Jury demands change management training improvements
An inquest that looked into the death of a mine worker has concluded, with the jury making a total of 15 recommendations to the employer, the labour ministry and the solicitor general.
The proceedings tackled the circumstances surrounding the death of 54-year-old Richard Pigeau on October 20, 2015. Pigeau died from injuries he sustained while working at the Nickel Rim South Mine in the City of Greater Sudbury.
After the two-week long process that began on August 29, the jury recommended that Glencore Canada – owner-operator of the mine – make “training related to the management of change process take place on a regular basis (annual as a minimum) to ensure that all employees are continually informed as to what requires the initiation of the management of change process”.
In 2017, Glencore Canada pleaded guilty and was fined $200,000 after the death of another worker, who was run over by a vehicle at the mine in Ontario.
The jury also recommended that the Ministry of the Attorney General (MAG) “examine the feasibility of applying the funds paid into the Ontario Victims’ Justice Fund towards defraying the costs incurred by a deceased’s family members to attend and meaningfully participate in the quest process as parties”.
The jury also recommended that the Ministry of Labour, Immigration, Training and Skills Development and the MAG work together to create an office or a program expansion of an office, such as the Office of the Chief Coroner, to provide family membres of a workplace death assistance in navigating the inquest process and assisting in accessing grief and counselling services.
The labour ministry was also told to:
- expedite the amendment to the Occupational Health and Safety Act, R.S.O. 1990 c. O.1. Regulation 854 (Mines and Mining Plants) proposed by the Mining Legislative Review Committee related to management of change processes
- examine the feasibility of amending the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, regulation 854 (Mines and Mining Plants) to mandate the use of seatbelts in mobile mining equipment in underground mines
- take steps to co-ordinate a risk assessment of the possible risks associated with door ajar interlock systems and subsequent loss of control on underground mining load haul dump machines in use today
- take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate that all new underground mining load haul dump machines be equipped with door ajar and unbuckled seatbelt alarm systems
- take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate that all underground mining load haul dump machines currently in use to be retrofitted with door ajar and unbuckled seatbelt alarm systems
- take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate that all mobile mining equipment in use be used in accordance with any operating manuals issued by equipment manufacturers similar to O.Reg. 213/91 at s.93(3) unless any deviation from the operating manual has first been appropriately risk assessed
- along with equipment manufacturers, take steps to coordinate a risk assessment of the possible risks associated with machine steering controls mounted on doors in underground mining load haul dump machines in use today
- along with equipment manufacturers assess the feasibility of integrating a sensor into the operator’s seat that would be part of the operator presence system (OPS)
The jury also recommended that the chief prevention officer of the MLITSD take steps to examine the feasibility of creating a reporting and/or notification system to promote the rapid sharing of information between mine operators and equipment manufacturers related to mobile equipment high potential risk incidents such that information could be shared expeditiously to proactively prevent the occurrence of similar events at other mines.
The jury also told Caterpillar of Canada Corporation, manufacturer of construction and mining equipment to:
- assess the hazards of loss of control on underground LHDs when the door opens on a STIC steer equipped machine during operation
- explore relocation of the door latching mechanism in order to make it more visible to the operator of LHD equipment, such as flipping the hinges and the latch to opposite sides
- assess the risks and feasibility of allowing the orientation of the operator’s seat to swivel in order to allow the operator to have more maneuverability to view the striker
