Date of incident: August 2022
Notice of incident number: 2022157440013
Employer: Auto service company

Incident summary
At a tire repair shop, a worker was mounting a repaired tire onto the tire’s rim. Using compressed air, he inflated the tube (inside the tire) but was unable to seat the bead of the tire in the well of the rim (to seal the air in the tire). The worker switched to a different compressed air hose and continued inflating the tube, periodically checking the tube pressure with a pocket tire pressure gauge. The tube exploded, resulting in the sudden release of the pressurized air, which forced the rim out of the sliding clamps on the tabletop and allowed the rim and tire to be propelled upward. The tire struck the worker, who was seriously injured.

Investigation conclusions

Cause

• Overinflation of tire tube. The tire had a maximum pressure rating of 45 psi. Unable to seat the tire bead, the worker switched from a regulated air source of 45 psi to an unregulated air source of 140 psi and filled the tube beyond 45 psi. This overinflation caused the tube to explode.

Contributing factors

• Manufacturers’ instructions not followed. The manufacturer’s instructions posted on the tire machine and the instructions printed on the sidewall of the tire were not followed. As a result, the maximum pressure rating of the tire was exceeded, causing the tube to explode. Also, the worker had not lowered the mount/demount head to touch the top of the rim, which might have prevented the rim and tire from leaving the tabletop and being propelled into the air as a result of the explosion.
• Lack of personal protective equipment. Safety glasses and hearing protection would have protected the worker’s eyes and ears.
• Lack of supervision. The employer did not provide supervision in the shop’s tire repair section to prevent unsafe acts from occurring. The worker’s supervisor had left after lunch, leaving a director of the company to oversee the entire shop, including the front counter, the automotive repair section, and the tire repair section. Because of this inadequate supervision, the hazard of the tube overinflating and exploding (from not following the manufacturers’ instructions) was not identified.
• Inadequate training and instruction. The worker and other workers in the tire repair section were not provided the tire machine’s instruction manual and were not trained to follow the manufacturer’s instructions. The employer provided training verbally and by demonstration but had not developed written safe work procedures based on the manufacturer’s instructions when servicing and repairing tires.
• Inadequate young or new worker orientation and training. The employer’s “New Employee Orientation Form” did not meet the requirements of the Occupational Health and Safety Regulation, including ensuring that young or new workers are aware of hazards they may be exposed to in their work. The employer was not able to locate a copy of the worker’s orientation form but did provide two records signed by the worker in the month after he was hired. The Regulation requires that training and orientation records be completed before a young or new worker begins work.
• Inadequate focus on safety. The employer had carried out casual inspections throughout the shop, but these inspections did not prevent unsafe acts and conditions from developing in the tire repair section. A lack of monthly safety meetings contributed to the development of complacency and the lack of adherence to manufacturers’ instructions.
• Lack of first aid attendant. The employer did not ensure that a certified first aid attendant was designated and present at the workplace.

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