Ontario’s Office of the Chief Coroner publishes the second annual report of the Construction Death Review

The second annual report of the Construction Death Review (CDR) has been published—and represents another important step in understanding the root causes of fatalities in Ontario’s construction sector.

The report covers the findings of the review, which looked at 44 workers whose deaths involved circumstances not related to working at heights. (The first CDR focused on falls from heights.) The fatalities largely occurred between 2015 and 2023, and involved factors including heavy material and equipment hazards, trench collapses, and electrical exposure.

From its review of these tragedies, the CDR identified systemic challenges related to health and safety culture in the construction sector, including two areas of significant concern: workplace experience and inexperience, and the use (or lack thereof) of manufacturer’s instructions for operating vehicles, machinery, and equipment.

These concerns helped inform the CDR’s 14 recommendations for strengthening health and safety in construction, which were put forward to the Ministry of Labour, Immigration, Training, and Skills Development (MLITSD), Infrastructure Health and Safety Association (IHSA), and other provincial health and safety system partners.

The recommendations include:

1. Reviewing the compatibility of formwork systems that are commonly used in Ontario.
2. Consulting with industry about enhancing and/or clarifying regulations regarding solar photovoltaic work and associated electrical safety hazards.
3. Publishing a health and safety advisory about the hazards of working on or near water.
4. Working with local groups to distribute that advisory to constructors and employers.
5. Enhancing supervisor awareness training requirements in O. Reg. 297/13.
6. Analyzing MLITSD data relating to non-compliance with subsections 93 (3) and/or 93 (4) of O. Reg. 213/91—regarding using all vehicles, machines, and equipment in accordance with their operating manuals—that resulted in a critical injury or fatality.
7. Developing an educational campaign on the importance of working in accordance with manufacturer’s operating manuals and/or instructions.
8. Reviewing section 43 of the Occupational Health and Safety Act with a focus on identifying barriers that may impede construction workers from exercising their right to refuse unsafe work.
9. Creating a stakeholder-informed plan to address those barriers and obstacles.
10. Making the results of the above review (i.e., Recommendation no. 8) publicly available.
11. Enhancing the requirements of a “competent person” and “competent worker” specific to work involving drill rig operation, rigging and hoisting, signalling for mobile equipment, demolition, and excavation and trenching.
12. Drawing on MLITSD data and consultation with relevant stakeholders to inform Recommendation no. 11.
13. Developing guidelines and performance indicators to better define the skills, experience, and training needed to be a “competent person” and “competent worker.”
14. Exploring opportunities to expand formal assessments of workplace health and safety programs for employers that experience more than one worker fatality, high numbers of critical injuries, and/or longer durations of lost time within a five-year period.

The Construction Death Review’s second report is available to the public. Click here to read it now.

The review was overseen by Lead Coroner Dr. Roger Skinner and 10 members of the Office of the Chief Coroner comprising the CDR Secretariat. Also involved in the review and report was the CDR’s Advisory Committee, made up of experts from government and the construction industry, including members of IHSA’s Labour-Management Network. They are:

• Brian Alexander – Financial Secretary, Director, Health and Safety, International Union of Operating Engineers, Local 793
• Monica Bienefeld – Director, Analytics and Evidence Branch, Prevention Division, Ministry of Labour, Immigration, Training and Skills Development
• Joanne Gordon – Director, Workplace Health and Safety Services, Workplace Safety and Insurance Board
• Eugene Gutierrez (Associate Member) – Executive Director, Threads of Life
• Darrin Husack – Environmental, Health and Safety Manager, CONDRAIN Group and Ontario Sewer and Watermain Association
• Alain Léger – Vice President, High Risk Activity Training and Operations, Infrastructure Health and Safety Association
• Jennifer McKenzie – Director, Environmental Health and Safety, Queen’s University
• Sean McFarling – General Counsel, Labourers’ International Union of North America, Ontario Provincial District Council, and Central and Eastern Canada Organizing Fund
• Stephen Moore – Manager, Construction Death Review, Office of the Chief Coroner
• Andrew Pariser – Vice-President, RESCON
• John Serafini – Manager, Health and Safety, Dufferin Construction Company
• Carmine Tiano – Director, Occupational Services, Provincial Building and Construction Trades Council of Ontario
• Jaimie Todd – Provincial Specialist, Skilled Trades, Fair, Safe and Healthy Workplaces Division, Ministry of Labour, Immigration, Training and Skills Development