Review of the Ministry of Labour Documents Pertaining to Holmes Foundry Sarnia, Ontario 1950 - 1988


Pertaining to Holmes Foundry Sarnia, Ontario 1950 - 1988


Mark Parent and Jim Brophy jointly prepared this report. They wish to acknowledge the assistance and support received by Nick DeCarlo, CAW National Health and Safety Representative. They would also like to thank the following; Paul Edwards, Kim Clout and Frank Marek, of the Canadian Auto Workers Union (CAW); Kathy Mayville, Jianping Cui, and Murray Lawrence of OHCOW; Larry Girard and Todd Brown of WOHIS; Vern Edwards (OFL Health and Safety); and Bill Hicks, President of Local 456 CAW.


In the spring of 1998, Mr. Robert Clarke, the CAW Plant Chairperson and first Health and Safety Representative of Holmes Foundry, approached OHCOW-Windsor with an alarming account depicting disproportionate numbers of Holmes workers with cancer, hearing loss, and respiratory and heart disease.

The CAW initiated a plan of action to investigate possible workplace exposures that might be related to potential health problems of former Holmes workers. Their efforts led to a public meeting held at the Communication, Energy and Paperworkers (CEP) Hall in Sarnia on September 18, 1998. Numerous Unions, OHCOW, the Windsor Occupational Health Information Service (WOHIS), and the Ontario Federation of Labour (OFL) participated in supporting this initiative. More than 200 former Holmes workers and their families turned out to report their health problems.

As part of its investigation, the CAW requested copies of the Ministry of Labour reports arising from the government's history of involvement with the former Holmes Foundry and Insulation plants.

This report is based on the documents that were surrendered to the CAW through the Freedom of Information Act. However, the CAW has been in a consultation process with the Workers Safety and Insurance Board (WSIB), and were shown important documents that were not turned over by the government. While we do not know the full extent of these missing records, we have chronicled some of the points that were highlighted in the WSIB chronological summary of documents pertaining to Holmes Foundry.

There was an earlier separate report prepared for the CAW, by Jim Brophy, Executive Director-Windsor Clinic, which focussed specifically on the former Holmes Insulation and Caposite Plant.

Holmes Foundry - Brief History:

Holmes Foundry of Sarnia, Ontario, was established in 1918. It was originally owned by Mr. J.S. Blunt and was called Holmes Blunt Limited. In those early years, Ford Motor Company contracted the plant for a steady supply of engine casting blocks. Workers have described conditions at this time as appalling.1 The plant was dirty and unsanitary, with no ventilation, no showers, no sanitary toilets, and no lunchroom.

In 1937, workers participated in one of the rare sit-down strikes in Canadian history. It ended 48 hours later in a riot, when workers were beaten and driven from the Holmes Plant by an armed mob of local goons. The UAW organised in 1943, chartering Local 456, becoming #13 of UAW Local Unions organised in Canada.

American Motors (AMC) acquired twenty-five percent interest in the plant in January of 1966. At that time, the plant had supplied AMC with motor castings (blocks) since 1962. In July of 1970, American Motors acquired 100% of Holmes Foundry. It was not until October of 1981 that Holmes Foundry finally became a Division of American Motors, Canada.

At one time, there were three separate operations in Sarnia at the Holmes facility. The Caposite Insulation Plant, the Holmes Insulation Plant (which were addressed together in a separate report), and the Holmes Foundry. The Caposite plant closed in 1974 and, at approximately the same time, Holmes Insulation moved to 561 Scott Road, in Sarnia.

With the acquisition of AMC, Chrysler Corporation took ownership of the Holmes Foundry facility and its manufacturing business in 1987. Chrysler scheduled the operation for closure on September 16, 1988, which ended Holmes Foundry's seventy-year legacy of exposing workers to harmful and excessive hazards.

Executive Summary:

On February 12, 1999, Canadian Auto Workers (CAW) Union President, Buzz Hargrove, released a report on the former Holmes Insulation and Caposite plant in Sarnia. The report was based on Ministry of Health and Labour documents, which were obtained under the Ontario Freedom of Information Act. These government documents revealed a legacy of neglect and failure resulting in asbestos exposures that, "were the highest ever encountered by this Branch in any of the plants in Ontario."

The Ministry of Labour commissioned a health study in 1987 of the asbestos exposed Caposite workers. The findings were staggering. There was a six-fold increase in lung cancer mortality among the Holmes workers exposed to asbestos for two years or more. It also documented an eleven-fold increase in respiratory disease mortality and a four-fold excess of all malignancies.

The study also cited five cases of mesothelioma among former Holmes workers. Three of the five workers died at less than fifty years of age and all were less than sixty years old!

This is the second report released by the CAW. It will bring to light government inspection documents regarding the work environment at the Holmes Foundry facility. These reports span a 38-year period beginning in 1950 and continuing until the plant finally closed in 1988.

As in the case of the Caposite plant, the government inspectors tolerated dangerous working conditions, which resulted in a pattern of ill health among the former foundry workers.

By mid 1998 the Workers Compensation Board (now called the Workplace Safety and Insurance Board) had accepted 51 of 54 claims for industrial diseases arising from the Holmes Foundry, Holmes Insulation and Caposite plants.

Today, the CAW has over 300 additional files on workers who are suffering diseases, a good number of which are related to their exposures at work.

Workers are reporting the following illnesses: asbestosis, silicosis, mesothelioma, lung scarring and thickening; Cancers such as, lung, colon, bowel, bladder, brain, pancreas and others; Heart disease and respiratory problems including: asthma, emphysema and chronic obstructive lung disease.

Government records indicate that the union at Holmes Foundry (Holmes Insulation and Caposite were not unionised) was extremely active in fighting for health and safety in the workplace. They reveal that Bob Clarke, the Union Plant Chairperson, and Health and Safety representatives, were actively demanding government action to reduce these toxic exposures. Time and time again government documents reported union grievances and letters chronicling poor working conditions and violations of the province's health and safety laws.

If it were not for the fight of the union, the number of diseased workers could well be higher.

As early as 1952, Ministry of Health inspections conducted at Holmes Foundry raised concerns about "silica, noise and smoke". Government officials in fact issued 7 Recommendations to reduce toxic exposures. There is no evidence in the Ministry documents supporting compliance to these Recommendations.

Only in 1968 did government inspectors begin to sample for the actual measure of silica dust. At that time, the silica levels were found to be as high as ten times over the legal limit.

Silica was known to cause a fibrotic lung disease, called silicosis. Like asbestos, the International Agency for the Research on Cancer (IARC) identified silica as a definitive Group 1 "human carcinogen". In Ontario the potential health risks of silica were recognised as early as the 1920s when the government began to record silica levels of the hardrock miners.

By the 1960s, the Workers Compensation Board had already identified at least three Holmes workers and possibly as many as five with silica-related diseases, including silicosis.

During the next twenty years, government inspectors took a total of 131 air samples at the foundry for respirable silica on seven different occasions. Two-thirds of these samples were over the legal limit. The levels, on average, were found to be 3 times over the standard.

In 1974, for example, the Ministry performed a silica assessment. Results found over 50% of the samples were over the legal limit. The Ministry issued 31 Directions. Despite a scathing internal government memorandum regarding the poor safety attitude of Holmes management, the inspectors failed to enforce any of these Orders.

After 38 years of issuing Recommendations, Directions and Orders, the final Air Quality Assessment, taken a year before the plant was finally closed in 1988, showed 49 of 64 workers sampled (75%) exceeded the legal limit for silica exposure. The average sample was three times the legal limit!

The Ministry Inspectors issued 108 Directions/Orders to control silica exposure. However, in spite of the well-known consequences of silica, the government consistently tolerated illegal levels of silica, which were never properly controlled in spite of specific government regulations.

Excess silica exposure was not the only example of governmentally tolerated health risks.

