WELDING AND CUTTING
LICENSING OF UNDERTAKINGS
DONOR: Office of the Chief Coroner
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
INDUSTRIAL SECTOR: Welding industry
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
tank under repair.
The jury heard that the 400 gallon aluminum tank was fabricated
one man welding shop in Barrie for CP Rail in 1992. It was to
used as a mobile diesel tank mounted on a flat bed truck. It
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
Fab Welding in Burlington for repair of a leak on September
1994. The owner/welder proceeded to weld without adhering to
Section 78 of the Regulations for Industrial Establishments
states that, "where repairs or alterations are to be made
drum, tank, pipeline or other container, the drum, tank, pipeline
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
psi to complete emptying and ran carbon dioxide gas for 6 -
(The M.O.L. engineer indicated that the tank was not designed
the pressures used). The three connections on top of the tank
left open overnight. The following morning he again ran carbon
dioxide and proceeded to weld with a MIG welder. He did not
had never used a combustible gas detector. He indicated that
repaired from 300-400 tanks of varying sizes and uses over a
period. One tank exploded in 1991.
About 30 seconds after commencing, he saw a tiny hole erupt
the weld zone and the tank immediately exploded. The deceased
was holding a tarpaulin beside one end of the tank was struck
the end was blown off and he was propelled against the side
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
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.
apart from the fabricator, no one knew what the tank looked
2. WELDING TRADE: The Jury heard that although welding is not
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
the Welding Institute of Canada, and the Provinces of Alberta,
Manitoba, and Nova Scotia have instituted trade certification.
Ministry of Education and Skills Development witness indicated
employer groups may request training standards for non-regulated
trades such as welding. Specific welding needs are generally
industry, but the owner\operated welding shops do not appear
have minimum standards of training.
3. GOVERNMENT: The previous explosion in this same shop in l991,
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
distributed as recommended by the Caledon jury. Sharing of
business registration information between municipalities and
Ministry of Labour would help in the distribution of vital
Occupational Health & Safety material. I wholeheartedly
5. CORONER'S OFFICE: The Jury felt the Chief Coroner should
an annual report to the Legislature on responses to inquest
recommendations. I agree.
6. LEGISLATION: Sec. 78 of Reg. 851/90 the Occupational Health
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
performed on vessels which have contained flammable or combustible
7. FUEL HANDLING: It was indicated in evidence that the CP workers
responsible for installing and filling the tank in question
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
MINISTRY OF LABOUR RECOMMENDATIONS
8. The Ministry of Labour develop an Engineering Data Sheet
the existing Hazard Alert - Welding on Container. The purpose
Engineering Data Sheet is to explain in greater detail the specific
measures which must be taken in order to safely perform welding
tanks used for flammable or combustible materials.
9. The existing Hazard Alert (and future Hazard Alerts) be modified
indicate the following:
- the reference to the accompanying Engineering Data Sheet (where
- a request to the Hazard Alert reader to further distribute
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
number for the closest Ministry of Labour office).
10. The Ministry of Labour develop a co-ordinated communications
distribution strategy for the communication and dissemination
Hazard Alert and Engineering Data Sheet. The strategy should
the following elements:
- The Ministry of Labour send the Hazard Alert and Engineering
Sheet, to all garages, repair facilities and welding shops known
the Ministry of Labour in the Province of Ontario; and/or
- Ministry of Labour inspectors personally distribute copies
Hazard Alert and Engineering Data Sheet, to workplaces known
Ministry of Labour and which perform welding of any kind;
- The Ministry of Labour undertake a mailing of the Hazard Alert
Engineering Data Sheet to all the trade schools, community colleges,
university engineering faculties, suppliers, manufacturers and
associations known to the Ministry of Labour, making them aware
the hazards of welding on tanks used for flammable and combustible
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,
Coroner for Ontario, informing them that the Hazard letter referred
in that letter was not circulated to all mechanic, body, radiator
repair, welding shops and small businesses in Ontario who may
involved in the repair of containers of flammable and combustible
substances; and further to inform these organizations of what
measures have been taken.
12. The Ministry of Labour consider amending section 78 of Regulation
851/90 (Regulation for Industrial Establishments) under the
Health and Safety Act to require industrial establishments which
welding on tanks used for flammable or combustible material
proper testing for traces of flammable or combustible materials
performing any welding on same.
13. The Ministry of Labour, Ministry of Education and Training
Ontario Training and Adjustment Board (OTAB) consider taking
ensure that "welding on enclosed vessels" is made a
under the regulations to the Trades Qualifications Act.
14. The Ontario Ministry of Consumer and Commercial Relations
of Transportation, in conjunction with their Federal counterparts,
the necessary measures to require that individuals who construct,
maintain or repair tanks used for the transportation and/or
fuels are properly trained and licensed.
15. The Ontario Ministry of Consumer and Commercial Relations
corresponding Federal department prohibit "after-market"
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,
Ministries of Labour and Consumer and Commercial Relations,
Association and other public and private industry associations
ordinate efforts in providing training, education and outreach
businesses on the risks of welding on tanks used for flammable
COMMENTS ON RECOMMENDATIONS BY CORONER:
4. I wholeheartedly agree.
5. I agreed.