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NI2005113830569 James H Hughes dba Alden Contracting December 16, 2005

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I!D"SAFEBC
WORKING
NI number

INCIDENT INVESTIGATION REPORT

TO MRKE A DIFFERENCE
Date of incident Incident site

2005113830569
Lead Investigating officer

Decernber16,2005

10335 - 133rd Street Surrey, BC

Mohinder Bhatti
Report approved by manager, Serious Injury Investigations Fatal and Date

Ken Bradley

July 19,2006
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-Pl'RTIESoINVOlVEQJNuJ61DI;NT
Employer Name and address Number

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CU and description

James H Hughes dba Alden Contracting 33885 Fern Street Abbotsford, Be V2S 1G4
Worker(s)

443511

764048 Sewer Installation
Occupation

I
Name and address

I

[ ] Injured [ x] Deceased Number

Labourer

Employer i

CU and description

-

677401 BC Ltd. 8015 Dominion Place Surrey, Be V3W 682
Employer Name and address

745122
~
Number

721027 House Construction
CU and description

Hub Engineering Inc 7485 - 130th Street Surrey, Be V3W 1H8
Employer Name and address

608427

763010 Consulting Engineering
CU and description

Number

Steve's Excavatinr
I

Not Registered

Employer

-

17140 - 24th Avenue Surrey, Be V4P 2S9
Name and address Number

721031 Excavating

CU and description

City of Surrey
14245 - 56th Avenue Surrey, BC V3X 3A2
Investigations Division

2541

I

753004 Local Government
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1

Workers' Compensation Board of Be Page 1 of 25 This report is supplied In you by the WeB for your information only. It ;s not to be made known to any other agency or person without the permission of th8 WeB.

NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

Persons mentioned in report
Name Known in the report as Role in the incident/investigation
Deceased Worked alongside Worke r 1

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Worker

1

Worker 2 Traffic Control Person (TCP)

Worked at the incident site during most of the period when the excavation work was carried out Hired Worker 1 to install sewer pipe

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I

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Contractor Excavator Developer Operator

Dug the excavation the incident Contracted project Contracted project Conducted

on the day of

James Hughe s for the James Hughes for the site inspections

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Co-develope r Engineering Inspector

E ngi neer -of -record Senior City Inspector City Inspector City Manager

Planned and designed the project Conducted Conducted site inspections site inspections

I I
Paul HAM

Signed the contract with the Developer a nd Co-developer

WorkSafeBC personnel involved in the investigation
Name
Mohinder BHATTI

Position
Occupational Occupational Occupational Safety Officer, Investigations Safety Officer, Worker and Employer Services Safety Officer, Worker and Employer Services

Larry SPOULER Anita CAIRNEY Jessica BERGLUND

Case Officer, Investigations

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

Scope
This incident investigation report sets out WorkSafeBC's analysis and conclusions with respect to the cause and underlying factors leading to the workplace incident of December 16, 2005, at 10335 - 133rd Street, Surrey, BC. The purpose of this report is to identify and communicate the findings of this incident to support future preventative actions by industry and WorkSafeBe. This investigation report does not address issues of enforcement action taken under the Workers Compensation Act and the Occupational Health and Safety Regulation. Any regulatory compliance activities arising from this incident will be documented separately.

Synopsis
On December 16, 2005, Worker 1 started employment with James H Hughes at 0800 hrs. At approximately 0840 hours on December 16, 2005, a crew of five workers, including the Contractor, began installing underground storm sewer pipe on 133rd street at 103rd Avenue, heading south, in Surrey, Be. At approximately 1530 hours, the Contractor dumped a bucket of gravel into the excavation. Workers 1 and 2 entered the excavation and spread the gravel at the bottom to make a bed for the pipe. The Contractor then lowered a length of pipe and the two workers attached it to the end of the previously installed pipe. The Contractor dumped more gravel into the excavation and the workers used shovels and their feet to tamp the gravel around the pipe. At approximately 1550 hours, Worker 2 left the excavation. About a minute later, the east side wall of the excavation collapsed. Worker 1 was covered with the dirt and died of asphyxiation. Shoring cages were not used during the work in the excavation on the day of the incident.

Incident Site

Figure 1. Street map show ing the incident site.

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

Table of Contents
1 Factual Information 1.1 Firms 1.1.1 James H Hughes dba Alden Contracting 1.1.2 677401 BC Ltd 1.1.3 Hub Engineering Inc 1.1.4 Steve's Excavating 1.1.5 City of Surrey 1.2 Sequence of Events 1.2.1 Before the incident 1.2.2 The incident 1.3 Findings at the Incident Site 1.3.1 The excavation 1.3.2 The shoring cages 1.3.3 Storm sewer pipes 1.3.4 Excavating machine 1.4 Workers 1.4.1 Worker 1 1.4.2 Worker 2 1.4.3 Traffic Control Person 1.4.4 Excavator Operator 1.4.5 The Contractor 1.5 Contracts 1.5.1 City of Surrey and 677401 BC Ltd 1.5.2 677401 BC Ltd. and Hub Engineering Inc 1.5.3 677401 BC Ltd. and James H Hughes dba Alden Contracting 1.6 Health and Safety Responsibilities 1.6.1 Prime Contractor 1.6.2 NoticeofProject 1.6.3 Supervision 1.6.4 Health and Safety coordinator 1.6.5 Health and safety program 1.7 Environmental Factors 1.8 Good Industry Work Practices for Excavation Work 1.8.1 Preventing collapse of the sides 1.8.2 Preventing materials from falling into the excavation 1.8.3 Underground services and utilities Analysis 2.1 Excavation 2.1.1 Water main installation
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6 6 6 6 6 6 7 7 7 9 11 11 11 12 13 13 13 13 14 14 14 14 14 15 15 15 15 15 16 16 16 17 17 18 18 18