The "Isocure Gassed Core Cold Box Process", first introduced in the early 1970's, created exposures to many hazardous chemicals such as Dimethylethylamine (DMEA), Trimethylamine (TEA), isocyanates (MDI and TDI), amine, phenol and formaldehyde. Some of these chemicals are known to cause respiratory problems or cancer.

The Ministry first investigated this process in 1973, in response to a union complaint of nausea, vomiting and sore throats from workers who worked on the cold box process. Orders were issued for local ventilation. They investigated union complaints in November of 1974 and found high levels of TEA in the cold box process. Orders were issued on local exhaust for the cold box operation. Again, an investigation in September of 1978 found high levels of TEA. More orders were issued for local exhaust.

There follows a pattern of investigations, measurements of high levels of various chemicals, orders issued and inaction by the company. On January 8, 1987 a government inspector wrote: "Local ventilation at several locations is considered inadequate due to low face velocity, incomplete enclosure, inappropriate design or location of hoods.""...many of the ventilation hoods are so placed that decomposition products produced during core making are drawn through the workers breathing zone before being exhausted."

The government records also document investigations of toxic chemicals including organic solvents, aromatic amines and isocyanates. Like silica, isocyanate is a designated substance in Ontario. It is well documented in the medical literature to cause severe respiratory sensitisation.

In June 1983, government inspectors issued an order to foundry management to undertake an assessment for possible isocyanate exposure. On November 2nd the inspectors re-issued the order, which the company had ignored. This order would be remanded and re-issued several times. In fact, Holmes Foundry was cited for deficiencies and non-compliance on this matter until the plant closed in 1988.

As early as 1955, government inspectors documented excessive noise levels:

"The shake-out area is extremely noisy. A few workers using cotton."

Long term exposure to excessive noise levels can lead to permanent, irreparable hearing loss. High noise levels have also been associated with heart, circulatory and digestive problems.

It would take, however, another 18 years before the government would once again address the adverse health effects of noise.

In a 1973 plant field report, prepared by a Ministry hygienist, the following was recorded:

"Even the background counts in the above mentioned areas exceeded the present TLV of 90 dBA for an eight hour exposure. In fact, there was not any place in the foundry where the noise level less than 85 dBA was encountered."

As in the case of the other Holmes facilities, high levels of toxic exposures were tolerated. Despite a recommendation from Ministry of Labour epidemiologist, Dr. Murray Finklestein, for a mortality study of Holmes Foundry workers to determine whether there was an increased risk of cancer, none was carried out. 2

Flagrant violations of government Directions/Orders, and even specific regulations, were ignored. At no point did these government documents reveal any willingness to aggressively enforce the law and prosecute in order to achieve compliance. Despite 401 Recommendations, Directions, and Orders issued, at no point in 38 years did government officials issue a "Stop Work Directive". Nor was the company ever charged with an offence, penalty or fine for violations of safety laws or failure to comply with Directions or Orders.

The Workers Safety and Insurance Board (WSIB) has recognised 51 of 54 compensation claims for occupational disease at Holmes. Many of these workers will have died as a result of these diseases. Even today workers are dying of diseases arising from their exposures at Holmes Foundry, Insulation and Caposite plants.

Bob Clarke, Union Chairperson and Health and Safety representative died last October from pancreatic cancer, which can be related to his workplace exposures.

In aggregate, the number of deaths resulting from toxic exposures at the Holmes site represents several times the number who died at the Westray mine disaster.

These deaths might have been prevented. Had the government and industry representatives acted on the information that they had, then almost all of these people would have been spared these diseases.

The Holmes experience raises serious questions about the historical role played by the government in its dealings with Ontario employers. It also reflects the current reality, whereby the Ontario government is tolerating exposures to toxic substances such as metal working fluids, diesel exhaust, electromagnetic fields and benzene at many times above their safe levels.

We know today, for example, that workers exposed to metal working fluids at levels 10-times below the current legal limit will still bear an excess cancer and respiratory disease risk.

The Holmes experience tells us a great deal about our past, as well as the present. It is also a warning about the consequences of negligence and indifference regarding toxic exposures in the workplace.


Ministry of Labour documents reveal that Holmes Foundry workers were exposed to a number of toxic substances as a result of various work processes. This review will address the role of the Ontario government agencies and the toxic exposure of workers as they relate to silica, the isocure gassed core cold box process, certain designated substance programs, solvents, industrial noise and other occupational hazards.

Powers of the Ministry

A review of the health and safety legislation that existed in Ontario during the 1950s, '60s, and '70s confirms that rules to protect workers from exposure to silica quartz existed. Also, provisions were in place, which gave inspectors strong and broad authority to issue directions (they called them Orders after 1980) to employers, including directives to stop work. Employers failing to comply with the provisions of the Act or regulations after 30 days of issuance of a "Direction" by an inspector were to be considered guilty of an offence and subject to fines and/or jail terms under the existing legislation. 3


Silica was known to cause a fibrotic lung disease, called silicosis. Like asbestos, the International Agency for the Research on Cancer (IARC) identified silica as a definitive Group 1 "human carcinogen". In Ontario the potential health risks of silica were recognised as early as the 1920s when the government began to record the silica levels of the hardrock miners.

Inhaling dust containing free crystalline silica will allow silica particles to deposit in the terminal air sacs of the lungs. Here the body tries to break down the silica particles to remove them from the lung, but due to their hardness, they are difficult to eliminate. During this process, some of the cells become damaged, releasing their contents, causing irritation of the surrounding lung tissue. This irritation causes the lungs to form round scars called nodules, a disease known as silicosis.

There are other complicating factors regarding silicosis. In addition to the direct effects on the lungs, the presence of scar tissue also affects the heart. The pressure of the tissue on the blood vessels of the lungs increases resistance to the flow of blood through these vessels. Therefore, the heart must work harder to circulate the blood. This extra strain on the heart increases the risk of heart failure. Many victims of silicosis will actually die due to heart attacks, rather than silicosis.

Ministry of Labour files contain 112 documents pertaining to respirable silica quartz. They document 108 Directions, Orders and Recommendations during the span of the 38 years between 1950 and 1988.

Of the 131 total air samples taken in the seven Air Quality Assessments conducted at Holmes Foundry for respirable silica quartz, 88 (67.2%) were found to be above the legal limit. Over the span of 38 years, levels recorded throughout the plant averaged 3 times beyond the legal limit. (TABLE #10). 4

The first recommendation regarding silica is dated September 19, 1952. A Ministry of Health hand written note, recommended "ratifying more frequent Air Quality testing," and mentioned cross fans at the "grinder-operator station" blowing sand (free silica quartz) throughout the building.

Three years later, on September 12, 1955, there was a plant field visit inspection by the Department of Health. The inspector noted:

"There was inadequate time to study and assess all hazards. Further changes are to be completed by mid-fall and then dust (respirable silica quartz) counts would be in order."

There is a lapse of ten years before the next Ministry Report concerning silica, and it would take an additional three years (1968) before the government would produce the first air quality assessment for "free silica quartz". On December 10, 1965, a visit was made to assess the ventilation. The inspector commented in his report about the abhorrent conditions in the plant:

"In the cleaning room for blocks, housekeeping is very poor. There are various piles of dry sand (silica) around that, in some instances, must be climbed over to get to work stations. The sand from the core shakeout is conveyed to the outdoors and dumped. This sand can then blow back into the building. The main sand conditioning area is not equipped with local or general exhaust. There were several sand conveyors dumping and spilling sand. The arrangement was such that, it was almost impossible to make a proper inspection. Housekeeping was not good and lighting was poor. Sand is piled up outside either deliberately or through spillage in such a way that it obstructs movement of workers and blows into the occupied areas."

The Inspector's report concludes with a list of 20 recommendations. Upon returning two years later on August 11, 1967, he determined that only 2 of his recommendations were "considered completed or adequate". However, the Ministry issued no Directions.

