RepoRt OntariO ElEctrical SafEty. Electrocutions and Electrical-related injuries. Powerline and Utility-related Equipment.

Transcription

1 2009 OntariO ElEctrical SafEty RepoRt Electrocutions and Electrical-related injuries Powerline and Utility-related Equipment fires Electrical Product Safety Emerging issues and case Studies ESa initiatives

2 TABLE OF COntents 3 Report from the Chief Public Safety Officer 4 Executive Summary Purpose Introduction How Data was Collected Review of the 2008 Ontario Electrical Safety Report Electrocutions and Electrical-related Injuries Electrocutions Occupational Electrocutions and Injuries Non-occupational Fatalities and Injuries Injuries Reported by the Canadian Institute of Health Information Case Study Powerline and Utility-related Equipment Case Study Fires Fire Source Data Overview of Fires in Ontario Fires Resulting in Fatalities Fire Incidents with Electricity as the Fuel of the Ignition Source Cooking Fires Electrical Distribution Equipment Fires Fire Investigation Case Studies Electrical Product Safety Case Studies Summary Initiatives 66 Appendix 67 Glossary

3 2009 OntariO ElEctrical SafEty report 3 RepoRt from the Chief public Safety officer, electrical Safety autho Rity The Electrical Safety Authority s (ESA) annual Ontario Electrical Safety Report is a key contributor to our mission of getting to zero zero electrical fatalities and serious incidents in Ontario. It is only by knowing and understanding the rates and nature of electrical safety incidents that we can make a meaningful effort to eliminate them. As ESA s Chief Public Safety Officer, it is my responsibility to ensure that ESA s priorities and initiatives align with the major drivers of harm. This annual report compiles information from multiple sources into a comprehensive reference guide and draws conclusions that we use to drive our safety strategy. Equally important, I want our safety stakeholders to see ESA as a source for unabridged and unbiased information on the state of electrical safety in Ontario. Our goal is to have other members of the safety system review and respond to this data and be part of a collective electrical safety effort in the province. ESA has dedicated resources to collecting and compiling electrical incident statistics and has augmented them with root-cause investigations. In addition, this report would not be possible without the assistance and information exchange of safety partners including the Ministry of Labour, the Office of the Fire Marshal, and the Coroner s Office. I thank them for their support. The single most significant finding from this data continues to be the same over the past two years 70% of all electrical injuries in Ontario are associated with five key areas: Powerline contact which accounts for 49% of all electrocutions over the last ten years. Although these incidents have declined by 29% over this period, we still have a long way to go; Workplace electrocutions make up 60% of all electrocutions in the last decade. The electrical trade is still experiencing serious injuries and fatalities, particularly when working on energized electrical panels; Stove-top cooking fires continue despite significant reductions in incidents. They accounted for more than 1,000 fires in 2009; In 2009, there were 1,000 fires and five fatalities associated with electrical wiring, extension cords, electrical panels, cords on appliances, etc. This edition of the Ontario Electrical Safety Report shows that we are making good progress overall: electrocution rates are down 43% and fire fatalities have declined 56% in the past ten years. But we are only part way down the path of getting to zero. By sharing this data and identifying the trends, ESA intends to provide insight and focus. Achieving further safety improvements will require a concerted effort of industry and stakeholders working throughout the province. We call on all Ontarians who can make a difference to consider how they can eliminate electrical safety risks. Together we can get to zero. Peter Marcucci Chief Public Safety Officer

4 OntariO O ElEctrical SafEty report ExEcutivE Summary DEAtHS PER million POPUlAtION There has been a steady decline in the rates of electrocutions, fire fatalities (where the ignition source was identified as electrical 1 ), and electrical injuries in Ontario over the past ten years. While good progress is being made, serious incidents still occur and the same causes and contexts drive the majority of events. Concerted efforts are required to continue to move incident rates down. This Ontario Electrical Safety Report (OESR) reflects data from multiple sources to provide a nuanced picture of what is happening in Ontario. Comparison of Electrocutions to Fire Fatalities, per million population Fire Fatalities Electrocution fatalities Key Findings: Fatalities Over the last ten years (2000 to 2009), there were 207 electricity-related fatalities in Ontario 90 from electrocutions, and 117 from fires where the ignition source was identified as electrical. By comparison, from 1999 to 2008, there were 219 fatalities: 95 electrocutions and 124 fire deaths 2. Electrocutions The rate of electrocutions (accidental death caused by contact with electricity) continues to decline: From 2000 to 2004, there were 51 electrocutions, a rate of 0.85 per million population; From 2005 to 2009, there were 39 electrocutions, a rate of 0.61 per million population; a decrease of 28%. Powerline electrocutions accounted for almost half (49%) of all electrocutions in the past decade, although in the last five years the percentage has dropped: From 2000 to 2004, 63% of all electrocutions in Ontario were from powerline contact; From 2005 to 2009, 34% were powerline-related. Occupational electrocutions (occurring in the workplace) outnumber non-occupational by a factor of 2 to 1: From 2000 to 2004, 35 of the total 51 (69%) electrocutions were occupational; From 2005 to 2009, 25 of the total 39 (64%) were occupational. Powerline electrocutions accounted for almost half (49%) of all electrocutions in the past decade. Within occupational electrocutions, electricians account for 20% and they also continue to be critically wounded on the job when working on energized electrical panels. Non-occupational electrocution rates have also declined. The low number of incidents makes trending difficult, however using five-year rolling averages we find: The number of non-occupational electrocutions dropped from 6.2 to 2.8 over the last ten years; The rate of electrocutions per million of people has dropped from to 0.218, a decline of 60%. 1 Such as a case of a grease fire on an electrical stovetop. 2 The difference in fire fatalities is due to a change in method by which ESA counts cooking fire fatalities.

5 2009 OntariO O ElEctrical Ectrical SafEty report 5 Executive Summary Fire Fatalities & Events The rate of fire fatalities (where the ignition source was identified as electrical) has declined steadily since 1996: From 1996 to 2000, the rate was 1.67 per million population; From 2000 to 2004, the rate was 1.050; From 2005 to 2009, the rate was The number of electrical fire incidents has declined 32% over the past ten years. Cooking-related fires continue to be the most common type of electrical fire although the rates are declining. In these events, electricity is the source of ignition, but grease or combustibles are the fuel source for the fire: In 1999, there were 1,655 cooking fires; In 2008, there were 1,132; a decrease of more than 500 fires. Electrical distribution fires, as defined by the Office of the Fire Marshal (OFM) 3, are also declining, as are the associated fatality rates: In 1999, there were 1,123; In 2008, there were 906, a reduction of more than 200; From 1996 to 2000, the fatality rate of these fires was 1.39; From 2005 to 2009, the fatality rate was Electrical-Related Injuries Occupational In 2008 (the most recent year for which we have data) there were: 85 non-critical electrical injuries, a decline of 39% over nine years: 78,256 lost-time injuries, a decline of 25%. Non-Occupational Over the last ten years, there were 21 reported nonoccupational electrical injuries. However non-occupational injuries are significantly under-reported, so ESA is less informed of the true picture of the rates of these injuries. Priority Issues Based on the data collected through successive years of the OESR, the Electrical Safety Authority has identified the following as priority areas of focus: Reducing powerline contact Powerline contact has accounted for almost half of all electrocutions in the past ten years. ESA s activities include establishment of the Powerline Safety Strategy Workgroup and initiatives targeting high-risk groups: dump truck operators, the farming community, and small contractors in siding, roofing and painting. Reducing serious injuries and incidents to electrical workers Fatalities to the electrical trade accounted for 28% of all occupational fatalities between 2005 and ESA s activities include: support to the Electrical Safety Coalition s Don t Work Live campaign through the Industrial Accident Prevention Association (now Workplace Safety & Prevention Services), Electrical & Utilities Safety Association (now Infrastructure Health & Safety Association), Greater Toronto Electrical Contractors Association, and International Brotherhood of Electrical Workers; sponsoring electrical safety apprentice training; partnering to present Workplace Electrical Safety Workshops; advancing the standards for workplace electrical safety; and researching why some electricians persist in working live. Reducing incidents associated with the misuse of electrical products, unapproved, or counterfeit products The use or misuse of these products results in more than 1,000 fires and an average five fatalities annually. These fires are primarily caused by misuse of stove-top equipment i.e. leaving cooking unattended. ESA is very active in the OFM s Public Fire Safety Council and the Stove-top Fire Working Group. The number of electrical fire incidents has declined 32% over the past ten years. 3 The OFM definition of distribution equipment is electrical wiring, devices or equipment, the primary function of which is to carry current from one location to another. Thus, wiring, extension cords, termination, electrical panels, cords on appliances, etc. are considered distribution equipment. This is different than Distribution Equipment as defined by Local Distribution Companies.

6 OntariO ElEctrical SafEty report Executive Summary Reducing electrical contact and fires associated with older buildings and electrical infrastructure Fires in older buildings account for roughly 1,000 fires and five fatalities annually. ESA sponsored the development of CSA s standard for Electrical Inspection for Existing Residential Occupancies to provide a consistent base for inspection of older residential properties. In addition, ESA is working on a set of emerging safety issues: Streetlighting Public Safety concerns raised in 2008 led to ESA forming a working group of Local Distribution Companies (LDCs) to develop guidelines for the design, installation, operation, and maintenance of these assets; 347V occupational safety concerns There were no fatalities in 2009 attributed to contact with 347V systems. However, ESA s inspection process has identified increasing concern regarding worker risk in this area. Electrical Devices and Bathtubs There have been two deaths in the last five years involving the use of an electrical device around a bathtub. In both cases the device inadvertently fell into the water-filled tub with the occupant in it. Fatalities with theft of copper and power Reports of a fatality in 2009 and two in prior years were criminallyrelated. Aging utility infrastructure Incidents associated with distribution equipment continue to present electrical risks to the public. ESA s Utility Advisory Council has established an Asset Management Working Group to seek advice and input from LDCs on the mitigation of these risks. Inadequate powerline clearance to new buildings Lack of attention or knowledge of requirements for adequate clearance between new structures and powerlines continues to result in incidents and increasing public safety concerns. Lack of attention or knowledge of requirements for adequate clearance between new structures and powerlines continues to result in incidents and increasing public safety concerns.

7 2009 OntariO O ElEctrical Ectrical SafEty report Purpose 1.0 P urpose 1.1 I ntroductiono The purpose of this report is to provide stakeholders the state of electrical safety in Ontario. This report is a culmination of statistics on electrical incidents: electrocutions and injuries of electrical nature; and fire incidents causing death, injuries, and damage identified by the Office of Fire Marshal of Ontario and local fire Departments in Ontario with electricity identified as the fuel source. ESA operates within a broader Electrical Safety System. This system includes electrical utilities and those organizations that generate, transmit and distribute electricity. It includes organizations that design, manufacture, distribute and supply electrical products and electrical contractors who install, repair and maintain electrical wiring installations and products in our homes, workplaces and public spaces. The broader integrated electrical safety system includes a vast array of organizations from the private and public sectors to end users all having contributing roles in electrical safety. Regulators and various levels of government write policies and regulations to protect public safety. Canadian and international organizations develop standards for electrical installation and products; academic and commercial organizations focus on safety research and development; and various insurance organizations create policies that drive organization and consumer behavior to reduce safety risk. Health care providers, workplace and community-based safety organizations, education and training organizations each provide public communication, increase hazard-mitigation skills and awareness. All these organizations have a role in improving electrical safety in Ontario. It is hoped that this report helps educate and inform members of the broader electrical safety system by helping them identify key electrical safety risks so that they will take appropriate action. This information can also help organizations developing and improving standards, to identify areas for continued safety research, to shape the development of workplace and community-based safety programs, and to lead to improvement in training, education and communications programs. This is the ninth report on the state of electrical safety in the Province of Ontario. The Electrical Safety Authority (ESA) operates as a delegated authority on behalf of the provincial government in accordance with Part VIII, section 113 of the Electricity Act, 1998, S.O. 1998, c.15, Sched. A, and the Safety and Consumer Statutes Administration Act, 1996, S.O. 1996, c.19. Within its mandate the ESA is responsible for electrical safety in Ontario as designated by Ontario Regulation 89/99, 570/05 and Regulation 22/04. The matters arising from these regulations include administration, inspection and enforcement in regard to electrical installations, electricity distribution systems and the licensing of Electrical Contractors and Master Electricians within the province. In 2007 the Government of Ontario established Ontario Regulation 438/07 Electrical Product Safety and ESA is the delegated authority for the administration of this new regulation. The number of incidents in this report are based on data and information provided to ESA as of July These numbers may change in subsequent reports due to additional information received after the publication of the report. These changes and explanations will be noted in future reports. The Electrical Safety Authority uses this report to identify the areas where ESA should focus its prevention, inspection and enforcement activities, making its action transparent to the people of Ontario.

8 OntariO ElEctrical SafEty report 1.2 How data was collected 1.2 H ow data was collected ESA receives data from various resources to compile this report. These include the Coroner, Ministry of Labour (MOL), the Office of Fire Marshal (OFM), and the Workers Safety Insurance Board of Ontario (WSIB). ESA crossreferences the data with the Coroner reports, the OFM s report and ESA s root-cause investigation data to ensure accuracy and understanding of the incidents. Data on nonserious incidents are taken at face value. ESA also uses data from Statistics Canada available from the internet to determine electrocution and death by fire as rate per population and rate per labour population to determine occupational injury rates. This report would not be possible without the assistance of the many industry partners who share data. ESA acknowledges and thanks the Ontario Ministry of Labour (MOL) for providing information, notifying ESA of occupational injuries (electrical) and cooperating with ESA in the investigation of these incidents. ESA also thanks the Office of the Fire Marshal (OFM) for continuing support in providing information on fire-related electrical incidents and accidents, partnering with ESA on Stove-top Fire initiatives, notifying ESA of electrical fire incidents and allowing ESA to take part in forensic investigation conducted in the OFM facilities. ESA also thanks the following organizations for their support: The Coroner s Office of Ontario for sharing coroner s information on electrocutions and other deaths in Ontario. The National Work Injury Statistics Program (NWISP) for occupational injuries and fatalities across Canada. The Canadian Institute of Health Information (CIHI) for hospital information of electrical injuries. The Workers Safety Insurance Board of Ontario (WSIB) for providing occupational injury. For benchmarking, ESA uses the next four largest provinces for reference. Other smaller provinces have much smaller population than Ontario and the rate of injuries are directly proportional to the labour population. 1.3 R eview of the 2008 Ontari O ElEctrical l Saf Ety report The 2008 OESR reported 178 fatalities between the 1999 and 2008 period; 95 were the result of electrocution and 83 were fatalities from fires with electricity identified as the fuel of ignition. Please note that with the exception of distribution equipment fires 1 and some appliance fires, electricity was not the primary fuel associated with the fires. These numbers now need to be adjusted to read 95 electrocutions and 124 deaths by fire with electricity identified as the source, with a total of 219 fatalities, due to an adjustment in deaths identified at the OFM. The jump in the OFM death total is due to a change in the way cooking fire deaths are counted; ESA assumes that all fatal stove-top fires not identified as gas or propane fuelled as electrically-fuelled fires. In the 2004 to 2008 period the rate of electrocution per million population was In the same period, the rate of death by fire where electricity was identified as one of the sources of ignition was There was a significant decrease in powerline-related deaths in the five-year period of 2004 to 2008; they accounted for 33% of all electrocutions, compared to 64% in the previous five-year period. From 2004 to 2008, the ratio of male-to-female deaths was 89 to 6. Work-related electrical deaths accounted for 64 out of 95 electrocutions between 1999 and 2008; the prevalence of occupational electrocution has increased in the last fiveyear period to 70%. With a steady reduction of workplace electrocutions to non-electrical trade workers, and virtually no change in the yearly deaths of electricians in the ten-year period, the prevalence of electricians electrocuted on the job has increased from 5.6% between 1999 and 2003 to 21.4% from 2004 to 2008, as a percentage of all electrocutions. Fires, with electricity identified as the fuel of ignition, decreased by 22.8% between 1998 and Cookingequipment fires continue to decline, while electrical wiring-equipment fires have remained relatively on the same level in the last ten years. 1 Fires from wiring installation or wiring devices

