INSPECTION REPORT

Worker and Employer Services Division

6951 Westminster Highway, Richmond, BC

Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

The Workers Compensation Act requires that the employer must post a copy of this report in a conspicuous place at or near the workplace inspected
for at least seven days, or until compliance has been achieved, whichever is the longer period. A copy of this report must also be given to the joint
committee or worker health and safety representative, as applicable.

A revised version of the Workers Compensation Act took effect on April 6, 2020. The B.C. government’s revisions aim to make the Act easier to read and
understand, and to reorganize the numbering to make laws easier to find. The revisions make no changes to B.C.’s laws concerning workers’ compensation,
occupational health and safety, and employers’ assessment premiums. Please be aware there may be a transitional period where correspondence from
WorkSafeBC may include references to either the previous Act or the revised Act. For more information, visit www.worksafebc.com/WCA2019 or call the
Prevention Information Line at 604.276.3100, or toll free within BC at 1.888.621.7233 (SAFE).

Inspection Report #202217819050A

Employer Name Jobsite Inspected Scope of Inspection
HOWE SOUND PULP & PAPER CORPORATION 3838 PORT MELLON HIGHWAY May 12/22 incident-- workers exposed to foul
PORT MELLON BC V0N 2S0 condensate fumes

Date of Initiating Inspection Date of This Inspection Delivery Date of This Report Delivery Method
May 13, 2022 May 13, 2022 May 18, 2022 Email

THERE ARE ZERO (0) ORDERS OR OTHER ITEMS OUTSTANDING

ACTION MAY STILL BE NECESSARY TO ENSURE COMPLIANCE

PLEASE READ FULL REPORT

IR 202217819050A Printed: May 18, 2022 17:57 Page 1 of 7

 INSPECTION REPORT
Worker and Employer Services Division
202217819050A
6951 Westminster Highway, Richmond, BC
Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

INSPECTION NOTES
I attended Howe Sound Pulp and Paper (HSPP) due to an incident which took place on March 12, 2022. The incident was
reported to WorksafeBC by both:

- The employer, Howe Sound Pulp and Paper Corporation

- The attending RCMP officers.

Note: There were no serious injuries to workers, but six (6) workers reported symptoms consistent with expose to low levels of
foul condensate gases. The symptoms included dizziness, nausea, headaches, and (for some workers) a sore throat and minor
breathing difficulty.

The employer interrupted the annual shutdown, and evacuated the mill until the source of the sour gases could be identified, the
contaminant levels in the area measured, the source controlled, and the area washed and re-tested. The evacuation lasted about
three hours, after which time the fire department checked the area one last time before shutdown activities resumed..

The various gas detectors did not register any air contaminants at or near the Occupational Exposure Levels (OEL), though strong
odours were confirmed in the building. As of the next day all affected workers were back to work.

It is the employer's policy to send any worker with any lingering symptoms of foul condensate gas exposure to medical aid via
ambulance, at per written first aid procedures and decision-making flow charts. Since several workers symptoms (nausea,
headaches, etc) did not immediately improve when oxygen was administered, they were transported via ambulance.

We discussed that the multiple ambulance rides probably were the reason for the RCMP to attend the incident
. However, the employer
was correct to follow their first aid procedures as written.

The first aid procedures err on the side of safety, but there is a cost to the employer in elevated community attention-- reinforcing
the idea among the work force that experiencing an odour equates to injury.

Preliminary and/or full investigation: I estimated this was 90% completed by the time of my arrival the next day. It had included
the safety committee, the plant fire department, process engineers, and management. It consisted of area inspections,
participation of multiple departments, and a review of the process and instrumentation diagrams (PIDs) and control computer
graphs, charts, print outs and records.

