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| Record Number: |
2669 |
| CIS Descriptors: |
PROPANE
BULK CARRIERS
EXPLOSION HAZARDS
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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Coroner
JURISDICTION: Ontario
REPORT TITLE: Verdict of the Coroner's Jury
INDIVIDUAL PRESIDING: Dr. Thomas Wilson, Coroner
PLACE OF INQUIRY: Woodstock
DATE OF INQUIRY : 1998-05-11
INFORMATION ABOUT DECEASED:
NAME: Randall McNab
OCCUPATION: Bulk truck delivery person
INDUSTRIAL SECTOR: Propane gas industry
ACCIDENT INFORMATION:
DATE OF ACCIDENT: 1996-09-06
PLACE OF ACCIDENT: Braemar Valley RV Park
BRIEF CAUSE OF DEATH: Complications of burns
BRIEF MANNER OF DEATH: Accidental
ACCIDENT DESCRIPTION:
Randall McNab was a bulk truck delivery person
employed by Superior Propane, who was making
deliveries to seasonal residences at Braemar Valley RV
Park in the early morning of Friday, September 6,
1996. His first deliveries went uneventfully. However,
just as he was in the process of beginning a delivery
at a seasonal residence at lot 88-89 Mr. McNab was
seen to be bent over wrestling with the end of an out
of control hose which was discharging propane. About
15 seconds later there was an explosion and fire. Fire
soon engulfed the residence, a nearby parked car and
encroached on the delivery truck itself. Mr McNab was
badly burned in the fire, and he died of his injuries
two days later on September 8, 1996. Subsequent
testing of the delivery nozzle did not show any
mechanical or structural failure of the metallic
components of the nozzle.
RECOMMENDATIONS ISSUING FROM INQUIRY:
1. The "Randy McNab Story" be documented in an
ongoing case study book of all hazardous incidents
occurring involving propane and that this case study
book, along with relevant protocols, be included in
the Propane Gas Association of Canada Awareness
Training Program and be mandatory training for propane
bulk truck operators across Canada.
2. The Propane Gas Association of Canada Awareness
Training Program "Propane Container Location" or
equivalent be implemented as part of the basic
training and retraining program for all propane
industry bulk truck drivers.
To encourage improvement and standardization of propane bulk
operator training we recommend that:
3. The propane gas industries develop and use
training modules that are based on real experience and
field conditions and are sequential in directions and
leave no margin for personal interpretation.
4. The propane industry retrain and re-qualify bulk
truck drivers every three years.
5. The propane industry review and update all
training programs on a three-year cycle.
To promote general safety and to encourage compliance of
safety codes we recommend that:
6. A government policy be put into effect to ensure
that all propane installations, tanks or appliances be
inspected by a qualified independent inspector within
30 days of installation.
7. A process be implemented whereby every new
appliance or installation that employs a source of
ignition such as a pilot light be clearly marked as a
possible hazard.
8. All propane gas companies include, on their bulk
invoice, a check box to be checked by the operator
indicating in the opinion of the operator, compliance
of safety codes was met and that the delivery was made
in a safe manner.
To promote safety and optimum maintenance of control of
propane fluid release we recommend that:
9. The propane industry and related government
agencies actively pursue the development of a "no flow
until connected" type nozzle and implement its use as
soon as this becomes a feasible method of delivery.
10. The propane gas industry address the issue of the
possible release of propane that could occur under
present conditions when, and if, the integrity of the
system is breached (example - nozzle is opened without
being attached to [a receiving tank] container or
[there is a] break in hose.)
To promote co-operation, progress and increased awareness in
emergency situations we recommend that:
11. The Propane Gas Association of Canada and the
Ontario Fire Marshal's Office develop a training
program and training video on proper fire fighting
techniques for propane based fires for the fire
service and that these materials be distributed to all
fire fighting agencies in Ontario.
12. In regards to trailer parks, RV parks,
campgrounds and similar [venues], each municipality,
within a reasonable time frame, and in cooperation
with the appropriate emergency department (fire,
police, ambulance) ensure the development of alternate
access, evacuation plans, standard regulations and
other safety measures including a resident education
program.
