WORKERS’ COMPENSATION BOARD OF BRITISH COLUMBIA ... · Each year in British Columbia, the Workers’ Compensation Board (WCB) reports numbers of fatal, work-related traumatic injury

WORKERS’ COMPENSATION BOARD OF

BRITISH COLUMBIA: FATALITIES INVESTIGATIONS

Susan Nelson-McDermott

Researcher, Royal Commission on Workers’ Compensation in British Columbia

30 September 1998

Nelson-McDermott \ Fatalities 30-Sept-98

“… It is so unfortunate that we must await a tragedy such as Westray to initiate

improvements designed to avoid such similar situations. We must strive to perfect a

system of review, both in the context of the advancement of safety that is not disaster

driven but, rather, results from continued review, earnest safety-oriented consultation,

and aggressive enforcement of the regulatory regime. Anything less may only result in

sustaining the disaster-driven safety mentality.”1

Purpose of Study

Each year in British Columbia, the Workers’ Compensation Board (WCB) reports

numbers of fatal, work-related traumatic injury accidents and occupational diseases

that have been registered with it in the form of claims for compensation. Between 1993

and 1997, the average number of fatal claims filed with the Board was 199 per year2.

The Board reports to have accepted, on average, 145 of these claims3 per year. Not all

fatalities that are registered with Compensation Services are investigated by the

Prevention Division as they are not within the Prevention Division’s regulatory

jurisdiction.

When a fatality occurs in the WCB Prevention Division’s inspectional jurisdiction,

ideally, field officers trained in occupational safety or occupational hygiene (OSO or

OHO) investigate the circumstances leading to the fatality. Accident investigations are

usually conducted by a field officer only for fatalities and near-misses and employers

are regulated in the immediate reporting of fatal accidents. The purpose of the accident

investigation is two-fold: to determine whether regulations have been violated and

causality. During the inspection, the OSOs or OHOs intent is to note regulatory

violations. Violations are documented (Inspection Report or IR), and where observed,

orders for corrective action are written. Corrective or preventive orders are written for

the employer’s action, and posted for all workers to read. Warning letters and sanctions

may be recommended by the inspecting officer based on the evidence and violations.

1 The Westray Story: a predictable path to disaster: report of the Westray Mine public inquiry, v.2, ch. 4, p. 631.2 See Table 1. “Fatalities that Occurred in the Year” - information compiled from WCB AnnualReports for the years 1993 through 1997.3 See Table 2. “Fatal Claims Accepted According to Agency With Inspectional Jurisdiction” -information compiled from WCB Annual Reports for the years 1993 through 1997.


Where workplace deaths fall within the Coroners Services mandate (generally, s.

9(1)(d) of the Coroner’s Act), the regional coroner may also investigate the fatality.

Each agency produces its own report and may make recommendations for action that

will prevent reoccurrence of the conditions that led to the fatality. This paper discusses

the statutory powers and the organizational policies of each agency, and attempts to

identify where their responsibilities overlap or connect , essentially, the working

relationship between the two.

Summary

Initially, the focus of this paper was to provide the commission with an understanding of

the WCB’s relationship to the Coroners Services. In the effort to understand this

relationship, other notable issues surfaced. WCB’s fatality reporting, the Board’s

relationship with the Vital Statistics Department, and the investigation of fatal accidents

generally, and how fatality data is gathered and used by the Board. Further, the issue

of the Board’s approach to occupational disease deaths is commented on as an issue

of concern, but outside of the coroner’s jurisdiction, and often not within the scope of

the field officer’s investigation either.

Methodology

To start, data for a comparison of cases where the Prevention Division and the

Coroners Services had both investigated and the coroner had made recommendations

was requested of the Workers’ Compensation Board4. The response was that although

the Board’s representative had attempted to locate the information requested, she

discovered that

… the processes with respect to fatalities and follow-up documentation seem to

remain quite necessarily fractured and that makes it challenging to obtain all of

the information from one source. … At this point of time there’s probably at least

six different areas in the Board that develop files with respect to fatals, so

getting all the necessary information you need might be difficult … If it is [focus

of the research], strictly the integrity of the coroner’s relationship with the Board,

4 12 January 1998 Email message to K. Mullins, Corporate Relations, WCB requesting “anyguidelines or policies the Board has for its internal process re workplace fatalities, investigations,and liaison with the coroner (and other involved agencies). … As well, I will need to see thefollow-up to all coroner’s recommendations.”


then the information that I have found so far isn’t going to help very much. We’ll

have to move on to another area that captures probably some of that

information or you may have to go back to the Coroner’s Office as well and say

“give us a copy of everything that you’ve sent to the Board,” because

unfortunately, it appears they sent it to many different areas of the Board for

many different reasons. …5

The Worker’s Compensation Board was then asked for a detailed list of all fatalities so

that the researcher could cross-reference those cases that involved the coroner’s

services and field officers. The list was to include:

• name• date of birth• date of death• cause of death• occupation• employer• coroner’s investigation and recommendations status• status of response to coroner’s investigation and recommendations• claim number• claim status• accident investigation status

The Board was unable to provide the royal commission with one comprehensive list

that included the above, and instead, again at the researcher’s reiteration of the initial

commission request, forwarded an array of reports, the data from which was then

manually compiled into one database to get a better view of who does what. Because

the Board does not electronically track coroner’s reporting and recommendations, this

information could not be tracked from the WCB end of things, and the reports provided

were the Board’s best attempt to meet the above criteria.

The Coroners Services Office was contacted and an interview with members of the

provincial Coroners Services provided some initial information about the inter-agency

relationship, from the coroners’ experience and point-of-view. As well, at the

commission’s request, the Coroners Services provided printed reports from its

database indicating work-related fatal accidents that regional coroners had investigated

5 Voicemail message from Karen Mullins, Corporate Relations, WCB, 27 January, 1998.


(with or without recommendations to the Board) for the years 1993 through 1997. This

data contained industry, cause of death, and recommendations to WCB; note, the list is

not a complete listing of all workplace fatalities in British Columbia - it is restricted to

coroner’s inquiries.

The lists provided to the commission by the Board were 1) fatals reported, 2) fatals

reported and accepted, 3) fatals that had accident investigations, 4) claim numbers for

reported, and 5) claim numbers for reported and accepted. After reviewing the data

contained in these reports, it appeared that none were able to give a complete picture

of all work-related fatalities in British Columbia, and data was requested from the royal

commission cohort project to verify some of the data missing from that provided by the

WCB. Table 3 in the appendix outlines what type of data was available from each

report and where the variances in information show up.6

Because of the lack of integrity between the data sources, and the Board’s inability to

verify the data or why fields were blank (even with the cohort data supplement), it was

decided that a file review would be appropriate. Because of the potentially large

number of files at the Board, a complete file review was not possible in the time

available. Instead, a sample of 100 claims (25 for each year of the five-year study) was

electronically chosen at random and forwarded to the Board. Of the 100 files, 99 were

located in Compensation Services (one number was a duplicate). Note, the sample

includes only fatalities where a claim was established whether the claim was accepted,

disallowed, or rejected. Of these files, three were pending section 11 challenges and

two were in “lock up” as evidence for an internal fraud case. The researcher was given

access to 91 of the claim files available through Compensation Services.

Prevention Division had accident investigation files for approximately 50% of the study

claims. Many of the fatal claims were outside of the Board’s inspectional jurisdiction,

and no Prevention files existed other than some preliminary accident investigation

reports.

6 Table 3: Variance Report. Sources are cited in the table.


Employer files were not readily produced for the commission’s review - the Board’s

Policy Bureau instructed the Prevention Division’s Support Services not to make these

files available as it was felt that the researcher was unaware of the amount of work that

would be involved in reviewing information in the employer files. Fifty-five employer files

were provided for review.

Documentation

In the attempt to give the commission a comprehensive view of what happens following

a fatal accident or death due to an occupational disease, the researcher attempted to

undertake a thorough workplace fatalities-related document review. It became clear

that the Board does not have, in either Compensation Services7 or the Prevention

Division, clearly stated processes that specifically address what to do when there is a

work-related death. This report could have ended there. However, in fairness to those

at the Board and in the field who appear to quite consistently follow-up fatalities, it

seemed right to try to understand and document what appeared to be a number of “soft

processes” as well as practices and philosophies that are understood, but not

formalized. This process also identified some seeming deficiencies of the system and

where it appears to breakdown, and this report looks at the Board’s system of response

to workplace fatalities in general. It does not measure the Board’s effectiveness in

applying its policies to the fatalities because those do not formally exist: some may be

inferred in the application of the Board’s existing policies and practices, but where

direct reference and instruction were not found, this report assumes that there is no

official direction and those in the Board’s divisions carry on of their own initiative,

experience, and cognizance.

Although the file review provided examples and some proof of many of the points made

in this paper, at best, the review of the sample of WCB’s fatality-related files can be

referred to as a survey, not a scientific study. Although all files related to fatal cases

7 With regard to fatal claims adjudication, there is no policy outside of the WCA to support thefatal claims desk and its decisions. There is an old “Fatal Claims Manual” that outlines basicprocedures. It is not an official document that represents the Compensation Service’s publishedpolicies about fatal claims adjudication, s.17 of the WCA provides albeit complicated algorithmsfor computation of benefits. Because there are no guidelines for decision-making for claims thatdo not strictly follow the statute, the fatal claims adjudicator, in an interview, informed theresearcher that he applies it with as much latitude and discretion as possible.


were requested for review, all files were not made available. Compensation Services

provided nearly 100% of files requested. Prevention Division, however, did not make

available any files beyond Accident Investigation and Employer Files that it houses in

its central storage facility. The integrity of data contained in any file could not be

verified and cross-referenced. When the researcher was informed that files outside of

the Richmond facility would not be provided, she asked for a list of the files that were

missing and why. The Policy Bureau did not prepare this list, and stated that it would be

too time-consuming to do so. The Policy Bureau did provide the researcher with an

opportunity to infer what was missing from the Richmond files and request specific

information based on that inference. The fact that this would not be appropriate, and

that the researcher’s role was to report out on what was provided, not to guess about

what was or was not in Richmond’s files, was made clear to the Board’s representative.

The Prevention Division’s Legal Office opened its files to the commission and provided

a glimpse at the actual follow-up to coroner’s inquests and recommendations following

an inquest. The areas of the Board where there exists some question as to whether or

not information was provided are: regional offices, Vice-President and upper

management files, WCB’s Legal Division, the Appeal Division, the Variance & Sanction

Review, as well as the Prevention Division’s Policy and Regulation Development

Bureau – files that referred to deceased workers in the study sample were not

provided. The Policy Bureau, in one of its answers to questions from the commission

provided copies of coroner’s recommendations and Board responses - the responses

contain references to Rex Eaton and the Policy Bureau as being the appropriate office

to take action to regulatory recommendations, yet files contained in this office were not

referenced or provided. Further, correspondence that may exist at the Board (outside of

the Prevention Division’s Legal Office’s files) was not made available. It should be

mentioned, however, that information about individual claims and sanctions is

contained in the Compensation Services and Prevention Division Employer Files.

Through this process the researcher did not gain confidence in the completeness of

information or the files provided.

The Board did not provide the commission with a briefing paper or much by way of

policy or literature about its fatalities investigation process, and so a list of questions


about fatalities and the coroners services, causation, data, targeting, and claims

adjudication was created and sent to the Board. The Board responded to these

questions two months later. Many of the cited passages in this report are taken directly

from the Board's written response to these research questions.

The layout of this report may at first seem awkward. To understand the relationship

between the Board and the Coroners Services and recommendations, one first needs

to try to understand the relationship of the Board to its own fatalities investigations and

follow-up. Much of this report deals with the latter to provide a context within which it

addresses the former.

Submissions:

Submissions have identified the role of the coroner, and what happens to coroner’s

recommendations as an issue of concern; particularly:

1. Whether or not investigation findings are conveyed to the deceased worker’s

survivor(s) and the public;

2. How recommendations made by the coroner influence health and safety regulation

and policy development;

3. How coroner’s recommendations translate into workplace health and safety.

Submissions to the commission referred to dissatisfaction or concern about how

fatalities are processed and the relationship between the Workers’ Compensation

Board and the Coroners Services.

Submission Quote #1:

“... How seriously do we treat workplace deaths in BC?

[The] Coroner ... accepted without further investigation the WCB’s incorrect initial

assumption that ... slipped and fell because his shoes were worn badly and used it as a

cause to deny me an inquest? ... Inquests should be automatic in workplace fatalities

and investigations ought to be more thorough.


... Since the recommendations of both coroner and jury were ignored by the Revision

Committee, the inquest must be seen as a waste of time and taxpayers’ money. I now

understand the reluctance to grant one in the first place. Perhaps it was arranged only to

appease me.

Whenever I pass a scaffold now, I think of my son and I look for guard rails. On almost

every occasion they are absent, even when the work site is within view of the ... office,

which has happened on at least three separate occasions. Four years after Mike lost his

life, the same violations that caused his death continue to occur with seeming impunity in

spite of the assurance given me that what was learned from Mike’s death would be used

to make meaningful changes. If there is little or no cost for non compliance, what would

motivate industry to be more vigilant about observing the rules?8


“I was totally shocked, disgusted and angry, not only with the investigation into my son’s

death, but also the fatal accidents of other young men whose families shared their

concerns with me. These fatality investigations are an affront and insult to the family left

to cope. For my own peace of mind, I needed to know exactly what happened and why

my son died. ...

“I really did not understand how my son died until after I met with the Coroner in Fort St.

John in October 1994. In a two hour meeting, she explained it to me, answered all of my

questions. It was after this meeting, that I started my own investigation. I obtained a copy

of the Industrial Health and Safety Regulations and applied under the Freedom of

Information Act for all documents from the WCB, RCMP and the Coroner’s office. It

wasn’t until January 1995, that the documents requested were received.”9


“... That a coroner’s inquest be conducted at the request of the surviving family member,

or of a union representing the workers in the workplace. In this way, those concerned

that the true causes of death have not been fully discovered can be assured that a full,

public and impartial inquiry will ... 10

8 Submission: Y-INJ-0679 Submission: S-GEN-05510 Submission: B-UNA-016v.doc, p. 5



“It is an unfortunate reality that British Columbia has one of the highest workplace fatality

rates in the country.

Adding to the frustration for workers is an awareness that workplace fatalities go

relatively unnoticed in public life, … Survivors have expressed a great deal of

dissatisfaction with the current process of fatality investigation and follow-up.

A frequent concern of grieving survivors is the feeling the investigation by public agencies

is superficial, and does not fully explore the factors that resulted in the worker’s death.

The sense of a need to know the reasons for the loss of a life is a normal part of the

grieving process, but the circumstances of most accidental workplace fatalities heighten

this sense. Survivors have no time to prepare emotionally, as they would in the progress

of a chronic disease. …

More importantly, most survivors understand that an employer may have a motive to

avoid any finding of responsibility because of the possibility of sanctions.

Similarly, many families believe the WCB has its own motives for making certain findings.

They believe, like most in the community, that the WCB had a responsibility to keep the

deceased worker safe. Some are suspicious the Board may not admit its own failings in

the course of an investigation.

As well, there is a feeling that the Coroner’s inquiry or WCB investigation that follows in

many fatality cases is superficial, given the nature of their loss. No probative hearing

takes place. There is a sense that the evidence regarding the cause of death is not

tested adequately in these circumstances, and that the recommendations regarding

preventing future fatalities are often faint-hearted, for fear of causing controversy.

When dissatisfied with these investigations, survivors sometimes seek a Coroner’s

Inquest into the fatality. For a number of reasons, which may include budget constraints

or a sense that the Board’s response is satisfactory, Coroners appear reluctant to

respond positively to these requests.


Compounding this problem is the lack of visibility of the Board’s response to fatality

investigation recommendations, and in a number of cases, the failure of the Board to

respond.

In the result, many survivors feel that society has placed little value on the life of the

deceased. The lack of follow-up response as exemplified by changes in regulations,

policies, programs and enforcement adds to the sense of meaningless loss.

We believe the Commission should consider recommending a series of measures for the

investigation of workplace fatalities that will reassure survivors that justice will be done,

and that the public interest in finding the cause of work-related fatalities will be served.

Recommendation 56:

“We recommend a requirement that a Coroner’s Inquest be conducted at the request of

the surviving family, or where there are no survivors, at the request of a union

representing the other workers in the workplace. In this way, those concerned that the

true causes of the death have not been fully discovered can be assured that a full of

inquiry, open to the public and judged by a jury representing the values of the community,

will be conducted into the fatality.

This right should be extended whenever the cause of death is suspected to be work

related.

To address the issue of the response from the WCB to Inquest recommendations, we

recommend a public reporting obligation be a duty of the Board.

There should be a requirement that the Board produces a response to each jury report

that concludes a death was work related, and recommended measures be taken to

prevent future fatalities. The Board should be required to report within a set time period,

and set out its response to the recommendations. Where it disagrees with the

recommendations, the Board should outline its reasons. Where it agrees with the

recommendations, it should set out its plans for implementing the recommendations.”11

11 BC Federation of Labour, Submission to the Royal Commission.


Fatalities and the Board’s Response

The Workers’ Compensation Board Prevention Division states that “Investigation of

fatal accidents are generally conducted in the same way as the investigation of other

serious accidents.” (Response to RC questions)

Section 71(8) of the WC Act states in part:

An officer of the board may investigate an accident resulting in injury to, or the death of,

a worker, and may inspect and inquire with respect to health and safety matters at any

place of employment, and may make the inquiries and inspect the documents he or she

considers necessary for these purposes, and any employer, worker or other person who

withholds information from the officer making inquiries, or who otherwise obstructs or

interferes with an officer in the exercise of the officer’s functions …

The Accident: Awareness of the Event

When there has been a fatal accident, the Board may be notified by EHS, the Fire

Department, the police, or the coroner. Sometimes the employer representative or

family member informs the Board, and, on occasion, a field officer will learn about the

incident by radio or newspaper article. Telephone calls are generally directed to

Richmond where an operator collects information and then relays it to the regional

office manager. If a fatality occurs after business hours, the operator contacts the “duty

manager” (after-hours on-call system) and the duty manager contacts the regional

manager. Off-hour calls are received by the emergency clinic.12

Accident Investigations

At the scene, police have usually attended to determine if there has been criminal

action, and then prepare a “sudden death report”. Board field officers are supplied with

field kits that contain specialized equipment for documenting their findings (eg,

camera). In conducting their accident investigations, field officers have access to “any

resource” that they require, the request must go through the area manager, however.

Often, the coroner is already on premises when the field officer arrives.13 The file

review showed that in some instances, the field officer is not immediately notified of the

fatality, and it is not unusual for the coroner and police to have conducted an initial

12 As described in an interview with Mr. Al Luck, Prevention Division, April 24, 1998.13 As described in an Interview with Mr. Al Luck, Prevention Division. April 24, 1998.


investigation before the field officer arrives at the scene. If the field officer is not

immediately notified and able to participate in the initial follow-up, that officer may have

to rely on information shared by other agency representatives and there may be an

issue of integrity of evidence and originality of evidence gathering.

Field officers collect observations, notes, investigative findings. Sometimes the field

officer recommends that evidence be impounded by the coroner. The field officer does

not have the authority to do this, and relies on the coroner’s support for maintaining

evidence. Fatality reports follow a standard format (52B15) which is the same for all

accident investigation reports. Materials and photos are attached to the 52B15 and all

of the information is transmitted to Richmond14.

Where there is coroner involvement, the Board states that “[t]he Prevention Division

plays mainly a supporting role to the adjudication of fatal claims and coroner’s

inquests.”15 “Where the coroner and the Board investigate an accident, they each

conduct their own separate inquiries. … the representatives of each organization will

informally assist each other. Sometimes, the Board officer may suggest to the coroner’s

representative that the coroner exercise powers under its statute where it is able to do

this more conveniently, … As noted in the 1995 Memorandum of Understanding with

the coroner, the Prevention Division may in some cases request an inquest or

participation in meetings between the coroner with the family or other interested parties.

…”

14 The Prevention Division states that “transmission of evidence and reporting” to Richmond is arelatively new procedure. In the past, information was held in regional areas, and it is thatinformation that is unavailable and undocumented in the Richmond files. The Assistant FieldServices Director stated that Prevention Division’s Support Services maintains all of theserecords and evidence in locked cabinetry - no one else has access. In an interview with arepresentative of Support Services, the researcher was informed that evidence other than paper,electronic, and photographic information is not stored in Support Services. Support Servicesmaintains accident investigation files (kept in large envelopes), however there is no specialprocedure for maintaining physical evidence outside of the filing system.15 Royal Commission on WCB answers to Question in April 22, 1998 letter A1.


See Diagram 1 for analysis of the Relationships Between Agencies and Accident

Investigations.

?Loss

Regional FieldManager

Yes

DenominatorNo review by WCB toevaluate work-related

deaths?

Episode

Death

Death InjuryInjury

monthly vital stats. report

Contract?

CertifiedDeath

DatabaseAccess

WCBVital Stats

Vital Stats

DIAGRAM 1

Traumatic

1st Responder

Occupational

100% Notify PoliceCoroner

Switchboard

WCB

? Coroner’sDatabase

Coroner calls WCB100%

Investigation

Call WCB

Starts Investigation- site visit

- views body

Replys toon-duty

manager

? NotifyCompensation

- pension

Criteria

Jurisdiction

Yes

Yes

NO

NoInvestigates Immediate ??

Not Satisfactory

Quality of Report

Pensions

MOUWCB

investigatesall deathsbut don’t


Accident Investigations and Reporting

When there is a fatal accident (or a near miss), employers must immediately report the

incident to the Workers’ Compensation Board. While there are few documented

procedures and guidelines for the how the system works, it has been suggested that

the information flow is as follows

Employer notifies police, EHS, and/or WCB ⇒ EHS or police notify coroner ⇒ police or

coroner notify the WCB.

Sometimes, the Workers’ Compensation Board is not informed of a workplace fatality,

and there are occasions where a field officer or Board employee has heard of a

possible work-related death over the radio or read it in the newspaper. There have

been instances when the workplace accident has resulted in a serious injury and the

Prevention Division may or may not be notified of the worker’s subsequent death. An

example of this can be found in the sample of files reviewed: an individual died of fatal

injuries following a fall (construction). The fatality was not reported to the Board;

however, a week later, a second worker fell in an almost identical accident, but his

injuries were not fatal. The field officer did not learn of the fatality until he was

investigating the near miss. The employer, ambulance service, and police had all

neglected to inform the Board.

A review of the files has shown that this may be the case: the central AIRS files are not

updated in all instances and some individuals listed as deceased in compensation

services records are listed as injuries in the accident investigation records. Clearly the

two divisions of the Board do not have agreed-upon and set written policies and

procedures for information sharing. It would appear from lack of evidence to the

contrary that no formal, established agreements between the Workers’ Compensation

Board, the Coroner’s Services, the BC Ambulance Service, and federal or municipal

police, or even its own Compensation Services or Statistics Division to ensure that the

WCB Prevention Division is notified in the case of an accident or disease leading to

death. Fatal accidents that are not reported cannot be investigated.


While information oversights might continue to occur in the field, it would be fairly

inexpensive to set up an internal notification system (ie, between Compensation

Services and the Prevention Division). Generally, the sensitive claims adjudicator

receives the “front page” of a preliminary accident investigation when there has been a

fatality-related benefits claim, and although the Prevention Division is not notified in all

instances of death, it does share this preliminary information with Compensation

Services Division.