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Page 4 of 25

Investigations Division

NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

2.2 2.3

Storm sewer pipe installation Would shoring cages at the site have been adequate for the storm sewer excavation? 2.1.4 Why were the shoring cages not used in the storm sewer excavation? Worker Orientation and Training 2.2.1 Worker 1 Health and Safety Responsibilities at the Worksite 2.3.1 City of Surrey 2.3.2 677401 BC Ltd 2.3.3 Hub Engineering Inc 2.3.4 James H Hughes dba Alden Contracting •....................................................... 2.3.5 Labour Ready Temporary Services Findings as to Causes 3.1.1 Unsafe excavation Findings as to Underlying Factors 3.2.1 Lack of excavation shoring and lor sloping 3.2.2 Site supervision and inspections 3.2.3 Condition of the ground 3.2.4 Previously backfilled sanitary sewer line 3.2.5 Vehicle traffic on the road 3.2.6 Inadequate health and safety coordination

2.1.2 2.1.3

19 19 20 20 21 21 21 22 22 22 23
23

3

Conclusions

3.1 3.2

23 23 23 23 23 24 24 24 24
25

Appendices

A.1 How the Investigation Was Conducted

25

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

1
1.1
1.1.1

Factual Information
Firms
James H Hughes dba Alden Contracting

James H Hughes was the general contractor for the site where the incident occurred. The firm had been contracted by a development company (677401 BC Ltd.) to install water and storm sewer pipes to accommodate the development of a 50-unit residential building at 10289 - 133rd Street, Surrey, BC. James H Hughes normally hires workers through a local labour supply company. On the day of the incident, Workers 1 and 2 and the Excavator Operator were working directly for James H Hughes. The Traffic Control Person had been hired through Labour Ready Temporary Services in Surrey, Be. James H Hughes has been previously inspected by WorkSafeBC officers at different locations. On June 6, 2004 a Board officer issued a verbal warning to this firm when a worker was observed working in an unshored/unsloped excavation approximately 6.5 feet deep. A Board officer also responded to complaints of unsafe excavation work on two occasions in 2003, although no violations were observed on either occasion.

1.1.2

677401 BC Ltd.

The Developer and Co-developer own this firm, which was constructing a 50-unit residential complex at 10289 - 133rd Street. On June 7, 2005, the firm contracted James H Hughes to install site services, including water main and storm sewer lines. According to the written contract, the work was to start on June 14, 2005, and was to be completed by July 31, 2005. 1.1.3 Hub Engineering Inc.

Hub Engineering Inc. is an engineering consulting firm that the Development company had hired as the Engineer-of-record. The firm designed, planned, and prepared blueprints for the project. It also conducted site inspections to ensure compliance with the City of Surrey design criteria.

1.1.4

Steve's Excavating

Steve's Excavating is an owner/operator business that is not registered with WorkSafeBe. The Excavator Operator is the principal ofthe firm. The day of the incident was the firm's first day of business at the incident site. On December 15,2005, James H Hughes hired the firm on an hourly basis to provide an excavation machine and operator to assist with the installation of the storm sewer line.

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

1.1.5

City of Surrey Surrey owns the street where the work was being conducted. On June 25,2005, the a servicing agreement, No. 7803-0313-00, with 677401 BC Ltd. to construct water and storm sewer services. City inspectors conducted regular inspections of to ensure compliance with the City's design criteria.

The City of City signed underground the worksite

1.2
1.2.1

Sequence of Events
Before the incident

In early 2004, the development company (677401 BC Ltd.) applied to the City of Surrey for a permit to construct a 50-umt residential apartment building at 10289 - 133rd Street. The City agreed to allow the construction provided that underground water and sewer services were upgraded by the development company, whom the City required to hire a consultant engineer as the Engineer-of-record. On January 20, 2004, Hub Engineering Inc. signed an agreement with 677401 BC Ltd. to provide the consulting services required by the City of Surrey. Also in 2004, the area was surveyed and blueprints were designed and submitted to the City of Surrey for approval Hub Engineering Inc. designed the blue prints which showed the depth of the water main to be approximately 4 feet. The depth of the storm sewer line varied from approximately 5 feet to 12 feet. On June 7,2005, the Development company contracted James H Hughes to be the general contractor to install the required underground services. On the same day, the City of Surrey Engineering Department held a preconstruction meeting attended by the Contractor, the Engineering Inspector, the Engineer-of-record, the Developer, the Co-developer, the City Inspector, and the Senior City Inspector. The City placed a number of conditions on the Contractor and the Engineer-of-record to ensure compliance with city laws, by-laws, and construction standards. The Contractor was required to facilitate and supply all necessary safety equipment required under the Occupational Health and Safoty Regulation for the City, its representatives, or the Engineer-of-record to inspect the sanitary sewer and storm sewer systems. Other safety-related issues and/or health and safety requirements of the Workers Compensation Act and Occupational Health and Safety Regulation were not discussed. The original plan was for the Contractor to begin his work on June 14,2005 and complete it by July 31, 2005; however, the work to install the water main did not begin until August 29, 2005. On August 29,2005, the Contractor and a crew of four workers began installing the water main along the east side of 133rd Street, beginning at 104th Avenue and proceeding south to 102nd Avenue. All-In-One Excavating Company provided the excavator and operator. The depth of the excavation was approximately 1.4 metres (4 feet, 7 inches). According to the Contractor and the

