Trichloroethylene used to clean the floors in Irish Air Corps cookhouse!

Every now and again when investigating poor health & untimely deaths of colleagues in the Irish Air Corps at Casement Aerodrome we come across a cluster of unexplained deaths or illness in particular work locations.

Exposures are briefly explained by location below those in RED were unexplained until personnel came forward to highlight misuse of chemicals in these locations.

Apprentice Hostel

Exposure to asbestos was the main problem in the apprentice hostel and it does not appear to have been fully removed until the mid 1990s although some efforts were made to remove the bulk of it in the late 1980s. The 1990s effort used a professional removal service while the late 1980s effort used apprentices without any PPE whatsoever. Persistent black marks on lino or floor tiles would be dealt with by calling to the nearest hangar or workshop to borrow some MEK or Trike

Avionics, ERF & Parachute Shop

Illness & untimely deaths in Avionics Squadron and Engine Repair Flight (Engine Shop) can be explained by unprotected exposure to the chemicals used in both locations and by their exposure to exhaust fumes from the Spray Paint Facility. The Parachute Shop which was part of ERF establishment also used toxic glues and exposed personnel to fumes from PU coated drysuits.

Basic Flight Training School

Illness & untimely deaths in BFTS can be explained by the IRAN inspections where DCM/Phenol paint strippers were used without PPE and the extensive use (like in heli) of corrosion inhibitors like Mastinox. Of course the fuel for the Marchettis was leaded gasoline with its own issues.

Battery Shop

Illness in the battery shop can be explained by exposure to battery electrolytes & charging fumes. The personnel walking around here with holes in their jumper, trousers and shirts from sulphuric acid was almost comical if it wasn’t such a serious risk to their health.

Cookhouse / NCOs Mess

Until now we had not been able to satisfactorily explain the unusual body count & illnesses of personnel who served in the old cookhouse kitchen, new cookhouse kitchen and NCOs Mess kitchen.

Recently we were made aware of a practice in the old cookhouse as far back as the mid 1970s whereby personnel who worked there procured solvent degreaser from up camp. We believe this degreaser again to be trichloroethylene.

This solvent was provided sometimes in 25 litre drums and sometimes in gallon containers where it was usually decanted into smaller vessels like milk bottles or coke bottles to be spread on the floor and then mopped and squeegeed until the floor was spotless.

And it turns out that this practice continued in the new cookhouse and technicians from ERF who dropped down 25 litre drums of Trike were rewarded with a wrap up of some food like steaks.

We believe this floor degreasing practice occurred in the NCOS Mess kitchen but we have no evidence yet that it occurred in the Officers Mess Kitchen but given the fluidity of personnel movements between the various catering locations it is a distinct possibility.

For some information on Illnesses caused by trichloroethylene click here.

Engineering Wing Hangar & Workshops

Illness & untimely deaths in Engineering Wing Hanagar can be explained by unprotected exposure to Paint Shop chemicals including isocyanates & thinners, Hydraulic Shop chemicals, Sheet Metal Shop chemicals, wood dust from the Carpentry Shop, welding fumes from the Welding Shop as well as paint stripper fumes and mastinox fumes from Marchetti IRANs or Alouette equivalent teardowns.

Fire Crew

Members of the fire crew would have had exposure to exhaust gasses of idling aircraft engines and would have also had exposure to fuel fumes  and burning fumes from training exercises. The Fire Crew also used PFAS based fire fighting foams.

Heli Wing

Illness & untimely deaths in Heli Wing are easily explained by unprotected exposure to the chemicals used maintaining helicopters, by exposure to fuel vapours from gravity refueling, exposure to exhaust gasses from gas turbine engines and the immune sensitisation capabilities of polyurethane coated immersion suits.  Toxic tubbing in Heli was also a thing.

Light Strike Squadron

Similarly illness & untimely deaths in Light Strike Squadron can be explained by unprotected exposure to refueling fumes, exhaust gasses and other lubricants, greases, hydraulic fluids and sealants used to maintain the Fougas. Toxic tubbing in LSS was also a thing.

