OCC Inquest - Rochette 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Rochette
Given name(s): Paul
Age: 36

Held at: Greater Sudbury
From: Jan. 22
To: Jan. 25, 2018
By: Dr. Raymond Sawkiw, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Paul Rochette
Date and time of death: April 6th, 2014 at 6:45 p.m.
Place of death: Casting and Crushing Plant, Vale Smelter, Copper Cliff
Cause of death: Massive blunt trauma to the head
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 25 of Jan., 2018
Coroner's name: Dr. Raymond Sawkiw
(Original signed by coroner)


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


Inquest into the death of:

Paul Rochette


Jury Recommendations

  1. To Vale, each plant and mine to jointly develop a site specific “Stored Energy” registry for equipment using existing risk registry process required by regulation 854 and make resulting information available to workers.
  2. To Vale, jointly develop a separate comprehensive “Stored Energy” training module in the Zero Energy State program.
  3. To Vale, where relevant, make manuals and troubleshooting guides, if available, readily available to workers.
  4. To Vale, to ensure all workers and supervisors are practiced on all steps and requirements of the Job Hazard Assessment.
  5. To Vale, review the process of inspection of Blunts and Moil Points.
  6. To Vale, add a grizzly to control the size of matte allowed into chute.
  7. To Vale, require a formal verbal and written documented supervisory shift handover, which should include at a minimum: state of equipment, hazards remaining at the end of the shift, and details around unusual conditions in the workplace.
  8. To Vale, ensure appropriate emergency shut off buttons are available for the Traylor Crusher, Farrell Crusher and conveyor belts.
  9. To Vale, jointly review the Vale Crusher Safety Program for any gaps identified in the inquest process and applicable to other Ontario operations.
  10. To Vale, investigate installing an emergency horn if an over pressurization occurs in the hydraulic system of the crusher.
  11. To the Ministry of Labour, that regulation 854 for mines and mining plants subsection 64(1) be amended to remove the statement “underground mine”.
  12. To the Ministry of Labour, to make the Management of Change (MOC) process a legal requirement.
  13. To the Ministry of Labour, to implement electronic access for relevant workers to the Hazard Bulletins.
  14. To the Ministry of Labour, to consider a requirement that cameras be installed for the visibility in the crushing circuit. The cameras should permit employees and/or supervisors to view the crusher jaws without the necessity of looking directly inside the jaws.
  15. To the Ministry of Advanced Education and Skills Development, include in the common core training modules specific training on working with crushers which should include a module on crushing hazard and stored energy with a focus on non-routine hazardous tasks.
  16. To the Province of Ontario Ministry of Community Safety and Correctional Services that the length of time it takes to get to an inquest be shortened.