The Ontario coroner’s jury looking into the deaths of four construction workers on Christmas Eve 2009 has ruled the deaths were accidental and produced seven recommendations for systemic reforms addressed to the Ministry of Labour, Training and Skills Development (MOL).

The jury’s findings came on the fifth day of a mandatory coroner’s inquest presided over by Dr. John Carlisle that began Monday, Jan. 31.

“To the families of these tragically deceased workers, we hope this process has given some measure of closure to them and that the improvements that have been made and will be made will serve as something of a memorial to their loss,” said Carlisle after reading the verdict.

The recommendations to the MOL included pleas to boost training of supervisors of workers working at heights and using a suspended work platform; to use emerging technologies to reduce worksite injuries; to upgrade the tracking of the effectiveness of working at heights training; and to consider accelerating the frequency of refresher courses for using suspended access equipment.

The jurors suggested the Chief Prevention Officer (CPO) provide annual reports tracking the progress in identifying the new technology that would be used.

The CPO would also be given the task of monitoring the effectiveness of the working at heights training program and reporting to indicate the link between the working at heights training program and falls from heights data generated through the prevention division.

The other recommendations included a request to amend the construction regulations to include a general mandatory requirement for training of health and safety representatives who work on construction projects; to amend the notification requirements regarding the installation and testing of work platforms; and to consider additional penalties for supervisors who violate the regulations.

“You’ve been very attentive, you’ve made excellent suggestions, you’ve produced an outstanding verdict,” Carlisle told the jurors. “You’ve represented the public very ably in considering these important matters.”

The five-person jury began deliberating yesterday, receiving a set of 14 proposed recommendations from inquest participants, five submitted jointly by the Ontario Building Trades and Metron Construction and nine others proposed by the Building Trades.

Metron Construction site supervisor Fayzullo Fazilov and workers Vladimir Korostin, Aleksey Blumberg and Alexander Bondorev fell 13 storeys to their deaths when their suspended swing stage platform broke apart at an apartment restoration jobsite in Toronto. An agreed-upon statement of facts identified substandard fabrication of the swing stage and failure to use a fall arrest system as causes of the fatalities.

During a 2015 trial, it was found that everyone who worked on the site was aware of the importance of being tied off to a lifeline while working on a swing stage, yet there were only two available on the swing stage that day and only one was used.

Metron’s project manager, Vadim Kazenelson, was charged with four counts of criminal negligence causing death and one count of causing bodily harm, found guilty and sentenced to serve three-and-a-half years in jail.

Metron owner Joel Swartz, the company itself and Swing N Scaff Inc., supplier of the swing stage, received heavy fines.

The jury was asked to determine by what means the deaths happened – natural causes, accident, homicide, suicide or undetermined. The parties with standing at the inquest had all recommended a finding of accident.

The incident prompted a nine-month review of Ontario’s health and safety system by Tony Dean in 2010, leading to an overhaul of training practices, regulations and health and safety certifications including mandatory working at heights training and the establishment of a CPO.

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