Record Number: 2520 CIS Descriptors: HEAD INJURIES PULP AND PAPER INDUSTRY STEAM VESSELS PAPER SHREDDERS BLEACHING FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of Coroner's Jury INDIVIDUAL PRESIDING: Dr. Gonzalo Perales, Coroner PLACE OF INQUIRY: Thunder Bay DATE OF INQUIRY : 1992-08-26 INFORMATION ABOUT DECEASED: NAME: Andrew McColl OCCUPATION: Pleach plant operator INDUSTRIAL SECTOR: Forest products industry ACCIDENT INFORMATION: DATE OF ACCIDENT : 1991-11-02 PLACE OF ACCIDENT: City of Thunder Bay BRIEF CAUSE OF DEATH: Skull fracture with massive subarachnoid haemorrhage. BRIEF MANNER OF DEATH: Industrial accident. ACCIDENT DESCRIPTION: Mr. Andrew McColl, whom had just returned to work at the mill, and was being trained as a Bleach Plant Operator, was cleaning the floors on the morning of November 1, 1991 around the area where the Shredder/Washer number 25 is located at the Bleach Plant, when the chute of the Shredder got plugged. A stream purge was to be done in order to unplug this chute and the warning was sent to the Utility Man and the Operators, as well as to Mr. Andrew McColl. Mr. Andrew McColl was standing at a stairway in the mezzanine about 15 feet away, where it was thought to be a safe place to be during a stream purge. The stream purge to unplug the chute was carried out . The stream valve was opened to a 60% capacity, and the load of the chute, which is approximately 4000 pounds was pushed upwards within the chute and unplugged. Unfortunately, it was pushed with so much force that the mass hit the hood of the shredder causing the shredder to be dislodged in the explosion and thrown several feet away, landing on the stairway where Mr. McColl was standing, hitting Mr. McColl on the head, and causing severe injuries to the skull and brain. Mr. McColl was taken to the Emergency Room of McKellar General Hospital in an Emergency vehicle from the Mill and stayed alive until the next day when he was pronounced brain dead. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. Mills and other industries with systems similar to that process of steam mixing used in the bleach plants of kraft mills, should definitely adapt from steam to water purges. This would facilitate the safe elimination of plugs and prevent the rapid surge of plugs which might cause death or serious injury. The water purge method is known to be in effective use in other plants. These adaptations should be designed and approved by appropriately trained engineers with specific knowledge of Hazop procedures. 2. A safe procedure should be established to relieve pressure in a stream mixer where the failure of a water purge necessitates the opening of the mixer. 3. Control rooms should provide visible readings of all temperature and pressure gauges. Further warning devices should be installed to alert operators of potential system breakdowns or hazardous conditions. Any systems using temperature and pressurized conditions must be adequately monitored by gauges. 4. There should be immediate communication to the Ministry of Labour of any unusual or unexpected workplace hazards, incidents, injuries and fatalities. Such information should be shared by the Ministry as quickly as possible with the Joint Health and Safety Committees of similar industries. 5. Time between shifts should be made mandatory to allow personnel the opportunity to exchange all pertinent information. All occurrences should be recorded in a log. 6. The Company and union should take steps to ensure operating training and procedures should be implemented, reviewed annually and updated as changes occur. This should maximise the safety and protection of all personnel within the Operating and control areas. 7. Attendance at applicable safety meetings should be mandatory with minutes posted for reinforcement of information. 8. Warning devices should be installed in control rooms to warn operators of potential system breakdowns or hazardous conditions. 9. Provide operators with better field communications such as wireless headsets or two-way radios to expedite trouble shooting procedures, particularly in areas out of range of the operator's visibility. In situations where several floor levels are involved, camera surveillance would be of benefit. 10. Where materials may exit with the steam in a system, fully enclosed covers with offset doors and hatches should be used. 11. The findings of this inquiry should be forwarded to other paper mills in Ontario in order that another death of this nature be prevented. COMMENTS ON RECOMMENDATIONS BY CORONER: 1. The jury heard evidence from experts that water purges are very safe and as effective as steam purges. Therefore, adaptation of the system to allow these chutes to be unplugged with water instead of steam has been recommended. Also, that the operators be trained appropriately by people with a specific knowledge of hazardous procedures. 2. An appropriate procedure should be established to unplug the steam mixer where there is a failure of the water purge. The opening of the mixer should be done under very strict supervision. 3. At the present time there is no alarm or gauges to provide information to the operator in the control room of increasing temperatures or increasing pressures. 4. There have been somewhat similar incidents in other places and the Joint Health and Safety Committee did not know about them. The Ministry of Labour is usually informed of any unexpected workplace hazards, incidents, injuries or fatalities and this was believed by the jury that it would be very advantageous to share this information from the Ministry of Labour with the Health and Safety Committee of different industries of similar nature. This information would certainly alert other workplaces of these problems. 5. The jury feels that there should be a period of time allowed so the operator that has finished the Shift and the one that starts the shift, has several minutes to discuss any unusual occurrences or any concerns that happen in the previous shift. Also, all of these occurrences, whether they are serious or not, should be kept in a log, so they could be reviewed from time to time. 6. The jury feels that a standard operating procedure should be developed and once this is done, enforced regarding the operation of the shredders and steam mixers and of the whole operation in general. These written guidelines should be reviewed annually and updated as necessary. 7. It was felt that not enough people attend meetings of the Joint Health and Safety Committees; they will be mandatory and the minutes of these meetings will be posted in different in different areas of the mill for information of people that did not attend these meetings. 8. This was mentioned before in a previous recommendation. This is based on the fact that at the present time, there are no warning devices in the control room to alert the operator of a possible plug in the chute or sudden increase of the pressures. 9. The jury felt that in this case, where the Bleach Plant has four floors involved in the operation, a very large area is not visible in the control room, perhaps cameras would help the operator to visualize the whole area exposed in the operation. 10. This recommendation was given because apparently, when the chutes are being unplugged, or even sometimes when they are just blow- backs that are unexpected, some of the material comes flying out of the top of the shredder with a possibility of injuring people. 11. It is felt that other mills in Ontario have very similar mode of operations with similar structures and it is felt that this recommendation be circulated among other mills so the other industries can review their operations and perhaps help prevent an incident of a similar nature.