Record Number: 2588
CIS Descriptors: GAS EXPLOSIONS
FUEL TANKS
GAS OIL
WELDING AND CUTTING
LICENSING OF UNDERTAKINGS

FATALITY REPORT



REPORT CHARACTERISTICS:

DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of the Coroner's Jury
INDIVIDUAL PRESIDING: Dr. K. Flynn, Coroner
PLACE OF INQUIRY: Milton
DATE OF INQUIRY : 1994-12-05

INFORMATION ABOUT DECEASED:

NAME: John Rostkowski
OCCUPATION: Welder
INDUSTRIAL SECTOR: Welding industry

ACCIDENT INFORMATION:

DATE OF ACCIDENT : 1994-09-20
PLACE OF ACCIDENT: 2429 Industrial Drive, Burlington
BRIEF CAUSE OF DEATH: Multiple injuries
BRIEF MANNER OF DEATH: Result of the explosion of a 400 to 500 gallon fuel
tank under repair.

ACCIDENT DESCRIPTION:
The jury heard that the 400 gallon aluminum tank was fabricated in a
one man welding shop in Barrie for CP Rail in 1992. It was to be
used as a mobile diesel tank mounted on a flat bed truck. It was
constructed without engineering specifications or approval.

Four anti-sloshing baffles were installed, creating five
compartments. This made it impossible to inspect the interior
completely as only three ports were installed. It also contributed
to the incomplete emptying and purging for repair.

The tank was moved from the CP Rail yard in Welland to the Aberdeen
yard and filled with gasoline. It did not meet Gasoline Handling
Act labelling requirements when it was taken to Ted's Custom Steel
Fab Welding in Burlington for repair of a leak on September 19,
1994. The owner/welder proceeded to weld without adhering to
Section 78 of the Regulations for Industrial Establishments which
states that, "where repairs or alterations are to be made on a
drum, tank, pipeline or other container, the drum, tank, pipeline or
other container shall be drained and cleaned or otherwise
rendered free from any explosive, flammable or harmful substance."

The welder had repaired a pinhole leak in the same tank a week
previously. He prepared the tank by running compressed air at 100
psi to complete emptying and ran carbon dioxide gas for 6 - 8 hours.
(The M.O.L. engineer indicated that the tank was not designed for
the pressures used). The three connections on top of the tank were
left open overnight. The following morning he again ran carbon
dioxide and proceeded to weld with a MIG welder. He did not own and
had never used a combustible gas detector. He indicated that he had
repaired from 300-400 tanks of varying sizes and uses over a 20 year
period. One tank exploded in 1991.

About 30 seconds after commencing, he saw a tiny hole erupt above
the weld zone and the tank immediately exploded. The deceased who
was holding a tarpaulin beside one end of the tank was struck when
the end was blown off and he was propelled against the side of an
adjacent building and immediately killed.

RECOMMENDATIONS ISSUING FROM INQUIRY:

1. TANKS: The jury feels that responsibility for meeting standards
for manufacture and repair of fuel tanks should be shared by both
the fabricator and the owner of the tanks. The tank in question
had been made for storing diesel oil but had been used for gasoline
prior to the explosion. There were no engineering drawings. and
apart from the fabricator, no one knew what the tank looked like
inside.

2. WELDING TRADE: The Jury heard that although welding is not a
certified trade, there is obviously the need to establish a
certification program for welding of fuel tanks. It should be
noted that this was also a recommendation of the Caledon jury.
Programs have been established by the Canadian Welding Bureau and
the Welding Institute of Canada, and the Provinces of Alberta,
Manitoba, and Nova Scotia have instituted trade certification. The
Ministry of Education and Skills Development witness indicated that
employer groups may request training standards for non-regulated
trades such as welding. Specific welding needs are generally met by
industry, but the owner\operated welding shops do not appear to
have minimum standards of training.

3. GOVERNMENT: The previous explosion in this same shop in l991, was
investigated by the Ministry of Labour and the Burlington Fire
Department but there was no follow-up.

4. DISTRIBUTION: There is no central listing of businesses where
welding of fuel tanks takes place. The jury felt strongly that
this fatality might have been prevented had the HAZARD ALERT been
distributed as recommended by the Caledon jury. Sharing of
business registration information between municipalities and the
Ministry of Labour would help in the distribution of vital
Occupational Health & Safety material. I wholeheartedly agree.

