OCC Inquest - Fram, Chenier 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Fram, Jordan and Chenier, Jason Richard



Held at: Sudbury, ON
From: April 20
To: May 1, 2015
By: Dr. David Eden, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Fram
Given name(s): Jordan
Age: 26
Date and time of death: presumed June 8, 2011 at 10:00 p.m. Pronounced June 9, 2011.
Place of death: Stobie Mine, Sudbury, Ontario
Cause of death: Smothering and compressional asphyxia due to a run of muck in an underground mine
By what means: Accident

Surname: Chenier
Given name(s): Jason Richard
Age: 35
Date and time of death: presumed June 8, 2011 at 10:00 p.m. Pronounced June 9, 2011.
Place of death: Stobie Mine, Sudbury, Ontario
Cause of death: Smothering and compressional asphyxia due to a run of muck in an underground mine
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 1 of May, 2015
Coroner's name: Dr. David Eden
(Original signed by coroner)


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


Inquest into the deaths of:

Jordan Fram and Jason Richard Chenier


Jury Recommendations

  1. It is recommended that the Ministry of Labour implement the recommendations contained in the Mining, Health, Safety and Prevention Review regarding water management in a mine and the Internal Responsibility System (IRS).
  2. It is recommended to the Ministry of Labour that a Supervisor be required to attend workplaces every work shift, where high risk tasks are being performed, such as ore handling or water management.
  3. It is recommended that the Ministry of Community Safety and Correctional Services and the Chief Coroner of Ontario strongly encourage any party who had been subject of a recommendation by an inquest jury to submit a written response within one year. It is encouraged that the response or lack of response is made public. When a recommendation is directed to an employer responses are encouraged to be shared with the Joint Health and Safety Committee of the employer involved.
  4. It is recommended to the Ministry of Labour that if a hazardous condition is recognized in an underground mine and the area is barricaded, no work shall take place except for work authorized by a supervisor for the purpose of correcting the hazardous condition. Any work authorized shall be recorded in the shift log.
  5. It is recommended to the Ministry of Labour that no worker shall be positioned so that he or she may be endangered by an uncontrolled run of material, water or slime, while operating controls for moving material.
  6. It is recommended to the Ministry of Labour, that a database be formed and maintained containing all field visits and Coroner's Inquest recommendations in the Province of Ontario. The database should be made available to Ministry of Labour inspectors at all times. The database should be reviewed during inspector training.
  7. It is recommended that the Ministry of Labour require employers to provide annual training to be jointly developed by the employer and the Joint Health and Safety Committee or the Worker Representative and presented to relevant employees, on the following: 1) water management, where applicable; 2) duties of workplace parties; and 3) work refusal/training.
  8. It is recommended that Vale jointly develop through the Safety Health Environment Executive Committee (SHEEC), a training program for the All Mines Standards.
  9. It is recommended that the Ministry of Labour conduct an investigation into optimal material conditions, including the ratio of moisture and fines in a mixture and establish a policy for Ontario mines to follow. We are concerned that the consistency of materials in mines seems to be based on personal opinion rather than facts.
  10. It is recommended to the Ministry of Labour that, where necessary for worker safety, blast holes be either filled or capped to prevent water from entering an ore pass.
  11. It is recommended to the Ministry of Labour that standardized signs be placed at all drain holes, open blast holes, capped blast holes, ore passes, raises, shafts, sumps and air vents and that they be placed in such a way that they are not blocked by material or water accumulations. This would ensure that all workers, supervisors, contractors, inspectors or visitors, etc., are aware of where the holes are situated.
  12. It is recommended to the Ministry of Labour to review and define the requirements for dealing with routine wet material situations, including treatment of slimes and consistency of material permitted to be dumped into ore passes.
  13. It is recommended to the Ministry of Labour that the Mines and Mining Plants Regulation 854.84 subsection 3 be amended to include the terms stope, raise, ore pass or open brow.
  14. It is recommended to the Ministry of Labour that the Mines and Mining Plants Regulation 854.63 subsection 2 be amended to include inactive or abandoned areas.
  15. It is recommended that the Ministry of Labour include a regulation to measure wet/dry material before and after dumping material into a chute, raise or ore pass and that these measurements be recorded. For example, a measurement shall be taken from the top of an ore pass to the top of the solid material and a measurement shall be taken from the top of an ore pass to the top of the wet material to determine both the volume of material and the volume of wet material, if any.
  16. It is recommended that the Ministry of Labour implement a policy where all double barricades and hazardous accumulations of water shall be discussed with workers prior to the beginning of a shift and that workers be made aware of steps being taken to mitigate the safety concern.
  17. It is recommended that Vale implement a policy where all equipment used to transport material be regularly inspected to ensure that all safety features are functioning. For example, to ensure that drainage holes on scoop trams are free of debris.
  18. It is recommended that Vale implement a policy where all ore passes be fitted with an appropriately sized mantle or grizzly.
  19. It is recommended that the Ministry of Labour include a regulation for Mines to inspect all active ore passes twice a year. Should any changes or abnormalities appear in the structure of the ore pass, the schematic shall be updated and stamped by an engineer.
  20. It is recommended to the Ministry of Training, Colleges & Universities that Common Core training be reviewed and updated to include more advanced training with respect to water management, if deemed necessary. For example, wet material, drainage of wet mines, clearing of drain holes, safe removal of hangups, and use of control gates, if deemed necessary.
  21. It is recommended that Vale review incentive programs to ensure a common goal of production and safety, where the safety conditions are given equal weight to production in order to foster an environment based on collaboration.
  22. It is recommended that Vale implement a policy where the Joint Health and Safety Committee is notified when a double barricade is erected or where significant accumulations of water are occurring.
  23. It is recommended that the Ministry of Labour conduct more announced and unannounced inspections of mines. This is to enforce regulations as outlined in the Occupation Health and Safety Act and to promote safe working conditions in all Ontario mines.
  24. We endorse the 42 recommendations identified by the Vale and USW mining review as outlined in the Stobie Fatality Recommendations and encourage the development of policy affecting all mining operations in Ontario, where applicable.