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

All-In-One excavator operator, the ground was very hard. The Contractor stated that he did not use shoring and/or other means of protection when workers entered the excavation because the ground was very hard. Installation of the water main was completed by October 23, 2005. On October 24, 2005, Direct Equipment West Ltd. delivered a shoring cage 6 feet (1. 8 metres) deep, 6 feet (1.8 metres) long, and 2.5 feet (0.8 metres) wide to the worksite. The Contractor began installing a storm sewer by making a connection at 104th Avenue and heading south on 133rd Street towards 102nd Avenue. The depth of the excavation at the starting point was approximately 5 to 6 feet (1. 5 to 1.8 metres). From October 24, 2005 to approximately December 12,2005, All-In-One Excavating Company provided the excavator operator and the machine. According to witnesses, the Contractor normally had a crew of five workers each day (two labourers, traffic control person, excavator operator and the Contractor). The ground was very hard and the excavator was very slow in digging the ground as required. The depth of the excavation gradually increased. Workers installed approximately three lengths of sewer pipes (each approximately 14 feet [4.3 metres] long and 18 inches [0.5 metre] in diameter) on a good work day. On most days work progressed slowly. The Engineering Inspector conducted regular inspections and the City of Surrey inspectors visited the site as required. According to the Traffic Control Person, shoring cages and/or other means of protection were rarely us ed when workers entered the excavation. Around December 12, 2005, All-In-One Excavating Company was replaced by Taha Contracting (617873 BC Ltd.). For the week leading up to the incident, Taha Contracting provided a larger excavation machine and three different operators. The operators were mostly new to the industry and lacked experience and slowed the progress of the work. The Contractor was getting frustrated. On most days, there was little or no activity at the site. The depth of the excavation was approximately 10 to 12 feet (3 to 3.6 metres). According to the Taha workers, shoring cages and/or other means of protection were not used when workers entered the excavation. On December 12, 2005, Direct Equipment West Ltd. delivered tw 0 shoring cages to the worksite. One cage was 6 feet (1.8 metres) deep, 8 feet (2.4 metres) long, and 2.5 feet (0.8 metres) wide. The other was 4 feet (1.2 metres) deep, 8 feet (2.4 metres) long, and 2.5 feet (0.8 metres) wide. On December 13,2005, the Taha Contracting excavator operator hit a residential service gas line. Terasen Gas was contacted and a Terasen crew repaired the line. On December 14,2005, the Contractor hit a residential service gas line with his loader. Terasen was contacted and sent another crew to repair the line. On December 15,2005, the Contractor terminated Taha Contracting due to operator inexperience. The Contractor contacted Steve's Excavating. Steve's Excavating agreed to provide an excavation machine and operator starting the following day. The Excavator Operator

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

asked the Contractor if he needed an extra labourer. He told the Contractor that he knew Worker 1, whom he described as a hardworking and good worker who was looking for work. The Contractor agreed to pay Worker 1Dper hour and asked the Excavator Operator to bring him to work the next morning. The Excavator Operator shipped the machine to the works ite and asked Worker 1 to report there the next morning.

1.2.2

The incident

On December 16,2005, the Contractor arrived at the worksite at approximately 0615 hours; the Excavator Operator arrived at approximately 0740 hours. The Contractor explained to the Excavator Operator the job that needed to be done. He also informed him of the service lines (hydro, water, and gas) and overhead wires to the houses along the west side of 133rd Street. At approximately 0800 hours, Worker 1 and the Traffic Control Person arrived at the site. The Contractor spoke with Worker 1 and learned that he had been working with Steve's Excavating forc=Jyears, although the Contractor did not enquire what the nature of this work was, and did not ask Worker 1 any questions about his experience with working in excavations. The Contractor provided Worker 1 with a hard hat and high-visibility vest. The Contractor does not recall any further discussion with Worker 1. At approximately 0830 hours, Worker 2 arrived at the site. The crew began work, locating the residential service lines at approximately 0840 hours. The gas line was damaged by the Contractor and Terasen Gas was contacted. A Terasen repair crew arrived at the site and isolated the damaged gas line; they received an emergency call, however, and left the site without repairing the line. At approximately 0845 hours, the Contractor, without providing a reason, directed the Excavator Operator to move the larger of the two shoring cages close to the excavation. The Excavator Operator complied, moving the cage from where it had been stored (approximately 200 feet away). At approximately 0900 hours, the Excavator Operator began digging the required excavation. The Contractor and Workers 1 and 2 began installing the sewer pipe. The Traffic Control Person directed traffic. The crew installed two lengths of pipe before noon. At approximately 1230 hours, the Traffic Control Person left the site for a] [appointment, after which the Contractor and Worker 2 directed traffic when required. The Traffic Control Person did not return to the site that day. At approximately 1300 hours, the Terasen repair crew returned. The Engineering Inspector also arrived and conducted an inspection of the work being done. According to the Engineering Inspector, after walking up to the excavation and not seeing any workers in it, he asked the

