| |
|
| Record Number: |
2628 |
| CIS Descriptors: |
SPORTS FACILITIES
WORK ON ICE
INFORMATION OF PERSONNEL
DESIGN OF EQUIPMENT
HOT-WATER HEATING SYSTEMS
|
|
-
REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of the Coroner's Jury
INDIVIDUAL PRESIDING: Dr. William A. Buckton, Coroner
PLACE OF INQUIRY: London
DATE OF INQUIRY : 1996-09-23
INFORMATION ABOUT DECEASED:
NAME: Timothy James Hickman
OCCUPATION: Ice surface operator
INDUSTRIAL SECTOR: Municipal industry
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1996-03-23
PLACE OF ACCIDENT: Silverwoods Arena, City of London
BRIEF CAUSE OF DEATH: (ARDS) Adult respiratory distress syndrome
BRIEF MANNER OF DEATH: Accidental
ACCIDENT DESCRIPTION:
On Saturday morning, March 23, 1996, Timothy Hickman, an employee
with the City of London, re-surfaced the ice at Silverwoods
Arena
with an Olympia ST95 Ice Resurfacer. He then drove the machine
outside to empty the snow. Although there were no eye witnesses
to
the subsequent accident, it was believed the following sequence
of
events transpired:
Upon returning the ice re-surfacer to the storage room, he proceeded
to refill the wash water tank. This was filled with hot water
supplied from twin natural gas water heaters. The heaters were
mounted 20 inches off the floor. Mr. Hickman then left the area,
presumably to work on a malfunctioning scoreboard clock. By
the
time he returned a few minutes later, the hot water was overflowing
on to the adjacent gasoline tank. This caused a pressure buildup
in
the gas tank and gasoline vapour could be heard escaping from
around
the cap. At this point, after turning of the water, he released
the
pressure by removing the gas cap. An explosion then occurred
when
the gasoline vapour, being heavier than air, settled on the
floor
and ignited, probably from the pilot lights of the gas water
heaters. The time of the explosion was approximately 1130 hrs.
The explosion blew the "roll-up" door, leading from
the storage
room to the ice surface area, off its track. Hickman, with his
clothing afire, ran from the area, making his way on to the
ice
surface. The fire was extinguished by individuals in the area.
Two
nurses attended Hickman until the ambulance arrived. He was
then
transported to Victoria Hospital-South St. Campus. On April
2, 1996
at 2230 Hrs., Timothy Hickman died as a result of internal injuries
due to the burns he suffered.
RECOMMENDATIONS ISSUING FROM INQUIRY:
Arena:
1. The appropriate ministry shall order that arenas must not
have water
heaters or other significant sources of ignition in the same
room as
an ice resurfacer.
2. The appropriate governing body shall better define a "repair
garage"
and a "storage garage," or find a more comprehensive
definition for
"arena facilities".
3. The design of all arenas shall be reviewed to ensure the
safety of
both employees and the public.
4. Municipalities shall design and implement a facility orientation
tour for all user groups especially those involving minors.
5. The appropriate ministry shall require the installation of
well
marked gates and exit signs clearly indicating all available
exits
from both the ice surface and the building providing for their
free
and clear access in all arenas.
6. The appropriate ministry shall require that all buildings
with
access to or used by the public have adequate emergency first
aid
kits and appropriate emergency devices available to all staff
at all
times.
The Resurfacing Machines:
7. The federal and/or provincial government shall appoint the
appropriate ministry to require the Resurface Corp. issue an
IMMEDIATE bulletin to all owners and dealers (world-wide) of
Olympia
gas powered ice resurfacing machines. This bulletin shall set
out
the circumstances of this accident and the recommended modifications
to the Olympia ice resurfacers.
8. The federal and/or provincial government shall set mandatory
safety
standards for the certification of design and manufacture of
all ice
resurfacers.
9. The operator's manual for ice resurfacing machines shall
contain
appropriate safety precautions, procedures and environmental
conditions for the use and storage of ice resurfacers.
10. All other ice resurfacer manufacturing companies shall be
advised of
all of the circumstances of this accident and the recommendations
of
the coroner's jury.
11. Modifications to existing equipment pertaining to safety,
handling
and operation be reviewed by employee user groups and corrective
action shall be taken.
Fire Department:
12. All City of London fire rescue vehicles shall be equipped
with two
full body water-gel burn suits.
13. The City of London Fire Department, the Fire Marshall and
the
Ministry ot Labour shall review and re-affirm their relationship
and
commit to ensure the security and preservation of fire scenes.
