Blog Post #591 – Confined Space Safety Deficiencies Identified

Excerpt from the OH&S Canada magazine

Investigators say the absence of an Occupational Health & Safety system and missed opportunities to remedy unsafe conditions contributed to the deaths of three workers and the life-altering injuries up to others at a mushroom composting farm in Langley, British Columbia in 2008.

In its November 28, 2011, investigation report, WorkSafeBC outline circumstances surrounding the confined space deaths in a pump shed at A-1 Mushroom Substratum Ltd. On September 5, 2008, two company workers are trying to clear a blocked intake pipe when they were overcome by hydrogen sulfide (H²S) and an oxygen, deficient environment.

Unaware of the conditions inside the shed, fellow workers and employees of two adjacent mushroom businesses – HV Truang Ltd. and Farmers’ Fresh Mushrooms – attempted to rescue. Without protective gear though, three men succumbed, one was left unable to speak or hear, and one remained in a coma.

“The investigation into this incident has probably been the most complex in WorkSafeBC’s history and required significant resources and highly technical expertise,” notes a statement from the Board. “It took months to access key areas of the worksite, many more months to fully understand the industrial process involved and the chronology of events and decisions over a five-year period that played a role in the incident.”

This past May, WorkSafeBC referred the case to the Ministry of the Attorney General. On November 25, 2011, $350,000 in fines were handed down: $200,000 for A-1 Mushroom Substratum (which has since gone bankrupt); hundred and $120,000 for H-V Truang; and $15,000, $10,000 and $5000 for three officials says defence lawyer Les Mackoff.

The WorkSafeBC investigation determined that none of the three employers had developed or implemented an OH&S program or co-ordinated safety activities. “The workers were told to ‘be careful’ on an informal basis, but no meetings were conducted to discuss health and safety matters,” the report notes.

“Poor housekeeping, lack of preventative maintenance, failing to correct anaerobic conditions in the process water tank, and lack of compliance with regulatory requirements for the facility (which may have led to detection of elevated levels of hydrogen sulfide gas production in the process water recycling system) represented missed opportunities to prevent the development of conditions that led to this incident,” the report states, acknowledging that, as a board, WorkSafeBC missed chances to advise on or enforce OH&S requirements.

It was further determined that, dating back to 2004, the facility was designed, built and operated with inherent flaws that created conditions for hazardous gases to build up and for pipe blockages to develop.

A WorkSafeBC 3-D re-enactment video shows that, on the day of the incident, two men were working in the shed and trying to clear a blockage of a butterfly valve in a pipe. One worker use a screwdriver to pry open the tall plants of a valve, the news another to pull out straw and sludge lodged in the valve.

As one worker “pulled straw from the valve, he complained to the supervisor that there was a strange smell,” the report notes. The supervisor told the workers to exit the shed. “The worker at the valve took a step and then collapsed.”

WorkSafeBC measurements of the air below the valve, taken four months after the incident, showed that maximum H2S readings were greater than 500 ppm (ppm), the highest rating available on WorkSafeBC monitors. At this level, notes report, there is “immediate loss of consciousness. Death is rapid, sometimes immediate.”

Raj Chouhan, Labour critic for British Columbia’s NDP, reports a plumber had been unable to clear the pipe. (The WorkSafeBC report notes the plumber inform the supervisor that a sewer service company would need to use in order to clear the blockage.) “Instead of having professionals look at it, the company told workers to go inside an enclosed compartment,” Chouhan says.

Both the NDP and British Columbia Federation of Labour had called for a coroner’s inquest. In late December 2011 the BC Coroners Service announced a public inquest would begin May 7, 2012.

Chief corner Lisa Lapointe concluded there is benefit to holding an inquest to examine some of the broader circumstances to prevent future deaths from happening in similar circumstances.

My opinion

Ontario regulation 632/05, is the central ‘Confined Space’ regulation dealing with any and all confined spaces regardless of the sector.

Confined spaces are tricky at best. The hardest part, sometimes, is that they are hard to recognize and training is required under the law.

HRS Group Inc. prides itself on its confined space entry safety awareness program and is ready to offer that to any and all clients. It covers all the demands for an employer to develop a program including training, rescue procedures, attendants, discussion of definition of terms such as IDLH (immediately dangerous to life or health) purging of the system, atmospheric testing, means for entering or exiting a confined space, and the need for preventing unauthorized entry. All hazards have to be recognized, assessed and controlled prior to entry. Here we find a company not understanding that aspect of the business and got away with it for very long time. It was going to happen regardless when shortcuts are used.

Please ensure your company deals with confined spaces properly, has a plan in place and a program to deal with that plan. (5 confined space means 5 separate plans) Train your workers, including supervisors, to ensure compliance with Ontario regulation 632/05 or whatever regulations govern your province. It is the only way to protect your company through ‘Due Diligence’.

Remember – In Ontario, “ALL Accidents are Preventable”

HRS Group Inc. has a great team that can help you with all your health and safety needs including ‘Confined Spaced Entry’ and ‘Lockout and Tagout’. Contact Deborah toll free at 1-877-907-7744 or locally at 705-749-1259.

We can also be reached at 

‘Work’ and ‘Play’ safe.

Daniel L. Beal
CHSEP – Advanced Level
VP & Senior Trainer
HRS Group Inc.

2 thoughts on “Blog Post #591 – Confined Space Safety Deficiencies Identified”

Leave a Comment