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

Contractor where the shoring was, to which the Contractor replied that he had just pulled it out of the excavation. By approximately 1530 hours, the excavation was approximately 20 feet (6 metres) long, 36 inches (1 metre) wide and 14 feet (4.3 metres) deep. The Contractor dumped a bucket of gravel into the excavation. Workers 1 and 2 entered the excavation and spread the gravel at the bottom to make a bed for the pipe. Worker 1 was working at the lead end of the excavation, while Worker 2 was working the rear end (see figure 3). The Contractor then lowered a length of pipe 14 feet (4.3 metres) long and 18 inches (0.5 metre) in diameter into the excavation. Workers 1 and 2 attached the pipe to the lead end of the previously installed pipe. The Contractor dumped more gravel into the excavation and the workers used shovels and their feet to tamp the gravel around the pipe. At approximately 1550 hours, Worker 2 walked out of the excavation. About a minute later, the east side wall of the excavation close to the recently installed pipe lead end collapsed. Worker 1 was covered with dirt. The local fire department received an emergency call at approximately 1559 hours, and arrived at the site at approximately 1602 hours. Rescue operations were initiated. At approximately 1800 hours, Worker l's head was uncovered. He was unresponsive. At approximately 1930 hours, Worker l's body was removed from the excavation. An autopsy was performed on Worker 1 and the cause of death was determined to be from asphyxiation.

Figure 2 showing excavation just before and after the incident

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

1.3

Findingsat the IncidentSite

The incident occurred on the west side of the public road at 10335 - 133rd Street, Surrey, Be. A water main had been installed on the east side of the street. A sanitary sewer line had been previously installed under the middle of the street by a different contractor. The present contractor was aware of the sanitary sewer line and backfilled trench under the middle of the street. Even though the storm sewer trench walls were of hard and packed dirt, the backfilled materials in the sanitary sewer line were loose and very unstable. At the site of the excavation collapse, the sanitary sewer line backfilled trench was within two feet of the storm sewer trench.

1.3.1

The excavation

The excavation was approximately 14 feet (4.3 metres) deep where Worker 1 was working at the time of the incident. Worker 1 was working at the lead end of the excavation, while Worker 2 was working at the rear end. The lead end was a straight cut, whereas the rear end sloped up to the top of the road (Figure 3). The shoring shown in Figure 3 was installed by the fire department to rescue Worker 1.

Lead end of the excavation

Location of Worker 1

Rear end of the excavation

Figure 3 showing the location a/Worker

1 in the excavation.

1.3.2

The shoring cages

There were three shoring cages at or near the incident site. One was 6 feet (1.8 metres) deep, 6 feet (1.8 metres) long, and 2.5 feet (0.8 metres) wide, and was located behind the excavation machine. Gravel had been piled against the shoring cage indicating that it had not been used for

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

some time (Figure 4). This was the cage delivered by Direct Equipment West on October 24, 2005.

Figure 4. One of the three shoring cages at the incident site.
Two other cages were located approximately 200 feet north of the incident site. One was 6 feet (1.8 metres) deep, 8 feet (2.4 metres) long, and 2.5 feet (0.8 metres) wide. The other was 4 feet (1.2 metres) deep, 8 feet (2.4 metres) long, and 2.5 feet (0.8 metres) wide. These were the cages delivered by Direct Equipment West on December 12,2005. These shoring cages can be stacked on top of each other to obtain different depths, although Worker 2's evidence was that this was never done. All the shoring cages were clean.

1.3.3

Storm sewer pipes

There were a number of plastic storm sewer pipes at the site. Each pipe was approximately 14 feet (4.3 metres) long and 18 inches (0.5 metre) in diameter. One end of each pipe was flared and could easily fit over the tail end of another pipe. The pipes were very light and could be easily handled by a worker (Figure 5).

Figure 5. Plastic storm sewer pipes.
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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

1.3.4

Excavating machine

The excavating machine was a Hitachi 200 with a bucket attached for digging the trench. The bucket was 32 inches (0.8 metre) wide. The Excavator Operator informed the lead investigator that the width of the excavation before the collapse was approximately the width of the hoe bucket. There was also a small bucket loader backhoe onsite. The Contractor would use the loader to backfill the excavation with gravel. Gravel was delivered to the site by a local trucking company as needed.

1.4

Workers

On the day of the incident, five workers were working at the site including the Contractor. A trucking company was delivering the gravel and sand as required.

1.4.1

Worker 1
1 was born

Iworker

on]

IThere are no records to show that Worker 1 had ever worked in an excavation. [but had only basic knowledge ofEnglish.I...--....!::::::=========:!.......,

Worker 1 was described by the Excavator Operator as a hardworking and good worker who would go out of his way to please his boss. The Excavator Operator doubted that Worker 1 would have known that shoring should be used in excavations.

1.4.2

Worker 2

Worker 2 was born onl IHe had been working for James H Hughes for approximatelyl I. He had a general knowledge of the risks of working in excavations, but had not received any formal training by the Contractor related to excavation work. Worker 2 said that the Contractor had told him to not be in an excavation any longer than he needed to. he was transferred to the Contractor's ~b-e£~o-r-e~th~e~in-c~i~de-n~t. payroll approximately
1
L~

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

1.4.3

Traffic Control Person

The Traffic Control Person was born on] ~~~=1~~~~ Ready Temporary Services fori June. He directed traffic at the site.