9 2009 OntariO O ElEctrical Ectrical SafEty report Electrocutions and Electrical-related Injuries 2.0 ElEctrocutions and ElEctrical-rElatEd injuries This section of the report covers the period from 2000 to 2009, with statistics for a ten-year running period. The electrocution statistic is based on Ontario Coroner s reports, ESA records and the Ministry of Labour s (MOL) report. It includes benchmarking statistics provided by NWISP. At the time of writing, the Coroner s data for 2008 and 2009 was still pending confirmation. This may affect the reported fatality numbers in these years. Where there are discrepancies in the number of fatalities reported by MOL, ESA and NWISP, ESA uses the data provided by the Coroner. The electrocution cases in the report are all incidental electrical contacts. Suicides, deliberate attempts to injure, and death by lightning strike are all excluded. Electrocution resulting from criminal activities such as theft of power or theft of devices, vandalism or prank or electrocutions resulting from vehicle accidents with utility poles are counted as part of the statistics but are not included as part of the preventable deaths. Death resulting from a fall but initiated by an electrical contact to a worker would not be recorded as an electrocution and therefore not counted as part of electrical injury data. The report separates occupational from nonoccupational (member of the public) incidents for reason of stakeholder interest and strategic initiatives. ElECtROCUtIONS PER million POPUlAtION FIGURE Five-year Rolling Average of Electrocution Rate ElEctrocutions Ontario reported 90 electrocutions in the ten-year span between 2000 and 2009, a decrease from 95 in the period of 1999 to Viewing the five-year rolling averages in Figure 2.1.1, one can see a gradual decline. Actual counts are shown in Figure 2.1.2, showing spikes of numbers due to the small number of electrocutions. Comparing five-year periods, there were 51 electrocutions between 2000 and 2004, and 39 in 2005 to 2009, a reduction of 12. Ontario reported 90 electrocutions in the ten-year span between 2000 and 2009, a decrease of 95 in the period of 1999 to NUmbER OF ElECtROCUtIONS FIGURE Electrocutions in Ontario

10 OntariO ElEctrical SafEty report 2.1 Electrocutions table Number of Electrocution Incidents in Ontario Five-year Comparisons with Occupational versus Non-Occupational Fatalities 2000 to 2009 FIvE-yEAR PERIOD total ElECtROCUtIONS ElECtROCUtION RAtE OCCUPAtIONAl ElECtROCUtIONS NON-OCCUPAtIONAl ElECtROCUtIONS 2000 to to % DEClINE 23.5% 28.1% 28.6% 12.5% Table shows the rate of electrocution per million of population was 0.85 for the first of the five-year periods, and 0.61 for the second period a reduction of 28%. Occupational electrocutions were prominent in both five-year periods, but these declined faster than nonoccupational (28.6% compared to 12.5%). Figure shows rolling averages in five-year periods for powerline electrocutions per million of population. The decline over the years can be further understood in the breakdown in Table Electrocutions through ladder contact and antenna-related contact have declined and have only contributed to one fatality in the past decade. ElECtROCUtIONS PER million POPUlAtION FIGURE Five-year Rolling Average of Powerline Electrocution Rate versus Population Between 2000 and 2004, there were six electrocutions involving a ladder. This number is reduced to two in the period from 2005 to 2009 a reduction of 66%. The significance of powerline-contact electrocutions can be seen on Table Overall, powerline contact accounts for roughly half of all electrocutions from 2000 to The prevalence of fatal incidents has dropped in recent years as shown on Table (from 57% to 38%). As seen in Table 2.1.4, males continue to dominate electrocution incidents; there have been no recorded female workplace electrocution in the past 15 years. The frequency of female electrocutions has been reduced from less than 8% of all electrocutions in the earlier five-year period, to less than 3% in the most recent period. table Powerline Electrocutions involving ladders and Antennae EqUIPmENt total ladder Antenna

11 2009 OntariO ElEctrical SafEty report Electrocutions table Powerline versus total Electrocutions Five-year Comparisons 2000 to to to 2009 total 2000 to 2009 total electrocutions Powerline electrocutions Percentage of powerline to all electrocutions 56.9% 38.5% 48.9% Occupational electrocutions were prominent in both five-year periods, but declined faster than non-occupational. table male-to-female Electrocutions FIvE-yEAR PERIOD COmPARISON FEmAlE ElECtROCUtIONS male ElECtROCUtIONS total ElECtROCUtIONS 2000 to to total Electrocutions in farming facilities continued to decline from nine (in the first five-year period) to one incident in the latest five-year period. As a percentage of the total, it has decreased from 18% to 3%. Current highest risk areas are residential, public place, industrial and commercial facilities (see Table and Figure 2.1.4), with residential and public place increasing slightly in recent years. Occupational and nonoccupational electrocution numbers remained the same in residential settings when comparing the two five-year periods. Workplace electrocutions in residential facilities accounted for eight fatalities, four in each of the two five-year periods. Non-occupational electrocution in residential facilities accounted for 16 fatalities, with eight in each of the two five-year periods. table Electrocution by Facility type FACIlIty type ElECtROCUtIONS 2000 to 2004 PERCENtAGE 2000 to 2004 ElECtROCUtIONS 2005 to 2009 PERCENtAGE 2005 to 2009 total INCIDENtS Campground 1 2.0% 0 0% 1 Commercial 4 7.8% % 10 Farm % 1 2.6% 10 Industrial % % 17 Institution 2 3.9% 2 5.1% 4 mining 1 2.0% 0 0% 1 Public place % % 20 Residential % % 24 Utility 0 0% 3 7.7% 3 total % % 90

12 OntariO ElEctrical SafEty report 2.1 Electrocutions FIGURE Electrocution by Facility type Five-year period Comparisons 2000 to to 2009 Campground 2% Institution 4% Residential 23% Utility 0 % Residential 31% Utility 8% Public place Public place Industrial 23% 20% 20% Industrial 18% Campground 0% Farm 18% mining 2% Commercial 8% Table shows the difference in the numbers of electrocutions occurring in occupational versus non-occupational settings in the ten-year period. The table shows the following: Electrocution in work-type facilities such as commercial, industrial, institutional and mining only occurs to workers. This illustrates that workplaces in general provide relatively good protection to the public from electrical hazards. The general public is more vulnerable to electrical hazards in facilities such as residential and public places. 1 table Electrocution by Facility type Occupational versus Non-occupational ten-year period from 2000 to 2009 FACIlIty type OCCUPAtIONAl NON-OCCUPAtIONAl Campground 0 1 Commercial 10 0 Farm 8 2 Industrial 17 0 Institution 4 0 mining 1 0 Public place 11 9 Residential 8 16 Utility 1 2 total ElECtROCUtION PER million POPUlAtION Institution 5% Occupational Commercial 15% mining 0% Non-occupational Farm 3% FIGURE Five-year Rolling Averages comparing Occupational to Non-occupational Fatalities 1996 to The rate of non-occupational electrocutions has not changed significantly, as shown in Figure The annual rate of these fatalities has been less than six since There were years where non-occupational electrocutions numbered less than two. The rate of occupational electrocutions has started to decline after a rise in the periods from 1996 to Public places are facilities such as street and parks.

13 2009 OntariO ElEctrical SafEty report Electrocutions Trending events The rate of electrocution continues to decline. This becomes more apparent when looking at the data in fiveyear rolling averages. The numbers of electrocutions have dropped from 51 to 39 fatalities, over the five-year periods 2000 to 2004, and 2005 to 2009 respectively. There was a decrease of 12 incidents in the number of fatalities between 2000 to 2004 and 2005 to Powerline electrocutions continue to decline with antenna, ladder and farming-related incidents, in spite of two ladder fatalities in There was only one electrocution in the farming sector, from 2005 to Ladder-related incidents accounted for six electrocutions in 2000 to 2004 and only two in 2005 to Powerline fatalities represented 62% of all electrocutions in 2000 to 2004, and only 47% in the subsequent fiveyear period. Electrocutions in public places have continued to decline. The continued absence of electrocutions in campgrounds, mining and military facilities shows that previous electrocutions in these facilities were more of an anomaly than a norm. In this period, there are no occupational female fatalities. The male-to-female electrocution ratio continues to be high with male-to-female ratios of 89:6 between 1999 and 2008 and 85:5 between 2000 and Occupational fatalities are still prevalent with a 2:1 ratio over non-occupational, but the prevalence has decreased over the last five years. Fatalities in residential facilities (in both occupational and non-occupational settings) remain at the same level when comparing the two five-year periods. (This is one of the most dominant facilities for occurrence of electrocution.) Electrocutions are most common between the months of May and October. There were two bathtub-related fatalities in the last five years. There has been one electrocution yearly from theft activities in each of the last three years. Non-trending events There are no electrician fatalities in 2009, but there are still critical injuries to the trade. There are a relatively high number of non-occupational fatalities in Utility-related electrocutions account for four of seven in There were two ladder fatalities in Figure shows that warmer months have more electrocutions than other months, for both occupational and non-occupational incidents FIGURE Count of Occupational and Non-occupational Fatalities month by month for the ten-year Period 2000 to 2009 DEAtHS 2 0 January February march April may June July August September October November December Occupational Non-occupational Powerline electrocutions continue to decline associated with antenna, ladder and farming-related incidents, in spite of two ladder fatalities in 2009.

14 OntariO ElEctrical SafEty report 2.2 Occupational Electrocutions and Injuries 2.2 O ccupati c a Onal ElEctrOcuti Ons and injuries Rate of Occupational Electrocutions compared to Labour Population Table is based on data collected from the NWISP. It should be noted that the numbers derived from NWISP can differ from the presented electrocution count from the MOL and the coroner because NWISP reflects only the fatalities and injuries to personnel at companies registered with respective WSIBs in each province. For example, a self proprietor and small family business are most likely not included in the NWISP fatality count. Benchmarking in the 2009 OESR is for a seven-year period from 2002 to 2008 and the labour population is based on Statscan data. In both electrocution and injury rates, Ontario has the lowest rate of the four provinces per capita (both labour and public). table Occupational Electrical and Injury Rates for 2002 to 2008 (per million population of labour force) ElECtROCUtION RAtE INJURy RAtE british Columbia Alberta Ontario quebec Saskatchewan INJURy RAtE FIGURE Rate of Occupational Injury Rate (per million population of labour force) british Columbia Alberta Saskatchewan Ontario quebec

15 2009 OntariO ElEctrical SafEty report Occupational Electrocutions and Injuries From 2000 to 2009 there was a total of 60 occupational electrocutions (an average of 6.0 electrocutions per annum) compared to 64 fatalities between 1999 and 2008 (an average of 6.4 electrocutions per annum) as reported in the 2008 OESR. Comparing the two five-year periods, the electrocution rate dropped from 1.18 (2000 to 2004) to 0.71 (2005 to 2009). The occupational electrocution rate dropped from 1.35 in 2000 to in Table compares the rates of electrocution to all workplace fatalities, through five-year rolling averages. With workplace fatalities, the rate was in the first period and in the later period (2004 to 2008), a drop of 25.1%. In the same two periods, the rate of electrocution dropped from 1.18 to 0.81 a decrease of 31.7%. Figure shows non-occupational and occupational electrocutions; with the exception of 2008, occupational electrocution incidents outnumbered the non-occupational fatalities FIGURE Occupational versus Non-occupational Electrocutions 2000 to 2009* Occupational Non-occupational *In 2007, there were no non-occupational deaths. table Rates of Electrocution versus All Workplace Fatalities Comparison of Five-year Rolling Averages 1999 to Electrocutions All workplace fatalities NA Statistics Directly Related to Harm Reduction Priorities Worker Safety Five-year Rolling Averages Compared This chart shows the number of worker-related electrical fatalities and critical injuries, and is based on data reported by the MOL, incidents investigated by ESA, and confirmed with the Coroner s office report. The five-year reduction refers to the reduction (or increase) from the first five-year period to the last five-year period. For example, the 2002 to 2006 figure is a comparison of to PERIOD 2002 to to to to 2009 Five-year rolling average Five-year reduction 28.2% 25.9% 28.1% 29.3% With the exception of 2008, occupational electrocution incidents outnumbered the non-occupational fatalities.

16 OntariO ElEctrical SafEty report 2.2 Occupational Electrocutions and Injuries FIGURE Five-year Rolling Averages of Occupational Electrocution Rates (per million population of labour force) 1996 to Figure compares rolling five-year averages, showing the rate of occupational electrocution dropped from 0.87 (1996 to 2000) to 0.71 (2005 to 2009). Over these years, the rate increased, peaking at the 1999 to 2003 period, and then declining steadily to Figure shows the rolling five-year averages of occupational electrocutions and critical injuries from 1998 to Fatalities remain flat, with critical injuries decling over the eight-year period. table Occupational Electrocutions by Facility type Five-year Comparisons 2000 to table Occupational Electrocution Rate Five-year Comparisons 2000 to 2009 FIvE-yEAR PERIOD ElECtROCUtIONS PER million OF labour POPUlAtION 2000 to to FIGURE Occupational Electrocutions and Critical Injuries Five-year Rolling Averages 1998 to Electrocutions Critical Injuries FACIlIty total OvER ten years 2000 to 2009 FIvE years 2000 to 2004 FIvE years 2005 to 2009 PERCENtAGE CHANGE Commercial up 50% Farm down 86% Industrial down 30% Institution even mining down 100% Public place down 43% Residential even Utility up 100% total down 29%

17 2009 OntariO ElEctrical SafEty report Occupational Electrocutions and Injuries As shown in Table 2.2.4, industrial, public place, commercial and residential facilities are the most prevalent in occupational electrocutions. Encouraging to the farming sector workplace fatalities were a concern but have been declining dramatically in the last five years. Figure shows the decrease in farm incidents, and the prevalence of industrial facility electrocutions. These figures are supported by the injury data from the WSIB, presented in Table In the industrial and commercial sectors, electrician and labourer are the occupations at highest risk 33% of occupational fatalities in this sector are electrical tradespeople. (See Table ) FIGURE Occupational Electrocution by Facility type for two Five-year Periods 2000 to 2009 Industrial 29% Farm 20% 2000 to to 2009 Public place 20% Commercial 11% Residential 11% Institution 6% mining 3% Institution 8% Utility 4% Commercial 24% Public place 16% Industrial 28% Residential 16% Farm 4% table Occupational Fatalities in Industrial and Commercial Facilities over ten years 2000 to 2009 OCCUPAtION total Electrical apprentice 2 Crane operator 1 Electrician 7 HvAC 2 labourer 5 maintenance 2 mechanic 1 millwright 2 Owner 1 Painter 1 Sign installer 1 Supervisor 2 total 27 Packing 1.7% Production 1.7% Utility 1.7% moving 1.7% FIGURE Occupational Electrocution by type of Work 2000 to 2009 Repair and maintenance 58.3% Farming 5.0% Construction 26.7% Other 1.7% Disassembling 1.7% In the industrial and commercial sectors, electrician and labourer are the occupations at highest risk 33% of occupational fatalities in this sector are electrical tradespeople.

