Inquest into Death of Stephen Cuthbertson - Recommendations made July 2010

Toronto, Canada: Mr. Cuthbertson, 27, died on October 3, 2007, from injuries received during the course of his employment at a construction site in Toronto. An inquest is mandatory under the Coroners Act.

Summary of the Circumstances of the Death:
Mr. Cuthbertson was employed as an electrical apprentice on a worksite with other electricians.  While he was working on setting up temporary lighting for one of the floors he was electrocuted during the connection process to an electrical panel.  His death occurred on October 3, 2007.  As his death occurred from injuries sustained while at a construction site his death met the criteria for a mandatory inquest as dictated by Section 10(5) of the Coroners Act.

The inquest was heard between July 26th – July 28th, 20010 in Toronto Ontario.  It was determined through evidence that while attempting to connect the temporary lighting to the panel the panel was still receiving power (“working live”).  The policy of the worksite was to connect the wiring to the panel but that work was not to be done without shutting down power t the panel.  This process was known as lock out/tag out.  All lock out/tag out events had to be scheduled beforehand to alert all trades o the worksite of power outages.  This process was not done on the day of Mr. Cuthbertson’s death although all the involved parties were aware that the connection to the electrical panel was planned for that day.

Representative from the Ministry of Labour reviewed the fact that the work on that day should not have been carried out “live” and the lock out/tag out policy should have been followed.  They also reviewed sections of the Occupational and Safety Act that state that the responsibility for training, supervision and instruction falls on the employer or in this case the contractor.  The contractor is the company hired to do the construction.  The Act does not list any obligations for unions or school’s to carry out in their daily operations.

While hearing testimony from the witnesses the inquest there were ten sets of exhibits entered into evidence for the jury to consider.  There exhibits included pictures of the construction site, the electrical panel and control room, work orders, safety manual and presentation for the worksite, and the post-mortem and toxicology report.  While reviewing the witness testimony and exhibits the training and safety procedure of the electricians was reviewed.  This included the training provided to apprentice electricians such as Stephen Cuthbertson.

Evidence was presented that Mr. Cuthbertson died of the electrical injuries incurred during the process of trying to connect the wiring.  The autopsy report results documenting his cause of death was reviewed by the Crown and accepted by all the parties with standing.  Mr. Cuthbertson was pronounced dead at St. Michael’s Hospital after resuscitation procedures by Emergency Personnel proved to be unsuccessful.
After the witnesses completed their testimony and all the exhibits were entered the jury deliberated for several hours and made six recommendations to help prevent future deaths of a similar nature.

Recommendations:
1. The Ministry of Training Colleges and Universities (MTCU), shall ensure that apprentice electricians receive training in the Occupational Health and Safety Act (OHSA) as related to their work
Coroner's Comments:
Evidence was provided to the jury that although there was no requirement of the school's to provide electrical apprentices with direct knowledge of the OHSA, the requirements regarding safety, lock out/tag out procedures, and the responsibilities of constructors were outlined in this act.

2. The MTCU shall renew licences to Journeymen Electricians only if they demonstrate completion of a MTCU approved course on the OH&SA.
Coroner's Comments:
The jury was presented with the evidence that there was also no requirement of licence renewal that required knowledge of the OHSA. This included the same requirements listed in recommendation one regarding safety, lock out/tag out procedures and constructor responsibilities.

3. The general contractor or constructor is responsible to ensure all apprentice and Journeymen Electricians are appropriately trained in the OHSA as outlined by the MTCU,
Coroner's Comments:
The jury was informed that a constructor's hiring policies was not required to document previous training of an electrician. This recommendation is proposed in conjunction with the first two recommendations to ensure adequate knowledge of the OHSA, safety and the rights and responsibilities of the individual electrician or electrical apprentice.

4. The general contractor or constructor is to provide site-specific and work-specific safety instructions and implement a process to obtain acknowledgement that all safety requirements including Job Hazard
Analyses as set out in the general contractor policy, have been executed/implemented as required.
Coroner's Comments:
During this inquest the jury heard testimony regarding the constructor's responsibility in providing site-specific safety training. A formal method of documenting that the constructor has carried out appropriate safety analyses, and trained the appropriate personnel was recommended.

5. The general contractor or constructor shall install locks on all temporary power panels and the key(s) shall be controlled by a general contractor supervisor(s) who has the ability to-control, plan and or schedule power outages. All power outages will be scheduled and enforced by the general contractor according to an established procedure as documented in the general contractor site-specific protocols.
Coroner's Comments:
During the inquest testimony was given that anyone could have accessed the panels that provided energy to the workers on the worksite. The electrical room supplying the separate panels was the only one that was locked. By locking the panel and limiting access it would provide another layer of protection in allowing any worker from working with live electrical equipment. This could also ensure that the appropriate lock out/tag out procedures were being followed as documented in the site specific safety manual.

6. The Constructions Association, Electrical Safety Authority (ESA), representatives of labour management and other relevant parties shall establish a working committee to Identify what qualifications a Journeyman Electrician must possess in order to supervise, train or mentor an apprentice.
Coroner's Comments:
Testimony was given that Journeymen electricians that supervised the electrical apprentices were not required to have a predetermined set of abilities knowledge requirements or documented teaching abilities. The goal of this recommendation is to try and bring some standard of training to all apprentices regardless of their supervisor.

This incident is explained in more detail in the 2009 Ontario Electrical Safety Report, on page 29.