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Executive Summary

Double Fatalities Investigation Report

June 8, 2011

USW Local 6500

Investigation

Jason Chenier and Jordan Fram died because of on-going and documented neglect of

safety standards by the owner of the Frood/Stobie Mine complex, the international

mining company Vale.

After an incident of this kind, in accordance with previous practice there would have

been a joint investigation by union and management representatives from the

Frood/Stobie JHSC (Joint Health and Safety Committee).

But Vale insisted on restrictions on what the joint committee could investigate,

demanded exclusive control of all documents and communication, and required

non-disclosure of all information and findings acquired in the investigation process.

In effect, Vale demanded that it would control the determination of the cause of the

fatalities, as well as the conclusions and recommendations drawn from the

investigation and findings (pg. 20/USW Report)

Because of Vale’s restrictions, the Health and Safety Chair of USW Local 6500, Mike

Bond, announced on June 23rd, 2011 that USW Local 6500 would initiate its own

investigation into the deaths of Jordan Fram and Jason Chenier.

Throughout the Union’s investigation, Vale officials refused to be interviewed by

members of the USW Team; dozens of USW members cooperated fully in

management’s investigation, attended interviews and answered their questions

fully.

Over the course of eight months, the USW Team examined evidence, conducted

interviews, performed research and considered all aspects affecting the fatality and

the mining processes that impacted upon the tragic events of June 2011.

The USW Local 6500 Report was submitted to the Ontario Ministry of Labour on

February 28, 2012.

Cause of Death

Jordan Fram and Jason Chenier died on the evening of June 8th, 2011, when an

uncontrolled torrent of wet ore material or run of muck burst out of the #7 ore pass,

and buried them. Ore passes allow miners to move ore from upper levels of the

mine down to lower levels, where it is eventually transported to the surface. The #7

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ore pass carries ore from the 2600 foot level of the mine past the 3000 foot level of

the mine where the June 2011 deaths occurred.

The run of muck occurred because wet ore from the 2600 level had “hung up” and

clogged the #7 ore pass at a narrowing of the ore pass above the 3000 foot level.

Fram and Chenier were working there when they died.

Miners, mining companies and health and safety regulators have long recognized

this as one of the most hazardous conditions in underground mining. USW Local

6500 members had complained for weeks about hang-ups in the #7 ore pass; the

issues were not adequately addressed by management (pg. 107/USW report).

When investigators arrived on the scene of the fatalities, they found that the crash

gate, which is used to move material in the #7 ore pass from above the 3,000 level to

levels below, was left in the open position. Jason Chenier had apparently opened the

gate in order to assess the “hang-up” and prepare to blast it loose. While this is an

accepted practice, it has also been recognized as a non-routine hazardous task for

which there were no listed or detailed procedures. It is one of the most hazardous

tasks in underground mining. (pg. 51, 61/USW Report)

Cause of Deaths

The deaths of Jason Chenier and Jordan Fram are directly attributable to the unsafe

accumulation of water in the Stobie Mine and the inadequate procedures in effect to

deal with the consequences of such foreseeable developments.

The Stobie Mine is located underneath and adjacent to three abandoned open-pits,

which collect water predictably and regularly. This is within the knowledge of the

company and its engineers. Water accumulation issues are exacerbated during the

spring runoff. The spring run off occurs every spring.

The company pumps and is obliged to safely manage 3 million gallons of water per

day. Shortly after the fatalities in June 2011, excessive water accumulation was

noticed on the 2400, 2450, 2600, 2800 and 3000 levels of the mine. (See photos pg.

40-42/USW Report).

When too much water saturates the ore, this creates sticky muck, a mixture that can

plug an ore pass. Since this is one of the most hazardous conditions in underground

mining, constant control of water is essential to maintain safety in the mine. A run of

muck is like an avalanche of wet rocks, wet gravel and wet sand.

The flow of water combined with mining material creates a mixture of mineralized

material, sand-fill and water. Stobie Mine’s technical service group stipulates that it

is acceptable to have sand and silt make up 30% of the ore material. A ratio in

excess of 30% has to be handled differently.