Main Block

Illness & untimely deaths in the Main block can be explained by unprotected exposure to photographic film & printing chemicals. These photographic chemicals used in photo section drove death, illness & harm to offspring in personnel throughout the main block

Chemicals in use by workshops in Air Sp Coy Signals further exposed personnel in the mainblock to chemicals they would not have expected to be exposed to like trichloroethane etc.

Units exposed in the main block would include 

  • Admin Wing HQ
  • AE Section
  • Drawing Office
  • Air Corps INT
  • Medical Aid Post
  • Sgt Majors Office
  • Signals Bottom Workshop
  • Signals Top Workshop
  • Signals COMCEN
  • Signals Orderly Room & CO’s Office
  • Signals PC Maintenance Workshop
  • Signals Stores
  • Station Commanders Office

Main Tech Stores

Illness & untimely deaths in Main Technical stores can be explained by the fact that the building is sited on the old Camp Stables where hundreds if not thousands of litres of toxic chemicals such as Ardrox 666 were dumped into the ground. Complaints were made by civilian & military personnel about poor air quality  in MTS and studies were carried out but the reports have disappeared. There is also evidence that used chemical drums containing isocyanates were stored in MTS in an open state.

Photo Section

When photo section moved out of the Main Block to the old cookhouse in the early 1990s they brought their dangerous chemicals to this new locations. This new location was better equipped than the expellair in the main block. But faulty equipment and lack of chemical health & safety training meant illness & death continued.

Photographers who flew regularly exposure to refueling fumes, exhaust gasses from gas turbine engines and the immune sensitisation capabilities of polyurethane coated immersion suits.

Refuelers

Obviously refuelers were exposed on an ongoing basis to high amounts of refueling fumes and aircraft exhaust gasses but also to other dangerous additives like FSII.

Training Depot

On at least two occasions that we are aware of there was catastrophic damage caused to floors and walls by misuse of chemicals in ACTD.

On the first occasion in the late 1980s we are aware of a recruit using what we suspect to be a large quantity of MEK on twine backed traditional lino the last room on the left of the depot. The use of the chemical on this occasion melted the lino through to the twine backing.

On the second occasion in the mid 1990s at least 25 litres of trichloroethylene was used to clean the floor of some of the demonstration rooms that had been recently redecorated. The Trike was spread on the floor using mops and squeegees making the apprentices carrying out the job high. The next morning it was discovered that all the floor tiles had shriveled up and that all the paint on the walls up to about 1m had dissolved and flowed down the walls to the floor.

For some information on Illnesses caused by MEK click here.

*****

The physical layout of Baldonne means that the prevailing wind blows the exhaust gasses from idling aircraft over the whole camp.

There does not appear to have been any initiative whatsoever to reduce camp personnel exposure to exhaust gasses and in many cases aircraft exhaust into hangars due to the prevailing wind.

We have little information on chemical exposures at Gormanston except for tubbing and the use of JetA1 powered heaters inside hangars. We would welcome any information in this regards. 

Baldonnel Bingo – Dichloromethane Edition

Baldonnel Bingo – Where only the good die young!

Who will be the champion ? ARF, Avionics, BFTS, ERF or MTS?

All the below illnesses are known* to be caused by dichloromethane (DCM) also known as methylene chloride.

DCM was banned after a vote in the European Parliament in January 2009. The ban came into place in 2011 but the Irish Air Corps were still happy to let unsuspecting personnel use DCM without PPE or training in 2015 & likely beyond.

The Irish Air Corps finally issued PPE to all personnel using chemicals in 2017 a full 20 years after being told to do so by state body Forbairt.