13. All bulk propane distribution companies should
have in place an emergency response team that can
offer technical advice and support to emergency
personnel in the event of an accident involving
propane.
14. An advertising campaign be undertaken by the
Ontario Fire Marshal's Office to acquaint the public
with safety procedures, possible hazards and related
issues in regards to propane and other related fuels.
COMMENTS ON RECOMMENDATIONS BY CORONER:
1. The jury heard that there was no consistent
program to disseminate across the propane industry the
exact details of hazardous incidents. The Propane Gas
Association of Canada does have extensive training
protocols for bulk truck operators, but the course of
study material was consistently generic. It appears
the jury wanted to ensure that lessons learned from
tragedies such as Mr. McNab's death would receive
distribution throughout the industry, and by
identifying the lesson to be learned specifically with
Mr McNab's name the lesson could be personalized and
better driven home to trainees. There was no evidence
that Mr McNab was anything other than a careful,
conscientious, informed bulk truck operator who had
received all the necessary training and certifications
then in place to qualify him for his job.
2. The jury heard that the explosion that led to Mr
McNab's fatal injuries resulted from two factors:
1. the inadvertent emission of propane from the end
of his delivery hose, and
2. the presence of an ignition source nearby.
Mr McNab (and perhaps others) had delivered propane to
this residence for the previous three years, but he
appears not to have recognized or responded to the
reality that the receiving tank he was delivering to
had been improperly installed (by another person
working for the same employer). The receiving tank was
installed against an outside wall of the seasonal
residence, but immediately adjacent to the tank was an
air intake vent. Right behind that vent was a pilot
light for the hot water heater. Regulations stipulate
that receiving tanks must be at least ten feet away
from possible ignition sources; in this case the
distance from the tank to the pilot light was
approximately one foot. The jury heard that subsequent
investigations revealed that other propane tanks in
this same recreational vehicle park had also been
installed improperly. The evidence was insufficient
for the jury to deduce whether Mr McNab had been
delivering propane to all these improperly installed
tanks without realizing the potential danger, or
whether he might have realized they were improper and
dangerous but he did not feel sufficiently empowered,
himself, to demand remedial action.
3. The materials produced by Superior Propane as
exhibits for the inquest included written instructions
of the sequence of maneuvers to be taken in making a
residential delivery. These instructions had last been
revised in 1997. The directions and instructions
seemed to be sequential. In the written instructions
the hose is uncoiled from the truck and the nozzle is
attached to the receiving tank; then the driver goes
back to the truck, opens valves and turns on the pump;
then goes back to the receiving tank and opens the
trigger valve on the nozzle to begin the flow of
propane from the bulk truck into the receiving tank.
Following the instructions as written would limit the
escape of propane, in the event of inadvertent nozzle
opening, to the contents only of the delivery hose (23
litres). However, the standard delivery procedure
demonstrated to the jury, and the procedure it
appeared Mr McNab adhered to, was to have all valves
open and the pump on before uncoiling the hose towards
a residence to make a delivery; then attaching the
nozzle to the receiving tank; and then opening the
trigger valve in the nozzle. Inadvertent opening of
the trigger valve on the way to the receiving tank
releases propane in substantial amounts into the
atmosphere (in Mr McNab's circumstance 600 litres of
propane, including the hose contents). In this
recommendation the jury was responding to the obvious
inconsistency between the written materials the
company itself had provided to the inquest and their
stated and demonstrated usual delivery procedures.
4. and 5. Both these recommendations (#4 and 5) flow
directly from evidence given by the employer relating
to ideal times in their experience for the frequency
of retraining. Counsel for the employer in his
closing submissions asked the jury specifically to
consider making these two recommendations.
6. The jury heard that qualified installers, in
effect, serve as their own inspectors, completing an
installation checklist at the end of their
installation. This arrangement is contrary to
electrical or plumbing installations where an outside
inspector must certify new installations. In the
circumstances of the improper propane tank
installation involved in this tragedy, the installer
was apparently properly certified, but, nevertheless,
he had improperly installed tanks at this and several
other residences. The jury appears to have recognized
that the potential for danger or disaster is at least
as great for propane installations as it is for
plumbing and/or electrical systems.