Accident Reporting: WCB

Employers’ responsibilities following a fatal accident are regulated by the Board:

Informing the Board3.7 Every employer must inform the board immediately of the occurrence of any accident which(a) resulted in death or critical condition with a serious risk of death,(b) involved a major structural failure or collapse of a building, bridge, tower, crane, hoist,

temporary construction support system, or excavation,(c) involved the major release of a toxic or hazardous substance, or(d) was a blasting accident required to be reported by Part 21 (Blasting Operations) or a diving

accident required to be reported by Part 24 (Diving, Fishing and other Marine Operations)Note: Accidents may be reported to the nearest board office, or to the Richmond office bytelephone, toll free in BC, 1-800-661-2112 (local 3100), or fax (604) 273-3247 from 8:30 am to4:30 pm on weekdays. Reports after normal business hours and on weekends and holidaysshould be made by telephone to (604) 273-7711.

Accidents to be investigated3.8 Except in the case of a vehicle accident occurring on a public street or highway, every

employer must immediately initiate an investigation into the cause of every accident which(a) is required to be reported by section 3.7,(b) resulted in injury requiring medical treatment, or(c) did not involve injury but had a potential for causing serious injury.Note: Medical treatment means treatment by a medical practitioner.

Investigators’ qualifications3.9 Accident investigations must be carried out by persons knowledgeable of the type of work

involved and, if feasible, include the participation of one worker representative and oneemployer representative.

Intent of an investigation3.10 An accident investigation must, as far as possible(a) determine the cause or causes of the accident,(b) identify any unsafe conditions, acts or procedures which contributed in any manner to the

accident, and(c) develop recommended corrective action to prevent similar accidents.

Accident investigation reports3.11 (1) An employer must ensure that an accident investigation report is prepared containing

(a) the place, date and time of the accident,


(b) the names and job titles of persons injured in the accident,(c) the names of witnesses,(d) a brief description of the accident,(e) a statement of the sequence of events which preceded the accident,(f) identification of any unsafe conditions, acts or procedures which contributed in any

manner to the accident,(g) recommended corrective actions to prevent similar accidents, and(h) the names of the persons who investigated the accident.

(2) Copies of the accident investigation reports must be forwarded without undue delay to theoccupational health and safety committee and to the nearest board office.

Follow-up action3.12 Every employer must initiate corrective action without undue delay to prevent recurrence of

similar accidents, and must make a report of the action taken to the occupational health andsafety committee, or if there is no such committee, must post the report for reference byworkers.

Preservation of evidence3.13 If practicable, the scene of any accident reportable under sections 3.7 must be leftuntouched, except for activity necessary for rescue work, or to prevent further failures or injuries,until the accident has been investigated by an officer, or until permission to clear the scene hasbeen granted by an officer.

Accident investigation reports (WCB)

Fatal accident investigation reports are kept with all accident investigation reports.

There is no special process that distinguishes how these records are maintained. The

data is collected by Prevention’s Support Services Section, and regular reporting on the

fatal accident investigations is done through the “Prevention Division Reports” and

“focus reports”.


See Diagram 2: Accident Investigation Reporting.

Prevention Division: Accident Investigations

Investigate

Documentfindings

Accident Investigation

ReportPrevention Division(Acc. Invest. Files)

InspectionReport

Prevention Division(Employers’ Files)**

• Inspector’s Findings• Police Report• Coroner’s Report - verbal• Engineering Report• Laboratory Report

• Orders• Recommendations for sanctions and prosecutions• Educational consultations

Follow-up?

** Note: Reference to inspection as follow-up to fatality is not 100%


When asked what happens to the fatal accident investigation reports and how the

information on the accident investigation report factors into overall prevention activities,

the Policy Bureau stated that, “An initial summary report is prepared by the

investigating officer. This is entered into a data base kept by the Support Services

Section and is widely circulated through the Board by e-mail. The database contains all

accident investigation reports, not just those on fatalities.16 Accident investigation files

are entered into Prevention’s database and reports listing these accidents have been

assigned numbers can be created; however, these lists do not distinguish preliminary

accident investigations from full investigations. That is, the information may be

misleading and inaccurate.

“The more detailed final report is also entered into the database kept by the Support

Services Section and can be used for research.” Although, the Policy Bureau states

that “…, a copy of the accident investigation report is provided to the fatal claims

adjudicator but usually the claim has already been adjudicated. The claims adjudicator

will usually request any information required from the prevention officer before the

accident investigation report is complete. The report is not placed on the claim file

because of concerns regarding the Freedom of Information and Protection of Privacy

Act.”17 Note, the Policy Bureau and Compensation Services are not in agreement

about whether the claims adjudicator receives a copy of the accident investigation

report. The claims adjudicator requires sufficient information to adjudicate the claim,

and a review of files showed that the claims files consistently contain a copy of the first

page of the preliminary accident investigation report, but rarely contain the entire report.

There appears to be some discrepancies between the points being made by the Policy

Bureau. Interestingly, as pointed out by the Policy Bureau, “The claims adjudicator

routinely obtains investigation reports from other jurisdictions where available, for

example, the coroner, the Coast Guard and the Police.”18 These reports are not

routinely forwarded to Prevention Services and are not requested by Prevention

16 Note: in practice, the front page of this report is circulated to interested parties throughout theBoard, not the entire report. For example, the special claims adjudicator receives notification of afatality by way of the front page of a preliminary accident report. Compensation Services doesnot generally receive a complete copy of the accident investigation report.17 Question B418 Question B5


because, except in the case of coroner’s Judgement of Inquiry documentation, the

fatality has often proved to be outside of the Board’s Prevention jurisdiction.

The recent Administrative Inventory states that the “data from accident investigation

reports do not provide the richness and detail of information that might best assist the

Prevention Division in targeting its field activities. Moreover, it is difficult for the

Prevention Division to retrieve information about particular types of accidents, such as

accidents caused by electrical contact. The data say little, if anything, about the root

causes of an accident; rather they focus on the cause of injury. … Once the electronic

AIRS reporting system undergoes planned revisions and becomes more widely used,

the collection and retrieval of information more useful for prevention will be possible. …

In addition to the accident investigation reports completed by safety and hygiene

offices, IH&S Regulations require employers to investigate and file reports on certain

types of accidents. … Field officers state that employers often do not report information

about non-fatal accidents or near-misses, and that first-aid records at the firm do not

address issues of causation. Thus, these reports also lack information that could further

help officers identify areas of weakness in employers’ health and safety programs.”19

The file review showed that, in fact, employer accident investigation reports appear with

consistency in only those files where the employer was facing sanctions and a

complete management investigation of the accident, employer history and safety

records had been done. The employer files did not, except in one case, have any

health and safety committee minutes or correspondence with the Board. Information in

the employer files was limited to inspection reports, compliance reports, and variance

and sanction information.

AIRS: Accident Investigation Reporting System

The Board’s strategic planning for decreasing fatalities and establishing causality

continues to hang on the implementation of its Accident Investigation and Reporting

System (AIRS). Because this system has not yet been implemented at either a

provincial- or industry-wide scale, it is not yet possible to talk about or report on the

outcomes for:

19 Rest and Ashford, Occupational Health and Safety in British Columbia: An AdministrativeInventory of the Prevention Activities of the Workers’ Compensation Board p. 93


• causality – the impact of AIRS on targeting

• accident investigations – the quality and dependability of accident investigations by

employers

Recently, a representative of the Board’s Corporate Services telephoned to inform that

the Prevention Division is in the process of reviewing its 52B15 format and AIRS

reporting to create a Prevention accident investigation database that will supplement

the information from AIRS. This project is in its very beginning stages.

Firm Files (Employer’s Files)

Another portion of the fatal accident-related information is contained in “firm files.” Firm

files are what field officers refer to when they are building a firm’s “report card” - these

files contain investigation reports, consultation reports, orders, warning letters, and

sanction proceedings. The file review found that in 31 our of 55 cases, the firm file did

not contain an inspection report that referenced the fatality. The Board did not provide

the commission with any employer-related files stored and maintained outside of the

Richmond central filing system. The Policy Bureau stated that it would be too time-

consuming to locate regional files, and did not undertake to do so. Instead, the Board

offered to respond to specific requests for information that researcher identified as

missing from the files. Unless specific sanction proceedings have been initiated

(beginning with a field officer’s recommendation), accident investigation reports are not

in the firm files. Accident Investigation Reports are filed separately and are individually

filed according to the report number. Information from the accident investigation reports

is transferred to an electronic version; however, in many instances where the accident

has occurred outside of the Board’s jurisdiction or the deceased was not entitled to

compensation (not registered or did not opt for POP), preliminary accident reports

which are essentially notification of a fatality are all the file contains. Firm files do not

contain cross-references to individual fatalities which means that a field officer would

have to check at least two sources to have an accurate view of an employer’s history

with respect to workplace fatalities.


Field Officer Training

“The initial training of new officers involves about a week of training on accident

investigations. This training is general in nature and does not distinguish fatal

investigations.” 20 In other words, accident investigation training and practice for fatal

accidents does not differ from the training for regular accident investigations. If the field

officers’ role in accident investigation is to a) educate employers, workers, and safety

committees in how to conduct an investigation, and b) investigate fatal and serious

accidents, then the accident investigation training, in fact, should be designed

specifically to look into fatal accidents. It may be a fine point to distinguish; however, if

field officers are conducting investigations because of the special nature of the

accident (ie, fatal or extreme nature of risk of fatality), it may be appropriate to expand

training to include discussion about how fatalities differ from routine accident

investigations: ie, routine investigations are undertaken by the employer, not the police,

the coroner, and the Workers’ Compensation Board field officers. While the purpose of

this paper is not to research training and support of field officers, the lack of formal

recognition about the specific demands of fatal accident investigation (ie, counselling,

support, guidelines) requires stating in brief.

“The memorandum [of understanding with the Coroners Services] is not part of the

training material provided to officers but they are given copies of the operating

instructions that summarize its content. New officers go through six weeks of

centralized training. One week is dedicated to accident investigations.21

There is no established program of region specific training. However, it is open to each

regional manager to provide education or training on different topics at regional

meetings.22

When interviewed, the Assistant Regional Director, stated that field officers are profiled

and selected according to their experience, educational background, and industry

knowledge. The Prevention Division is interested in the potential field officer’s

“comprehensive understanding”. Training for accident investigation is a one-week

20 Question A421 Question A5


intensive training session that focuses on both theoretical and practical knowledge.

While the MOU does not have supplementary written information or practices

appended to it, the Board’s Legal Services representative to Prevention makes a

presentation to new field officers where he interprets the MOU and provides advice for

matters pertaining to inquests.

Relationship of the Board to Survivors and the Public

In its 1997 Business Plan, the Board writes, “Widows and parents of deceased workers

want/demand severe punishment and assurance that Prevention actions will prevent a

repeat of the tragedy that took their loved one. The Board is seen as failing them if

penalties are not severe or prosecutions are not undertaken. Yet, conversely, there is

support for de-regulation and reduced monitoring on good performing employers. 23

The Board states that “Prevention Division managers do communicate with the

deceased’s family. Sometimes, the investigating officer may do this after consulting

with the manager. The Board does not provide copies of the coroner’s reports as this is

a matter for the coroner. The Board will, however, provide a copy of its own

investigation report through a request under the Freedom of Information and Protection

of Privacy Act. Some information may be severed to, for example, protect the privacy of

witnesses. The Prevention Division manager or officer will also discuss their findings

with the family.” (RC questions to WCB) The Board does not offer to provide

information, the individual seeking disclosure must request it.

The Board does not have an official statement about its relationship to the deceased

worker’s family outside of its obligation to provide benefits where the worker’s

dependants are entitled to receive them. What the Board does state is that it is

committed to reducing workplace accidents and disease: its statutory responsibility in

light of the “historic compromise” is to the worker and the employer communities. Its

responsibilities following a fatal accident are to work to decrease the probabilities of

future similar accidents, and to provide compensation to the worker’s dependants,

within the limitations of the WCA.

22 Question A523 WCB: 1997 Business Plan, p. 20


Coroners Services

Simply stated, the coroner acts on behalf of the dead person. The coroner’s role is to

investigate deaths that occur in certain situations outlined in the Coroners Act and then

report its findings to the public. The investigative process brings the circumstances of

the fatality out into the open, and the public has an expectation that that process will

remain open to public scrutiny. The Workers’ Compensation Board does not publicly

report its responses to coroner investigations and inquests, but initiates an internal

process. The public does not become “officially” informed about what the outcome of

recommendations has been and how those recommendations influence the Board’s

own prevention policies and regulations.

The Coroner’s Act states that a coroner must investigate deaths under the following

circumstances:

9 (1) A person must immediately notify a coroner or a peace officer of the facts andcircumstances relating to a death if he or she has reason to believe that a person has died

(a) as a result of violence, misadventure, negligence, misconduct, malpractice orsuicide,

(b) by unfair means,(c) during pregnancy or following pregnancy in circumstances that might reasonably be

attributable to pregnancy,(d) suddenly and unexpectedly,(e) from disease, sickness or unknown cause, for which the person was not treated by a

medical practitioner,(f) from any cause, other than disease, under circumstances that may require

investigation, or(g) in a correctional institution, lockup or prison.

The Coroners Services has, in its Policy and Procedures Manual, under “Other

Investigative Agencies”, a section that addresses its relationship to the Workers’

Compensation Board:

PREAMBLE The Workers’ Compensation Board has a statutory obligation to inspect placesof employment and issue orders and directions for preventing injuries and industrial diseases.WCB officers are also charged with investigating accidents and causes of industrial diseases inorder to help employers and employees develop industrial health and safety programs.

AUTHORITY Coroners Act, Section 16

POLICY 1) The coroner shall meet annually with the local WCB representative todiscuss their respective roles; a written report of the meetings shall beforwarded to the Regional Coroner.


2) Prior to completion of the Judgment of Inquiry or Inquest, the coroner shallliaise with the WCB investigator to discuss possible recommendations and/orwitness list.

Overlap: Coroner Services and Prevention Division

In the coroner’s investigation he or she may decide to hold an Inquiry (without jury) or

an Inquest. Due to limited resources, the Coroner’s Services is able to conduct

approximately 120 inquests per year. In 1996, there were only two industrial fatality-

related inquests. 24 Rather than an inquest, the coroner generally makes what is

referred to as an inquiry and produces the coroner’s “Judgement of Inquiry.” The

coroner relies heavily on police and prevention cooperation and information to produce

this report. The report includes not only cause of death information, but a narrative of

events that led up to the death, and recommendations to agencies and individuals

involved, should the coroner see fit to do so25. In most of the fatality files reviewed

which, although not complete in terms of file content, are representative of workplace

fatalities, there is evidence that in all traumatic deaths, a regional coroner conducts an

investigation, and produces a Judgement of Inquiry (which is forwarded to the Chief

Coroner for review). Often the regional coroner categorizes these deaths as

“accidental” and makes no recommendations. In some instances, the coroner notes

that WCB has regulations governing the safety violations and reports that the Board will

provide those to the employer involved. In few instances, the coroner may make

recommendations which may or may not be addressed to the WCB for follow up.

Diagram 3: WCB and Coroner’s Services Reporting.

24 Based on 1996 statistics and discussion provided in December 9, 1997 interview with ChiefProvincial Coroner, Deputy Chief Provincial Coroner, and Coroner Services Policy Analyst.25 Examples of Coroner’s Judgement of Inquiry documentation can be found as Appendix 4.

DIAGRAM 3

WCB and Coroner’s Services Reporting

WCB100% of alltraumaticfatalities

100%

100%ATI

Non-Jurisdiction

Coroner

C1

C2

Fatal Claims Desk- Vital Stats- Coroner’s Report- Autopsy Report- Prelim. investigation report

- Compensation Services - Prevention Lawyer - if recommended- May go to Regional Field Office- May go to Richmond

Adjudicative decisions

Recommendations

- duplication of efforts- reliance on external reports

A B File

Richmond

FieldOffice


In most cases, the files showed that while the Compensation Services files consistently

contain Judgement of Inquiry documentation from the Coroners Services, the

Prevention files do not. The Prevention Division does not appear to routinely ask for

Judgement of Inquiry documentation - if these documents are received at regional

Prevention offices, the documents are not being forwarded to Richmond for inclusion in

the accident investigation or employer files. There did not seem to be general

awareness at Prevention that Compensation Services has this documentation. There is

no arrangement between the two divisions to share files or provide each other with

information outside of formal requests and the “front page” of preliminary accident

investigations.

Investigative Powers: Coroners Services and Prevention Division

Both agencies are supported in their investigate powers by statue: The Coroners Act

states that

Investigative powers15(1) A coroner, or a medical practitioner or a peace officer authorized by a coroner to exerciseall or any of the coroner’s powers under this subsection, may do one or more of the following: (a) view any dead body; (b) take possession of any dead body;

(c) enter and inspect any place where a dead body is and any lace from which thecoroner has reasonable grounds for believing the body was removed.

(2) A coroner who believes on reasonable grounds that it is necessary to do so for the purposeof the investigation may do the following:

(a) inspect any place in which the deceased person was, or in which the coroner has reasonable

grounds to believe the deceased person was, within a reasonable time before his orher death;

(b) inspect information in any records relating to the deceased or the deceased’s circumstances;(c)seize anything that the coroner has reasonable ground to believe is material to theinvestigation;

(3) If in the coroner’s opinion it is necessary for the purposes of the investigation, the coronermay authorize a medical practitioner or a peace officer to exercise all or any of the coroner’spowers under subsection (2) but, if the power is conditional on the belief of the coroner, thebelief must be that of the coroner personally.

(4) The coroner must keep anything seized under subsection (2)(c) in safe custody and must

return it to the person from whom it was seized as soon as is practicable after the conclusionof the investigation or, if there is an inquest, after the conclusion of the inquest, unless thecoroner is authorized or required by law to dispose of it otherwise.


The Coroner’s Act also provides for and sets out the powers of the coroner to issue

warrants for inquest (that an inquest should be held). They also determine when and

how an inquest will be held without a body.

As mentioned above, the Coroners Services does not routinely recommend and hold

coroner’s inquests for workplace fatalities. Submitters and stakeholders have

suggested that more inquests would better serve the public’s interests. S. 27 of the CA

outlines what the purpose of an inquest is.

27(1) If an inquest is held, the inquest must inquire into and determine who the deceased wasand how, when, where and by what means he or she died.(2) The jury must not make any finding of legal responsibility or express any conclusion of law

on any matter referred to in subsection (1).(3) Subject to subsection (2), the jury may make recommendations about any matter arising out

of the inquest.(4) A finding that contravenes subsection (2) is improper and must not be accepted by the

coroner.(5) If a jury fails to deliver a proper finding, the jury must be discharged.

Although no formal documentation was provided, the researcher was informed that

there has been a decision between the Board, the Coroners Service, and Crown

Counsel that where prosecution is being pursued, a coroner’s inquest will not be held.

The Coroner’s Act allows for the postponement of an inquest at the Attorney General’s

request.

The file review showed that in most traumatic workplace deaths (insert number/deaths

here), the regional coroner does conduct an inquiry. The Coroners Act supports the

coroner’s decision to not proceed with an inquest and provides some guiding law about

conducting an inquiry:

20 (1) If a death has occurred other than in a correctional centre, penitentiary or police lockup, orin a place or under circumstances that require an inquest under any other Act, and if the coroneris satisfied that the circumstances surrounding the death plainly indicate that an inquest is notnecessary, instead of summoning a jury, the coroner may make an inquiry into the death of thedeceased as the coroner considers proper.

(2) On an inquiry, the coroner must view and identify the body and may, in his or her discretion,put into writing the statements on oath of any person willing to supply information about thecircumstances surrounding the death.

(3) For the purposes of the inquiry, the coroner may issue an order for the attendance as a

witness before the coroner of any medical practitioner who attended the deceased during hisor her last illness, or who was at the time actually practising in or near the place where thedeath occurred.


(4) On completing the inquiry, the coroner must forward to the chief coroner

(a) all depositions and statements in writing taken by the coroner, and(b) a report on the results of the inquiry.

In some inquiry reports, the coroner classifies the workplace death as “accidental” and

makes no recommendations. In some inquiry reports, the coroner classifies the death

as “accidental”, and defers its recommendations to the WCB.

The MoU between the two agencies outlines the “[f]actors which will be considered by

the Coroner in deciding whether or not to conduct an inquest …:

(a) Whether the investigation into the fatality should be essentially completed before thedecision is made?

(b) What the wishes of any persons who would be entitled to standing at an inquestincluding next of the deceased are?

(c) Whether or not an appropriate response is being generated by the government ofother agencies such as the Workers’ Compensation Board, the Police or other publicagencies?

(d) Will the public interest be further served by conducting an inquest rather than aninquiry?

(e) Is there an appropriate role for a Coroner’s jury in the circumstances of the fatalitysuch that useful recommendations can be generated and appropriate public attentioncan be fostered?

(f) Will a Coroner’s inquest have an effect on public faith in public institutions?(g) Is there a large community interest in the outcome of a Coroner’s inquest in the

circumstances of the fatality?(h) Would a Coroner’s inquest stimulate useful public debate on issues surrounding the

fatality?(i) Is there a need for public education, community knowledge or awareness about the

circumstances of the death to assist in improving implementation ofrecommendations?

(j) Is an inquest necessary to successfully obtain necessary evidence?(k) Does it appear that the circumstances of the death are being suppressed?(l) Is there a serious concern that similar deaths may occur?(m) Are there competing interests and complex social, moral, ethical or other

consideration on which the assistance of five jury members would be of value?

The MOU goes on to state:

9. During the inquiry as opposed to the inquest proceeding, a Coroner may decide to conduct ameeting with the family and other interested parties to canvass facts found to date anddetermine whether or not all relevant issues have been appropriately explored. In the case ofan industrial fatality, participation by the investigating officer or other staff of the preventionDivision of the Workers’ Compensation Board will be considered. The Coroner will considerrequests for such a meeting by officers or staff of the Prevention Division.26

26 Memorandum of Understanding between WCB and the Ministry of the Attorney General -Office of the Chief Coroner, pp. 3-4.


It is plain that the Coroners Act provides specific statutory powers to coroners in

discharging their duties of investigation. They have powers to seize evidence and

bodies. The Workers’ Compensation Board’s statutory powers of investigation allow it

to make regulations and investigations (s. 71) and the Board’s efforts are focused on

regulating and inspecting workplaces. It’s statutory powers appear to lie in its ability to

regulate these workplaces and require that “employers, workers and all other persons

working in or contributing to the production of an industry …,”27are subject to those

regulations. There has been some discussion within and without the Board about the

need for WCB to be more proactive in its prevention focus. S.71 of the WCA allows for

a proactive approach, and its strongest powers seem to lie not in the investigative

aspect of workplace accidents, but in the enforcement and application of workplace

regulations so that accidents and injuries do NOT happen. This includes fatalities.

S.71(8) speaks specifically to the Board’s investigation of workplace accidents: “An

officer of the board may investigate an accident resulting in injury to, or the death of, a

worker, and may inspect and inquire with respect to health and safety matters at any

place of employment, and may make the inquiries and inspect the documents he or she

considers necessary for these purposes, and any employer, worker or other person

who withholds information from the officer making inquiries, or who otherwise obstructs

or interferes with the officer in the exercise of the officer’s functions under this section,

commits an offence and is liable on conviction to a fine …, or to imprisonment …

S.71(9) states that “Notwithstanding anything contained in any Act, the board may

enter

(a) an arrangement with any minister of the Crown in right of Canada or the Province, wherebyinspectors in the employ of Canada or the Province or an agency of them may, whenconsidered necessary in the interests of safety and accident prevention, be authorized andrequired to carry out the duties and responsibilities of an inspector under this Act, and everyinspector in the course of those duties and responsibilities is under the direction of the board;and

(b) a similar arrangement by which officers of the board may carry out the duties of inspectors orsafety officers under any other Act, or by which the board and its officers may cooperate inresearch into the causes of injuries and occupational diseases and in programs for theirreduction or prevention.