Training:
14. Formal, mandatory safety and W.H.M.I.S. training shall be
developed
and delivered to employees. This training shall be reinforced
through regular mandatory safety meetings with an appointed,
certified safety officer attending such meetings and available
to do
regular safety inspections.
15. All employees shall receive regular, mandatory training
with regular
updates by certified trainers with respect to their job functions.
16. The City of London shall publish, as soon as possible, the
comprehensive Arena Operations Manual and relevant material
shall be
given to each employee upon hire. The manual shall be reviewed
and
updated on a regular basis.
17. The City of London shall establish a formal certification
process
for all equipment operations.
Communication:
18. Nationwide municipalities, in conjunction with organizations
such as
O.R.F.A., shall regularly share information on health and safety
issues.
19. The City of London shall increase the frequency of on site
scheduled
supervisory visits and shall improve communications with all
arena
employees.
20. All employees of all arenas shall regularly be evaluated
and
reviewed to ensure proper procedures and practices are followed.
A
training profile document and job description shall be updated
and
maintained.
21. Guidelines or procedures shall be established to ensure
the
reporting of "near misses" followed by corrective action.
22. A portable two-way radio system to be made available to
operation
staff shall include a man down function. Any employee working
alone
shall maintain hourly contact with central dispatch.
23. There shall be a clear, documented understanding of a chain
of
responsibility for each arena employee in the absence of the
immediate supervisor.
Public Information:
24. Cost-free counseling, such as L.E.A.C., shall be made available
to
all individuals affected by critical incidents.
25. A public service announcement shall be made to clearly inform
the
general public that 911 is a free service to callers from pay
phones.
COMMENTS ON RECOMMENDATIONS BY CORONER:
A. Arena
1. The fire marshall stated that this explosion would not have
occurred if the hot water heaters were in another room.
2. Evidence revealed that if this was deemed to be a repair
garage
rather than a storage garage, then the building code would have
specified that the water heaters be 54 in. off the floor rather
than
20 in. Since gas vapour is heavier than air, and settles to
the
lowest level, then ignition would have been less likely.
3. Self-explanatory.
4. Self-explanatory.
5. At Silverwoods arena not all gates from the ice surface were
marked as such, and during the ensuing explosion and fire everyone
on the ice attempted to get off through one gate.
6. The first aid kit was locked in the arena office and the
snack bar
attendant, the only other arena employee, did not have key access.
The Resurfacing Machines:
7. Evidence revealed that the water tank and gas tanks were
only 1/4
in. apart and it was the hot water overflowing on to the gas
tank
that caused the gas vapour to expand. Modifications proposed
for
Olympia, included moving the tanks further apart and separating
them
by a heat shield. (N.B. The company name is Resurfice Corp.)
8. Currently there are no licensing standards for the manufacturing
or
design of ice resurfacers.
9. The existing manual had some ambiguities, such as the water
temperature to be used in the wash water tank. Arena employees
in
London have now been instructed to use cold water.
10. Self explanatory.
11. Self explanatory.
Fire Department:
12. A fireman gave evidence that these water-gel suits retard
the burn
damage to the body, but the fire trucks do not have them due
to
funding cutbacks.
13. The fire marshall arrived at the scene to find it unsecured
and
various parts of the scene had actually been removed. This naturally
made his investigation into the cause of the fire more difficult.
Training:
14. There was evidence presented that showed training largely
consisted
of one employee showing a new employee how to operate the ice
resurfacer with little formal or classroom training. Little
emphasis
was placed on W.H.M.I.S.(Workplace Hazardous Materials Information
System). The inquest revealed the importance of safe fuel handling
for ice resurfacer operators.
15. Self-explanatory.
16. This arena manual has been under development since February/96
and
although almost complete, has not been distributed yet.
17. Self explanatory.
Communication:
18. O.R.F.A.(Ontario Recreational Facilities Association) holds
an
annual classroom course in Guelph and could be an ideal forum
for
sharing such information.
19. Self explanatory.
20. Self explanatory.
21. This would alert other employees of potential dangers in
the
workplace.
22. After midnight there is only one arena employee on duty.
23. Self explanatory.
Public Information:
24. L.E.A C.(London Employee Association Consortium) was made
available
to City of London employees for debriefing but it was not clear
if
the public using the arena could use this service. Some of the
coaches and young hockey players who witnessed this tragedy
were
also emotionally traumatized.
25. The snackbar attendant at the arena felt she couldn't phone
911
because she didn't have a quarter for the pay phone and the
office
was locked. The 911 call was placed by someone in the arena
using
their cellular phone.
|
|
|