OCC Inquest - Norman 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Norman
Given Name(s): Mark
Age: 43

Held at: 25 Morton Shulman Avenue, Toronto
From: September 19
To: September 28, 2016
By: Dr. Roger Skinner, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Mark Norman
Date and time of death: March 12, 2013 at 12:38 p.m.
Place of death: 34 Clayson Road, Toronto
Cause of death: Compression asphyxia
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on September 28, 2016
Coroner's name: Dr. Roger Skinner
(Original signed by coroner)


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


Inquest into the death of:

Mark Norman


Jury Recommendations

To the Ministry of Labour, Infrastructure Health and Safety Association, Labourers International Union of North America (Local 183), International Union of Operating Engineers, Ontario Sewer and Watermain Construction Association and the Municipalities of Ontario:

  1. Contractors are reminded of the dangers that abandoned underground structures can pose to workers. Whenever possible, such structures should be removed as soon as they are no longer in service. When such structures are found, appropriate third party consultations should be made to identify the structures and to advise regarding their management.  The circumstances of this death should be considered for use in training workers in this regard.

To LiUNA Local 183, Ontario Sewer and Watermain Construction Association and Workplace Safety and Insurance Board

  1. Recommend that LiUNA Local 183, OSWCA and the Workplace Safety and Insurance Board develop a critical incident support service for workers.

To the City of Toronto, Toronto Fire Service

  1. The City of Toronto and the Toronto Fire Service should consider acquiring an additional technical rescue truck and training the appropriate corresponding personnel for its operation in order to reduce response time. Further consideration be given to increasing the number of Fire Service responders trained in trench/excavation rescue.

To the Ministry of Labour, Infrastructure Health and Safety Association (IHSA), Association of Municipalities of Ontario

  1. Municipalities in Ontario should consider making the IHSA Certificate of Recognition (COR) or similar certification a condition for contractors seeking to bid on municipal construction projects.

To the Ministry of Labour

  1. The Ministry of Labour should consider increasing the number of health and safety inspectors employed by the ministry in high-volume areas.
  2. The Ministry of Labour should accelerate the development and implementation of the mandatory Construction Health and Safety Awareness training.
  3. The MOL should work with the IHSA and the OSWCA to produce an information bulletin with respect to hazards associated with abandoned underground structures.
  4. The MOL should work with the IHSA and the OSWCA to produce an information bulletin encouraging contractors to have a dedicated foreman on site (without worker duties) to optimize site supervision.
  5. The MOL explore the viability of creating a public database of convictions and infractions.

To the Ontario College of Trades, Ministry of Advanced Education and Skills Development

  1. Ontario College of Trades and Ministry of Advanced Education and Skills Development should accelerate consideration of LiUNA (Local 183) Training Centre's application for accreditation to deliver backhoe operator training.

To the City of Toronto

  1. The City of Toronto should consider additional training for Toronto Water inspectors with respect to how contractors are to deal with underground utilities.
  2. The City of Toronto should consider creating and implementing site inspection reports/checklists supporting contractual and health and safety matters.

To Rabcon Contractors Limited, Ontario Sewer and Watermain Construction Association

  1. Rabcon Contractors Ltd. and all members of Ontario Sewer and Watermain Construction Association should invite Bell Canada to conduct seminars for workers on how to identify and safely work in proximity to their underground utilities or structures.

To Infrastructure Health and Safety Association (IHSA)

  1. The IHSA should incorporate into IHSA training material a segment on how to identify and safely work in proximity to underground utilities or structures not identified on locate sheets.
  2. The IHSA should consider the feasibility of incorporating hands on or practical training into the trench safety awareness curriculum and consider alternatives to written evaluations to assess worker comprehension upon completion of the training.
  3. The IHSA should make training and presentation materials available in multiple languages and/or in plain language to ensure that workers receive training in a way that best facilitates their understanding.