Record Number: 2688 CIS Descriptors: CONNECTIVE TISSUE DISORDERS PROPANE BLOWPIPES GAS EXPLOSIONS FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: Ontario REPORT TITLE: Verdict of the Coroner's Jury INDIVIDUAL PRESIDING: Dr. David Giddens, Coroner PLACE OF INQUIRY: Toronto DATE OF INQUIRY : 1999-04-19 INFORMATION ABOUT DECEASED: NAME: Frank Monardo OCCUPATION: Construction Labourer INDUSTRIAL SECTOR: Construction industry ACCIDENT INFORMATION: DATE OF ACCIDENT : 1996-02-03 PLACE OF ACCIDENT: 4700 Keele Street, York University Campus, Construction Site BRIEF CAUSE OF DEATH: Multiple blunt force injuries BRIEF MANNER OF DEATH: Propane inside the container was ignited and he was blown away from the container and suffered massive injuries ACCIDENT DESCRIPTION: The deceased is known to have rigged this heater inside the trailer for the purpose of preventing the hose and other equipment from freezing during the night. This was to ensure the equipment would be available for use the following morning. On Saturday, February 3, 1996, the deceased returned to the construction site, after having rigged the tiger tail heater inside the construction trailer during the night before. During the night, the flame of the tiger tail stopped burning. Unfortunately, when the flame was extinguished, the propane continued to escape into the construction trailer. It was unknown how long the propane continued to escape without a flame. On Saturday, the deceased arrived at the site at 9:00 am. and performed other duties associated with his job. About 10:30 he attended the construction site trailer where the hoses and pumps were stored. The deceased in some way ignited the propane in the container. It is not known whether or not he had gone in to the container at first, then shut the door and a spark from this may have ignited the propane inside, or whether or not he had possibly used a Bic lighter, later found at the scene, to try to thaw out the lock on the container in order to open it. In any case, the propane inside the container was ignited and he was blown away from the container and suffered massive injuries. Much of the equipment within the trailer was strewn about, very limited damage resulted, as most of the explosion was contained within, and then expelled through the two doors. It was noted that the lock, which the deceased was possibly trying to thaw, was still found attached to the right hand door of the trailer. The equipment was tested and was found to be without flaw. It should be noted that the tiger tail torch was not, and never was designed for the purpose of heating the interior of a structure for any purpose. The deceased did not have the generally accepted training program, which is now standard for persons handling propane at a site. RECOMMENDATIONS ISSUING FROM INQUIRY: 1. That the Ministry of Consumer and Commercial Relations amend Regulation 158/97 under the Energy Act to require the Record of Training for propane usage and handling to be renewed every three years. 2. That the Technical Standards and Safety authority review and update the propane handlers' training program on a 3 to 5 year cycle. 3. That the Construction Safety Association and the Ontario General Contractors Association advise all members that they should be responsible for verifying that all subcontractors handling propane have the required Records of Training. 4. That the Standards Council of Canada considers the mandatory requirement of a safety shut-off device for flame-out for hand-held utility torches. 5. That the Ministry of Labour requires all supervisors to undertake appropriate mandatory training in health and safety issues. COMMENTS ON RECOMMENDATIONS BY CORONER: 1. This was put in place to make sure that an individual would have appropriate, up-to-date training in the use of propane handling. In the past, there have been a number of classifications for handlers on propane, and certain certificates that had to be obtained in order to install, alter, purge, activate, repair, service, remove, or remove construction heaters and containers, piping and tubing. This required people to hold various categories of licenses, including PCHI and PCH2, which involve a significant amount of training, and which for the most part, in most jobs, would provide an over-qualification for the standard kinds of jobs that a person, such as the deceased, might need. However, a new stream-lined course has been put into place by the industry, particularly through the drive of PCL, so that there is now a "Record for Training" for propane usage and handling, which is modified in such a way that the basics can be taught to individuals who would not be using big units, but who would have to be trained on proper techniques for smaller propane units. It was felt that re-training should be done on a three-year basis so that handlers would retain their skills in the handling and safety features involved with propane. 2. Apparently, the programs are generally updated on a three to five year basis, and for this reason it was thought that the training program should be updated in the same space of time. There are sometimes various standards that change over a course of a number of years, and handlers should be made aware of these. 3. The jurors felt it was important that supervisors at work places should make sure that not only the individuals under their direct supervision, but also those who come into their workforce and are subcontracted, have appropriate records of training in propane usage. There was some concern that although large companies might be able to audit and control their own workers, to make sure that they would have appropriate training in propane handling, subcontractors might be employed in other companies who may not have monitored their workers as closely. It was thought that the supervisors, under whom these subcontractors would work, should make sure that they themselves check the subcontractors to make sure that all the handlers have appropriate training. 4. The utility torch used by this man did not have a safety shut-off valve, and therefore it allowed propane to continue to be expelled through the torch, even though the flame had been extinguished. This particular utility torch was not meant to be left turned on without direct supervision, nor was it ever intended to be used as a heater in an enclosed space, especially without somebody being in attendance. A safety shut-off valve would have prevented the torch from continuing to have propane enter it, if it were unattended. 5. The Ministry of Labour, at this point, does not require mandatory training, but apparently only recommends it for supervisors. Mandatory training would certainly help increase the knowledge base in health and safety issues in the workplace for supervisors.