We have learned from Workplace Safety and Insurance Board documentation regarding Holmes Foundry that there were at least three workers and possibly as many as five identified with silica related diseases or silicosis by the 1960s.5 Other government agencies, such as the Ministries of Health and Labour, must have been aware of the occupational illnesses suffered by Holmes Foundry. Despite this, the Ministry of Labour issued no Directions or Orders related to investigations arising out of these illnesses.

A year later on October 31, 1968, 18 years after the government was aware of the excessive exposure to respirable silica quartz and 16 years after the first recommendation for air quality testing, an air quality assessment (AQA) analysis report showed workers exposed to an excess of 10 times higher than the legal limit for free silica (see TABLE #2, pg. 108 of Chronological Summary). The Inspector noted:

"Sixty-one % of the air samples taken were above the calculated threshold limit value (TLV) which is based on the free silica content of the dust. In particular the air sample taken in the tunnel (shakeout area) was ten times over the TLV. One man worked 4-5 hours in the tunnel and was equipped with a "Flex-a-Foam" dust mask (made by Flexo Products, Westlake, Ohio) which is not recommended for free silica exposure." 6

Five years later (1973), 23 years after the first reference to air quality issues regarding Silica, the Ministry made its first attempt to address engineering controls to lower the levels of free silica. On November 23, 1973, the following comments are detailed in the field visit report:

"Among those which could be checked, the local mechanical exhausts at the knockout operation were considered to be totally inadequate. According to the company, the sand Muller is provided with about 13,000-cfm local mechanical exhaust. However, no airflow was detected during the visit. None of the portable grinders are fitted or provided with local mechanical exhaust."

Later, on January 3, 1974, the Ministry performed another air quality assessment. Eight of the fifteen dust samples (53.3%) were above the legal limit.

In view of these findings the Ministry issued 31 Directions to the Company on February 6, 1974.

Eight months later, on October 31, 1974, the Ministry of Labour met with the company to review their poor safety performance. The Inspector's internal memorandum noted management's poor safety attitude:

"It soon became quite evident by the discussion between the three members of management present that they had not given much consideration to their accident prevention program. A list of safety rules proposed in April 1974 has not been circulated at the Supervisor's level, no indoctrination of new employees, no review of accidents or liaison with supervision.. This was a repeat performance of the first meeting with a lot of window dressing which does not bring required results."

Despite mounting evidence of management's failure to comply with government safety standards, the Ministry failed to force full compliance with the Directions issued in February. (Industrial Safety Act) 7

Almost three years later on November 29, 1976, in a letter addressed to the Director of the Occupational Health Branch, the Chief of the Industrial Chest Disease Services wrote:

"Holmes Foundry is under medical supervision by the Industrial Chest Disease Service. The company is subject to Regulations under the Silicosis Act, and all foundry personnel are required to have a health certificate. During our last clinic, approximately 145 employees were to be x-rayed. However, only 22 employees showed up for chest x-ray. Some of their employees have not been x-rayed since 1974. We have had very poor co-operation from the company for the past two years" (our emphasis)

On May 17, 1977, after 25 years of noting "totally inadequate" ventilation throughout the plant, the Ministry sent a Hygienist to assess engineering controls. After noting poor ventilation and evidence of high silica dust, he stated:

" . only 2 of the 4 types of respirators are approved for silica dust. All nuisance respirators should be replaced with approved respirators since they are completely ineffective for protecting a worker from industrial dust exposures normally encountered in a foundry."

These findings prompted the Ministry to produce another Air Quality Assessment on May 19, 1977. Of the 12 dust samples taken, all readings (100%) of free silica quartz were above the legal limit (see TABLE #3, pg. 109 of Chronological Summary). The Ministry Inspector divulged the following to the Chief of Occupational Health Engineering in a memo dated May 27, 1977:

"The sample taken at the Muller mezzanine floor is three times the standard. It is apparent that this dusty operation is not being controlled by exhaust provided." (our emphasis)

Despite identification of many cases of silicosis, government officials did not feel it was necessary for a government physician to visit the plant. A June 15, 1977, Ministry internal memorandum addressed to the Chief of Occupational Health Medical Services, stated the following regarding health concerns of Holmes Foundry workers:

"A combined visit to this foundry was requested in order to review the exposure of employees of the foundry to 'free' silica. All dust samples gave results above the accepted TLV for free silica. The company has a medical program already established. Under these circumstances, I feel that a visit by a physician to this plant is not indicated, as a visit by an engineer of our Branch has already been done."

Shortly after this, on June 21, 1977, the Union brought a grievance to the Ministry of Labour's attention:

Grievance #50-1977 - 100 MIXER AREA: "Union and undersigned grievor demand the 100 mixer building and area be cleaned up immediately. Most of the time you cannot see the man up there because of all the dust and dirt. It will have a very serious effect on a man's lungs working in it. This has been brought to the attention of the company several times with no results. This is a very serious health and safety problem and we demand immediate action on this matter."

In responding on August 23, 1977, to the Union's complaint, the attending Inspection Safety Officer wrote:

"It is apparent in our discussion, Mr. Clarke (Union Rep.) feels management have been passing the problem up year after year going back prior to American Motors taking over the operation, grievances go back in the 1960s. It was prevalent dust (that) was in the area..."

No re-directions issued at this time [our emphasis]. The employees in this area are provided with masks. A follow-up form letter was forwarded to Toronto office August 16, 1977 stating the firm's intention to complete silo and enclosed system commencing installation in Oct. 77. Mr. Clarke was in agreement of the action being taken, but was still very bitter in the length of time taken to correct the condition."

On December 11 & 12, 1979, the fifth Air Quality Assessment was administered. Seventeen of the Twenty-two air samples (77.3%), were above the TLV of 0.1 mg/m3, including the highest sample results to-date at one workstation, where levels were 10.3 times over the legal limit (see TABLE #4, pg. 110 of Chronological Summary).

Five months later on May 14, 1980, the Ministry issued Order #0063 in reference to these findings.

One year later, on December 17, 1980, an investigation was conducted to assess the following recurring Union concerns:

Union Complaint #1: Some dust was observed at the shakeout line, but mechanical exhausting is provided. An Occupational Branch visit will be instituted to evaluate dust exposure.

Union Complaint #2: Some dust and fume were observed at the Taccone line, but mechanical exhausting is provided. An Occupational Branch visit will be instituted to evaluate dust exposure."

These Union complaints compelled the Ministry to produce another Air Quality Assessment on January 8, 1981. Eleven of fifteen (73.3%) samples taken measured concentrations in excess of the TLV for respirable silica quartz (see TABLE #5, pg. 111 of Chronological Summary). Four months later on May 19, 1980, the Ministry issued Order #0055, which replaced Order #0063.

This Order (#0063) was remanded and re-issued a total of eight times over the period of the following three years, with no stipulation respecting time-compliance. On April 21, 1983, the Ministry of Labour issued Order #0222, which pertained to silica exposure and inadequate ventilation throughout the plant:

"ORDER #0222:
Above order re-issued to replace Order #0028 dated: 27/01/83 replacing
Order: #0080 dated: 22/06/82 replacing
Order #0012 dated: 22/04/82 replacing
Order #0194 dated: 17/12/81 replacing
Order #0044 dated: 28/09/81 replacing
Order #0055 dated: 19/05/81 replacing
Order #0063 dated: 14/05/80
Expected completion date of order 0022 is May 15, 1983."

In the footnote of his eighth issuance, the Inspector attached an expected date of completion. However, despite evidence of poor management co-operation in the past, the Ministry accepted an estimated completion date of May 15, 1983, which was conveyed in a letter from Holmes Foundry (March 3, 1983).

Furthermore, the Ministry of Labour throughout this 3-year period of non-compliance never issued an Order to cease operations pending compliance.