Board officers have the statutory authority to close operations,28 write and enforce

orders29. Given that the statutory purpose of the coroner is to investigate deaths in the

27 WCA s.71 (1)28 WCA s.74(1) Where the board of an officer of it considers that conditions of immediate dangerexist in any employment or place of employment which would likely result in serious injury, death


Province of BC, and the purpose of the Board is to prevent workplace deaths, there are

at least two agencies legally responsible for uncovering the circumstances surrounding

workplace deaths. The difference is that the Board is charged with taking that

information, analyzing it to better understand accident causation, and applying that

cumulative findings and prevent further workplace deaths. The Board appears to be the

only agency whose role is to establish work-relatedness and causation with the focus of

prevention. Although not current practice, the Board officers may investigate all

workplace fatalities in the province of British Columbia if for nothing other than to

establish causality for prevention purposes.

Relationship Between the Coroner and the OSO (or OHO)

The MOU between the Coroners Services and the Prevention Division does not lay out

specific guidelines cooperation. It lays out what will happen in the incidence of a

coroner’s inquest, the powers of the coroner’s services, and the procedure for

prevention officers who believe that an inquest should be held.

Field officers are trained in understanding the Board’s jurisdictional “lines” for

Prevention Services. The Board adjudicates most workplace fatal claims, it does not

have prevention jurisdiction over deaths caused by motor vehicle incidents (RCMP),

drownings at sea (Coast Guard), plane and train crashes(Transport Canada), mining

accidents (Ministry of Energy, Mines and Resources Canada), industrial camp incidents

or swimming pool accidents (Ministry of Health), and grain elevator accidents (Ministry

of Labour).

There exists a “spirit of cooperation” between the prevention officers and the safety

representatives, but other than MOUs and the two respective Acts, there appear to be

no clearly delineated policies supporting the field officers’ participation in these

investigations. It was reported that the coroner expects that the field officers will

participate in all fatal investigations30, including those outside of the Prevention

Division’s jurisdiction. Field Officers may find themselves to be in an awkward position

or occupational disease to any worker employed there, the board or officer may order theemployer to immediately close down …29 WCA s.75(1) - (5).30 Memorandum of Understanding


because their mandate to stay within their jurisdiction is part of the Prevention Division’s

culture and history. Field officers are instructed that their priority is to investigate those

accidents/fatalities that happen within Prevention Division’s jurisdiction; however,

coroners are provided with a copy of the memorandum of understanding that clearly

states that prevention will participate in ALL workplace deaths in the Province of British

Columbia – it does not refer to jurisdictions or other ministries. The MOU is signed by

Ralph McGinn, then Vice-President of Prevention, and Larry Campbell, Chief Coroner

for the Province. Further, the WCAct allows for any workplace investigation by the

Board.

In an interview with the Chief Coroner, Deputy Chief Coroner, and Coroners Services’

Policy Analyst, all expressed their satisfaction with the cooperation and abilities of Field

Officers. It was stated that coroners are generalists: their role is to investigate all

sudden or suspicious deaths within the province of British Columbia. In the instance of

a workplace fatality, coroners rely heavily on the industry-specific expertise of the field

officers, and overall, the Coroners Services is satisfied with its relationship to the

Board. The Chief Coroner did, however, suggest that the two agencies could better

cooperate in training its officers in the other agency’s practices and policies. At present

there is no formal exchange where WCB provides the coroners service with training

material or presentations, and vice versa. The chief coroner stated that the regional

coroners try to have a WCB field officer make a presentation at any coroner training

sessions, but that it was rare if coroners were invited to WCB field officer training

sessions. He suggested that this is an area for improvement.

In an interview with Assistant Director of Regional Services, the Assistant Director

stated that historically the relationship between Prevention and the Coroners Services

has been very good. With the Freedom of Information and Protection of Privacy Act,

however, the relationship began to fray. It is the Board’s opinion that the Coroners

Services has over-stepped an assumed trust boundary about using Prevention

Division’s accident investigation and personal information in the coroner’s public

reporting, and this has, more than anything, soured the relationship somewhat. Field

officers are careful with what they provide to the coroner31. When approached for any

31 Al Luck interview.


documentation supporting the above, the Board’s response was that none existed.

However, the Board’s 1995 Annual Report of the Freedom of Information and

Protection of Privacy Office at the Workers’ Compensation Board states otherwise:

Inter-agency agreements

A written protocol between the Board and the Coroner’s Office, dealing with the

exchange of records between organizations, remains in draft form at this time.

In 1995, the Board and the Coroner’s Office agreed to conduct themselves

according to the draft protocol, while awaiting independent designation of the

Coroner’s Office as a public body under the FIPPA legislation. It is anticipated

that when the Coroner’s Office achieves status as a public body independent of

the Ministry of the Attorney General, the protocol will be finalized as a written

agreement under Section 33(d) of the FIPPA legislation.32

The Board did not provide a copy of this draft agreement initially. On second request

(with reference to the Reporter), the draft agreement was forwarded with the written

caveat that “Pursuant to the advice of …, then of the Coroner’s Office, the Coroner’s

Office wanted to delay signing the Protocol until the Office became a “public body”

under the FIPP Act in its own right.” This agreement has not been enacted, but it is

appended to this report33, when enacted it should resolve some of the trust issue that

has developed:

… 1. The Ministry of the Attorney General, the Chief Coroner and the Workers’

Compensation Board hereby agree that when an officer or authorized agent of

the Workers’ Compensation Board is satisfied that a request has been made by

the Chief Coroner, a coroner subject to the Chief Coroner’s direction, or one of

their authorized agents, for a record in the custody and control of the Workers’

Compensation Board, and the officer or authorized agent of the Workers’

Compensation Board is satisfied that the request is for a record which is

necessary for the purposes of an investigation under the Coroners Act, the

32 Workers’ Compensation Reporter: 1995 Annual Report of the Freedom of Information andProtection of Privacy Office at the Workers’ Compensation Board. Date: May 15, 1996. PP 112-13.33 Appendix 6.


officer or authorized agent of the Workers’ Compensation Board shall, without

delay, as part of the ordinary course of business of the Workers’ Compensation

Board, provide a copy of the record in question to the requester, be it the Chief

Coroner, a coroner subject to the Chief Coroner’s direction, or one of their

authorized agents.

The agreement gives similar credence to requests for information by the WCB or its

authorized agents. The agreement outlines how information will be used, and rights of

disclosure under the FIPP Act.

When asked to describe the relationship of the Prevention Division to fatal claims and

coroner’s investigations, the Prevention Division responded:

“The Prevention Division plays mainly a supporting role to the adjudication of

fatal claims and coroner’s inquests.

Where the coroner and the Board investigate an accident, they each conduct their own

separate inquiries. Freedom of information rules prevent the automatic exchange of

information. However, the representatives of each organization will informally assist

each other. Sometimes, the Board officer may suggest to the coroner’s representative

that the coroner exercise powers under its statute where it is able to do this more

conveniently, for example, as to the seizure of equipment required as evidence.

As noted in the 1995 memorandum of understanding with the coroner, the Prevention

Division may in some cases request an inquest or participation in meetings between the

coroner with the family or other interested parties.”

If one again reviews the WCB Prevention Division’s statutory obligation to investigate

workplace fatalities, providing a “supporting role” to the coroner’s investigation is not

one of its purposes of investigation. The Board, in and of its own legislation, conducts

an accident investigation for prevention purposes, and while there is no lack of general

understanding that the Board’s inspectors are supportive of the investigating coroner,

and provide invaluable assistance and information, the above statement appears to


devalue the critical role that every fatal accident investigation and its findings should

have on the Board’s own prevention activities.

Response to Coroner’s Recommendations

In some instances, the coroner or coroner’s jury may make recommendations to the

Workers’ Compensation Board, the employer, or other agencies involved in the

investigation or accident. Coroner’s recommendations are in writing and appear in the

Judgment of Inquiry or the Judgement of Inquest documentation. Under statute, the

coroner may make recommendations but cannot enforce those recommendations or

ensure implementation of new practices. The coroners services requests written

responses to its recommendations, but cannot compel the recipients to respond. The

coroners services views inquests and public reporting as its way of applying pressure

where changes are needed. When asked to define it’s responsibility (response to RC

questions) and relationship to coroner recommendations, the Board writes

The Board formally responds to the coroner on all recommendations. This

process is administered by Kevin Murray. He circulates the recommendations to

the persons concerned within the Prevention Division and obtains any

necessary input to the response which he prepares. The response states

whether the Board proposes to take and action and what the action will be. The

response may include, for example,

• an explanation of how the recommendation is already covered by the

regulations,

• action that the Board will take immediately,

• an explanation of why no action can be taken, or

• a referral to the Policy and Regulation Development Bureau for

consideration in the regulations review process or explanation of how the

issue will be dealt with through some other process.34

In reviewing coroners recommendations and Board answers, it appears that the Board

only responds to recommendations made directly to it. This is another instance of “soft

processes”: there is a system in place for dealing with coroner’s recommendations, but


it is not documented or formalized. As there are no documented procedures, the

process following coroners recommendations as dictated in an interview with

Prevention Division management is consistent with the written response from the Policy

Bureau with some expansion: where there is an inquest, the field officer requests a

written copy of jury recommendations immediately following the inquest proceedings.

The field officer then provides that list of recommendations to the regional manager

who then forwards the recommendations to the Richmond Prevention Division office.

Recommendations are conveyed to the Prevention Division’s lawyer, who then

coordinates a meeting of senior management. Senior management discusses the

recommendations and provides its own recommended response(s) to Prevention’s

legal representative who then coordinates communicating senior management’s

directives to regional managers.

In an interview with Prevention’s legal representative, the above was confirmed.

Recommendations from an inquest are received at the Prevention Legal Department

and reviewed, and forwarded to the appropriate industry-specific manager and senior

management. The industry manager provides a response to the recommendations (in

writing) to Prevention’s Legal Adviser who then distributes it. A decision is made about

what action, if any, will be taken, and a response to the coroner is drafted.

The Board is not legally bound to uphold or implement any recommendations and has

not developed an information management system for making all coroner

recommendations and the Board’s response and follow-up, not just inquest outcomes,

available. Prevention’s legal files contain some of this information, including

correspondence to regional managers, but this office’s responsibilities do not include

tracking and monitoring follow-up to coroner recommendations. It is unclear whose duty

that would be. Examples of responses can be found in Appendix 5 – note that detailed

information about what happened after the response from the Board is not available.

Again, when the Prevention Division was approached by the Board’s royal commission

liaison requesting all coroner’s recommendations and documentation, nothing was

forthcoming. The Coroners Services pointed out that for the recent regulatory review

34 Question B1


process, ten years’ worth of case information and recommendations were provided to

the Regulation and Policy Development Bureau at the Board for its deliberations. That

summary was not provided to the royal commission. Furthermore, when the entire

Prevention Division was again approached and asked for all files relating to fatalities

and, specifically, to coroner’s involvement, the Policy Bureau did not make any

information available. The Prevention Division’s Legal Department provided some files,

but again, it appears that in part there is no records management of coroner’s

information at the Board and this information is “lost” to research and the Board.

It should be noted that although the Board has counsel who coordinates the actual

responses to coroner’s recommendations and attends inquests, there is no one position

responsible for ensuring all correspondence with the Coroners Services is tracked,

distributed, and followed up on.

In some instances, there appeared to be a hierarchy of statute where the coroner will

defer to the Board’s inspection and regulatory making role, referring those identified by

the coroner as requiring recommendations WCB’s recommendations instead of making

its own.

The Workers’ Compensation Board does not follow-up on coroner’s recommendations

that are made to any agency other than itself. In its response(s) to the coroners

services, the Legal Office will describe what action the Board may take, whether

regulations and policies already exist in relation to the issue being addressed. While

the coroner may make specific recommendations to other agencies, the Board views its

own investigation process as the limit of its statutory responsibility to the employer or

other agencies. For example, if safety recommendations are addressed to the

employer, unless the field officer has inspected and noted the same deficiencies and

written orders or observations, the Board will not take action on those specific

recommendations.

Compensation Services and Claims Adjudication

The accepted practice is that when a workplace death occurs, the field officer creates a

preliminary accident investigation report. The front page of this report is transmitted to


Richmond (Prevention) and from there it is sent out electronically as a “notice” of death

– often jurisdiction has not yet been established but the field officer may have attended

the scene of a fatal accident. This “front page” gives notice to the special claims

adjudicator that a fatality has happened, who, and where. The fatal claims adjudicator

then contacts the RCMP, the coroner, and the worker’s employer and family for more

information. The claims adjudicator in an interview stated that he is not always informed

of workplace deaths and as part of his own investigations, reads the provincial

newspapers in an effort to find work-related fatalities that have “slipped through the

cracks.” Neither Prevention nor Compensation claim that the province has a system

where nearly all workplace deaths are reported and investigated.

Although the Policy Bureau reported that “a copy of the accident investigation report is

provided to the fatal claims adjudicator”, a review of fatal files indicates that what the

claims adjudicator receives is the first page of the preliminary investigation report

informing the recipients that a fatality has occurred. File contents do not support the

fatal claims adjudicator’s receipt of the full report in most instances. The Policy Bureau

follows up its initial statement with “The claims adjudicator will usually request any

information required from the prevention officer before the accident investigation report

is complete. The report is not placed on the claim file because of concerns regarding

the Freedom of Information and Protection of Privacy Act.” This latter statement

suggests that if an authorized individual were to apply to the Board for disclosure

related to a deceased worker’s compensation service’s file, the applicant may not

receive information about the accident. Further, the employer information other than the

initial investigation report and orders written is not in the AIRS file. Follow-up to orders

and sanctions that are written at the time of a fatality are not placed in the accident

investigation file.

The Prevention Division does not routinely request information from outside agencies

where a death occurs in another agency’s jurisdiction. The claims adjudicator, however,

does. For example, if there is a plane crash and a logger dies in that crash, the claims

adjudicator will write to Transport Canada and request a copy of the accident

investigation which is placed on the individual’s file. Please note, the file review

indicates that outside agencies are forthcoming in providing the Compensation

Services with a full investigation report (outside agencies include Transport Canada,


Labour Canada, RCMP, Coroners Services). We can infer from the above that these

other agencies do not share the Prevention Division’s concerns and views about

difficulties that may arise by a request for disclosure re Freedom of Information and

Protection of Privacy issues.

The Policy Bureau states that coroner’s information may be used by the sensitive

claims adjudicator “to make his or her decision,” but the coroner’s recommendations

“will not influence the decision. The coroner and the Board may be applying different

rules and criteria and dealing with different issues.” There is no written guideline for

what to do in instances where conflicting information is received.

The fatal claims adjudicator sees one aspect of his role as communicator with the

family. He does convey information he has learned from the regional coroners when

possible. The adjudicator cannot make a claim decision without cause of death

information (to establish work-relatedness), and he does not adjudicate claims until this

information is received.

Vital Statistics and the Board

All deaths in the province of British Columbia are registered with the Vital Statistics

Division of the Ministry of Health (VS). In a telephone interview, a quoted figure is about

11,000 deaths per month. VS transmits a record of all provincial deaths to the Workers’

Compensation Board with the belief that the Board is the agency in British Columbia

that establishes work-relatedness. Vital Statistics does not maintain an exhaustive

database that establishes work-related deaths, from either a traumatic injury or

industrial disease standpoint. It believes this to be the role of the WCB because VS is

not in the business or position of establishing work-relatedness. All coroner certified

deaths and physician certified deaths are registered at VS.

See Diagram 4: Flow of Information To and From Vital Statistics.

FLOW OF INFORMATION TO AND FROM VITAL STATISTICS(Diagram 4)

Death

VitalStats

WCB Comp Services

Claims(all jurisciations)

Pensions

Statistical Services(no casuality info)

Prevention:Accident Investigation(previous jurisdiction only)

FocusReport

AnnualReport

Targeting Outreach

EngineeringLaboratory

- Electronic death records

- Physician’s Med. Cert. of Death

(not 100%)

(not 100%)*

Registration of Death -Coroner’s Med. Cert. of Death -

Physician’s Med. Cert. of Death -

Coroner’s Med. Cert. of Death -

Coroner -Judgement of Inquiry

- Autopsy

Physician-treatmentautopsy

* Preliminary reports - Board states F.O.I.P.P. Act keepstwo divisions from having reports on time.


VS and the WCB have a contract for services. This contract specifies what information

the Board requires, and is to be transmitted monthly. The data is received in the

Disability Awards area of the Board and are not forwarded to either Prevention or the

special claims section of Compensation Services. When asked for a copy of the

contract, the Board was unable to provide one. After several requests, however, the

Board provided the commission with several documents that nevertheless do not define

its relationship to VS or agree on the type of information that the Board requires. The

record of deaths in British Columbia is not reviewed by the Board, for

• establishing work-relatedness

• maintaining a reliable data base of work-related deaths

• locating workers who have died and whose survivors are entitled to benefits

• ensuring that all workplace deaths within the Board’s jurisdiction have been

investigated

• monitoring trends in possible industrial disease-related deaths.

The fatal claims adjudicator stated that the only incident of using information from Vital

Statistics in relation to ongoing fatal claims processing was the Widow’s Projects where

the data was used to track down widows who had passed away. The adjudicator states

that he is the only person at the Board who establishes which fatalities are work-related

in a way that directly affects the claim (accept or disallow). He believes that he should

be receiving the vital statistics lists for verifying work-related deaths and following up on

possible work-related deaths where they have not been reported to the Board.

WCB: Statistics and Causality

When asked about other health and safety jurisdictions’ fatal claims information and

statistics, the Policy Bureau responded that

The only data kept by the Board regarding other jurisdictions’ fatalities is the

claims data on fatalities that occur within B.C. but are outside the Board’s

jurisdiction. This data is included with other data regarding claims for injuries

and occupational diseases in the Prevention Division’s planning and targetting

process. Except where claims are made, the Board does not routinely make


special inquiries about fatalities outside its jurisdiction but may do so in

particular cases.

Statistical Services does not maintain detailed data on cause of death. The

Prevention Division uses the claims data provided by Statistical Services to

target its activities to industries or employers. It obtains data on the cause of

injuries and diseases from its own accident investigation reports and from

accident investigation reports prepared by employers and filed with the Board

under section 3.11(2) of the Occupational Health and Safety Regulation. Under

the AIRS system, the Division will receive electronic data on causation from

employers.35

The Board maintains data on cause of injuries and diseases (slip, fall, electrocution)

from its own accident investigation reports; however, in its targeting it uses claims data

received from the Statistical Services Department and includes data from areas outside

of its own jurisdictional area. This suggests that although the Board does not view its

role as including the fatal accident investigation and fatality data collection from

jurisdictions outside its Prevention Division’s mandate, it uses the sum of all data to

direct and target its Prevention activities. If the Board’s preference is to target its

prevention activities within its own jurisdiction (due to resources, statutory limitations

and so on), it not understood why Prevention’s targeting is based on a) claims

information as opposed to causality data from its own database, and b) claims

information that is taken from claims outside of its own jurisdiction.

The Board has stated that its own database is not yet reliable for fatalities research,

that much of the work has to be done manually, and that the information is not readily

available. The Board has stated that it must use claims data, not prevention data.

However, the Board is not limited to examining its own databases for causality and

fatality-related data.

35 Question C8


The Division of Vital Statistics records up to 48 fields of cause of death. Presently, no

causality information is electronically provided to the Board. The Board’s use of Vital

Statistics data is limited to fraud detection in the Disability Awards Section.

The Policy Bureau states that the “Vital Statistics information on deaths that the Board

receives is not routinely used by Statistical Services or the Prevention Division. There is

therefore no documentation [of this relationship].”36

Further, the compensation claims adjudicator does not receive or review the statistics

provided to the Board. With each fatality, the sensitive claims adjudicator completes a

request for a certificate of death.

In the data provided to the royal commission, there are instances of missing death

dates and birth dates (also date reported). In a telephone interview with a VS

representative,37 it was stated that there should be no reason for this information to be

missing from the Board’s fatalities data. The data provided to the Board can be

customized and agreed to by contract between VS and WCB. This existing contract

has not been revised since it was established (approximately 1993). The fatal claims

adjudicator stated that such information would be useful to him in his effort to capture

all work-related deaths in the province.

In its 1997 Business Plan, the Board states, “[a]nother related problem is the difficulty

of measuring the link between cause and effect of divisional programs. At present

divisional systems do not provide sufficient detail to allow correlation’s [sic] between the

time preventative action taken and the time when a measured reduction in resultant

claims occurs. This difficulty in measurement presents additional challenges to the

division in terms of justifying investment in new or enhanced preventative activities.”

Compensation Services does not track or analyze statistical trends for diseases and

injuries. The fatal claims adjudicator stated that he was unaware of anyone at the

Board does this in a comprehensive way (monitoring trends) although Prevention does

36 Question C337 Telephone discussion with Julie MacDonald, Vital Statistics Division, April 2nd, 1998.


some trend analysis for injuries to support their targeting efforts. Fatal statistics do not

enter the system at the fatal claims adjudication level, the physical file is forwarded to

the Statistics Services area and data is entered there.

When asked to describe and chart the Statistics’ Division’s relationship to fatal claims

and investigations (how the information is received, how it is maintained, how it is

utilized), the Policy Bureau stated that

[t]he Statistical Services department maintains a data base of information about

fatal claims. … The data is compiled from claims sent from the Disability Awards

Department, from records of claims where fatal benefits have been awarded,

and from accident investigation reports sent by the Prevention Division. The

data base includes fatal claims reported but not accepted as well as accepted

fatal claims. …The accident investigation reports are used to add a brief text

description of the circumstances of the fatality to the data base.

This information is used to:

• Publish counts of accepted fatal claims by subclass in the Statistical

Supplement to the Annual Report

• Publish in Statistics ’97 brief … descriptions of the circumstances of each fatal

claim accepted in the year, and a table showing the injury/disease status of

the accepted fatal claims by the agency with inspectional jurisdiction. Agency

with inspectional jurisdiction is coded onto each of these claims by the

Prevention Division.

• Publish a table in Statistics ’97 breaking down the deaths that occurred in the

year by injury/disease status and claim adjudication status.

• Provide information to the National Work Injuries Statistics Program on fatals

accepted in the year.

• Report to Human Resources Development Canada (HRDC) on a quarterly

basis a data sheet for each fatal reported in the quarter. …

• Provide information to requesters from inside the Board (primarily from the

Prevention Division) and from outside the Board on, for example: the kinds of

circumstances that have led to fatalities in a given industry; or how many

fatalities arising from a particular circumstance have been accepted in a given


year; or how many fatalities have been accepted by year for workers in

specified occupations.

This kind of information has formed part of the basis of studies undertaken by

Prevention Division on the circumstances of fatal accidents in selected

industries. It has been used by Statistical Services to do ad hoc analyses.38

Fatality rates … are computed, but not routinely published. One statistical issue

with fatality rates is that the number of fatal claims is low for most subclasses,

so a statistic like a fatality rate has high statistical variability. We sometimes put

fatality rates on a moving average basis for this reason. The fatality rates are

based on claim counts maintained by Statistical Services and on person years

estimated by Statistical Services.