I and

He had been an employee of Labour had been working at this site, on and off, since

I

The Traffic Control Person had received basic training and education related to excavation work. He had been provided with clear instructions by Labour Ready not to enter any excavation deeper than 3 feet (0.9 metre). He was concerned about the unsafe excavation work and made three separate complaints to the Labour Ready Temporary Services Counter Service Representative that workers were working in an excavation which was deeper than four feet and that shoring was not being used. He had also expressed his concerns to Worker 2 and was told that the shoring cages could not be used because underground utility service lines to residences were in the way. The Traffic Control Person said that he did not ever see shoring cages being used. He also said that the Contractor directed the workers to get out of the excavation whenever the City or engineering inspectors showed up.

1.4.4

Excavator Operator

The Excavator Operator was born on He is the owner of Steve's Excavating and had been operating an excavator for approximately years. He had known Worker 1 as a friend for approximatelyDyears. The investigation has shown that the Excavator Operator had a general knowledge of excavation work and shoring requirements.

I

I

D

1.4.5

The Contractor

The Contractor was born on

The investigation has shown that the Contractor had a good knowledge of excavation work and understood the risks and requirements of working in excavations deeper than 4 feet (1.2 metres).

1.5
1.5.1

Contracts
City of Surrey and 677401 BC Ltd.

The City of Surrey signed a servicing agreement with 677401 BC Ltd. on June 25, 2005. The servicing agreement was 16 pages long and outlined the conditions and standards that the development company had to comply with. City inspectors reviewed engineering inspections and also conducted regular site inspections to ensure compliance with the City standards. The
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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

servicing agreement also required the development company to comply with the provisions of the Workers Compensation Act, but the City, as prime contractor, did not have a system in place to ensure such compliance.

1.5.2

677401 BC Ltd. and Hub Engineering

Inc.

677401 BC Ltd. had a written agreement with Hub Engineering Inc. dated January 20,2004. The agreement outlined the work that Hub Engineering would perform, and the cost of the services. There was no requirement for either party to ensure compliance with the provisions of the Workers Compensation Act or the Occupational Health and Safety Regulation.

1.5.3

677401 BC Ltd. and James H Hughes dba Alden Contracting

677401 BC Ltd. had a written agreement with James H Hughes dba Alden Contracting dated June 7,2005. The generic contract outlined the responsibilities of the contractors and subcontractors. Under the heading "Construction Safety," the agreement stated that the Contractor would be solely responsible for construction safety at the place of work. The development company did not have a system in place to ensure that construction work was conducted safely. Before signing the contract, the development company did not check whether James H Hughes had a health and safety program in place.

1.6
1.6.1

Healthand Safety Responsibilities
Prime Contractor

There was no written agreement between the City of Surrey, 677401 BC Ltd., Hub Engineering Inc., and James H Hughes assigning prime contractor responsibilities to any firm or individual. There was a lot of misunderstanding among the above parties as to which party had the prime contractor responsibilities. The development company assumed that because James H Hughes was the general contractor, this firm would also be the prime contractor. The City of Surrey assumed that the development company (67401 BC Ltd.), as the owner of the property under development, would be considered the prime contractor for the street project.

1.6.2

Notice of Project

Whenever a construction project includes a trench deeper than 4 feet (1.2 metres) and longer than 100 feet (30.5 metres) and workers are required to enter the excavation, the owner or the prime contractor is required to submit a ''Notice of Project" to WorkSafeBC. A WorkSafeBC officer may conduct a site visit to ensure compliance with the Workers Compensation Act and the Occupational Health and Safoty Regulation. In the case of this project, no Notice of Project was submitted to WorkSafeBC.

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NI2005113830569 James H Hughes dba Alden Contracting December 16,2005

1.6.3

Supervision

The Contractor was the site supervisor. Along with supervision duties, he operated the bucket loader backhoe and worked in the excavation as required. On the day of the incident, there were five workers working at the site under the supervision of the Contractor and a truck driver was delivering sand/ gravel as required. The Engineering Inspector also inspected the site.

1.6.4

Health and Safety coordinator

The Occupational Health and Safety Regulation requires that a multiple employer worksite with a workforce of more than five have a qualified health and safety coordinator whose duties include: • informing employers and workers of the hazards at the work site; and • ensuring that the hazards are addressed throughout the duration of the work activities. There was no health and safety coordinator appointed by the prime contractor at this work site.

1.6.5

Health and safety program

The Contractor The Contractor did not have any health and safety program in place. New workers were expected to learn on the job. There was no formal system to orient and educate new workers to the hazards ofthe job and all instructions were verbal. The Contractor said that he would ensure that workers had a vest and hard hat, and that he would tell workers to get in and out of excavations and not "hang around". No safety meetings were conducted at this worksite since the commencement of work in June 2005. On the morning of December 16,2005, Worker 1 was not given an orientation to, or education about, the excavation work despite the fact that it was his first day of doing this type of work. City of Surrey The City of Surrey has a health and safety program in place. City inspectors have been oriented, educated, and trained on the risks of working in excavations. City inspectors conducted regular inspections at this worksite but never needed to enter the excavation. All the inspections were conducted from street level. Hub Engineering Inc.