18 OntariO ElEctrical SafEty report 2.2 Occupational Electrocutions and Injuries table Occupational Electrocution by type of Work Five-year Comparisons 2000 to 2009 type OF WORk 2000 to to 2009 total FOR ten-year PERIOD Construction Disassembling Farming moving Other Packing Production Repair and maintenance Utility total The greatest number of electrocutions from 2000 to 2009 occurred when performing construction, and repair and maintenance. These areas account for 85% of all electrocutions in the ten-year period. Repair and maintenance in fatalities have declined in the past fiveyear period, while construction incidents have increased. Electrocutions, while performing other tasks, have decreased in the last five years. Twenty-one of the 25 electrocutions were the result of repair and construction (80% of fatalities). Figure displays the probable cause for fatalities and critical injuries in the workplace. 75% was directly attributed to a human-error-related cause (improper procedure, improper use, incorrect installation or human error) in comparison to equipment design or failure. table Electrical trade Fatalities by Work type Compared to All Occupational Electrocutions 2000 to 2009 FIGURE Fatalities and Critical Injuries by Probable Cause 2000 to 2009 Improper procedure 68.9% Unknown 13.1% Equipment failure 1.6% Faulty equipment 4.9% Human error 4.9% lack of maintenance 1.6% Aging equipment 1.6% Poor design 1.6% System failure 1.6% type OF WORk total Apprentice Electrician lineperson total electrical trade total of all occupational electrocutions Prevalence of electrical trade in occupational electrocution % 20.0% 33.3% 28.6% 28.6% 42.9% 14.3% 40.0% 50.0% 0.0% 25.0%

19 2009 OntariO ElEctrical SafEty report Occupational Electrocutions and Injuries FIGURE Electrocutions Electrical trade versus All Other Occupations for two Five-year Periods 2000 to to to 2009 Apprentice 4% Other trades 77% Apprentice 6% Other trades 72% Electrician 8% Electrician 20% lineperson 9% lineperson 4% In the past ten years, the prevalence of electrical tradespeople killed on the job accounted for 25% of all electrocutions in the workplace the same as the 1999 to 2008 period despite the fact that no one in the electrical trade was killed in (See Table ) As illustrated in Figure 2.2.8, in the earlier five-year period, the electrical trade accounted for 23% of all electrocutions in the workplace; this increases to 28% in the more recent period. The prevalence of electricians is higher, increasing from 8% to 20% between the two five-year periods, in spite of the fact that there were fewer electrocutions in the second period (and none in 2009). Table shows the contrast when observing serious injuries (both fatalities and critical injuries). The number of serious incidents with electricians has increased in the latest five-year period, from five to 30 incidents, an increase of 600%. The serious injury count to all workers of an electrical nature in the 2000 to 2004 period was 256: this was reduced by more than 50% to 111 in the latest five-year period. The number of serious injuries to the electrical trade has increased from 18 to 34 for the same two five-year periods. This results in prevalence to the electrical trade increasing from 7.0% to 30.6% over the two periods. table Electrical trade Fatalities and Critical Injuries by Work type Compared to All Occupational Fatal and Critical Injuries 2000 to 2009 type OF WORk 2000 to 2004 PREvAlENCE 2000 to to 2009 PREvAlENCE 2005 to 2009 Apprentice % 3 8.8% Electrician % % lineperson % 1 2.9% total electrical trade total of all fatal and critical injuries % % The number of serious incidents with electricians has increased in the latest five-year period, from five to 30 incidents, a six-fold increase.

20 OntariO ElEctrical SafEty report 2.2 Occupational Electrocutions and Injuries Figure shows the prevalence of panelboard-related injuries to electrical-related critical injuries. The prevalence is increasing to The increase in the numbers may be attributed to better reporting procedures over time. In the final period, panelboard injuries accounted for almost 50% of the total; from all the cases that were ESA-investigated, these incidents were preventable. Table illustrates how the number of serious incidents involving electricians and apprentices have increased when compared using five-year rolling averages. The number has increased from 1.0 in the first period to 6.6 in the latest period. 60% 50% 40% 30% 20% FIGURE Panelboard Injuries as a Percentage of All Critical Injuries Five-year Rolling Averages 1998 to % 0% table Electrical trade (apprentices and electricians) Fatalities and Critical Injuries Five-year Rolling Averages Compared PERIOD Five-year rolling average Five-year reduction % % % -43.5% table Comparison of Electrical Injuries to all Workplace Injuries 2000 to 2009 ElECtROCUtIONS CRItICAl ElECtRICAl INJURIES NON-CRItICAl ElECtRICAl INJURIES traumatic WORkPlACE FAtAlItIES lost-time INJURIES , , , , , , , , , Not available Not available Not available total Not available Not available Not available Ratio of electrocution to electrical injuries (2000 to 2008 only) 4:1 15:1 Ratio of traumatic fatalities to lost-time injuries 755:1

21 2009 OntariO ElEctrical SafEty report Occupational Electrocutions and Injuries Table shows the reduction of electrical non-critical injuries in the ten-year span was 39% compared to the reduction of traumatic fatalities in the workplace at 27%. The majority of claims recorded by WSIB from electricalrelated injuries were to males, which accounted for 78% of all electrical-related injuries. (See Table ) The majority of these incidents occurred in the manufacturing and construction sectors. table Comparison of Non-critical, traumatic and lost-time Injuries 2000 to REDUCtION OvER NINE years Non-critical electrical injuries* traumatic workplace fatalities % % lost-time injuries 104,154 98,359 95,568 93,234 90,397 89,734 83,179 80,863 78, % *mol figures table Electrical-related Injuries by Gender (number of claims to WSIb) 1997 to 2008 GENDER NUmbER OF ClAImS male 1,563 Female 435 total 1,998 Panelboard-related injuries accounted for almost 50% of all critical injuries. In those cases that were ESA-investigated, these incidents were preventable. table Four Sectors of WSIb Electrical Injuries Claims showing Prevalence of male versus Female PREvAlENCE WItHIN the GENDER FEmAlES PREvAlENCE WItHIN the GENDER males Construction 0.5% 21.9% Health Care 15.2% 1.1% manufacturing 14.7% 23.9% Services 45.7% 17.5%

22 OntariO ElEctrical SafEty report 2.2 Occupational Electrocutions and Injuries table Electrical-related Injuries by Occupation (number of claims to WSIb) 1997 to 2008 OCCUPAtION NUmbER OF ClAImS Electricians (except Industrial and Power System) 234 Occupation not stated 98 Janitors, Caretakers and building Superintendents 74 Construction millwrights and Industrial mechanics 73 Welders 69 Other labourers in Processing, manufacturing and Utilities 59 Cooks 58 Industrial Electricians 47 kitchen and Food Service Helpers 47 motor vehicle mechanics or technicians 46 Construction trades Helpers and labourers 41 Electrical Powerline and Cable Workers 38 Retail Salespersons and Sales Clerks 35 light Duty Cleaners 32 When looking into sectors as classified by the WSIB, the service sector has the most electrical injuries with manufacturing and construction as the second and third most prevalent, as shown in Table Table shows the occupations with the largest numbers of electrical injuries. Electricians (industrial and construction), janitors, caretakers, building superintendents, construction millwrights, labourers, cooks and kitchen helpers are most prominent in injuries. The prevalence of injuries to janitors, caretakers and building superintendents supports Figure 2.2.6, where repair and maintenance work results in almost 60% of the fatalities. Typically, these occupations would perform repair, maintenance work as opposed to new installations or construction. Table provides relativity to the prevalence of injuries to each sector. The labour market research conducted by the research and planning branch of the MTCU does not categorize labour sectors in the same manner as the WSIB. Service sectors, which are hotels, food industry and retail, are not classified as a group. table Number of WSIb Electrical Injury Claims by Sector SECtOR NUmbER OF ClAImS Services 472 manufacturing 437 Construction 344 Government, municipalities 171 Automotive 98 Health Care 83 Chemical 74 The service sector has the most electrical injuries with manufacturing and construction as the second and third most prevalent.

23 2009 OntariO ElEctrical SafEty report Occupational Electrocutions and Injuries table Employment by Industry 2005 to 2009 (000s) may 2009 may 2010 UNADJUStED All IndustrIes 6,398 6,493 6,594 6,687 6,526 6,530 6,689 Agriculture Forestry, Fishing, mining, Oil and Gas Utilities Construction manufacturing 1,064 1, trade 995 1,016 1,027 1, ,017 transportation and Warehousing Finance, Insurance, Real Estate and leasing Professional, Scientific and technical Services business, building and other support services Educational Services Health Care and Social Assistance Information, Culture and Recreation Accommodation and Food Services Other Services Public Administration table Number of WSIb Electrical Injury Claims by Source SOURCE NUmbER OF ClAImS Electrical wiring 332 Electric Parts NEC 259 Switchboards, switches and fuses 149 Spot welding machinery 55 machinery, unspecified 48 Ranges, cooking ovens, grills, toasters 48 Powerlines 46 Fire, flame 38 Other machinery NEC 35 Other sources NEC 31 Table shows the claims by source. Electrical wiring was the most prevalent source of injury, next to electrical parts and switchboards/fuses. Note the prevalence of welding machinery contact is consistent with the number of injuries to welders. In the ten-year span, ESA reported two fatalities related to poor wiring in welding machines. ESA investigations showed that in most incidents victims were touching a device or piece of equipment or appliance with their hand or hand tool when the injury occurred.

24 OntariO ElEctrical SafEty report 2.3 Non-occupational Fatalities and Injuries In Table , the WSIB statistics show the most common body part injured is the hand, when making contact with electricity (25% of the cases). Table provides confirmation of the danger of electricity (see Bird Triangle, Figure ). The ratio of third-degree burns, to electric shock and burns is 1:16. table Number of WSIb Electrical Injury Claims by Part of body Injured PARt OF body INJURED NUmbER OF ClAImS Hand(s), except fingers 501 multiple body parts, NEC 385 Systems, body, NEC 146 Fingers, except thumb 116 Forearm(s) 85 multiple body parts, unspecified 80 Arm(s), unspecified 77 Systems, body, unspecified 69 FIGURE bird triangle of Electrical Injury, Critical Injury and Fatality 2000 to 2008 table Number of WSIb Electrical Injury Claims by Severity NAtURE 1 Death 4 Critical Injuries 15 Non-critical Injuries NUmbER OF ClAImS Electrocutions, electric shocks 1003 Electrical burns, unspecified 368 Second-degree electrical burns 349 First-degree electrical burns 139 third-degree electrical burns 87 Electrical burns, NEC 52 total NoN-occu upational Fatalities and injuries From 2000 to 2009 there were 30 non-occupational electrocutions, as shown in Figure 2.3.1, an average of three per year. The low numbers of incidents make trending difficult; however, a five-year rolling average provides some insight for analysis. (See Table ) During the ten five-year periods the rolling average of electrocutions reduces from 6.2 to 2.8. In examining the rate of electrocution per million of population, using five-year rolling averages, there is a steady decline from to This represents a decline of more than 60% over the ten periods. (See Figure ) FIGURE Non-occupational Electrocutions 2000 to 2009 table Non-occupational Electrocutions Five-year Rolling Averages 2000 to Rolling average

25 2009 OntariO ElEctrical SafEty report Non-occupational Fatalities and Injuries The ratio of fatalities to critical and non-critical injuries appears quite different than in the occupational sector. Attributing to this is the fact that non-critical injuries are more likely not reported or under-reported in the non-occupational sector; ESA is less informed of these injury cases, than fatalities. Table shows genders involved in injuries and fatalities in non-occupational settings that ESA has investigated or reported. The ratio is closer here than with the occupational sector with male-tofemale ratios of 40:11 with injuries and 5:1 for fatalities. table Non-occupational Injuries and Electrocutions 2000 to 2009 NAtURE NUmbER OF ClAImS ElECtROCUtIONS PER million POPUlAtION FIGURE Non-occupational Rate of Electrocution per Population Five-year Rolling Averages 1998 to Critical injuries 5 Fatal incidents 30 Non-critical injuries 16 total 51 table Non-occupational Injuries and Electrocutions by Gender 2000 to 2009 GENDER total All INJURIES FAtAlItIES male Female 11 5 total table Non-occupational versus Powerline-related Electrocutions Five-year Comparisons 2000 to 2009 There was one fatality recorded in 2009 involving an electrical device falling into a bathtub, in an older building with no GFCI, giving a total of two fatalities in the last five years involving an electrical device in the bathroom. Powerline electrocution incidents remained consistent over the two five-year periods. However, in the 2005 to 2009 period, there were more male fatalities and fewer female fatalities than in the previous five-year period. (See Table ) In the non-occupational sector, the ratio of fatalities to critical and non-critical injuries appears greater than in the occupational sector. FIvE-yEAR PERIOD 2000 to to 2009 total male (non-occupational) Female (non-occupational) total non-occupational Powerline-related

26 OntariO ElEctrical SafEty report 2.3 Non-occupational Fatalities and Injuries 5 Table shows that wiring and vehicles are of highest risk in non-occupational electrocutions. Female electrocutions only occurred in residential facilities or public places while electrocution of males were more broadly spread across facility types. Public places and residential facilities are the most common facility types associated with nonoccupational electrocutions. (See Table ) Figure shows that in the non-occupational sector, electrocutions of females involved vehicles and recreation, all outdoor activities. The remaining 40% occurred with tasks involving items such as a toaster, lamp or clock. table Non-occupational Electrocutions by Facility type and Gender 2000 to 2009 FACIlIty FEmAlE male total Campground Farm Public place Residential Utility equipment or enclosure total FIGURE Non-occupational Electrocutions of Gender versus total Five-year Rolling Averages 1997 to 2009 table Equipment Used in Non-occupational Electrocutions 2000 to 2009 EqUIPmENt USED total Not available, none or unknown 6 vehicle 4 Wiring 4 Flagpole 2 lamp 2 balloon 1 Clock 1 Electrical cord 1 Handglider 1 ladder 1 lawnmower 1 Pipe 1 Plumbing 1 Pole 1 Pump 1 tree trimmer 1 trouble light 1 total males Females total FIGURE Non-occupational Fatalities Female only, by task Performed 2000 to 2009 Recreation 20% vehicle 40% Other 40%