An overall fatality rate (over all subclasses) is computed and tracked in the

same way we compute and track the rate of short term disability injuries. A

special historical time series on the fatal rate in logging has been developed.

The Prevention Division produces statistical reports for the subset of fatal claims

where they have done the accident investigation.39

When asked if the Board ensures that its fatality statistics are as complete as possible,

the Policy Bureau replied that

Statistical Services does monthly reconciliation with the Disability Awards

Department to ensure that all fatal claims that have been allowed are entered

into the Statistical Services TSO data set.

There is an annual reconciliation of data on fatal reserves and awards from the

Compensation Detail Tape with the TSO data set to ensure that the “accepted”

status that appears in the data set is correct.40

38 Question C139 Question C240 Question C5


Given that the Workers’ Compensation Board is the authority in British Columbia on

workplace fatalities due to traumatic injury or disease, and given that there are, on

average, about 200 deaths attributable to work-related accidents or injuries, it seems

reasonable for the public of British Columbia to expect a functioning and reliable

fatalities database whereby accurate and verifiable data on causality and circumstance

is readily available. The two other agencies looked at in this research paper maintain

“live” databases that are dedicated to deaths: the Coroners Services office’s database

can provide coroner’s recommendations as well as statistics. The Division of Vital

Statistics can provide the Board with records of all deaths in British Columbia which

could then be used to a) verify the Board’s data, b) ensure that all suspected workplace

deaths were captured by the Board, and c) a causality database could readily be built

and verified.

Policy and Regulation Development

Although the Board has records of all coroner’s recommendations, it is unable to

access them in a reliable and complete fashion. For the regulatory review process, the

Board requested the previous ten years’ worth of recommendations from the Coroners

Services Office in Burnaby. Prior to the 1997 process, regulation had not been

significantly amended although coroners had been making recommendations. Further,

“[t]here is no process for interim amendments to the regulations. The Workers

Compensation Act requires public notice and a public hearing before any regulation is

amended.”41

One of the suggestions that the Coroners Services provincial office had of the Board is

that the Board use coroner’s recommendations in developing and reviewing its

regulations in an ongoing manner.42 For the recent regulatory review process, the

Board requested coroner’s reports that had recommendations to WCB from 1982 to

1992. “The specialty subcommittees that prepared the initial recommendations in each

area of regulation were provided copies of the recommendations relevant to the area.

41 Note: This is a complete quote of the Policy Bureau’s response to the question: “Whereregulations were found to be violated in the workplace, the result being a fatality, what is theprocess of review to ensure that the regulations are appropriate and applicable? Is there aninterim process for immediate modifications to the regulations?” Question B6.42 December 9 interview with Provincial Chief Coroner, Provincial Deputy Chief Coroner,Coroner Services Policy Analyst.


… The Policy and Regulation Development Bureau is currently working on a proposal

for the future, ongoing regulation review process. This will likely involve an even greater

degree of participation of officers in regulation development that occurred in the past.”43

The Board did not provide any documentation that showed consistent application of

recommendations to written regulation amendments, new regulations, or documented

policies that were changed or implemented based on a field officer’s or coroner’s

recommendation for new regulation or change. An example of the Board’s response to

the suggestion for regulatory changes follows:

Date of

Death

Recommendat

ion Date (Date

Sent)

Response

Date

Case Number Claim Number Recommendations Made to

WCB

Response by WCB

14 Mar 1994

(Lifeguard

drowning)

15 June 1994 15 May 1995 1994-165-

0027

94421462 10. Recommend that WCB

to do a safety inspection

prior to facility opening.

12. We recommend that the

wave chamber grills be

specified to be of

stainless steel

construction or similar

material and that the

design of securing

structures for grills not

allow for grill movement.

13. Recommend that wave

chamber grills in all

existing wave pool be

engineered and retro-

fitted to be of stainless

steel construction or

similar acceptable

material and that the

design of securing

structures for grills be

retro-fitted so as not to

allow for grill movement.

14. Recommend that all

water pump intakes be

designed or retro-fitted

with appropriate attention

to safety through the use

of:

Following this inquest, OSO

Steve Duffy was mandated to

review existing diving facilities

in the Province and to meet

with their existing staff for the

purpose of determining

whether the requirements of

the existing s. 11 of the

Industrial Health and Safety

Regulations which are

applicable to diving operations

ought to apply to lifeguards, to

review whether there is a need

for further underwater diving

regulatory development and to

otherwise review the

circumstances in the various

public pool facilities in the

Province. A recommendation

was directed to all area officers

outlining the recommendations

from the inquest in advising

that inspections of pools within

the geographic jurisdiction of

each of the Board’s area

offices be undertaken with

these recommendations in

mind. OSO Duffy

recommended that further

regulatory development was

not necessary to deal with the

43 Question H1


a) vacuum cut off switch at

pump

b) engineered protective

grating

c) multiple intake pipes

15. Recommend that all

piping related to pool

operation be properly

identified through a

standard system of color

coding, flow directional

arrows and function

labeling.

16. Recommend that all the

above recommendation

be of urgent priority.

hazards associated with work

in pools by lifeguards. As a

result of the inspections, no

physical hazards, including

unsecure grills, unguarded

suction intakes or drains were

observed.

The Prevention Division’s Occupational Safety Officer reviewed the conditions in public

swimming pools using the standard of commercial diving operations and s. 11 of the

Industrial Health and Safety Regulations.

Section 11 is the section of the old regulations that sets out regulations for underwater

diving. Section 11 covers issues of medical fitness (11.04), evidence of competency

(11.06), diving logs (11.08), dive procedures (11.10) which inform the diver of

regulations for commercial diving operations and require a published “set of Safe Diving

Instructions, scuba (11.12), surface supply diving (11.14), diving tenders (11.16),

procedures for tables for decompression (11.18), diving hazards (11.20), and reports of

diving accidents (11.22).

Under section 11.20(2), Intakes, pipes, tunnels:(a) When a diver is required to approach or enter any intake, pipe, tunnel, or duct he shall be

provided with means to identify such intake positively and to differentiate it from any othersimilar intakes in the vicinity, and

(b) the diver shall not approach such an intake until flow through the intake is stopped bypositive means, and

(c) flow shall not be re-established until the diver;(i) leaves the water, or(ii) is verified to be clear of the hazardous location by the diving supervisor.

Interestingly, public swimming pools are outside of the Board’s jurisdiction, yet here the

coroner is making a recommendation for action that is clearly within the Board’s


prevention capacity, yet statutorily outside of its mandate – demonstrated by its lack of

specific regulation for public swimming pools. It has no authority to write orders or

conduct workplace inspections in this instance.

In a submission to the commission, a lifeguard addresses this same issue:

“I work as a lifeguard in the Victoria area, and over the years I have had a number of

serious concerns about health and safety in my workplace that the Workers’

Compensation Board seems to have been unable to address. … I outline the situations

leading up to the contacting of the Workers’ Compensation Board and the results of the

investigations.

I then offer suggestions to make the Worker’s Compensation Board more

responsive to and responsible for the worker health and safety. These include: … 4)

inclusion of recommendations from Occupational Health and Safety Committees and

Coroner’s Inquests. …

There is another hazard that is of much greater concern. The danger of deep water is

well recognized and safety precautions for others [sic] workers near deep water (i.e.

longshore workers, commercial divers) are very clearly spelled out and tightly enforced.

Rescue gear, personal flotation devices, buoyancy compensators, the buddy system and

many other regulations apply. There are none for lifeguards.

Lifeguards are caught between two immovable bureaucracies. The Workers’

Compensation Board has no regulations to protect us. The Health Act, which ensures the

safety of the swimming public, requires us to perform rescues. …

…, preventive regulations must cover everyone whose work requires them to perform a

specific task or endure certain work environments. It is an absurdity to say that someone

is not covered by regulations governing a working condition simply because they are not

on a list. It must be the hazard that is prohibited, not the workplace that is described.

It is also important that there be a mechanism whereby the Worker’s Compensation

Board could adopt recommendations issued by Occupational Health and Safety

Committees and Coroner’s Inquest juries. These are bodies that hear all side[s] of any


remedial action relating to worker health and safety. As it now stands, recommendations

from these bodies cannot be incorporated into regulations, regardless of the danger. …44

The question of whose jurisdiction and whose regulations are relevant to the

prevention, investigation, and claims of swimming pool workers is a good example of

the complicated nature of inter-jurisdictional co-opting of safety and health, including

implementation of regulatory practices. There are no specific WCB regulations for

public swimming pools. The Board may inspect any workplace in the province, but

whether or not it may implement and change regulation is another matter.

Neither the coroner’s recommendations nor the Board’s investigation and response was

publicly reported by the Board. Because of the multi-jurisdictional involvement of the

Board in overall provincial health and safety and prevention, it may be helpful to

determine where the Board’s authority begins and ends and how appropriate its

regulations are to the prevention and safe functioning of all who are working under its

statutory jurisdiction. This may be an organizational effort that would benefit from

including field officers in regulation and policy development review and development in

relation to the Board’s actual areas of jurisdictional responsibility (whether partial or full

jurisdictional responsibility).

The Policy and Regulation Bureau states that

Prevention Division field officers participate in [policy and regulation

development process] in a number of ways. These vary depending on the

circumstances. However, they include the following:

• a proposal for policy or regulation change may be initiated by an officer,

• the officer may participate in discussions concerning the detailed formulation

of the proposals or be asked to comment on draft proposals, (In the regulation

review process that lead up to the Occupational Health and Safety Regulation

in 1997, officers were technical adviser/members of the specialty

subcommittee’s that formulated the proposals but did not have voting rights)

and

44 Submission


• officers may draft or be consulted in drafting policy proposal or draft

regulations (several parts of the Occupational Health and Safety Regulation

were drafted by field officers).

The Policy and Regulation Development Bureau is currently working on a

proposal for the future, ongoing regulation review process. This will likely involve

an even greater degree of participation of officers in regulation development

than occurred in the past.45

… As part of this [review of regulations], it is being suggested that, the Bureau

establish research and program evaluation capability within the Regulation

Review component of the Bureau. …” The evaluation process will be to

conduct, review, and evaluate “research” as it relates to prevention regulations.

…

The Policy Bureau goes on to state that the “mechanisms by which this work would be

performed will depend on the specific part or topic under review. To ensure that

appropriate study plans are developed, a number of options are being explored.” The

options listed refer to literature reviews, “brainstorming” sessions with committees that

drafted the 1997 regulations, and creation of “small technical task forces to develop

part-specific study plans.”

Sources of data for these studies would depend on the particular part being

reviewed. These sources may include, but would not be limited to, data routinely

collected by the Board, such as: accident and injury reports, including coroner’s

reports, …

There are not, as yet, any specific and documented plans for the inclusion of coroner’s

report recommendations or how they will fit into the larger picture of regulation review,

or where and how field officers or regional managers fit into the overall regulatory

development process. Further, how to integrate and use fatals statistical information

that is not claims-driven has not been documented and included in the regulatory

45 Question A10


review plan supplied by the Policy Bureau. The Policy Bureau states that “[T]here is no

process for interim amendments to the regulations. The Workers’ Compensation Act

requires public notice and a public hearing before any regulation is amended.” 46

When asked how fatalities in other jurisdictions influence the Board’s development of

policy and regulation, the Board responded that it “… does receive ‘hazard alerts’

concerning fatalities in other provinces. These are usually forwarded to the Engineering

and Outreach Sections or other interested persons to determine whether action is

required.”47 Who “interested persons” are is not defined. The Policy Bureau states that

“[T]he coroner receives copies of reports of the Ontario Coroner and provides …

[WCB’s Prevention Division’s legal representative] with a copy. Again, copies are

circulated to interested staff/managers within the Division.”48

This response did not address the question of how the fatals information influences the

Board’s policy and regulation development. Furthermore, there is no written procedure,

aside from the materials being provided to the Prevention Division.

Statistics from other jurisdictions do not influence regulatory development, and “Except

where claims are made, the Board does not routinely make special inquiries about

fatalities outside its jurisdiction but may do so in particular cases.”49 It would appear

from the Board’s response to an inquiry into its use of outside jurisdictions’ statistics

and information in its own policy development, that the Board may integrate outside

data concerning occupational diseases and setting exposure limits.

Overall, a plan for incorporating accident information into an ongoing regulatory review

process has not existed in the past and does not yet exist. Submissions from

stakeholders were clear about the vital importance of ongoing regulatory review from

the public’s point of view.

46 Question B647 Question A1148 Question A1149 Question A12


Strategic Planning, Outreach, and Program Targeting

The Policy Bureau states that, “The Board does not normally target publication

specifically at fatalities. Hazards that cause fatalities are usually just as likely to

produce non-fatal injuries. The Board aims to prevent both fatal and non-fatal injuries

and diseases.

“The Board does publish regularly a fatals alert, which consists of a single legal size

sheet summarizing the facts of a particular accident and what could have been done to

prevent it. The sheet includes a diagram of the accident scene. … None of these relate

to diseases … unless they result from a specific incident of some kind. If such an

incident did occur, it might well be included in the fatals alerts.

The Prevention Division has limited resources and so in its targeting it chooses where

its efforts would have the greatest effect. There are approximately 15,000 large

employers and 125,000 small ones. A realistic approach suggests that the Board would

be more effective in targeting the bigger employers.

New initiatives include regional managers attempting to meet with aggrieved families in

a “non-offensive” manner. The managers try to apprise the families of details of the

accident and findings without breaching issues of confidentiality. This initiative is about

two years old, and there are no documented procedures or formal training for the

managers. Mr. Luck requires that the regional managers inform him when they are

going to meet with families, and he attempts to provide support.

The Board’s strategic planning for decreasing fatalities and establishing causality

continues to hang on the implementation of its Accident Investigation and Reporting

System (AIRS). Because this system has not yet been implemented on either a

provincial- or industry-wide scale, it is not yet possible to talk or report about the

outcomes for:

• causality (the impact of AIRS on targeting)

• accident investigations – the quality and dependability of accident investigations by

employers.


It may be noted that, when it was asked about the Prevention Division’s “philosophy”

about causality for non-fatal accident and disease prevention versus philosophy about

causality and prevention of fatal injuries and diseases, the Policy Bureau responded

that, “It is not clear what is meant by ‘philosophy of causality’. In determining whether

an injury or disease was caused by employment or by a violation of the regulations, the

issues will be essentially the same, whether the injury is a fatality or less serious. The

Board recognizes that, when an unsafe situation exists, it may be simply a matter of

good or bad fortune whether an injury actually occurs and whether the injury is minor or

serious. … Nonetheless, the Prevention Division recognizes that more effort should be

devoted to preventing more serious than less serious injuries, and in dealing with

higher than lower risk situations. The regulations, policies and the Prevention Division’s

targetting of its activities reflect these considerations.”50

The Board has consistently recognized fatalities as a priority. In its 1995 “Five Year

Strategy for Prevention”, the Prevention Division highlights “four priority outcomes with

annual performance targets for which the Making a Difference plan will be held

accountable.” One of these priority outcomes is a reduction in fatalities. The Board’s

targeted reductions are

Year 1 (1995): decrease in fatalities by 2





To achieve these goals, the Prevention Division devised its WorkSafe initiative which

incorporates its six major strategies.51

50 Question B1051 The six strategies are: Strategy #1: Focus on High Risk Firms; Strategy #2: Focus on LargeFirms; Strategy #3: Strengthening Outreach and Education; Strategy #4: Increasing Compliance;Strategy #5: Research Causality; and Strategy #6: Finding New Opportunities to Reduce Costs.


In its 1997 First Quarter Operating Report, the Prevention Division reports the following

statistics:

TraumaticFatalities 1st quarter 1995 1st quarter 1996 1st quarter 1997 % 96-97

Logging 7 4 6 inc. 50%Sawmills 1 1 1 0Building

Construction 1 0 3 inc. 100%

HeavyManufacturing 1 0 1 inc. 100%

Fishing 7 0 0 0Totals 24 13 22 inc. 69.2%

1997 First Quarter Operating Report, 30 April 1997

According to the above table, fatalities reported in the first quarter of the year have not

declined over the past three years. Verifying this information using the Board’s

reporting mechanism (its annual report) is difficult as the tables, graphs, and figures are

provided in a summary and comparative fashion; they report on overall claims reported

and paid. This information includes claims outside of the Prevention’s jurisdiction. To

measure whether rates have changed, one must refer to the “Number of Claims

Accepted for Fatal Benefits by Subclass and Year Accepted”. Again, however, this is

claims-driven information; no information is reported about the number of fatal claims

investigated by the Prevention Division. Further, data provided in the claims section

about fatalities combines industries that, in its WorkSafe strategies, the Board makes

distinctions between; for example, the 1997 Annual Report combines Heavy

Manufacturing and Construction. No analysis in the annual report can be found to

support the efficacy of the WorkSafe strategies which are the Board’s main targeting

strategies aimed at lowering fatalities in the workplace. The Annual Report does report

on the Board’s strategic plan, highlighting some goals, but in 1997, this section does

not refer to fatalities. In reports about Operational Highlights and the Prevention

Services, WorkSafe strategies are referred to in a general manner, but again, no

information about fatalities and the plan to reduce them is provided. In addition, the

Board speaks in general terms only about injury rates.

Speaking definitively about causality has been difficult for the Prevention Division:

“Prevention is at a distinct disadvantage in British Columbia as our ability to determine

causality in workplace accidents and injuries is constrained. Data sources and

resources for analysis are both limited. For example, 80% of the records on fatalities


are incomplete; further, because the data is not held in a database, to analyze any of

the fatals causality data, one must construct individual tables and draw inferences

manually.

“Yet the information is invaluable. In construction fatalities, for example, the causality

data suggests that all workers killed on the job in 1994 had very limited orientation to

the particular job site, although they may have had many years experience in the

industry or with a particular company. This information helps direct the type of

intervention necessary, i.e. a focus on worker orientation.

“Specific work is needed to improve the quality of data coming in, to improve our

methods of storing and retrieving data, to improve our ability to analyze and draw

inferences from our data, to improve our ability to evaluate the success of our various

interventions and to improve our abilities to report on and to communicate the results of

our analysis and interventions to our stakeholders.

“In addition to analysis of current causality data, we need to undertake future projects

and comprehensive trend analysis regarding causality, especially regarding issues

affecting future workload and potential interventions.”52 While AIRS is being developed

and released and Prevention employees and field officers are being trained to

implement and manage AIRS, key individuals at the Board appear unaware that a

wealth of information is already available to the Board through the Vital Statistics

Division, by direct data transfer.53 While the Workers’ Compensation Board is the only

agency in British Columbia that establishes whether or not fatalities are work-related,

and is expected to maintain the definitive data source for research and information,

including data for causality studies, the Board is currently unable to provide this service.

52 Making a Difference: A Five Year Strategy for Prevention Prepared by: Prevention Division, Last Revised: February 20, 1995 pp. 20-22.53 Telephone discussion with Julie MacDonald, Vital Statistics Medical Branch: The followinginformation would be available to the Board 1. The Workers’ Compensation could receiveinformation electronically, the Vital Statistics Division collects up to 48 conditions contributing todeath. Fields can include cause, employment information (employer, place of employment,profession), and where fatality took place.


Occupational Diseases

Occupational diseases posed the biggest difficulty to the Board. In terms of accident

investigation, often the time lag is so long that the “hypothetical flavor of the worksite is

gone.” That is, witnesses cannot be located and the worksites don’t exist anymore.

Prevention is limited to investigating current situations where a significant release of

substance has been reported, and where this occurs, OHOs conduct a regular

accident investigation. Years after the fact, however, it is difficult to validate information.

The fatal claims adjudicator’s comments suggest that occupational disease deaths are

increasing because of better awareness (public), more testing, and peaks in long-

latency cancers. Presently, the main source of occupational disease-related deaths is

mesothelioma. The other main occupational disease-related deaths are scleroderma,

cancers, hepatitis, and tuberculosis.

Claims for potentially terminal diseases can remain in the ODS for years, and are

transferred when an individual is diagnosed as “terminal” with up to a two-years life

expectancy.

Where an illness is not listed on Schedule B, the sensitive claims adjudicator must

establish “likelihood” of causation and work-relatedness. Mr. Blackler undertakes his

own investigation in these cases, and his contacts may include occupational hygiene

officers, occupational medicine physicians (within and without the Board), and outside

consultants. Mr. Blackler may do a literature review and then present all of the evidence

to the Board’s internal medicine consultant for establishing “likelihood” of causation.

When asked how occupational disease-related fatalities are tracked and what efforts

the Board makes to ensure all occupational disease-related deaths have been reported

to it, the Policy Bureau provided the following response:

It is not clear what is mean[t] by “tracked”. Once a claim is made or a fatality is

reported to the Board, there are processes for following up and tracking the

work required to be done. … Prevention Officers will sometimes notify the

claims adjudicator of the occurrence of a fatality that the officer is investigating.


The Compensation Services Division takes the initiative in other ways to ensure

that claims for occupational deaths are commenced. For example:

• The claims adjudicator automatically reviews the circumstances of death of all

persons dying with permanent disability awards in excess of 50% or in other

high risk categories to determine whether a claim should be initiated.

• The claims adjudicator also follows up on major accidents, for example, aircraft

accidents reported in the media to ascertain whether claims should be started.

• The claims adjudicator and other in Compensation Services will sometimes

have meetings with outside groups, … to provide them with information on the

claims process.54

The Policy Bureau goes on to quote the WCA’s requirement that employers

immediately report deaths, and that if employers do not, the Board has the “normal

means of enforcing these provisions …However, these provisions may be less effective

in the case of occupational disease related deaths. This is due to the long period that

sometimes occurs between the exposure and the onset of the disease, and the general

difficulties of distinguishing between occupational and non-occupational diseases.

The AIRS system will provide a more effective method of ensuring deaths are

reported to the Board but will not alleviate the general difficulties relating to

occupational diseases.55

In terms of its relationship to the coroner, the Policy Bureau states that

… the coroner’s intervention in a case is not normally contingent on notification

by the Board. As far as the Board is aware, the coroner does not normally

become involved in deaths related to occupational diseases. … The Board is

aware of the coroner becoming involved where the death results from a specific

occurrence, for example a heart attack.56

54 Question E155 Question E156 Question E3


However, heart attacks would normally be investigated by the coroner with or without

Board notification as it qualifies as a “sudden and unexpected death.” The Board and

the Coroners Services Chief Coroner appear to be in agreement that investigating

occupational diseases is outside of the coroner’s area of responsibility.

When asked how the Prevention Division is involved in identifying and recommending

changes to Schedule B and in identifying diseases that may potentially be work-related,

the Policy Bureau replied that

[t]he Prevention Division Occupational Physicians keep a database of

occupational disease claims that includes more detailed information than is kept

by the Statistical Services Department. It includes the industry, the worker’s

occupation and the suspected causative factors in the workplace. This is done

for both allowed and disallowed claims.

Regular reports are circulated to officers summarizing the claims received that

can be used by the officers to follow up at the particular workplaces. For

example, the data has shown claims for latex allergy gloves by non-medical

personnel in hospitals who do not need to wear such gloves. The reports alert

the officer who can then contact the employer to prevent future occurrences.

The database can also be used to show trends and provide for more general

interventions, for example, a hazard alert to industry.

