Ministry of the
Solicitor General

OCC Inquest - Raposo 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Raposo
Given name(s): Kevin
Age: 29

Held at: 25 Morton Shulman Avenue, Toronto
From: May 27, 2019
To: May 31, 2019
By: Dr. Robert Boyko
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Kevin Raposo
Date and time of death:  August 23, 2013 at 8:16 p.m.
Place of death: 424 Yonge Street, Toronto, Ontario
Cause of death: Multiple blunt impact trauma
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on May 31, 2019
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)


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


Inquest into the death of:

Kevin Raposo


Jury Recommendations

To the Government of Ontario:

  1. It is recommended that the Government of Ontario prioritize amending Ontario Regulation 213/91 of the Occupational Health and Safety Act. Item 3 of subsection 26.1(3) should be amended from ‘CAN/CSA-Z259.2.2-98 (R2004): Self-Retracting Devices for Personal Fall-Arrest Systems’ to the current standard of ‘CAN/CSA-Z259.2.2-17: Self-Retracting Devices for Personal Fall-Arrest System’.

To the Ministry of Labour:

  1. It is recommended that the Ministry of Labour Training Program Standard of the provincially mandated Working at Heights course be amended to require specific training on the hazards associated with leading edge work and the identification of appropriate fall protection equipment, including Self-Retracting Lifelines for Leading Edge work.
  2. It is recommended that the Ministry of Labour update the Working at Heights Training Program Standard with particular consideration of the Canadian Standards Association’s (“CSA”) standard Z259.2.2-17: Self-Retracting Devices.
  3. It is recommended that the Ministry of Labour update the Working at Heights Training Program Standard with particular consideration of the CSA’s standard Z259.17-16: Selection and use of active fall-protection equipment and systems.
  4. It is recommended that the Ministry of Labour review its procedures and processes regarding hazard alerts and other similar types of notifications or cautions, including their timely issuance and distribution.
  5. It is recommended that the Ministry of Labour consider a study on Self-Retracting Devices testing random samples of active units in the field to determine their effectiveness within the expected lifespan.

To the Canadian Standards Association and the Ministry of Labour:

  1. It is recommended that the CSA and the Ministry of Labour create a working group, which may include manufacturers and distributors, to study the possibility of having an online registry for tracking and safety purposes, that includes information from section 12.7 of CSA Standard Z259.17-16. This information would include, but not be limited to, serial number, date of manufacture and service date, as well as a record of every Self-Retracting Device pulled from service with data regarding when and why this item was removed from service.
  2. It is recommended that the CSA request that the Technical Committee on Fall Protection and/or the Subcommittee on Self-Retracting Devices develop a recommended checklist for the pre-use inspection of each classification of Self-Retracting Devices and incorporate such a checklist into CSA Standard Z259.2.2-17. This checklist should be considered by the Ministry of Labour for inclusion in the Working at Heights fall prevention course.
  3. It is recommended that the CSA request that the Technical Committee on Fall Protection and/or the Subcommittee on Self-Retracting Devices: Develop a standardized set of icons/ symbols/ pictograms to be incorporated into CSA Standard Z259.2.2-17; and determine which set of icons/symbols/pictograms, if any, should appear on all applicable Self-Retracting Devices and in the accompanying instructions. These standardized icons/symbols/pictograms should be considered by the Ministry of Labour for inclusion in the Working at Heights fall prevention course.

To the Canadian Standards Association:

  1. It is recommended that the CSA request that the Technical Committee on Fall Protection and/or the Subcommittee on Self-Retracting Devices consider revising Standard Z259.2.2-17 to require that all instructions accompanying Self-Retracting Devices contain information relating to certification and/or test results, including the entity responsible for performing said certification and/or testing.

To Labourers’ International Union of North America, Local 183:

  1. It is recommended that the Labourers’ International Union of North America, Local 183 advocate to ensure that employees across Ontario are properly compensated for on-site safety training, safety certification training, safety re-certification training and on-site safety meetings (including equipment checks).