Ministry of the
Solicitor General

OCC Inquest - Johnson 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario

Surname: Johnson
Given name(s): Scott
Age: 33

Held at: 25 Morton Shulman Avenue, Toronto
From: March 25, 2019
To: April 10, 2019
By: Dr. David Cameron
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Scott Johnson
Date and time of death: June 16, 2012
Place of death: 35 Carl Hall Road, Toronto, Ontario
Cause of death: Crushing injury of head and brain
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on April 10, 2019
Coroner's name: Dr. David Cameron
(Original signed by coroner)

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

Inquest into the death of:

Scott Johnson

Jury Recommendations

I. Working Group

To the Government of Ontario

The Government of Ontario (“Ontario”) should:

  1. By December 2019, establish a permanent working group in conjunction with representatives of the live entertainment industry and labour working in the industry as well as Professional Engineers Ontario (the “Working Group”). The Working Group should be funded by Ontario and develop and maintain a fully integrated and consistent approach to the processes involved in the live performance industry, including the construction and use of demountable event structures (also known as temporary performance stages).
  2. Ensure the Working Group:
    1. Includes Ken Johnson, father of Scott Johnson;
    2. Consists of experts from the live performance and staging industry, including all levels of government, professional engineers, staging companies, production managers, promoters, artists, relevant worker groups and unions, and emergency services;
    3. Meets regularly to ensure an integrated multidisciplinary approach to the development of standards and best practices based upon recent developments and experiences in the industry that protects both workers and members of the public in attendance at such events;
    4. Completes, as an initial task, the development of a readily accessible publication compiling relevant legislative and regulatory provisions, guidelines, standards and best practices in the live performance industry, which could be known as the “Scott Johnson Book”. This publication should be updated regularly, distributed to relevant stakeholders, and be available online without charge;
    5. Addresses inquest recommendations, provides advice when consulted, and reports annually to relevant stakeholders and ministries, including the Ministry of Labour and the Ministry of Municipal Affairs and Housing;
    6. Works with the engineering community to promote structural engineering work in the live performance industry as a special area of interest.
  3. Ensure that the Working Group considers the following matters that have been identified in this inquest:
    1. The establishment of an Entertainment Industry Health and Safety Organization similar to the British Columbia "Actsafe Safety Association" (;
    2. The need for consistent and appropriate use of design drawings by all people involved in the construction of demountable event structures;
    3. The time pressures that exist in the scheduling and execution of a live performance event;
    4. The need for a trained supervisor on site at all times who has overarching responsibility for the construction and coordination of construction of the demountable event structure;
    5. The prohibition of workers from being on the stage floor while any work occurs overhead unless there are measures in place to protect the workers;
    6. Best practices, education, training, and formal certification or licensing for workers on demountable event structures, including scaffolders and riggers;
    7. Worker education and awareness of measures to ensure to whom and how to report safety concerns;
    8. The adoption of a requirement that a risk assessment be carried out by the constructor in conjunction with the responsible engineer prior to commencement of construction, and the results of that assessment be shared with all involved parties, for every installation of a demountable event structure.

II. Building Oversight

To the Government of Ontario:

Ontario should:

  1. Amend the Ontario Building Code in a manner consistent with the proposed amendments arising from the 2015 Report of the Expert Advisory Panel on Outdoor Temporary Stages related to demountable event structures established by the Ministry of Municipal Affairs and Housing.
  2. Consider additional amendments to the Ontario Building Code with respect to demountable event structures, including:
    1. At the conclusion of construction, the party responsible for the construction should provide the chief building official of the municipality with written confirmation that the project did not deviate from the approved design drawings and confirm that the structure is ready for intended use; 
    2. Requiring applicants for a building permit to construct a demountable event structure to apply a minimum of ten (10) business days in advance of the commencement of construction;
    3. Requiring a municipality to engage a professional engineer (“engineer”) as part of its building permit process.
To the Government of Canada and the Government of Ontario:

The Government of Canada (“Canada”) and Ontario should:

  1. Work to develop an agreement to ensure that demountable event structures constructed on federal crown land in the Province of Ontario comply with the Ontario Building Code or applicable federal regulatory regime, whichever provides greater protection.

Ontario should:

  1. Submit all changes that are made to the Ontario Building Code regarding demountable event structures to the Canadian Commission on Building and Fire Codes as code change proposals to the National Building Code of Canada.

III. Occupational Health and Safety

To the Government of Ontario

Ontario should:

  1. Amend the regulations under the Occupational Health and Safety Act to include new provisions that specifically address demountable event structures. This should include: 
    1. Demountable event structures should be designed by an engineer;
    2. An engineer should be present throughout the construction of a demountable event structure;
    3. An engineer should inspect the demountable event structure before it is used and certify that it is erected in accordance with the approved building permit drawings;
    4. d. A notice of project should always be filed in advance of the construction of a demountable event structure.  
  2. Consider the nature of the live-performance industry and appropriately consult with the Working Group when developing regulations and guidelines related to demountable event structures.
  3. Require that the Ministry of Labour develop and publish a Hazard Alert regarding the hazards and responsibilities involved in the construction of demountable event structures specifically referencing occupational health and safety issues and concerns raised by this inquest.

