Ontario’s chief coroner says the release of the first annual Construction Death Review (CDR) by his office represents a significant improvement to the way deaths in the sector are studied, with the potential for broad impact to improve workplace safety.
The new system of comprehensive reviews of construction fatalities by a new CDR Secretariat, supported by an advisory committee of technical experts, replaces the old regime of mandatory inquests into each death with recommendations submitted by lay jurors.
The chief coroner, Dr. Dirk Huyer, served as the lead coroner for the review.
The report focuses on falls from heights and contains seven recommendations.
“It’s my hope that it will allow more timely, impactful perspectives relating to themes and trends that occur when people die in construction work, and also really looking at things from a systemic level,” said Huyer July 18 upon the release of the report.
“It’s a significant change that allows us to not only look at the individual death, which we still do, but also to look across those deaths to see what systemic issues may be present, because each individual death is one loud voice, but all of those deaths together is a much louder voice and will give a much clearer perspective of what might have happened across those deaths.”
Deaths from falls from heights accounted for 43 per cent of all construction fatalities in the province in the past 15 years. The CDR Secretariat studied data from 131 deaths from falls from heights that occurred between 2009-2024, with a focus on the deaths of 26 workers between 2017-2023.
Deep data dives
The report found though older workers represent under 20 per cent of the construction population, they account for 35 per cent of the deaths.
Among the 26 deaths under review, 13 of the workers had been in their positions less than one year and three had started working that day.
The data also showed more deaths occurred proportionately between Friday to Sunday.
“The findings of the report are a first step toward building a comprehensive, sector-focused, root-cause analysis,” stated the report.
The advisory committee offers observer status to Threads of Life, a construction victims support group, and the report includes details of the circumstances of each of the 26 deaths.
Among them, on Jan. 20, 2020, 61-year-old Michael Wheeler was working as a gas fitter at a low-rise residential building in Markham. Wheeler was using a 10-foot A-Frame ladder to install a pipe when he fell three metres to his death, landing on an unfinished garage floor. There were no witnesses.
“We really feel so strongly that each death, and each life, and each family and each community, is so important, and we should not get lost in a high-level numbers report or a lot of words without remembering all of those individuals,” said Huyer.
The previous system often led to delays of several years. The CDR runs on a three-year cycle which includes the year the death occurs, the year a review starts and the year a report is released.
The report states, “The review process has demonstrated that engaging experts with significant sectoral experience enhances the analytical ability of the CDR and supports recommendations that are practical, reasonable and implementable.”
Carmine Tiano, a health and safety specialist with the Provincial Building Trades and a member of the CDR advisory committee, noted one of the recommendations calls for the provincial government to increase health and safety funding.
“We need the people that are on that panel, myself included…if we want the recommendations to move forward, we need to individually lobby the government and collectively lobby the government,” said Tiano.
Other recommendations included a call for the Ministry of Labour and the Chief Prevention Officer to “analyze why non-compliance with the working at heights training and/or fall protection regulatory duties contributed to the 26 deaths”; for the Provincial Labour Management Health and Safety Committee (PLMHSC) to explore options for enhanced supervision on projects with five or fewer workers; and for the ministry to consider requiring heights training of site supervisors.
Huyer explained falls from heights were studied first because the category represents a significant proportion of deaths and also, by focusing initially on one category, he said, it helped the Secretariat understand how to evaluate for systemic issues.
Enzo Garritano, the CEO at Infrastructure Health and Safety Association, attended a PLMHSC meeting July 2 where Huyer gave a preview of the CDR report. Garritano said he viewed the report as a starting point in a longer process.
“Now we’ll look, after the first iteration, how do we make it better and continue to make it better,” said Garritano.