I walked through the area, sketched the equipment and took equipment numbers, and then reviewed the DCS screen shots,
graphics, and flow diagrams presented by the engineers. While the process engineers are still looking into the source of foul
condensate contamination, the mechanism by which it was released into the building had been determined. I summarize it as
follows:

1- Area with loss of containment

• The area of gas release was the 260t Feed Chute Drain in the "New O2 basement".
• This narrow, 40' tall tank was empty, and for the shutdown it had an open drain valve at its bottom.
• Normally, this tank has two sources of wash water-- fresh hot water and fouled combined condensate.
• The two feeds enter the tank through proportional flow controllers (metering valves) at the top.
• There are numerous mechanical (gate) valves providing isolation.
• In the morning of May 12, 2022 the drain suddenly started to dribble water.
• The water carried a strong odour of foul condensate, sickening several nearby workers.

2-Source of water to 260t Feed Chute drain known, but not source of contamination

• The combined condensate comes from the VE2 area, through approximately 200m of pipe.

IR 202217819050A Printed: May 18, 2022 17:57 Page 2 of 7

 INSPECTION REPORT
Worker and Employer Services Division
202217819050A
6951 Westminster Highway, Richmond, BC
Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

• However, this pipe had been drained and isolated with a manual valve earlier in the shutdown.
• The employer planned to install new fittings on the VE2 tanks, so had drained all tanks.
• Additionally, the tanks had been cleaned out, drained again, and boiled out and drained twice.
• The tanks and their discharges had been tested for DNCG vapours, and none had been found.
• The employer had taken extra care and attention to "safe" the vessels prior to having to open them up
• They had also flushed the supply line to the 260t tank (to the manual value, but not the 260t side).

3- Sequence of events led to inadvertent activation of combined condensate pump and feed to the 260t:

• In preparation for start-up, hot water is applied to various tanks and subsystems.
• In the VE2 area, operators sent hot water to the Reflux tank, intending to drain it through a valve.
• However, that valve faulted so the Reflux tank remained full. The ot
• Operators then sent the flow of clean, hot water to the remaining valve, to VE2 Stripper tank instead.
• When the Stripper tank reached 80% full, the condensate pump automatically started to drain the tank.
• There are four valve pathways, However, all but one was deactivated for the shutdown: the 260t drain.
• However, the manual valve between the Stripper tank and 260t tank was closed.
• The Combined Condensate A pump dead-headed on the valve and the Stripper tank could not be drained.
• Meanwhile, at the other building a different set of operators opened the valve several hours later in preparation for startup.
• At some point after this, either the VE2 operators activated the pump manually in another attempt to drain the tank of hot
water, or the pump automatically started by itself again.
• Without the manual valve closed, the flow control valves experienced hot water pressure.
• Flow control valves are not "isolation" valves. Water dribbled through into the 260t vessel and out the drain pipe.

4 - The hot water was somehow contaminated between VE2 inlet and New O2 basement drain:

It is still unclear why the fluid (which should have been hot water) contained so much foul condensate. One possibility is that the
hot water was contaminated near the 260t tank, since the pipe typically contains foul condensate. An engineer also advised it was
possible that sour gases were siphoned into clean VE2 pipes (which were empty, with no fluid to hold back the gases) from the
ejectors (which were higher pressure and hotter than VE2). Those gases may have condensed into liquid inside VE2 after it had
been boiled out.

At this time the actual source of the foul condensate is unknown, and the employer may never know because the volume of foul
condensate might only have been in the litres, and the pipes and vessels are large and enclosed.

Discussion point: Pumps that start by themselves indicates need for DCS interlock review

At this time, I advised the employer that I am unclear whether the distributed control system (automation), specifically the
Condensate Pump A programming, was adequately interlocked to prevent start-up when it is not desired. As described by the
employer, it is interlocked with the tanks level sensor (which is normal) but it was unclear if it was interlocked with a enable/disable
permissive such as "run VE2 system= OK" or "at least one target destination is available", or similar.

It is also possible that the programming is adequate, and that the VE2 operators manually over rode the pumps to empty the tanks
of what they thought was clean hot water by applying multiple forces or jumpers. This makes it difficult to identify or issue any
corrective orders that should apply. However, this event resulted in a mill evacuation during the annual turn-around, which is a loss
for the employer. In my previous inspections reports I've observed similar setbacks when:

• There is miscommunication between departments or a general lack of a "heads up" when an action is taken.,.
• There is a deficiency of programming / alarm management / interlocking that creates operational difficulties.