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Six (6) weeks after the June 2011 tragedy, the ore was found to contain 50% sand

and silt and 13% moisture. (pg. 47/USW Report)

Safety Requirements:

Ore Pass Design, Operation, and Maintenance are critical to the safe transfer of

material in a mine. It is important that the original design takes into account the

type and consistency of material that will go through a pass. This would include a

sizing device to restrict the size of material being dumped, a cavity monitoring

system, crash gate operation procedures, prohibitions against the introduction of

water into an ore pass, procedures to maintain ore pass dimensions, safe crash gate

operation, and safe procedures for clearing “hang ups” in ore passes. (pg. 29/USW

Report)

Drain holes are one of the principal strategies to control and redirect excess water

in an underground mine such as Stobie. At the time of the incident, drain holes at the

2400, 2600 and 2800 levels were known to have been plugged by rock, sand fill and

debris. Water at the 2400 level was approximately 5 feet above the top of the drain

holes. Water at the 2600 level was about 4 feet above the top of the drain holes. This

caused water to flow into the top of #3715 ore passes, mixing with the ore and

creating sticky muck. (pg. 35-38/USW Report)

Blast holes are drilled into an ore pass to allow miners to blast or breakup a

blockage. Safety procedures require that the blast holes must be sealed and grouted

after use. The blast holes at the 2600 level broke through into the #7 ore pass since

they are below the level of the accumulated water. The blast holes provided a path

for water to enter the #7 ore pass. The blast holes drilled at the 2800 level were also

below the level where water had accumulated, providing another way for water to

enter the #7 ore pass. (pg. 52/USW Report)

Guardrails: Jason Chenier erected double guardrails at the 2450 and 2600 levels

to prevent the dumping of any more ore into the #7 ore-pass. This, in effect, was a

shut down signal for this production area. Jason Chenier wrote in an e-mail in the

days before he died that the Company “should not be dumping or blasting this ore

pass until the water situation is under control.” For reasons that require further

forensic investigation by appropriate authorities, and which the USW Investigation

Team was unable to ascertain because of non co-operation by Vale management

officials, the double guardrails were removed under management’s directions and

re-installed up to 3 times over the course of 2 days. It appears that this was done to

allow miners to continue to dump wet ore into the #7 ore pass. The company has

provided no explanation for the removal of the double guard rails which Jason

Chenier , a supervisor at the time of his death, had erected as a safety measure. (pg.

83/USW Report)

Crash Gate Station: The design of the by-pass station at the 3000 level put Jason

Chenier and Jordan Fram in immediate harm’s way from a run of muck incident. The

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company had installed no cameras to allow them to view and operate the crash gate

from a safe distance. The crash gate at the station was not designed to close

automatically. This means that if a miner needed to leave the area quickly, the crash

gate would remain open, and material would continue to flow. Miners also had no

way of leaving; there was no second exit. (Pg. 90/USW Report)

This danger involving the type of location where Jason Chenier and Jordan Fram

were apparently undertaking a hazardous task was noted in the Inquest Report into

the 1995 death of Stobie miner Clifford Bastien.

The USW Report notes that this is a violation of mining regulations. (pg. 90/USW

Report)

Health and Safety Requirements:

Clifford Bastien Inquest: Following the death of Clifford Bastien in a similar run of

muck accident in 1995 at Stobie Mine, a coroner’s jury made 33 recommendations.

Six of these addressed the issue of reducing the threat of another fatal run of muck

accident.

The fact is that there have been at least six (6) other run of muck incidents at the

Stobie Mine in the period 2005 to 2011, the six years before the deaths of Jason

Chenier and Jordan Fram. (pg. 69&74/USW Report)

All Mine Standards: The All Mine Standards, the Ontario Occupational Health and

Safety Act and Regulation 854 of the OHSA, establish the legal requirements for

workplace health and safety in mines. The company failed to meet these

requirements by allowing excess water to accumulate and by failing to provide a

training package that addressed the safe operation of the crash gate at the #7 ore

pass. (Pg. 122/USW Report)

Management failed to follow the legal requirements of OHSA when a worker refused

to work because of unsafe conditions. Workers who were told to blast suspended

material hung-up in the #3715 ore pass were NOT told other workers had refused

to do such work. (Pg. 125/USW Report)

All miners working at Stobie were given a two-day training program. Only one

bullet point in the two PowerPoint presentations dealt with the danger of run of

muck incidents. (Pg. 112/USW Report)

079 Form: When an unsafe working condition is reported, company procedures

require the completion of what is known as a “079 form.” After the lengthy

2010/2011 labour dispute, workers and the Joint Health and Safety Committee have

been denied the right to initiate 079 forms and know that their health and safety

concern/complaint would be filed and addressed by management. The filing of such

a complaint is now done at the “discretion” of the supervisor. In addition, when

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interviewed during the Local 6500 investigation, many miners reported that they

were and are discouraged from reporting hazards. Miners recounted that when they

did report hazards, this was not logged on 079 forms. Miners reported having fears

of retaliation for raising health and safety concerns. This reflects a “culture issue”

that requires further investigation and positive steps to redress. (Pg. 57/USW

Report)

SafeProduction: Vale’s safety program is known as SafeProduction. It purports to

ensure that management is accountable for preventing injuries, and that employee

involvement is essential. Unlike the 079 form processes, there is no process under

SafeProduction to ensure a hazard is communicated to others. (Pg. 105/USW

Report)

Hazard Alerts communiqués are issued as a warning of hazards that have been

identified. There were no Hazard Alert warnings issued in relation to the water

conditions that developed at the time of the June 2011 double fatality. Management

has provided no explanation for this failure. (Pg. 100/USW Report)

After the June 2011 tragedy, a USW Local 6500 Worker Representative requested

the issuance of a Hazard Alert, but his request was denied by Vale (Pg. 59/USW

Report).