27 2009 OntariO ElEctrical SafEty report Injuries Reported by the CIHI Figure shows that male electrocutions occur in more diverse settings. Unique to these fatalities are theft, construction, installation, repair and maintenance. FIGURE Non-occupational Fatalities male only, by task Performed 2000 to 2009 Unique to male non-occupational fatalities by task are theft, construction, installation, repair and maintenance. Repair or maintenance 24% Recreation 32% theft 12% Construction 4% Installation 4% lawn cutting 4% vehicle 4% Not available 8% Other 8% 2.4 I njuries reported by the C anadian InstItutet of health InformatIon (CIHI) Information in this section is derived from data from CIHI. Within the data there is no distinction between injuries that occur in occupational or non-occupational settings. CIHI is a not-for profit organization responsible for collecting all health information across Canada. (See Table ) Ontario and Quebec are the provinces with the highest number of people hospitalized as a result of an electrical contact, representing more than 60% of the electrical injuries in Canada. Between 2008 and 2009, Ontario accounted for about half of the electrical injuries in Canada. Decreases are seen across all provinces, with the biggest declines apparent with Ontario and Quebec, with almost a 50% decline in Ontario over the ten-year period. Male injuries consistently outnumber injuries to females. Of the injury types, burns have declined the most over this period. table Number of Hospitalizations by Province Alberta british Columbia Ontario quebec N/A N/A N/A Saskatchewan

28 OntariO O ElEctrical SafEty report 2.4 Injuries Reported by the CIH FIGURE Number of Hospitalizations by Province Alberta british Columbia Ontario quebec Saskatchewan table Number of Hospitalizations by Gender GENDER Female male total table Number of Hospitalizations by Injury type INJURy type burns limb fracture Head or spinal cord injury N/A N/A N/A 6 6 N/A N/A Other injuries total

29 2.5 Case Study 2009 OntariO ElEctrical SafEty report 29 THIS REPORT features several case studies of the findings of ESA s rootcause investigations. ESA conducts root-cause investigations of serious incidents (fatalities, critical injuries and serious fires), highprofile incidents, and incidents that could result in harms to the public. Investigations are performed to support the prevention of future incidents and fatalities. The investigation is not limited to electrical safety, but examines occupational health and safety and the integrated safety infrastructure. ESA s investigation goes beyond compliance with any Code, Regulations or Standard. Root-cause investigations contain the following: Events leading up to the incident and the surrounding conditions. Events or conditions that went wrong and contributed to the incidents. These case studies have been de-personalized to protect the identity of the individuals involved. Case CASE Study STuDy ONE An electrical apprentice was fatally injured while working within an energized temporary electrical panel in a construction site. The following explains the chain of events. The victim was working for one of many subcontractors on a large construction project to build a heavy industrial facility. The function of this subcontractor was maintenance work, including installing and removing temporary lighting. There were three electrical tradespersons working for this subcontractor performing electrical duties: a foreman; an electrician; and an apprentice, the victim. Temporary lights were needed on one of the mezzanines of the project. The crew strung the lighting on the mezzanine first; connection to power was to be performed last to a temporary panel below. Connection to the power supply had to be done through the bottom of the temporary panel, on the left side, as this was the only access for cables to enter the panel. The temporary lighting cables needed to be pulled from the hole on the left side of the panel at floor elevation to the upper right side of the panel, where connection to the power supply could be made. To perform this task, the front left and right panel covers needed to be removed and opened, exposing the transformer windings and electrical terminations that were situated at the bottom right of the panel. When the panel was energized, the open transformer terminations would also be in an energized state. Direct contact with any of the transformers terminations would result in serious injuries. Cable access through panel floor The temporary distribution panel. Transformer winding behind door On the day of the fatality, the three-man crew was connecting the temporary lighting cables to the electrical panel. The foreman was feeding the wire from the mezzanine to the two workers below. The power to the temporary panel was left energized. There was no thought of disconnecting the panel from power by any of the crew, and no personal protective equipment was worn. The journeyperson was feeding the cable under the back of the temporary power panel. The apprentice entered the open and energized transformer section at the front of the panel to be able to reach the cable that was being fished under the back by the journeyperson. It was their intent to then pull up the cable, and hook it into the power panel. The journeyperson was not the one performing the work on the energized side of the temporary panel. At the time of the accident, the victim was situated at the right side of the panel, either kneeling or bending over, in close proximity to the exposed transformer winding terminations.

30 OntariO ElEctrical SafEty report The temporary lighting cable was not stiff; the worker at the back could not successfully push the wire to the front of the panel so that the victim could reach it. This caused the victim to reach further into the panel, inadvertently coming into contact with the exposed energized terminations on the transformer windings. The victim either lost his balance and fell into the panel, or was reaching and simply forgot about his close proximity to the exposed terminations. The right inside bottom of the panel, where the electrical contact took place. During the investigation of this incident, ESA found: The project manager seemed to have a well-placed health and safety framework Policies were not followed. For example, this particular subcontractor has been known to have performed work in an energized state despite the project s Health & Safety policy not to do so. The loss of power during normal working hours was seen as unacceptable since it would disrupt progress of the construction project. (This was confirmed by an incident one day prior to the fatality, when a carpenter had inadvertently shorted out and tripped one of the fuses in one of the temporary electrical panels while attempting to move the panel from one location to another in an energized state.) Although the site safety policy required a work safe permit for the connection of power that led to the fatality, none had been taken out. No hazard assessment was conducted prior to performing the work. FIGURE Causal factors Figure is a Causal Factor Chart. This chart summarizes the safety gaps found in this investigation. These are not unique to this situation. The investigation found there is a need: for the general contractor and the project manager to take ownership of ensuring safety of all workers, including subcontractors, especially when conducting hazardous work on site. (Safety ownership falls in line with the Occupational Health and Safety Act, requiring facility owners, project managers and general contractors to be accountable for workers safety.) for supervisors and forepersons to follow health and safety policies and lead by example. This investigation showed that health and safety policy, must be followed by everyone from project manager to worker, to be effective. for supervisors and forepersons to review work tasks and assess hazards before proceeding with work, regardless of how routine the task seems. Assumptions often lead to miscommunication and preventable injuries. to consider all other options prior to deciding to perform the work in an energized state.

31 2009 OntariO O ElEctrical Ectrical SafEty report Powerline and Utility-related Equipment 3.0 Powerline and U tility-related equipment 1 Powerline and utility-related equipment electrocutions numbered 50 in Ontario from 2000 to 2009, accounting for more than 50% of all electrocutions in the ten-year period (50 of 90 deaths). This figure is down by three when comparing to the ten-year period from 1999 to Contact with powerline accounted for 44 of the electrocutions in the latest ten-year period, the majority of distribution equipment-related fatalities. (See Figure ) Table shows the rate of electrocution in powerline decreased from to per million of population in the ten-year period. 14 FIGURE Powerline and Utility-related Equipment Electrocutions versus All Electrocutions 2000 to 2009 NUmbER OF ElECtROCUtIONS Powerline electrocutions only All Electrocutions All utility-related equipment electrocutions (including powerline) table Utility-related Equipment Electrocutions 2000 to Powerline electrocutions Powerline rate of death per million population Other utility equipment-related electrocutions All distribution equipment-related electrocutions All electrocutions Percentage of distribution to all electrocutions 76.9% 76.9% 60.0% 50.0% 25.0% 44.4% 41.7% 40.0% 50.0% 71.4% 1 Utility-related equipment means electrical equipment and devices used by a Local Utility Company (or privately owned company) to distribute electricity to facilities or buildings. Examples of such equipment are overhead or underground powerline (including equipment on utility poles), substation, electrical vaults, high voltage switchgear and transformer.

32 OntariO ElEctrical SafEty report 3.0 Powerline and Utility-related Equipment Table shows that in the nine-year period, fatalities involved with voltages over 750V were consistently more prevalent that those involved in voltages 750V or under. In 750V and under, there were two fatalities compared to 37 in over 750V, and there were five critical injuries compared to 58, respectively. Table illustrates the changes between the two fiveyear periods. The number of powerline electrocutions decreased by almost half (48.2%), occupational fatalities were down by 55.0% (continuing down from last year s OESR where the decrease was 62.5%) and nonoccupational down by 33.3%, comparing the most recent five-year period to the last. Note: One fatality in 2009 involved the theft of copper. From 2000 to 2004, occupational powerline fatalities accounted for 69% of powerline electrocutions, and 40% of all electrocutions. In the period from 2005 to 2009, occupational powerline accounted for 60% of powerline electrocutions, and 25% of all electrocutions. The number of occupational powerline electrocutions has decreased in the past five years. Statistics Directly Related to Harm Strategy Priority Powerline Contact Five-year Rolling Averages Compared This chart shows the number of worker and non-worker powerline-related contact incidents, and is based on worker data reported by the MOL; the non-worker incidents are based on reports to ESA. The five-year reduction refers to the reduction (or increase) from the first five-year period to the last five-year period. For example, the 2002 to 2006 figure is a comparison of to PERIOD 2002 to to to to 2009 Five-year rolling average Five-year reduction (400.0%) (371.4%) (175.0%) (43.5%) table Powerline Incidents with voltage Comparison 2001 to v OR UNDER OvER 750v Fatalities Critical injury Non-critical injury Other Fatalities Critical injury Non-critical injury Other * total ,159 *2009 statistics are based on ESA-reported incidents only; statistics from 2001 to 2008 are based on the MOL and ESA- reported incidents.

33 2009 OntariO ElEctrical SafEty report Powerline and Utility-related Equipment table Utility-related Equipment Electrocutions Five-year period Comparisons 2000 to 2009 FIvE years 2000 to 2004 FIvE years 2005 to 2009 ten years 2000 to 2009 PERCENtAGE CHANGE Powerline down 48.3% Other utility equipment-related up 100.0% Occupational powerline down 55.0% Non-occupational down 33.3% DEAtHS PER million POPUlAtION FIGURE Rolling Five-year Average of Powerline Electrocutions by Rate per million Population The decrease over time becomes more obvious when viewing the rolling five-year averages. The average rate increases from the 1999 to 2003 period and then shows a steady decrease to the most recent five-year period. Over the ten-year period, it decreases by almost 50% decreasing from 0.4 in the 1996 to 2000 period to in the latest period. Figure shows the prevalence of utility equipment-related fatalities to all electrocutions in five-year rolling averages. In the last five years, it hovers in the 40 to 50% area. % OF UtIlIty to All ElECtROCUtIONS FIGURE Rolling Five-year Average of Utility-related Equipment Fatalities versus All Electrocutions 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Especially in the last five years, powerline fatalities continue to decrease, but still account for 50% of all electrocutions in Ontario.

34 OntariO ElEctrical SafEty report 3.0 Powerline and Utility-related Equipment Table shows the breakdown of utility equipment incidents by system type. Overhead contact is consistently most prevalent in all ten years. Public places and residential facilities are where fatalities with powerlines are most prevalent they account for 32 of 44 electrocutions that are powerline-related, and onethird of all electrocutions in the ten-year period (32 of 90). (See Table ) Figure shows that in the five-year period between 2000 and 2004, public places, residential and farming facilities account for 89% of all the powerline fatalities. In the period from 2005 to 2009, powerline fatalities are mainly in public places and residential facilities, accounting for 87% of all powerline electrocutions. table Rolling Five-year Average of Powerline Electrocutions Powerline Rate of powerline electrocutions per million population total distribution All electrocutions Percentage of utility to total electrocutions 55.4% 71.0% 70.5% 67.3% 60.8% 53.2% 43.5% 41.3% 40.0% 48.7% table Powerline Incidents by System type 2001 to 2009 year OvERHEAD UNDERGROUND vaults, SUbStAtIONS AND PAD-mOUNtED EqUIPmENt total * *Based solely from ESA data.

35 2009 OntariO ElEctrical SafEty report Powerline and Utility-related Equipment table Powerline Electrocutions by Facility type Five-year period Comparisons 2000 to 2009 FIGURE Powerline Electrocutions by Facility type Five-year period Comparisons 2000 to to 2009 total 2000 to 2009 Commercial Farm to 2004 Residential 24% Industrial 4% Industrial mining Public place Residential total Public place 41% Farm 24% Commercial 4% mining 3% Figure illustrates five-year rolling averages of powerline fatalities occurring in residential and public places and shows a decline in both facilities fatalities in the period. In the residential area, the numbers declined from an average of three to an average of one from the first to the last period, a reduction of 66%. Similarly there was a decline of almost 50% in public places, from 2.4 in the first period to 1.6 in the last period. FIGURE Five-year Rolling Average of Powerline Electrocutions by Facility type Residential and Public Places to 2009 Residential 33% Public place 54% Commercial 13% Farm 0% Industrial 0% mining 0% Powerline electrocutions in residential places have declined 66% since Residential Public place

36 OntariO O ElEctrical SafEty report 3.0 Powerline and Utility-related Equipment Figure shows the prevalence of incidents specific to the type of equipment used. In the first five-year period, ladder contact is the most common occurrence. In the next five-year period no one piece of equipment dominates. The highest is three electrocutions associated with a dumptruck. FIGURE Powerline Electrocutions by Equipment Used Five-year Comparisons from 2000 to 2009 EqUIPmENt Auger Aerial work platform balloon broom vehicle Crane Dumptruck Eavestrough Flagpole Handglider ladder None Pipe Pole Radial boom derrick Sprayer tree trimmer Wiring Number of Deaths 2000 to to 2009

37 3.1 Case Study 2009 OntariO ElEctrical SafEty report 37 THIS REPORT features several case studies of the findings of ESA s rootcause investigations. ESA conducts root-cause investigations of serious incidents (fatalities, critical injuries and serious fires), high-profile incidents, and incidents that could result in harms to the public. Investigations are performed to support the prevention of future incidents and fatalities. The investigation is not limited to electrical safety, but examines occupational health and safety and the integrated safety infrastructure. ESA s investigation goes beyond compliance with any Code, Regulations or Standard. Root-cause investigations contain the following: Events leading up to the incident and the surrounding conditions. Events or conditions that went wrong and contributed to the incidents. These case studies have been de-personalized to protect the identity of the individuals involved. CASE STuDy TWO A grader blade operator was electrocuted when the dumptruck attached to his grader contacted an overhead powerline. Unaware of the hazard, and rather than remaining on the grader equipment until the situation was safe, the operator stepped off the machine. As he stepped off, he received a shock from the difference in voltage potential between the energized equipment and grade, killing him instantly. The following documents the chain of events. As a country road was recently paved, the road shoulder required re-grading. The township was aware of the overhead powerlines going perpendicular to the road at various sections where the crew would be working. Caution Overhead Wires signs could be seen near the area where the powerlines crossed the road. The grading operation consisted of two vehicles and a shoulder-grading device: a large dumptruck, a grader and a grading blade device attached to both the dumptruck and the grader. The dumptruck would slowly tilt its gravel and sand mix onto a two-elevation trough as part of the grading device. The two-elevation trough would regulate the flow of the mix onto the road shoulder and the angle of the shoulder would be controlled by the blade on the shoulder-grading device. The two vehicles and the device were all attached to each other and all would move as a unit at a walking pace (less than 5 kph) to grade the shoulder. The dumptruck/grader combination device working on the shoulder of the road. the township. The work started at around 7:00am on the day of the fatality. It was a clear day with clear visibility; nothing obstructed the view of the powerline. As the work progressed, the angle of the dumptruck was raised gradually to unload the mixture into the grader hopper. Within 30 to 40 minutes of the start of the day, the bucket of the dumptruck was raised to exceed the clearance of the powerline. Unaware of the powerline, the bucket of the dumptruck contacted the powerline, making the bucket of the dumptruck, the grader and the shouldergrading device energized to the voltage of the powerline. Realizing he had made contact with the powerline, the The county contracted an independent dumptruck driver and his vehicle for the job. The remaining crew, the grader driver and the grader blade operator were employees of The dumptruck bucket nears the powerline.