The database could be the basis for suggested amendments to Schedule B, but

this has not yet occurred in practice. The database has only existed for about 2

years. There have been no changes to Schedule B in recent years.57

As outlined above, the Board does not necessarily need to rely on the fatal claims

adjudicator’s ability to catch deaths in the newspaper or by radio broadcast, as is the

present case. Using the resources available, such as VS and the Coroners Services

databases, as well as agencies such as the BC Cancer Agency, the Board may be

better able to identify potential claimants for occupational disease-related fatal benefits.

57 Question E6


Accountability Framework

In a functioning system, the relationship between all parts is dynamic and interrelated.

Action in one point of the system affects the activities of all the other parts. The Policy

Bureau has stated that each fatality is viewed independently (see above) and that there

is no feedback loop whereby the event of a fatality triggers internal and external

changes. Fatalities as a whole statistic does effectively challenge the administrative

controls in place in the Prevention Division, but this activity is outwardly focused: What

action can the Prevention Division take that will positively alter (decrease) the

conditions that allow for workplace fatalities? The ultimate goal is a reduction in claims

and a decrease in costs, costs which are passed on to the public of BC in both financial

and human terms. Traumatic fatalities, as well as historically researched and

established diseases, are factored into the Prevention Division’s targeting (but claim-

based) strategies. The strategies include

• focus on Field Officer activities

• educational activities (Outreach)

• research (occupational cancers, causality)

• information systems (AIRS).

Significantly, however, the rest of the system that provides for self-examination and the

development and implementation of policies, guidelines, practice directives, and

regulations as they specifically relate to fatalities in an overall and continuous process

does not exist. Further, even during the recent regulatory review and development

process, a specific fatality-focused aspect was not developed. Concurrent firm

guidelines for including accident investigations and coroners’ recommendations did not

come into being.

The fact that the Prevention Division is now implementing its new regulations allows an

opportunity to build into the future process factors that allow for accident investigations,

sanctions, prosecutions, statistics, coroner’s recommendations, and field officer

knowledge and recommendations to influence regulation or policy review and

development.


In 1998, WorkSafe strategies now include a focus on activities that are intended to

reduce logging fatalities.58 At this point, however, the Board is limited in planning its

focus because of its lack of available data and information. Causality studies that would

provide insight and allow the Board to make definitive statements about what actually

causes logging fatalities do not yet exist. The only strategy the Prevention Division can

currently generate to support its efforts are “Focus Reports” and industry-related

fatalities analyses according to the Engineering Section to raise awareness and provide

general information in the industry sector.

The industries examined in focus reports are listed in the Board’s WorkSafe targeting

strategies (eg, logging, mining, construction as leading in industrial fatalities). Focus

Reports include copies of the ‘Fatal’ posters that the Outreach Division creates when

forwarded the documentation and requested to do so. Each poster provides a diagram

of the condition leading to the fatality and a ‘Prevention Alert’ that gives workers

information about how to avoid a similar situation. For example, Fatal poster 94-29

alerts workers to “Ensure adequate direction and instruction of workers in the safe

performance of their duties.” Sometimes Fatals posters include coroner

recommendations. The Focus reports list recommendations for employers, workers,

and the WCB. Some of these points are generated out of coroner recommendations,

but reference to the coroner’s report or the fact that the recommendations are from the

coroner is not noted anywhere. Outreach did not provide any fatal files for review, so

the process by which it compiles information from the coroner is unknown.

The Focus Reports give information about the primary causes of fatalities such as “lack

of worker training” and “equipment failure,” and the statistics in the reports are claims-

driven. However, accident investigations and coroner’s reports contain detailed

information about the conditions that led up to the fatality as well as what happened

after the worker’s demise. All totaled, a data management system that captured,

analyzed, and applied such critical information would prove invaluable as a tool for

Prevention’s targeting and focus.

58 WCB: Prevention Division’s 1998 Business Plan


Organizational Self-Assessment Following a Fatality

When asked if the Prevention Division assesses and reviews its own role in monitoring

and educating industries that have fatal accidents, the Policy Bureau replies that

Data on fatalities is part of the data used in planning the main Worksafe

Strategies. In addition, summaries of fatal accident reports are widely circulated

within the Prevention Division and can lead to different types of action, for

example the issue of hazard alerts, … changes in policy, practice or regulations

[note: a request was made for fatality related policy and practice and none was

provided to the royal commission. The Board’s representative and commission

liaison stated that the Board does not have written policy and practice

specifically for fatal accidents]. … However, apart from the file on the particular

case, there is no formal process for tracking the action taken in response to fatal

accidents. In addition, there is not always a direct and clear link between the

occurrence of an accident and an action taken.

The occurrence of one accident may initially be seen as an exceptional situation

to which no general response is required. It may only be after the occurrence of

several accidents over a period of time that a trend can be seen. In addition,

there are a number of other factors that can determine whether action is taken

and the nature of the action, for example, legal authority or lack of authority,

political acceptability, awareness among those affected and practicality of the

proposed action.59

Of the examples provided, all were aimed at changes to publications or consideration

for regulation addition or change in the 1997 regulatory review process. It should be

noted that, although the recommendations listed in the Board’s response were taken

from the years 1994 through 1997, changes were not made to regulation until 1997.

None of the examples given addressed the Board’s self-assessment and review to

develop and implement changes to the Board’s own processes in monitoring and

education.

59 Question B7


Accountability Framework

In the human experience, unexpected and avoidable death of a family member of co-

worker is a heart-wrenching and life-altering event. Whether all workplace deaths are

avoidable is a topic for more intensive research than this project can provide. The

question of whether an accident leading to death is equal to an accident leading to

injury and recovery (or disability) is another difficult topic that the findings of this study

cannot answer.

Is the Board thorough and accountable in its delivery of service for fatality

investigations? Does the Board have processes in place to implement accident

investigation findings and coroner’s recommendations? Do fatal accidents affect

regulatory and policy development? What does the Board “learn” from fatalities?

These questions are difficult to answer, but all speak to the principle of effectiveness.

Principles of effectiveness include:

1. Clear Management Direction

2. Relevant Objectives

3. Appropriate Design

4. Achieving Intended Results

5. Satisfied Clients

6. Reasonable Costs and Productivity

7. Responsive

8. Positive Working Environment

9. Protecting Assets

10. Positive Financial Results

11. No Negative, Unintended Impacts

12. Regular Monitoring and Reporting60

The process of trying to piece together and understand the fatalities review and follow-

up has, as was initially reported by the Board’s liaison, revealed (as suggested at the

outset) a fractured approach at best, the necessity of it is in question.

60 Auditor General’s Office: Workers’ Compensation Board of British Columbia – AccountabilityReporting Review: 12 Principles of Effectiveness.


There is no one source for complete fatals information whether it be causative,

process, policy, directive, or regulatory in nature – and there is no map to find the

different divisions that may play a part in the fatalities process. Not only this, but the

different divisions do not communicate with each other. It is not surprising that

submissions identified public frustration in trying to work with and understand this

agency’s approach to workplace deaths.

Coroners appear to consistently investigate workplace deaths and, in fact, provide their

findings to the Board. Some coroner’s recommendations are responded to, but no one

can say that all are as there is no confidence that all are captured by the individual who

carries this responsibility – what is not provided cannot be responded to. It seems that

no one compiles coroner’s recommendations in particular, but also field officers’

findings and recommendations. Follow-up is not guaranteed. Even where

recommendations are responded to, there is no one to ensure that vital information

goes anywhere but into a file and forgotten.

There appear to be several data gathering mechanisms, but none that tie all of the fatal

accident or disease information together into a comprehensive and reportable form.

The Board does not report out on Prevention activities as they relate to fatalities in its

annual report. It does not report out on coroner recommendations and whether or not

the Board took action on those recommendations. This suggests that a lot of effort and

useful analysis has gone unused. The Board does not seem to have self-check

mechanisms to ensure that its approach to fatalities is appropriate. The focus is

outward, and each fatality appears to be viewed as an event independent of other fatal

episodes. The Board cannot provide a list or documentation that states otherwise.

Coroners recommendations do not necessarily affect regulation or policy development.

The Policy and Regulation Development Bureau did not open its files to the

commission for this file review. Where the Board responds to recommendations,

applicable regulations appear to be compared to the coroner recommendations, but

where regulation could be more specific to the recommendations (as shown in the

above example about the situation in public pools) , there appears to be no action

taken. This is not to say that the Board does not consider coroner’s recommendations,


it suggests, however, that there is no evidence that was provided outside of the

reference to coroner’s reports in the regulation review subcommittee terms of

reference.

How much time prevention officers and staff spend working on fatal accident

investigations and information is unknown and unreported. While field officers are

trained in accident investigations, there appears to be no evidence that field officers

receive specific fatals-focused training. That having been said, this is an area where

there appears to be invisible, but existent processes. Further, regional managers and

officers appear to have latitude in how they respond to fatalities and the follow-up

information and documentation – the Board could not say one way or other whether

their central accident and employer files were complete, and to provide the file

information requested would have had to contact each regional office to inquire about

whether or not information was missing from central files.

Where the Board could be verifying and collecting data from outside agencies,

processes and agreements were not provided to the commission. Vital Statistics and

Coroners Services are two agencies that maintain death-related databases and could

provide electronic information to support and aid the Board in its efforts to understand

and target workplace deaths.

The file review has shown that Compensation Services does consistently apply a

process of inquiry when notified of a fatality. The adjudicator actively seeks information

until such a time as the adjudicator receives sufficient information to adjudicate the

claim. If information requested before that point is not received, there is no follow-up

mechanism. It is no secret that the only reason the Board has been successful in

managing its fatal claims is because the individual who is adjudicating on the Board’s

behalf currently possesses a wealth of understanding and years of “organizational

memory” about how fatalities claims are processed, information gathering, and flow.

This is an area of the Board that consistently gathers coroner’s and other jurisdictional

reports. If this position is identified as critical to the fatal claims processing, and the

individual filling this position is recognized as an “asset” to the organization, providing

specialized services and knowledge as well as compassion that he offers, it may be in


the Board’s best interests to open dialogue with the fatal claims adjudicator as to how

Compensation Services can support this position administratively. In addition, because

human resources are eventually lost to time, the Board may consider beginning

documenting in a clear and easily accessible way, the institutional memory currently

held by one individual.

That there is adequate follow-up and short turn-around for fatals investigations, speaks

to the dedication and understanding of the field officers and their abilities to function

without administrative guidelines, policies, and processes. They work on behalf of the

Board to inspect, enforce, and educate. Their responsibilities are not limited to simply

educating the workforce and employers, but they also cooperate with and act as

industry experts for coroner’s investigations and recommendations. With 49% of its

inspectorate reaching retirement age within the next two years, the Board may want to

consider creating a process for investigating, reporting, and following up on fatal

accidents and diseases before this large percentage of its organizational memory

disappears.

To pretend to know what an ideal system would look like is beyond the scope of this

paper and perhaps better suggested by experts in the fields of compensation services

and prevention activities. This paper has attempted to identify the missing or weak links

in the WCB of BC’s investigation and follow-up of workplace fatalities - what seems

clear is that while the Board may feel itself to have limited resources, it is not currently

using those available to it for creating a connected and continuous process for

investigating workplace deaths and learning whether those deaths were predictable

and preventable, and then applying its experiences to the effort of reducing and

eliminating work-related deaths in the province of British Columbia. The recent Auditor

General’s Accountability Reporting Review provides a “Prevention Logic Model” that

could be used as a tool to identify where the fatalities information and activity flow

could be improved.

In addition to statutory powers of investigation and prevention, the Workers’

Compensation Board has what appears to be a dedicated and knowledgeable cadre of

staff - occupational safety officers, occupational hygiene officers, support staff, fatal


claims adjudicator, medical professionals, technical writers, analysts, information

workers, and management - who together create a formidable expertise. It appears that

the Board has the resources to develop and implement a model for improved and

ultimately, proactive services that address all of the issues outlined in this paper.

Nelson-McDermott \ Fatalities 30-Sept-98Appendix 1: Fatalities that Occurred in the Year Page 69

Appendix 1: TABLE 1

FATALITIES THAT OCURRED IN THE YEAR

YearAdjudicationCompleted /

AcceptedDisallowed Rejected

AwaitingAdjudication

Total

1997 125 20 3 47 195+

1996 116 16 6 44 182*

1995 120 31 49 200**

1994 114 34 51 199***

1993 100 20 49 169****

+ There were 21 deaths that occurred in 1996 but were not included in last year’s table;they were reported to the WCB after February 21, 1997.

*152 first payments cannot be compared to the 182 fatalities. Also, there were 11deaths that occurred in 1995 but were not included in last year’s table; they werereported to the WCB after February 22, 1996.

**134 first payments cannot be compared to the 200 fatalities. Also, there were 8deaths that occurred in 1994 but were not included in last year’s table, they werereported to the WCB after February 17, 1995.

***152 first payments cannot be compared to the 199 fatalities. Also there were 12deaths that occurred in 1993 but were not included in last year’s table; they werereported to the WCB after February 21, 1994.

****124 first payments cannot be compared to the 169 fatalities. Also, there were 14deaths that occurred in 1992 but were not included in last year’s table, they were

reported to the Board after February 20, 1993.

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es)

no

WC

B: C

omp.

Ser

vice

s(g

ener

ated

by S

tatis

tical

Ser

vice

s)

Fat

al C

laim

sR

epo

rted

firs

t re

po

rtre

ceiv

ed -

furt

her

info

rmat

ion

had

to

be

req

ues

ted

- ye

ar fa

talit

yre

porte

d-

clai

m n

umbe

r

nono

yes

acce

pted

or

clai

mre

port

ed o

nly

nono

no

WC

B: C

omp.

Ser

vice

s(g

ener

ated

Fat

al C

laim

sA

ccep

ted

(see

no

te

year

fata

lity

repo

rted

clai

m n

umbe

r

nono

noac

cept

edon

lyno

nono

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 3:

Doc

umen

tatio

n V

aria

nce

Rep

ort

Pag

e 72

AG

EN

CY

Sou

rce

Doc

umen

tId

entif

iers

Cor

oner

Inve

stig

atio

nC

oron

erR

ecom

men

d.C

laim

Num

ber

Cla

im S

tatu

sC

ause

of

Dea

thD

ate

ofD

eath

Acc

iden

tIn

vest

igat

ion

Rep

ort

by S

tatis

tical

Ser

vice

s)ab

ove

)

WC

B:

Pre

vent

ion

Div

isio

n

Nu

mb

er o

fT

rau

mat

icF

atal

itie

sR

epo

rted

to

the

WC

Ban

dA

tten

ded

by

Fie

ldO

ffic

ers

93-

98 Y

TD

AIR

no.

nam

eda

te o

f birt

h(w

here

not

ed)

date

of d

eath

(whe

re n

oted

)in

jury

sum

mar

yfir

m n

ame

nono

nono

inju

rysu

mm

ary

yes

(whe

reno

ted)

yes

BC

Cor

oner

sS

ervi

ces

BC

Dea

th a

tIn

du

stri

alS

ties

(93

-97)

case

yea

rin

jury

pre

mis

eca

se n

umbe

rna

me

date

of

deat

hcl

ass

deat

h pr

emis

eca

se r

ecom

.

Yes

yes

nono

no (

clas

sgi

ven

- eg

,na

tura

lac

cide

nt,

hom

icid

e)

yes

no

BC

Cor

oner

sS

ervi

ces

Rec

om

/R

esp

on

seb

y A

gen

cy

Age

ncy

reco

m.

sent

toda

te s

ent

issu

e (?

)re

spon

se d

ate

reco

mm

end/

res

pons

e

yes

yes

nono

nono

no

Roy

alC

omm

issi

on:

Coh

ort D

ata

nam

eoc

cupa

tion

caus

eda

te r

epor

ted

date

of a

ccid

ent

date

of d

eath

curr

ent s

tatu

sem

ploy

ercl

aim

num

ber

date

of b

irth

(not

e: a

llin

form

atio

n is

prov

ided

nono

yes

yes

yes

(as

note

dby

Com

p.S

ervi

ces)

yes

no

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 3:

Doc

umen

tatio

n V

aria

nce

Rep

ort

Pag

e 73

AG

EN

CY

Sou

rce

Doc

umen

tId

entif

iers

Cor

oner

Inve

stig

atio

nC

oron

erR

ecom

men

d.C

laim

Num

ber

Cla

im S

tatu

sC

ause

of

Dea

thD

ate

ofD

eath

Acc

iden

tIn

vest

igat

ion

Rep

ort

WH

ER

E it

has

been

not

ed b

yS

tat S

ervi

ces)

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

74

Ap

pen

dix

4:

TA

BL

E 4

Exa

mp

les

of:

CO

RO

NE

RS

RE

CO

MM

EN

DA

TIO

NS

an

d W

CB

RE

SP

ON

SE

S

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

Bur

ns, D

anie

lC

oron

er’s

Jud

gem

ent o

f Inq

uiry

1. T

hat t

he lo

ggin

g in

dust

ryre

view

the

indu

stria

l sta

ndar

ds in

rega

rds

to v

ehic

le b

rake

and

air

syst

em a

djus

tmen

t lev

els,

and

that

this

rev

iew

be

carr

ied

out b

ya

body

con

sist

ing

ofm

anuf

actu

rers

, mec

hani

cs,

owne

rs a

nd d

river

s.

The

Boa

rd is

cur

rent

ly a

mem

ber

of th

e C

omm

erci

al S

afet

y V

ehic

leT

askf

orce

, whi

ch is

, you

may

be

awar

e, a

task

forc

e co

mpo

sed

ofva

rious

reg

ulat

ory

body

age

ncie

san

d in

dust

ry a

ssoc

iatio

ns w

hich

has

been

con

vene

d to

add

ress

the

vario

us is

sues

sur

roun

ding

the

oper

atio

n of

com

mer

cial

vehi

cles

in th

e P

rovi

nce.

Mr

… o

fth

e W

orke

rs’ C

ompe

nsat

ion

Boa

rd is

a m

embe

r of

this

task

forc

e. I

have

rev

iew

ed th

isre

com

men

datio

n w

ith h

im a

nd h

eha

s ag

reed

to p

lace

this

reco

mm

enda

tion

befo

re th

eT

askf

orce

for

thei

r co

nsid

erat

ion.

1.

BC

Tru

ckin

g A

ssoc

iatio

n2.

C

anad

ian

For

est I

ndus

trie

sC

ounc

il3.

In

terio

r Lo

g T

ruck

Ass

ocia

tion

4.

Cou

ncil

of F

ores

t Ind

ustr

ies

5.

Wor

kers

Com

pens

atio

nB

oard

(A

ttn: K

evin

Mur

ray)

2. T

hat t

he M

inis

try

of T

rans

port

incl

ude

off r

oad

logg

ing

truc

ks in

the

vehi

cle

insp

ectio

n pr

ogra

mpr

esen

tly in

pla

ce.

1.

Veh

icle

Tra

nspo

rt P

olic

y an

dS

tand

ards

Dep

t.,C

omm

erci

al V

ehic

leT

rans

port

atio

n, M

VB

2.

ICB

C3.

M

inis

try

of T

rans

port

atio

nan

d H

ighw

ays

3. T

hat t

he lo

ggin

g in

dust

ryre

view

and

enf

orce

sta

ndar

ds fo

ral

low

able

load

to g

radi

ent r

atio

s.

I can

adv

ise

that

I sh

all a

lso

ask

Mr.

… to

pla

ce th

isre

com

men

datio

n be

fore

the

Tas

kfor

ce fo

r th

eir

cons

ider

atio

n.I w

ould

adv

ise

how

ever

that

the

Boa

rd h

as a

new

Occ

upat

iona

lH

ealth

and

Saf

ety

Reg

ulat

ion

1.

BC

Tru

ckin

g A

ssoc

iatio

n2.

In

terio

r Lo

g T

ruck

Ass

oc.

3.

Cou

ncil

of F

ores

t Ind

ustr

ies

4.

Can

adia

n F

ores

t Ind

ustr

ies

Cou

ncil

5.

Wor

kers

Com

pens

atio

nB

oard

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

75

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

whi

ch w

ill c

ome

into

forc

e in

Apr

il15

, 199

8. A

lthou

gh th

e ne

wre

gula

tion

does

not

spe

cific

ally

prov

ide

for

safe

load

to g

radi

ent

ratio

s, s

ever

al s

ectio

ns o

f the

new

reg

ulat

ion

bear

on

this

issu

e.

In p

artic

ular

, sec

tion

26.6

7(6)

prov

ides

“A lo

ggin

g tr

uck

mus

t not

be

oper

ated

with

a g

ross

com

bine

dve

hicl

e w

eigh

t or

gros

s ax

lew

eigh

t in

exce

ss o

f the

man

ufac

ture

r’s s

peci

ficat

ions

,un

less

the

mod

ifica

tions

and

ane

w g

ross

com

bine

d ve

hicl

ew

eigh

t or

gros

s ax

le w

eigh

t rat

ing

are

cert

ified

by

a pr

ofes

sion

alen

gine

er.”

Sec

tion

26.7

7 fu

rthe

r pr

ovid

esth

at

“If t

he b

raki

ng p

ower

of

equi

pmen

t is

insu

ffici

ent t

opr

ovid

e ad

equa

te c

ontr

ol o

n a

slop

e, th

e ve

hicl

e m

ust b

esn

ubbe

d or

ass

iste

d.”

… s

ectio

n 26

.79

of th

e ne

wO

ccup

atio

nal H

ealth

and

Saf

ety

Reg

ulat

ion.

It p

rovi

des

as fo

llow

s:

“Roa

ds, b

ridge

s, e

leva

ted

plat

form

s an

d ot

her

stru

ctur

esus

ed b

y ve

hicl

es tr

ansp

ortin

gw

orke

rs, l

ogs

or o

ther

fore

stpr

oduc

ts in

fore

stry

ope

ratio

ns

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

76

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

mus

t be

cons

truc

ted

and

mai

ntai

ned

to a

sta

ndar

d w

hich

will

per

mit

safe

tran

sit.”

Tha

t the

Min

istr

y of

Tra

nspo

rtca

rry

out a

rev

iew

of d

river

trai

ning

sta

ndar

ds fo

r th

eop

erat

ion

of lo

ggin

g tr

ucks

.

1.

Mot

or V

ehic

le B

ranc

h2.

IC

BC

3.

Min

istr

y of

Tra

nspo

rtat

ion

and

Hig

hway

s

BO

DE

N, A

lan

Cor

oner

’s J

udge

men

t of I

nqui

ry(n

ote

resp

onse

was

del

ayed

beca

use

“It a

ppea

rs th

at th

eor

igin

al c

opy

of th

e Ju

dgem

ent o

fIn

quiry

faile

d to

be

dire

cted

to th

eap

prop

riate

par

ty.”

The

hou

se th

at th

e de

ceas

ed w

asw

orki

ng o

n w

as b

eing

bui

lt by

the

owne

r w

ho, o

n hi

s ow

n,co

ntra

cted

out

to v

ario

usin

divi

dual

s to

pro

vide

the

serv

ices

.

The

ow

ner

did

not h

ave

Wor

kers

’C

ompe

nsat

ion

Boa

rd c

over

age

and

neith

er d

id th

e de

ceas

ed.

Thi

s is

not

an

unco

mm

onoc

curr

ence

.

The

dec

ease

d w

as n

ot u

sing

afa

ll pr

otec

tion

syst

em w

hich

wou

ld b

e re

quire

d fo

r th

ose

regi

ster

ed w

ith W

orke

rs’

Com

pens

atio

n B

oard

. He

was

also

wor

king

alo

ne a

nd, i

deal

ly,

shou

ld h

ave

had

anot

her

pers

onon

the

wor

ksite

as

wel

l.

