The deaths of Robert Luggi and Carl Charlie - both killed in the explosion at Babine Forest Products in January 2012 - were ruled accidental.
About 50 witnesses were heard at the Island Gospel Fellowship Hall in Burns Lake since the beginning of the inquest on July 13, 2015.
The inquest into the mill deaths concluded July 31, 2015, with 41 recommendations to improve safety in the industry and prevent similar incidents from happening again.
The coroner’s jury deliberated for two days, making 33 recommendations while presiding coroner Chico Newell added eight recommendations.
Recommendations were made to Babine Forest Products, Hampton Affiliates, United Steelworkers Union, WorkSafeBC, minister of jobs and the minister of justice.
Workers’ testimony showed that, during the explosion, it was too dark outside of the mill, which caused disorientation and the inability to find a safe place in a reasonable amount of time.
The jury recommended Babine Forest Products to ensure all plants have proper outdoor lighting, a fire pumping system and a stand-alone first aid facility. All of these installations should be serviced by a fully functional automatic emergency power system.
According to the coroner’s report, the testimony also showed “major gaps” in fire code knowledge and inspection requirements. Therefore, the jury recommended Babine Forest Products to ensure compliance with the National Fire Code, including that an annual fire inspection be completed by a qualified person having jurisdiction in the area. In addition, the company should review its evacuation procedures annually with all workers and conduct fire drills periodically.
The testimony also highlighted workers’ concerns with topics such as bullying, intimidation and discrimination, which they say prevented them from bringing forward safety concerns. The jury recommended professional training for all employees in workplace harassment. In addition, the company should consider an Aboriginal liaison coordinator or worker ombudsman to assist employees with workplace concerns.
Evidence also suggested that cold weather, humidity and changes in air flow may have been contributing factors in the explosion. The jury recommended WorkSafeBC to ensure that work environment hazard alerts are communicated effectively, and to update regulations and guidelines promptly to reflect current knowledge in regard to combustible dust explosions.
Testimony also showed a lack of workers’ knowledge to the hazards of wood dust. The recommendation on this case was to develop a video or visual presentation using Power Point to demonstrate to all workers in the wood manufacturing industry the health and safety hazards associated with combustible dust.
Furthermore, the jury suggested the mill to use a combustible gas monitor to investigate reported gas smells by workers.
The presiding coroner added a recommendation to WorkSafeBC and the office of the fire commissioner, suggesting they should collaborate in the creation of a regulation to ensure companies in the wood products manufacturing industry have an annual fire inspection.
The coroner’s report adds that “a lack of communication” may have contributed to the incident.
A recommendation was made to WorkSafeBC, the B.C. forest safety council, manufactures’ advisory group and the associated health safety associations that they should ensure the "effective sharing of information to ensure ongoing risks can be evaluated by all members of the safety community."
The report also included a recommendation for the minister of justice and attorney general of Canada. The recommendation was to amend section 217.1 of the criminal code to add the following section, “anyone who fails to take reasonable steps to prevent death or bodily harm under this section is guilty of an indictable offence.”
The westray act amendments created a duty to prevent death or bodily harm under section 217.1, but did not create an offence for failing to fulfill that duty.