Record Number: 2493 CIS Descriptors: BURNS WELDING AND CUTTING EXPLOSIONS VEHICLE REPAIR AND SERVICING FUEL TANKS CONTAMINATION TANK TRUCKS FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. K. Flynn, Coroner PLACE OF INQUIRY: Mississauga DATE OF INQUIRY : 1992-02-20 INFORMATION ABOUT DECEASED: NAME: Roger Wilder OCCUPATION: Class A mechanic INDUSTRIAL SECTOR: Vehicle repair industry ACCIDENT INFORMATION: DATE OF ACCIDENT : 1991-06-26 PLACE OF ACCIDENT: Balzan Truck Centre, 13059 Airport Road BRIEF CAUSE OF DEATH: Fourth degree burns to the entire body. BRIEF MANNER OF DEATH: In the process of welding, an explosion occurred spewing the contents of the tank towards the back of the truck and completely engulfing both men in flames. INFORMATION ABOUT DECEASED: NAME: Charles Huber OCCUPATION: Apprentice automotive mechanic INDUSTRIAL SECTOR: Vehicle repair industry ACCIDENT INFORMATION: DATE OF FATALITY : 1991-06-28 PLACE OF FATALITY: Toronto Wellesley Hospital, Burn Unit BRIEF CAUSE OF DEATH: Ninety percent burns over body complicated by smoke inhalation and acute respiratory failure. BRIEF MANNER OF DEATH: In the process of welding, an explosion occurred spewing the contents of the tank towards the back of the truck and completely engulfing both men in flames. ACCIDENT DESCRIPTION: Charles Huber, aged 28, an Apprentice Automotive Mechanic, and Roger Wilder, age 32, a Class A Mechanic, were assigned to the task of repairing a white, 150 gallon tank located in the box of a pickup truck (1985 GMC model) owned by Beth Neil Farms. The repair was being conducted at the Balzan Truck and Mechanical Repair Centre, 13059 Airport Road, Caledon, Ontario. The tank, originally used as a pesticide container, was then being used by Beth Neil Farms to refuel their farming equipment with dyed diesel. The tank had a hairline crack (two inches) on the upper right rear corner. They were told the tank had been pumped and had contained diesel. A quantity of diesel fuel had remained in the tank that was later found to be contaminated with gasoline. We believe the following sequence of events took place: set up equipment; removed tank filler cap; looked inside and sniffed the contents; the crack was cleaned with a grinder; a short blast of CO2 from a portable fire extinguisher was shot into the fill hole; the ground clamp for the MIG welder was attached to the fill hole; proceeded to weld the crack. RECOMMENDATIONS ISSUING FROM INQUIRY: Education and training 1. All fuel tank repairs should be done in shops fully equipped for the job. 2. Circulation of bulletins by the Ministry of Labour and Fuel Safety Branch concerning potential hazards of welding fuel tanks, to all garages, repair facilities and welding shops in the province of Ontario. 3. Federal and provincial Transportation of Dangerous Goods Acts set a standard training program for drivers, as well as certification program for drivers transporting dangerous goods specific to the requirements of each section of the industry. Such training should be conducted by an accredited instructor. 4. Endorsement certification program for welding of fuel tanks be instituted. Recommendations to bulk plant 5. Bulk plant operators be responsible for orientation of new fuel delivery drivers. 6. All bulk plants to have correct charts and detailed map on site. 7. Reconciliation of dip figures within 48 hours of delivery and all discrepancies be reported to fuel supplier forthwith. 8. Testing devices be made available to operators of bulk plants. 9. Better labelling of tanks to specify product, capacity, interior dimensions and standard or non standard tank. 10. Colour coding of pumps and pipes at the depots should be consistent and mandatory. Recommendations for fuel tankers 11. Tankers be inspected yearly or at 90000 kilometers, whichever comes first, and at each change of ownership. Inspection should include examination and testing of all manifold components. 12. All tankers carrying unleaded fuels be inspected for BUNA-N disks and be replaced by VITON. 13. Manufacturers of fuel trucks, manifolds and valves update their parts listings, manuals, etc. to indicate that VITON discs be used on all fuel trucks. Legislative changes 14. Increase penalty for failure to comply with Section 16(6) of the Coroners Act. 15. Amend the Occupational Health and Safety Act, Regulation 692, Section 82(1)(b) as applied to repairs on containers, by including the word "combustible" as per Ministry of Labour hazard alert. 16. Gasoline Handling Act be amended to prohibit simultaneous offloading of incompatible fuels through a manifold. 