Click on image to download a 30 player PDF or organise a game online here

*****

References*

Klaassen CD, Ed. Casarett and Doull’s Toxicology: The Basic Science of Poisons, 6th Edition. New York: McGraw-Hill 2001.
LaDou J, Ed. Occupational and Environmental Medicine, 3rd Edition. New York: Lange Medical/McGraw-Hill Company, 2004.
Leikin JB, Davis A, Klodd DA, Thunder T, Kelafant GA, Paquette DL, Rothe MJ, Rubin R. Selected topics related to occupational exposures. Part V. Occupational cardiovascular disease. Disease-a-Month. 2000 Apr;46(4):311-322.
Lynge E, Anttila A, Hemminki K. Organic solvents and cancer. Cancer Causes and Control. 1997 May;8(3):406-19.
Rom WM. Environmental and Occupational Medicine, 3rd Edition. Philadelphia: Lippincott Williams & Wilkins Publishers, 1998.
Severe Optic Neuropathy Caused by Dichloromethane Inhalation
Atsushi Kobayashi, Akira Ando, Nobuko Tagami, Masahiko Kitagawa, Emi Kawai, Masako Akioka, Eiko Arai, Toshio Nakatani, Satoshi Nakano, Yoshie Matsui, and Miyo Matsumura Published Online:8 Dec 2008https://doi.org/10.1089/jop.2007.0100
Environmental and Chemical Toxins and Psychiatric Illness By James S. Brown. Publisher: American Psychiatric Association Publishing (27 Feb. 2002) Language: English ISBN-10: 0880489545

Dáil Éireann Written Answers 12/06/19 – Irish Air Corps – Health & Safety

Aengus Ó Snodaigh (Dublin South Central, Sinn Fein)

QUESTION NO: 75

Deputy Aengus Ó Snodaigh asked the Taoiseach and Minister for Defence when he first received the report on the findings of the independent third party appointed to investigate protected disclosures relating to chemical exposure in the Air Corps; the steps he has taken to act on its findings since then; and if he will make a statement on the matter. [24571/19]

Paul Kehoe (Wexford, Fine Gael)

Three written disclosures were made, in November and December 2015 and January 2016, under the provisions of section 8 of the Protected Disclosures Act 2014, relating to alleged failings in the Defence Organisation in the area of Health and Safety. Legal advice was sought on how best to progress certain disclosures as elements related to matters which are the subject of the ongoing litigation. As the Deputy will be aware, the State Claims Agency is currently managing nine claims taken against the Minister for Defence, for personal injuries alleging exposure to chemical and toxic substance whilst working in the Air Corps in the period 1991 to 2006.

I appointed an independent reviewer to examine the disclosures. Following receipt of the report of the independent reviewer, which was submitted to me on 19 June, 2016, I invited the views of those who had made the disclosures and published the report. I also sent the report to the Chief of Staff for the views and actions of the military authorities to be set out.

In parallel to the independent review, following an inspection in 2016, the Air Corps had continued to work with the Health and Safety Authority (HSA) to improve its health and safety regime. I have been informed by the military authorities that the HSA has formally noted the considerable progress made to-date by the Defence Forces towards implementation of a safety management system for the control of hazardous substances. Subject to completion of the improvement plan the HSA investigation is closed. However, it must be noted that in the Air Corps health and safety is a matter of ongoing monitoring, supervision and adjustment.

The matter of the disclosures is receiving consideration in the context of the responses I received from the parties and legal advices in the context of ongoing active litigation…..blah blah blah blah blah blah blah blah blah 18 22 men dead since Minister for Defence first notified minister considering report for a year 2-years now. 

DELAY – DENY – DIE

  1. Minister for Defence was first notified of ongoing Health & Safety issues at Irish Air Corps in November 2015.
  2. Twenty Two men have died since this date, three by their own hand. Some of these men could have been saved.
  3. There has been ZERO medical assistance offered to Air Corps survivors.
  4. There has been ZERO assessment of the chemical exposure effects to even serving personnel.
  5. Minister Kehoe is happy to let serving and former Air Corps personnel die while he takes 2 years to consider his next step.
  6. Meanwhile the State Claims Agency who were awarding the Air Corps awards for excellence in Health & Safety while they actively poisoned personnel are frustrating legal cases by tying them up in appeals.
  7. Tune in next year for another bullshit reply in the Dail from Paul Kehoe.

