Ministry of Justice File NO. 2012:0612:0002 Coroners Service Province of British Columbia VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS As A RESULT OF THE INQUEST PURSUANT TO SECTION 38 OF THE CORONERS ACT, 2007] 15, INTO THE DEATH OF CHARLIE Carl Rodney SURNAME GIVEN NAMES An Inquest was held at ISland GOSPGI F6110W5hip Hall in the municipality of Burns Lake, BC in the Province of British Columbia, on the foii?owing dates July 13-31, 2015 before: TE- Presiding Coroner. into the death of CHARLIE Carl Rodney 42 Male Femaie (Last Name) (First Name) (Middle Name) (Age) The following findings were made: Date and Time of Death; January 20, hours place of Death; Babine Forest Products milisito East of Burns Lake, BC (Location) (Municipaiity/Province) Medical Cause of Death: (1) Immediate Cause of Death,- a) Exposure to Explosion and Fire Due to or as a consequence of Antecedent Cause if any: b) none Due to or as a consequence of Giving rise to the immediate cause above, stating C) underlying cause last. (2) Other Signi?cant Conditions none Contributing to Death: CEassification of Death: Accidental Homicide Natural Suicide El Undetermined The above verdict certified by the Jury July AD, 2015 Chico Nowell jg" Presiding Coroner's Printed Name Pr?sj?ing Caroner's Signature Page 1 of 6 Ministry of Justice File No. 2012:0612:0002 Coroners Service i Province of British Columbia in VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST PURSUANT TO SECTION 38 OF THE CORONERS ACT, [sac 2007] 15, INTO THE DEATH OF CHARLIE Carl Rodney SURNAME GIVEN NAMES Pursuant to Section 38 of the Coroners Act, the following recommendations are forwarded to the Chief Coroner of the Province of British Columbia for distribution to the appropriate agency: JURY RECOMMENDATIONS: To Bahine Forest Products Ltd. and the Manufacturers' Advisory Group: 1. Ensure that all plants have proper outdoor lighting, a fire pumping system, a stand-alone first aid facility and well identified muster stations. All of these installations should be serviced by a fully functional automatic emergency power system. Background to the Recommendation: Worker testimony Showed that it was dark outside as power had been cut off during the explosion causing disorientation and the inability to make it to a safe place in a reasonable amount of time. They also showed that the fire pump was unable to operate because of loss of power. The first aid station attached to the sawmill was destroyed in the explosion. To Babine Forest Products Ltd.: 2. Discuss WorkSafeBC and BC Safety Authority inspection reports, orders, hazard alerts and investigations at crew meetings. Background to the Recommendation: Many workers testified that they never saw results of inspections and investigations. 3. Ensure a hot work policy is followed and enforced. Background to the Recommendation: Many workers were concerned that hot work policy was not being followed and hot work can easily be the cause of fires. 4. Develop a comprehensive preventative maintenance program with a focus on potential ignition sources. Include the use of thermal guns and thermal imaging to identify hot spots throughout an operation. Background to the Recommendation: Friction and electrical faults were identified as a possible ignition source of the explosion. 5. Ensure all operator booths are built or upgraded to a 1 hour fire rating. Background to the Recommendation: Testimony showed that worker protection and refuge was important during the fire that ensued after the explosion. 6. Task a member of the Joint Occupational Heaith and Safety Committee (JOHSC) to post and update safety notices and minutes of meetings throughout the operation. Background to the Recommendation: Many workers were not aware of notices and meeting minutes. 7. Ensure compliance with the Nationai Fire Code including that an annual fire inspection be completed by a qualified person having jurisdiction in the area. Annually review evacuation procedures with all workers and conduct fire drills on all shifts. Ensure that all fires are recorded and reported to JOHSC. Background to the Recommendation: Testimony showed major gaps in Fire Code knowledge and inspection requirements. This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007] 15. Page 2 of 6 Ministry of Justice File No. 2012:0612:0002 Coroners Service Province of British Columbia VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST PURSUANT TO SECTION 38 OF THE CORONERS ACT, [sec 2007] 15, INTO THE DEATH OF CHARLIE Carl Rodney SURNAME GIVEN NAMES 8. Provide professionai training for all employees in workplace harassment. Background to the Recommendation: Testimony highlighted workers?concern with topics including bullying, intimidation and discrimination that prevented them from bringing forward safety concerns. 