On the contrary, eventually, following a confusing series of circumstances and conditions, the Ministry dismissed the order #0222 and accepted partial compliance as sufficient.

Two years later, on October 3, 1985, the Ministry of Labour visited Holmes Foundry to investigate Union grievances initiated by Robert Clarke, Plant Chairperson, UAW Local 456. The Inspector's observations and opinions are as follows:

"As identified by grievances #84 and #85. potential exposure to silica dust and actions of supervision on or about September 19, 1985. Workers are potentially exposed to silica sand at the blow out area. The JHSC have reviewed the area and have made recommendations for improvements. In order for the health and safety program to be effective there needs to be a commitment and credibility established from senior management through to front line supervision. There is some doubt whether this commitment has made it as far as all of these supervisors."

In a Ministry of Labour letter dated November 27, 1985, the Director of the Industrial Health and Safety Branch responded to the Union concerns:

"Thank you for your letter of October 30, 1985 and your phone call of October 29, 1985 advising me of your concerns about worker health and safety at the Holmes Foundry. You listed a number of concerns, which include exposure to silica, threats to workers, Orders not issued by Industrial Health and Safety Branch inspectors and, a lack of assistance offered to the joint health and safety committee by the inspectors. I understand that on November 22, 1985, you met with Jim Gill of the UAW, the union health and safety representative and senior members of my staff to discuss the issues raised. I have sent your letters to the Director of Appeals, and notwithstanding your right to appeal, I have asked Mr. Hank Hendrickson, Area Administrator, to continue the Branch's efforts to resolve all matters raised in your letter. Thank you for bringing this matter to my attention."

Union complaints compelled the Ministry to produce yet another Air Quality Assessment on December 6, 1985. Six of six (100%) samples recorded concentrations in excess of the legal limit for respirable silica quartz (see TABLE #7, pg. 113 of Chronological Summary).

One year later, in an internal Ministry of Labour letter dated November 18, 1986, the Inspector made these remarks when requesting a "Plant Field Visit Inspection":

"The employer had the enclosed ventilation report done. It shows some areas of concern. The Union has a copy of the report and during the last code 10 inspection, raised some unresolved concerns that ventilation is not adequate based on the report. O.H.B. (Occupational Health Branch) assistance is requested to review and advise if further action is required by I.H.S.B. (Industrial Health Safety Branch)"

On January 8, 1987, yet another Air Quality Assessment showed 27 of 54 (50%) workers sampled exceeded the TLV of, 0.1 mg/m3 for respirable silica quartz (see TABLE #8, pgs. 114, 115 of Chronological Summary). The Hygienist noted the following analysis:

"A comprehensive hygiene air quality assessment was carried out in this grey iron foundry. Excessive exposures to silica are likely at several workstations. Local ventilation at several locations is considered inadequate due to low face velocity, incomplete enclosure, inappropriate design or location of hoods. Management and JHSC are advised that further modifications to the existing ventilation system are required to control worker exposure. The Industrial Health and Safety Branch is advised that there is contravention of Section 4 of the silica regulations. A comprehensive respiratory protection program, except the documentation of fit testing, is in place but is offered to the employees who may wish [our emphasis] to have it. There has been considerable concern from the union regarding the company's obligation to provide training for all employees who wear respirators and to provide this training during regular working hours. A letter from the Health and Safety Representative to the Industrial Health and Safety Branch on November 5, 1986 asked for the adjudication of this matter. It is the Occupational Health Branch's opinion that the company should provide this training to all respirator users both full as well as part time employees. Deficiencies in the ventilation system and excessive exposures to silica are documented. Extensive modifications, improvements and redesign of control measures would be required to lower silica exposures."

On January 22-30, 1987, an Air Quality Assessment showed 49 of 64 workers sampled (75.38%) exceeded the legal limit for respirable silica quartz. (see TABLE #9, pgs. 116, 117 of Chronological Summary)

On March 12, 1987, 37 years after the first government document relevant to Holmes Foundry, a Ministry of Labour Occupational Health Technician noted:

"Noticeably dusty conditions were observed."

Ministry documents covering 38 years clearly establish throughout that Holmes Foundry workers were exposed to an excess risk of disease from respirable silica quartz. The government, fully aware that workers' were at increased risk of occupational disease, permitted Holmes Foundry to maintain production without interruption and failed to force compliance to their Recommendations, Directions, or Orders.

These findings mirror those of the asbestos exposures chronicled at Caposite and Holmes Insulation Plants. There too, the Ontario government had issued Directions/Orders and recommendations, yet continually failed to enforce accountability.

While the company demonstrated disregard for workers' safety, the government failed to enact statutory authority to protect the health and safety of the Holmes Foundry workers.

Chemical Exposure
Industrial chemicals can cause a variety of bodily reactions depending on the type, amount and route of exposure. Some chemicals will have an acute effect on the body. This means that within minutes or hours of exposure you will have signs of poisoning. Other chemicals can have a chronic effect, which means that in the long term, perhaps even as long as 20 or 30 years after exposure, you can have an incurable disease of the vital organs. Cancer, for example, can take anywhere from 10 to 30 years to develop after the initial exposure.
Isocure Gassed Core Cold Box Process:

The isocure gassed core cold box was a new process introduced into the plant in early 1970s. Sand mixed with Isocyanates (MDI, TDI) and resins is added automatically to the metal moulds, and an air mixture containing an amine as a catalyst then converts the isocyanate/resin to a polyurethane, binding the sand to make moulds and cores. The resins and isocyanates will decompose and produce various gases and fumes when the sand reacts to a catalyst [triethylamine (TEA) or dimethylethylamine (DMEA)] during the no-bake process. Some of the most common gases produced are carbon monoxide, hydrogen cyanide, methane, ammonia, phenols, amines, and aldehydes.

On November 30, 1973, the Union Plant Chairperson complained of adverse health effects in a letter sent to the Director of Industrial Safety Branch. The letter requested an inspection by Environmental Health with reference to fumes from the Isocure Cold Box Core making machines:

"On behalf of the employees of Holmes Foundry Ltd., I am requesting an investigation of some complaints concerning the Ashland Process of new Cold Box Binders System for making cores and moulds."

The Ministry investigated the complaints on December 14, 1973, and observed these findings:

"The burns and rashes did not stem from the Cold Box core machines but other processes, burns from handling of cores from the oven, rashes from KEROSENE. The nausea, vomiting, sore throats did not prevail at the time of my call. This believed was attributed to on the occasion of the complaint by part of the roof being removed to lower new equipment into the plant. With the roof removed this caused cold drafts, and a turbulence of air defeating the exhaust system at that time, allowing over-spray to float to other personnel in the near vicinity, causing irritant to the eyes and skin, coughing and nausea to two."

Still, no testing was conducted for exposure levels. Although the Ministry issued Orders to improve ventilation, no significant improvements were documented. In the span of the 38 years the government had issued more than 100 Orders/Directions or Recommendations to improve ventilation. However, according to Ministry accounts they were largely ignored.

Shortly thereafter, on January 2, 1974, a laboratory analysis report revealed levels of "triethylamine" exceeded 18 times today's legal limit at one workstation.

Again, later that year, on October 17, 1974, the Plant Chairperson and Bargaining Committee sent another letter to the Director of the Ministry of Health:

"We have had a number of complaints about burns, rashes, nausea, vomiting, sore throats, burning eyes. Also the metal cleaner that is used to clean the core boxes is used very carelessly. The barrels are very hazardous strewn all over the place, and I understand they are suppose to be kept in a red lined area. It might be a coincidence but we have had a number of pneumonia cases last year.

