Ministry of the
Solicitor General

OCC Inquest - Branco 2015

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Branco
Given name(s): Jose
Age: 50

Held at: 100 John West Way, Aurora
From: October 27, 2015
To: October 30, 2015
By: Dr. Mary Beth Bourne, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jose Branco
Date and time of death: October 17, 2014 at 1:51 p.m.
Place of death: Lot 79, Woodgate Pines Drive, Vaughan
Cause of death: Blunt impact trauma to head and neck as a direct result of a fall
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 30 of October, 2015
Coroner's name: Dr. Mary Beth Bourne
(Original signed by coroner)


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


Inquest into the death of:

Jose Branco


Jury Recommendations

Ministry of Labour (MOL):

  1. Pre-fabricated metal (including aluminum, steel etc.) guardrail post assemblies should not be used in fall protection applications on construction sites unless they meet the specifications in the Regulation for Construction Projects under the Occupational Health and Safety Act (Regulation 26.3).
  2. The Alert drafted by MOL regarding temporary aluminum guardrail post assembly should be released immediately.
  3. A constructor and employer shall ensure that a worker who uses a pre-fabricated metal guardrail post assembly (guardrail system) provides documentation indicating that the system complies with the load requirements outlined in Regulation 26.3 of the Construction Regulations under the Occupational Health and Safety Act. Such documentation shall include manufacturer’s instructions/documentation on how to install the system including anchoring requirements.
  4. MOL should consider creating a standardized construction safety checklist specific to construction projects as a template. The MOL Occupational Health and Safety inspector will spot audit these on site to ensure compliance.

To the Ministry of Labour, Infrastructure Health and Safety Association (IHSA) and the Workplace and Safety Insurance Board (WSIB):

  1. All safety guardrails shall be inspected by a qualified and designated safety representative upon its installation and before its use at a construction site.
  2. The MOL’s mandatory Fall Protection (Working with Heights) Program which came into effect in April, 2015, should be mandatory every two years instead of every three years. The safety representatives and general contractors must receive proper fall protection training and safety training. The safety representatives should receive monetary compensation to attend the training.

To the IHSA:

  1. IHSA should recommend safety inspection frequency for construction projects. Safety inspections must be carried out on ALL work sites and inspection reports available for MOL inspectors when requested.

To the IHSA and WSIB:

  1. Organizations that design and develop safety training, should provide the instruction, materials and assessment in multiple languages.
  2. In addition to guardrail protection, workers exposed to falling more than three metres, should have fall restraints such as a full body harness. Such equipment should be readily available at the construction site.

To the Ontario Legislative Assembly:

Occupational Health and Safety Act

  1. Joint Health and Safety Committee (JHSC) policy and its requirements shall be adopted by all construction companies and employers.
  2. If the JHSC policy is adopted, MOL should enforce the policy and its safety inspectors should provide enforcement through validating their JHSC certificate of status. Company JHSC members and safety inspection checklists should be audited by MOL inspectors for compliance.