unreported pre-Tokaimura industrial fatality

["Franta, Jaroslav" <frantaj@AECL.CA>]

Dear Radsafers,
Below is an article reproduced from last Friday's Montreal Gazette, with an
account of a fatal industrial accident that occurred less than 48 hours
prior to the Tokaimura, Japan, nuclear fuel plant criticality accident on 30
September 1999. The accident occurred at a plant at Montreal's Dorval
airport. In sharp contrast to the Tokaimura accident, the former was not
publicized ANYWHERE, never mind around the world - as Tokaimura was for
months after (needless to say, even the article below was not posted on the
Gazette's internet web site, and thus remains hidden from most of the world;
...but I was only a bit surprised to find out about it four months after the
accident occurred  !). 
A friend who works at an aircraft maintenance hangar in Dorval acknowledged
that he knew about it, but wasn't aware of the cause of the fatality as
determined by the investigation. He also acknowledged that other work
accidents have occurred at Dorval in the past, but luckily without any
deaths. Just last week, he told me, several people barely escaped being
killed when the front-end of a Boeing 767 came crashing to the ground in the
maintenance hanger, after its nose gear collapsed (reportedly due to a
"procedural error"). The crew below jumped out of the way, with only one man
suffering a shoulder injury as the plane's fuselage grazed him, on its way
to the ground, while others suffered only shock (the wreck is presently
sitting there, awaiting the arrival of a repair team from Boeing's Seattle
plant). Of course the reason why these incidents are kept confidential is
the company's fear of scaring away their airline customers. Here's another
sharp contrast with the nuclear industry. But its really the drastic
difference in media coverage, IMHO, that makes all the difference, and that
needs to be addressed in some way(s).

The Montreal Gazette, 21 January, 2000

QUEBEC
Change unsafe system: board
Gas-plant firm cited after death
Amanda Jelowicki
The Gazette
______________

Praxair Distribution Inc. has to make procedural changes to its system of
filling cylinders with compressed breathable air in the wake of the death of
a 25-year-old Bombardier Aéronautique employee last September, Quebec's
workplace health and safety board said yesterday.
The Commission de la Santé et de la Sécurité du Travail's conclusions follow
a four-month investigation after Joey Rioux, 25, died while on the job as a
painter at a Bombardier plant in Dorval on Sept. 28.
Rioux was suffocated because there was no oxygen being fed to a gas mask he
was wearing as he painted the cockpit of a Challenger jet.
Praxair, a medical, industrial and specialty-gas supplier, supplied
Bombardier with compressed air. It erred in filling two of 38 cylinders with
oxygen being used that week at the Bombardier plant. Cylinders 18 and 19
were full of nitrogen and only had a 3.9-per-cent oxygen level.
Roger Dubois, a CSST inspector who investigated the incident, said humans
need about a 21-per-cent oxygen level to function normally. Levels as low as
3.9 will kill a person, he said.
In his investigation, Dubois found that a Praxair employee responsible for
filling the 38 containers with oxygen failed to notice the valves on
cylinders 18 and 19 didn't open and, therefore, weren't filled with oxygen.
Another company had used the same cylinders for nitrogen, which had not been
removed.
At one point, an employee realized the cylinder's valves were closed, but
thought they had already been emptied of nitrogen. He opened the other 36
cylinders, and thought cylinders 18 and 19 would be able to get enough
oxygen from them.
That accounts for the 3.9-per-cent oxygen level, Dubois said. Otherwise, the
level would have been zero.
While finding Praxair, and not the employee, responsible for the mistake,
Dubois said Praxair must make three procedural changes:
n Praxair must ensure that all cylinders have been emptied of previous
contents.
n If there is any malfunction in emptying and refilling cylinders, or if an
employee feels there is something wrong, the company must investigate to see
if a problem exists.
n Praxair must verify the oxygen level of every cylinder.
Praxair was fined $9,500 by the CSST for the incident.
Praxair said it co-operated fully with the investigation, deeply regretted
what happened, and said it was working with the CSST to ensure a similar
incident would not happen again.
<><><><><><><><><><><><><>

Request: does anyone else know of other fatal industrial accidents on or
around the date of the Tokaimura one ? It would be educational to document
just how many accidents the international media have ignored in their drive
to hammer all things nuclear.
Thank you.
Jaro
frantaj@aecl.ca
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