17. Reconciliation of opening and closing dip measurements to be done by driver on site following delivery of fuel. Discrepancies should be reported to both fuel carrier and customer. These changes of procedures should be reflected in the Gasoline Handling Act. 18. Require all fuel suppliers and all fuel carriers to render a written report to the Fuel Safety Branch within 24 hours all incidents involving any suspected or actual fuel contamination or loss of products, however caused, providing at a minimum the following details: a) date, time and location of the incident b) type and amount of fuel involved c) nature and circumstance of the incident d) name and address of the owner of the facility and carrier as applicable e) name and address of all witnesses to the incident f) steps taken to remedy the contamination or investigate the incident g) steps taken or to be taken to dispose of the contaminated fuel h) steps to be taken to prevent a recurrence. COMMENTS ON RECOMMENDATIONS BY CORONER: The contamination of dyed diesel with gasoline occurred during the night of June 11, 1991 during the delivery at the UCO (United Co-op) Georgetown Bulk Depot. This resulted in dyed diesel tank #5, capacity 22700 litres, being contaminated with approximately 2000 litres of gasoline. This contamination went undetected by anyone for over two weeks and consequently was delivered to many UCO customers; one of them was Beth Neil Farms. Factors which may have contributed to the fuel contamination are as follows: a) the delivery truck driver was unfamiliar with the bulk fuel depot in Georgetown b) the method of double offloading of incompatible fuels was used c) gas may have been drawn across the defective splitter valve by the continuous running of the diesel pump after the diesel compartment on the tanker had emptied d) a damaged splitter valve disc was found on the tanker two months after the tragedy e) damaged splitter valve disc was found to be a BUNA-N type which is known to deteriorate when in contact with no lead gas f) reconciliation of dip measurements was not performed by the driver or the delivery fuel company; the bulk depot owners had a reconciliation process in place, but never acted on discrepancies g) possible fatigue from long hours of work by the delivery truck driver. 1. It was clear from the evidence that while the practice of welding is a skill gained by a combination of training and experience, the special risks associated with welding fuel tanks require additional training and testing equipment. Various testing devices are available which test for the presence of combustible or explosive substances in containers and a protocol is recommended for tank repairs. The protocol generally calls for testing the contents, draining, cleaning or otherwise rendering free of hazardous substances (such as by purging with an inert gas or substance) and retesting prior to welding. When using carbon dioxide for purging, it should be supplied by continuous flow from a CO2 cylinder (not a portable fire extinguisher) and introduced into the tank through a hose extending to near the bottom of the tank with all tank openings closed except the fill and vent openings. Low pressure CO2 should be used to prevent static electricity throughout the welding operation. The tank in question did not meet specifications of the federal Transportation of Dangerous Goods Act, Section 2.31 which deals with labelling and fastening, Section 5.39(1) which deals with marking of leaking tanks or Section 5.41 which requires the manufacturer's identification. 2. See recommendation #1. 3. Federal and provincial Transportation of Dangerous Goods Acts currently do not have a standard training and testing program for drivers and the scope of existing programs ranges from a brief orientation, showing of a video of the Mississauga train derailment, to intensive in house training. The larger companies in the petroleum industry usually have full time instructors. Certification at present can be by another driver who might or might not be a certified instructor. There is no minimum training period and no requirement for testing of drivers of dangerous goods. 4. See recommendation #1. 5. The driver in this case was new to the site and was provided only with a rough map of the plant. There was some difficulty with offloading gasoline on June 11 as one pipeline valve was not fully closed and another not fully open, thus allowing gasoline to recirculate within the pipeline instead of going into the bulk tank. 6. A non standard tank was not identified as such, and required use of a special conversion chart from centimeters by dipstick to litres. Although this was not a direct contributing factor to the accident, it was evidence of inaccurate auditing procedures by the bulk plant operator and the fuel carrier. 