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Appendix G – Mining Sector Coroner’s Jury Recommendations Analysis

  • Issued: April 15, 2015
  • Content last reviewed: April 2015
  • See also: Final Report

Report on Coroner Jury Reports Analysis for Mining Sector


This report provides an overview of the preliminary analysis of Coroners Jury Reports (CJRs) in the mining sector.


The Office of the Chief Coroner (OCC) for Ontario is responsible for death investigations and inquests in Ontario to ensure that no fatalities are overlooked, concealed, or ignored.

Deaths that occur as a result of an accident in the course of employment at construction sites, mining plants and mines are subject to mandatory inquests. According to Section 10 (5) of the Coroners Act:

Notice of death resulting from accident at or in construction project, mining plant or mine

  • (5) Where a worker dies as a result of an accident occurring in the course of the worker’s employment at or in a construction project, mining plant or mine, including a pit or quarry, the person in charge of such project, mining plant or mine shall immediately give notice of the death to a coroner and the coroner shall hold an inquest upon the body. R.S.O. 1990, c. C.37, s. 10 (5); 2009, c. 15, s. 6 (5).

The process for assessing risks in underground mining was launched in the spring of 2014, and the workshop drawing the SMEs together was held in June, 2014. The purpose of this process was to identify and assess the risk events (including the “latent” risks) within a system so as to discern the components of an event and permit study of their structures and dynamics until it is determined what it will take to unravel or “sabotage” the event. Malcolm Sparrow stresses on a government’s need to be vigilant, so they can spot emerging threats early, pick up on precursors and warning signs, use their imaginations to work out what could happen, and to do these things even before much harm is done. Nimbleness, flexibility to organize quickly and appropriately around each emerging risk, rather than being locked into patterns of practice constructed around the risks of a preceding decade, being adeptat creating new approaches when existing methods turn out to be irrelevant or insufficient to suppress a risk, is being a true risk-based regulator.

The CJRs provide a synopsis of the events leading to the fatality and outline recommendations by the Jury to prevent future incidents.

Scope of Review

In March 2014, the Data Management and Performance Metrics Unit gained access to inquest reports received by the Ministry of Labour to analyse the incidents description and Coroner Jury’s recommendation (CJRs) to the MOL, for findings that could support prevention-related initiatives.

The qualitative analysis of the CJRs included inquests that took place between 1996 and 2009. There was a total of 36 inquests in the mining sector, representing 18% of all CJRs received by the MOL in 13 years. The following discussion is specific to this subset of CJRs.

To ensure inter-rater reliability, once all CJRs were coded, the two coders met to review all the inquests for the coding of the ‘primary cause of fatal incident’. Where there were discrepancies between coders, the language used in the inquest determined the primary cause of fatal incident.

There was a total of 37 fatalities among the 36 inquests: one inquest included two fatalities. The analysis highlights trends related to these fatalities by worker characteristics and other incident characteristic factors.

Overall Findings

  • Most victims were workers 25 to 54 years old.
  • Almost 60% of fatal incidents in mining sector were caused by being struck by equipment, crushes and being pinned.
  • When the accident time was mentioned, over half occurred in the afternoon hours: from noon to 5 pm.
  • The most critical day of the week for fatal accidents was in the middle of the week: Wednesday (27%), followed by the beginning and the end of week: Mondays and Fridays (19% each).
  • When weather was mentioned as a contributing factor for the fatality, the cold was the primary weather condition identified but weather was only mentioned in four inquest reports.
  • The majority of the inquest recommendations were related to the OHSA and its regulations (61%), followed by communications (11%), and training related (10%).

Detailed Findings

  1. Demographics

    All fatalities in Mining sector involved males. From an age perspective, the majority of fatalities involved workers between 25 to 54 years old (86%).

    Table 6 – Percentage of fatalities versus percentage of average Ontario employment (1996-2009), Victim’s Age n=37[19]
    Young (<25)Middle Aged (25-54)Older (>=55)
    14% versus 15%86% versus 74%0% versus 11%
  2. Cause of Fatal Incident

    The top three primary causes of death were: 1) struck by equipment (24%), 2) crushed (18%), and 3) pinned (18%). Fatalities from crushes included being crushed by equipment (e.g., trailer, loader) and by materials (e.g., stone, rock). All the falls were falls from heights, and included falls from ladders, in ore passes or in holes. The category of “Other” includes: asphyxiation, swept by, and unknown.

    Table 7 – Primary Cause of Fatal Incident (n=37)
    Primary Cause of DeathPercentage
    Struck By24%
    Run Over3%
    Blunt Force1%
  3. Workplace Context

    By far most fatalities involved workers (91%), followed by supervisors (9%). Most fatal incidents occurred while working (73%). For 27% of the incidents the information was insufficient to determine what was being done at the time of the incident.

    The majority of incidents occurred while victims worked with others on the same work site (69%), while 31% of victims were alone in the workplace at the time of incident.

  4. Incident’s Timing

    Most fatal incidents occurred during the afternoon (noon to 5 pm) at 53%, followed by the night (10 pm to 4:59 am) at 27%, morning (5 am to 11:59 am) at 20%, and evening (6-10 pm) at 0%.

    The majority of fatal incidents occurred on Wednesdays (27%), followed by Mondays and Fridays (19%), Tuesdays and Thursdays (11%), Saturdays (8%) and Sundays (5%). Most fatal incidents occurred during the working week (86%) comparing with the weekend (14%).

    The months with the highest rate of fatal incidents in the mining sector were April (19%) and August (19%).

    Table 8 – Fatal Incidents by Month (n=37)
  5. Weather

    Although there were few mentions of the weather in the inquest reports, there were four reports (or 11% of all mining CJRs) which specifically mentioned the weather as a contributing factor to the fatal incident. The cold (50%, n=2) was the primary weather condition mentioned to contribute to the incident.

  6. Location

    As expected, the majority of fatalities in the mining sector occurred in the MOL’s Northern Region (68%). The Western Region was next (19%), followed by Eastern Region (8%) and Central Region (5%).

  7. Recommendations

    Each inquest included one set of recommendations which apply to the fatal incident included in that inquest. A total of 249 recommendations were directed to the MOL, equaling 24% of all recommendations made in 36 mining sector inquests. On average, each inquest in the mining sector had 7 recommendations, with a range from 0 to 22 recommendations.

    The majority (61%) of the recommendations were related to the OHSA and its regulations.

    Of the total recommendations related to OHSA:

    • 63 recommendations were related to the OHSA (42%)
    • 55 recommendations were related to the Mining Regulations (36%)
    • 29 recommendations were related to both OHSA and Mining Regulations (19%)
    • 5 recommendations were related to the Construction Projects Regulations (3%).

    The second most common theme among the recommendations was related to communication and collaboration (11% or 28 recommendations). These recommendations pertained to communication and cooperation between the Ministry and workplaces, as well as collaboration between the Ministry and various agencies and workplaces.

    Recommendations for training enhancement and certification (10% or 25 recommendations) were also frequently mentioned. These recommendations covered issues such as additional workplace training, new training frequencies and lengths of training, different types of training, additional training requirements and proof of certification.

[ 19 ] Employment data source: Statistics Canada, CANSIM Table 282-0002

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