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Mining death inquiry yields 15 recommendations

Mandated use of seatbelts in mobile mining equipment, door ajar and unbuckled seatbelt alarm systems among the recommendations intended to prevent future death and injury to miners

Last week’s inquiry into the underground mining death of Richard Pigeau yielded 15 recommendations from the jury. 

Among these recommendations are added safety components for mining equipment, greater support for grieving families and additional training, most of which aimed at helping prevent future death and injury to miners.

The inquiry looked into Pigeau’s Oct. 20, 2015 death, and the passage of time didn’t go unnoticed. 

Seven years waiting for an inquest is “far, far, far too long,” said Dave Stewart, a former Glencore health and safety co-chair who served as an agent for Pigeau’s family during the inquest.

“Finally we have it done; finally we have some solid recommendations.”

An emotional week for the family, Stewart spoke to Sudbury.com following the Sept. 2 conclusion of the week-long inquest at the Sudbury courthouse, which began on Aug. 29

Pigeau was operating a load haul dump machine at Glencore’s Nickel Rim South Mine in Sudbury at the time of his death. Also known as a scooptram, the specific model he was operating was a Caterpillar R1700G, which weighed in at more than 84,000 pounds without a load and had an enclosed operator cab. 

There were no witnesses, but the data recording on the machine shows he was driving down a ramp at the 1380 level when the machine suddenly turned right within a tight space, continued to slide down the ramp against the wall as it moved.

Though it is unclear by what means the door opened and how Pigeau was ejected from the vehicle (he was not wearing a seatbelt), the scooptram did not stop moving. He was then run over by the rear wheel of the scoop, across his torso. 

This, according to the statement of fact read in court, was his cause of death.

Pigeau was discovered by other workers at 10:20 a.m. and was officially pronounced dead at 12:10 p.m.

Among the 15 recommendations outlined in the jury’s verdict document are added safety measures to ensure the operators of machines such as this cannot be ejected in this manner. They recommended the use of seatbelts in mobile mining equipment be mandated and that machines be equipped with “door ajar and unbuckled seatbelt alarm systems.”

Recommendations have been made to various government ministries, a ministry chief prevention officer, the Caterpillar of Canada Corporation, and Glencore Corporation.

In 2017, Glencore was fined $200,000 in connection to Pigeau’s death after entering a guilty plea for failing as an employer to provide information, instruction and supervision to a worker to protect his safety, contrary to the Occupational Health and Safety Act. 

After the verdict was read, Stewart told Sudbury.com he’d also like to see the province do more work on the Mining Health, Safety and Prevention review

“Things have not been completed,” he said. “We need to get the sub-committees up and running again and do meaningful work and complete a lot of the work that’s been done.”

With some work delayed by the COVID-19 pandemic, he said he’s hoping to impress “almost an urgency to get back to work. … It’s all for the benefit of all workers in Ontario.”

The following is the full text of the jury recommendations following the inquest into Pigeau’s death:

To the Ministry of the Attorney General:

  1. It is recommended that 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.

To the Ministry of Labour, Immigration, Training and Skills Development and the Minister of the Solicitor General:

  1. It is recommended that the MLITSD and the SolGen work together to determine the feasibility and creation of 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.

To the Ministry of Labour, Immigration, Training and Skills Development:

  1. It is recommended that the MLITSD 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. 
  2. It is recommended that the MLITSD 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.
  3. It is recommended that the MLITSD 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.
  4. It is recommended that the MLITSD 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. 
  5. It is recommended that the MLITSD 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. 
  6. It is recommended that the MLITSD 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. 
  7. It is recommended that the MLITSD and equipment manufacturers take steps to co-ordinate 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.
  8. It is recommended that the MLITSD and equipment manufacturers assess the feasibility of integrating a sensor into the operator’s seat that would be part of the operator presence system (OPS).

To the Chief Prevention Officer of the Ministry of Labour, Immigration, Training and Skills Development:

  1. It is 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. 

To Caterpillar of Canada Corporation:

  1. It is recommended that CAT take steps to assess the hazards of loss of control on underground LHDs when the door opens on a STIC steer equipped machine during operation. Specifically, to address a transmission shift to neutral and steer lockout.
  2. It is recommended that CAT 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. 
  3. It is recommended that CAT 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. 

To Glencore Corporation:

  1. It is recommended that 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.

— Sudbury.com

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