Dáil Debates Other Questions 17/1/19 – Defence Forces Equipment

Aengus Ó Snodaigh (Dublin South Central, Sinn Fein)

QUESTION NO: 11

To ask the Taoiseach and Minister for Defence if all Defence Forces and Air Corps officers are trained in the use of respirators and-or breathing apparatus in the context of handling chemicals and toxic material; if the use of same is now mandatory; and the date on which it became mandatory. [1803/19]

This question relates to the change in the health and safety regime brought about in recent years because of disclosures from whistle-blowers, which have led to changes in health and safety in the Air Corps in particular. Are all Defence Forces and Air Corps officers trained in the use of respirators and breathing apparatus in the context of handling chemicals and toxic material which, in the past, were wrongly handled and possibly exposed people to poisoning and ill-health?

Paul Kehoe (Wexford, Fine Gael)

I am advised by the military authorities that all members of the Defence Forces are trained in the fitting of the general service respirator as part of their basic training and that tests of elementary training are conducted annually in a respirator test facility. This training is in keeping with chemical, biological, radioactive and neurological (WTF?) training that all Defence Forces personnel undergo following basic training.

I am further advised by the military authorities that only those Defence Forces personnel who are required to work with chemicals and toxins are required to undergo respiratory protective equipment training. Such training is provided to members of the Defence Forces in accordance with the relevant health and safety legislation.

With regard to the Air Corps, I am advised that it uses two types of respiratory protective equipment depending on the type of activity being carried out. These are respirators, which are air purifying, and breathing apparatus, through which air is supplied. I am advised that personnel who require respiratory protective equipment training are trained as necessary.

Aengus Ó Snodaigh (Dublin South Central, Sinn Fein)

I welcome the Minister of State’s statement but part of the question was when did it become mandatory. The final part of the reply seems to suggest that not all Air Corps personnel are trained in the use of respirators. When exactly did it become mandatory for all Defence Force personnel to have this training? Is the training in full use currently?

Paul Kehoe (Wexford, Fine Gael)

With regard to the Air Corps, I am surprised that people who specifically deal with chemicals are trained in the wearing of respirators only if they are involved in dealing with these types of chemicals. Full training is given to these people and they undergo relevant retraining to ensure they are fully trained.

Aengus Ó Snodaigh (Dublin South Central, Sinn Fein)

The question is when that happened.

Paul Kehoe (Wexford, Fine Gael)

I do not have a specific date but to my knowledge full training is carried out in line with what is required. I will come back to the Deputy with a specific date.

*****

DELAY – DENY – DIE

Dáil Éireann Written Answers 23/10/18 – Department of Defence – Air Corps Health Monitoring

Jack Chambers (Dublin West, Fianna Fail)

QUESTION NO: 172

To ask the Taoiseach and Minister for Defence the changes in health and safety policies that have been implemented following the publication of the report of the independent reviewer, protected disclosures, Air Corps; and if he will make a statement on the matter. [43404/18]

Paul Kehoe (Wexford, Fine Gael)

I have sought the information from the military authorities and will revert to the Deputy when it is to hand.

 

Jack Chambers (Dublin West, Fianna Fail)

QUESTION NO: 173

To ask the Taoiseach and Minister for Defence if a programme that monitors actual exposure of Defence Forces members to hazardous substances either via personal air monitoring or biological monitoring as outlined in the report of the independent reviewer, protected disclosures, Air Corps is in place; and if he will make a statement on the matter. [43405/18]

Paul Kehoe (Wexford, Fine Gael)

I have sought the information from the military authorities and I will revert to the Deputy when it is available.

 

14th November 2018

Mr Jack Chambers, T.D.,
Dail Eireann,
Leinster House,
Dublin 2.
Dear Deputy,

You will recall my recent-replies to written Parliamentary-Questions 43-404/18 and 43405/18, wherein I advised you that I had sought the requested information from the military authorities and that I would revert to you when it was to hand.

I have now received the aforementioned information from the military authorities. At the outset I would like to advise you that while the exposure monitoring programme is referenced in the June, 2017 report of the independent reviewer, it is actually outlined (as a recommendation) in the Health & Safety Authority’s Report of Inspection to the Air Corps dated 21 October, 2016, which followed three inspections by the HSA at Casement Aerodrome during 2016.