38 OntariO ElEctrical SafEty report touch AND StEP POtENtIAl Injuries and fatalities relating to high voltage powerlines arise from touch and step potentials created by these systems. A touch potential (voltage), is created when an object touches a high-voltage powerline. This object (e.g. the boom of a truck), now energizes the truck to the same voltage as the powerline. Anyone in proximity of the object that has contacted the powerline, is at risk of electrocution if they touch the energized object. The victim stepped out of the machine, producing a difference in potential, killing him instantly. A step potential (voltage) is created when an energized high voltage object is dissipating voltage into the ground (e.g. a powerline touching the ground, or the boom of a crane touching a powerline and the voltage is dissipating into the ground). As the high voltage dissipates into the ground, this creates a risk of electrocution to persons in the area, due to the differences in voltage levels between their feet. dumptruck driver stopped. The dumptruck and the grader driver remained in their respective vehicles. Instead of remaining on the raised platform of the shoulder-grading device, the blade operator stepped to the ground. The voltage potential difference between the grading device and the ground caused current to flow from the victim s foot to the equipment, resulting in his death. FIGURE The following gaps identified in the safety framework as a result of the investigation. There is a need: to review job hazards prior to starting work. Posting danger overhead signs is not sufficient to ensure workers awareness of the hazard, and their safety. even though the vehicles were moving slowly, and there were no visibility issues, it should not be assumed that danger would be detected easily and injuries averted. for a worker to be a designated spotter where vehicles, cranes and similar equipment can encroach on powerlines, and breech the safe limits of approach as per the Occupational Health and Safety Act (OHSA). This worker would be available to warn the operator that they are approaching the minimum distance. to educate workers on the danger of overhead powerline contact electrocution by step potential, and the appropriate safety procedure in the event of inadvertent contact with powerline. In this event, had the victim acted properly and stayed on his device until the dumptruck was manoeuvred away from the powerline, the incident would have not occurred.

39 2009 OntariO ElEctrical SafEty report Fires 4.0 Fires 4.1 Fire source data ESA reports fire incidents based on data provided by the OFM to ESA from: All fires where the fuel of the ignition source was reported as electricity OFM-investigated fire incidents ESA conducts its own investigation of fires when requested by the local fire department to assist or when jointly investigating fire incidents with the OFM. To align with the reporting convention of the OFM, ESA is changing the manner in which fires are presented. Fires will be reported by ignition source where the fuel of the ignition source was reported as electricity. It is worth noting that with the exception of fires associated with electrical distribution equipment, fires identified with electricity as the ignition source by the fire departments or OFM, electricity was not the primary fuel associated with the fire. These situations are illustrated below. In the OESR, these fires will be categorized into two types of fires. These are: 1. Fires caused by the ignition of combustibles (liquid and solids) around an electrical device, equipment, appliance or installation, but were not the direct result of a failure of electrical equipment or devices or electrical current or arc flash coming into contact with the object. When the primary fuel associated with the fire is not electricity (such as leaving a stove unattended with the oil catching fire), the OFM label these fires as cooking fires rather than electrical fires. In addition, the OFM does not recommend using numbers of fire deaths to identify trend and key issues. Typically, these types of fire were the direct result of misuse of the equipment, device or appliance. Some examples of these types of fires are: Grease fires on an electrical stove top as a result of cooking left unattended. Clothing catching fire during cooking activities. Clothes dryer catching fire caused by overheating of the appliance caused by improperly cleaned lint cache. Combustible catching fire around heaters or electronics when they are placed too close to the heat source. 2. Fires caused by the ignition of combustibles around an electrical device, equipment, appliance or installation and were the direct result of the failure of the device, equipment or installation. Typical are fires caused by failure of the insulation of electrical wiring igniting a combustible in close proximity or failure of the equipment or devices that causes overheating and later, a fire. The failure of the insulation could be caused by natural aging, premature aging resulting from overloading, or by mechanical breakdown of the insulation. Fires related to wiring and wiring devices are classified by the OFM as distribution equipment. Please note that the definition of distribution equipment in the fire section is quite different than the distribution equipment in the powerline section of the report. Examples of these types of fires are: Carpet igniting caused by heat build-up of an extension cord placed under a carpet. Over time the insulation of the extension cord fails due to foot traffic on the cord which leads to mechanical breakdown of the insulation. Electrical wires poorly terminated and an installation performed without appropriate protective container. Arcing occurs over time resulting in a fire of combustibles around the wires. Fire caused by a failure of a seized motor powered by electricity. In the fire section of the OESR, ESA uses OFM s method of categorizing types of ignition source class. By OFM s definition, distribution equipment represents electrical wiring, devices or equipment, the primary function of which is to carry electrical current from one location to another. Thus, wiring, extension cord, termination, electrical panel, cord on appliances are considered distribution equipment. Please note that distribution equipment defined by the OFM is not the same as Distribution Equipment defined by the Local Distribution Companies.

40 OntariO O ElEctrical SafEty report 4.2 Overview of Fires in Ontario 4.2 Overview v e Of fires in OntariO FIGURE Overview of Fires 2004 to 2008 NUmbER OF FIRES Structural loss all fires* Residential loss all fires* Electricity identified as one of the ignition sources Stove-top fires *data directly taken from the OFm website Residential fires account for 75% of the fires in Ontario from 2004 to Approximately one-third of fires with structural loss are attributed to fires with electricity identified as one of the fuel of the ignition sources 1. Stove-top fires account for about 11% of structural loss fires. Comparing 2004 to 2008, the number of fire incidents, with electricity identified as the one of the fuel ignition sources, was up by 3%, while incidents involving structural loss were down 5% and fires with residential loss down 4%. Statistics Directly Related to Harm Reduction Priorities Product Safety Number of electrically-related product fires: Products fitting this category are appliances, cooking equipment, lighting equipment, other electrical and mechanical equipment and processing equipment, and is based on data reported to the OFM with fuel energy identified as electricity. The five-year reduction refers to the reduction (or increase) from the first five-year period to the last fiveyear period. For example, the 2002 to 2006 figure is a comparison of to ROllING FIvE-yEAR AvERAGE Residential fires account for 75% of the fires in Ontario from 2004 to to to to to FIvE-yEAR REDUCtION 15.5% 12.5% 8.5% For all structure fires the OFM for the 2004 to 2008 period identified these as the most prevalent ignition sources: cooking 17% arson 13% heating and cooling equipment 10% electrical wiring 2 9% cigarettes 6% appliances 4% 1 In many cases, such as stove-top fires, the primary fuel source causing the fire was grease or combustibles placed on the cooktop, but electricity was identified as the source of energy fuelling the stovetop. 2 Electrical wiring as identified in the graph represents all types of distribution equipment such as temporary and permanent wiring, cord, panel, fuses, or terminations.

41 FIGURE Structure Fires by Ignition Source 2004 to 2008 Electrical wiring 9% matches or lighters 1% Candles 2% Cooking 17% Appliances 4% Other electrical or mechanical 3% 2009 OntariO O ElEctrical SafEty report Overview of Fires in Ontario Processing equipment 1% Heating and cooling 10% Arson 13% Other open flame tools 4% miscellaneous 8% Undetermined 18% Cigarettes 6% lighting (excluding candles) 2% When fires were profiled with electricity as the identified fuel source, but not necessarily the primary fuel energy source, the breakdown of ignition source by prevalence is as follows: Cooking equipment 39% Electrical distribution equipment 29% Appliances 11% Lighting equipment 6% Mechanical and electrical 5% Heating equipment 5% Combined, cooking equipment and electrical distribution equipment account for 67% of these types of fires. Distribution equipment as a source is more prevalent when electricity was identified as the fuel source (29% compared to 9%), where the prevalence of heating and cooling equipment incidents is halved (5% compared to 10%). Heating equipment fires are often caused by placing combustibles around the equipment or device. table Structure Fires by Ignition Source 2004 to 2008 IGNItION SOURCE NUmbER OF FIRES PERCENtAGE OF total Appliances 1, % Arson 5, % Candles 1, % Cigarettes 2, % Cooking 7, % Electrical wiring 4, % Heating and cooling 4, % matches or lighters % lighting (excluding candles) % Processing equipment % miscellaneous 3, % Undetermined 8, % Other open flame tools 1, % Other electrical or mechanical 1, % total 43, % FIGURE Fires with Electricity as one of the identified Fuel Sources Classed by Ignition Source 1999 to 2008 Electrical distribution equipment 28.7% Cooking equipment 39.1% Other electrical or mechanical 4.8% lighting equipment 6.3% miscellaneous (combine with open flames) 2.2% Open flame tools, smokers articles 0.8% Heating equipment, chimney etc. 4.9% Processing equipment 1.5% Undetermined 0.8% Appliances 10.8%

42 OntariO ElEctrical SafEty report 4.3 Fires Resulting in Fatalities 4.3 Fires res sulting Fire deaths in Ontario have declined from 7.8 to 6.3 (fire deaths per million of population) between 2000 and 2009, a decline of 19% over the ten-year period. There were 117 deaths in the ten-year period. Fire deaths in Ontario have declined from 7.8 to 6.3 (fire deaths per million of population) between 2000 and 2009, a decline of 19% over the ten-year period. There were 117 deaths in the ten-year period. See Figures and Fire deaths identified by the OFM data with electricity as the being the fuel of ignition source with the fire have declined from 1.29 deaths per million of population to 0.54 as a five-year rolling average. This represents a decline of 56% over this ten-year period. Given the small number of incidents, it is best to compare the fatalities in five-year increments. This approach, as seen in Figure 4.3.3, can support us in making better comparatives. For a five-year rolling average, between 1996 and 2000, the fatality rate was In 2009, this rate was close to FIGURE Rate of Death by Fire 2000 to 2009 in Fatalities FIRE DEAtHS PER million FIGURE Fire Death Rate in Ontario Structure Fires *2009 Fire death rate structure fires Ontario population in millions * Indicates preliminary data subject to revision The OFM determined that 51% of fatal fires in Ontario from 1999 to 2008, were preventable. For fires identified with electricity as fuel of the ignition source of the fire, 89% of the fires were considered unintentional or preventable. (See Figure and Figure ) These types of fires have a greater percentage classified as preventable/unintentional fires Referring to Figure 4.3.5, the number of fires and fatalities may change for the years 2008 and 2009, pending the conclusion of current investigations. FIRE DEAtHS PER million OF POPUlAtION The number of fire fatalities in the 2009 OESR has been altered after consultation with the OFM. ESA is now changing how fire fatalities are reported, in particular, fatalities as a result of cooking with electrical appliances. These fires are more accurately reflected when counting all cooking fires and discount natural gas or propane-fueled fires 3. In addition, the number of fatalities and fires for 2008 has been altered from last year s OESR (from five fatalities to now read 10 fatalities) to reflect the updated record of the OFM. Based on past history, the number of fatalities and events for 2009 is likely to change with the updates from the OFM by year end. This is due to the fact that investigation of most recent fires has not been completed and the source and cause of the fires have not been confirmed. 3 Based on the OFM Stovetop survey revealing that 90% of Ontario cooking appliances are powered by electricity, it is assumed that the majority of the remaining fires were from electrical cooking appliances.

43 2009 OntariO ElEctrical SafEty report Fires Resulting in Fatalities FIRE DEAtHS PER million OF POPUlAtION FIGURE Rate of Death by Fire Comparison of Five-year Rolling Averages 1996 to FIGURE Fire Events versus Fire Fatalities 2000 to FIGURE Cause Classification of Fatal Fires 1999 to 2008 Unintentional / Preventable 51% Undetermined 30% Intentional 16% FIGURE Cause Classification of Fatal Fires with Electricity as the Fuel of the Ignition Source Fire Events from 1999 to 2008 Unintentional 89% Figure shows the yearly fire events versus fatalities from 2000 to Fires continue to result in an average of more than one fatality per event. In 2009, seven fire events resulted in ten deaths. Under Investigation 3% Intentional 3% Under Investigation 1% Undetermined 7% Events Fatalities For fires identified with electricity as the fuel of the ignition source, 89% of the fires were considered unintentional or preventable.

44 OntariO ElEctrical SafEty report 4.3 Fires Resulting in Fatalities Fires resulting in fatalities when electricity was identified as the ignition fuel source with the fire, the two most common ignition sources were cooking equipment and electrical distribution equipment. The fire fatality count of those two sources can be seen on Figure With the number of cooking fires resulting in fatalities totalling 69 for the 2000 to 2009 period, and natural gas and propane accounting for six fatalities for the same period, it is most likely the number of cooking fatalities with electricity as one of the fuel sources associated with the fire is under-reported. Figure illustrates fatal fires by the ignition source. Stove fires continue to be the most prevalent as the ignition source, accounting for over 50% of fires with fatalities. Copper wiring as the source is the next prevalent at over 15%, with extension cords next at close to 8%. NUmbER OF FAtAlItIES FIGURE Fire Fatalities with Cooking Equipment and Electrical Distribution Equipment 2000 to Cooking equipment Electrical Distribution FIGURE Fire Fatalities by Ignition Source 2000 to 2009 vehicle electrical 0.9% terminations (inc receptacles, switches, lights) - copper 1.8% television, radio, stereo, tape recorder, etc. 0.9% Space heater portable 0.9% Stove or range-top burner 18.3% Other lighting equipment 0.9% Other heating equipment 0.9% Other electrical distribution equipment 2.8% Other electrical 2.8% Other cooking items (e.g. toaster, kettle, electric frying pan) 1.8% Open-fired barbeque fixed or portable 0.9% Other electrical cooking 41.3% Water heater 0.9% Circuit wiring aluminum 1.8% Circuit wiring copper 9.2% Clothes dryer 0.9% Cord or cable for appliance or electrical articles 2.8% Electric blanket or heating pad 0.9% Deep-fat fryer 0.9% Extension cord or temporary wiring 4.6% Incandescent lamp light bulb, spotlight 2.8% meter 0.9% Stove fires continue to be the most prevalent as the ignition source, accounting for over 53% of fires with fatalities.

