TIMMINS – A coroner’s inquest jury in Timmins has recommended that Ontario’s Occupational Health and Safety Act should be amended to include specific written procedures for operating certain pieces of equipment. That was just one of four recommendations delivered by the jury Friday at the inquest into the death of 22-year-old miner Alexie Dallaire-Vincent, who was killed at the Holloway Holt mining complex east of Matheson, a couple of years ago. The inquest revealed that Dallaire-Vincent died after being struck by an underground train on the 925-metre level on Saturday, May 23, 2015. It is believed she is the first woman to die in an underground mining accident in Ontario. She was in the process of tramming ore at the mine and while waiting in front of her parked train on a rail siding, Dallaire-Vincent was hit from behind by another underground train. The impact threw her into the arms of her supervisor standing nearby. The supervisor, Warren Mann, testified that he held the woman up briefly because he didn’t want her to fall onto the wet and muddy floor of the drift (mine tunnel). Mann said Dallaire-Vincent went limp, her face lost colour and her eyes were half closed. He said he wasn’t sure how bad the injuries were, but he knew it was serious. He shouted for help and a furious effort began immediately to try to save the woman’s life. After two days of testimony and written evidence from the post-mortem exam, the official cause of death was revealed Friday morning as a crushing chest injury. Coroner Dr. David Cameron said Dallaire-Vincent suffered profound damage to her heart. “This injury could have occurred right outside the doors of a cardiac operating theatre and it wouldn’t have helped Lexi. She had a four-centimetre laceration of the main chamber of her heart, the left ventricle,” said Cameron. “I can’t imagine how that could ever be survivable.” Cameron also revealed that in the process of the post-mortem exam, the coroner’s office also looked into toxicology. Cameron said “there were no drugs of any kind” in her system. As for the circumstances of the accident itself, the inquest was told that Dallaire-Vincent was operating one underground train, while her partner Charlène Corbeil operated the other train. As locomotive operators, they would take turns loading their trains with ore and then rolling out on a 1,480-metre run to the ore pass, near the central shaft, to dump their trains. Dallaire-Vincent had loaded her train and was waiting her turn to go to the ore pass. This meant waiting for the other train to arrive back from dumping. As part of the process, she had parked her train on the left side-switch, which would allow the returning train to go to the right side-switch. The problem was that for some reason Dallaire-Vincent had not returned the track switching device back to the right side. It was her responsibility to do that. There was no firm evidence given as to why this happened. One theory was suggested that Dallaire-Vincent simply became distracted and forgot about the switch. To make things worse, the operator of the second train had no way of knowing the switch was in the wrong position. Dallaire-Vincent was parked on the left side track waiting for the second train. She had gotten out of the locomotive and was standing on the tracks, her back to the switch. The second train arrived at the switch moments later. Everyone expected the train to move to the right into the loading area. As it happened, the train stayed on the left track, hitting Dallaire-Vincent from behind and crashing into her train. It was revealed that in the days following the accident, St. Andrew Goldfields made changes. One of those was to install 200 feet of additional track past on the left side switch. This would allow trains to be parked further away from the switch in case any other train would inadvertently run past the switch junction. There was also discussion during the inquest as to whether a visual indicator or flashing lights that would have let the operator of the second train locomotive know that the switch was in the wrong position, in enough time to stop the train before a collision. Mine manager Peter Fiset told the jury that the mine had “definitely considered” various devices to indicate the position of a track switch because similar devices already exist on surface with commercial railways. Fiset said things are different underground due to the continued presence of mud, slime and water on the floor of mine tunnels, where the switches are located. He said electric or electronic signals likely would not survive those conditions. In other testimony, Ministry of Labour mining inspector John Miller told the inquest he had been in a gypsum mine in Southern Ontario where a long metal bar was being used as a mechanical indicator on a rail switch. He said it did not need any electronics. He said the metal bar was simply attached to the turning mechanism on the rail switch. “What they had at this mine was a long arm reflector, so if you turned it one way the arm came up. When you turned if the other way, the arm went down,” said Miller. He said a locomotive operator approaching the switch from a distance would know, even in the dark, if the switch was in the proper position, thus giving the operator more time to stop the train. The inquest also heard testimony respecting how much information was provided to Dallaire-Vincent in the training process for operating the locomotive and running the train. Insp. Miller told the inquest that he found no violations of the health and safety act, but he still wrote one directive order following the 2015 accident. “I did write one order. And it was to do with procedures. They did have a procedure in place in regards to tramming with the two locis (locomotives) but it wasn’t in writing. So I ordered them to put it in writing and to train people. That was the only order I wrote,” said Miller. He said the company complied with the order. Miller also agreed that in general terms there is no obligation in the Occupational Health and Safety Act to have procedures in writing, but he quickly added that training instructions are “better in writing”. Based on submissions by lawyers representing the Ministry of Labour, Kirkland Lake Gold and the Coroner’s office, the jury deliberated for roughly two hours and came back with four recommendations, as follows:

 1. Develop and implement a switch-based visual indicator to signify the position of the switch to the tram operators and other workers;

 2. Determine and implement a minimum safe distance to park underground mobile equipment away from operational rail switches during production or development activities; 

3. To consider an amendment to the Occupational Health and Safety Act to ensure all procedures are written and accessible to all employees; and 

4. Follow up with the Office of the Chief Coroner in one year to identify which recommendations have been implemented and/or are still being considered. The recommendations were welcomed by Crown counsel Dale Cox, who said despite the negative circumstances, there was a positive outcome. “I think it was helpful to the family to have some closure. It was helpful to hear recommendations as to how this can be prevented in the future,” said Cox. “It is clear here we’re dealing with a family that is part of the mining culture in the North and they have a great concern for others. We can’t bring back Lexi, but certainly if we can prevent the death of one other person, then we’ve done a great job here today.” Speaking on behalf of the family, Mario Vincent, Alexia’s father said he liked the recommendations. “I am very happy. They were well thought out,” said Vincent, who is a mining health and safety representative. He said this was especially so in the recommendation for written procedures. “To me it is a big step,” he explained. Vincent said it is one thing to outline work and safety procedures by word of mouth, but it is better when things are literally spelled out. By having everything written down, it’s like a checklist. You go through the procedures step by step and it increases the chance of everything being covered and understood,” said Vincent. He added that he is personally relieved the inquest was held. “It brings closure,” he said with a sigh, Friday afternoon. “It’s been rough for two and a half years, that’s for sure.” He said he and his family can now realize the ordeal for them is over and they can move forward without having to re-live what happened. “The inquest brought that peace of mind to me and my wife,” he said. Vincent added he was not sure what to expect but there was no animosity, hard feelings or anger with anyone. He admitted it was a personal struggle trying to cope with his daughter’s death, especially since he too worked in the mining industry. “I am still in mining. I am still in health and safety,” he said. Vincent said he considered retirement and questioned himself often. He said he was ready to quit. “For quite some time I had lost the will to fight, the will to work. It was not there. It was emptiness. Today, it’s two and a half years. I’ve found that will to work again, I am happy to say. I will continue to work for as long as I can.”n