The resultant Air Corps improvement plan confirmed the Air Corps’ full commitment to implementing improved safety measures that protect workers and ensure risks are as low as reasonably practicable. The plan was implemented over eight phases, seven of which the military authorities have advised are now complete, while phase 8 – Chemical awareness training and respiratory equipment training – is a continuous, ongoing process.

Phase 7 comprised a review of the Defence Forces policy on hazardous substances. This policy was subsequently amended in September, 2017 and, inter alia, describes the Defence Forces methodology for the assessment of risk arising from the transport, storage and disposal of hazardous substances. The new policy also provides guidance for military personnel. civilian employees and other relevant persons on the risk assessment process and control and measures to be implemented to reduce the risk of injury from the use, transport, storage and disposal of hazardous substances to a level that is as low as reasonably practicable.

Insofar as a programme that monitors exposure to hazardous substances is concerned, I am advised by the military authorities that the Air Corps have conducted and continue to conduct air monitoring studies at Casement Aerodrome and that the Air Corps are currently planning further air monitoring  studies in targeted areas next year.

Yours sincerely,

Paul Kehoe, T.D.,
Minister with responsibility for Defence

DELAY – DENY – DIE

Dáil Éireann Written Answers 15/01/19 – Irish Air Corps – State Claims Agency

Catherine Murphy (Kildare North, Social Democrats)

QUESTION NO: 133

To ask the Taoiseach and Minister for Defence the health and safety management system reports and or audits carried out on the Air Corps by the State Claims Agency in each of the years 2006 to 2015; the year and author of each report and or audit in the timeframe; if the reports have been published and or classified as confidential; and if he will make a statement on the matter. 1180/19

Paul Kehoe (Wexford, Fine Gael)

I am advised by the State Claims Agency that it has a statutory remit under the National Treasury Management Agency (Amendment) Act 2000 to provide risk management advices to Delegated State Authorities. Such risk management advices include the provision of Health & Safety Management System audits, inspections and reviews.

From this, State Claims Agency conducted a number of Health & Safety Management System Defence Forces audits within the Air Corps between the years 2006 – 2015. The Reports are authored by the State Claims Agency and are confidential between the Agency and their Client.

*****

The State Claims Agency audited the Irish Air Corps for a decade before the Health & Safety Authority were forced to intervene and stop the ongoing CMR & toxic chemical exposure of the Baldonnel workforce.

The HSA file was opened in January 2016 and was only closed in September 2018 but the “superb” health and safety performance of the Air Corps for the decade prior to HSA intervention helped the State Claims Agency & NTMA staff earn discretionary performance-related payments.

DELAY – DENY – DIE

Dáil Éireann Written Answers 18/12/18 – Department of Finance – State Claims Agency Bonus Pay

Catherine Murphy (Kildare North, Social Democrats)

QUESTION NO: 146

To ask the Minister for Finance if staff at the State Claims Agency receive discretionary performance related payments; the amount paid to staff from 2006 to date; if these payments related to particular projects and or audits; and if he will make a statement on the matter. 53022/18

Paschal Donohoe  (Dublin Central, Fine Gael)

When performing its statutory functions regarding claims against the State, the National Treasury Management Agency is known as the State Claims Agency.

The NTMA have informed me that discretionary performance-related payments are intended to reward exceptional performance having regard to the employee’s own performance, the performance of the employee’s area of responsibility, and the overall performance of the NTMA. Performance related payments are made in accordance with parameters approved by the Agency’s non-executive Remuneration Committee.

The NTMA have also informed me that it provides details of performance related payments made each year to all NTMA staff in its annual reports which are available on the NTMAs website through the following link

http://www.ntma.ie/publications

*****

DELAY – DENY – DIE

Dáil Éireann Written Answers 18/12/18 – Irish Air Corps – State Claims Agency Audits

Catherine Murphy (Kildare North, Social Democrats)

QUESTION NO: 119

To ask the Taoiseach and Minister for Defence if the State Claims Agency supplied the Health and Safety Authority with copies of its audits and or reports regarding the Air Corps; and if he will make a statement on the matter. 53026/18

Paul Kehoe (Wexford, Fine Gael)

I have been advised by the State Claims Agency that it does not provide reports of Health and Safety Management System Audits conducted by the Agency in Delegated State Authorities (including the Defence Forces) to the Health and Safety Authority. I am advised that these are provided to the Delegated State Authorities only.