9. Consider an aboriginal liaison coordinator or worker ombudsman to assist employees with workplace concerns. Background to the Recommendation: Testimony highlight workers?concerns with topics including bullying, intimidation and discrimination that prevented them from bringing forward safety concerns. 10. Implement a gradual employee orientation process during the job shadow period that includes continual training and emphasis on workers' rights and responsibilities. Background on the Recommendation: Many workers gave evidence that they remembered little from their employee orientation. Numerous in?class sessions during the job Shadow period would assist with information retention. 11. Use combustible gas monitor to investigate reported gas smells by workers. Background to the Recommendation: Evidence showed there were many concerns raised by workers about gas smells. To Hampton Resources 12. Ensure Hampton Resources Inc. shares all health and safety information and alerts it receives from any heaith and safety organization across the full geographical breadth of their logging and milling operations. Background to the Recommendation: Evidence revealed that information on the explosive nature of wood dust was available in the public domain as early as 2008. It was heard that this information was not effectively shared throughout Hampton's milling operations. To United Steelworkers Union District 3 and WorkSafeBC: 13. Ensure that Joint Occupational Health and Safety Committees are audited semi-annually for effective function. Background to the Recommendation: Evidence showed a lack of knowledge as to the findings of the JOHS Committee and the progress and training of Committee members. To United Steelworkers Union District 3: 14. Develop a protocol to ensure an auditable two?way communication between all levels of the union with emphasis on information reaching the Shop floor with respect to health and safety issues, both for identified and emerging risks. Background to the Recommendation: Evidence showed a communication breakdown at all levels of the union organization. 15. Ensure that union representatives fully understand their responsibilities and the content of the collective agreement. Background to the Recommendation: Evidence showed that there was not full confidence in having job related complaints carried forward. This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007] 15. - Page 3 of 6 Ministry of Justice File No. 2012:0612:0002 Coroners Service Province of British Columbia VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS As A RESULT OF THE INQUEST PURSUANT TO SECTION 38 or THE CORONERS ACT, 2007] 15, INTO THE DEATH or CHARLIE Carl Rodney SURNAME GIVEN NAMES 16. Share applicable WorkSafeBC hazard alerts and BC Forest Safety Council safety alerts with affected local unions. Background to the Recommendation: Evidence showed that information was not being shared with all affected parties. To WorkSafeBC: 17. Ensure that work environment hazard alerts are communicated effectively. Update regulations and guidelines to reflect current knowledge in regard to combustible dust explosions, include within the guidelines that a contained space can be an entire plant. Background to the Recommendation: Evidence suggested that cold weather, humidity and changes in air flow may have been contributing factors in the explosion. Closing up the plant also created 3 contained area for the explosion to take place. 18. Develop an industry-specific checklist for Officers to follow at a worksite inspection. Include in the checklist reviews of Joint Occupational Health and Safety Committee meeting minutes, crew safety meeting minutes, near miss reports, incident reports, investigation reports and receipt of recent relevant hazard alerts. Background to the Recommendation: Evidence showed that there was no uniform format for inspection content at high risk workplaces. In turn there was no means for effectively comparing successive inspection findings or findings across different milling operations. 19. Create a system to share workplace incident information and educational workshops within WorkSafeBC including an auditabie mechanism for confirming the receipt of information. Background to the Recommendation: Evidence showed communication gaps in information transfer and no accountability for receipt of information. 20. Host an annual meeting of representatives of the wood products manufacturing industry, including employers, worker representatives and technical experts to share health and safety results and best practices. Background to the Recommendation: The inquest heard that a round-table of influential and committed representatives can share information about risks or improvements to health and safety to ensure better outcomes for workers. 