Executive Summary Double Fatalities Investigation Report June 8, 2011 USW Local 6500 Investigation Jason Chenier and

Jordan Fram died because of on-going and documented neglect of safety standards by the owner of the Frood/Stobie Mine complex, the international mining company Vale. After an incident of this kind, in accordance with previous practice there would have been a joint investigation by union and management representatives from the Frood/Stobie JHSC (Joint Health and Safety Committee). But Vale insisted on restrictions on what the joint committee could investigate, demanded exclusive control of all documents and communication, and required non-disclosure of all information and findings acquired in the investigation process. In effect, Vale demanded that it would control the determination of the cause of the fatalities, as well as the conclusions and recommendations drawn from the investigation and findings (pg. 20/USW Report) Because of Vales restrictions, the Health and Safety Chair of USW Local 6500, Mike Bond, announced on June 23rd, 2011 that USW Local 6500 would initiate its own investigation into the deaths of Jordan Fram and Jason Chenier. Throughout the Unions investigation, Vale officials refused to be interviewed by members of the USW Team; dozens of USW members cooperated fully in managements investigation, attended interviews and answered their questions fully. Over the course of eight months, the USW Team examined evidence, conducted interviews, performed research and considered all aspects affecting the fatality and the mining processes that impacted upon the tragic events of June 2011. The USW Local 6500 Report was submitted to the Ontario Ministry of Labour on February 28, 2012. Cause of Death Jordan Fram and Jason Chenier died on the evening of June 8th, 2011, when an uncontrolled torrent of wet ore material or run of muck burst out of the #7 ore pass, and buried them. Ore passes allow miners to move ore from upper levels of the mine down to lower levels, where it is eventually transported to the surface. The #7 1

ore pass carries ore from the 2600 foot level of the mine past the 3000 foot level of the mine where the June 2011 deaths occurred. The run of muck occurred because wet ore from the 2600 level had hung up and clogged the #7 ore pass at a narrowing of the ore pass above the 3000 foot level. Fram and Chenier were working there when they died. Miners, mining companies and health and safety regulators have long recognized this as one of the most hazardous conditions in underground mining. USW Local 6500 members had complained for weeks about hang-ups in the #7 ore pass; the issues were not adequately addressed by management (pg. 107/USW report). When investigators arrived on the scene of the fatalities, they found that the crash gate, which is used to move material in the #7 ore pass from above the 3,000 level to levels below, was left in the open position. Jason Chenier had apparently opened the gate in order to assess the hang-up and prepare to blast it loose. While this is an accepted practice, it has also been recognized as a non-routine hazardous task for which there were no listed or detailed procedures. It is one of the most hazardous tasks in underground mining. (pg. 51, 61/USW Report) Cause of Deaths The deaths of Jason Chenier and Jordan Fram are directly attributable to the unsafe accumulation of water in the Stobie Mine and the inadequate procedures in effect to deal with the consequences of such foreseeable developments. The Stobie Mine is located underneath and adjacent to three abandoned open-pits, which collect water predictably and regularly. This is within the knowledge of the company and its engineers. Water accumulation issues are exacerbated during the spring runoff. The spring run off occurs every spring. The company pumps and is obliged to safely manage 3 million gallons of water per day. Shortly after the fatalities in June 2011, excessive water accumulation was noticed on the 2400, 2450, 2600, 2800 and 3000 levels of the mine. (See photos pg. 40-42/USW Report). When too much water saturates the ore, this creates sticky muck, a mixture that can plug an ore pass. Since this is one of the most hazardous conditions in underground mining, constant control of water is essential to maintain safety in the mine. A run of muck is like an avalanche of wet rocks, wet gravel and wet sand. The flow of water combined with mining material creates a mixture of mineralized material, sand-fill and water. Stobie Mines technical service group stipulates that it is acceptable to have sand and silt make up 30% of the ore material. A ratio in excess of 30% has to be handled differently. 2