With regard to the Air Corps, the Deputy will be aware that the Health and Safety Authority (HSA), following a number of inspections in 2016, issued a Report of Inspection to the Air Corps on the 21st October 2016, listing a number of matters requiring attention which included the areas of risk assessment.

The Air Corps as a consequence of this HSA report have implemented an improvement plan which is being conducted over eight phases. Seven of the eight phases have now been fully completed. The final phase is a continuous on-going process. The implementation plan focuses on a number of areas, including risk assessment.

I wish to assure the Deputy that the health and welfare of the Defence Forces personnel is a high priority for me and the military authorities.

*****

For 10 years BEFORE the Heath & Safety Authority were forced to investigate the Irish Air Corps, due to the ongoing safety risks to personnel, the State Claims Agency had been carrying out Health & Safety Risk Management System audits at Baldonnel. 

In the eyes of the State Claims Agency the Irish Air Corps risk profile was continuously improving whilst personnel on the ground were still being exposed to toxic & CMR chemicals without appropriate PPE or training causing lifelong injures to themselves and their children. 

It is now obvious that the State Claims Agency audits were incompetent  especially considering it took the Health & Safety Authority 2 years and 9 months to close their investigation file on the Irish Air Corps.

The State Claims Agency audits need to be released to the Oireachtas without delay.

DELAY – DENY – DIE

Dáil Éireann Written Answers 18/12/18 – Irish Air Corps – Legal Cases

Catherine Murphy (Kildare North, Social Democrats)

QUESTION NO: 117

To ask the Taoiseach and Minister for Defence the number of open cases the State Claims Agency is handling in respect of the Air Corps, its staff and former staff; and if he will make a statement on the matter. 53027/18

Paul Kehoe (Wexford, Fine Gael)

I am advised by the State Claims Agency that their reports indicate that currently the Agency is managing 21 active compensation claims in respect of the Air Corps where it is alleged that a staff member is the injured party.

Given that litigation is on-going, the Deputy will appreciate that it would be inappropriate for me to comment further in relation to these claims.

*****

Considering the limited media coverage of this scandal to date, this figure can only be expected to climb as serving & former personnel become aware that their ongoing health issues are likely a result of unprotected toxic chemical exposure whilst serving in the Irish Air Corps.

DELAY – DENY – DIE

Dáil Éireann Written Answers 4/12/18 – Department of Defence – Air Corps senior management withheld Trike Report from government appointed investigator

Catherine Murphy (Kildare North, Social Democrats)

QUESTION NO: 108

To ask the Taoiseach and Minister for Defence if a report on the use of Trikelone N in the Air Corps workshop compiled in 2014 by the formation safety office of the Air Corps was made available to the independent person (details supplied) appointed to investigate health and safety matters in the Air Corps; if not, the reason it was not available to them; and if he will make a statement on the matter. [50343/18]

Paul Kehoe (Wexford, Fine Gael)

The report of the independent person appointed to investigate health and safety matters in the Air Corps is published and available on my Department’s website. Appendix C of that report lists documents and materials consulted and reviewed by him.

The document, to which the Deputy refers, is the subject of legal advice and in light of ongoing litigation, I am not in a position to comment further.

*****

Introduction

Trikelone N is a vapor de-greaser which was used as a cleaning agent in the process of cleaning engine parts due to be overhauled. Its use was  discontinued in the Air corps just prior to September 2007.

Work practices

One (1) pair of gloves was available to be used between all personnel who could be required to carryout the process. No personnel P.P.E. issue was made to individuals. MSDS sheets were available but no records of training on the dangers of using Trikelone N or the process or how to properly carryout the process exists. Two large extractor fans were placed on the wall behind where the process took place, but there is no record of the capacity of the fans, their specification or if they were adequate. There was no organised segregation of work areas. The double doors that separated the area where the Degreasing process took place from the adjoining area here normally left open. The personnel’s tea making and meeting room was in an annex off this adjoining Engine assembly area. The workshop heating system was also located in the adjoining Engine assembly area. Originally peoples personnel lockers were located in the immediate area where the Degreasing process took place, but the lockers where relocated into the adjacent Engine assembly area at a later date.