I would appreciate an investigation as soon as possible because we feel the health and safety of the employees are being jeopardised by the company. We are also getting additional fumes and smoke on moulding floor, due to the new type of cores, also environment checks on isocure afterburners"

This letter prompted the Ministry to return November 19, 1974, and investigate the Union's concerns for worker exposure to smoke and fumes produced by the Isocure Cold Box core process:

"This visit was made following a union complaint of smoke and fumes in several areas of this plant, which manufacture automotive castings. There did appear to be intermittent exposures to smoke and triethylamine. There were several areas of complaint in the letter from the union. In the Isocure process, cores and moulds are made in the cold Box Binders. Sand mixed with Isocyanate/resin is added automatically to the metal moulds, and an air mixture containing trimethylamine (TEA) as a catalyst is injected for a few seconds. This converts the isocyanate/resin to a polyurethane, binding the sand. The cores and moulds are then removed, and the process is repeated. The metal moulds are sprayed at intervals with a release agent. In one machine (the south machine - 258) the moulds are sprayed about every two hours with kerosene, while the other machines are only sprayed at the end of shift. The complaint was that triethylamine gas and kerosene spray from Isocure machine 258 were drifting across to the core filing and inspection area at the east end of the flywheel Isocure machine (north machine).

The use of kerosene spray was demonstrated, and as with the TEA, there was some drifting of fumes towards the other machines. The drift was confirmed by the use of smoke tubes. While in the area it was pointed out that smoke was being evolved from the afterburners. These units are basically furnaces, which incinerate the chemicals in the airflow from the local exhausts on the isocure machines. At times the afterburners may become overloaded with the chemicals, such as the mould release spray, and at these times smoke is evolved and spreads through the room below the roof.

Measurements showed . 30 ppm TEA at a position between the centre and the west machines. The general level of carbon monoxide was 10 ppm. At the twin machine in the south core room, the escape appeared to be more general, with quite a high level (above the threshold value limit of 25 ppm) being detected."

Acting on the report's findings, the Ministry issued Directions to install adequate local mechanical exhaust on the Isocure machine, afterburners, and mould cooling room to prevent the emission of smoke and fumes into the plant area. However, this Direction would be remanded and re-issued several times without ever achieving full compliance.

In a letter sent three years later (June 13, 1977) to the Ministry of Health, the Director and Medical Officer of Health noted:

"I have had a complaint about high smoke levels inside the plant. I would be grateful if you could arrange for an inspection."

There is no record of a Ministry follow-up to the complaint in the government documents. In fact, the Ministry did not attempt to address the concern for smoke or fumes until more than a year later.

In a letter to the Ministry dated August 29, 1978, Union Chairperson Robert Clarke, complained of workers' health concerns:

"I would appreciate it very much if an Industrial Hygienist could be sent to our plant to take air tests in the North and South Core Rooms. I have had several complaints of the fumes and vapours in above said departments. The cores are made on core box core moulding machines and "Zip Slip" is sprayed on core boxes as a release agent. When core boxes are sprayed there is nowhere for spray to go but into the atmosphere where employees must work.

Metal Cleaner is also sprayed on core boxes to clean them also. I have also had complaints on the extreme heat, and fumes that come from the ovens in both core rooms. We have also observed that barrels have been put in Departments without labels including any information regarding remedies and antidotes for such chemicals. In The Core machines in the North Core Room they had local exhaust ventilation but it was removed for some unknown reason. In the core rooms they are using cooling fans that just blow fumes throughout atmosphere.

In 1976, we mentioned the problems to management that exist in the Core Rooms and the commitment was made to install odour removal systems on all cold box core machines, but not fulfilled due to companies budget.

We realise that it cost money to correct such conditions, but also feel it is a responsibility of the employer to provide a safe and healthy atmosphere.

We have co-operated with company on such problems, but feel necessary action must be taken, as company has had ample time to correct such conditions. Also, with the cold weather just around the corner problems will be worse. Hopefully, someone from your department can come and investigate the above. I have also submitted copies of the letter to several company officials."

On September 8, 1978, the Ministry discussed an increased number of complaints from the Union in an internal letter of memorandum:

"This is a cold box core mould isocure process. Previously, 12" flexible hoses were located at point of the moulds and spraying operations. This has been removed. The reason the medical box is checked as the employees are complaining of headaches - can't eat. They want to know what damage the chemicals have on their systems."

Ten days later in an Air Quality Assessment Report, the Ministry technician noted very high levels (45 times more than today's legal limit) of Triethylamine in the cold box process:

"At one time. the reading taken for TEA in the area using the Draeger was 46 ppm."

The Union complaints (#78/72) were substantiated in a report dated September 28, 1978, by Dr. Budlovsky from the Ministry of Labour:

"This visit was made to review the occupational exposure to methyldiphenyl isocyanates (MDI) and to dimethylethylamine (DMEA), and to assess the occupational hazard of this exposure. A possible occupational hazard of exposure to DMEA does exist. DMEA is a. strong irritant of skin and mucous membranes and may cause on contact with the skin, local chemical burns or dermatitis. Its vapours can irritate eyes and when inhaled in sufficient concentration, they may cause inflammation of the upper airways with cough and in high concentrations the vapours may even cause chemical inflammation of the lungs and/or pulmonary adema.

There is no established TWA for DMEA nor are there any indicator tubes for DMEA available. However, DMEA has a chemical structure similar to TMA and its action upon health for all practical purposes identical with TMA. This is why indicator tubes for TMA and the TWA of Tma were used to assess the possible hazard."

The aforementioned findings generated issuance of Directions from the Ministry of Labour on November 3, 1978:

Direction #0262: Maintenance of the system conveying the resin mixture and DMEA shall be regularly carried out and shall be on a high level in order to prevent leakages.

Direction #0263: The station where DMEA and resin are drawn from drums shall be locally exhausted."

Health effects attributed to Dimethylethylamine (DMEA) include; eye, nose, throat, lung and skin irritant. It can produce allergic-type reactions resulting in dermatitis or asthma-like responses. DMEA is known to form nitrosamines. Nitrosamines can cause cancer.

Other chemical by-products (Formaldehyde, Amine, Phenol) produced by the Isocure Cold Box moulding process were discussed the following year on September 27, 1979:

"Only one core machine was operating. Very high figures from the core box. The CN valve is generally less than 1. Formaldehyde a bit high also. Freshly extracted cores - 8 ppm. In south core room - 37 ppm."

A few months later on December 5, 1979, the Ministry Hygienist visited Holmes Foundry to assess the excessive occupational exposure to Dimethylethylamine (DMEA) and recommended:

"The company should maintain the TEA testing program, in the interim period prior to the installation of the exhaust hood, to ensure a safe work environment at the defining worksite."

Four years later on August 24, 1983, the Union sent another letter to the Ministry regarding their concerns:

"With reference to our previous conversation, I expressed my concern over chemicals used in the isocure (gassed core cold box) process of making cores.

I have made you a copy of correspondence I received relating to the hazards in this operation. "Heading on Documentation Reads" - Bakes - Common Chemical Binders and their Hazards.

In reading the document it causes great concern of the effects which is related to such operation, and for years the union grieved the unsuitable conditions, and also submitted a petition to (the) Company, including complaints to the Ministry of Labour.

We received such complaints as burns, rashes, nausea, vomiting, sore throats, burning of the eyes, and chest pains from workers.

In 1976 Management made a commitment to put in an odour removal system and it was to be completed in the summer of 1977, but was not complied with and was just finally completed in the last year or so, after another commitment was made in 1978 to have the total system completed by December 31, 1981. I have also attached correspondence from the Ministry regarding the Cold Box operation, and am requesting the Ministry review all chemicals relating to the operation, to assure that regulations are correct, and T.L.V. submitted are accurate and up-to-date.

I have attached letters from M.O.L. and information given to the Company, but not to the Union, over the Cold Box procedure until I receive such from our U.A.W. Office.

I would appreciate it very much if you could relate my concern to the responsible parties in the Ministry, and send me a reply, as to any changes in the T.L.V. or regulations."

