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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4009
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-30618385
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Human
Packaging Failure
4. Date registrant was first informed of the incident.
22-JUN-125. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
Unknown
Product Description
7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.
Active(s)PMRA Registration No. 28642 PMRA Submission No. EPA Registration No.
Product Name: Axial
- Active Ingredient(s)
- PINOXADEN
PMRA Registration No. 28151 PMRA Submission No. EPA Registration No.
Product Name: Adigor Adjuvant
- Active Ingredient(s)
- SURFACTANT BLEND
PMRA Registration No. 28738 PMRA Submission No. EPA Registration No.
Product Name: Infinity
- Active Ingredient(s)
- BROMOXYNIL
- PYRASULFOTOLE
PMRA Registration No. PMRA Submission No. EPA Registration No.
Product Name: Assert FL
- Active Ingredient(s)
- FLORASULAM
- IMAZAMETHABENZ-METHYL
- MCPA (PRESENT AS ESTERS)
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Nausea
- Symptom - Stomach cramps
- Symptom - Diarrhea
- Respiratory System
- Symptom - Shortness of breath
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
Unknown
7. Exposure scenario
Occupational
8. How did exposure occur? (Select all that apply)
Pesticide Spill
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
1-30618385- The reporter, an employee of a shipping agent, indicated an employee was exposed to an herbicide containing the active ingredient pinoxaden and a petroleum hydrocarbon surfactant blend. She indicated two vaguely identified nonregistered products were handled by the exposed party the same day. The first was identified as Assert FL and the second as an unknown fungicide. The reporter indicated five days prior to her account an employee had described a puncture on the bottom of a container of the registrants product. Subsequently the bottom of the container had given out and the product had spilled in the back of a pickup truck. The reporter was unable to clarify how or why the puncture had taken place. It is unclear if the package failure is secondary to some sort of transportation related damage that had taken place. The reporter went on to describe the employee that had spilled the product neglected to clean up the spill and a second employee, a twenty seven year old male (Subform III, #1), used the same truck to make deliveries the same day. That employee described the back of the pickup smelled like the registrants product. His exposure was described as inhalation of aromas. He reported to the hospital later the same day with the described symptoms of stomach cramp, nausea, diarrhea, and shortness of breath. He was admitted to the hospital but did not stay the night. His treatments are unknown. His symptoms resolved the following day. No further information is available. The symptoms described would not be anticipated following inhalation of aromas associated with this product.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Jug-plastic / Cruche-plastique
2. Did packaging failure occur during?
Other
3. Did packaging failure result in?
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
1-30618385- The reporter, an employee of a shipping agent, indicated an employee was exposed to an herbicide containing the active ingredient pinoxaden and a petroleum hydrocarbon/surfactant blend. She indicated two vaguely identified nonregistered products were handled by the exposed party the same day. The first was identified as Assert FL and the second as an unknown fungicide. The reporter indicated five days prior to her account an employee had described a puncture on the bottom of a container of the registrants product. Subsequently the bottom of the container had given out and the product had spilled in the back of a pickup truck. The reporter was unable to clarify how or why the puncture had taken place. It is unclear if the package failure is secondary to some sort of transportation related damage that had taken place. The reporter went on to describe the employee that had spilled the product neglected to clean up the spill and a second employee, a twenty seven year old male (Subform III, #1), used the same truck to make deliveries the same day. That employee described the back of the pickup smelled like the registrants product. His exposure was described as inhalation of aromas. He reported to the hospital later the same day with the described symptoms of stomach cramp, nausea, diarrhea, and shortness of breath. He was admitted to the hospital but did not stay the night. His treatments are unknown. His symptoms resolved the following day. No further information is available. The symptoms described would not be anticipated following inhalation of aromas associated with this product.