5. CORONER'S OFFICE: The Jury felt the Chief Coroner should produce
an annual report to the Legislature on responses to inquest
recommendations. I agree.

6. LEGISLATION: Sec. 78 of Reg. 851/90 the Occupational Health and
Safety Act does not specify the use of a combustible gas detector
although it is implied. The Ministry of Labour engineer
recommended that such a device be required when hot work is being
performed on vessels which have contained flammable or combustible
liquids.

7. FUEL HANDLING: It was indicated in evidence that the CP workers
responsible for installing and filling the tank in question were
not familiar with the Gasoline Handling Act. Switch-loading,
(change of use between fuel oil, diesel and gasoline) introduces
the risk of reducing the flash point of the contents to a dangerous
level.

MINISTRY OF LABOUR RECOMMENDATIONS

8. The Ministry of Labour develop an Engineering Data Sheet to accompany
the existing Hazard Alert - Welding on Container. The purpose of the
Engineering Data Sheet is to explain in greater detail the specific
measures which must be taken in order to safely perform welding on
tanks used for flammable or combustible materials.

9. The existing Hazard Alert (and future Hazard Alerts) be modified to
indicate the following:

- the reference to the accompanying Engineering Data Sheet (where
applicable);
- a request to the Hazard Alert reader to further distribute the Hazard
Alert and Engineering Data Sheet to groups, employers, workers,
manufacturers, suppliers, who should be made aware;
- a phone number for further information (or where to find the phone
number for the closest Ministry of Labour office).

10. The Ministry of Labour develop a co-ordinated communications and
distribution strategy for the communication and dissemination of the
Hazard Alert and Engineering Data Sheet. The strategy should include
the following elements:

- The Ministry of Labour send the Hazard Alert and Engineering Data
Sheet, to all garages, repair facilities and welding shops known to
the Ministry of Labour in the Province of Ontario; and/or

- Ministry of Labour inspectors personally distribute copies of the
Hazard Alert and Engineering Data Sheet, to workplaces known to the
Ministry of Labour and which perform welding of any kind;

- The Ministry of Labour undertake a mailing of the Hazard Alert and
Engineering Data Sheet to all the trade schools, community colleges,
university engineering faculties, suppliers, manufacturers and safety
associations known to the Ministry of Labour, making them aware of
the hazards of welding on tanks used for flammable and combustible
materials.

11. The Ministry of Labour send a letter to each of the organizations
referred to in its August 27, 1993 letter to Dr. J. G. Young, Chief
Coroner for Ontario, informing them that the Hazard letter referred to
in that letter was not circulated to all mechanic, body, radiator
repair, welding shops and small businesses in Ontario who may be
involved in the repair of containers of flammable and combustible
substances; and further to inform these organizations of what new
measures have been taken.

12. The Ministry of Labour consider amending section 78 of Regulation
851/90 (Regulation for Industrial Establishments) under the Occupational
Health and Safety Act to require industrial establishments which perform
welding on tanks used for flammable or combustible material to conduct
proper testing for traces of flammable or combustible materials prior to
performing any welding on same.

13. The Ministry of Labour, Ministry of Education and Training and the
Ontario Training and Adjustment Board (OTAB) consider taking steps to
ensure that "welding on enclosed vessels" is made a certifiable trade
under the regulations to the Trades Qualifications Act.

14. The Ontario Ministry of Consumer and Commercial Relations and Ministry
of Transportation, in conjunction with their Federal counterparts, take
the necessary measures to require that individuals who construct,
maintain or repair tanks used for the transportation and/or storage of
fuels are properly trained and licensed.

15. The Ontario Ministry of Consumer and Commercial Relations and the
corresponding Federal department prohibit "after-market" repairs on
tanks used to store fuels unless they have the appropriate
manufacturer's seal and specification approvals.

16. Efforts be made by the Workplace Health and Safety Agency, IAPA,
Ministries of Labour and Consumer and Commercial Relations, the Welding
Association and other public and private industry associations to co-
ordinate efforts in providing training, education and outreach to small
businesses on the risks of welding on tanks used for flammable or
combustible material.

COMMENTS ON RECOMMENDATIONS BY CORONER:

4. I wholeheartedly agree.

5. I agreed.