Gas detectors of many types were available for sign out at Gate House, but were any worn?

IR 202217819050A Printed: May 18, 2022 17:57 Page 3 of 7

 INSPECTION REPORT
Worker and Employer Services Division
202217819050A
6951 Westminster Highway, Richmond, BC
Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

When I signed in at the Gate House, I observed the employer continues to charge and bump a full complement of portable gas
detectors for workers to sign out and wear. They were available for any worker to sign out, but to my knowledge, they are only
required for certain positions and/or tasks.

When I asked if any of the contractors or HSPP workers (any of those who had been exposed to foul odours and reported to
medical aid) had been wearing any gas detector, and if any of these had shown any elevated readings, the employer could only
report that their investigators wore them, and the HSPP fire department had swept the air in the affected areas with multiple
meters and not measured any contaminant above 1 ppm. The only readings at all were directly adjacent to the 260t tank drain.

Potentially, the workers exposed to the foul condensate odours were not wearing any of the available gas monitors and had no
way of knowing if the concentrations in the building very harmful, or not, except by the presence and intensity of the odour.

Escape respirators are mandatory for all mill entrants, and I observed they were featured prominently in gate-to-gate PPE signs.
The problem is that workers may not know when to don them, or are reluctant to don them. When I asked if any workers had
donned their escape respirators when detecting an odour, the employer could not confirm if they had.

To summarize, the personal gas detectors primary function is to warn workers when to don their escape respirator and get
out, but they would also serve to reassure workers when something is "only" a bad smell, as well.

The basic problem that HSPP has been dealing with for the last several years is that some of the gases associated with kraft
pulping are extremely odiforous, but an obnoxious odour and a harmful level of gas smell much the same. The odour threshold
can be at very low concentrations (parts per billion), far below any related occupational exposure limit (parts-per-million), but once
exposed to high concentrations of the gases workers rapidly lose their ability to smell some of these gases at all.

This means that only gas detectors are reliable for determining harmful levels of gas, or not. "Smell" is an unreliable
indicator of the actual concentration of harmful vapours at a kraft pulp mill.

Continuing to evacuate workers who had experience a strong odour at a pulp mill by ambulance, when they may not be injured,
instead of requiring gas detectors be used may eventually become un sustainable.

Suggestions to employer

SIMOPS, or "simultaneous operations" is process safety terminology for the interconnected equipment in complicated facilities
(like pulp mills) where one node or process or type of work is adjacent to another, and the two processes affect each other. One
piece of equipment may be shut down for work, but the work affects the adjacent process downstream or upstream of it. SIMOPs
require a high level of coordination and communication to manage.

There are many examples and studies of how employers can conduct a thorough reassessment of its DCS, or distributed control
system, in order to improve both the safety and the reliability of their industrial processes. Function loop checks and periodic
alarm reviews are recommended.

In the debrief meeting which included several HSPP and Paper Excellence upper management, I advised that if the employer is
interested in learning more about either SIMOPs or functional loop or alarm checks, several members of the WorkSafeBC process
team could provide examples of those studies.

Full investigation received after the inspection, with recommendations to employer by safety committee

The employer's investigation had a step-by-steo timeline of actions taken, procedures followed, and precautions in place. It also
included recommendations. There were:

1. Installed department lock on manual valve X 649 in Post DD waster on combined condensate line into.

IR 202217819050A Printed: May 18, 2022 17:57 Page 4 of 7

 INSPECTION REPORT
Worker and Employer Services Division
202217819050A
6951 Westminster Highway, Richmond, BC
Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

- (Completed immediately)

2. Lockout to be modified to include lock on manual valve X 649 in Post DD waster on combined condensate line
- June 1, 2022

3. Check sheets to be developed from procedure to ensure all check points are in the proper position
- July 1, 2022

4. Functional control loop check to be completed on VE2

- Sept 30 2022

5. Develop a multi department communication standard

- (process safety goal, date TBD)

***************************************************************************************************************************************