Hub Engineering Inc. IS a consulting firm that employs approximately 10 workers. The firm does not have a health and safety program in place, but new inspectors are given specific verbal instructions to follow when they visit construction sites. Inspectors and engineers are aware of

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the safety requirements for working in excavations. This firm provided regular site inspections for the incident site. All the inspections were conducted from street level. The Engineering Inspector was aware of the shoring cages at the site and observed them being used "on and off', although he never observed workers in the excavation without the shoring cage. The Engineering Inspector did not enquire or check the cages to ensure they would provide the required protection to the workers when working in the excavation. During most of his visits, the workers were out of the excavation, taking a break. 677401 Be Ltd. The Developer and Co-developer were the only two employees of this firm. They generally hired subcontractors to conduct construction work. There was no health and safety program in place, although the investigation has shown that the Developer and Co-developer were aware of the general safety requirements for work in excavations. One or the other of them conducted site visits to monitor the progress of work when excavation work was being done. The Developer and! or Co-developer conducted site visits approximately twice a week but never discussed the health and safety of the workers with the Contractor. The Co-developer said that, at one point in the cons truction, he spoke with the Contractor about the depth of the excavation and the shoring requirements. The Contractor told the Co-developer that the ground was very hard and that he had a shoring cage onsite if needed. The Developer did not check whether the shoring cages onsite were appropriate for the depth of the excavation.

1.7

Environmental Factors

On the day of the incident, the weather was clear. The average daytime temperature was approximately 4°C.

1.8

Good Industry Work Practices for Excavation Work

In order to prevent accidents and to meet the standard of the Occupational Health and Safety Regulation, excavation work has to be planned, managed, and supervised adequately. Before digging any excavation, it is very important to: • • • plan against collapse of the sides; plan against materials falling on workers working in the excavation; and locate underground utilities and services.

These are some of the serious issues faced by workers working in and around excavations. Risks of accidents increase with the depth of the excavation because the walls of an excavation can collapse at any time. A worker buried to the chest level or above can suffocate very quickly.

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1.8.1

Preventing collapse of the sides

The sides of an excavation can be prevented from collapsing by: • sloping the sides to a safe angle that will ensure that the faces are stable; • benching the sides; • supporting the sides; • using prefabricated trench boxes or shoring cages; or • working under the written instructions of a professional engineer. 1.8.2 Preventing materials from falling into the excavation

Loose materials should be stored away from the edge of the excavation. Any excavation wall supports or shoring cages should extend at least one foot above the excavation to prevent loose material from falling into the excavation.

1.8.3

Underground services and utilities

Underground services should be located and marked clearly to prevent damage by the excavator. Whenever possible, the ground around the underground services should be dug out by hand.

2
2.1 2.1.1

Analysis
Excavation
Water main installation

Excavation at the site began in August 2005 with the installation of the water main along the east side of 133rd Street. The depth of the excavation for the water main was approximately 1.4 meters (4 feet, 7 inches). The Contractor did not consider and plan for the possibility of excavation walls collapsing when installing the water main. From the blueprints, he was aware that the excavation was deeper than 4 feet (1.2 metres). He should have planned and made arrangements to use some form of shoring or other acceptable form of protection before starting the job. However, a shoring cage was brought to the site only after the water main had been completed. Shoring cages and/or other means of protection were not used because the Contractor considered that the ground was very hard and did not present any risk of collapsing. This was a wrong decision, because even though the ground was very hard, the walls of the excavation were subjected to vibrations from vehicle traffic. The Contractor was also aware that a sanitary sewer line had been previously installed in the centre of the street, which meant that behind the inside wall of the excavation, there was excessive loose material that had been used to refill the sanitary sewer excavation.
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2.1.2

Storm sewer pipe installation

The depth of the storm sewer excavation at its starting point was approximately S to 6 feet (1.S to 1.8 metres). A shoring cage of appropriate height and length should have been used to protect the workers who were working in the excavation. The Contractor focused mainly on the condition of the ground, which was extremely hard; he did not consider the location of an existing sanitary sewer line in the middle of the road. Ifhe had contacted a professional engineer, he would likely have been advised to use adequate shoring cages because the presence of loose ground within approximately 3 feet (0.9 metres) of the excavation wall can cause the excavation to collapse anytime, no matter how hard the excavation walls are. The Contractor also did not consider the vehicle traffic on the road next to the excavation. Vehicle traffic causes exces sive vibration in the ground, which in turn causes the ground to shift. The Contractor was also using his backhoe to dump the backfill gravel into the excavation, approaching from the road side perpendicular to the excavation edge. The weight of the backhoe could also have caused the ground to shift.

2.1.3

Would shoring cages at the site have been adequate for the storm sewer excavation?