7. This recommendation flowed from evidence that the
vent cover on the outside wall of the seasonal
residence was not labeled with any unique identifier
to warn that there was an open flame immediately
behind it. Not only for the circumstances of this case
where a propane delivery person might be reminded of
an ignition source, and deduce that the receiving tank
had been improperly installed, but also it was pointed
out that householders might benefit from the reminder
of the closeness of an open flame before they would
refuel their gasoline lawn mower or strip paint beside
a labeled vent cover.
8. This recommendation addresses, once again, the
issue of reminders to bulk truck operators to be
cautious of the possibility of dangers from equipment
improperly installed by others. It also might serve to
reinforce the emphasis on safety and conformity with
the industrial standards for proper delivery
procedure.
9. The jury heard evidence that the presently-used,
end-of-the-delivery-house nozzle is the industrial
standard for North America. One of the orders issued
by the Ministry of Labour in response to their
investigation of Mr McNab's death was that the nozzles
of this design be replaced by a more "fail-safe"
design -- a nozzle that would not allow transfer of
propane until it was properly attached to the
receiving tank. The employer successfully had this
order set aside on the grounds that there was no other
available technology at the present time. The jury
heard that a company in Australia was currently
proceeding with research and development of a newer
nozzle design that would incorporate a no-flow-until-
connected feature.
10. Although it remains a mystery what happened to
cause the inadvertent release of propane that led to
Mr McNab's death, there was no evidence that the
company's job-training curricula included any
suggestions for their operators on what to do in the
event of this occurrence. There was evidence from an
eye witness that Mr McNab appeared to be struggling
with the end of the hose for about 15 seconds before
the explosion while the hose was whipping around in
his arms, out of control and releasing propane. There
was no evidence in the company's training materials,
for instance, about whether a better option for Mr
McNab might have been to drop the hose and run to the
truck to turn off a valve there, or whether there was
a preferable strategy for him to bring the hose under
control.
11. There was evidence that the local fire department
brought under control the fire they were called to
fight, and that their interventions prevented any
further injury or loss of property. In retrospect,
considering the extent of damage that might have
occurred if the bulk truck had exploded, it was the
evidence of an expert firefighter that the
firefighters on the scene might have been more
assertive in communicating the urgency of and ensuring
the prompt evacuation of the other residents from the
park and they might have directed water at the burning
tires on the bulk truck as a priority earlier to
minimize flame encroachment on the bulk tank.
12. The jury heard that this recreational vehicle
park had no emergency plan or evacuation contingency
planning. It was on a rural property, surrounded by
farm land owned by others. The population of the park
was approximately 160 people, primarily retirees.
There were actually gates and exits on each of the
four sides of the site, but some of the witnesses who
had been residents for several years were unaware of
them. The sole, official entrance and exit was a one
lane road. As the fire was in a residence near the
entrance there were several transportation
difficulties:
1. The fire trucks could not get up-wind of the fire,
nor could they take advantage of the park swimming
pool as a potential source of water for their pumper
trucks,
2. The ambulance could not get close to where Mr
McNab and the two other injured victims had collapsed,
3. Other residents could not evacuate the park until
police officers kicked down a portion of a rail fence
and a temporary track was created across a cultivated
farm field.
The jury heard that these sorts of seasonal parks
often are developed in the absence of planning and
municipal input into their layout and design. Pre-
plans and some anticipation of potential challenges
for emergency access and evacuation, particularly as
the residents of these parks are often elderly,
obviously seemed like a good idea to the jury.
13. The jury heard that the propane company had
experts on site promptly in this occurrence. The
recommendation seems to suggest that such a response
was appropriate and ought to be the industrial
standard.
14. The jury heard considerable evidence about the
nature and properties of propane that was, frankly,
quite frightening. Mr McNab died even though he was a
highly trained, professional propane handler.
Considering that propane is commonly used in home
barbecues and in camping and recreational vehicles the
jury may have wanted to share their conclusions about
the lay-person's lack of everyday information about
the potential dangers associated with propane.
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