Excerpt from the government of Ontario’s ‘Newsroom’
A worker, employed by Satin Finish Hardwood Flooring, Limited (now known as Prodtor Inc.), a manufacturer of pre-finished hardwood flooring of Toronto died after becoming trapped in an operating wood drying kiln.
On December 13, 2017 suffered fatal thermal injuries after becoming trapped in an operating wood-drying kiln at the workplace.
The company’s factory included three large wood-drying kilns made of sheet metal and capable of holding large quantities of wood while it is dried with high heat from a gas-fired appliance.
The kilns are equipped with large hanger-style doors that open to load and unload wood. There are two ‘man doors’ on each kiln, one at the front and one at the rear of each kiln, through which workers enter or exit. The inside of the kilns has no source of either natural or artificial lighting.
On that day, two workers were asked to fix a malfunctioning damper on kiln #3. The workers determined that the damper was frozen open, and that the best course of action would be to let the heat from the kiln melt the ice on the damper.
Later that day, the two workers met at kiln #3 to check the status of the damper. One of the workers turned off the kiln; it would remain hot for some time after that. After attending the control room, the workers opened the rear man door that leads to the heated wood-drying area in the kiln to assess if they could see sunlight through the dampers on the roof and thus determine the functioning of the frozen damper. The workers were unable to see any sunlight due to the steam in the kiln and the overcast day.
One of the workers ascended to the roof of the kiln to free up the previously frozen damper, and the other went into the kiln’s control room. The co-worker descended to the ground level and could not locate the other worker.
The co-worker and a supervisor proceeded to kiln #3 and opened the front man door. They found the worker lying on the floor unresponsive with vital signs absent. At the time, the kiln was operating at a temperature of 149 degrees Fahrenheit or 65 degrees Celsius, with very high humidity. Emergency services were called and attended but were unable to save the worker.
The Ministry of Labour investigated with the assistance of a ministry engineer who examined the front man door where the worker had been found. There was a door lock assembly designed to be used to open the door either from inside or outside the kiln. In the closed-door position, the lock assembly had a latch which locked the door closed. The lock assembly was functional from outside the kiln, allowing workers to enter the kiln. However, on the inside there was a push bar (also known as an “anti-panic system”) used to release the door latch from inside the kiln.
The door could not be opened from the inside. Corrosion was observed under the push bar and cracks seen in the body of the man door on the kiln-facing side. After disassembling the door lock, the engineer noted that an internal component known as a “push pin” was corroded and seized, which prevented the door from being opened with the push bar from inside the kiln once the door was latched in the closed position. The engineer concluded that this was the direct cause of the fatal event, as the worker was unable to open the latched man door and leave the operating kiln.
The manufacturer’s instructions for the door lock assembly outlines routine maintenance on the door lock assembly, including checking for corrosion of metal parts. The defendant did not have a preventative maintenance schedule at the workplace for the door assembly, and the door lock assembly was not maintained as recommended by the manufacturer.
In addition, the weatherstripping and metal around the push bar had deteriorated and corroded, creating openings that allowed moist air to enter and corrode the door lock assembly. Both the corrosion and malfunctioning of the push bar could be detected during the normal use of the door. The ministry’s engineering consultant concluded that maintenance would have prevented malfunctioning of the door lock assembly.
The defendant failed as an employer to ensure that a man door to kiln #3 could be opened by a worker from inside the kiln once the door latched closed, and failed to ensure that the man door to kiln #3 and its “anti-panic system” or door lock assembly were maintained in accordance with the manufacturer’s instructions.
Upon conviction, Satin Finish Hardwood Flooring, Limited was fined $225,000 in provincial offences court in Old City Hall, Toronto, by Justice of the Peace Lynette Stethem; Crown Counsel Daniel Kleiman.
The court also imposed a 25-per-cent victim fine surcharge as required by the Provincial Offences Act. The surcharge is credited to a special provincial government fund to assist victims of crime.
The law(s) in contravention:
Satin Finish Hardwood Flooring Ltd. was found guilty of a contravention of the Ontario Occupational Health and Safety Act (OHSA) section 25, subsection 2(h) which states,
“An employer shall,
(h) take every precaution reasonable in the circumstances for the protection of a worker.”
What a tragic event to take place! I cannot believe that the door was given a high priority of scheduled maintenance as one form of hazard control since the alternative was death! No, I cannot believe that this type of incident/accident still occurs today.
Now the reader better understands the need to hire health and safety professionals to ensure a culture of workplace safety!
HRS Group Inc. has a great team that can help you with all your health and safety needs including ‘Due Diligence’ and ‘Standard Operating Procedures’. Contact Deborah toll free at 1-877-907-7744 or locally at 705-749-1259.
We can also be reached at email@example.com
Ensure your workplace is a safe place.
Remember – In Ontario, “ALL Accidents are Preventable”
‘Work’ and ‘Play’ safe.
Daniel L. Beal
CHSEP – Advanced Level
VP & Senior Trainer
HRS Group Inc.