The first shoring cage was brought to the site on October 24, 200S, when the storm sewer pipe installation commenced. The cage was 6 feet (1.8 metres) deep, 6 feet (1.8 metres) long, and 2.S feet (0.8 metres) wide. The depth of the excavation at the starting point of the storm sewer was between Sand 6 feet (1.S to 1.8 metres). The length of the pipes being installed was approximately 14 feet (4.3 metres). In order to provide adequate protection to the workers while in the excavation, the shoring cage would have to have been at least 7 feet (2.1 metres) deep and 16 feet (4.9 metres) long at the start of the storm sewer line. This would have enabled the workers to work inside the cage when installing pipes that were 14 feet (4.3 metres) long. The Contractor could have easily overcome the presence of residential service lines by using two 8-foot-Iong (2.4-metre-Iong) shoring cages by installing one cage on each side of the service lines. Other combinations of shoring cages could have been used and/or wooden planks could have been used to stabilize excavation walls. The depth of the excavation increased as the work progressed south due to the street slope. This was clearly indicated on the blueprints and the Contractor was aware of it, but he did not have adequate shoring cages onsite, On December 12, 200S, Direct Equipment West Ltd. delivered two shoring cages to the worksite, One cage was 6 feet (1.8 metres) deep, 8 feet (2.4 metres) long, and 2.S feet (0.8 metres) wide. The other was 4 feet (1.2 metres) deep, 8 feet (2.4 metres) long, and 2.S feet (0.8 metres) wide. The depth of the excavation at this time was approximately 10 feet (3 metres). Even stacking the two cages on top of the other to give a total depth of 10 feet (3 metres) would have not provided adequate protection to the workers inside the excavation. A
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14 feet deep excavation would require at least a 15 feet deep shoring cage. The third cage on site was 6 feet (1.8 metres) deep, 6 feet (1.8 metres) long, and 2.5 feet (0.8 metres) wide and was not long enough to be stacked properly on top of the other two cages. In any event, Worker 2 states that the shoring cages were never stacked.

2.1.4

Why were the shoring cages not used in the storm sewer excavation?

The Contractor's decision not to use the shoring cages in the storm sewer excavation was based mainly on the condition of the ground. He had been working in the area for approximately three months and had not been using shoring cages and/or other means of protection. This may have led him to believe that he could complete the work without using shoring even when the excavation depth increased drastically. He did make an effort to have extra shoring cages onsite when the depth of the excavation reached approximately 10 feet, but these cages were never used. The Contractor was far behind schedule and using the shormg cages properly would have required more time. Furthermore, during the days preceding the incident, the underground natural gas service line had been damaged three times. All these factors may have contributed to the Contractor's decision not to use the shoring cages. Even though the shoring cages present at the site were not adequate to provide complete protection for the workers in the excavation, the use of the two 8-foot-Iong (2.4-metre-Iong) cages stacked one on top of the other would have provided some protection. When stacked, they would have been 10 feet (3 metres) deep, compared with the depth of the excavation of 14 feet (4.3 metres). If Worker 1 had been inside the cage during the collapse, he would have been buried under approximately 4 feet (1.2 metres) of dirt, and there was a good possibility that he would have survived the collapse.

2.2

Worker Orientation and Training

The Contractor did not have a health and safety program in place. Formal orientation and training had not been provided to the workers. The workers were expected to learn on the job. Tailgate meetings were not conducted to discuss health and safety matters. The Traffic Control Person was concerned about the unsafe excavation and mentioned it to Worker 2 but was told that the shoring cages could not be used because underground utility service lines to residences were in the way. This was an inadequate excuse for not using shoring cages because with a little planning the excavation could have been made safer for the workers to enter. Shoring cages of different lengths could have been used on each side of the utility service lines. Wooden shoring could have been also used to prevent the walls of the excavation from collapsing.

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2.2.1

Worker 1

Worker 1 began employment with the Contractor on the day of the incident and did not receive any orientation and training for work in an excavation. There is no evidence to indicate that Worker 1 had any experience working in excavations and most likely was not aware of the risks of working in an excavation deeper than 4 feet (1.2 metres). The Excavator Operator and Worker 1 told the Contractor that Worker 1 had been working in construction for approximatelyc::::::::J years, which may have led the Contractor to believe that Worker 1 had some experience working in excavations. The Contractor did not verify Worker l's knowledge of excavation work. Worker 1 was following the Contractor's directions and conducting the work in the excavation as directed. Just before the collapse of the side wall, he was tamping the gravel around the pipe. It is unlikely his actions contributed to the excavation collapse.

2.3

Health and Safety Responsibilities at the Worksite

There was a lot of confusion among the parties involved in this project regarding who was responsible for the health and safety of the workers at the site. The City of Surrey believed that the development company was the prime contractor and thus had this responsibility. The Developer and Co-developer believed that the Contractor was the prime contractor and was responsible for health and safety at the site. The Developer and Co-developer also believed that the Engineer-of-record was responsible for the health and safety of all workers at the site. There was no written agreement, however, between the City of Surrey and any other party for another party to assume the duties of a prime contractor.

2.3.1

City of Surrey

The City of Surrey, as the owner of the street and hence the worksite, did not assign the prime contractor's responsibilities to the Development company, the Engineer-of-record, or the Contractor. The City of Surrey is therefore responsible as a prime contactor of this worksite. A Notice of Project was not submitted to WorkSafeBC. The City of Surrey had been conducting business in this manner for a long time. The City was unaware that, unless another party was assigned, in writing, the prime contractor responsibility, the City would be designated the prime contractor. The City of Surrey Engineering Department held a preconstruction meeting at the City premises and assigned a number of duties to the development company, the Engineer-of-record, and the Contractor. Without proper permits from the City, work could not proceed; furthermore, a number of conditions set by the City had to be complied with in order for the work to proceed further. Regular inspections were conducted by City inspectors to ensure compliance with City requirements; however, the City of Surrey did not have a system to ensure compliance with the health and safety requirements under the Workers Compensation Act, even though this was one of the requirements placed on the development company by the City.