Joint Health and Safety Committee: In the months immediately before the June

2011 double fatality, the worker representatives on the JHSC raised concerns about

stuck drain holes, hang-ups, sticky muck and the excessive accumulation of water.

The company failed to address these concerns prior to the deaths of Jason Chenier

and Jordan Fram. (Pg. 114/USW Report)

Supervisors Log Book: The Supervisor Log Book was not being used as is intended

by applicable mining regulations. On June 6, 2011, Supervisor Jason Chenier tried to

enter his concerns about the danger of a run of muck incident in the safety section of

the Supervisor’s log book. There was no room, because the safety section was filled

with previously reported safety concerns. Chenier was forced to send two e-mails to

management instead. (Pg. 106, USW Report)

Wet-Dry Measurements: Given the excessive water accumulation on the levels

immediately above the 3000 level, wet and dry measurements were required to be

taken at both the #7 ore pass and #3715 ore pass. A wet measurement would

quantify the amount of water in the ore mixture, show if there was water

accumulation in the ore passes, and alert supervisors and management to the

possibility of a run of muck incident. The wet and dry measurements are supposed

to be recorded and communicated.

No such wet measurements were found in the daily shift log for the year previous to

the fatalities. No explanation for this omission has been provided by Vale. (Pg.

35/USW Report)

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Criminal Code Offences

The Westray Bill, also known as Bill C-45, amended the Criminal Code of Canada in

2004 and placed an occupational health and safety duty on individuals,

organizations and their decision-makers across Canada.

Among other changes, the Westray Bill made workplace negligence a criminal

offence by adding a new duty on organizations and individuals to take reasonable

steps to prevent bodily harm and death. Not acting to protect health and safety

became a violation of the Criminal Code of Canada.

The USW Local 6500 investigation into the June 2011 double fatality at Vale’s Stobie

Mine has revealed a failure to manage water conditions and other potential hazards

in the underground workplace environment and an overall failure to abide by and

implement provincial and internal safety requirements. These failures demonstrate

a wanton and/or reckless disregard for the lives and safety of those working in

Vale’s mines, in addition to demonstrating that Vale and its managerial officials and

representatives failed to take all reasonable steps to prevent bodily harm and death.

Recommendations

After eight months of research and interviews, the investigation team of Local 6500

of the United Steelworkers has made 165 separate recommendations to improve the

safety and working conditions at Vale’s Stobie Mine, and by extension at all of Vale’s

mines in the Sudbury Basin and at all underground mines throughout Canada. (pg.

147/ USW Report)

The recommendations include:

• That the Government of Ontario establish a Public Inquiry into the causes of

the fatalities at the Stobie Mine, and more generally into underground mine

safety in Canada, with special emphasis on water management issues,

monitoring and enforcement. There have been substantial changes to mining

processes since the last significant Ontario/Canada health and safety inquiry

30 years ago.

• That Ontario’s Assistant Deputy Attorney General – Criminal Law take

immediate steps to determine whether charges under the “Westray”

provisions of the Criminal Code of Canada should be laid against company

officials. The review would consider the USW Report’s findings and

undertake further investigation, as Crown Attorneys and police authorities

consider necessary.

• That a Committee be appointed by the Ontario Minister of Labour to review

whether the Occupational Health and Safety Act and that Act’s enforcement

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provisions are adequately safeguarding the safety of workers employed in

underground mines and surface mining plants in Ontario.

• 78 recommended changes to health and safety rules at the Stobie Mine, to

ensure, among other things, that Hazard Alerts are initiated without fear of

reprisal and that workers have the protected right to file “079 forms” without

interference or intervention by Vale.

• 27 recommended changes respecting the use of ore passes at the Stobie

Mine, including an absolute and enforceable obligation ending the practice of

dumping of wet muck into any ore pass, such as the #3715 and #7 ore

passes.

• 16 recommended changes to water drainage practices, including the

monitoring and elimination of hazardous water conditions such as occurred

on the 2400, 2450, 2600 and 2800 levels at Stobie Mine in June 2011.

• 16 recommended improvements to blasting procedures, including

developing, implementing and enforcing new techniques for the sealing of all

drill holes into ore passes.