Ministry of the
Solicitor General

OCC Inquest - Goulet 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Goulet
Given name(s): Pascal Joseph Richard
Age: 38

Held at: Thunder Bay
From: Sept. 12, 2018
To: Sept. 14, 2018
By: Dr. Michael B. Wilson
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Pascal Joseph Richard Goulet
Date and time of death: July 10, 2014 at 2 p.m.
Place of death: Lac Des Iles Mine, 825-961 Stope
Cause of death: Blunt force trauma to the head from a fallen rock
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on Sept. 14, 2018
Coroner's name: Dr. Michael B. Wilson
(Original signed by coroner)


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


Inquest into the death of:

Pascal Joseph Richard Goulet


Jury Recommendations

To the Mining Legislative Review Committee

  1. Create a sub-committee to develop a guideline for mining employers to use in order to determine the safe distance for workers to be located when working in a stope that has an open brow.
  2. Develop a sub-committee to evaluate the hazards at draw points and to recommend best practices and guidance for employers and consider regulatory changes.
  3. Create a regulation prescribing that no worker is allowed to go past the safe-limit line on foot without the written permission of the area supervisor, who must inspect the draw point and provide written permission, and that the supervisor must remain in the work area until completion of the task.
  4. Create a regulation prescribing the location of sprays in stopes.

To the Ministry of Labour

  1. Develop guidance materials in order to assist workplace parties to comply with mining regulation 854.
  2. Define and communicate to the Mining Industry the term " adequate illumination" with guidance on how best to achieve it.

To The Ministry of Community Safety and Correctional Services

  1. Work to ensure that inquests are scheduled as soon as feasible after the expiry of any legal proceedings that by statute or otherwise prohibit an inquest from being scheduled.

To North American Palladium

  1. Ensure that medical staff are trained in Critical Stress Management.
  2. Increase visibility of the brow with a 1-metre wide visible paint strip across the brow.