I would appreciate any pertinent information regarding my concerns, and feel the Ministry should have a list of all chemicals at Holmes Foundry, if they do not have such, so direction can be made."

Five months later on January 16, 1984, the Ministry of Labour followed up with a visit by their Hygienist:

"Due to the type of operations at the core boxes, fugitive emissions and leaks into the workplace are possible from time to time which may cause symptoms described by some workers. Further sampling will be done for dimethylethylamine in the near future.

It must be remembered that the cold box gassing core main process utilises gassing purging cycles with the box exhaust directed to an air sampling device prior discharges to the outside environment. Such operations sometimes give rises to leakage and out of pattern venting, which may enter the workplace (and) possibly cause the symptoms described as burns, rashes, nausea, vomiting, sore throats, etc.

Escape of chemicals from the core boxes to the workplace should be minimised and the practice of spot sampling for DMEA should continue. Whenever leaks occur they should be remedied expeditiously. Also the boxes and auxiliary equipment, e.g. seals, ducts, etc. should be properly maintained."

Later that year on October 10, 1984, the Ministry visited the foundry to obtain information regarding an incident where a worker developed health symptoms from the Isocure Cold Box core process. The inspector noted:

"Apparently there was a small pin hole leak in a recently changed pipe in the isocure transport pipeline system. This was immediately corrected."

One year later on October 3, 1985, the Ministry investigated grievance complaints identified by Robert Clarke (Union Chairperson):

"ISSUE #3: As identified by grievance #88 and addressing actions taken by persons involved in the cleaning of DMEA spill in the South Core Room on or about September 21, 1985. While attempting to clean a tank containing DMEA, a spill occurred and individuals in the area responded by attempting to contain and neutralise the spill. No personal protective equipment was utilised and persons suffered exposure symptoms. Upon review of worker representative of the issue, a number of concerns were noted, (including note of similar instance May 24, 1983). Based upon the statement provided, a number of Orders are issued to the parties involved.

ISSUE #5: That workers are being exposed to unknown vapours from curing oven. A request to the OHB will be submitted, to review the area of concern for possible hazards or exposure. Until this review has been conducted the earlier report will be considered valid and at this time no further action will be directed.

REVIEW: In order for the health and safety program to be effective there needs to be a commitment and credibility established from senior management through to front line supervision. There is some doubt whether this commitment has made it as far as all of these supervisors."

On this occasion the Inspector issued 34 Orders to the company. Two weeks later, while addressing another unresolved concern he noted additional health concerns from vapours produced by the Isocure Cold Box process:

"No samples were taken and employees complain of eye irritation and throat discomfort."

Four months later on February 11, 1986, the plant was visited in response to the Union's concerns for discharged contaminants from the North Core oven, and at the Blow-Out workstation. The Inspector wrote:

"While in the plant the Shake-Out and the isopropyl alcohol spraying work stations were assessed at the request of the work representative on the JHSC. The Dimethylethyl amine storage was assessed also. It was found that steps should be taken to prevent contaminated air from the Core oven being discharged into the work environment.

Engineering control of the Isopropyl Alcohol spraying station appeared inadequate and the personal protective device worn by the operator was inappropriate.

The DMEA storage area should be enclosed and the enclosure adequately exhausted.

Isopropyl Alcohol is sprayed over the surfaces of the cores in one operation of the manufacturing processes. This alcohol spraying workstation is a 55" x 48" and 24" deep spray booth. The operator uses an air pressure powered gun to dispense the alcohol onto the parts, which are placed on the bottom of the booth. As he dispenses the liquid over the irregular surfaces of the core a noticeable build-up of the atomised material appears in his breathing zone."

Two months later on April 24, 1986, the Ministry Inspector investigated a worker's claim of exposure to dimethylethylamine (DMEA). A spill occurred during a filter change on September 21, 1985, and workers were exposed. Following his investigation, (which took place seven months after the exposure), the Inspector noted the following without issuing any Orders:

"Three workers were sent to the hospital for treatment. Normally 15 employees work in the core room per shift. In high concentrations it (Dimethylethylamine) is an irritant to the mucous membranes and the respiratory tract. Some amines in low concentration can act as a respiratory sensitising agent. At this point in time, there is no sufficient information on the potential long-term health effect of DMEA.

The company is in the process of phasing out the use of DMEA. A new compound commonly known as "T GAS" will be used instead. "T GAS" is reported to be Trimethylamine."

The final document pertaining to the Isocure Cold Box core process is dated January 8, 1987. After documenting decades of the Union complaining of adverse health effects, the government wrote the following in their report:

"A comprehensive hygiene air quality assessment was carried out in this grey iron foundry. Local ventilation at several locations is considered inadequate due to low face velocity, incomplete enclosure, inappropriate design or location of hoods. Management and JHSC are advised that further modifications to the existing ventilation system are required to control worker exposure. Additional Orders are advised to ensure use of air supplied respirators during cupola teardown and relining.

In this foundry, one of the binder resins contains a mixture of MDI and TDI. Although worker exposure to TDI and MDI were found to be below the limits of detection, many of the ventilation hoods are so placed that decomposition products produced during core making are drawn through the workers breathing zone before being exhausted. Careful consideration is therefore warranted in this regard.

Presence of detectable amounts of DMEA should be considered an alert indicating a leak in the system e.g. measurement of 8.6 ppm in the "DMEA Shack". Although there is no assigned exposure standard established for DMEA, based on its chemical similarity with other tertiary amines, a working guideline of 10 ppm should be used."

Note: today's legal standard for DMEA is 5 ppm and TEA is 1 ppm - suggesting that the today's standard for DMEA is too high.

The Ministry chronicles expose the government's failure to protect workers from excessive exposure to the hazardous chemicals used in the Isocure Cold Box core process.

Designated Substances and Control Programs:

The Ontario Ministry of Labour has established specific regulations for certain designated substances in the early 1980's. These regulations include the requirement for an emergency program or a control program, which may include an assessment to be made, in writing, of the exposure or likelihood of exposure in a workplace to the substance. Written assessments were required from Holmes Foundry for Regulations respecting Silica and Isocyanates.

Each designated substance regulation includes requirements for the employer to take all necessary measures and procedures by means of engineering controls, work practices and hygiene practices to ensure that the time-weighted average exposure of a worker to the designated substance shall not exceed the designated levels. Such compliance "shall" be achieved without requiring a worker to wear and use respiratory equipment.

At Holmes Foundry the Ministry relied upon the "firm's intention" (August 23, 1977, on page 38 of Chronological Summary) to install engineering controls to limit workers' exposure to free silica. The Inspector also relied solely on wearing Personal Protective Equipment, which had been cited as inadequate on two previous occasions. No "time-compliance" Order was issued to facilitate workers' safety.

On June 9, 1983, the Ministry issued Order #0137 for an assessment to be made in writing to comply with the existing Regulation respecting Isocyanates. Again, on November 2, 1983, the Order was re-issued with an estimated completion date of December 2, 1983. This Order was remanded and re-issued several times. In fact, Holmes Foundry will invariably be cited for deficiencies and non-compliance on this matter for the remaining 5 years of the government documents.

A recurrent pattern also transpired in the Ministry's failed attempt to enforce Holmes Foundry's compliance with the Regulations respecting Silica. On January 11, 1984, the Ministry issued the following Order:

#0228: 1) Every employer to whom this Regulation applies shall cause an Assessment to be made in writing of the exposure or likelihood of exposure in a workplace of a worker to the inhalation of Silica, etc. (2), (3), & (4). NOTE: Silica is present in this workplace an assessment shall be completed. Estimated completion date of the above order is June 25th, 1984.

Although the company eventually submitted an assessment on September 21, 1984, it had many deficiencies and remained a contentious issue until the plant closed in September of 1988.