21. Continue the Risk Analysis Unit of WorkSafeBC to review relevant local and worldwide occupational health and safety alerts and share the information in a timely manner with all affected parties. Background to the Recommendation: Information was shown to exist within the wood products manufacturing industry, but was never assembled in one place to recognize the extreme risk associated with wood dust combustibility. 22. Engage the Risk Analysis Unit to review preliminary investigation reports to identify emerging risks. Background to the Recommendation: The Risk Analysis Unit was introduced as a committee of specialists examining emerging risks and may have identi?ed the extreme risk of combustible wood dust prior to the explosion. This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007] 15. Page 4 of 6 Ministry of Justice File NO. 2012:0612:0002 Coroners Service Province of British Columbia Q-?rt?iiri?im VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST PURSUANT TO SECTION 38 OF THE CORONERS ACT, 2007] 15, INTO THE DEATH OF CHARLIE Carl Rodney SURNAME GIVEN NAMES 23. Authorize the Risk Analysis Unit to recommend the issuance of a hazard alert. Background to the Recommendation: The Risk Analysis Unit was introduced as a committee of Specialists examining emerging risks and may have identified the extreme risk of combustible wood dust prior to the explosion. 24. Ensure Officers with wood product manufacturing facilities in their region have the relevant and current training to carry out their inspections. Background to the Recommendation: Evidence showed that inspectors lacked current training specific to wood product manufacturing plants with respect to regulations and guidelines applicable to those facilities. 25. Implement an initiative to ensure all wands used in a combustible dust environment are properly grounded. Background to the Recommendation: Evidence was heard that wands create electricity capable of igniting an explosion in a combustible environment. Grounding will eliminate this hazard. To WorkSafeBC, Manufacturers? Advisory Group, Babine Forest Products Ltd. and United Steelworkers Union District 3: 26. Develop a video or visual presentation (PowerPoint) to demonstrate to all workers in the wood manufacturing the industry health and safety hazards associated with combustible wood dust. Background to the Recommendation: Evidence showed a lack of workers? knowledge to the hazards of wbod dust. To Manufacturers? Advisory Group: 27. Compile and make available best practices including life safety engineering related to construction of new wood processing plants and for refitting old plants to address combustible dust issues. Background to the Recommendation: Evidence revealed that engineering controls of wood dust were inadequate to control dust levels in the sawmill. 28. Encourage employers to utilize the existing Manufacturers? Advisory Group dust audit tool regarding combustible dust mitigation. Background to the Recommendation: Evidence showed that dust mitigation was the key to preventing the explosion. To Minister of Jobs, Tourism Skills Training and Responsible for Labour of British Columbia: 29. Expand Section 132 of the Workers Compensation Act to give a WorkSafeBC Officer the power to address issues that are unresolved at the Joint Occupational Health and Safety Committee for an extended period of time. Add to the current wording co?chair of the committee may report this to the to include the co-chair or a WorkSafeBC Officer. Background to the Recommendation: Evidence revealed that the wood dust issue remained unresolved for a long period of time and WorkSafeBC Officer intervention may have addressed and highlighted the need for dust mitigation. This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007] 15. Page 5 of 6 Ministry of Justice File No. 2012:0612:0002 .. Coroners Service {itiSH Province of British Columbia i VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS As A RESULT OF THE INQUEST PURSUANT To SECTION 38 OF THE CORONERS ACT, [sac 2007] 15, INTO THE DEATH OF CHARLIE Carl Rodney SURNAME GIVEN NAMES 30. Amend Section 176(2) of the Workers Compensation Act to ensure that a copy of the fuii incident investigation report is provided to the Joint Occupational Health and Safety Committee or the worker representative. Add in a new section as follows: ?either, provide the report to the joint committee or worker health and safety representative, as applicable, or (ii) if there is no joint committee or worker health and safety representative, strategically post the report at the workplace.? Background to the Recommendation: Evidence revealed workers were not informed about results of investigation reports. The knowledge of such reports can serve as training information and safety awareness. To Minister of Justice and Attorney General Canada: 31. Amend Section 217.1 of the Criminal Code to add Section 217.103) with the suggested text as follows: 21 7. 