Class: Application of the OSH/EM Acts Case Study #2: Flash Fire in Confined Space

Date: 2011-10-17

1) List the primary and secondary causes and explain why

Primary Cause Mixing of paint and hardener as well as redistribution of it to other drums inside the pontoon tank Use of non-flame proof lighting Exposed filament and exposed electrical wires Suitable and sufficient Risk Assessment not done Reason This action caused an increase in the accumulation of flammable vapours in the pontoon tank which is directly related to increasing the occurrence of a fire

Presence of combustible/flammable substances

This is a source of ignition especially in a confined space with flammable chemicals and vapour and is directly related to the start of the fire These exposed electrical elements were a direct source of ignition for a fire in the confined space with highly flammable vapour emissions If this was done adequately, it would have identified the hazard of mixing paint inside the confined space and instructions put in place to mix the paint outside and using a better ventilation system, therefore the presence of such high flammable vapour emission would not have been present to cause the fire in the first place. This is a primary safe system tool There were a lot of drums with flammable paint and solvents that were not necessarily needed at the time, nor were they properly sealed and enclosed. This caused flashbacks and further escalated the fire Reason This was only implemented for normal accumulation of flammable vapor but does not work as a good safety measure for heightened painting activity. If the exhaust ventilation was used then it could have dissipated more of the emissions and reduce the levels accumulating in the confined space hence making it less flammable The electrical bulb filament would have become exposed most likely due to electrical overloading. In the presence of no such system in place then it can be a gateway through which a fire can be started This is usually the last line of safety so will be secondary to the cause of the accident. To ensure a continuous monitoring of flammable vapour by providing the workers with suitable gas detectors to check the LEL concentration, at least some fire retardant clothing and respiratory masks would have reduced the severity of the injuries sustained A proper Safety Management System would be as a result of an adequate Risk Assessment, hence a secondary cause. If the right procedures were implemented then it would have eliminated the high accumulation of flammable vapours from mixing paint inside 1

Secondary Cause Improper ventilation system

No system to stop electrical overloading (e.g. a breaker)

No provision of proper PPE

Inadequate implementation and communication of Safety Management System

Class: Application of the OSH/EM Acts Case Study #2: Flash Fire in Confined Space

Date: 2011-10-17

Inadequate Permit to Work (PTW)

No maintenance upkeep checks were done frequently

the platoon and have provisions in place for the use of additional gas detectors and flame proof lighting. If the existing procedures were properly communicated then the workers would have known to have at least an oxygen detector to continuously check LEL and become aware that there was a rise. However, this alone was not sufficient The PTW was lacking since it did not properly identify the correct PPE and equipment the workers needed, like additional gas detectors nor was it given to the workers to review or be conscious off otherwise they would have been aware that at least one oxygen detector was needed Although the exposed wires were probably a primary cause of ignition for the fire, if maintenance was done frequently and the insulation and wires kept in good condition then it would have reduced or eliminated that source of ignition

2) State the breaches in the OSH Act

OSH Act Part II, Section 6, sub-section 1 Breach Although it was reasonable practical for the use of an exhaust ventilation system instead of a forced one this was not done. The workers were not equipped with a gas detector and the condition of the electrical wiring and insulation in the confined space was in poor condition. The safety, health and welfare of the workers were therefore not ensured although it was reasonably practical for the employer to have most of these provisions in place There was not a reasonably practical provision and maintenance of plant and systems of work since the electrical wires and insulation was not kept in good condition nor was there flame proof lighting, a suitable and sufficient risk assessment of the confined space was not conducted and there was not proper ventilation to accommodate heightened chemical vapour emissions Proper arrangements for the handling, storage and transport of the paint and solvents were not made. Drums with highly flammable substances were kept within the confined space that was not properly sealed and mixing of these were done inside the confined The workers were not provided with suitable and adequate PPE or devices no additional gas detectors were given to adequately the LEL. There was no mention of the provision or use of respiratory masks or any type of gloves for handling chemical paint and solvents and flame retardant clothing Safety management system was ineffectively communicated to the workers. Workers were unaware of the need to have an oxygen detector The amenities and arrangements for the workers welfare was not adequate as there was not provision for proper ventilation for heightened vapour emissions as well as the provision of additional equipment besides the oxygen mask to keep proper continuous check of the LEL. The electrical wiring was also in poor condition with damaged insulation and 2

Part II, Section 6, sub-section 2(a)

Part II, Section 6, sub-section 2(b)

Part II, Section 6, sub-section 2(c)

Part II, Section 6, sub-section 2(d) Part II, Section 6, sub-section 2(e) and (f)