Six (6) weeks after the June 2011 tragedy, the ore was found to contain 50% sand and silt and 13% moisture. (pg. 47/USW Report) Safety Requirements: Ore Pass Design, Operation, and Maintenance are critical to the safe transfer of material in a mine. It is important that the original design takes into account the type and consistency of material that will go through a pass. This would include a sizing device to restrict the size of material being dumped, a cavity monitoring system, crash gate operation procedures, prohibitions against the introduction of water into an ore pass, procedures to maintain ore pass dimensions, safe crash gate operation, and safe procedures for clearing hang ups in ore passes. (pg. 29/USW Report) Drain holes are one of the principal strategies to control and redirect excess water in an underground mine such as Stobie. At the time of the incident, drain holes at the 2400, 2600 and 2800 levels were known to have been plugged by rock, sand fill and debris. Water at the 2400 level was approximately 5 feet above the top of the drain holes. Water at the 2600 level was about 4 feet above the top of the drain holes. This caused water to flow into the top of #3715 ore passes, mixing with the ore and creating sticky muck. (pg. 35-38/USW Report) Blast holes are drilled into an ore pass to allow miners to blast or breakup a blockage. Safety procedures require that the blast holes must be sealed and grouted after use. The blast holes at the 2600 level broke through into the #7 ore pass since they are below the level of the accumulated water. The blast holes provided a path for water to enter the #7 ore pass. The blast holes drilled at the 2800 level were also below the level where water had accumulated, providing another way for water to enter the #7 ore pass. (pg. 52/USW Report) Guardrails: Jason Chenier erected double guardrails at the 2450 and 2600 levels to prevent the dumping of any more ore into the #7 ore-pass. This, in effect, was a shut down signal for this production area. Jason Chenier wrote in an e-mail in the days before he died that the Company should not be dumping or blasting this ore pass until the water situation is under control. For reasons that require further forensic investigation by appropriate authorities, and which the USW Investigation Team was unable to ascertain because of non co-operation by Vale management officials, the double guardrails were removed under managements directions and re-installed up to 3 times over the course of 2 days. It appears that this was done to allow miners to continue to dump wet ore into the #7 ore pass. The company has provided no explanation for the removal of the double guard rails which Jason Chenier , a supervisor at the time of his death, had erected as a safety measure. (pg. 83/USW Report) Crash Gate Station: The design of the by-pass station at the 3000 level put Jason Chenier and Jordan Fram in immediate harms way from a run of muck incident. The 3

company had installed no cameras to allow them to view and operate the crash gate from a safe distance. The crash gate at the station was not designed to close automatically. This means that if a miner needed to leave the area quickly, the crash gate would remain open, and material would continue to flow. Miners also had no way of leaving; there was no second exit. (Pg. 90/USW Report) This danger involving the type of location where Jason Chenier and Jordan Fram were apparently undertaking a hazardous task was noted in the Inquest Report into the 1995 death of Stobie miner Clifford Bastien. The USW Report notes that this is a violation of mining regulations. (pg. 90/USW Report) Health and Safety Requirements: Clifford Bastien Inquest: Following the death of Clifford Bastien in a similar run of muck accident in 1995 at Stobie Mine, a coroners jury made 33 recommendations. Six of these addressed the issue of reducing the threat of another fatal run of muck accident. The fact is that there have been at least six (6) other run of muck incidents at the Stobie Mine in the period 2005 to 2011, the six years before the deaths of Jason Chenier and Jordan Fram. (pg. 69&74/USW Report) All Mine Standards: The All Mine Standards, the Ontario Occupational Health and Safety Act and Regulation 854 of the OHSA, establish the legal requirements for workplace health and safety in mines. The company failed to meet these requirements by allowing excess water to accumulate and by failing to provide a training package that addressed the safe operation of the crash gate at the #7 ore pass. (Pg. 122/USW Report) Management failed to follow the legal requirements of OHSA when a worker refused to work because of unsafe conditions. Workers who were told to blast suspended material hung-up in the #3715 ore pass were NOT told other workers had refused to do such work. (Pg. 125/USW Report) All miners working at Stobie were given a two-day training program. Only one bullet point in the two PowerPoint presentations dealt with the danger of run of muck incidents. (Pg. 112/USW Report) 079 Form: When an unsafe working condition is reported, company procedures require the completion of what is known as a 079 form. After the lengthy 2010/2011 labour dispute, workers and the Joint Health and Safety Committee have been denied the right to initiate 079 forms and know that their health and safety concern/complaint would be filed and addressed by management. The filing of such a complaint is now done at the discretion of the supervisor. In addition, when 4