45 2009 OntariO ElEctrical SafEty report Fires Resulting in Fatalities FIGURE Fire Fatalities with Cooking Equipment by Ignition Source 2000 to 2009 misuse of ignition source or equipment 62.5% Other 12.5% blank 8.3% misuse of material first ignited 4.2% Design, construction, installation or maintenance deficiency 4.2% mechanical or electrical failure 4.2% Undetermined 4.2% FIGURE Fire Fatalities with Electrical Distribution Equipment by Ignition Source 2000 to 2009 mechanical or electrical failure 65.4% misuse of ignition source or equipment 15.4% Under investigation 3.8% Undetermined 11.5% Design, construction, installation or maintenance deficiency 3.8% Misuse was identified as the most common cause of fires leading to cooking fatalities at 67% (based on 62 incidents from 2000 to 2009). In comparison, mechanical failure was identified as the most common cause in distribution equipment fires (based on 26 incidents from 2000 to 2009) investigated by the OFM, as shown in Figure FIGURE Fire Fatalities When Electricity is Associated as the Fire Fuel by Ignition Source 2000 to 2009 The prevalence of the two causes above is consistent with the overall data submitted to the OFM. It is also noted that there are more cooking-related fatalities than electrical distribution equipment-related fatalities in the ten-year period. Figure shows that the number of events sourced from electrical distribution equipment is one third to that of cooking equipment, where fatalities occurred. Cooking equipment 65% Electrical distribution equipment 22% Other electrical or mechanical 3% lighting equipment 3% Heating equipment, chimney etc. 3% Appliances 5% FIGURE Property Classification of Fatal Fires 1999 to 2008 Institutional 1% Industrial 1% vehicles 7% Figure is taken directly from the OFM website. The figure shows residential property as the most prevalent at 86% when categorizing fatal fires by property class. Institutional facilities represent 1% and industrial facilities1%. Residential 86% Outdoor or structures not classified by Ontario building Code 5%

46 OntariO ElEctrical SafEty report 4.3 Fires Resulting in Fatalities table Fatal Fires When Electricity is Identified as the Fuel Energy Associated with the Fire by Property Classification 1999 to 2008 PROPERty ClASSIFICAtION OR FACIlIty type NUmbER OF FIRE INCIDENtS WItH FAtAlItIES PERCENtAGE OF total Detached/semi/attached residential % Dual/residential/business/apartment 3 4.2% miscellaneous property 1 1.4% mobile home or dwelling 4 5.6% multi-unit dwelling % Other residential 1 1.4% Road vehicles 2 2.8% vehicle sales or service 1 1.4% total 71 Table shows a similar percentage of prevalence when categorizing fatalities according to property class. Residential-type dwellings prevail similarly. It is noted that there is an absence of industrial, commercial and mercantile deaths in fires where electricity is identified as the fuel energy associated with the fire. Figure shows the ignition source identified with residential fires with fatalities. Cigarettes, arson and matches figure prominently in these fires. Cooking equipment and electrical wiring total 13% in total prevalence. FIGURE Residential Fatal Fires by Ignition Source 1999 to 2008 Appliances 1% Undetermined 36% Cigarettes 18% Arson 13% Candle 4% Cooking 9% Electrical wiring 4% Heating 3% table Fire Fatalities with Electrical Distribution Equipment by Object First Ignited 2000 to 2009 Other electrical mechanical 1% lighting (exc. candles) 1% matches or lighters 7% miscellaneous 2% Other open flame tools 1% ObJECt FIRSt IGNItED NUmbER OF INCIDENtS PERCENtAGE OF total bedding 1 3.8% Curtain or drapery 1 3.8% Electrical wiring insulation % Gasoline 1 3.8% Insulation 2 7.7% Interior wall or ceiling % Other (see narrative) 1 3.8% Other soft goods or wearing apparel 1 3.8% Paper or cardboard 1 3.8% Rug or carpet 1 3.8% Undetermined % Upholstered sofa, chair etc % Wood 1 3.8%

47 2009 OntariO ElEctrical SafEty report Fires Resulting in Fatalities Table shows that wiring insulation, interior walls or ceilings, and insulation were most prevalent as the first objects to ignite in these fatalities. Later pages of the report show consistency in data of non-fatal fires where the ignition source was identified as electrical distribution equipment. (See Table ) In comparison, cooking oil or grease, and wearing apparel were the most prevalent in cooking-related fatal fires. (See Table ) Cooking and grease fire deaths were associated with stove-top cooking left unattended, resulting in combustion while wearing apparel deaths were associated with elderly having their clothing catch fire while cooking. Physical condition of the elderly to escape the fire is a factor often attributed to the fatalities. The profile of the two sources (cooking equipment and electrical distribution equipment) were quite different, consistent with findings from the previous report. table Fire Fatalities with Cooking Equipment by Object First Ignited 2000 to ObJECt FIRSt IGNItED NUmbER OF INCIDENtS PERCENtAGE OF total Cabinetry 1 4.5% Cooking oil or grease % Fabric synthetic or combination 1 4.5% linen other than bedding 1 4.5% Other (see narrative) % Plastic 1 4.5% Propane 1 4.5% Undetermined 2 9.1% Wearing apparel on a person % Wood 1 4.5% 4.4 Fire incidents With Electricity as the Fuel of the Ignition Source of the Fire The number of fire incidents continues to decline over this past ten-year period. Total fires are down by 32%; fires with loss decreased by 31.7%, and fires with no loss decreased by 34.6%. (See Table ) A shift in the number of fire incidents, categorized by the ignition source, continues, as shown in Figure Between 1999 and 2003, cooking equipment as the ignition source accounted for 39% of fires, where electrical distribution equipment accounted for 29%. As a total they account for total of 68% of fires. Between 2004 and 2008, cooking equipment accounted for 37% of fires, and distribution equipment 30% of the fires, accounting for a total of 67% of fires, as shown in Table and Figure table Summary of Fires in Ontario 1999 to 2008 year NUmbER OF FIRES WItH loss NUmbER OF FIRES WItH NO loss total FIRES , , , , , , , , , , , , , , , , , , , ,045 total 28,743 5,021 33,764 4 Based on electricity as the associated fuel energy.

48 OntariO ElEctrical SafEty report 4.4 Fires with Electricity as the Fuel of the Ignition Source of the Fire table Fires by Classification of building or Structure 1999 to 2008 building OR StRUCtURE Classified under National Farm building Code FIvE-yEAR PERIOD FROm 1999 to 2003 FIvE-yEAR PERIOD FROm 2004 to 2008 total PERCENtAGE CHANGE - DECREASE OR (INCREASE) PREvAlENCE % 1.7% Assembly , % 5.0% Care and Detention % 2.2% Residential 13,594 11,753 25, % 75.1% business and Personal Services % 2.7% mercantile ,373 (5.5%) 4.1% Industrial 1,551 1,281 2, % 8.4% Structures/Properties not classified by ObC % 0.9% total 18,029 15,735 33,764 FIGURE Fires with Electricity as the Fuel of the Ignition Source of Fire for two Five-year periods from 1999 to to to 2008 Cooking equipment 39% Electrical disribution equipment 29% Heating equipment, chimney etc. 5% lighting equipment 6% Cooking equipment 37% Electrical disribution equipment 30% Heating equipment, chimney etc. 5% lighting equipment 7% Appliances 11% Other 10% Appliances 10% Other 11%

49 2009 OntariO ElEctrical SafEty report Cooking Fires 4.5 Cooking Fires In the ten-year period from 1999 to 2008, there were 12,791 fires identified as cooking fires, with 9, % of these recognized as stove-top or range-top burner fires. (See Table ) FIGURE Fires with Electricity Identified as the Fuel of the Ignition Source of the Fire Cooking Equipment versus Distribution Equipment 1999 to It should be noted that 81% of stove-top fires were caused by some form of misuse of the equipment. In most of these cases, though electricity was identified as the fuel of the ignition source, although the primary fuel of the fire was not electricity. Figure shows the continued decrease of cooking equipment fires in the ten-year period. More than a 25% decrease is seen from 1,655 in the year 1999 to 1,132 in The figures also show that the decrease in incidents with electrical distribution equipment is not as great for the same period a less than 20% decrease (from 1,123 to 906). NUmbER OF FIRES Cooking equipment Electrical distribution equipment table Stove-top Fires versus All Cooking Equipment Fires by Ignition Source 1999 to 2008 IGNItION SOURCE total PERCENtAGE OF total COOkING FIRES Stove or range-top burner 9, % Range hood % Oven 1, % Other cooking items (eg. toaster, kettle, electric pan, etc) 1, % Open-fired barbeque - fixed or portable % microwave % Stove-top fires have accounted for 72% of all cooking-related fires. For cooking equipment fires other than stove-top fires, see Tables and Misuse is still the largest cause but not as prominent (49% as opposed to 80% in stove-top fires). Deep-fat fryer % total COOkING FIRES 12, % Stove-top fires have accounted for 72% of all cooking-related fires.

50 OntariO ElEctrical SafEty report 4.4 Fires table Stove-top Fires versus All Cooking Equipment Fires by Possible Cause 1999 to 2008 COOkING FIRES StOvE-tOP FIRES Possible cause Number of fires Percentage of total Number of fires Percentage of total Children playing % % Design, construction or maintenance deficiency % % Intentional % % mechanical or electrical failure 1, % % misuse of ignition source or equipment 7, % 6, % misuse of material first ignited 1, % 1, % Other or undetermined 1, % % vehicle accident 8 0.1% 7 0.1% total 12, % 9, % Between the two five-year periods there has been a decrease of 19% in total stove or range-top fires. (See Table ) Of the fires investigated by the OFM (170 cases), 69% were caused by misuse, and 89.7% of stovetop fires were deemed as preventable by the reports submitted to the OFM. Of 9,185 stove-top incidents from 1999 to 2008, 5,083 were associated with cooking oil or grease as the object first ignited (55% of the total). Only 117 incidents identified electrical wiring insulation as the first object ignited (less than 2%). table Cooking Equipment Fires without Stove-top Fires by Possible Cause 1999 to 2008 POSSIblE CAUSE NUmbER OF FIRES PERCENtAGE OF total Children playing % Design, construction or maintenance deficiency % Intentional % mechanical or electrical failure % misuse of ignition source or equipment 1, % misuse of material first ignited % Other or undetermined % vehicle accident 1 0% total 3, % table Stove or Range-top Fires 1999 to 2008 with Five-year Comparisons year total INCIDENtS IN the FIvE-yEAR PERIOD AvERAGE NUmbER OF INCIDENtS PER year 1999 to , to , PERCENtAGE DEClINE 18.9% total OvER the ten-year PERIOD 9,

51 2009 OntariO ElEctrical SafEty report Electrical Distribution Equipment Fires 4.6 ElEctrical Distribution EquipmEnt Fir Es The profile of electrical distribution equipment fires is different than that of stove-top fires. The percentage decrease of the past ten years is smaller with an 8.4% decline in electrical distribution equipment fires (see Table 4.6.1) versus 18.9% in cooking equipment fires. Electrical failure accounted for 61.2% of the cause of fire and 8.2% was attributed to misuse. More than 10% was attributed to installation or maintenance deficiencies. (See Table ) OFM investigations of electrical distribution equipment fires identify most common first-ignited items as electrical wiring insulation and interior walls or ceilings, as seen in Table This finding is consistent with the submissions from local fire departments, as seen in Table table Electrical Distribution Equipment Fires investigated by the OFm (non-fatal) by material First Ignited material FIRSt IGNItED NUmbER OF FIRES Other gases 7 Structural member 9 Wood 15 Interior wall or ceiling 16 Undetermined 21 Electrical wiring insulation 26 total 131 table Electrical Distribution Equipment Fires 1999 to 2008 with Five-year Comparisons year total INCIDENtS IN the FIvE-yEAR PERIOD AvERAGE NUmbER OF INCIDENtS PER year 1999 to , to , total OvER the ten-year PERIOD 9,910 PERCENtAGE DEClINE 8.4% table Electrical Distribution Equipment Fires investigated by local Fire Departments by material First Ignited material FIRSt IGNItED NUmbER OF FIRES Wood 394 Insulation 418 Structural member 449 Undetermined 605 Other 681 Interior wall or ceiling 1,422 Electrical wiring insulation 3,115 total 9,910 Statistics Directly Related to Harm Reduction Priorities Aging Infrastructure Distribution Equipment Fires The number of electrical wiring-related fires such as copper and aluminum wiring, extension cord, appliance cord, termination and electrical panel electrical devices categorized by the OFM as Distribution Equipment. This is based on data reported to the OFM with fuel energy identified as electricity. The five-year reduction refers to the reduction (or increase) from the first five-year period to the last five-year period. For example, the 2002 to 2006 figure is a comparison of to ROllING FIvE-yEAR AvERAGE 2001 to to to to FIvE-yEAR REDUCtION 4.2% 5.8% 4.9%

52 OntariO ElEctrical SafEty report 4.6 Electrical Distribution Equipment Fires FIGURE Electrical Distribution Equipment Fire trends by Ignition Source top Six for 1999 to 2007 Extension cord or temporary wiring terminations (including receptacles, switches, lights) - copper Other electrical distribution Item Cord or cable for appliance or electrical article Distribution equipment (including panel boards, fuses, circuits) Circuit wiring - copper FIGURE Appliance Fires from 1999 to 2008 Electric blanket or heating pad 2.0% Iron or pressing machine 2.5% Clothes dryer 41.6% Other appliances 26.4% Air conditioner - window or room unit 2.6% Washing machine 4.4% television, radio, stereo, recording device, etc. 8.5% Refrigerator or freezer (includes vending machine) 12.0% With objects first ignited in clothes dryer-related fires, only 10% were initiated by electrical wiring insulation. A breakdown of electrical distribution equipment fires can be seen in Figure When reviewing electrical appliance fires, the clothes dryer was most prevalent, with refrigerators and freezers and others, as shown in Figure It is important to note that dryer fires were most often attributed to lint, fabric or material catching fire. Table shows the top objects first ignited in clothes dryerrelated fires. As can be seen, from 1399 fires of this type, only 141 (10%) were initiated by electrical wiring insulation.