1 Anyone who fails to take reasonable steps to prevent death or bodily harm under this section is guilty of an indictable o??ence. Background to the Recommendation: The Westray Act amendments created a duty under section 21 7.1 but did not create an offence for failing to ful?ll that duty. To BC Safety Authority: 32. Have flow restricting or automatic cut?off valves installed on natural gas lines where combustible wood dust is present. Background to the Recommendation: Evidence showed that the main gas line flowed freely for 40 minutes before being shut off. To WorkSafeBC, BC Forest Safety Council, Manufacturers? Advisory Group and the associated Health Safety Associations: 33. To ensure the effective sharing of information to ensure ongoing risks can be evaluated by all members of the safety community. Background to the Recommendation: Throughout the inquest there were many instances of a lack of and a breakdown in communication that contributed to the incident. This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007] 15. Page 6 of 6 Ministry of Justice File No. 2012:061220002 Coroners Service Province Of British Columbia 6?3 VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST PURSUANT TO SECTION 38 OF THE CORONERS ACT, [sec 2007] 15, INTO THE DEATH OF CHARLIE Ca rl Rodney SURNAME GIVEN NAMES PRESIDING CORONER RECOMMENDATIONS: To Sabine Forest Products Ltd.: 1. Conduct an employment equity audit pursuant to the Employment Equity Act. Background to the Recommendation: Testimony identi?ed there was a lack of First Nations representation in supervisory and management positions. To Burns Lake Native Development Corporation and Babine Forest Products Ltd.: 2. Move forward in a timely manner to ratify the Relationship Accord. Background to the Recommendation: Evidence indicated that the completion of this undertaking will serve to solidify healthy working relationships. To United Steelworkers District 3: 3. Proactiver recruit Aboriginal persons for positions on the plant committee and as job stewards. 4. Proactively recruit Aboriginal persons to represent the Union on the Joint Occupational Health and Safety Committee. Background to the Recommendation: It was heard inclusion and promotion of Aboriginal persons in these roles will serve to support healthy working relationships. To WorkSafeBC and Office of the Fire Commissioner: 5. Collaborate in the creation of a regulation to ensure companies in the wood products manufacturing industry in all lands of the province have an annual fire inspection to ensure compliance with the application of the Fire Code tO be conducted by an inspector approved by the Office of the Fire Commissioner. Background to the Recommendation: Evidence revealed there is no regulation regarding fire inspections in unincorporated and First Nations lands. To Office of the Fire Commissioner: 6. Develop a iist of inspectors approved to conduct fire inspections pursuant to the National Fire Code or the British Columbia Fire Code. Background to the Recommendation: The recommended fire inspections are to be completed by qualified and approved ?re inspectors. To Minister of Justice of British Columbia: 7. Ensure the Office of the Fire Commissioner is sufficiently resourced to inspect industrial facilities in all unincorporated lands in the Province of British Columbia on a regular and consistent basis. Background to the Recommendation: Testimony revealed that the Of?ce of the Fire Commissioner is currently lacking in sufficient resources to fulfill this recommendation. This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007} 15. Page 2 Of 2 Ministry of Justice File No. 201206120002 Coroners Service Province of British Columbia VERDICT AT CORONERS INQUEST FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST PURSUANT TO SECTION 38 OF THE CORONERS ACT, [sec 2007] 15, INTO THE DEATH or CHARLIE Carl Rodney SURNAME GIVEN NAMES 8. Amend the Fire Services Act so that it stipulates that the British Columbia Fire Code, including provisions which require fire inspections, appiies to unincorporated and First Nations lands. Background to the Recommendation: It was heard that there is currentiy no provision in the Fire Services Act that mandates fire inspections on unincorporated and First Nations lands. I TE. Chico Nowell 5r: gift?; g, - Presiding Coroner's Printed Name "fraying Coroner's Signature This document has been prepared pursuant to the authority of the Chief Coroner as provided in Section 53 (2) of the Coroners Act, 2007} 15. Page 2 of 2