Record Number: 2597 CIS Descriptors: YOUNG PERSONS EXPLOSION HAZARDS BURNS TEMPORARY EMPLOYMENT CONSTRUCTION INDUSTRY CONSTRUCTION WORK SAFETY TRAINING IN SCHOOLS PERMITS-TO-WORK 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: Mississauga DATE OF INQUIRY : 1995-03-13 INFORMATION ABOUT DECEASED: NAME: Sean Marshall Kells OCCUPATION: Labourer INDUSTRIAL SECTOR: Construction industry ACCIDENT INFORMATION: DATE OF ACCIDENT : 1995-11-19 PLACE OF ACCIDENT: Unavailable BRIEF CAUSE OF DEATH: Massive Pulmonary Edema BRIEF MANNER OF DEATH: Accidental ACCIDENT DESCRIPTION: While working as a casual worker pouring rubberized undercoating, which produced an explosion, engulfing his body in flames, causing burns to 90% of his body. RECOMMENDATIONS ISSUING FROM INQUIRY: MUNICIPAL LEVEL: 1. Before a Building Permit or Certificate of occupancy is granted, the Municipality would require a copy of Form 1 (Appendix A) under the Occupational Health and Safety Act as submitted to The Ministry of Labour. This would serve as the Letter of Use required by the industrial establishment that would be carrying on the business. 2. All correspondence between the owner of the industrial establishment and the Ministry of Labour along with the Municipality including the Fire Department, should be sent to the owner of the building site and the owner of the industrial establishment by registered mail. 3. Upon submission of the permit request, the Municipality will provide a list of legislation they must comply with and where copies of the legislation may be obtained. Also included should be the names of the different resource groups and agencies that can be contacted for further information and/or education. PROVINCIAL LEVEL: 1. Part 4 of the National Fire Code 1995 should be immediately adopted as part of the Ontario Fire Code. (Appendix B, exhibits 29 and 30). 2. The Ministry of Labour should issue a HAZARD ALERT on this fatality and publish all HAZARD ALERTS in 3 daily newspapers and appropriate industrial journals. 3. The Ministry of Labour should include in their advertising targeted at young workers information about their rights under Occupational Health and Safety Act and information about identifying hazardous situations. This advertising should also be forwarded to high schools. 4. Inspectors from the Ministry of Labour, Fire, Building, Fire Marshalls, OPP, etc. should co-operate to combine existing data bases for quick exchange of information with regards to investigations, infractions and work orders. These inspectors should also be cross-trained to acquire knowledge in each other's field to recognize hazardous situations. 5. All companies should be required to obtain a permit in order to buy, sell or handle hazardous products at production and distribution levels. Permits would be issued only when proper Workplace Hazardous Materials Information System (WHMIS) and/or workplace Health and Safety Agency (WHSA) training is completed. A permit would be issued for a fee, and administered by the Ministry of Labour. 6. We strongly recommend that the Ministry of Education immediately provide mandatory introduction to WHMIS and Occupational Health and Safety in the workplace. Starting in grade nine this could be incorporated into Shop, Home Economics, Law and Science courses. OTHER: 1. All products containing hazardous materials should be permanently labelled. 2. The information on the Material Safety Data Sheets: a) Must be fully completed b) Must be in clear and easy-to-understand language c) Follow the International Standards of 16 sections (Appendix C, exhibit 22). d) Must have a large recognizable warning on the front when dealing with hazardous material e) Should be displayed in the same workplace area where the product is located. 3. During the course of this inquest, the jury learned that in the past, other inquests put forward similar recommendations which in the end were not translated into any concrete action. We recommend that the Chief Coroner's Office follow up on the jury recommendations which it distributes. At the same time, this Office should measure the effectiveness of all Jury recommendations and publish its results on a yearly basis. RECOMMENDATION: 1. Adopt Part 4 of the National Fire Code (1995) into the currently reserved Part 4 of the Ontario Fire Code. 2. All new construction should be required to comply with the provisions of Part 4 of the National Fire Code (1995). 3. Permit existing facilities to achieve phased compliance as follows: - Require high benefit low cost provisions to achieve compliance in a short period (1 year) - Permit lower benefit high cost provisions to achieve compliance over a longer period (2 to 3 years) - Permit a short (1 year) extension of compliance time, where warranted 4. Permit existing facilities to be exempt from requiring to comply with those provisions where the costs are very high and the potential benefit is very low. 5. Permit flexibility for compliance where an equivalent level of safety can be provided by an acceptable alternate design. RATIONALE FOR RECOMMENDATION: 1. New construction is already required to comply with the National Fire Code under the provisions of the Ontario Building Code. 2. Higher levels of fire safety can be expected to be achieved in existing facilities. 3. Higher levels of fire safety standards can be expected to be achieved in the long term. 4. Ontario industry will have a higher level of flexibility to comply with the provisions that will ensure equivalent levels of life safety standards are maintained. This is also likely to foster innovations and minimize compliance costs for industry for both new and existing facilities. 5. Owners and Fire Departments will have sufficient time to plan, train, educate, notify, budget and execute their respective responsibilities associated with the higher cost low benefit items. 6. Voluntary compliance is likely to be greater as undue hardship for compliance is minimized, thus reducing enforcement efforts. 7. Ontario provisions will be consistent with most other provinces that have adopted National Fire Code. This is likely to foster a more level playing field for the Ontario industry in the National arena. 8. Assist industry to plan for future expansions, as it will reduce uncertainty with respect to what the regulations might be and avoid expensive alterations later. 9. NFC provisions have begun to address the concepts of minimizing the environmental impact of fires. Thus compliance with these provisions should assist in minimizing the environmental consequences of fires involving Flammable liquids. 10. NFC provisions come as close to performance based codes as currently available, a concept which several international jurisdictions are planning to implement in the near future. This is likely to foster the principle of International Free Trade and provide a level playing field for Ontario industry in the international arena.