53 2009 OntariO ElEctrical SafEty report Electrical Distribution Equipment Fires Electrical wiring insulation is the most common object first ignited with all appliances with the exception of clothes dryer fires, as shown in Table The prevalence ranges from 21% in television, radio and stereo to 38% for washing machines. The next prevalent object first ignited was other. These are various objects not categorized by the fire department and OFM. From all distribution equipment fires, circuit wiring was the most common ignition source with more than 2000 incidents in the ten-year period. Prevalence of this type of fire changed the least at 1.4% between the two periods. Extension cord incidents increased while the change in cord or cable appliance fires saw little change in the two five-year periods. table Objects First Ignited with Clothes Dryer-related Fires ObJECt FIRSt IGNItED NUmbER OF INCIDENtS Other soft goods or wearing apparel 391 Other or undetermined 322 Fabric natural (e.g. cotton, wool etc.) 179 Fabric synthetic or combination 149 Electrical wiring insulation 141 linen other than bedding 111 Wearing apparel, on a person 38 Plastic 27 bedding 22 Interior wall or ceiling 19 All other 86 total 1485 Dryer fires were most often attributed to lint, fabric or material catching fire. table Appliance Fires by Object First Ignited WASHING machine television, RADIO, StEREO, tape RECORDER, EtC. REFRIGERAtOR, FREEzER (INClUDING vending machines) OtHER APPlIANCES ClOtHES DRyER Other soft goods or wearing apparel Undetermined Plastic Other Electrical wiring insulation

54 OntariO O ElEctrical SafEty report 4.6 Electrical Distribution Equipment Fires table Electrical Distribution Equipment Fires by Cause from the OFm and local Fire Department Reports 1999 to 2008 OFm-INvEStIGAtED FIRES local FIRE DEPARtmENt-INvEStIGAtED FIRES Cause Number of incidents Percentage of total Number of incidents Percentage of total Arson 6 4.6% 0 0 Children playing % Design, construction, or maintenance deficiency % 1, % mechanical or electrical failure % 6, % misuse of ignition source or equipment 8 6.1% % misuse of material first ignited 2 1.5% % Other or undetermined % 1, % Under investigation 3 2.3% vehicle incident % table Electrical Distribution Equipment Fires by Ignition Source Five-year Comparisons IGNItION SOURCE terminations (including receptacles, switches, lights) in copper 1999 to to 2003 PERCENtAGE PREvAlENCE 2004 to to 2008 PERCENtAGE PREvAlENCE PERCENtAGE CHANGE DECREASE OR (INCREASE) % % 22.2% Circuit wiring in copper 1, % 1, % 1.4% Distribution equipment (including panel boards, fuses, circuits) % % 24.2% Other electrical distribution items % % 7.7% Extension cord or temporary wiring % % (6.1%) Cord or cable for appliance or electrical article % % 3.8% meter % % (5.0%) transformer % % 8.3% Service or utility lines (includes power/hydro lines) % % (1.8%) terminations (including receptacles, switches, lights) in aluminum % % 25.0% Circuit wiring in aluminum % % (18.2%) total 5, % 4, % 8.4%

55 4.7 Fire Investigation 2009 OntariO ElEctrical SafEty report 55 Fire Case Studies ESA WOuLD LIKE to share some of the investigations undertaken by the Office of Fire Marshal for Ontario (OFM). The purpose of showcasing these investigations is to provide readers an inside look on how fires can start, and the damage and injury they create. The OFM uses using a systematic and scientific approach, as outlined by the NFPA921 Standard, the Guide for Fire and Explosion Investigation. The report includes assessments of areas of least damage to areas of greatest damage; it includes an overall look at both the interior and exterior structure, and all pertinent areas surrounding the building. CASE STuDy ONE Misuse of an extension cord causing a fatality and $400,000 damage to property A fire occurred in a pair of two-storey semi-detached residences, constructed prior to This fire resulted in one fatality and an estimated $400,000 of property damage. The fire was caused by an extension cord used to power a portable heater in one of the units. The OFM, the local fire department, OPP and the office of chief coroner were involved in this fire investigation. For the unit where the fire originated, some of the damages were: Partial collapse of the exterior wall of the second floor Consumption of the roof assembly Charring and smoke staining to the central portion of the soffit and main floor windows, consumption of upper portion of the frames Collapse of the second floor wall Collapse of the ceiling Kitchen and dining room View of severed extension cord in area of origin A 50-foot long 16-gauge extension cord plugged into a duplex receptacle along the north wall of the dining room was routed on the floor along the west wall and randomly coiled behind a chair and plugged into a portable baseboard heater. Remnants of fabric adhered to the cord. The portable heater had been set on high. A second extension cord was located along the floor and was also plugged into the same receptacle but the cord was not powering any appliances at the time. Investigation findings: A permanent baseboard heater was found in the dining room The baseboard heater was not functioning, causing the occupants to resort to the portable heater. The 16-gauge extension cord was damaged 29 feet from the receptacle. Several cuts to the flexible cord were noted, as well as three locations where electrical tape had been used to repair the flexible cord. X-ray images revealed damaged strands at two locations in a one-foot length of wire where the cord had been repaired. The flexible cord failed where it had been damaged (poor connection), creating a high impedance path, which generates heat. The heat was at a sufficient temperature to ignite combustibles in close proximity (NFPA 921 sec ). North elevation of the structure

56 OntariO ElEctrical SafEty report The 16-gauge cord was not the correct extension cord to be used for this application. The heater was a 1500 W Electric Air-type heater. Testing of the heater determined the current draw would have been close to the maximum allowable current draw of the extension cord. The high-resistance connection would increase the current draw but not enough that it would cause the circuit breaker to trip in the initial stages. Extension cords are one of the major sources of ignition of residential fires. By their very nature they are exposed to mechanical damage and abuse, are often run through doorways and windows, under carpets, stapled along baseboard, located behind movable beds and appliances View of areas of extension cord repaired with electrical tape where there is ample opportunity for the flexible cord, over time, to become abraded and damaged, leading to eventual failure, fault, and a source of ignition. This case history is a perfect example of the type of misuse seen everyday. CASE STuDy TWO Stove-top fire ignited clothing; victim succumbed to injury A local fire department responded to a report of South elevation of the residence a smoke alarm to an older (constructed in 1945 or before), 800 square-foot wood frame bungalow. Upon arrival at the residence, the fire fighters forced their entry and located an occupant suffering from thermal injuries as a result of burn to her body caused by her clothing catching fire. Due to the nature of the incident, the OFM was contacted to initiate an investigation which also included the Coroner s office and the local fire prevention officer. The home was comprised of framed porches on the north and A field demonstration: fabric test over stovetop a portion of the person s clothing held over the energized stove element ignited immediately. south sides. The two bedrooms sit next to the living/dining area. The home also contained a kitchen, a bathroom and a laundry room. Both porches, living room, dining room and bedrooms did not suffer any fire damage. The fire was contained in the kitchen area. Examination of the kitchen revealed the following items: A 24-inch electrical stove. A metal kettle on the right rear burner. Remnants of a melted substance in the sink basin adjacent to the stove. Remnants of the same substance on the counter top in front of the sink. The same substance was also located at the floor level and extended across the kitchen floor to the door opening of the bathroom. At the floor level in front of the sink, remnants of white material cuff, similar to the sweatshirt worn by the victim. A portion of material displayed charring and evidence of direct-flame impingement. Melted droplets were found in the bathroom, adhered to the counter top and remnants of charred fabric at the floor level near the doorframe. Supporting evidence shows that the occupant was in the process of using the stovetop. In doing so, the occupant s sweater came into contact with the energized burner and ignition of clothing occurred. Field tests revealed that when a portion of the sweater was placed on an energized burner and flaming ignition was achieved, the flame continued following removal from ignition source. The sweatshirt was Remnants of melted substance on the kitchen floor. made from a cotton-polyester blend, which has the highest combustibility potential in comparison to other fabrics. 1 1 The danger of polyester-cotton blends Science News 129 (May 10,1986):297

57 2009 OntariO O ElEctrical Ectrical SafEty report Electrical Product Safety 5.0 ElEctrical l P roduct SafEty The mandatory reporting to ESA of electrical product safety issues, which started in June 2008, brings complaints and reports. Figure identifies an increase of 43% in product safety issues starting in This number continues to increase as awareness of mandatory reporting obligations grows in the manufacturing and associated industries. From January to December 2009 ESA investigated 679 issues relating to potential electrical product safety concerns. In addition to the 679 confirmed potential safety issues, ESA received 145 reports that do not meet ESA s reporting threshold. FIGURE Reports Submitted 2005 to FIGURE Electrical Product Incidents by Report Category 2009 voluntary 71.8% mandatory 25.8% Consumer Enquiry 2.4% FIGURE Safety Issues based on Priorities Priority % Priority % Priority % Voluntary reports were submitted by a variety of constituencies including consumers, ESA field investigators and product safety staff, fire departments, other authorities having jurisdiction (e.g. Office of the Fire Marshal), and other groups. The investigation type and priority category determine the proper response strategy and associated timelines. Figure shows the distribution of the reported safety issues based on the risk prioritization methodology. Based upon the results of the investigation, ESA works with the industry to ensure corrective action plans are in place to assure that no further serious electrical incidents or accidents occur. At ESA, product safety investigations are classified into three major categories; namely unapproved (product that does not meet the labeling criteria but may not be necessarily be unsafe), certified (product that was properly certified but reported to have a safety problem or perceived safety problem) and counterfeit. In 2009, over 50% of investigations dealt with certified products, as shown in Figure FIGURE Distribution of Product Safety Investigations 2009 Counterfeit 5.4% More than 25% of investigations initiated in 2009 were received in accordance with Regulation 438/07 s mandatory reporting requirement. (See Figure ) Certified 54.3% Unapproved 40.2%

58 OntariO ElEctrical SafEty report 5.0 Electrical Product Safety Figure shows a comparison of the reported incidents in 2008 versus The analysis confirms that the following product types are considered the top six categories: 17% Small Appliances 17% Lighting Products 11% Wiring/Distribution Products 11% Heavy machinery/industrial Products 11% Large Appliances 9% Consumer Electronics FIGURE Distribution of Incident Reports by Product type 2008 Public Notifications of unsafe Products the following were reported: in 2008, there were 55 recalls and one safety alert in 2009 there were 92 recalls and 26 safety alerts The impact of ESA product recalls starting in late 2008 and into 2009 resulted in an estimated 450,000 product recalls in Ontario and over 1,100,000 products recalled within Canada. Analysis of the first year following the mandatory reporting requirements the first year analysis after the mandatory reporting requirements came into affect resulted in a distribution of reports as shown in Figures (all), (voluntary) and (mandatory). Pool and spa equipment 3% Lighting products 14% Large appliances 7% HVAC products 6% Small appliances 28% Trailers/Mobile homes 5% Wiring/Electrical distribution products 14% Consumer electronics 7% Electric tools 5% Health and sciences products 1% Heavy machinery/ Industrial products 11% 2009 Pool and spa equipment 2% Small appliances 17% Lighting products 17% Trailers/Mobile homes 5% Wiring/Electrical distribution products 11% Consumer electronics 9% Electric tools 3% Large appliances 11% Health and sciences products 6% HVAC products 8% Heavy machinery/ Industrial products 12%

59 2009 OntariO ElEctrical SafEty report Electrical Product Safety FIGURE Distribution of Reports July 2008 to July 2009 total voluntary mandatory Other As a result of the combined efforts of ESA and safety/industry stakeholders Final Industry Guidelines for the Management of Electrical Product Safety were revised and posted on ESA s website in February The revisions focus on methods and tools for identifying the root cause of the safety issues in a timely fashion. The results of the root-cause analysis are key in identifying the required corrective and preventive actions. To view this document, access: esasafe.com/pdf/wg/stakeholder_findings_final_ Document.pdf FIGURE Distribution of voluntary Reports July 2008 to July 2009 total Consumers ESA Field Staff ESA Product Safety Staff Cbs Others FIGURE Distribution of mandatory Reports July 2008 to July 2009 total manufacturers Importers Distributors Retailers Cbs lawyers (On behalf of the supply chain) The impact of ESA product recalls starting in late 2008 and into 2009 resulted in an estimated 450,000 product recalls in Ontario and over 1,100,000 products recalled within Canada

60 OntariO ElEctrical SafEty report 5.1 Electrical Product Safety C s Case studies CASE STuDy ONE Water Dispenser August 2008 The Electrical Safety Authority (ESA) following notification by a local fire department, worked with Canadian Standards Association (CSA) and the manufacturer to investigate an issue following an incident with a water dispenser. Following review, it was found that the particular models of the counter-top water dispensers were produced with a different and uncertified base with openings contrary to the original listing in the CSA Certification Report. The deviation in construction would permit the dropping of molten metal onto the surface underneath the product, posing potential shock, and smoke or fire hazards. The manufacturer agreed to recall these units; there had been approximately 45,373 sold across Canada. CASE STuDy TWO Electric Kettle December 2009 Based on mandatory reporting requirements of Regulation 438/07, an electrical product manufacturer submitted a report regarding a house fire allegedly caused by a model of their electric kettle. This situation is under investigation by the claimants insurance providers restricting access to information. A retailer also submitted a report that a consumer experienced a fire created by the same model of electric kettle. ESA confirmed that the similarities between these two incidents resulted in fires. Given these findings, the priority level of the investigation was escalated to Priority One *. A Product Incident Report (PIR) was sent to the certification body and manufacturer requesting ESA assistance to conduct a joint investigation. The root cause of the fire incidents related to an unauthorized manufacturing change in the position of the safety thermostat. This repositioning rendered the safety thermostat ineffective in preventing the kettle from overheating. ESA requested corrective action by the manufacturer and provided guidelines for the supply chains to notify the public that this electric kettle was unsafe. A recall notice was prepared and posted to notify the public. *For information on ESA s Product Incident Risk Assessment Methodology, please see Appendix.

61 2009 OntariO ElEctrical SafEty report 61 CASE STuDy THREE Sharp-edged Dishwasher Door December 2009 ESA was notified a child was injured when his foot had been caught under a dishwasher door and required professional medical attention. ESA engaged the certification body and the manufacturer in the investigation, requesting formal assistance. Another similar incident was reported to ESA involving a different model of dishwasher from the same manufacturer. ESA conducted a non-official market surveillance of over 20 dishwashers by various manufacturers. Several models of dishwashers were found to have an accessible edge whereby it was possible for an individual to unintentionally access an edge below the dishwasher, which could result in a laceration injury. ESA worked to identify if there were any gaps during the construction review, examination and testing of dishwashers and identified inconsistent practices in testing for sharp edges on these electrical appliances. A review of the standard requirement in this area was deemed to be unclear. In response, ESA issued a safety alert in conjunction with the certification body and Health Canada. The certification body issued a news release in Canada and the U.S. The manufacturer agreed to distribute the safety alert to all customers and distributors. ESA has submitted a proposal to change this standard to address the issue and establish a consistent practice between all manufacturers and the certification bodies in this area. To increase industry and public awareness, ESA s product safety staff continues to engage in outreach activities. ESA continues to work collaboratively with all stakeholders to collect their feedback, to establish a consistent understanding of Reg. 438/07 and its reporting threshold, and to identify opportunities to improve and streamline its investigative process.

62 OntariO ElEctrical SafEty report 6.0 Summary 6.0 Summary Between 2000 and 2009, there were 90 deaths by electrocution and 117 deaths by fires where the fuel of ignition source was reported as electricity and activity reported as cooking. Both raised equal concern to ESA. Electrocutions are primarily workrelated with two-thirds of the electrocutions occurring in the workplace. In contrast, all fire deaths occurred at home. There were no deaths to the electrical tradespeople in 2009, but critical injuries when working with electrical panels continue to happen. For the five-year period of 2005 to 2009, panel injuries account for almost 50% of all electrically-related injuries. table Summary of Electrocutions by Occupation 2000 to 2009 OCCUPAtION total ElECtROCUtIONS Electrical trade 14 Occupational powerline 29 maintenance or general labour unskilled 8 Other workers 3 Skilled workers 6 Non-occupational bathtub 2 Non-occupational other 5 Non-occupational improper wiring 2 Non-occupational powerline 15 Non-occupational using defective equipment 1 Non-occupational with criminal intent 2 Non-occupational fool hardy 3 total 90 Electrocutions and injuries Contact with powerline and utility-related equipment Powerline fatalities in non-occupational sectors continue to decline. Powerline fatalities still account for 50% of all electrocutions, particularly in the occupational sector with small to medium-sized companies. Workplace fatalities and injuries to the electrical trade Though there were no deaths to the electrical trade in 2009, critical injuries continued to occur. Incidents continue with 600- volt panel or buss ducts. table Fire Fatalities When Electricity is Associated as the Fire Fuel by Ignition Source 2000 to 2009 IGNItION SOURCE FAtAlItIES Appliances 4 Cooking equipment 62 Electrical distribution equipment 33 Heating equipment, chimney etc. 6 lighting equipment 4 Other electrical, mechanical 8 total 117 Workplace injuries to non-skilled trades Revealed by the Workplace Safety and Insurance Board (WSIB), janitors, caretakers and building superintendents were the second highest occupation group with electrical injuries next to electricians. Other problems Problems still exist with 347-volt installations. Improper wiring by unqualified people creates hazardous conditions for ballast repair; work of this type resulted in two fatalities in the last five years. Due to the increase in ESA s Continuous Safety Services activities, there is more frequent detection of incorrect wiring in 347-volt systems in commercial settings. Stove-top and distribution equipment fires Stove-top fires continue to be one of the two major fire occurrences in the province, and are also the top reason for death with fires. With stove-top fires, combustibles such as grease and cooking oil are often identified as the primary fuel causing the fire (i.e. leaving cooking unattended), though the stoves are electrically powered. Stove-top fire incidents have declined by 32% in the last ten years. Electrical distribution equipment represents the other major source of ignition of fires. The incidence of these types of fires has decreased very little in the past ten years. Older buildings Older buildings present many hazards. Because of older equipment and wiring, often without protection against electrocution (i.e. GFCIs), there is a larger potential for injuries. In the last five years there were two bathtub fatalities and one (in cottage country) involving a pump that should not have been immersed in water.