Possible Trikelone N exposure sources

Current Trikelone N MSDS states that exposure through, skin, hair, eyes and inhalation should be avoided and that contaminated clothes should be removed.

  • Trikelone N exposure through inhalation, skin, hair and eyes could have resulted as individuals were not issued P.P.E. to protect against the substance. Due to the lack of records it can not be assumed that the two fans located on the wall behind where the process took place offered adequate ventilation.
  • The lack of organised segregation of work areas where doors between areas were left open meant that vapours could travel from one area to another. No seals or segregation areas existed.
  • Vapours could have travelled to the personnel’s tea making and meeting room which was located in an annex off the adjoining Engine assembly area and could have resulted in ingestion of the chemical by way of food contamination.
  • The location of people’s personnel lockers which were located in the immediate area where the Degreasing process took place, and then relocated into the adjacent Engine assembly area at a later date. Would give a reasonable assertion that the contamination of persons clothes contained in their lockers would have taken place.
  •  The heater located in the Engine assembly area took air in just above floor level and pushed out hot air above head height circulating the air around the Engine assembly area. When the doors between the Engine assembly area and the area in which the De-greasing took place were left open, the air would be circulated between both areas. Due to the Trikelone N being heavier than air a high concentration of Trikelone N would have been located near the heaters inlet vents.
  •  The heater was adapted by Cpl. XXXXX so that the air being heated would be circulated into various other areas in the building including the Machine Workshop, NTD bay and Workshop offices by way of ventilation duct which could have exposed a risk of contamination of the air in those locations that might not have occurred previously. There is no record available if this work was approved, who authorised it, or was the design appropriate.
  • Due to the fact that Trikelone N expands when heated, the risk of explosion
    increased when the Trikelone N contaminated air passed through the  heater.
  • Poor hygiene controls before food consumption and going to the toilet would also be a cause of exposure.

Controls

The following controls are currently recommended when using Trikelone N.

  • Isolating controls should be put in place to limit exposure.
  • Adequate ventilation and extraction should be in place.
  • Do not use in a confined space as vapour is heavier than air.
  • Appropriate P.P.E to be provided including overalls, boots, chemical eye protection, impervious gloves and organic vapour respirator.
  • Wash hands before smoking, eating, drinking or using the toilet.
  • Contaminated clothes to be washed.

The Defence Forces Safety Standards 1991 which were a precursor to the Defence Forces Safety Statement is the closest thing I could find regarding some form of documented control standard in the Defence Forces. The Safety, Health and Welfare at Work Act 1989 would have been in affect, but the Safety, Health and Welfare at Work (Chemical Agent) Regulations 2001 would have only been in affect for a short period of the exposure. The Defence Forces Safety Standards 1, Control of Substances Hazardous to Health (COSHH) covers…

Section 1 Information Sources
  • MSDS sheets should be given by suppliers of Chemicals to the Defence
    Forces.
Section 3 Principles of Assessment
  • Obtaining and Passing on knowledge about a Chemical
  • Assessment of Hazards posed by its use, byproducts, storage and disposal.
  • Control of the Chemical using Engineering techniques, safe operating procedures and Personal Protective Equipment (PPE)
  • Monitoring the Effectiveness of the Control strategy.
Section 4 Control

Documents how controls are to be put in place using a hierarchy of Controls
not unlike what is currently used.

  • Elimination
  •  Substitution
  • Enclosure
  • Isolation
  • Local exhaust ventilation and reduced time exposure
  • Dilution ventilation
  • Use of PPE
  • Personnel hygiene and washing facilities
  • Training

Summary

As time, processes and technology has changed It is clear that the appropriate controls that would be the standard today were not in place at the time of the process taking place and that potential exposure risks were prevalent. The question posed should be was everything reasonably practicable done to ensure personals safety and health at the time.

On that note did the controls deemed reasonable at the time mirror those deemed reasonable in the present. Can the Defence Forces be found not to have done everything reasonably practicable?

DELAY – DENY – DIE