath Engineering Limited of Mississauga has been performing this function over the last number of years. This company had been involved in a previous fatality in 1985 when removal of gasoline petroleum sludge from the bottom of a tank was ignited by a lamp that had been placed near the opening of this tank. Since that time, Mr. Windel Daley had been working for that firm processing over 300 of these underground storage tanks. Members of the Pickering Fire Department arrived very shortly on the scene. Apparently, Mr. Daley was not wearing a lifeline but there was an attempt to remove him by using the electrical cords. This proved to be unsuccessful as the opening on the tank was too small to allow a folded-over body through. The Pickering Fire Captain entered the tank in order to locate the victim. He was not wearing any protective equipment and the jury, in their recommendation, felt that this was a risk he should not have assumed. Shortly thereafter, two Pickering Firefighters with scott air packs entered the tank and the victim was removed. On attempting to leave the gasoline tank, an electrical shock was felt by one of the firefighters. At that time it was found that the electrical current to the sandblasting equipment had not been tuned off. The jury felt that this also was an undue risk and that the scene should have been secured further prior to their entry into the gasoline tank. Testimony given at a later time in the inquest indicated that the fumes in the tank were still adequate to cause a further fire and explosion. Because of these problems, the jury made two further recommendations, one that the manhole cut into the storage tank be at least 24 inches square and that a second similar entrance be also cut in order to assure one clear agress. The jury also felt that a full body harness would have been more effective in removing an unconscious man than a simple line around his waist. Testimony given indicated that Mr. Daley had performed the required tests in the morning prior to entering the tank but had not performed any further tests on the percentage of volatile gases after having removed the sump pipe. They made a recommendation that a constant air monitoring system with an alarm be provided in order to assure a safe environment is maintained at all times. This recommendation was initially suggested by Mr. Bibeau of the Ministry of Labour. The jury agreed that was a reasonable recommendation and should be included in the Health and Safety Act. A lot of testimony was given relating to the training and safety courses provided by Heath Engineering. This company seems to perform a lot of on-the-job training with numerous safety meetings of both a formal and informal nature. There is a detailed manual prepared by the company for their employees relating to both procedures and safety. With relationship to this manual, the jury recommended that they agreed with Heath Engineering that a pneumatic deadman switch should be used on all sandblasting equipment. The only fault with all this training was that there did not seem to be any specific follow-up to ensure that the employees had read the manual or understood the safety training. The jury felt that follow-up by a supervisor should be performed and that supervisors should have and implement a safety checklist for onsite visits. Because Mr. Daley was on his first job as a foreman and acting as the technically trained representative under the Act when this accident occurred, the jury felt that he should have had some period of direct supervision until they felt he was competent in his new position to allow for the adjustment from taking to giving orders.