7. Discrepancies occurred between amounts of gasoline and dyed diesel delivered and received. This went undetected for about two weeks. During this time, the contaminated fuel was distributed to customers. 8. After the mix up was discovered, the delivery fuel truck driver required from his employer that a testing device be made available to him. He wanted to confirm that the fuel he was delivering to customers was not contaminated. Up to the inquest closing, the bulk plant operator was still considering the request. 9. See recommendation #6. 10. Pumps and pipes generally conform to a standard colour system. The premium and regular gasoline pipes at this plant had reversed colours, but this did not contribute to the contamination. 11. The tanker in this case was purchased from a previous owner in 1987. The manifold valves were not included in regular inspections. It was stated by the maker of the manifold system that since unleaded gasoline can cause rapid deterioration of the BUNA-N material used in the valve gaskets and "O" rings, they were supplying VITON which resists deterioration by unleaded gas. However, recent written specifications and the service manual continued to list BUNA-N parts. It could not be confirmed if the gaskets removed by the mechanic in September 1991 were of BUNA-N, but they were replaced by VITON. 12. See recommendation #11. 13. See recommendation #11. 14. The investigation was hampered by failure to provide relevant and vital information to the investigator, who was acting on behalf of the Coroner. The owner of the tanker and the driver knew that the Coroner's investigation into the deaths of two men was ongoing, and had been interviewed earlier. They knew that the tanker was a key factor in the contamination which led to the deaths, and were aware in September 1991 of the discovery of a damaged manifold splitter valve gasket in the tanker. The damaged gasket was put aside by the mechanic. The owner and the driver saw it and knew it was available. It was missing when the investigator was made aware of it on January 27, 1992 one week before the inquest opened. Had the valve gasket been saved, it is likely that tests could have been ordered to determine if it could have allowed gasoline to cross over to the diesel tank. Only photographs and negatives taken of the gasket by the mechanic were made available. The initial investigation also was impaired temporarily when the bulk plant owners, on the advice of their solicitor, were reluctant to provide access to the delivery truck and records. The Coroner invoked the requirements of the Act successfully. The jury feels that the penalty for failure to comply with Section 16(6) should be increased to a level which would emphasize the duty to provide information. 15. Section 82(2)(b) Occupational Health and Safety Act, Regulation 692 states that before performing hot work on vessels, they must "be drained and cleaned or otherwise rendered free from any explosive, flammable or harmful substance". Since diesel fuel is combustible, the Ministry of Labour recommended that this word be added. It was suggested that this regulation be posted in every automotive mechanic workplace. 16. This is probably the most important recommendation from the jury. Since it has been shown that double offloading of incompatible fuels can occur when a manifold splitter is used, it has been suggested that fuel tankers carrying gasoline and diesel at the same time should not be equipped with manifolds. Less than 2% gasoline in diesel creates an explosive mixture. Mixing can occur by a number of circumstances: driver error, mechanical error, deliberate dilution, vandalism. Risk of driver error and mechanical error at offloading can be markedly reduced by eliminating manifold use. 17. As referred to in "By what means", reconciliation of opening and closing dipstick measurements of the bulk storage tanks, at the time of offloading gasoline and diesel on June 11, should have revealed the possibility of discrepancies and alerted the carrier and/or the bulk plant operator to the possibility of contamination. 18. Public safety requires a system of monitoring suppliers, carriers, and bulk storage owners for contamination or loss of fuel which could endanger the public. The inquest heard of incidents of major fuel thefts, contaminations corrected and not reported, and the practice of diluting contaminated fuel to raise the flash point. Since large fuel thefts have been reported from unattended bulk storage plants, the possibility exists of unauthorized mixing of incompatible fuels or hazardous waste. Reports of theft and vandalism at a number of bulk plants belonging to the same owner, were presented in evidence and there appears to be a problem of security which should be addressed.