Homegrown Me Pty Ltd
[2021] ACTCD 2
•27 April 2021
CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY
Case Title: | Homegrown Me Pty Ltd |
Citation: | [2021] ACTCD 2 |
DecisionDate: | 27 April 2021 |
Before: | Coroner Theakston |
Decision: | See [17]–[19], [24]–[29] |
Catchwords: | CORONIAL LAW – inquiry into fire – gas explosion – portable commercial kitchen – uncapped gas pipe – misleading compliance plate |
Legislation Cited: | Coroners Act 1997 (ACT) Gas Safety Regulation 2001 (ACT) Gas Safety Act 2000 (ACT) |
File Number(s): | CF 2 of 2018 |
CORONER THEAKSTON:
Introduction
On the evening of 24 October 2018 there was an explosion at a commercial kitchen in Fyshwick. Four young men were seriously burned.
The incident was reported to me as the duty coroner and I decided to exercise jurisdiction under s 18(2) of the Coroners Act 1997 (ACT). WorkSafe ACT conducted an investigation and provided the Court with a comprehensive brief of evidence.
This incident raises a number of issues, including:
(a) the cause of the explosion;
(b) the injuries suffered by those present; and
(c) a matter of public safety.
I will initially describe the general situation and the circumstances of the night on which the explosion occurred and then address the above issues.
Situation
The kitchen was housed within a transportable shipping container and owned by HOMEGROWN ME Pty Ltd. It was located at Canberra City Farm, on Dairy Road Fyshwick, and available for hire.
The kitchen comprised of refrigerators, sinks, benches, combined hob/oven, exhaust hood, large serving window and two separate entry doors. Two large LPG gas cylinders were located outside, with the gas supplying an external hot water heater and the internal combined hob/oven.
The shipping container had originally been owned by Ms Sunita Kumar and possibly her husband, Sanjay Kumar. The couple had purchased the container and had it professionally fitted out as a kitchen for their use. The builder had arranged the installation of the gas piping and appliances by a licensed gasfitter in September 2015. The gasfitter certified that work.
HOMEGROWN ME purchased the shipping container in November 2016 and it was subsequently moved to the location at Canberra City Farm.
When the kitchen was initially installed, the gas appliances comprised of the hot water heater, combined hob/oven, and a gas hotplate. The hotplate was located next to the hob/oven. The hob/oven and hotplate were fed by two separate gas lines, connected to separate regulators and valves, which were each in turn fed from two separate pipes protruding from the wall. Those sets of gas fittings were located on the wall close to the floor and approximately 30 cm apart.
The hotplate was not fitted to the container when it was sold to HOMEGROWN ME. Mr Kumar indicated that prior to HOMEGROWN ME taking possession of the shipping container, one of the friends assisting him at the time removed the hotplate. He was not sure which friend removed the hotplate or whether that person was a licensed gasfitter. The hotplate hose was disconnected from the regulator, leaving the valve and regulator attached to the pipe protruding from the wall. The regulator had not been capped, to prevent gas from discharging into the kitchen should the valve be placed in the open position. This gas valve was marked with the words ‘Do not use’, ‘Do not touch’ or ‘Do not open’.
In March and September 2017 and prior to the explosion, HOMEGROWN ME arranged for the hob/oven appliance to be serviced by two different licensed gas appliance workers. Their work was focused on the appliance, in particular the ignition or lighting mechanism of the hob/oven. The gas appliance workers denied seeing the disconnected gas regulator or working on the gas piping.
Circumstances on the night
On the night in question, Mr Lasitha Rathnayake booked to use the kitchen from 6:00 pm. He had wanted to start earlier, but the kitchen had already been booked by another that afternoon. Mr Rathnayake and his friends had used the kitchen before without incident.
At approximately 8:30 pm, Mr Rathnayake and a friend, Mr Eashaan Dassanayaka, arrived. They unloaded a quantity of food and started preparing the meals they intended to cook. Sometime after 9:00 pm, Mr Supun Polgolla arrived to help with the preparation. A little while after 9:30 pm, Mr Ishan Jayasekara arrived to cook the meals.
Mr Jayasekara ignited the stove to cook a curry. As part of the process, he turned the valve on the wall on the right to the open position. Mr Jayasekara was aware the valve on the right was connected to the stove and the valve to the left was not connected to any appliance. At some point the flame on the stove was lower than expected. Another burner was tested, but it also had a low flame. Mr Rathnayake went outside and switched the gas supply from one of the cylinders to the other. To do so he opened a locked cage and accessed the changeover valve. The flame on the burner remained lower than expected, and Mr Jayasekara continued to cook as best he could.
