OCC Inquest - Rochette 2018
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): Paul
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:
- 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.
- To Vale, jointly develop a separate comprehensive “Stored Energy” training module in the Zero Energy State program.
- To Vale, where relevant, make manuals and troubleshooting guides, if available, readily available to workers.
- To Vale, to ensure all workers and supervisors are practiced on all steps and requirements of the Job Hazard Assessment.
- To Vale, review the process of inspection of Blunts and Moil Points.
- To Vale, add a grizzly to control the size of matte allowed into chute.
- 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.
- To Vale, ensure appropriate emergency shut off buttons are available for the Traylor Crusher, Farrell Crusher and conveyor belts.
- To Vale, jointly review the Vale Crusher Safety Program for any gaps identified in the inquest process and applicable to other Ontario operations.
- To Vale, investigate installing an emergency horn if an over pressurization occurs in the hydraulic system of the crusher.
- To the Ministry of Labour, that regulation 854 for mines and mining plants subsection 64(1) be amended to remove the statement “underground mine”.
- To the Ministry of Labour, to make the Management of Change (MOC) process a legal requirement.
- To the Ministry of Labour, to implement electronic access for relevant workers to the Hazard Bulletins.
- 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.
- 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.
- 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.