interviewed during the Local 6500 investigation, many miners reported that they were and are discouraged from reporting hazards. Miners recounted that when they did report hazards, this was not logged on 079 forms. Miners reported having fears of retaliation for raising health and safety concerns. This reflects a culture issue that requires further investigation and positive steps to redress. (Pg. 57/USW Report) SafeProduction: Vales safety program is known as SafeProduction. It purports to ensure that management is accountable for preventing injuries, and that employee involvement is essential. Unlike the 079 form processes, there is no process under SafeProduction to ensure a hazard is communicated to others. (Pg. 105/USW Report) Hazard Alerts communiqus are issued as a warning of hazards that have been identified. There were no Hazard Alert warnings issued in relation to the water conditions that developed at the time of the June 2011 double fatality. Management has provided no explanation for this failure. (Pg. 100/USW Report) After the June 2011 tragedy, a USW Local 6500 Worker Representative requested the issuance of a Hazard Alert, but his request was denied by Vale (Pg. 59/USW Report). Joint Health and Safety Committee: In the months immediately before the June 2011 double fatality, the worker representatives on the JHSC raised concerns about stuck drain holes, hang-ups, sticky muck and the excessive accumulation of water. The company failed to address these concerns prior to the deaths of Jason Chenier and Jordan Fram. (Pg. 114/USW Report) Supervisors Log Book: The Supervisor Log Book was not being used as is intended by applicable mining regulations. On June 6, 2011, Supervisor Jason Chenier tried to enter his concerns about the danger of a run of muck incident in the safety section of the Supervisors log book. There was no room, because the safety section was filled with previously reported safety concerns. Chenier was forced to send two e-mails to management instead. (Pg. 106, USW Report) Wet-Dry Measurements: Given the excessive water accumulation on the levels immediately above the 3000 level, wet and dry measurements were required to be taken at both the #7 ore pass and #3715 ore pass. A wet measurement would quantify the amount of water in the ore mixture, show if there was water accumulation in the ore passes, and alert supervisors and management to the possibility of a run of muck incident. The wet and dry measurements are supposed to be recorded and communicated. No such wet measurements were found in the daily shift log for the year previous to the fatalities. No explanation for this omission has been provided by Vale. (Pg. 35/USW Report) 5

Criminal Code Offences The Westray Bill, also known as Bill C-45, amended the Criminal Code of Canada in 2004 and placed an occupational health and safety duty on individuals, organizations and their decision-makers across Canada. Among other changes, the Westray Bill made workplace negligence a criminal offence by adding a new duty on organizations and individuals to take reasonable steps to prevent bodily harm and death. Not acting to protect health and safety became a violation of the Criminal Code of Canada. The USW Local 6500 investigation into the June 2011 double fatality at Vales Stobie Mine has revealed a failure to manage water conditions and other potential hazards in the underground workplace environment and an overall failure to abide by and implement provincial and internal safety requirements. These failures demonstrate a wanton and/or reckless disregard for the lives and safety of those working in Vales mines, in addition to demonstrating that Vale and its managerial officials and representatives failed to take all reasonable steps to prevent bodily harm and death. Recommendations After eight months of research and interviews, the investigation team of Local 6500 of the United Steelworkers has made 165 separate recommendations to improve the safety and working conditions at Vales Stobie Mine, and by extension at all of Vales mines in the Sudbury Basin and at all underground mines throughout Canada. (pg. 147/ USW Report) The recommendations include: That the Government of Ontario establish a Public Inquiry into the causes of the fatalities at the Stobie Mine, and more generally into underground mine safety in Canada, with special emphasis on water management issues, monitoring and enforcement. There have been substantial changes to mining processes since the last significant Ontario/Canada health and safety inquiry 30 years ago. That Ontarios Assistant Deputy Attorney General Criminal Law take immediate steps to determine whether charges under the Westray provisions of the Criminal Code of Canada should be laid against company officials. The review would consider the USW Reports findings and undertake further investigation, as Crown Attorneys and police authorities consider necessary. That a Committee be appointed by the Ontario Minister of Labour to review whether the Occupational Health and Safety Act and that Acts enforcement

provisions are adequately safeguarding the safety of workers employed in underground mines and surface mining plants in Ontario. 78 recommended changes to health and safety rules at the Stobie Mine, to ensure, among other things, that Hazard Alerts are initiated without fear of reprisal and that workers have the protected right to file 079 forms without interference or intervention by Vale. 27 recommended changes respecting the use of ore passes at the Stobie Mine, including an absolute and enforceable obligation ending the practice of dumping of wet muck into any ore pass, such as the #3715 and #7 ore passes. 16 recommended changes to water drainage practices, including the monitoring and elimination of hazardous water conditions such as occurred on the 2400, 2450, 2600 and 2800 levels at Stobie Mine in June 2011. 16 recommended improvements to blasting procedures, including developing, implementing and enforcing new techniques for the sealing of all drill holes into ore passes.