OCC Inquest - Arcia 2015
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given Name(s): Onil
Held at: 5 Ray Lawson Boulevard, Brampton
From: Oct. 26
To: Oct. 28, 2015
By: Dr. James Kovacs, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Onil Arcia
Date and time of death: Sept. 30, 2011 at 2:47 p.m.
Place of death: Construction site at the North East corner of Queen Street and Mississauga Road, Brampton ON
Cause of death: Crush injury to the head
By what means: Accident
(Original signed by: Foreperson)
The verdict was received on the 28th of October, 2015
Coroner's name: Dr. James Kovacs
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
- To ensure that no gaps exist in the gantry portion of a tunnel project, when a potential shearing hazard exists.
A gap in the gantry portion of the tunnel was the primary hazard responsible for the fatal injury sustained.
- All locomotive devices must have a covered metal roof or similar overhead metal protection where an operator is seated or located, where a potential shearing hazard exists.
Rationale: A covered metal roof preventing raising the head would have prevented the fatal accident from happening.
- All locomotive operators must be able to sit straight up when operating a locomotive.
If the victim had been able to sit up straight he would not have been uncomfortable, and may not have felt the need to raise his head into a dangerous position.
- All locomotives shall have battery gauges.
A battery gauge would have enabled safer and predictable scheduling of battery replacement.
- All locomotives shall be inspected at least weekly when on site, before first usage, and the inspection logs shall be maintained and readily available for inspection. A copy of the most recent inspection log will be kept with the locomotive for reference by the operator.
The locomotive was not in proper working order at the time of the accident, and regular inspections and their logs would have helped to ensure that proper maintenance was undertaken.
- All locomotives shall be regularly and routinely serviced and maintained, and service logs shall be maintained and readily available for inspection.
The locomotive was not in proper working order at the time of the accident. Regular servicing, with written logs would have helped to ensure that the locomotive was in proper working order.
- All locomotive devices shall have an automated audible tone and warning lights activated momentarily prior to the device being put in motion.
An audible tone or warning light would have warned the operator that the locomotive was about to move , and he could have taken preventative measures. This would also alert bystanders that a locomotive is about to move.
- Any operator shall have undergone training by a competent person, and confirmation of that training shall be recorded and be readily available for inspection.
It was unclear that operators had been properly trained in the safe usage of the locomotive.
- Introduce a reporting system for any compromised equipment, which allows direct, transparent, and auditable communication between the operators of the equipment, and those responsible for its maintenance and care. Operators shall be obligated to report any deficiencies in equipment using this system.
This ensures that any safety or operational problems with the locomotive are recorded, resolved, and auditable.
- Alert bulletins should be issued in a timely manner.
Alert bulletins can provide critical information to prevent similar accidents from occurring. It was unclear why this alert was not issued in a timely manner.
- Wheel chocks shall be manufactured from a non-slip material so that they can better prevent cars from moving unintentionally.
This will avoid accidental slippage or shifting of the train.
- Walkthroughs of hazards at construction site should be completed at the beginning of each shift.
The gap in the gantry may not have been appropriately identified to the operator as a safety hazard.
- All tunneling regulations shall be revised to reflect current tunneling practices.
This will encourage the application and enforcement of best practices for tunneling.