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According to the preconstruction meeting, the Contractor was required to ensure that adequate safety equipment was available onsite for the City inspectors If needed; however, the City did not conduct any audits or inspections of the worksite to ensure that the required safety equipment was available. An audit and/or safety inspection by the City would have indicated that adequate shoring cages were not available onsite.

2.3.2

677401 BC Ltd.

The development company, 677401 BC Ltd., placed health and safety responsibilities on the Contractor, but the development company did not conduct any safety audits or inspections of the worksite to ensure that he was carrying out these responsibilities. An audit and! or a safety inspection by the development company would have mdicated that the Contractor had not planned to provide adequate protection for workers working in the excavation. Furthermore, a crew talk with workers by the development company would have indicated that the excavation was not adequately shored or sloped before the workers entered the excavation.

2.3.3

Hub Engineering

Inc.

The Engineering Inspector was aware of the safety requirements for working in an excavation deeper than 4 feet (1.2 metres). He conducted regular inspections of the worksite when work was in progress, but never observed the workers in the excavation. Most of the time when he arrived at the site, the workers would be out of the excavation. Until December 12,2005, there was only one shoring cage at the site. This cage was only 6 feet (1. 8 metres) deep and 6 feet (1. 8 metres) long. The depth of the excavation was greater than 6 feet (1.8 metres) and the length of the pipes being installed was approximately 14 feet (4.3 metres). Had the Engineering Inspector made this observation, he would have noticed that the shoring cage was inadequate for the safety of the workers working in the excavation. These indicators should have caused him to realize that adequate shoring was not bemg used, and also that adequate shoring would not be available in case he himself needed to enter the excavation for any reason.

2.3.4

James H Hughes dba Alden Contracting

The Contractor was the site supervisor and was responsible for ensuring that all work was carried out safely. He made the decision to not use the shoring cages without discussing it with a professional engineer. This was a multiple-employer worksite with more There should have been a qualified site health and supervisor was directing all the work at the site as excavation, ensuring that the pipe was installed to than five workers of different employers. safety coordinator. The Contractor as site well as operating the backhoe, working in the the required grade, and carrying out traffic

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control responsibilities when required. The Contractor appeared to be more focused on getting the job done than on safety.

2.3.5

Labour Ready Temporary Services

The Traffic Control Person notified the Labour Ready Temporary Services Counter Service Representative (CSR) on three different occasions that the excavation work at this site was not being done safely. The CSR made notes and forwarded them to the local manager, but the local manager did not receive the complaint notes. The district manager left employment with this firm on the morning of December 16,2005. The complaints from the Traffic Control Person were not acted upon.

3
3.1
3.1.1

Conclusions
Findings as to Causes
Unsafe excavation

Worker 1 entered an excavation approximately 14 feet (4.3 metres) deep and 20 feet (6 metres) long under the direction of his employer (the Contractor) to install a storm sewer pipe. One side wall of the excavation collapsed, and Worker 1 was buried under the loose material and died of asphyxiation.

3.2
3.2.1

Findings as to Underlying Factors
Lack of excavation shoring and lor sloping

The excavation was not shored or sloped to prevent the side walls from collapsing. Use of an adequate shoring cage would have prevented the wall from collapsing.

3.2.2

Site supervision

and inspections

As the owner of the street and the prime contractor, the City of Surrey did not conduct any safety audits or inspections of the work site to prevent the development of unsafe conditions and to ensure proper supervision. The Developer and/or Co-developer conducted regular site visits but did not conduct safety inspections or audits to prevent the development of unsafe conditions and to ensure proper supervlslOn. The Engineering Inspector conducted regular inspections of the site but did not conduct an audit of the safety equipment, including shoring cages, onsite. A close inspection and a meeting with the workers onsite would have indicated that workers were not protected when working in the excavation.

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3.2.3

Condition of the ground

The ground was very hard, which led the Contractor to believe that the excavation was safe to enter.

3.2.4

Previously backfilled sanitary sewer line

A previously backfilled sanitary sewer line ran parallel to the excavation. Excessive weight of the loose materials in the sanitary sewer trench may have forced the wall of the excavation to collapse.

3.2.5

Vehicle traffic on the road

Vehicle and mobile equipment traffic next to the excavation wall would cause vibrations in the ground, which in tum may have caused the wall of the excavation to crack and collapse.

3.2.6

Inadequate health and safety coordination

There was no health and safety coordinator at the site to address the hazards of the work site.

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Appendices
A.1 How the Investigation Was Conducted
WorkSafeBC Investigations Division conducts health and safety investigations using the integrated safety investigation methodology (ISIM). This is a methodology developed by the Transportation Safety Board and adopted by WorkSafeBC for investigating workplace incidents. This involves collecting information from various sources to understand the facts and circumstances of the incident and analyzing that information to identify the causal factors that led to the incident. The field investigation generally involves the following methodology: • Securing and examining the incident site, including any equipment involved • Taking notes and photos • Interviewing persons with relevant information such as employer representatives, supervisor, workers, and witnesses • Collecting pertinent documents such as equipment operating manuals, written procedures, and training records • Conducting tests of materials or equipment The analysis of the data includes: • Documenting a sequence of events • Examining each event for unsafe acts and conditions • Exploring the underlying factors that made the unsafe act or condition possible • Assessing the adequacy of defences that normally protect workers from hazards • Identifying health and safety deficiencies

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