In o

rder

to e

duca

te th

e pu

blic

on

such

haz

ards

in th

e w

orkp

lace

, Im

ake

the

follo

win

gre

com

men

datio

n:

Tha

t the

Wor

kers

’ Com

pens

atio

nB

oard

and

the

BC

Ass

ocia

tion

ofM

unic

ipal

ities

wor

k in

liai

son

toed

ucat

e th

e pu

blic

in s

afe

wor

k

I can

adv

ise

that

the

Wor

kers

’C

ompe

nsat

ion

Boa

rd w

ill c

onta

ctth

e U

nion

of B

C M

unic

ipal

ities

and

seek

an

arra

ngem

ent

whe

reby

the

Boa

rd m

ater

ials

are

mad

e av

aila

ble

to th

e va

rious

mem

ber

mun

icip

aliti

es o

f the

Uni

on s

o th

at th

ey c

an b

edi

strib

uted

to p

erso

ns a

t the

tim

eth

at th

ey s

eek

mun

icip

al a

ppro

val

or o

btai

n pe

rmits

for

build

ing

activ

ities

. It i

s ex

pect

ed th

at th

em

ater

ials

that

the

Boa

rd c

ould

prov

ide

wou

ld in

clud

e bo

th c

opie

sof

the

new

Occ

upat

iona

l Hea

lthan

d S

afet

y R

egul

atio

n an

d ot

her

mat

eria

ls th

at m

ight

ass

ist t

hose

pers

ons

in d

evel

opin

g an

awar

enes

s of

thei

r w

orkp

lace

resp

onsi

bilit

ies

and

thei

r ne

ed to

adop

t saf

e w

ork

prac

tices

.

1.

WC

B2.

U

nion

of B

C M

unic

ipal

ities

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

77

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

proc

edur

es. P

amph

lets

and

mat

eria

ls a

re a

vaila

ble

from

the

Wor

kers

’ Com

pens

atio

n B

oard

and

thes

e sh

ould

be

cons

iste

ntly

avai

labl

e to

the

agen

cies

prov

idin

g bu

ildin

g pe

rmits

and

beco

me

part

of a

pac

kage

that

isgi

ven

to in

divi

dual

s or

com

pani

esta

king

out

per

mits

, adv

isin

g th

emof

thei

r re

spon

sibi

litie

s an

d sa

few

ork

proc

edur

es.

BR

YS

KI,

Gor

don

D.

Cor

oner

s’ J

udge

men

t of I

nqui

ry1.

T

hat s

tand

ards

or

regu

latio

ns b

e dr

awn

upco

verin

g m

arin

e ve

ssel

sbe

ing

used

as

com

mer

cial

tugb

oats

(re

gard

less

of s

ize)

addr

essi

ng:

n

basi

c eq

uipm

ent

n

quic

k re

leas

e m

echa

nism

sn

ci

rcum

stan

ces

requ

iring

one

-ve

rsus

two-

men

cre

wn

ba

ckgr

ound

and

/or

trai

ning

of c

rew

n

mai

nten

ance

of t

he tu

gn

ho

urs

of w

ork

The

new

Occ

upat

iona

l Hea

lthan

d S

afet

y R

egul

atio

n ha

s co

me

into

effe

ct o

n A

pril

15, 1

998.

The

coro

ner’s

rec

omm

enda

tion

with

resp

ect t

o th

e de

velo

pmen

t of

cert

ain

stan

dard

s or

reg

ulat

ions

cove

ring

mar

ine

vess

els

has

been

forw

arde

d to

Rex

Eat

onP

olic

y D

irect

or, R

egul

atio

nR

evie

w P

olic

y &

Reg

ulat

ion

Dev

elop

men

t Bur

eau

at th

eW

orke

rs’ C

ompe

nsat

ion

Boa

rd. I

tis

Mr.

Eat

on’s

res

pons

ibili

ty to

ensu

re th

at m

atte

rs o

f on-

goin

gre

view

are

bro

ught

forw

ard

asam

endm

ents

to th

e B

oard

sO

ccup

atio

nal S

afet

y an

d H

ealth

Reg

ulat

ion.

1.

Min

iste

r of

Lab

our

2.

WC

B A

ttn: K

evin

Mur

ray

3.

WC

B A

ttn: P

en E

aton

[not

e:s/

b R

ex E

aton

]4.

F

ores

t Ind

ustr

ial R

elat

ions

5.

Indu

stria

l Woo

d an

d A

llied

Wor

kers

Nat

iona

l Uni

on6.

T

rans

port

Can

ada

2.

Tha

t the

pro

cess

of f

ores

hore

leas

e in

clud

e co

nsid

erat

ion

of h

ow s

afe

the

area

is fo

r its

prop

osed

use

.

1.

Min

iste

r of

Env

ironm

ent,

Land

, and

Par

ks2.

M

inis

ter

of F

ores

ts

3.

Tha

t tug

ope

rato

rs e

mpl

oyed

in c

omm

erci

al lo

ggin

gop

erat

ions

be

subj

ect t

o th

esa

me

‘hou

rs o

f wor

k an

dov

ertim

e re

quire

men

ts’ a

s

3.

Min

iste

r of

Lab

our

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

78

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

oper

ator

s in

the

tug

indu

stry

.

MIL

LIG

AN

, Lan

ce W

illia

mC

oron

er’s

Jud

gem

ent o

f Inq

uiry

1. It

is r

ecom

men

ded

that

regu

latio

ns b

e es

tabl

ishe

d w

hich

requ

ire fr

ont e

nd lo

ader

s in

a)

log

sort

ing,

b)

log

load

ing

and

c)he

licop

ter

logg

ing

land

ings

be

equi

pped

with

cam

eras

and

mon

itors

whi

ch p

rovi

de th

eop

erat

or o

f the

fron

t end

load

erw

ith a

con

stan

t vie

w o

f are

as to

the

rear

of t

he m

achi

ne.

As

you

know

the

Wor

kers

’C

ompe

nsat

ion

Boa

rd h

asre

cent

ly a

dopt

ed th

e ne

wO

ccup

atio

nal H

ealth

and

Saf

ety

Reg

ulat

ions

follo

win

g an

exte

nsiv

e pr

oces

s of

con

sulta

tion

with

em

ploy

ers

and

wor

kers

inth

e P

rovi

nce.

The

new

regu

latio

ns d

o no

t con

tain

are

quire

men

t tha

t loa

ders

or

othe

rm

obile

equ

ipm

ent o

pera

ting

inso

rtin

g lo

g, lo

adin

g or

hel

icop

ter

logg

ing

land

ings

, be

equi

pped

with

cam

eras

.

Sec

tion

16.8

(1)

of th

eO

ccup

atio

nal H

ealth

and

Saf

ety

Reg

ulat

ion

how

ever

, now

requ

ires

an a

udib

le w

arni

ngde

vice

on

all e

quip

men

t whe

reth

e op

erat

or c

anno

t dire

ctly

, by

mirr

or o

r ot

her

effe

ctiv

e de

vice

see

imm

edia

tely

beh

ind

the

mac

hine

. The

aud

ible

dev

ice

mus

t be

capa

ble

of b

eing

hea

rdab

ove

ambi

ent n

oise

leve

ls. I

f it

is im

prac

ticab

le to

pro

vide

an

audi

ble

war

ning

dev

ice

then

the

oper

ator

has

the

duty

und

erse

ctio

n 16

.42;

If a

mob

ile e

quip

men

top

erat

or’s

vie

w o

f the

wor

kar

ea is

obs

truc

ted

the

oper

ator

mus

t not

mov

e th

eeq

uipm

ent u

ntil

prec

autio

nsha

ve b

een

take

n to

pro

tect

the

oper

ator

and

any

oth

er

Wor

kers

’ Com

pens

atio

n B

oard

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

79

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

wor

ker

from

inju

ry, i

nclu

ding

a)

imm

edia

tely

bef

ore

the

mov

emen

t, th

ein

spec

tion

by th

eop

erat

orb)

di

rect

ion

by a

sig

nalle

rst

atio

ned

in a

saf

epo

sitio

n in

con

tinuo

usc)

di

rect

ion

by a

traf

ficco

ntro

l or

war

ning

syst

emO

f cou

rse,

the

optio

n of

inst

allin

gca

mer

as o

n th

e eq

uipm

ent w

ould

be a

com

plia

nce

optio

n op

en to

the

empl

oyer

in th

ose

circ

umst

ance

s.2.

It is

rec

omm

ende

d th

atre

gula

tions

be

esta

blis

hed

whe

reby

all

empl

oyee

s, w

orki

ngon

foot

a)

at lo

g so

rtin

g, b

) lo

glo

adin

g an

d c)

hel

icop

ter

logg

ing

land

ings

be

equi

pped

with

rad

ioco

mm

unic

atio

ns, p

refe

rabl

y ha

rdha

t mou

nted

, in

acco

rdan

ce w

ithW

CB

Indu

stria

l Hea

lth a

nd S

afet

yR

egul

atio

n 60

.192

(11)

.

The

new

Occ

upat

iona

l Hea

lthan

d S

afet

y R

egul

atio

n pa

ralle

lsth

e re

quire

men

ts o

f the

old

OH

&S

Reg

ulat

ion

60.1

92 in

that

it d

oes

not r

equi

re r

adio

sig

nalin

gde

vice

s bu

t rat

her

spec

ifies

cert

ain

requ

irem

ents

whe

n su

cheq

uipm

ent b

eing

use

d. O

ne o

fth

e pr

oble

ms

reco

gniz

ed b

y th

efo

rest

ry o

pera

tions

sub

com

mitt

eein

thei

r de

liber

atio

ns o

n th

ede

velo

pmen

t of t

he n

ewre

gula

tion

was

the

prob

lem

of

exce

ssiv

e ra

dio

chat

ter

in a

bus

ylo

ggin

g op

erat

ion

with

man

yre

sult

in m

isco

mm

unic

atio

n. T

heus

e of

rad

io s

igna

lling

dev

ices

how

ever

, doe

s re

mai

n a

com

plia

nce

optio

n op

en to

empl

oyer

s in

thes

eci

rcum

stan

ces.

Thi

sre

com

men

datio

n ho

wev

er w

ill b

ein

clud

ed in

the

Boa

rds

file

for

a

Wor

kers

Com

pens

atio

n B

oard

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

80

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

furt

her

revi

ew o

f par

t 16

mob

ileeq

uipm

ent,

part

26

fore

stry

oper

atio

ns, a

nd p

art 2

9 ai

rcra

ftop

erat

ions

as

part

of t

he B

oard

sco

mm

itmen

t to

ongo

ing

revi

ew o

fth

e ne

w r

egul

atio

n.3.

It is

rec

omm

ende

d th

at s

afe

area

s be

est

ablis

hed

at a

) lo

gso

rtin

g, b

) lo

g lo

adin

g an

d c)

helic

opte

r lo

ggin

g la

ndin

gs to

whi

ch e

mpl

oyee

s w

orki

ng o

n fo

otha

ve r

eady

acc

ess

and

in w

hich

mob

ile e

quip

men

t sha

ll on

ly b

epe

rmitt

ed to

ent

er w

hen

sign

alle

dto

do

so.

Sec

tion

25.5

6 of

the

new

Occ

upat

iona

l Hea

lth a

nd S

afet

yR

egul

atio

n es

sent

ially

mirr

ors

this

rec

omm

enda

tion.

It p

rovi

des;

Log

land

ing

and

othe

r w

ork

area

s m

ust b

e;a)

loca

ted,

con

stru

cted

,ar

rang

ed, m

aint

aine

d an

dop

erat

ed s

o th

at th

e lo

gs c

an b

elo

aded

saf

ely

and

wor

kers

may

wor

k in

the

clea

r of

mov

ing

logs

and

equi

pmen

t.

Wor

kers

Com

pens

atio

n B

oard

4. It

is r

ecom

men

ded

that

an

incr

ease

d nu

mbe

r of

insp

ecto

rsbe

em

ploy

ed b

y th

e W

CB

inor

der

to in

crea

se th

e fr

eque

ncy

ofin

spec

tions

at j

ob s

ites

and

insu

re c

ompl

ianc

e w

ith IH

&S

regu

latio

ns.

The

Wor

kers

Com

pens

atio

nB

oard

has

rec

ently

incr

ease

d th

enu

mbe

r of

logg

ing

insp

ecto

rs in

coas

tal o

pera

tions

in o

rder

tom

ore

effe

ctiv

ely

insp

ect t

hose

oper

atio

ns. T

he W

orke

rs’

Com

pens

atio

n B

oard

is h

owev

erlim

ited

by th

e bu

dget

ary

cons

trai

nts

with

res

pect

to th

enu

mbe

r of

sta

ff th

at it

can

enga

ge.

Wor

kers

Com

pens

atio

n B

oard

5. It

is r

ecom

men

ded

that

pena

lties

be

max

imiz

ed fo

r re

peat

offe

nder

s in

ord

er to

com

pel

com

plia

nce

with

exi

stin

gre

gula

tions

.

Pen

alty

rec

omm

enda

tions

and

thei

r ap

plic

atio

n ar

e at

this

tim

ede

pend

ent u

pon

and

adju

sted

acco

rdin

g to

the

seve

rity

of th

eha

zard

and

the

stat

e of

know

ledg

e of

the

offe

nder

as

evid

ence

d by

the

issu

ance

of

prev

ious

ord

ers

and

or s

anct

ions

agai

nst t

hat e

mpl

oyer

for

viol

atio

ns o

f the

reg

ulat

ions

. The

Wor

kers

Com

pens

atio

n B

oard

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

81

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

Boa

rd h

as a

lso

rece

ntly

ado

pted

a pi

lot p

rogr

am, i

nvol

ving

the

sele

ctiv

e us

e of

pub

licpr

osec

utio

ns fo

r vi

olat

ions

of

thos

e re

gula

tions

. It i

s ho

ped

that

thro

ugh

the

sele

ctiv

e us

e of

pros

ecut

ions

, the

aw

aren

ess

ofth

e ne

ed to

ens

ure

com

plia

nce

with

the

Boa

rds

regu

latio

ns w

illac

hiev

e a

high

er p

ublic

pro

file.

OP

DA

HL,

Har

old

S.

Cor

oner

s’ J

udge

men

t of I

nqui

ry(D

eath

from

bei

ng h

it on

the

head

with

a s

nag)

1. E

ncou

rage

felle

r bu

nche

rs(M

echa

nica

l Fal

ling)

to p

lace

timer

in fr

ee a

nd o

pen

area

sw

here

pra

ctic

al.

The

Cor

oner

’s J

udge

men

t of

Inqu

iry w

as c

onsi

dere

d by

the

For

estr

y O

pera

tion

Sub

com

mitt

ee in

thei

r re

view

of

the

exis

ting

Indu

stria

l Hea

lth a

ndS

afet

y R

egul

atio

ns. T

hesu

bcom

mitt

ee d

eclin

ed to

inco

rpor

ate

the

Cor

oner

’sre

com

men

datio

ns in

to s

peci

ficre

gula

tions

, how

ever

ther

e ar

eex

istin

g re

gula

tions

in th

eIn

dust

rial H

ealth

and

Saf

ety

Reg

ulat

ions

, whi

ch w

ill b

e ca

rrie

dth

roug

h in

the

new

Occ

upat

iona

lH

ealth

and

Saf

ety

Reg

ulat

ions

whe

n th

ey a

re a

dopt

ed, w

hich

bear

upo

n th

is a

ctiv

ity.

Reg

ulat

ion

60.0

2 pr

ovid

es th

at in

“the

man

agem

ent o

f eve

rylo

ggin

g op

erat

ion

shal

l pla

n an

dco

nduc

t suc

h op

erat

ions

in a

man

ner

cons

iste

nt w

ith th

ese

regu

latio

ns a

nd w

ith r

ecog

nize

dsa

fe w

ork

prac

tices

.”

I ref

er to

this

reg

ulat

ion

as it

is e

xpec

ted

that

man

agem

ent w

hen

plan

ning

the

logg

ing

oper

atio

n w

ould

mak

eap

prop

riate

pro

visi

on fo

r

Jim

Dor

sey,

Pre

side

nt, W

CB

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

82

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

mec

hani

cal f

elle

rs to

be

able

topl

ace

time

in o

pen

area

s th

usm

inim

izin

g th

e ha

zard

to w

orke

rs.

Reg

ulat

ion

60.7

2 pr

ovid

es th

at“m

echa

nize

d fa

lling

sha

ll be

cond

ucte

d in

suc

h a

man

ner

asno

t to

enda

nger

buc

kers

or

othe

rw

orke

rs o

r eq

uipm

ent.”

T

his

regu

latio

n im

pose

s an

obl

igat

ion

on th

e em

ploy

er to

ens

ure

that

mec

hani

zed

falli

ng is

con

duct

edge

nera

lly in

a m

anne

r so

as

not

to e

ndan

ger

buck

ers

and

all o

ther

wor

kers

or

equi

pmen

t. T

his

regu

latio

n co

uld

be a

pplie

d to

requ

ire fe

ller

bunc

hers

to p

lace

timbe

r in

free

and

ope

n ar

eas

whe

re th

e pl

acin

g of

tim

ber

wou

ldot

herw

ise

cons

titut

e a

haza

rd to

wor

kers

.2.

Enc

oura

ge li

ne s

kidd

erop

erat

ions

to m

aint

ain

am

inim

um o

f tw

o tr

ee le

ngth

s fr

omot

her

logg

ing

activ

ities

.

… c

urre

nt a

nd p

ropo

sed

regu

latio

n re

quire

all

wor

kers

tore

mai

n a

min

imum

of t

wo

tree

leng

ths

from

act

ive

falli

ngac

tivity

. In

man

y ca

ses

it is

impr

actic

al to

sep

arat

e so

me

activ

ities

suc

h as

del

imbi

ng a

ndlo

adin

g fr

om a

line

ski

dder

oper

atio

n.

LAM

B, P

eter

A.

Cor

oner

’s J

udge

men

t of I

nqui

ry1.

Ens

ure

all s

uper

viso

rs a

reaw

are

of th

e ru

les

and

regu

latio

ns c

once

rnin

g sa

fety

inth

e w

orkp

lace

, and

that

ther

e is

regu

lar

trai

ning

of s

uper

viso

rs.

Cou

lson

For

est P

rodu

cts

2. T

hat s

uper

viso

rs c

heck

on

are

gula

r ba

sis

with

em

ploy

ees

toen

sure

pro

per

safe

pro

cedu

res

are

bein

g ca

rrie

d ou

t, an

d th

at

Cou

lson

For

est P

rodu

cts

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

83

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

the

empl

oyee

s ar

ekn

owle

dgea

ble

abou

t the

proc

edur

es.

3. T

hat p

roce

dure

s be

enf

orce

d to

proh

ibit

empl

oyee

s en

terin

g th

ear

ea b

ehin

d a

load

ed b

undl

ebu

nk.

Cou

lson

For

est P

rodu

cts

4. T

hat s

afet

y re

spon

sibi

litie

s be

mad

e in

a w

ritte

n fo

rm.

Cou

lson

For

est P

rodu

cts

5. T

hat a

sys

tem

be

put i

n pl

ace

for

the

bund

ler

and

load

erop

erat

or to

ens

ure

that

the

bund

ler

is in

a s

afe

area

bef

ore

the

load

er o

pera

tor

push

es th

ebu

ndle

.

Cou

lson

For

est P

rodu

cts

6. T

hat t

he r

ecom

men

datio

ns in

this

rep

ort b

e ci

rcul

ated

to o

ther

logg

ing

com

pani

es in

BC

.

The

Boa

rd c

urre

ntly

has

und

erde

velo

pmen

t, a

fata

l pos

ter

depi

ctin

g th

e ci

rcum

stan

ces

ofth

is tr

agic

fata

lity.

The

cor

oner

'’re

com

men

datio

ns w

ill b

ere

pres

ente

d ei

ther

vis

ually

or

inth

e ac

com

pany

ing

text

to th

ispo

ster

.

Thi

s po

ster

will

be

dist

ribut

ed to

all l

oggi

ng c

ompa

nies

in B

ritis

hC

olum

bia

who

hav

e be

enid

entif

ied

eith

er th

roug

h th

eB

oard

s lis

t of r

egis

tere

dem

ploy

ers

or th

roug

h a

list o

flo

ggin

g co

mpa

nies

pro

vide

d by

the

maj

or e

mpl

oyer

’sas

soci

atio

ns e

ngag

ed in

logg

ing

in B

ritis

h C

olum

bia.

Wor

kers

Com

pens

atio

n B

oard

McI

VE

R, L

uke

R.

Cor

oner

’s In

ques

t38

. Whe

re a

ser

ious

inju

ry o

rde

ath

occu

rs w

e re

com

men

d th

atth

e W

CB

insp

ect w

ith a

freq

uenc

y of

a[t]

leas

t onc

e ev

ery

… I

can

advi

se th

at a

n of

ficer

inst

ruct

ion

is b

eing

pre

pare

dw

hich

will

dire

ct B

oard

offi

cers

such

that

whe

re a

ser

ious

inju

ry

Wor

kers

Com

pens

atio

n B

oard

(oth

er r

ecom

men

datio

ns n

otfo

rwar

ded

to c

omm

issi

on)

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

84

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

six

mon

ths

for

a pe

riod

of tw

oye

ars

(una

nnou

nced

).or

dea

th o

ccur

s, fo

llow

-up

insp

ectio

ns w

ith th

e fr

eque

ncy

ofat

leas

t onc

e ev

ery

six

mon

ths

for

a pe

riod

of tw

o ye

ars

will

be

cond

ucte

d.

… N

o. 4

2 [n

ote

not r

epro

duce

dfo

r th

e co

mm

issi

on] t

o th

eW

orke

rs’ C

ompe

nsat

ion

Boa

rd. I

can

advi

se th

at th

e B

oard

will

cont

inue

with

its

You

ng W

orke

rP

rogr

am a

nd th

is s

umm

erco

ntin

ued

with

a p

rovi

nce

wid

era

dio

tran

sit s

helte

r, in

-the

atre

and

mal

l pos

ter

adve

rtis

ing

cam

paig

n to

adv

ertis

e th

ede

bilit

atin

g co

nseq

uenc

es o

fw

ork-

rela

ted

inju

ries.

It w

as ti

med

to c

oinc

ide

with

the

entr

y of

man

yyo

uth

into

the

wor

kfor

ce. T

heB

oard

als

o re

leas

ed e

arlie

r th

issu

mm

er it

s co

mpr

ehen

sive

rep

ort

entit

led

Pro

tect

ing

youn

gW

orke

rs w

hich

out

lines

the

scop

ean

d ca

uses

of i

njur

ies

to w

orke

rsag

ed 1

5 to

24.

Offi

cers

of t

heB

oard

will

con

tinue

to ta

ke th

ism

essa

ge to

hig

h sc

hool

stu

dent

s,sp

ecifi

cally

the

Gra

de 1

1po

pula

tion.

In 1

994-

95 W

CB

offic

ers

reac

hed

30%

of t

hepr

ovin

ce’s

Gra

de 1

1 po

pula

tion.

Itis

hop

ed th

at th

roug

h th

eco

ntin

uatio

n of

this

pro

gram

, ahi

gher

per

cent

age

of th

epr

ovin

ce’s

Gra

de 1

1 po

pula

tion

will

rec

eive

the

bene

fits

of th

ispr

ogra

m.

1.

1.

