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| Donor: |
Office of the Chief Coroner
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| Jurisdiction: |
ONTARIO |
| Report Title: |
Verdict of Coroner's Jury |
| Individual Presiding: |
Dr. Ken Ockenden, Coroner |
| Place of Inquiry: |
Welland |
| Date of Inquiry: |
2001-10-22 |
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| INFORMATION ABOUT DECEASED |
| Name: |
Robyn LaFleur |
| Occupation: |
Factory worker |
| Industrial Sector: |
Manufacturing industry |
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| Date of Accident: |
1999-11-08 |
| Place of Accident: |
Esquire Canada of Thorold |
| Brief Cause
of Death: |
Cerebral infarction, multi-system
failure due to blast injuries |
| Brief Manner
of Death: |
Accidental |
- Accident Description:
- The accident occurred on
Monday morning, November 8, 1999 shortly after 0700 when
employees were beginning to produce caps for the week
since the plant was shut down on weekends. Robyn began
her work by pouring logs (cap rolls joined in groups of
six) of caps into a hopper for sorting and packaging.
In the bottom of the hopper were logs of caps which had
been left over the weekend and which were likely very
dry and hence very volatile. It was learned that the stainless
steel hopper being used had been installed without the
knowledge or approval of Natural Resources Canada, had
not been grounded against static electricity and had not
been designed for use with caps. As the caps were being
poured by Ms. Lafleur either a static charge was generated
or sufficient vibration from the bouncing caps occurred
to detonate the caps. Unfortunately there was a laundry
hamper half full of dry caps about 6 ft. from the hopper
which secondarily detonated with the resulting massive
explosion causing part of the roof to collapse. Ms. Lafleur
was pinned by a partition so that part of her right leg
was amputated and she received extensive burns.
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- Recommendations Issuing From Inquiry:
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1. The Federal Government should have the maximum fines payable
for violators of its statutes [increased] from five thousand
dollars to fifty thousand dollars.
Rationale: To ensure compliance with existing regulations.
2. The Ministry of Labour and the Ministry of Natural Resources
are to consider an improved system of informing the management
and employees of small businesses of their requirements and
responsibilities contained in the various Acts.
Rationale: To better inform small businesses and their employees
of their responsibilities and requirements under the Act.
3. All workplaces that manufacture or package explosive materials
are to be surrounded by a secure perimeter. Warning and/or danger
signs must be posted along perimeter.
Rationale: To limit access to authorized personal only and to
create a safer work environment.
4. As a provision to the issuing of an explosive licence (for
the manufacturing or packaging of explosive devices whose end
result is to be used in toys) the employer must provide the
M.N.R. with detailed documentation outlining procedures that
will ensure compliance with the Explosives Act according to
the guidelines set forth by the M.N.R. Also the aforementioned
documents must be approved by the M.N.R. and the Ministry of
Labour be informed of the small business' compliance.
Rationale: To ensure that health and safety practices are followed.
- Comments on Recommendations by Coroner:
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1. Evidence was heard that the maximum fines which could be
levied against violators of statutes governing the manufacture,
storage and use of explosives were too small to have an effect
on conduct.
2. The Inquest heard testimony from the plant manager that she
was unaware of various provincial and federal regulations and
that she understood that she did not need to report changes
in the plant. Likewise, based on informal telephone conversations
with ministry officials, she believed that recurrent fires in
the plant were not required to be reported. Testimony from employees
revealed poor understanding of the various regulations so the
Jury felt the Ministries could better inform employees as well
as employers.
3. Evidence revealed that the factory hod no fence around it.
While this played no port in this accident the Jury felt future
accidents might be avoided if companies using explosives were
properly segregated.
4. As mentioned in the Specifics of the Case it appeared that
the ultimate cause of the accident was the installation of equipment
without approval and licence by the Ministry of Natural Resources
because the Ministry had not been notified. The jury heard that
regulations were in place but had not been followed.
Also it was apparent to the Jury that communication between
the various Ministries was informal and irregular and it was
their opinion that there should be closer cooperation to ensure
that small businesses complied with all requisitions.
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