Ni 2012165410307 core 5 Sun Excavating Ltd. OGIOOQP11, 2012 INCIDENT INVESTIGATION REPORT WORKING Tl) MRKE DIFFERENCE Noflce of incident number Date oimcldem Lacaiim 2012165410307 Ociober11, 2012 Rear city ianeway north of 4009 St. Burnaby, B.C. Lead investigating oiflner lnveshgallon file number Incident ourmme Gary Anderson LEATAL HUN-JURY mapm approved uy manager, ram: and Si Dane fl sermus injury invssiigalmns Steven Ramadan 2&3. r7. Employer Name and J. Cote Son Excavating Ltd. 5488 152 St. Surrey BC V35 8E5 Jeffrey w. CARON Ernployev ID lnuuslry classification 225807 721031 Land Clearing, Excavation, or Site Surface Preparation Deceased Pipe Layer Thomas Alex RICHER Occupaiion Pipe Layer Empmyer Name and aauress Emninyerib City of Burnaby 405 753004 4949 Canada Way Local Burnaby BC V56 1M2 Government and Relaiad Operations Employer Name and address 3375 Narland Ave. Burnaby 50 V59 3A9 Vector Engineering Services Ltd. Employer ID Indusivy massmcauon 1 51737 76301 0 Consulting Engineering Namo and sddress Earthbitat Engineering Inc. Employer to industry 710295 763010 27541780 River Rd. Consulting Richmond BC VGX 1Z7 Engineering worksaresc Investigations Workers' (Ianipcnsaiwn Board Page 1 0130 Thu it supplicdla yau by vuamsarssc laiyomln/omtalmn an/y 15 not la in may. /mm ro any umer agency orpelson warm in. punnusaoln pi Ni 201216541030? J. Cote Son Excavating Ltd. October 11, 2012 Persons mentioned in report Name Known in the report as Role in the incidentlinvestigation Jeffrey W. CARON Pipe Layer 1 Deceased worker; employed by J. Cote Son Excavating Ltd. as a pipe layer. Thomas Aiex RICHER Pipe Layer 2 Seriously injured worker; employed by J. Cote Son Excavating Ltd. as a pipe layer. David GREEN Pipe Crew Foreman Employed by J. Cote Son Excavating Ltd.; was the foreman of Pipe Layer 1, Pipe Layer 2, and the Excavator Operator at the time of the incident. Marc LOIS ELLE Excavator Ope rator Employed by J. Cote 8: Son Excavating Ltd. as a heavy equipment operator. Road Crew Foreman Employed by J. Cote Son Excavating Ltd. as the foreman of the road crew. Superintendent Employed by J. Cote Son Excavating Ltd. as a project superintendent; filmed a video documenting existing damage at the site the day before the excavation began. Jamie COTE Company President Principal of J. Cote Son Excavating Ltd. Professional Engineer Principal of Earthbitat Engineering lnc.; conducted a soil inspection and provided written instructions to J. Cote Son Excavating Ltd. in relation to the trench excavation. Contract Administrator Principal of Vector Engineering Services Ltd.; administered project contracts between the City of Burnaby, Vector Engineering Services Ltd., J. Cote Son Excavating Ltd., and other stakeholders. Design Engineer Employed by Vector Engineering Services Ltd.; con?rmed the poor condition of one of the walls" within the project boundaries. Workers? Compensation Board of B.C. Page 2 of 30 This report is supplied to you by WorkSafeBC for your infonrration onmade known to any other agency or person without the permission of Wori4 mr?vm 1.2.4 J. Cote 8. Son Excavating Ltd. J. Cote is located in Surrey, BC. The ?rm has been in business since the mid 1970s, engaged mainly i11 municipal work and some private utilities including road works and pipe works. Depending on the workload, J. Cote employs, on average, approximately 20 employees including office staff. The firm owns several pieces of heavy equipment. For the purpose of this contract, I. Cote?s work included excavating for the removal of the existing combination storm/sanitation line, installing the new separate storm and sanitary sewer lines complete with manholes and service connections, back?lling, and the reclamation of the asphalt curb and paving. As part of the written contract with the City, J. Cote was designated as the prime contractor for the purpose of health and safety for this project. The Superintendent was listed. on the Notice of Project as the quali?ed health and safety coordinator. 1.3 Sequence of events 1.3.1 Pre-incident events On February 1 and 2, 2012, EXP Services was on site and completed a pre?project excavation geotechnical assessment report for the project on behalf of Vector. (For more information, see section 1.4.1 of this report.) On September 18, 2012, the Construction Inspector was on site and filmed and narrated a video on behalf of Vector. The video identi?ed existing damages to structures on several private properties that would be affected by the excavation. Speci?cally, it acknowledged a construction WorkSafeBC Investigations Workers? Compensation Board of B.C. Page 8 of 30 This report is suppiied to you by Worksa feBC for your information oniy. it is not to be made known to any other agency or person without the permission of Wori(SafeBC. NI 2012165410307 J. Cote Son Excavating Ltd. October 11, 2012 joint-??two sections of concrete poured separately and not joined together in any way?in the rear of the east end of the concrete wall that later failed. (For more information, see section 1.4.2 of this report.) On September 19, 2012, a pre-construction meeting was held with representatives ?om Vector, J. Cote, and the City. The meeting minutes con?rm that a discussion took place about the prime contractor?s general duties. However, attendees did not talk about the existence of gravity walls, excavation safety, adjacent structures, or any other known hazards that may have been present at the workplace. On October 1, 20l2,"J. Cote arrived on site to prepare for the start of the project, scheduled for the following day. Construction materials and equipment were delivered. The crew set up the job site and located existing services at the east end of the laneway at North Gilmore Avenue. On the same day, the Superintendent was on site and ?lmed and narrated a video on behalf of J. Cote. The video identi?ed, detailed, and documented existing damages to structures on private properties located within the vicinity of the contract. The video included the concrete retaining wall that later failed. When the Superintendent arrived at the concrete wall while ?lming (see Figure 2), he commented that ?the wall appears to be in good condition and hasn?t been hit by a counterweight yet.? He also commented on the joint, stating it was ?a hand-formed joint of some kind, probably for drainage.? No actions were taken, such as obtaining a professional engineer?s advice in order to brace or otherwise secure the wall in place. As well, the potential hazard of trenching in close proximity to this concrete retaining wall (a gravity wall) was not recognizedConstruction joint that was present in the concrete wall prior to excavating Figure 2: A still photograph of the construction joint in the concrete retaining wall captured from the video taken prior to the start of work in the area and excavating directly aa?acent to it. Source: J. Cote Son Excavating Ltd. WorkSafeBC Investigations Workers? Compensation Board of B.C. Page 9 of 30 This report is supplied to you by Wori