During the evening the men could smell gas in the kitchen. This included when the stove was first ignited. They appear to have assumed that this was in some way due to the burner ignition process. When the gas cylinder was switched over, a door was opened, but later closed because it was a cold night. The other door and serving window were also closed.
At approximately 11:00 pm and while the four men were working in the kitchen there was a sudden and brief explosion. Both Mr Rathnayake and Mr Dassanayaka saw the flames and exited the container quickly. Mr Polgolla and Mr Jayasekara remained in the kitchen for a short period before walking outside. All four men suffered burns.
Cause of the explosion
The kitchen was inspected the following day by a licensed gasfitter. Both valves on the wall were found to be in the ‘on’ position. This included the line that supplied the combined hob/oven, as well as the line that was installed for the hotplate, since removed and which remained uncapped. There was significant charring near those valves and moderate charring elsewhere in the kitchen.
The gasfitter opined that gas would have been free to flow into the kitchen. The gas, being LPG and heavier than air, would have pooled at the lowest level in the kitchen, with the upper part of that cloud rising higher until it eventually reached an ignition source, which then triggered its ignition and the resultant explosion.
It is unclear from the evidence who moved the uncapped valve on the left to the open position.
Injuries
Mr Rathnayake sustained burns to his face, ears and hands, with scarring subsequently forming. The scars on his face are slowly disappearing but remain visible. He has suffered a psychological injury as a result of the incident.
Mr Dassanayaka sustained burns to his face, ears and arms. He has been left with visible scarring. He has reduced sensation in his lips, issues with his hearing and a psychological injury.
Mr Polgolla sustained serious burns to his face, arms and back, and spent three weeks as an inpatient in Concord Hospital, Sydney. He has been left with scarring, pain and sensitivity, as well as a psychological injury.
Mr Jayasekara sustained serious burns to his face, ears, arms, hands and legs, and spent six weeks as an inpatient in Concord Hospital, Sydney. He has been left with scarring subsequently forming. The injury to his leg remains uncomfortable and he has suffered a psychological injury.
Matters of public safety
This incident arose due to the existence of an uncapped gas line. That line was connected to a supply of gas and located adjacent to other gas fittings that were used on a frequent basis. The uncapped fitting was located in a confined space, used by people and near an ignition source. The valve to that gas line amounted to a single point of failure that, if turned on, would almost certainly lead to a gas explosion. The initial gas works had been certified by a licensed gasfitter, and a plate evidencing that certification remained fixed to the kitchen notwithstanding the subsequent removal of the hotplate and the creation of the hazard.
The owner of the kitchen had appropriately engaged a gas appliance worker on two occasions in relation to the adjacent oven and does not appear to have received any advice or warning about the uncapped gas line. The appliance gas workers attended to the oven repair as requested but did not inspect the adjacent gas fittings.
The Gas Safety Regulation 2001 (ACT), regs 6 and 10 require any disconnected gas line to be capped. The reasons for that are obvious. The capping of such lines provides a simple and reliable measure to prevent the inadvertent release of flammable gas. Once the line is capped it would not matter whether someone move an upstream gas valve to the ‘on’ position. This is particularly important for confined spaces, occupied by people and proximate to an ignition source.
The regulatory regime requires that approved gas appliances be disconnected only by licensed gasfitters: see the Construction Occupations (Licensing) Act 2004 (ACT), ss 7, 12 and 84, and the Gas Safety Act 2000 (ACT), ss 6E and 6F. A licensed gasfitter would be aware of the need to cap a disconnected gas outlet. In this case it remains unclear who precisely removed the hotplate. In any event the uncapped disconnection occurred well after the compliance plate had been affixed and in circumstances where it may not have been obvious to the owner of the kitchen that the gas piping system was no longer compliant. Accordingly, the existence of the compliance plate following the removal of the hotplate would have been misleading to the new owner.
The regulatory scheme does not contemplate the periodic inspection and re-issuing of compliance plates. In the absence of such an arrangement, there would be utility in consumer information being added to the compliance plate. That information could include a statement that it is dangerous for an unlicensed person to modify the gas piping system or install or disconnect a gas appliance to the gas piping system, and that it may from time to time be appropriate to have the gas piping system and gas appliances inspected by a licensed gasfitter and gas appliance worker.
I recommend that the Construction Occupations Registrar consider including the above information in any recommended compliance plate, as anticipated by the Gas Safety Regulation 2001, reg 18.
| I certify that the preceding twenty-nine [29] numbered paragraphs are a true copy of the findings of his Honour Coroner Theakston Associate: Neerja Thirunavukarasu Date: 27 April 2021 |
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