Coroner’s inquest jury recommends construction safety measures
By Jenn Watt
Published March 27, 2018
The coroner’s inquest into the death of Haliburton construction worker John Francis Smith returned eight recommendations from jurors concerning safety equipment, practices and education.
The inquest, held at Pinestone Resort March 21 and 22, examined the circumstances surrounding Smith’s death on July 31, 2013, and included testimony from witnesses.
Counsel Rebecca Griffin told the five-member jury composed of community members that the inquest served the purpose of identifying the circumstances of Smith’s death and that recommendations put forward would add weight to any ongoing efforts to improve safety for construction workers in the province.
John Smith was 37 when he died after falling 21 feet from the peak of the roof of a cottage he was helping to build on Percy Lake, north of Haliburton. He was not wearing a fall prevention harness, nor was he wearing a hard hat or work boots.
Terry Smith, John’s brother, was working on the same job site.
Terry was in the process of taking plywood sheeting up to the roof where John was working when he heard him slip.
As the first witness to speak at the inquest, Terry was asked to recall the events of July 31, 2013, as well as the safety measures taken by the workers and employer, Solid Ground Home Building.
He said neither he nor his brother wore fall prevention equipment while on the roof and that although John had just purchased work boots, they were still in the box.
When a worker dies while on a construction site, a mandatory coroner’s inquest is called. Although the format was similar to that of the courtroom, the mandate is not to assign blame. Jurors were instructed by inquest coroner Dr. Mary Beth Bourne to listen to the evidence and answer the basic questions about how Smith’s death came to happen and then make recommendations to avoid future tragedies.
The jury heard from Terry Smith, but also from several other witnesses, that using safety equipment was not a universally adopted practice on that site.
Griffin asked Terry why his brother had chosen to wear running shoes rather than work boots on the job site.
“A lot of roofers do,” he responded. “Including myself.”
He said it was easier to travel with running shoes, that work boots were too bulky.
He said the safety ropes were a tripping hazard and made the task of climbing ladders with sheets of plywood more difficult.
That impression was echoed by Terry’s former co-worker Justin Burk, who had been working for Solid Ground Home Building for six months prior to John Smith’s accident.
Burk said having one hand on the rope and one on the plywood sheet made it harder to move.
On the Percy Lake site, Burk said he knew of no supervisor or safety representative. He said it was his decision whether to use a harness or not.
The last witness on Wednesday was Adam Cannon, who was the sole proprietor of Solid Ground Home Building. He said he provided safety equipment, but “I didn’t push it hard enough,” on workers to use it.
Previous testimony that day indicated while components of the fall prevention equipment were available on site, not all of it was. In particular, the rope grab, or slide, wasn’t there.
In 2015, the province instituted a new mandatory training called Working at Heights, which created a standard course using a certified instructor that all construction workers who do jobs such as roofing would need to have.
But the jury heard that in 2013 the system was more relaxed and harder to track.
According to a spokesperson for the Ministry of Labour, “Adam Cannon, carrying on business as Solid Ground Home Building, was convicted on January 21, 2015 for failing, as an employer, to ensure that the measures and procedures prescribed by section 26.1(2) of Ontario regulation 213/91 were carried out in a workplace contrary to the Occupational Health and Safety Act. ... The court imposed a fine of $5,000 plus a 25 per cent victim surcharge and a one-year probation period with a condition to complete 100 hours of community service.”
Cannon told the inquest that he is no longer an employer.
Testimony from Jeff McColl, construction health and safety inspector with the Ministry of Labour, pointed to several resources that would have been available to workers and employers in 2013 to ensure they observed safety procedures.
He said that any company who paid WSIB would be part of the Infrastructure Health and Safety Association, which provides training.
McColl said he still encounters companies unaware they are part of the IHSA.
(In his testimony, Cannon said he did not know what the IHSA did when he was running his business.)
Workers who choose not to take safety precautions often perceive the equipment as time consuming and cumbersome, McColl said. Some assume a fall won’t happen to them.
He told the inquest that a culture change was needed to compel some workers to don their safety gear, referencing how attitudes have shifted around drunk driving and seat belts in recent decades.
He said the Ministry of Labour gets thousands of calls a year on its tip line, 1-877-202-0008, which can be used by anyone, including community members, who see something unsafe happening. Comments can be left anonymously.
According to the post mortem examination report Griffin read in court, John Smith died of “multiple trauma.”
“He suffered massive chest and abdominal injuries, he suffered a cardiac arrest en route to the hospital and could not be revived,” Griffin read.
Several members of John Smith’s family attended the inquest. John’s sister Debbie Palmer said the process had been difficult.
“How much [Terry] had to go through definitely was hard to watch,” she said.
She said she was happy to hear the recommendations and, in particular, the idea to implement workplace safety training in the schools.
The inquest process was a good one, she said, but it was “unfortunate it takes five years” to commence.
To the Ministry of Labour:
1. Prioritize initiatives to improve the use and design of fall protection equipment in residential construction and roofing sectors. Fall protection equipment should assist and not impede construction productivity and should not create other safety concerns such as tripping hazards.
2. Develop an information resource kit to highlight key construction health and safety issues for small and medium sized employers.
3. In order to improve awareness and compliance with the use of safety equipment, mandate the use of signage on construction sites which indicates the types of safety equipment (eg. hard hats, fall protection, ear protection, safety boots, etc.) required to work on a site. The signage should also include information on how to contact the Ministry of Labour to report non-compliance.
4. Explore new methods to monitor compliance with the Occupational Health and Safety Act in the construction industry, such as implementing an auditing program where companies are required to submit health and safety documentation for specific projects.
5. Increase the inspection of high risk construction activities, such as residential roofing.
To the Ministry of Labour, Ministry of Government and Consumer Services, Ministry of Municipal Affairs and Infrastructure Health and Safety Association:
6. Establish distribution protocols for the construction health and safety information resource kit to include Ministry of Labour inspectors, Service Ontario locations, and municipal offices. The contents of the resource kit should be easily accessible through the Ministry of Labour and Infrastructure Health and Safety Association websites.
To the Ministry of Labour and the Ministry of Education:
7. Work together to create and implement mandatory workplace health and safety curriculum for elementary, high school and post-secondary students. The curriculum goal should be to develop knowledge and foster positive attitudes from an early age that safety in the workplace is a priority and everyone’s responsibility.
To the Ministry of Labour and the Ministry of Advanced Education and Skills Development:
8. Prioritize work with the Ontario College of Trades to identify, renew and enhance health and safety content of apprenticeship training standards in order to increase awareness, training and skill level for those preparing to enter the workforce.