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

85

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

Har

vey

LaC

ours

iere

(Jud

gem

ent o

f Inq

uiry

)2.

T

hat t

he M

inis

try

of F

ores

tsde

velo

p m

ore

prec

ise

rain

fall

shut

dow

n gu

idel

ines

.a)

R

ainf

all s

hutd

own

guid

elin

esne

ed to

con

side

r:•

curr

ent r

ainf

all

• pa

st r

ainf

all

• sn

owm

elt

• te

rrai

n (s

oil t

ype,

slo

pe, e

tc.)

• lo

cal c

limat

e (b

iocl

imat

iczo

ning

map

s)b)

R

ainf

all s

hutd

own

guid

elin

esne

ed to

incl

ude

perio

dic

mon

itorin

g of

:•

Indi

cato

rs o

f det

erio

ratin

gco

nditi

ons

in w

ork

area

ie:

silta

tion

slou

ghs,

etc

. (S

eeR

oad

Wor

kers

Shu

tdow

nIn

dica

tors

in th

e F

ores

t Roa

dE

ngin

eerin

g G

uide

book

Pg.

127)

• O

n si

te r

ain

gaug

em

easu

rem

ents

.(B

ackg

roun

d to

reco

mm

enda

tions

pro

vide

d in

Judg

emen

t of I

nqui

ry)

I am

info

rmed

that

rai

nfal

l shu

tdo

wn

guid

elin

es a

re c

urre

ntly

bein

g de

velo

ped

by th

e M

inis

try

of F

ores

ts a

nd a

re a

lmos

tco

mpl

ete.

I am

furt

her

advi

sed

that

mos

t lic

ense

es w

ho w

ill b

eef

fect

ed b

y th

ese

guid

elin

es h

ave

alre

ady

impl

emen

ted

proc

edur

esto

shu

t dow

n op

erat

ions

in th

iski

nd o

f circ

umst

ance

.

I can

als

o ad

vice

that

sec

tion

26.1

7 an

d se

ctio

n 26

.18

of th

eB

oard

s ne

w O

ccup

atio

nal H

ealth

and

Saf

ety

Reg

ulat

ion

bear

on

this

issu

e.

Sec

tion

26.1

7 pr

ovid

esW

hen

wea

ther

cond

ition

s pr

even

tha

zard

s to

wor

kers

,ad

ditio

nal p

reca

utio

nsm

ust b

e ta

ken

asne

cess

ary

for

the

safe

cond

uct o

f the

wor

k.

Sec

tion

26.1

8 pr

ovid

esIn

a fo

rest

ry o

pera

tion

whe

re th

ere

may

be

aris

k of

a la

ndsl

ide

orav

alan

che

(a)

the

ris

k m

ust b

eas

sess

ed in

acco

rdan

ce w

ith a

stan

dard

acc

epta

ble

to th

e B

oard

,(b

) i

f a r

isk

is fo

und

tobe

pre

sent

, writ

ten

safe

wor

k

2.

Inte

rnat

iona

l For

est P

rodu

cts

Ltd.

3.

Wor

kers

’ Com

pens

atio

nB

oard

of B

.C.

4.

Min

istr

y of

For

ests

5.

Line

ham

Log

ging

Ltd

.

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

86

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

proc

edur

es m

ust b

ede

velo

ped

mee

ting

the

requ

irem

ents

of

the

stan

dard

, and

(c)

wor

kers

mus

t be

educ

ated

in th

e sa

few

ork

proc

edur

es.

2. T

hat o

ld fo

rest

roa

ds a

bove

prop

osed

roa

ds o

r cu

t blo

cks

beas

sess

ed fo

r st

abili

ty b

efor

e w

ork

com

men

ces.

The

ass

essm

ent

shou

ld b

e do

ne b

y a

qual

ified

supe

rvis

or, p

rofe

ssio

nal f

ores

ter,

prof

essi

onal

eng

inee

r or

geos

cien

tist,

depe

ndin

g on

the

terr

ain

and

degr

ee o

f ris

k.A

dditi

onal

mon

itorin

g an

dre

asse

ssm

ent o

f suc

h ol

d ro

ads

shou

ld b

e do

ne if

ther

e is

hea

vypr

ecip

itatio

n, s

now

mel

t, or

oth

erco

nditi

ons

that

may

cau

seun

usua

l run

off.

3. T

hat f

ores

t ope

ratio

ns e

nsur

eth

at r

egul

ar in

spec

tions

and

rem

edia

tion

of fo

rest

roa

ds, a

sre

quire

d by

the

For

est P

ract

ices

Cod

e R

egul

atio

ns, b

e co

mpl

eted

.T

he fr

eque

ncy

of in

spec

tions

shou

ld b

e pr

edet

erm

ined

and

base

d on

crit

eria

suc

h as

: reg

ular

time

inte

rval

s, s

torm

cyc

les

orot

her

unus

ual e

vent

s, s

prin

g ru

nof

f, an

d th

e ris

k in

volv

ed. T

heF

ores

t Pra

ctic

es C

ode,

at t

his

time,

doe

s no

t spe

cify

freq

uenc

yof

insp

ectio

ns.

4. A

s a

stan

dard

saf

ety

proc

edur

e, o

ld lo

ggin

g ro

ads

that

are

not r

equi

red

to b

e m

aint

aine

d

Res

pons

e to

2, 3

, and

4:

The

se th

ree

reco

mm

enda

tions

refe

r to

var

ious

kin

ds o

f

As

abov

e

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

87

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

or d

eact

ivat

ed b

ecau

se th

ey a

reno

t und

er p

erm

it sh

ould

be

asse

ssed

for

pote

ntia

l haz

ard

toin

dust

rial o

pera

tions

.

insp

ectio

ns a

nd w

orks

ites.

The

sein

spec

tions

are

all

addr

esse

d in

the

new

Occ

upat

iona

l Hea

lth a

ndS

afet

y R

egul

atio

n in

sec

tions

3.15

, 3.1

7 an

d 26

.2.

Sec

tion

3.15

pro

vide

sE

very

em

ploy

er m

ust e

nsur

eth

at r

egul

ar in

spec

tions

are

mad

e of

all

wor

kpla

ces,

incl

udin

g bu

ildin

gs, s

truc

ture

s,gr

ound

s, e

xcav

atio

ns, t

ools

,eq

uipm

ent,

mac

hine

ry a

ndw

ork

met

hods

and

pra

ctic

es,

at in

terv

als

that

will

pre

vent

the

deve

lopm

ent o

f uns

afe

wor

king

cond

ition

s.

Sec

tion

3.17

furt

her

prov

ides

A s

peci

al in

spec

tion

mus

t be

mad

e w

hen

requ

ired

[b]y

mal

func

tion

or a

ccid

ent.

Sec

tion

26.2

furt

her

prov

ides

The

man

agem

ent o

f for

estr

yop

erat

ions

mus

t pla

n an

dco

nduc

t suc

h op

erat

ions

in a

man

ner

cons

iste

nt w

ith th

isre

gula

tion

and

with

rec

ogni

zed

safe

wor

k pr

actic

es.

5.

Min

istr

y of

For

ests

sho

uld

wor

k in

con

junc

tion

with

For

est R

enew

al B

.C. a

ndlic

ense

es to

com

plet

e an

aeria

l rec

onna

issa

nce

leve

las

sess

men

t of a

ll ol

d fo

rest

road

s in

B.C

. Suc

h an

With

res

pect

to th

isre

com

men

datio

n, it

is th

e B

oard

svi

ew th

at in

spec

tions

sho

uld

take

plac

e pr

ior

to th

e co

mm

ence

men

tof

wor

k ac

tiviti

es. T

he a

bove

refe

renc

ed s

ectio

ns o

f the

Occ

upat

iona

l Hea

lth a

nd S

afet

y

As

abov

e

Nel

son-

McD

erm

ott \

Fat

aliti

es S

ept 3

0 98

App

endi

x 4:

Exa

mpl

es o

f Cor

oner

s R

ecom

men

datio

ns a

nd W

CB

Res

pons

esP

age

88

CA

SE

:R

EC

OM

ME

ND

AT

ION

RE

SP

ON

SE

AG

EN

CIE

S A

DD

RE

SS

ED

asse

ssm

ent s

houl

d in

clud

e:•

a lo

w le

vel f

light

alo

ng e

very

road

usi

ng a

hel

icop

ter

• us

ing

an e

xper

ienc

edob

serv

er to

ass

ess

the

cond

ition

of t

he e

ntire

leng

thof

eve

ry r

oad

• id

entif

ying

prio

rity

area

s

Reg

ulat

ion

impo

se o

blig

atio

ns o

nem

ploy

ers

to c

ondu

ct th

ose

insp

ectio

ns b

oth

prio

r to

the

com

men

cem

ent o

f wor

k an

dw

hile

wor

k co

ntin

ues.

The

empl

oyer

s ob

ligat

ion,

on

anon

goin

g ba

sis

to in

spec

t and

mon

itor

the

wor

kpla

ce is

par

t of

the

empl

oyer

s ob

ligat

ion

unde

rth

e O

ccup

atio

nal H

ealth

and

Saf

ety

Reg

ulat

ion

to im

plem

ent

and

mai

ntai

n an

ong

oing

effe

ctiv

ehe

alth

and

saf

ety

prog

ram

.

Nelson-McDermott \ Fatalities 30 Sept 98Appendix 5: Draft Protocol

APPENDIX 5:

Draft Protocol Between: The Ministry of the Attorney General

and the Chief Coroners for the Province of British Columbia

and the Workers’ Compensation Board

WHEREAS the Chief Coroner and coroners subject to his direction under Section 4 ofthe Coroners Act. R.S.B.C. 1979 c.68 and amendments thereto (the "Coroners Act")require, from time to time, records in the custody and control of the Workers'Compensation Board in order to fulfill their statutory responsibilities under the CoronersAct in investigating deaths;

WHEREAS Section 16(2) of the Coroners Act provides that a coroner, where hebelieves on reasonable grounds that it is necessary to do so for the purposes of aninvestigation, many inspect information in any records relating to the deceased or hiscircumstances, and seize anything that the coroner has reason to believe is material tothe investigation;

WHEREAS the Workers' Compensation Board requires, from time to time, records inthe custody and control of the Chief Coroner and coroners subject to his direction inorder to carry out its responsibilities under the Workers' Compensation Act, R.S.B.C.1979, c.83 and amendments thereto (the "Workers' Compensation Act")'

WHEREAS Section 87 of he Workers' Compensation Act provides that the Workers'Compensation Board has the like powers as the Supreme Court of British Columbia tocompel the production and inspection of books, papers, documents and things; andSection 88 of the Workers' Compensation Act provides that an officer of the Workers'Compensation Board and every other person appointed to make an inquiry has all thepowers of the Workers' Compensation Board under Section 87 of the Workers'Compensation Act;

WHEREAS Section 33(d) of the Freedom of Information and Protection of Privacy Act,S.B.C. 1992, c.61 (the "Freedom of Information and Protection of Privacy Act") providesthat a public body may disclose personal information for the purpose of complying withan enactment of, or with a treaty, arrangement or agreement made under an enactmentof, British Columbia or Canada;

WHEREAS the Workers' Compensation Board is a public body designated in Schedule2 of the Freedom of Information and Protection of Privacy Act;

WHEREAS the Ministry of the Attorney General is a public body as defined in Schedule1 of the Freedom of Information and Protection of Privacy Act;

WHEREAS under Section 66 of the Freedom of Information and Protection of PrivacyAct the Attorney General has delegated his duties, powers and functions under theFreedom of Information and Protection of Privacy Act with respect to disclosure issues

Nelson-McDermott \ Fatalities Sept 30 98

arising under the Coroners Act to the Chief Coroner and coroners subject to hisdirection;

WHEREAS the records required from the Workers' Compensation Board by the ChiefCoroner and coroners subject to his direction under Section 4 of the Coroners Act maycontain "personal information" as defined in Schedule 1 of the Freedom of Informationand Protection of Privacy Act;

WHEREAS the records required from the Chief Coroner and coroners subject to hisdirection may contain "personal information" as defined in Schedule 1 of the Freedomof Information and Protection of Privacy Act;

WHEREAS it is in the public interest that there be efficient, efficacious and appropriatedisclosure of records between the Chief Coroner and coroners subject to his direction,and the Workers' Compensation Board, in accordance with the Freedom of Informationand Protection of Privacy Act;

NOW THEREFORE the Ministry of the Attorney General, the Workers' CompensationBoard and the Chief Coroner agree to adhere to the following protocol to ensure thatthey fulfill their respective obligations under the Coroners Act and the WorkersCompensation Act in accordance with the Freedom of Information and Protection ofPrivacy Act.

1. The Ministry of the Attorney General, the Chief Coroner and the Workers'Compensation Board hereby agree that when an officer or authorized agent of theWorkers' Compensation Board is satisfied that a request has been made by the ChiefCoroner, a coroner subject to the Chief Coroner's direction, or one of their authorizedagents, for a record in the custody and control of the Workers' Compensation Board,and the officer or authorized agent of the Workers' Compensation Board is satisfiedthat the request is for a record which is necessary for the purposes of an investigationunder the Coroners Act, the officer or authorized agent of the Workers' CompensationBoard shall, without delay, as part of the ordinary course of business of the Workers'Compensation Board, provide a copy of the record in question to the requester, be itthe Chief Coroner, a coroner subject to the Chief Coroner's direction or one of theirauthorized agents.

2. The Ministry of the Attorney General, the Chief Coroner and the Workers'Compensation Board hereby agree that when the Chief Coroner, a coroner subject tohis direction, or one of their authorized agents, is satisfied that a request has beenmade by an officer or authorized agent of the Workers' Compensation Board for arecord in the custody and control of the Chief Coroner or a coroner subject to hisdirection, and the Chief Coroner, coroner subject to his direction or one of theirauthorized agents, is satisfied that the request is for a record which is necessary for thepurposes of an investigation or inquiry or other statutory purpose under the Workers'Compensation Act by the Workers' Compensation Board, the Chief Coroner, coronersubject to his direction or one of their authorized agents, shall, without delay, as part ofthe ordinary course of business of the Chief Coroner or a coroner subject to his

Nelson-McDermott \ Fatalities Sept 30 98

direction, provide a copy of the record in question to the officer or authorized agent ofthe Workers' Compensation Board.

3. The Ministry of the Attorney General and the Chief Coroner hereby agree thatany record obtained from the Workers' Compensation Board pursuant to this Protocolshall be used by the Chief Coroner, a coroner subject to the Chief Coroner's directionor their authorized agents, only for purposes of fulfilling statutory responsibilities underthe Coroners Act, and no record will be used or disclosed by the Chief Coroner, acoroner subject to the Chief Coroner's direction, or their authorized agents, for anyother purpose without the express written permission of the Workers' CompensationBoard;

4. The Workers' Compensation Board hereby agrees that any record obtainedfrom the Chief Coroner, a coroner subject to the Chief Coroner's direction, or theirauthorized agents, pursuant to this Protocol shall be used by the Workers'Compensation Board, including it officers and authorized agents, only for the purposesof fulfilling statutory responsibilities under the Workers Compensation Act, and norecord will be used or disclosed by the Workers' Compensation Board, its officers orauthorized agents for any other purpose without the express written permission of theChief Coroner or a coroner subject to his direction.

5. The Ministry of the Attorney General, the Chief Coroner and the Workers'Compensation Board agree that nothing in this Protocol precludes disclosure wheresuch disclosure is required by law, that is, under the authority exercised by the Courtsor tribunals or as required by the Freedom of Information and Protection of Privacy Act.

IN WITNESS WHEREOF this Protocol has been signed this _____ day of________________, 1994 by:

____________________________________for the Ministry of the Attorney General

____________________________________Chief Coroner

__________________________________Chair, Workers' Compensation Board

Nelson-McDermott \ Fatalities 30 Sept 98Appendix6: Prevention Logic Model Page 92

Appendix 6:

Prevention Logic Model61

61 Auditor General’s Office: Workers’ Compensation Board of British Columbia – AccountabilityReporting Review: “Prevention Logic Model” flow chart.

Nelson-McDermott \ Fatalities Sept 30 98Appendix 7: Fatal Investigations: Review of WCB Files Page 93

APPENDIX 7:

FATAL INVESTIGATIONS:Review of Workers’ Compensation Files: 1993 through 1997

INTRODUCTION

To supplement the review of the Workers’ Compensation Board (WCB) of BritishColumbia’s relationship to the provincial Coroners Services, a file study was proposedfor 1993 through 1997. A sample of 100 claims files was chosen at random(electronically), and the commission requested that the Board give the researcheraccess to these files. Out of the 100 claims, 99 were located in Compensation Services– one number had been a duplicate record (claim registered under two different namesin the Statistical Services’s database).

The Board was asked to provide ALL files that may pertain to these reported deaths.The Board did not. It gave the researcher access to Compensation Services files aswell as Prevention Division’s accident investigation and employer files that were inRichmond. The Prevention Division’s Legal Office also provided files as they pertain tocoroner’s recommendations and cases that the Legal Office has followed up on. Filesfrom the following areas were not provided:• WCB’s Legal Division: any legal information that the researcher was given access

to was contained within the main Compensation Services file;• Policy and Regulation Development Bureau;• Engineering, Laboratory, Outreach;• regional office files as they pertain to any aspect of the fatality;• Statistics Services files;• senior management files;or any other office at the Board through which fatalities-related information may beprocessed. The researcher has no confidence that she was provided with anexhaustive complement of case files.

COMPENSATION SERVICES

97 out of 99 files were provided for the researcher to review. Although the Boardprovided a list of the full complement of 99, in the final analysis 97 had been pulled forreview. The 97 files included one that was in “lock up” for internal fraud, and three thatwere in the Legal Department pending s.11 reviews at the Appeal Division. Both ofthese divisions of the Board made the requested files available.

The Compensation Services Division has a Sensitive Claims Section. Within thissection, the Fatal Claims Adjudicator (FCA) determines entitlement and allows ordisallows all of the fatal claims made to the Board. Fatal claims includes workplacedeaths that are outside of the Prevention Division’s inspectional jurisdiction.

The fatal claims adjudicator (FCA) appears to initiate claims consistently: the FATAL


CLAIMS INFORMATION form is filled out (attached). This form gathers togetherinformation about the deceased, the next-of-kin, the employer, and somecircumstancesof the accident. The FCA appears to initiate communication with Vital Statistics (requestfor Registration of Death and the Coroner’s or Physician’s Medical Certificate of Death),the Coroners Services, and the RCMP (or local police) - a form letter is sent out askingfor copies of all reports. Where the FCA is aware of next-of-kin, he also sends a letterconveying the Board’s condolences and information for filing a claim.

The Coroners Services Judgement of Inquiry reports, including autopsy andsupplementary information (including recommendations) were in the claims files. TheFCA does not forward copies to the Prevention Division or to any other individuals oroffices at the Board.

Where fatal claims that were outside of the Prevention Division’s inspectionaljurisdiction, the FCA had corresponded with the appropriate government agency (eg,Transport Canada Safety Board), and requested a copy of that agency’s accidentinvestigation. One file contained an accident investigation report that had been misfiledand one contained an accident investigation that had been sent to the WCB in error.The correct report had been forwarded when the error was caught at the sender’s end,but the original document was not returned or destroyed. To remove documentationfrom claim files, the Board maintains a severance policy that the FCA appears toadhere to.

Judgement of Inquiry reports were located in 46 Compensation Services files. Otherthan the Coroner’s Medical Certificate of Death and autopsy reports, no other coroner’sinformation is found in the Compensation Services files.

Fifty-three claims were as a result of death due to traumatic accident injuries. Twoemployers had not been listed with the WCB and one was assessed. Five claimantsappeared to be self-employed, two had personal optional protection. The “front page”of the preliminary accident investigation from the Prevention Division was in thirty-eighttraumatic fatality claims files. One traumatic injury claim was a suicide that wascommitted at home and was not work-related.

Ten claims were for occupational disease-related deaths (asbestosis, mesothelioma,and lung cancer). One claim was for carbon-monoxide poisoning, and two asthma (oneexposure to pesticides, and one exposure to zinc oxidate). Two claims were for deathsdue to medical problems arising from a work-related injury. Fourteen claims wereestablished where death was due to heart attack as a result of heart disease. Twoclaims were for brain aneurysms and one for death due to brain cancer (all non-work-related).

Note: evidence shows that the FCA assigns a claim number to any fatality that may bework-related. Not all claim numbers reflect work-relatedness. This study does not lookat entitlement, allows, disallows, rejects, or appeals. Its purpose is to look into coroner’sinvestigations.

All claim files where a claim has been adjudicated (some are withdrawn beforeadjudication) have medical evidence that is either a Medical Certificate of Death (issued


by Vital Statistics), a Registration of Death (issued by Vital Statistics), hospital records,coroner’s findings and autopsy reports. Where there is a question about disease andwork-relatedness the FCA has sought the advice of the Board’s Internal MedicineConsultant.

PREVENTION DIVISION

Employer Files

Employer files contain inspection reports (IR), consultation reports (CR), compliancereports (from the employer), and Sanction & Variance Review information where a fieldofficer has recommended warning letters, sanctions, and prosecutions. Fifty-five claimshad employer files in the Prevention Division. Of these, twenty-five inspection reportsnote that they are in response to a fatal accident. Of the twenty-five, one fatality wentforward as a prosecution, and four had penalty recommendations that were related toviolations in the fatal accident. The other 30 employer files did not refer fatalities in thisstudy’s sample. Two files did, however, refer to injuries, but not that complicationsended in the worker’s death. One employer was partial and did not contain anyinformation for the year requested, and one was the wrong employer file altogether.

The only employer files that contain coroner’s recommendations or any reference to acoroner’s (or other agency’s involvement) are those where the field officer hasrecommended a warning letter or sanction, or those that are forwarded to thePrevention’s Legal Office for prosecution.

Note: Inspection Reports are standard reports and are consistent throughout all filesreviewed. They contain the employer information, date, time, location, employer andworker representatives that participated in the inspection. IR’s cite regulation andviolation as well as corrective or preventive orders. Compliance reports and employeraccident investigation reports (or safety committee minutes) do not appear to be inmost employer files.

Accident Investigation Report Files

The Prevention Division provided forty-seven accident investigation reports. There isnothing to distinguish preliminary accident investigations from full investigations and allare filed together in a numerical system (year-investigation number). Of the forty-seven,thirty-three are complete investigations. Fourteen are preliminary, and one is an injuryfollow-up investigation, not a complete post-fatality accident investigation.

Where an accident investigation is complete, the file will contain a completed 52B15report, photographs, witness information, and supplementary documentation pertinentto the accident (police reports, engineering reports, vehicle inspection reports). Thesupplementary documentation sometimes includes coroner’s reports, although this isthe exception rather than the rule. Most coroner’s reporting can be found in theCompensation Services files.


Prevention Division’s Legal Office

The Prevention Division’s Lawyer provided the researcher with access to three filesfrom the sample provided. These files are created in response to coroner’srecommendations. One file was in response to a coroner’s inquest, one containedextensive accident investigation information where the Board was requesting aninquest, and one was in response to coroner’s recommendations. The Legal Officeprovided the researcher with photocopies of the confidential contents of the fatal casethat went to inquest as an example of the Legal Office’s process for responding tocoroner’s recommendations.

