Ministry of the
Solicitor General

OCC Inquest - Bisallion Norman 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Bisaillon, Methé; Norman, Marc
Held at: Sudbury
From the: Sept. 30, 2019
To the: Oct. 4, 2019
By: Dr. Steven Bodley, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Bisaillon
Given name(s): Methé
Age: 49
Date and time of death: May 6, 2014 at 12:42 p.m.
Place of death: Lockerby Mine, 1000 Gordon Lake Road, Chelmsford, Ontario
Cause of death: Traumatic asphyxia caused by fall of ground
By what means: Accident

Surname: Norman
Given name(s): Marc
Age: 34
Date and time of death: May 6, 2014 at 12:42 p.m.
Place of death: Lockerby Mine, 1000 Gordon Lake Road, Chelmsford, Ontario
Cause of death: Traumatic asphyxia caused by fall of ground
By what means: Accident

(original signed by Foreman and Jurors)


This verdict was received on the 4th of October, 2019
Coroner’s Name: Dr. Steven Bodley
(original signed by coroner)


Inquest into the deaths of:

Methé Bisaillon and Marc Norman


Jury Recommendations

  1. Recommendation to the Ministry of Training College and University:
    The Ministry of Training College and University prepare a training package for all mine employees regarding s. 43 of the Ontario Health and Safety Act (O.H.S.A) and the Internal Responsibility System.
  2. Recommendation to the Ministry of Labour:
    The Ministry of Labour shall require the employer to post a copy of s. 43 of the O.H.S.A and a document explaining the Internal Responsibility System in a prominent place in each workplace.
  3. Recommendation to the Province of Ontario specifically the Ministry of Labour:
    The Mining Legislative Review Committee (M.L.R.C.) must recommend to the Ministry of Labour that they develop legislation with respect to re-entry protocol after a recorded seismic event in an underground mine. The legislation should include ensuring the appropriate micro-seismic monitoring system exist in areas where individuals are located. The results of micro-seismic monitoring system must be made visible and the re-entry protocol displayed prominently.
  4. Recommendation to the Province of Ontario, specifically the Ministry of Northern Development and Mines:
    The Closure plan must include data collected pursuant to s. 72 of the Mines and Mining Plants, R.R.O. 1990, Reg. 854.
  5. Recommendation to the Ministry of Labour:
    The Jury recognizes that the M.L.R.C. is currently working towards amendments to Regulation 854 with respect to adopting a “Management of Change Process” (recommendation 2.1). It is recommended that the M.L.R.C. prioritize finalizing their recommendation to the Ministry of Labour in order to implement the proposed “Management of Change Process”.
  6. Recommendation to the Ministry of Labour:
    The Jury recognizes that the M.L.R.C., specifically the ground control sub-committee is currently working towards amendments to Regulation 854 with respect to recommendation 1.4 to create guidelines pertaining to ground control. It is recommended that the M.L.R.C. prioritize finalizing their recommendation to the Ministry of Labour to create a guideline that covers all ground control related sections in the Regulation for Mines and Mining Plants.
  7. Recommendation to the Ministry of Labour:
    Mining companies in Ontario be required to ensure proper communication of the existence of any potential or actual danger to the health and safety of contract workers on their property. In particular, maintain a consolidated log book of pertinent information recorded and read by all contractors as well as mine employees, that would facilitate communication of information within the workplace