After reviewing the company "Assessment" for the legislated Regulations respecting Silica, the Ministry Industrial Hygienist wrote:

"The Assessment made under the Regulation respecting Silica prepared by the company was reviewed and found to be deficient as no conclusion as to the likelihood of silica exposure was made. The deficiencies were pointed out and advice given on the preparation of the Control Program."

One year later on September 30, 1985, following another consultation field visit the Ministry Hygienist commented:

"This visit was made to audit the Medical Surveillance Programs for workers exposed to silica and isocyanates. Both programs are in need of further development."

Two years later, on March 13, 1987, the inspecting Officer reviewed the medical surveillance programs respecting the Regulations for "designated substances" at Holmes Foundry, and found them both to be deficient:

"This visit was made to audit the medical surveillance programs which are in place for the workers exposed to silica and isocyanate (MDI). Deficiencies in both medical surveillance programs need to be upgraded to meet the provisions of the Code for Medical Surveillance of the respective designated substance regulation."

Later that year, on October 7, 1987, Steve Nield, the Union Health and Safety Representative for Holmes Foundry sent a letter of complaint to the Industrial Safety Health Branch inspection officer:

"I am hereby requesting your involvement to address the following unresolved concerns: Housekeeping is not being kept up on a regular basis. There are areas where accumulation could cause a tripping or slipping hazard. There are also areas, namely the Millroom that falls under the Silica Control Program that is not being kept up with. Although these areas are being addressed to the company there is too much delay and no consistency in keeping up with these areas. Please contact me at your earliest convenience, set up a meeting to address these unresolved issues."

The last correspondence in the Ministry documents was dated July 29, 1988, which was only 48 days prior to the announced closure of Holmes Foundry (September 16, 1988). In a letter to the Ministry of Labour, the Joint Health and Safety Committee wrote:

"Please be advised that since the most recent correspondence concerning the status of the above-referenced (Silica Control Program), copies of which I have attached, several silica control initiatives have been started at the plant in the past few months that formerly were not in place."

These findings reiterate the Holmes workers' excessive exposure to respirable silica. The government failed to enforce the Regulations respecting Silica and Isocyanates. It also further illustrates the company's pattern of lawlessness.


Holmes Foundry workers often complained of various acute effects from chemicals in the workplace, which prompted action from the government to investigate. Such was the case in 1968. A visit was made to the foundry to investigate the use of materials for checking cracks in the engine block castings. Three different substances were applied to the block castings and then air-dried. A worker near the blowing operation had complained about experiencing various acute effects resulting from his exposures.

A dye (SpotCheck Penetraul), which contained trimethylbenzenes, was brushed on the engine casting blocks. The Penetraul was then washed from the casting surface by spraying Toluol (toluene), then air-dried. Following this operation Spotcheck Developer Type SKD-NF was then dabbed on at specific spots of the engine blocks surface and then it was air sprayed to dry. The solvent for the developer was Trichloroethylene. The Hygienist assigned to the investigation noted:

"High exposure could cause headache, nausea, and dizziness. Good ventilation should be provided in the work area. An operator near the blowing has complained. In general, while a health hazard is not determined, it is the writer's opinion the complaint is justified. The operation is done on 3 shifts, with about 1 gallon/day of Penetraul, 2 gallons/day of developer and perhaps about 1 gallon/day of toluol used. There is no local exhaust at the brushing and blowing operation. About 8 ft. from the operation is located a water test rig for blocks. The operator has complained about solvent fumes making him sick."

Although the Hygienist had determined the worker's complaint was justified, there was no testing conducted to ascertain levels of exposure, and consequently, the unsafe inspection procedure was continued.

Thirteen years later, a new product was applied on warm castings to aid in the detection of fractures and cracks. The material's trade name was SKL-HF- Magnaflux Corp. (Methyl Chloroform). Again, workers complained of adverse health effects (sore throats and eye irritation) from fumes generated from this same inspection procedure. The initial Ministry investigation on October 21, 1981, noted:

"I requested to talk to Mr. Ray Adams, a union Safety Committee member. Mr. Adams stated fumes from SKL-HF were causing himself and inspectors to have sore throats, eye irritation. Mr. Adams feels more ventilation is required. Advised. I would request a visit by the occupational health branch to take samples and would send the sample to the lab for analysis. Material label shows methyl chloroform as an ingredient. Ventilation is general only (i.e. no local exhaust). UNION CONCERN"

Following a visit three months later on January 5, 1982, the Industrial Hygienist's report stated:

"A hygienist visit was made to this foundry to assess occupational exposure at one workstation to a penetrant used as an aid in detection of fractures and cracks on finished castings. This penetrant was found to have petroleum naphtha as the main solvent ingredient. The company had already changed work procedures to reduce penetrant exposure by brushing on, not spraying, the material and ensuring the castings are cool, not warm (for minimisation of volitization of the solvents)."

Later, on March 22, 1982 the Ministry of Labour ruled on their findings regarding the naphtha solvents used during the inspection process:

"Analysis of area and personal samples taken on February 15 and 16, 1982 at a penetrant application workstation and at the pallet loading area at this foundry showed that there is no likelihood of a serious occupational exposure from solvents. It was ascertained that 1,1,1,-trichloroethanane is used as a dilutent in the penetrant."

Naphtha is a complex mixture in the chemical family of mixed hydrocarbons or petroleum hydrocarbon distillate. This chemical may cause headache, nausea, dizziness, drowsiness, unconsciousness and death. It causes skin, eye, and respiratory irritation. The liver, kidney and blood system may be affected. The other chemical used as a dilutent in the penetrant, 1,1,1-Trichloroethane is a volatile liquid that decomposes at high temperatures forming toxic gases, such as hydrogen chloride, chlorene and phosgene. It can cause lung injury, central nervous system depress, skin and eye irritation, cardiac sensitisation, liver and neurological changes. Their mixture will not reduce their potential hazard.

Industrial Noise and Hearing Loss:

Occupationally induced hearing loss continues to be one of the leading occupational illnesses in Ontario. Long-term exposures of excessive noise leads to permanent, irreparable hearing loss. The effects of loud industrial noise on workers are numerous. The stress produced by excessive noise can contribute to heart, circulatory and digestive problems. In addition, equilibrium, metabolic and nervous system disturbances can result.

Several recent studies have documented an association between worker exposures to solvents and occupationally related hearing loss.

The best way to control noise and vibration (a common cause of noise) is at the source. Re-design of equipment for noise control often does not require a great deal of inventiveness. However, there is no evidence of the government enforcing engineering controls to reduce risk of excessive noise in the Holmes Foundry government documents.

In the earliest document regarding noise, the government inspector from the Department of Health made these observations on September 12, 1955:

"Shake-out area is extremely noisy. A few workers using cotton."

In reality, hearing protection used at the time would not prevent injury against such high noise levels.

Noise would not be given any further consideration until 18 years later. Following a conversation with Dr. Sinclair, and deeming it a "Priority" issue, the inspecting officer requested the first Holmes Foundry "noise survey" on September 26, 1973:

"A measurement of the sound level in the Mill room, swing grinder area, knock-out area and shot-blast area."

In a Plant field visit report prepared by the Ministry of Health dated November 23, 1973, the Hygienist details the following comments:

"The results of the noise survey done during the visit indicate an exposure to noise in excess of the present accepted criteria for hearing conservation in (a) the mill room, (b) the knock-out room, and (c) shot blast area. Even the background counts in the above mentioned areas exceeded the present TLV of 90 dBA for an eight hour exposure. In fact, there was not any place in the foundry where the noise level less than 85 dBA was encountered. For example, in the south core room the background level of 100 dBA was measured. It is recommended that the company consider the adoption of an audiometric programme."

In his January 9, 1978, quarterly report, the inspector made the following comments:

"Millroom are especially (noisy) - due to continuous grinding and chipping activities. Ear protection provided, signs posted (in) designated areas."