63 2009 OntariO ElEctrical SafEty report Initiatives Emerging Issues Powerline clearance ESA is closing the information gap to address powerline clearance issues when constructing new buildings. ESA continues to work with local distribution companies (LDCs) and municipalities to develop an information kit that addresses the minimum clearance required from overhead powerlines to the building so that minimum clearance to overhead powerlines are adhered to. Streetlighting and aging infrastructure of utility equipment Aging streetlight assets and utility equipment continue to be a public concern with recorded incidents throughout the province. Electrocution around bathtubs ESA is aware of two electrocutions, in the last five years, involving electrical devices used in the vicinity of bathtub. 6.1 InItIatIves Addressing inadvertent powerline contact ESA is continuing with its six-pronged strategy (engagement, encouragement, education, enforcement, engineering and evidence) addressing inadvertent contact with overhead powerlines. The strategy is part of the ESA Utility Advisory Council s Ontario Powerline Safety Strategy for 2009 to 2013 continuing with: Targeting of dumptruck-contact incidents by partnering with industry associations, the MOL and independent operators. ESA continues to make available road signage to road and construction projects. Awareness campaigns in the farming communities. The campaign appears successful with no fatalities to report in this sector in the last six years. Targeting small contractors who perform siding, roofing and eavestrough repairs or installations. The two fatalities in 2009 with ladder contact from these activities confirm the necessity of continuing to target the high risk of these activities. Addressing fatalities and serious injuries to electrical trades Continued support for the Don t Work Live Campaign To address the need for contractors to work de-energized, ESA continues to work and provide material in conjunction with the Greater Toronto Electrical Contractor Association, the IAPA, EUSA and IBEW. Conference on Workplace Electrical Safety ESA partnered with the IAPA (now called Workplace Safety and Prevention Services) to present the CSA Z462 Standard, Workplace Electrical Safety workshops in four regions in Ontario. There were 68 one-day sessions, attended by 138 people, held in Mississauga, London, Ottawa, and Sudbury. Continued presence in the development of the second edition of the CSA Z462 Standard To keep abreast of the NFPA 70E (the National Fire Protection Association s Standard for Electrical Safety in the Workplace ), the CSA Z462 TC committee is actively involved in making recommendations to the NFPA 70E to improve the Standard that will then be reflected in the Z462 standard. ESA-sponsored electrical apprentice trade school ESA is continuing in its fourth year in the delivery of electrical safety awareness to electrical apprentices at the entry and advanced level in community colleges throughout Ontario. The half-day awareness program outlines the danger of working energized and the necessity of ensuring and verifying that electrical devices are indeed de-energized when disconnects are switched to the off position (an issue especially when equipment is not maintained on a regular basis). Thirty-four sessions were conducted in % surveyed indicated they are requested to work outside established safe work practices.

64 OntariO ElEctrical SafEty report 6.1 Initiatives 2008 Electrician Survey ESA conducted a survey with IBEW electricians. The purpose of the survey was to obtain a baseline measure of the electrical trades safety awareness when working with 347V. Of the 1,200 responses: 79% were construction and maintenance electricians 64% were engaged in the trades for more than 20 years 65% conducted electrical maintenance work sometimes, frequently, or almost always. The responses revealed the following: 42% of respondents associated a high risk with working on energized circuits. 57% indicated that they almost always take precautions concerning electrical safety (such as using personal protective equipment). 83% indicated that they almost always test with meters before working on electrical systems. 64% of those who worked energized did so to test. 36% of those who worked energized did so because they (i) believe that they can manage the risk, (ii) to save time, or (iii) because they are asked to do so. 88% indicated they have been educated to minimize the risk of working energized. 49% indicated they are requested to work outside established safe work practices. 89% indicated that information on electrical safety requirements would have an average to high impact on improving safety on the job. 92% indicated more information and effort is required to support worker safety. Addressing serious fires and fire fatalities Addressing stove-top fires ESA continues to support the OFM with addressing stove-top fires (see 2008 OESR, page 65). ESA continues to chair the OFM public fire safety council s stove-top fire working group. The report Reducing Residential Stovetop Fires in Ontario was finalized and published, and was the result of cooperation with the OFM, ESA, ULC, CSA, Canadian Appliance Manufacturers Association (CAMA) and Health Canada. Developing a Standard for Existing Homes The aging electrical infrastructure in older dwellings has been identified as a significant risk to public safety, as well as the cause of numerous fires over the years. Two bathtub deaths in the past five years illustrate this point. Many of the risks associated with the aging electrical infrastructure can be eliminated through a detailed inspection of the electrical system. Sponsored by ESA, in 2008, CSA started the development of CSA standard C22.6 No.1, Electrical Inspection Code for Existing Residential Occupancies. This new standard is currently in the draft stage, with the final version scheduled for publication late 2010 or early This standard will provide a consistent base for the inspection of older residential occupancies. The new CSA standard will address these risks and provide a minimum level of safety on older electrical installations. The standard addresses common deficiencies in older electrical systems and provides an appendix that lists additional minimum safety requirements. As the electrical code in Ontario/Canada has evolved significantly over the last 70 plus years, the new CSA C22.6 No.1 standard recognizes that some older installations may have to be updated to provide a minimum level of safety for today s modern electrical utilization. Some examples from the standard where updates could be required: The addition of GFCI protection on outdoor receptacles outdoors or near sinks. The installation of additional receptacles where excessive use of cords/power taps are identified. Installation of additional branch circuits where chronic overfusing is identified. Other issues Specialized Investigations to better understand the root cause of serious incidents Starting in 2008, ESA began to investigate serious incidents using root-cause analysis to improve its focus on prevention initiatives. In 2009, ESA conducted four investigations of the seven electrocution cases using root-cause analysis. Other aging utility infrastructure In 2009, spurred by increasing incidents with some older utility equipment, under the umbrella of the Utility Advisory Council (UAC), ESA has formed a working group to best address the issue of aging infrastructure. The working group is in its initial stage of formulating how to best address the issue. Fatalities associated with theft of power and copper Theft of copper continues, with at least one fatality a year caused by the activity. Streetlighting The 2009 symposium on street lighting safety sponsored by ESA in Toronto resulted in participants agreeing that a standard on repair and maintenance should be developed for streetlighting. A working group, facilitated by ESA, met in November of 2009 for an initial meeting; the group is now working on developing the standards. A section of ESA s

65 2009 OntariO ElEctrical SafEty report Initiatives website is dedicated to the streetlighting asset committee, with news on the working group s progress, minutes of meetings, etc. Guidelines will be developed on design and installation, operation and maintenance, and management. ESA is working with Toronto Hydro with the inspection of streetlights, in ensuring that streetlighting assets do not cause further public concerns. Over 2000 assets were repaired by Toronto Hydro but all needed to be inspected to ensure they meet the installation standard. Partnering with Electrical Safety Office (ESO) Queensland, Australia ESA, through its posting of the Ontario Electrical Safety Code (OESC) on the website, was contacted by the ESO of Queensland in the spring of The ESO is part of the Queensland Government and has some of the same functions as ESA does with Ontario. ESO is responsible for electrical inspection, product safety, and workplace safety. They have similar issues as in Ontario, such as powerline and worker safety. ESA and ESO now have bi-monthly discussions with ESA on safety concerns. One particular discussion could lead to a joint venture in vicinity device powerline and engineering solutions for electrical panels. Linking ESA s daily operation to corporate safety goals Regional Contractor s meetings provide information on the following: OESC as a minimum standard OESC updates and bulletin Dealing with smoke, fire and flood damage OESC bulletins (condensed) CSA Z462 workplace electrical safety training outline Update on electrical incidents and fires Applying the Electrical Safety Index to wiring notification In 2008, ESA established an electrical safety impact measurement (ESI) for the purpose of aligning Operations business decisions with corporate safety goals. ESI applies specifically to wiring-inspection activities, identifying five key safety attributes to support the assessment of ESA inspection activities. In 2009, Operations has successfully included ESI ratings to 99% of their wiring notifications.

66 OntariO ElEctrical SafEty report Appendix In consultation with industry stakeholders, ESA developed targeted-response strategies for products identified as unsafe based upon a customized risk assessment methodology that calculates both the severity and likelihood of the identified risk. Service Requests (SRs) are triaged into priority categories based upon the results of the risk assessment, as seen in the chart below. The risk assessment methodology defines high-risk incidents as are those that could cause death, the need for permanent life support, permanent impairment of a body function, permanent damage to a body, chronic health effect or long-term psychological trauma. Even recoverable injuries requiring hospitalization or professional medical treatment can be categorized as high-risk incidents if the likelihood of injury is very high. With regard to impact upon property, high-risk incidents are those that could cause loss attributed to flame emitted from product, failure to contain an ignition source or hazardous material, partial or total loss of contents accompanied by structural damage to or total loss of building. Incidents causing partial loss to contents without structural damage to building may also be classified as high risk if the likelihood of damage is very high. Likelihood of injury or damage is estimated as the combination of the likelihood of the product being or becoming defective, and the likelihood of the negative effect materializing. Both investigation type and priority category determine the proper response strategy and associated timelines. Based upon the results of the investigation, ESA may direct a range of corrective action plans to assure that no further serious electrical incidents or accidents occur, and that any defect that affects or is likely to affect the safety of any person or cause damage to property is corrected. Corrective actions could include recommending changes to applicable product safety standards, product recall (for replacement, refund, or disposal), withdrawing products from the supply chain, safety alerts (disseminating information and warnings about the hazard and/or additional information about correct use and maintenance), and other types of public notification. ESA Product Incident Risk Assessment methodology likelihood OF INJURy OR DAmAGE SEvERIty OF RISk very High High medium low very low Priority 1 Priority 2 Priority 3 INSIGNIFICANt minor moderate major

67 2009 OntariO ElEctrical SafEty report 67 Glossary Glossary Accident An undesired or unplanned event, resulting in property damage, injury or fatality. Aerial Work Platform (AWP) A selfpropelled work platform device, capable of lowering and lifting its work platform by mechanical means. AFI Application for Inspection, an application for performing electrical installation that requires inspection, as defined by the Ontario Electrical Safety Code. Apprentice In this document, it refers to an electrical apprentice, a worker who has yet to satisfy academic and field experience to become an electrician journeyperson. CIHI Canadian Institute of Health Information, a subsidiary of Health Canada, a not-for-profit organization responsible for collecting all health information across Canada. Cost of Injury Cost of injury as calculated by the WSIB in compensation, medical aid and pension. CSAO Construction Safety Association of Ontario, an accident prevention advisory organization, funded by the WSIB, serving the construction sector. CSS Continuous Safety Services Program (ESA) designed to help maximize electrical safety in customers facilities, and supports businesses in Ontario in complying with the requirements of the Ontario Electrical Safety Code. Distribution equipment (Section 4.0) Electrical equipment or device carrying electricity from one point to another, or electrical equipment or devices that connect or disconnect one conductor to another. ECAO The Electrical Contractors Association of Ontario a contractor association of unionized electrical contractors. Electrician A worker whose occupation is identified as working primarily with low voltage electricity. Electricians in this report can be someone designated by the employer to perform low-voltage electrical work. Electrocution An accidental death, caused by contact with electricity. Fatality An injury resulting in a death. Five-year Rolling Average Statistical data averaged over the past five years. This often smoothes out short-term fluctuations and highlights longer-term trends. Foolhardy Foolish and reckless behaviour, needlessly taking risks. High Voltage An electrical system with the load (voltage) equal or greater than 750V. High Resistance Fault Long-lived events in which the fault current is not high enough to trip the circuit overcurrent protection. Human error An inappropriate or undesired human decision or behaviour that reduces or has the potential to reduce the safety or system performance. IAPA Industrial Accident Prevention Association, now called WSPS (see in Glossary). IBEW International Brotherhood of Electrical Workers IEC International Electrotechnical Commission LDC Local Distribution Company Lineperson A worker whose occupation is identified as someone working with high voltage electricity. Low Voltage An electrical system with the load (voltage) less than 750V. LTI Lost Time Injury, a term defined by the WSIB for an occupational injury that resulted in a worker missing more than one shift of work. MOL Ministry of Labour of Ontario NEC Not elsewhere classified MTCu Ontario s Ministry of Training, Colleges and Universities Non-occupational injuries Injuries occurring other than in the workplace. NFPA921 Guide to Fire and Explosion Investigation. NWISP National Work Injuries and Statistics Program, an organization that serves as a repository of all occupational injuries in Canada. OBC Ontario Building Code Occupational Injury An injury occurring in a workplace. OEL Ontario Electrical League a contractor-based association of non-unionized electrical contractors. OFM The Office of Fire Marshal, a provincial organization responsible for the prevention of fires in Ontario. OHSA Occupational Health and Safety Act Overlamping The practice of installing lamps with larger wattage than what is recommended by the lighting manufacturer. Overfusing The practice of installing a larger-capacity fuse in the electrical panel than what the circuit is intended to bear, resulting in overheating of the electrical wire which results in premature failure of the wiring insulation and eventually resulting in a fire. Powerline Outside/outdoor electrical cable or wire, used to distribute electrical energy. RBD Radial Boom Derrick Serious Injury A fatality or critical injury. Supply Authority Any person, firm, corporation, company, commission, or other organization responsible for an electrical power distribution network that connects to a consumer s service. Traumatic Injury Injury as a result of a sudden or violent act. utility-related Equipment Refers to electrical equipment and devices used by Local Distribution Companies or privatelyowned companies to distribute electricity to the general public or to buildings owned by the private companies. WSIB Workplace Safety and Insurance Board, an organization responsible for compensation of workplace injuries. WSPS (was IAPA) Workplace Safety and Prevention Services

68 This document was prepared by the Engineering and Regulatory Division of the Electrical Safety Authority. For queries and additional information, please contact Francis Hardy at