IV. Engineering Practice

To Professional Engineers Ontario

Professional Engineers Ontario (“PEO”) should:

  1. Ensure that its guidelines explicitly make clear that:
    1. Drawings should be clear and consistent, including in their measurement system;
    2. Guidelines and best practices applying to design and review of structures also apply to demountable event structures, wherever built;
    3. Design drawings should explain key elements in plain language, and include acronyms in a legend;
    4. As part of the engineer’s scope of work, engineers should work with clients to develop a checklist of components to be reviewed and the schedule for inspections;
    5. In providing design drawings to clients, engineers should clearly outline which drawings are included by including a comprehensive index as part of the package;
    6. There should be a disclaimer in the “title block” in an engineer’s drawings that the drawings are not complete and cannot be relied upon unless they are stamped, signed and dated by the engineer;
    7. Engineers, as part of the package, should provide a separate page of build details in the design drawings, including details for connections;
    8. Engineers should confirm that all custom components shown in the design drawings have manufacturer’s results, or have been subjected to specific testing;
    9. After design drawings are finalized and before construction has begun, engineers should meet with the party responsible for the construction, and where applicable, with the head rigger, to review and ensure a detailed understanding of the design drawings;
    10. Engineers should ensure that all critical components of demountable event structures have been subjected to a rational sampling process as set out in PEO guidelines prior to their incorporation into the demountable event structures;
    11. Engineers should be present from the beginning to the end of the construction of demountable event structures;
    12. Engineers should consider all available means, including the assistance of workers and technology, to ensure all critical components are properly used and installed.
  2. Advocate for appropriate standards consistent with the above referenced guidelines.
  3. Advocate for the enactment of a standard making clear that the engineer sealing the design of a demountable event structure is presumed to be responsible for the entire structure unless otherwise specified in writing on the drawing.
  4. Develop specialization criteria for engineers working on demountable event structures, including educational opportunities.
  5. Require members to file an annual report, which would include identifying the engineering areas in which they work.
  6. Provide members who work with demountable event structures with guidelines, special alerts, and any other information that will assist them in this area of work.
  7. Require that all engineers undertake a minimum number of hours of professional development activities and submit a record of such activities each year to PEO.
  8. Revise PEO’s Standard Project Completion Notice Template to add the following:
    1. The scope of work for which the engineer was retained;
    2. Identification of the party responsible for the project;
    3. Identification of the critical points in the construction;
    4. Identification of components inspected;
    5. Times physically present at the construction;
    6. Any limitations in the review and inspections;
    7. Confirmation that all field review reports have been provided to the party responsible for submission to the chief building official;
    8. Confirmation that the final report was made after all construction activities had been concluded.
  9. Inform its members of the engineering issues and concerns raised by this inquest through a Practice Bulletin.
  10. Inform its members of developments in PEO standards and guidelines in a timely manner.  

V. Owner/Operator and Promoter Obligations

To the owners and operators of live performance venues and promoters of live events:
  1. In the absence of an applicable building permit regime that provides equivalent or greater protection than the Ontario Building Code, owners and operators of venues being used for live performance events on demountable event structures in the Province of Ontario, such as Parc Downsview Park Inc., and promoters of live events, should include in the contract between them a requirement that the promoter provide the owner or operator with:
    1. a municipal building permit prior to the construction of a demountable event structure, and
    2. any report as required in the building permit process confirming general compliance with approved design drawings prior to the commencement of the live performance.  
  2. Promoters of live events should ensure that a second engineer, who is independent of both the staging contractor and the original design engineer, review the design drawings and review the construction of the completed demountable event structure before the event can be commenced.
To Industry Associations:
  1. Canadian Live Music Association, Event Safety Alliance Canada, Professional Association of Canadian Theatres and Canadian Institute for Theatre Technology should share these recommendations with their members and encourage their members to distribute them more broadly.

VI. Training for Workers

To the Government of Ontario

Ontario should:

  1. Work with educational providers to develop education and training opportunties for riggers and scaffolders working on demountable event structures.
  2. Require that local riggers working on performance venues in Ontario undergo a certification or licensing process similar to that in place for electricians in Ontario and certified riggers in the United Kingdom.
  3. Require the operators of Ontario businessess that erect demountable event structures be subject to licensing and qualification requirements that parallel those in place for electrical and gas contractors under the auspices of the Technical Standards and Safety Authority.
To the International Alliance of Theatrical Stage Employees

International Alliance of Theatrical Stage Employees (“IATSE”) should:

  1. Share and promote these recommendations with its members and employers.
  2. Develop training opportunities for working on demountable event structures.