In the inspector's assessment of the company on June 25, 1979, he noted:

"There appears to be a better attitude toward safety with all employees wearing protective clothing at their respective jobs, at no time did an infraction appear of failing to wear glasses, hearing protection, masks or foot protection."

In an internal Ministry of Labour memo dated April 20, 1983, regarding WCB claims, the following information is provided:

"In February 1983 there was one claim for industrial disease. In 1982 there were four disease claims, none of which occurred in the last six months. The source of these claims is noise, and all are for hearing loss or impairment."

As late as January 11, 1984, the inspecting officer investigated a Union complaint of excessive noise in the Millroom. Once the equipment repair was initiated, he dismissed the concern with the following remark:

"Workers wearing hearing protection in this area. Concern resolved."

On November 13, 1986, the Ministry inspector issued Order #0091:

"During the maintenance of #110 core machine, supervisors and workers observed without hearing protection."

Holmes Foundry's history of high noise level readings throughout the plant should have prompted the government to enforce regular sound surveys, while ensuring the company implemented a hearing conservation program. Nevertheless, there are no records (obtained by the CAW) indicating such an initiative took place at Holmes Foundry.

Other Occupational Health Hazards:

On March 6, 1978, the government Inspector made a special visit to assess concerns for "Radiant Heat" near the cupolas. However, there are no further accounts or follow-up regarding this concern in the Ministry documents:

"This visit was made to assess the possible occupational origin of an eye condition of an employee working in the melting department. Radiant heat emitted from white to red-hot surfaces can induce formation of opacities (cataracta) in the lens of the eyes after prolonged exposure. These conditions usually start at the posterior wall of the lens in the area where the pupil would be projected. Later they may grow and involve the entire lens. This condition has been recognised as an occupational origin in glass blowers and furnace workers whose eyes are exposed to radiant heat. The time of exposure necessary for the development of these opacities is on the average 10 to 20 years depending on the intensity of the exposure. Employees working on the feeding platform of furnaces and at the pouring stations should have eye examinations - pre-employment and at two-year intervals."

During a regularly scheduled Inspection on June 16, 1981, workers in the Cupola and Metal Holding Furnace areas complained of sulphur fumes and throat irritations. The inspecting Officer noted:

"Smoke is visible with sulphur like fume noted. General exhausting is 30' away (ceiling fan). Workers in the area are complaining of a raspy cough."

The Ministry Hygienist investigated and made the following recommendations in his report dated August 13, 1981:

"During the Cyclic Air quality Assessment on the Plant, air samples for Iron Oxide should be taken in the Holding Furnace - Cupola work area."

Part of the foundry process involved cupola repair on a daily basis. The cupola repairmen tear down the inside coating of the copula and reline it. The removing of the cupola lining involves hammering, chiselling, and chipping of the slag. The waste material falls through the opening in the bottom of the cupola and generates significant amounts of dust. The Ministry of Labour communicated the following in a report dated January 8, 1987:

"Dust created during tear down operations will contain a variety of products including aluminum, chromium, iron, lead and silica. The metals and their oxides are due to the scrap charge in the cupola. Air samples of these contaminants revealed small quantities of these materials in addition to a large quantity of dust that may be classified as nuisance dust. Experience in other foundry involved in similar operation indicate that extremely high and variable exposures to be anticipated during tear down and the only acceptable protection is the supplied air respirator.

The cupola is relined with "DixiPatch" - a clay, containing trace amounts of aluminum and iron oxides. DixiPatch is received in paper bags and excessive amounts of dust are produced when bags are broken and dumped into the mechanical sprayer. Excessive dust generation may be prevented by adopting proper work practices of bag opening and slow dumping.

A comprehensive respiratory protection program, except the documentation of fit testing, is in place but is offered to the employees who may wish [our emphasis] to have it.

There has been considerable concern from the union regarding the company's obligation to provide training for all employees who wear respirators and to provide this training during regular working hours. A letter from the Health and Safety Representative to the Industrial Health and Safety Branch on November 5, 1986 asked for the adjudication of this matter. It is the Occupational Health Branch's opinion that the company should provide this training to all respirator users both full as well as part time employees.

Deficiencies in the ventilation system and excessive exposures to silica are documented. Extensive modifications, improvements and redesign of control measures would be required to lower silica exposures."


Documents obtained under the Freedom of Information Act reveal a pattern of neglect and failure to act to protect workers. Workers have died prematurely as a result of workplace exposures. Surely the role of government is to enforce the law and protect the health and safety of workers in this province.

Events as documented at Holmes Foundry, demonstrate a failure of government to live up to that responsibility and leaves in question government's ongoing role with regard to enforcement.

Workers, suffering diseases as a result of their exposures at Holmes Foundry, Caposite and Holmes Insulation Plants must be fully compensated. Their story must be told in order to protect workers today, and in the future.

It is incumbent on the Government of Ontario; to take whatever action is necessary to ensure that workers in Ontario are adequately protected against work related disease.


1 "The Holmes Foundry Strike of March 1937: "We'll give their jobs to white men!," written by Duart Snow, Carleton University, from Ontario History 1977.

2 In 1987, Dr. Murray Finklestein, PhD, working for the Ministry of Labour, released a mortality health study regarding the Caposite and Holmes Insulation Plants. An appendix was included, which discussed several studies of iron and steel foundry workers, which consistently showed an excess risk for lung cancer. He cites the findings of eight studies as reference to substantiate his recommendation for a mortality study of Holmes Foundry workers, to determine whether the increased risk observed elsewhere has also occurred in the Holmes environment. A recent interview with Dr. Finklestein, established that his recommendation was never acted upon.

3 [1971, c. 43, s. 10 Subsections (1), (3)(a)(i)(ii)(iii), (b)].

Industrial Safety Act, 1971, CHAPTER 43:

10. -(3) where an inspector finds any place, matter or thing, or any parts or parts thereof, or a method or manner of work in an industrial establishment does not comply with the requirements of this Act or the regulations and is a source of danger or a hazard to a person employed therein or having access thereto he,

  1. may direct in writing that any place, matter or thing shall not be used until his direction or directions are complied with.

4Table #10



(Free Silica Quartz)






Oct. 31, 1968




3.17 TIMES


May 19, 1977




2.66 TIMES


Dec. 11, 12, 1979






Jan. 8 & 9, 1981






Dec. 6, 1985






Jan. 8, 1987




2.09 TIMES


Jan. 22-30, 1987








NOVEMBER 27, 1964 Dept. of Health memo re visit to HF- discussion of monitoring for silicosis, and particular worker H. Nibleek
MARCH 4, 1965 Dept. of Health memo re particular worker J. Ancevicius suffering from silicosis whose certification to continue in Foundry revoked.
MAY 7, 1965 Dept. of Health letter to HF re same worker. Discussion of jobs in plant that did not involve silica exposure.
MARCH 21, 1966 Dept. of Health memo stating only have record of two workers with silicosis at HF and both have WCB claims.
NOVEMBER 29, 1968 Dept. of Health letter to HF re need to remove worker Fred Gramlich from exposure to silica. Any job in small castings dept. deemed suitable.
MAY 8, 1969 Dept. of Health, Occupational Health Laboratories analysis of sands from HF.

6Table #2 - Air Sampling Results (October 31, 1968)

Shaded Areas Denote Exposures Above TLV

For a continuous eight hour per shift day exposure to dusts containing free silica the threshold limit value (T.L.V.) is calculated from the following formula:

T.L.V. = ____250______

% free S102 + 5
































































































7Industrial Safety Act, 1971, CHAPTER 43:

10. -(3) where an inspector finds any place, matter or thing, or any parts or parts thereof, or a method or manner of work in an industrial establishment does not comply with the requirements of this Act or the regulations and is a source of danger or a hazard to a person employed therein or having access thereto he,

(b) may direct in writing that any place, matter or thing shall not be used until his direction or directions are complied with.

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