Class: Application of the OSH/EM Acts Case Study #2: Flash Fire in Confined Space

Date: 2011-10-17

Part II, Section 6, sub-section 3(d)

Part II, Section 6, sub-section 4

Part II, Section 13A, sub-section 1

Part IV, Section 25, sub-section 3(b) Part IV, Section 25, sub-section 3(c) Part IV, Section 25, sub-section 5(a) and (b)

exposed wires hence the non- maintenance was a risk to the employees Information was not provided to workers on the proper handling of transfer of paint and solvent from one drum to another and the hazards with leakage or trails of the chemicals on the floor back to and around the drums as this was most likely what caused a flashback to occur It was not ensured that the paint and solvents in the confined space was handled and stored correctly in the drums and a flashback occurred indicating that the they may not have been properly sealed, nor was there any indication that chemical data sheets were provided or proper training and instructions given to the workers to not mix these highly flammable chemicals inside the confined space A suitable and sufficient risk assessment was not done and therefore it was not taken into consideration the risk of mixing paint inside the confined space that can cause an increase in emission of flammable vapours The confined space was not ventilated adequately for the heightened increase in paint vapours hence not providing a safe atmosphere The measures necessary to maintain a safe atmosphere was not taken as there were no provision of the proper monitoring equipment for workers to keep continuous check of the LEL The workers were only provided with oxygen detectors and this was not suitable for the continuous monitoring of LEL to ensure that it did not exceed 50% and it was most likely higher than this. Additionally, work other than cleaning and inspecting was being carried out in this environment where the flammable vapour emissions were high.

3) Give recommendations to prevent occurrence The following are our recommendations which, if implemented would have assisted in significantly reducing or preventing the occurrence of this accident and would also serve to prevent future re-occurrence of similar accidents in this type of confined work-space environment: a. A suitable and sufficient risk assessment should be carried before the work is to be done in the confined space. This is needed to take into account and identify all of the hazards associated with the work such as the chemicals used, the amount of chemicals, the increase of flammable vapour from painting activities and the type of monitoring and personal protective equipment needed to name a few. As a result of the Risk Assessment, safe work procedures and appropriate measures to eliminate or reduce the hazards identified should be put in place. The provision of an MSDS should be made available to employees with instructions outlining the proper use,

Class: Application of the OSH/EM Acts Case Study #2: Flash Fire in Confined Space

Date: 2011-10-17

handling and storage of these paint chemicals and this should have also been part of the permit to work (PTW).

b. In a confined space, flammable substances should be eliminated or reduced as far as reasonably practicable. In this instance, the mixing of paint and hardener was done by the worker inside the pontoon tank but should have been done outside of the confined space. Mixing of flammable substances outside of the confined space is a safe work procedure that should be implemented and included in the risk assessment as well as in the permit to work. Also, there should not have been such a high presence of combustible substances such as the paint and solvents sored in drums inside the confined space.

c. The workers should have been provided with all the necessary equipment to properly monitor the concentration of flammable vapour. The provision and use of gas detectors to do so should have been identified in the risk assessment and listed in the PTW so that it will be known and communicated to the workers that this is another safety procedure to follow.

d. The Safety Management System in place should be clear and well communicated to all workers. This could be made available through their through permit to work system identifying all the necessary PPE to be worn, monitoring equipment to be used and the necessary precautions to be taken and each worker should read and sign in this in front of a supervisor. In this instance one such example is making sure each worker is aware that they must wear an oxygen detector in the confined space.

e. The provision of flame proof electrical lighting and/or a breaker system that could control surges in electricity should be used in the confined space to eliminate any potential sources of ignition. Additionally, where there are electrical wires, frequent maintenance checks should be done. This should also be part of the safety system in place to ensure that any electrical cables used in the confined space are properly

Class: Application of the OSH/EM Acts Case Study #2: Flash Fire in Confined Space

Date: 2011-10-17

insulated and are in a good condition and those that are damaged should be replaced or repaired thus reducing the chance of ignition.

f. Proper ventilation such as additional exhaust ventilation should be put in place especially in areas where there are heightened chemical vapour emissions such as this one where there was increased painting activity which included the mixing of paint and additional release of vapours within the confined space. g. There should also be the use of some hazard signs around or inside the confined space which would serve to communicate, remind and reinforce in the minds of the workers both the potential dangers and necessary safety practices that should be complied with while working in the area. An example is a sign just before the entrance of the confined space saying One person should have an oxygen detector. h. The provision of PPE for the workers such as fire retardant suits in case of a fire or respiratory masks to reduce the inhalation of chemical paint vapours in the confined space, with the proper training on how they are to be used and the importance of using them should be given.