SUMMARY

The purpose of this file review was to establish where coroner’s recommendations andreports are kept at the Board, and whether the working relationship between thePrevention Division and the Provincial Coroners Services is reflected in the accidentinvestigation process. Categorically, Compensation Services consistently requests andkeeps coroner’s reports. Prevention Division’s two investigation files: accidentinvestigations and employer files do not routinely contain coroner’s reports orrecommendations. The Prevention Division’s Legal Office’s files all pertain to coroner’sinvestigations, inquests, and recommendations. Where coroner’s reports have not beenforwarded to the Legal Office, however, they are unaware of the document. Except forpreliminary accident investigation documentation, Compensation Services does notkeep accident investigations. Employer information is not contained in claims files.Claims information does not show up in the Prevention Division’s files.

Nelson-McDermott \ Fatalities Sept 30 98Appendix 8: Fatalities Investigations: Data Analysis Page 97

Appendix 8Fatalities Investigations: Data Analysis

The data analysis is summary information of a database constructed from severaldifferent, and sometimes conflicting sources: the Coroners’ Services electronic recordsfor the cases investigated by coroners between 1993 and 1997; the Workers’Compensation Board’s Prevention Division’s records for cases investigated byPrevention Division Safety and/or Hygiene officers between 1993 and 1997; theWorkers’ Compensation Board’s Statistics Division’s records for claims reported to theBoard and claims accepted by the Board between 1993 and 1997; and claims datafrom the Royal Commission’s Data Cohort Project.

In some instances, the Workers’ Compensation Board’s records are missing data suchas death date, birth date, and claim date.

The Workers’ Compensation Board’s Compensation Services, Statistics Department,and Prevention Division do not verify one another’s records – not between thedepartments in an annual audit, nor with an outside agency, such as Vital Statistics.The Coroners’ Services verifies its records with the Division of Vital Statistics, but theCoroners’ Services database does not contain a definitive record of every work-relateddeath in the province as not all are investigated by coroners. The Prevention Division’srecords may contain some fatalities information for deaths occurring outside of thePrevention Division’s jurisdiction. The Prevention Division’s records managementsystem assigns its accident investigation identifying numbers to all cases whether theyare thoroughly investigated, partially investigated, reported and not investigated. Itsdatabase is not linked to either Statistics or Compensation Services. In some instances,the only data in the commission’s database is from the Coroners’ Services: no claimhas been reported (or if it has, is not recorded), and no Prevention Division accidentinvestigation has been done (or, if it has, the information was not provided). It is difficultto get an accurate picture of how many deaths occurred from a Prevention standpointbecause where multiple deaths occur in one accident, regardless of how many workersdied, the count is “one” and the same accident investigation number is assigned to all.Because of this, the count is not by deaths investigated, it is by fatal accidentsinvestigated.

None can state that it has captured all of the fatalities records, and so the datacontained in the commission fatalities database cannot be considered an authoritativesource. The Division of Vital Statistics’ records would need to be incorporated into thisdatabase. It is, however, sufficient to track trends and support statements made in theFatalities Investigations paper about the relationship between the Workers’Compensation Board and the Coroners’ Services as well as provide a look at the kindof fatalities reported to the Board, accepted by the Board, and investigated by FieldOfficers. Again, however, this cannot be considered definitive for the reasons statedabove.

This database covers the years 1993 through 1997. The numbers of deaths recordedhere differ from the Board’s records. The Board maintains its database by numbers ofclaims reported and accepted, with a cut-off that is enforced in February of thefollowing year. For example, if a worker dies in May of 1995, but the death is not


reported to the Board, and, therefore, a claim number assigned by the Board until Mayof 1996, that fatality is recorded in the 1996 statistics. This fact supports the impressionthought that the Board is in the insurance business, following claims, not people.

An issue of concern to the public is that the Board does not follow-up with coroner’srecommendations. The data reported to the commission by both agencies suggeststhat the Board does respond, at least in writing, to some of the Coroners’ Servicesrecommendations. This data is supplied solely by the Coroners’ Services, the Boardwas asked to provide data stating which deaths were investigated by the Coroners’Services and in which cases recommendations for action or consideration were madeto the Board (by individual coroners or coroners’ juries), and which of thoserecommendations were responded to (not necessarily followed up on). The Board failedto provide this information and stated that it was unable to do so as it does not have asystem for recording and tracking coroner’s recommendations if they are not forwardedto the Prevention Division’s Legal Office. The Legal Office responds but does notmaintain a database of recommendations and responses. The Policy and RegulationBureau does not maintain a record of coroner’s recommendations and correspondence.

The data provided to the commission is unable to state how many deaths occurredoutside of the Prevention Division’s jurisdiction. Although this data was requested, theBoard failed to provide it.

The following data is organized contrast claims and investigations. Tables 1993 through1997 are broken down into two summaries of the data available. Tables “A” show thetotals of incidents of mortality by cause. They also show total numbers of claimsreported, and total numbers of investigations (prevention and coroners). Tables “B”show a more in-depth analysis of the total numbers by cause. These tables showwhere claims, prevention, and coroners services overlap or not. They do not provide anexplanation for the results.

FatalitiesYear Instances of

Mortality62WCB: Claims Investigations:

PreventionInvestigations:Coroners’

1993 208 186 62 881994 248 207 90 1071995 225 200 78 881996 226 201 95 681997 219 183 104 6663

62 All records from all sources totaled.63 1997 records are incomplete. Although they represent the content of the Coroners Services’database to January 1998, coroners’ cases take up to nine months to process and it can beassumed that the database records at the time they were forwarded to the commission areincomplete.


Fatalities Investigation by the Coroners’ Services and the Prevention DivisionYear Coroners’

InvestigationsPrevention DivisionInvestigations

Parallel Coroners’ andPrevention’ Investigations64

1993 88 62 451994 107 90 581995 88 78 571996 68 95 421997 66 104 25

Breakdown of Investigations and Number of Claims Made by Type of Death: 199365

(Table 1993A)Type ofDeath(Cause)

Total Prevention66

InvestigationsCoroner67

InvestigationsClaims68

Unknown(unlisted)

71 29 48 49

Asbestosis 13 0 0 13Asphyxiated 2 1 2 2Buried 1 1 1 1Cancer 7 0 0 7Collapsed 1 1 1 1Crushed 11 10 11 11Drowning 6 1 5 6Exposure 8 0 0 8Fall from 3 0 0 3Head Injury 1 0 0 1Heart Attack 22 0 7 22Homicide 3 0 2 3MVA 32 9 3 32Plane Crash 13 4 1 13Pneumococ. 1 0 0 1Rolled Skid. 1 1 1 1Silicosis 2 0 0 2Stroke 1 0 0 1Struck By 6 5 6 6Suicide 3 0 0 3Totals 208 62 88 186

64 Accidents where both the coroner and the Prevention Division conducted investigations. Note:these are not “joint” investigations, they are considered to be “parallel” investigations.65 Note: “Type” of death is a designation assigned by the researcher. “Cause” is a designationused by the Workers’ Compensation Board. It does not suggest that this is the commission’sdefinition of “cause.” Unknown is used where the Board has supplied a narrative of the event butgives no “cause,” or the Board’s records state “unknown.” Further, in Tables labeled “Breakdownof Investigations and Number of Claims Made …,” the totals for Prevention Investigations,Coroner Investigations, and Claims do not total the number of deaths: they indicate the numberof investigations or claims made within the total number of deaths.66 Prevention = Accident Investigation Case Numbers assigned67 Coroner = Coroner Case Numbers assigned68 Claims = where there are no accident or coroner’s investigations and the only record providedto the commission is a claims number. Accident investigation may be by another agency or noinformation provided at all - death certificate from Vital Statistics establishes cause of death andother applicable information to Compensation Services.


Breakdown Detail (Table 1993B)Type of Death(Cause)

Total PD,CO, Cl

PD,CO (noCl)

PD, Cl(noCO)

PD (noCl, CO)

Cl, CO(no PD)

CO (noCl, PD)

Cl only Incidence of JointPrevention andCoroner Invest.

Unknown(unlisted)

71 23 0 5 1 4 21 17 23 (32%)

Asbestosis 13 0 0 0 0 0 0 13 0Asphyxiated 2 1 0 0 0 1 0 0 1 (50%)Buried 1 1 0 0 0 0 0 0 1 (100%)Cancer 7 0 0 0 0 0 0 7 0Collapsed 1 1 0 0 0 0 0 0 1 (100%)Crushed 11 10 0 0 0 1 0 0 10 (91%)Drowning 6 1 0 0 0 4 0 1 1 (17%)Exposure 8 0 0 0 0 0 0 8 0Fall from 3 0 0 0 0 0 0 3 0Head Injury 1 0 0 0 0 0 0 1 0Heart Attack 22 0 0 0 0 7 0 15 0Homicide 3 0 0 0 0 2 0 1 0MVA 32 2 0 7 0 1 0 22 2 (6%)Plane Crash 13 0 0 4 0 1 0 8 0Pneumococ. 1 0 0 0 0 0 0 1 0Rolled Skid. 1 1 0 0 0 0 0 0 1 (100%)Silicosis 2 0 0 0 0 0 0 2 0Stroke 1 0 0 0 0 0 0 1 0Struck By 6 5 0 0 0 1 0 0 5 (83%)Suicide 3 0 0 0 0 0 0 3 0Totals 208 45 0 16 1 22 21 103 45 (22%)

Breakdown of Investigations by Type of Death: 1994(Table 1994A)Type of Death(Cause)

Total Prevention Coroner Claims

Unknown(unlisted)

58 4 42 21

Asbestosis 15 0 0 15Asphyxiated 2 2 1 2Burns 2 2 1 2Cancer 10 0 0 10Cardio/Res. 2 1 1 2Crushed 20 16 16 20Drowning 18 13 9 18Electrocution 2 2 2 2Embolism 1 1 1 1Exposure 7 0 0 7Fall from 6 3 2 6Hantavirus 1 1 0 1Head Injury 8 8 6 7Heart Attack 31 14 9 28Helicopter Crash 2 0 0 2Homicide 1 0 0 1MVA 35 8 3 35Other 6 6 5 6Plane Crash 7 0 0 7Pneumococ. 1 0 0 1Silicosis 3 0 0 3Struck By 9 9 9 9Suicide 1 0 0 1Totals 248 90 107 207


Breakdown Detail (Table 1994B)Type of Death(Cause)

Total PD,CO, Cl

PD,CO (noCl)

PD, Cl(noCO)

PD (noCl, CO)

Cl, CO(no PD)

CO (noCl, PD)


Unknown(unlisted)

58 2 0 0 2 5 35 14 2 (3%)

Asbestosis 15 0 0 0 0 0 0 15 0Asphyxiated 2 1 0 1 0 0 0 0 1 (50%)Burns 2 1 0 1 0 0 0 0 1 (50%)Cancer 10 0 0 0 0 0 0 10 0Cardio/Res. 2 0 0 1 0 1 0 0 0Crushed 20 14 0 2 0 2 0 2 14 (70%)Drowning 18 4 0 9 0 5 0 0 4 (22%)Electrocution 2 2 0 0 0 0 0 0 2 (100%)Embolism 1 1 0 0 0 0 0 0 1 (100%)Exposure 7 0 0 0 0 0 0 7 0Fall from 6 2 0 1 0 0 0 3 2 (33%)Hantavirus 1 0 0 1 0 0 0 0 0Head Injury 8 6 0 1 1 0 0 0 6 (75%)Heart Attack 31 6 2 5 1 1 0 16 6 (19%)Helicopter Crash 2 0 0 0 0 0 0 2 0Homicide 1 0 0 0 0 0 0 1 0MVA 35 3 0 5 0 0 0 27 3 (9%)Other 6 5 0 1 0 0 0 0 5 (83%)Plane Crash 7 0 0 0 0 0 0 7 0Pneumococ. 1 0 0 0 0 0 0 1 0Silicosis 3 0 0 0 0 0 0 3 0Struck By 9 9 0 0 0 0 0 0 9 (100%)Suicide 1 0 0 0 0 0 0 1 0Totals 248 56 2 28 4 14 35 109 56 (23%)



Unknown(unlisted)

44 6 25 19

Asbestosis 14 0 0 14Asphyxiation 2 2 1 2Asthma 1 0 0 1Cancer 12 0 0 12Cardio/Res. 10 8 7 10Crushed 15 13 13 15Drowning 20 18 16 20Electrocuted 4 4 3 4Exposure 4 0 0 4Fall from 7 6 4 7Hantavirus 1 1 1 1Head Injury 4 4 3 4Heart Attack 16 0 1 16Heat/Cold 2 2 1 2Helicopter Crash 3 0 0 3Homicide 3 0 0 3MVA 25 2 1 25Other 8 8 6 8Plane Crash 17 0 0 17Silicosis 5 0 0 5Struck By 4 4 4 4Suicide 1 0 0 1Train Crash 2 0 2 2Undetermined 1 0 0 1Totals 225 78 88 200


Breakdown of Detail (1995B)Type of Death(Cause)

Total PD,CO, Cl

PD,CO (noCl)

PD, Cl(noCO)

PD (noCl, CO)

Cl, CO(no PD)

CO (noCl, PD)


Unknown(unlisted)

44 2 0 1 3 2 21 15 2 (5%)

Asbestosis 14 0 0 0 0 0 0 14 0Asphyxiation 2 1 0 1 0 0 0 0 1 (50%)Asthma 1 0 0 0 0 0 0 1 0Cancer 12 0 0 0 0 0 0 12 0Cardio/Res. 10 5 0 3 0 2 0 0 5 (50%)Crushed 15 11 0 2 0 2 0 0 11 (73%)Drowning 20 15 0 3 0 0 1 1 15 (75%)Electrocuted 4 3 0 1 0 0 0 0 3 (75%)Exposure 4 0 0 0 0 0 0 4 0Fall from 7 4 0 2 0 0 0 1 4 (57%)Hantavirus 1 1 0 0 0 0 0 0 1 (100%)Head Injury 4 3 0 1 0 0 0 0 3 (75%)Heart Attack 16 0 0 0 0 1 0 15 0Heat/Cold 2 1 0 1 0 0 0 0 1 (50%)Helicopter Crash 3 0 0 0 0 0 0 3 0Homicide 3 0 0 0 0 0 0 3 0MVA 25 1 0 1 0 0 0 23 1 (4%)Other 5 4 0 1 0 0 0 0 6 (75%)Plane Crash 17 0 0 0 0 0 0 17 0Silicosis 5 0 0 0 0 0 0 5 0Struck By 4 4 0 0 0 0 0 0 4 (100%)Suicide 1 0 0 0 0 0 0 1 0Train Crash 2 0 0 0 0 2 0 0 0Undetermined 1 0 0 0 0 0 0 1 0Totals 225 57 0 18 3 9 22 116 57 (25%)



Unknown(unlisted)

35 1 18 17

Asbestosis 21 0 0 21Cancer 16 0 0 16Cardio 10 9 8 10Crushed 21 19 15 21Drowning 9 9 1 9Electrocuted 3 2 0 1Exposure 2 0 0 2Extreme Temp. 1 0 0 1Fall from 7 5 2 7Head Injury 7 7 3 7Heart Attack 15 4 1 11Helicopter Crash 4 0 3 4Homicide 3 2 0 2MVA 24 8 1 24Other 9 8 3 9Plane Crash 9 6 1 9Run Over 1 1 1 1Silicosis 7 0 0 7Stroke 1 0 0 1Struck By 15 12 10 15Suicide 2 0 0 2Temp Exposure 1 0 0 1To Be Determ. 2 2 1 2Trauma/Strss 1 0 0 1Totals 226 95 68 201

Breakdown of Detail (Table 1996B)


Type of Death(Cause)

Total PD,CO, Cl

PD,CO (noCl)

PD, Cl(noCO)

PD (noCl, CO)

Cl, CO(no PD)

CO (noCl, PD)


Unknown(unlisted)

35 0 0 1 0 0 18 16 0

Asbestosis 21 0 0 0 0 0 0 21 0Cancer 16 0 0 0 0 0 0 16 0Cardio 10 7 0 2 0 1 0 0 7 (70%)Crushed 21 14 0 5 0 0 1 1 14 (66%)Drowning 9 1 0 8 0 0 0 0 1 (11%)Electrocuted 3 0 0 2 0 0 0 1 0Exposure 2 0 0 0 0 0 0 2 0Extreme Temp. 1 0 0 0 0 0 0 1 0Fall from 7 2 0 3 0 1 0 1 2 (29%)Head Injury 7 3 0 4 0 0 0 0 3 (43%)Heart Attack 15 1 0 3 0 1 0 10 1 (7%)Helicopter Crash 4 0 0 0 0 3 0 1 0Homicide 3 0 0 2 0 1 0 0 0MVA 24 1 0 7 0 0 0 16 1 (4%)Other 9 3 0 5 0 1 0 0 3 (33%)Plane Crash 9 0 0 6 0 1 0 2 0Run Over 1 1 0 0 0 0 0 0 1 (100%)Silicosis 7 0 0 0 0 0 0 7 0Stroke 1 0 0 0 0 0 0 1 0Struck By 15 8 0 4 0 2 0 1 8 (53%)Suicide 2 0 0 0 0 0 0 2 0Temp Exposure 1 0 0 0 0 0 0 1 0To Be Determ. 2 1 0 0 0 1 0 0 1 (50%)Trauma/Strss 1 0 0 0 0 0 0 1 0Totals 226 42 0 52 0 12 19 101 42 (19%)



Unknown (unlisted) 59 18 30 28Aneurysm 1 0 0 1Asbestosis 13 0 0 13Asphyxiated 1 1 0 1Asthma 1 0 0 1Bear 1 1 0 1Brain Hemm. 1 0 0 1Cancer 7 0 1 6Cardio/Res 4 4 1 4Crushed 15 14 8 15Drowning 6 5 2 6Electrocution 5 5 1 5Exposure 5 0 0 5Fall from 10 9 3 10Head Injury 3 3 3 3Heart Attack 10 1 2 10Heat/Cold 2 2 0 2Helicopter Crash 5 0 1 5Hepatitis C 1 0 0 1Homicide 3 1 0 2Medical Compl. 1 1 0 1MVA 38 8 2 38Other 12 11 4 9Plane Crash 9 8 1 9Seizure 1 0 0 1Struck By 11 10 4 11Suffocated 1 1 0 1Suicide 1 0 0 1To Be Determined 1 1 1 1Train 3 0 3 3Totals 231 104 66 196

Breakdown of Detail (Table 1997B)


Type of Death(Cause)

Total PD, CO,Cl

PD, CO(no Cl)

PD, Cl(no CO)

PD (noCl, CO)

Cl, CO(no PD)

CO (noCl, PD)

Cl only Incidence ofPrevention andCoroner Invest.

Unknown (unlisted) 59 2 1 12 3 0 27 1 2 (3%)Aneurysm 1 0 0 0 0 0 0 1 0Asbestosis 13 0 0 0 0 0 0 13 0Asphyxiated 1 0 0 1 0 0 0 0 0Asthma 1 0 0 0 0 0 0 1 0Bear 1 0 0 1 0 0 0 0 0Brain Hemm. 1 0 0 0 0 0 0 1 0Cancer 7 0 0 0 0 0 1 6 0Cardio/Res 4 0 1 3 0 0 0 0 0Crushed 15 7 0 7 0 1 0 0 7 (47%)Drowning 6 2 0 3 0 0 0 1 2 (33%)Electrocution 5 1 0 4 0 0 0 0 1 (20%)Exposure 5 0 0 0 0 0 0 5 0Fall from 10 2 0 7 0 1 0 0 2 (20%)Head Injury 3 3 0 0 0 0 0 0 3 (100%)Heart Attack 10 0 0 1 0 2 0 7 0Heat/Cold 2 0 0 2 0 0 0 0 0Helicopter Crash 6 0 0 0 0 1 0 5 0Hepatitis C 1 0 0 0 0 0 0 1 0Homicide 3 0 0 1 0 0 0 2 0Medical Compl. 1 0 0 1 0 0 0 0 0MVA 38 0 0 8 0 1 0 29 0Other 12 3 0 5 3 1 0 0 3 (25%)Plane Crash 9 0 0 8 0 1 0 0 0Seizure 1 0 0 0 0 0 0 1 0Struck By 11 4 0 6 0 0 0 1 4 (36%)Suffocated 1 0 0 1 0 0 0 0 0Suicide 1 0 0 0 0 0 0 1 0To Be Determined 1 1 0 0 0 0 0 0 1 (100%)Train 3 0 0 0 0 3 0 0 0Totals 219 25 2 71 6 11 28 76 25 (11%)

Data attempting to draw a relationship between the Prevention Division andCompensation Services (claims) remains irrelevant as accident investigation findings donot affect claim determination or eligibility. Data is provided, however, on claims,acceptance, and Coroners’ Investigations. Claims may or may not be accepted oncoroner’s evidence – some are accepted based on information received by VitalStatistics, hospitals, autopsy reports or other acceptable sources – whichever isreceived by the Compensation Services Division first.

Coroners’ Investigation and claim status: 1993 through 1997Year Coroners’

InvestigationsClaims made Coroners

investigations ofcases where claimswere made

1993 88 186 671994 107 207 701995 88 200 661996 68 201 541997 66 183 36

A final word: The above data cannot be compared to any one institution. To build asimilar database at the Workers’ Compensation Board, it would need to redesign itsinformation systems to a) connect its divisions and implement information sharing; b)


link data from outside agencies with its internal data (e.g., Vital Statistics (which is notfeatured above) and the Coroners’ Services).

The commission data cannot be compared with the Workers’ Compensation Board dataas it is already known that information collected and reported by the Board isincomplete and unverified. Prevention data is not incorporated into the universalstatistical database, so it is a unique set of data, separate from the officially reportednumbers of workers’ deaths reported to the Board as claims. Data used by thecommission includes the Board’s data as well as records supplied by the coroner’sservices. The best conclusions that can be drawn from an analysis of the data providedand in the context of fatalities investigations are no definitive statements, but indicatorsof trends and patterns that support the commission’s research findings:

1. The Board’s fatalities targeting is driven by claims information. The StatisticsDivision produces its reports based on claims data, not Prevention. Prevention’srecords of death are specific to its own investigations.

2. The Statistics Division counts claims reported and reports deaths by claims reportedand accepted within a given year. The Board does not manage its data so that itreports out on number of people who have died of work-related causes in any givenyear.

3. The Statistics and Prevention Divisions at the Workers’ Compensation Board do notcompare their data to, or compare their data with, outside agencies.

4. Incidence of coroner’s involvement and recommendations is not tracked ormaintained at the Board. The Board could not provide this information to thecommission.

5. Responses to the coroner’s recommendations received at the Board is notmaintained in a central filing and records management system at the Board.

6. The Board does not maintain records that would indicate what information sourcesare considered for accepting claims.

7. The Board does not consistently “code” its fatalities data: cause, industry,occupation, and other descriptives are neither universal in application or use. Forexample, a “logger” may be called a logger, a buckerman, a bucker, a riggingslinger, a skidder operator, and so on. Cause of death may be reported as anarrative, or by different terms. For example, death caused by a crushing injury maybe listed as “crushed” or as an MVA. Motor vehicle accidents are not within thePrevention Division’s jurisdiction and so no further information to qualify the data inthe Statistics Division may be obtained.

The only conclusion that can be drawn from the above is that the Board’s datamanagement and information control systems are inadequate for the scope of theBoard’s programs and responsibilities. The above findings are referred to in theFatalities Investigations report to the commission.

Documents

WORKERS’ COMPENSATION BOARD OF BRITISH COLUMBIA ... · Each year in British Columbia, the Workers’ Compensation Board (WCB) reports numbers of fatal, work-related traumatic injury