OCC Inquest - Angus 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Angus
Given Name(s): Ross
Age: 48

Held at: Ottawa, Ontario
From: March 3
To: March 5, 2015
By: Dr. Daniel Dufour, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ross Angus
Date and time of death: October 12, 2011
Place of death: 101 Richmond Road, Ottawa, Ontario
Cause of death: Multiple blunt force injuries
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 5 of March, 2015
Coroner's name: Dr. Daniel Dufour
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Ross Angus


Jury Recommendations

  1. The Technical Standards and Safety Authority (TSSA) should, by a regulation or director’s order, require that every elevator that is a new installation or major alteration be equipped with a two-stage door unlocking device system, such that the first stage of unlocking permits the landing door to be opened no more than six (6) inches, and a second action is required to fully open the landing door.
  2. The Canadian Standards Association (CSA) should amend the Safety Code for Elevators, CSA B44-10 to include a requirement that every elevator that is a new installation or major alteration be equipped with a two-stage door unlocking device system, such that the first stage of unlocking permits the landing door to be opened no more than six (6) inches, and a second action is required to fully open the landing door.
  3. The Technical Standards and Safety Authority (TSSA) should make training in the safe access of elevator hoistways a pre-requisite for every class of elevating device mechanic certificate, including mechanic-in-training. Moreover, periodic refresher training in the safe access of elevator hoistways should be a continuing education requirement for elevating device mechanics.
  4. The Technical Standards and Safety Authority (TSSA) should incorporate the following safety principles into the minimum training requirements of every class of elevating device mechanic, including mechanics-in-training:
    1. Any elevator technician arriving at any site where more than one elevator technician is expected to be engaged in the work to be done, shall ensure they establish communication with all other elevator technicians at the earliest practical opportunity, in addition to letting the general contractors and/or building manager know of their arrival.
    2. Under no circumstances shall any elevator technician change the condition or location of an elevator being worked on by more than one elevator technician, without informing all other affected elevator technicians (and getting acknowledgement of the receipt of the information) when such change might endanger the safety of anyone not aware of the change.
    3. The requirement to establish communication on arrival at a site also applies to an employee who leaves a site and then returns.
    Training in the above safety principles should also form part of the continuing education requirement for elevating device mechanics.
  5. That an industry committee be struck consisting of, at a minimum, National Elevator and Escalator Association (NEEA) and International Union of Elevator Constructors (IUEC) representatives, and any other relevant stakeholders, to explore the feasibility of installing an audible alarm on every se t of landing doors to indicate the absence of an elevator cab when the landing doors are open.
  6. In the interest of workplace safety, The Technical Standards and Safety Authority (TSSA) should, by a regulation or director’s order, require all elevator hoistways to be permanently equipped with lighting, such that lighting of not less than 500 lux is present throughout the complete rise.
  7. The National Elevator and Escalator Association should continue its effort to make permanent lighting in elevator hoistways a requirement of the Safety Code for Elevators, Canadian Standards Association (CSA) B44-10.