Peder Gorseth, Occupational Hygiene Officer

Process Safety Team & Construction Team (Region 5219)
WorksafeBC Prevention Field Services | 604.232.1552
210-220 Brew Street, Port Moody, BC www.worksafebc.com

IR 202217819050A Printed: May 18, 2022 17:57 Page 5 of 7

 INSPECTION REPORT
Worker and Employer Services Division
202217819050A
6951 Westminster Highway, Richmond, BC
Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

REFERENCES
In addition to any orders, or other items, and the information provided in the Inspection Notes section in this Inspection
Report, the officer may discuss other health and safety issues with the employer arising out of the inspection. The
information below sets out the health and safety requirements discussed with the employer, and unless otherwise noted,
violations of these requirements were not observed.

Reference Details Discussed

WCA69(1)
The requirement to conduct both a preliminary and full
investigation into this incident was discussed with the employer.
An employer must conduct a preliminary investigation under
section 71 and a full investigation under section 72 respecting
any accident or other incident that:
(a) is required to be reported under section 68,
(b) resulted in injury to a worker requiring medical treatment,
(c) did not involve injury to a worker, or involved only minor
injury not requiring medical treatment, but had a potential for
causing serious injury to a worker, or
(d) was an incident required by regulation to be investigated.

WCA71(2)(c)
The requirement to submit a copy of the preliminary
investigation report to WorkSafeBC as soon as it is completed
The employer must ensure that a report of the preliminary
was discussed with the employer.
investigation is provided to the Board on request of the Board.

WCA72(2)(b)
The requirement to submit a copy of the full investigation report
to WorkSafeBC within 30 days of the date the incident occurred
The employer must ensure that a report of the full investigation
was discussed with the employer.
is submitted to the Board within 30 days of the occurrence of
the incident.

OHS10.2
Start-ups after a major shutdown (re comissioning) are one of
the the most hazardous times at a pulp mill. Close coordination
If the unexpected energization or startup of machinery or
between department is required before operators make
equipment or the unexpected release of an energy source could
operational choices that affect other areas of the plant.
cause injury, the energy source must be isolated and effectively
controlled.
After the incident, multiple manual valves were locked out (or,
locked out again) as a precaution.

OHS19.36(1)
The employer advised that part of the corrective actions are to
check the pump programming (permissives and interlocks).
A control system must be designed, installed, operated and
maintained in accordance with a standard acceptable to the
Board.

IR 202217819050A Printed: May 18, 2022 17:57 Page 6 of 7

 INSPECTION REPORT
Worker and Employer Services Division
202217819050A
6951 Westminster Highway, Richmond, BC
Mailing Address: PO Box 5350 Stn Terminal, Vancouver BC, V6B 5L5
Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

Employer # Mailing Address Classification Unit # Operating Location

852214 3838 PORT MELLON HIGHWAY 714044 001
PORT MELLON BC V0N 2S0

Lab Samples Direct Readings Results Presented Sampling Inspection(s) Workers onsite during Notice of Project
Taken Inspection Number
N N N 600

Inspection Report Delivered To Employer Representative Present Worker Representative Present Labour Organization & Local
During Inspection During Inspection
Todd Lansi Stew Gibsons Unifor local 1119

WorkSafeBC Officer Conducting

Inspection
Peder Gorseth

*Inspection Time *Travel Time

10.00 hrs 8.00 hrs

*The time recorded above reflects the inspection time and travel time associated with this inspection report and includes time
spent on pre and post-inspection activities. Additional time may be added for subsequent activity.

Request a Review
Any employer, worker, owner, supplier, union, or a member of a deceased worker's family directly
affected may, within 45 calendar days of the delivery date of this report, in writing, request the
Review Division of WorkSafeBC to conduct a review of an order, or the non-issuance of an order,
by contacting the Review Division. Employers requiring assistance may contact the Employers'
Advisers Office at 1-800-925-2233.

To submit a request online, visit https://www.worksafebc.com/en/review-appeal/submit-request

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to complete a survey.

IR 202217819050A Printed: May 18, 2022 17:57 Page 7 of 7